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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. Ca oxalate induced arthritis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
ESRD
Prednisone and cyclophosphamide
Symmetrical proximal weakness; increased CPK

2. schirmer test
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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.
PPD
Pseudogout/hemochromatosis;

3. neck mass in sjogren patient
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

4. When to order MRI in LBP
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
If symptoms persist >6weeks
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

5. mcp and PIP joint involvement
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Viral arthritis or RA
Supplementation ca and vitamin D
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

6. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Anti-ds DNA; the levels have been associated iwth development of lupus nephritis; immune complexes of these antibodies are seen glomeruli of patient with lupus nephriis
C for c ; crest syndrome
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

7. How often disease activity is monitored in AS?
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
Disseminated gonoccal infection
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Xray every 3m

8. When to start DMARD in RA
If person is HLA B27 positive
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
SLE - only minutes; RA; hours;

9. increased ALP; liver or bone origin?
Hypertriglyceridamia and hypercholesterolemia
Order LFT - heat fractionation (bone burns and liver lives) - GGT
If symptoms persist >6weeks
Coronary atherosclerosis due to SLE

10. xanthelasma
Osteoarthirit (bouchard at pip - b comes first);
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Deposition of cholesterol in the periorbital skin
Hyper triglyceridemia

11. Gait in spinal stenosis
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Hyper triglyceridemia

12. conjunctivitis - urethritis - and spondyloarthopathy

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13. anti-centromere ab
If symptoms persist >6weeks
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
Symmetrical proximal weakness; increased CPK
C for c ; crest syndrome

14. criteria for AS
Prednisone and cyclophosphamide
SLE - only minutes; RA; hours;
Deposition of cholesterol in the periorbital skin
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

15. Tx of inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Decrease urate secretion from kidney
AS; sometime only symptom is uveitis;

16. 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
Arthritic sweling of DIP
High incidence of opportunistitc infection; reactivation of TB;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

17. anti-ds DNA antibody
Specific of dx of SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

18. How glucocorticoid leads to bone loss
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Nodular lung densitieis with RA;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

19. DIP joint involvement

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20. SLE with pleural effusion
Disseminated gonoccal infection
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Patello femoral pain syndrome
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

21. phalen test
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
Hyperflexion of both wrists--characteristic pain in one min
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Patello femoral pain syndrome

22. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Hypertriglyceridamia and hypercholesterolemia
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
PMR and giant cell arteritis; can be seen both together;
Deposition of cholesterol in the periorbital skin

23. patient is having pain when he moves hands above shoulder
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Symmetrical proximal weakness; increased CPK
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Specific of dx of SLE

24. carpal tunnel syndrom
Minocyclin - inhibits metalloproteases and slows joint damage
Viral arthritis or RA
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

25. carpal tunnel
Xray every 3m
Hyper triglyceridemia
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
Decrease urate secretion from kidney

26. morning stiffness hand joints
SLE - only minutes; RA; hours;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Check pedal pulses; in claudication pulses should diminish
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

27. role HLA B27 in dx of ankylosing spondylitis
Measure ca and ALP; increased ALP and normal ca for dx;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

28. common valvular abnormalities with AS?
Hyper triglyceridemia
Viral arthritis or RA
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
A for aortic regurg; s for prolapSe (MVP)

29. nicotinic acid
PPD
Hypertriglyceridamia and hypercholesterolemia
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

30. Tx of RA
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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
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

31. What marker is used to follow up disease activity in SLE
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Anti-ds DNA; the levels have been associated iwth development of lupus nephritis; immune complexes of these antibodies are seen glomeruli of patient with lupus nephriis
Prophylactic agent to prevent recurrent attack; not given during acute attack
Malignancy - infection - vertebral fracture

32. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
If symptoms persist >6weeks
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

33. Use of antibiotic in RA
Pt with significant organ involvement and have incomplete response to prednisone alone
Deposition of cholesterol in the periorbital skin
ESRD
Minocyclin - inhibits metalloproteases and slows joint damage

34. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Pseudogout/hemochromatosis;

35. anterior shoulder pain
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Measure ca and ALP; increased ALP and normal ca for dx;

36. postoeriod shoulder pain
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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.
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

37. PIP joint involment
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Osteoarthirit (bouchard at pip - b comes first);
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

38. allpurinol
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Prophylactic agent to prevent recurrent attack; not given during acute attack
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Measure ca and ALP; increased ALP and normal ca for dx;

39. MCP joint involvement
Measure ESR; polymyalgia rheumatica; tx prednisone
Patello femoral pain syndrome
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
SLE - only minutes; RA; hours;

40. What is heliotrope sign
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
Erythematous-violaceous rash on the eyelids
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

41. anti-mitochondrial
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Primary biliary cirrhosis
Minocyclin - inhibits metalloproteases and slows joint damage
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

42. patient pw groin pain; on steroid
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Erythematous-violaceous rash on the eyelids
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

43. Rayanaud's disease vs phenomenon
Measure ESR; polymyalgia rheumatica; tx prednisone
Hypertriglyceridamia and hypercholesterolemia
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

44. How to monitor disease activity in SLE
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Hyperflexion of both wrists--characteristic pain in one min
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

45. How to perform schober test
If symptoms persist >6weeks
Hyperflexion of both wrists--characteristic pain in one min
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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

46. How to prevent glucocorticoid induced bone loss
Viral arthritis or RA
Pt with significant organ involvement and have incomplete response to prednisone alone
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
Supplementation ca and vitamin D

47. When to stop statin if cpk elevated
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
If person is HLA B27 positive
Primary biliary cirrhosis

48. tx pagets
Check pedal pulses; in claudication pulses should diminish
AS; sometime only symptom is uveitis;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Measure ca and ALP; increased ALP and normal ca for dx;

49. heberdeen nodes
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
If person is HLA B27 positive
Arthritic sweling of DIP
Order LFT - heat fractionation (bone burns and liver lives) - GGT

50. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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
Malignancy - infection - vertebral fracture
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`