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USMLE Step3 Rheumatology

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
No benefit of nsaid; firstline therapy night time splinting; oral corticosteroid for short term improvment; surgery for moderate to severe symptoms; occupational rehab before surgery eg less typing - less wrist flexion-extension
Increased serum ferritin (acute phase protein)
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

2. neck mass in sjogren patient
Minocyclin - inhibits metalloproteases and slows joint damage
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

3. who gets reiters syndrome after chlamydia infection
SLE - only minutes; RA; hours;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
If person is HLA B27 positive
Symmetrical proximal weakness; increased CPK

4. Use of antibiotic in RA
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Minocyclin - inhibits metalloproteases and slows joint damage
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

5. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
PMR and giant cell arteritis; can be seen both together;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Deposition of cholesterol in the periorbital skin

6. phalen test
Specific of dx of SLE
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Decrease urate secretion from kidney
Hyperflexion of both wrists--characteristic pain in one min

7. When to give methotrexate in SLE
Hyperflexion of both wrists--characteristic pain in one min
C for c ; crest syndrome
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Pt with significant organ involvement and have incomplete response to prednisone alone

8. Finding of MRI in stenosis
Hyperflexion of both wrists--characteristic pain in one min
Renal biopsy is needed when kidney is involved; Type 1 and type 2 need no tx; type 3 and 4 need immunosuppresion cyclophosphamide; more frequent patter; type 5 needs tx when it is proliferative
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Disseminated gonoccal infection

9. xanthomatous nodule
Prednisone and cyclophosphamide
Dorsum of hands and the Achilies tendon
Abx -bedrest - exercise
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

10. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Arthritic sweling of DIP
If symptoms persist >6weeks
Order LFT - heat fractionation (bone burns and liver lives) - GGT

11. anti-centromere ab
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
AS; sometime only symptom is uveitis;
C for c ; crest syndrome
PPD

12. glucocorticoid therapy
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Coronary atherosclerosis due to SLE
Abx -bedrest - exercise
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

13. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Deposition of cholesterol in the periorbital skin
Hyper triglyceridemia
Pseudogout/hemochromatosis;
SLE - only minutes; RA; hours;

14. How to differential lumbar spinal stenosis and disc herniation pain?
Measure ca and ALP; increased ALP and normal ca for dx;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Disseminated gonoccal infection

15. bouchard nodule
Viral arthritis or RA
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
NSAID if kidney function is OK and no hx of GI bleeding; very important; in kidney transplant patient - NSAID decrease renal PG production - other immunosuppresive like cyclosporine also decreases renal PG; concomitant use will compromise renal funct

16. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Reactive arthritis (reiter's syndrome); 80% HLA b27 positive - preceding genitourinary or gi infection eg chlamydia cervicitis or urethritis or shigella salmonesll and campylobacter infection
Prednisone and cyclophosphamide
Osteoarthirit (bouchard at pip - b comes first);

17. conjunctivitis - urethritis - and spondyloarthopathy

18. MCP joint involvement
Symmetrical proximal weakness; increased CPK
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Hyper triglyceridemia

19. anti-ds DNA antibody
Deposition of cholesterol in the periorbital skin
Specific of dx of SLE
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Abx -bedrest - exercise

20. Rayanaud's disease vs phenomenon
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Hyper triglyceridemia
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

21. How glucocorticoid leads to bone loss
Arthritic sweling of DIP
C for c ; crest syndrome
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Order LFT - heat fractionation (bone burns and liver lives) - GGT

22. What is heliotrope sign
If more than 10 times about the upper limit of normal range; chances of statin myopathy higher if statin is used in combination with fibric acid derivative
Check pedal pulses; in claudication pulses should diminish
Erythematous-violaceous rash on the eyelids
Specific of dx of SLE

23. postoeriod shoulder pain
Osteoarthirit (bouchard at pip - b comes first);
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

24. Use of allopurinol after kidney transplant
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

25. SLE with pleural effusion
Hyper triglyceridemia
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Pseudogout/hemochromatosis;
Nodular lung densitieis with RA;

26. common valvular abnormalities with AS?
Prophylactic agent to prevent recurrent attack; not given during acute attack
Pseudogout/hemochromatosis;
A for aortic regurg; s for prolapSe (MVP)
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

27. night back pain
Reactive arthritis (reiter's syndrome); 80% HLA b27 positive - preceding genitourinary or gi infection eg chlamydia cervicitis or urethritis or shigella salmonesll and campylobacter infection
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Malignancy - infection - vertebral fracture
To test adequate tear production in sjogren syndrome; filter paper is placed along lower eyelid and wetting of paper measured after a defined period of time.

