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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. What should be chekcked before starting infliximab
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
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
PPD
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

2. inflamed tendons in wrist - ankle - arms; sexual history
Order LFT - heat fractionation (bone burns and liver lives) - GGT
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Disseminated gonoccal infection
Erythematous-violaceous rash on the eyelids

3. mcp and PIP joint involvement
AS; sometime only symptom is uveitis;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Viral arthritis or RA
Minocyclin - inhibits metalloproteases and slows joint damage

4. anti-ds DNA antibody
If symptoms persist >6weeks
Specific of dx of SLE
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

5. primary muscle disease
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
Symmetrical proximal weakness; increased CPK
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

6. caplan syndrom
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Measure ESR; polymyalgia rheumatica; tx prednisone
Nodular lung densitieis with RA;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

7. tx pagets
Coronary atherosclerosis due to SLE
Hyperflexion of both wrists--characteristic pain in one min
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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

8. When to start DMARD in RA
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

9. Rayanaud's disease vs phenomenon
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Specific of dx of SLE
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Coronary atherosclerosis due to SLE

10. xanthomatous nodule
Arthritic sweling of DIP
Dorsum of hands and the Achilies tendon
Hyperflexion of both wrists--characteristic pain in one min
Order LFT - heat fractionation (bone burns and liver lives) - GGT

11. When to order MRI in LBP
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
High incidence of opportunistitc infection; reactivation of TB;
If symptoms persist >6weeks

12. Tx of gout
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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
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
Patello femoral pain syndrome

13. bouchard nodule
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Malignancy - infection - vertebral fracture

14. when SLE patient needs steroid
Pseudogout/hemochromatosis;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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

15. anti-centromere ab
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Pt with significant organ involvement and have incomplete response to prednisone alone
C for c ; crest syndrome

16. heberdeen nodes
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Arthritic sweling of DIP
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Viral arthritis or RA

17. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

18. complications of anti-cytokine therapy
Patello femoral pain syndrome
High incidence of opportunistitc infection; reactivation of TB;
PPD
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

19. anterior shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Deposition of cholesterol in the periorbital skin
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT

20. management of LBP
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Disseminated gonoccal infection
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

21. colchicine
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Hyper triglyceridemia
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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

22. pain in shoulder and pelvic girdle
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
Measure ESR; polymyalgia rheumatica; tx prednisone
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

23. Use of antibiotic in RA
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Pseudogout/hemochromatosis;
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

24. inflammatory myositis
Coronary atherosclerosis due to SLE
Increased serum ferritin (acute phase protein)
Prednisone and cyclophosphamide
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

25. anti-mitochondrial
Erythematous-violaceous rash on the eyelids
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
Measure ESR; polymyalgia rheumatica; tx prednisone
Primary biliary cirrhosis

26. Tx of inflammatory myositis
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.
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

27. common valvular abnormalities with AS?
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Think about reiter (cannot see - cannot pee - cannot climb a tree)
A for aortic regurg; s for prolapSe (MVP)
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

28. What marker is used to follow up disease activity in SLE
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
Viral arthritis or RA
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
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

29. DIP joint involvement

30. tinel sign
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Xray every 3m
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

31. Tx of RA
Disseminated gonoccal infection
ESRD
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
If symptoms persist >6weeks

32. carpal tunnel syndrom
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 - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Prednisone and cyclophosphamide
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

33. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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
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

34. When to stop statin if cpk elevated
Pt with significant organ involvement and have incomplete response to prednisone alone
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
Hypertriglyceridamia and hypercholesterolemia
Viral arthritis or RA

35. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Hypertriglyceridamia and hypercholesterolemia
Primary biliary cirrhosis
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

36. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Decrease urate secretion from kidney
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

37. who gets reiters syndrome after chlamydia infection
ESRD
Decrease urate secretion from kidney
Malignancy - infection - vertebral fracture
If person is HLA B27 positive

38. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

39. patient pw groin pain; on steroid
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Supplementation ca and vitamin D
AS; sometime only symptom is uveitis;
Pseudogout/hemochromatosis;

40. 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
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
Xray every 3m

41. phalen test
Hyperflexion of both wrists--characteristic pain in one min
Nodular lung densitieis with RA;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

42. spondyloarthopathy
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Deposition of cholesterol in the periorbital skin

43. How to differential lumbar spinal stenosis and disc herniation pain?
SLE - only minutes; RA; hours;
If symptoms persist >6weeks
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

44. carpal tunnel
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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

45. Ca oxalate induced arthritis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Measure ca and ALP; increased ALP and normal ca for dx;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
ESRD

46. criteria for AS
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Measure ESR; polymyalgia rheumatica; tx prednisone
Symmetrical proximal weakness; increased CPK

47. night back pain
Erythematous-violaceous rash on the eyelids
Malignancy - infection - vertebral fracture
Measure ca and ALP; increased ALP and normal ca for dx;
Hypertriglyceridamia and hypercholesterolemia

48. painless ulcer over glans penis and inflammatory arthritis
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Patello femoral pain syndrome

49. SLE with pleural effusion
Check pedal pulses; in claudication pulses should diminish
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

50. gemfibrozil
Symmetrical proximal weakness; increased CPK
Hyper triglyceridemia
Arthritic sweling of DIP
PMR and giant cell arteritis; can be seen both together;