Test your basic knowledge |

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. complications of anti-cytokine therapy
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
High incidence of opportunistitc infection; reactivation of TB;

2. Finding of MRI in stenosis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Pt with significant organ involvement and have incomplete response to prednisone alone
A for aortic regurg; s for prolapSe (MVP)
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

3. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Increased serum ferritin (acute phase protein)

4. Tx of reiter
Xray every 3m
Abx -bedrest - exercise
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

5. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Viral arthritis or RA
Arthritic sweling of DIP

6. Use of allopurinol after kidney transplant
AS; sometime only symptom is uveitis;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

7. allpurinol
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Prophylactic agent to prevent recurrent attack; not given during acute attack
Erythematous-violaceous rash on the eyelids
Pseudogout/hemochromatosis;

8. Tx of lupus nephritis
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Prednisone and cyclophosphamide
Abx -bedrest - exercise

9. probenecid
Check pedal pulses; in claudication pulses should diminish
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

10. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Dorsum of hands and the Achilies tendon

11. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Check pedal pulses; in claudication pulses should diminish
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Symmetrical proximal weakness; increased CPK

12. xanthomatous nodule
Dorsum of hands and the Achilies tendon
PMR and giant cell arteritis; can be seen both together;
Primary biliary cirrhosis
Measure ca and ALP; increased ALP and normal ca for dx;

13. How to monitor disease activity in SLE
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
If person is HLA B27 positive
ESRD

14. pagets in xray
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Abx -bedrest - exercise
Increased serum ferritin (acute phase protein)
Measure ca and ALP; increased ALP and normal ca for dx;

15. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Hypertriglyceridamia and hypercholesterolemia
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
High incidence of opportunistitc infection; reactivation of TB;

16. neck mass in sjogren patient
Check pedal pulses; in claudication pulses should diminish
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Patello femoral pain syndrome

17. When to stop statin if cpk elevated
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
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
Prednisone and cyclophosphamide
PPD

18. carpal tunnel syndrom
C for c ; crest syndrome
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.
Xray every 3m

19. Tx of gout in patient with ESRD or hx GI bleeding
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
SLE - only minutes; RA; hours;
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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

20. PIP joint involment
Malignancy - infection - vertebral fracture
Patello femoral pain syndrome
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
Osteoarthirit (bouchard at pip - b comes first);

21. Management of HTN during acute gout
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Disseminated gonoccal infection
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

22. anti-centromere ab
Patello femoral pain syndrome
Prednisone and cyclophosphamide
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
C for c ; crest syndrome

23. caplan syndrom
Nodular lung densitieis with RA;
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
Measure ESR; polymyalgia rheumatica; tx prednisone
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

24. heberdeen nodes
Arthritic sweling of DIP
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Increased serum ferritin (acute phase protein)
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

25. pain in shoulder and pelvic girdle
Viral arthritis or RA
Measure ESR; polymyalgia rheumatica; tx prednisone
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

26. bouchard nodule
Dorsum of hands and the Achilies tendon
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Hypertriglyceridamia and hypercholesterolemia
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

27. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
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
Minocyclin - inhibits metalloproteases and slows joint damage
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

28. inflammatory myositis
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Increased serum ferritin (acute phase protein)
If symptoms persist >6weeks
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

29. tinel sign
If person is HLA B27 positive
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Measure ca and ALP; increased ALP and normal ca for dx;
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

30. phalen test
Xray every 3m
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Specific of dx of SLE
Hyperflexion of both wrists--characteristic pain in one min

31. What is heliotrope sign
Patello femoral pain syndrome
Erythematous-violaceous rash on the eyelids
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Abx -bedrest - exercise

32. How to perform schober 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
Hyper triglyceridemia
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
SLE - only minutes; RA; hours;

33. tx pagets
Disseminated gonoccal infection
A for aortic regurg; s for prolapSe (MVP)
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

34. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
PPD

35. What should be chekcked before starting infliximab
PPD
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

36. increased ALP; liver or bone origin?
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Deposition of cholesterol in the periorbital skin
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

37. colchicine
Prednisone and cyclophosphamide
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Abx -bedrest - exercise
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

38. xanthelasma
AS; sometime only symptom is uveitis;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Deposition of cholesterol in the periorbital skin
Viral arthritis or RA

39. What marker is used to follow up disease activity in SLE
ESRD
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

40. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
If person is HLA B27 positive
Primary biliary cirrhosis
Pseudogout/hemochromatosis;

41. Tx of gout
Hyperflexion of both wrists--characteristic pain in one min
If person is HLA B27 positive
AS; sometime only symptom is uveitis;
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

42. gemfibrozil
SLE - only minutes; RA; hours;
Prednisone and cyclophosphamide
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
Hyper triglyceridemia

43. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
Viral arthritis or RA
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Order LFT - heat fractionation (bone burns and liver lives) - GGT

44. night back pain
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
Malignancy - infection - vertebral fracture
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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

45. anti-ds DNA antibody
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Specific of dx of SLE
Osteoarthirit (bouchard at pip - b comes first);

46. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
Specific of dx of SLE
Measure ca and ALP; increased ALP and normal ca for dx;
Measure ESR; polymyalgia rheumatica; tx prednisone

47. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
PMR and giant cell arteritis; can be seen both together;

48. Low back pain
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

49. 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.
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Prophylactic agent to prevent recurrent attack; not given during acute attack
SLE - only minutes; RA; hours;

50. carpal tunnel
Patello femoral pain syndrome
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
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.