28. schirmer test
To test adequate tear production in sjogren syndrome; filter paper is placed along lower eyelid and wetting of paper measured after a defined period of time.
No NSAID - no colchicine (CI-ARF); r/o septic arthritis - similar presentation; give intraarticular corticosteroid if one joint involvement; if multiple joint involved give oral prednisone
Patello femoral pain syndrome
SLE - only minutes; RA; hours;

29. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Primary biliary cirrhosis
To test adequate tear production in sjogren syndrome; filter paper is placed along lower eyelid and wetting of paper measured after a defined period of time.
No benefit of nsaid; firstline therapy night time splinting; oral corticosteroid for short term improvment; surgery for moderate to severe symptoms; occupational rehab before surgery eg less typing - less wrist flexion-extension

30. PIP joint involment
Erythematous-violaceous rash on the eyelids
Increased serum ferritin (acute phase protein)
Osteoarthirit (bouchard at pip - b comes first);
PMR and giant cell arteritis; can be seen both together;

31. proximal muscle weakness; decreased tendon reflex; normal creat and ck
If more than 10 times about the upper limit of normal range; chances of statin myopathy higher if statin is used in combination with fibric acid derivative
High incidence of opportunistitc infection; reactivation of TB;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

32. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Minocyclin - inhibits metalloproteases and slows joint damage
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
AS; sometime only symptom is uveitis;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

33. How to perform schober test
Increased serum ferritin (acute phase protein)
Primary biliary cirrhosis
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Spinous process of 5th lumbar disc identified and maked; a point 10cm above the first mark. the patient is asked bend forward; then two points are measured. normal 15 cm

34. patient is having pain when he moves hands above shoulder
Pseudogout/hemochromatosis;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

35. morning stiffness hand joints
Deposition of cholesterol in the periorbital skin
SLE - only minutes; RA; hours;
Disseminated gonoccal infection
PMR and giant cell arteritis; can be seen both together;

36. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Prophylactic agent to prevent recurrent attack; not given during acute attack
Arthritic sweling of DIP
C for c ; crest syndrome

37. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
AS; sometime only symptom is uveitis;
Pt with significant organ involvement and have incomplete response to prednisone alone
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

38. How to prevent glucocorticoid induced bone loss
Think about reiter (cannot see - cannot pee - cannot climb a tree)
High incidence of opportunistitc infection; reactivation of TB;
Supplementation ca and vitamin D
Hyperflexion of both wrists--characteristic pain in one min

39. Tx of reiter
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
No NSAID - no colchicine (CI-ARF); r/o septic arthritis - similar presentation; give intraarticular corticosteroid if one joint involvement; if multiple joint involved give oral prednisone
Abx -bedrest - exercise

40. What should be chekcked before starting infliximab
PPD
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Check pedal pulses; in claudication pulses should diminish
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

41. when SLE patient needs steroid
Renal biopsy is needed when kidney is involved; Type 1 and type 2 need no tx; type 3 and 4 need immunosuppresion cyclophosphamide; more frequent patter; type 5 needs tx when it is proliferative
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

42. painless ulcer over glans penis and inflammatory arthritis
Xray every 3m
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

43. carpal tunnel
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
No benefit of nsaid; firstline therapy night time splinting; oral corticosteroid for short term improvment; surgery for moderate to severe symptoms; occupational rehab before surgery eg less typing - less wrist flexion-extension
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
PPD

44. heberdeen nodes
Arthritic sweling of DIP
Specific of dx of SLE
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
NSAID if kidney function is OK and no hx of GI bleeding; very important; in kidney transplant patient - NSAID decrease renal PG production - other immunosuppresive like cyclosporine also decreases renal PG; concomitant use will compromise renal funct

45. primary muscle disease
Renal biopsy is needed when kidney is involved; Type 1 and type 2 need no tx; type 3 and 4 need immunosuppresion cyclophosphamide; more frequent patter; type 5 needs tx when it is proliferative
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Symmetrical proximal weakness; increased CPK
Osteoarthirit (bouchard at pip - b comes first);

46. Management of HTN during acute gout
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

47. Tx of inflammatory myositis
Decrease urate secretion from kidney
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
ESRD

48. anti-mitochondrial
Nodular lung densitieis with RA;
Primary biliary cirrhosis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Coronary atherosclerosis due to SLE

49. How to differentiate radicular pain with claudication
Check pedal pulses; in claudication pulses should diminish
Pseudogout/hemochromatosis;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Erythematous-violaceous rash on the eyelids

50. How often disease activity is monitored in AS?
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Xray every 3m