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. Use of allopurinol after kidney transplant
Minocyclin - inhibits metalloproteases and slows joint damage
Hyperflexion of both wrists--characteristic pain in one min
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
PMR and giant cell arteritis; can be seen both together;

2. conjunctivitis - urethritis - and spondyloarthopathy

3. How to monitor disease activity in SLE
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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
Pseudogout/hemochromatosis;

4. when SLE patient needs steroid
Xray every 3m
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
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

5. Use of antibiotic in RA
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
SLE - only minutes; RA; hours;
Minocyclin - inhibits metalloproteases and slows joint damage

6. When to stop statin if cpk elevated
PMR and giant cell arteritis; can be seen both together;
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
Hyper triglyceridemia
Hypertriglyceridamia and hypercholesterolemia

7. anti-centromere ab
C for c ; crest syndrome
Prednisone and cyclophosphamide
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

8. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Primary biliary cirrhosis
Osteoarthirit (bouchard at pip - b comes first);
Check pedal pulses; in claudication pulses should diminish

9. schirmer test
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
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.
If person is HLA B27 positive

10. Management of HTN during acute gout
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Symmetrical proximal weakness; increased CPK
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

11. caplan syndrom
Nodular lung densitieis with RA;
PPD
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

12. pain in shoulder and pelvic girdle
Minocyclin - inhibits metalloproteases and slows joint damage
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Measure ESR; polymyalgia rheumatica; tx prednisone
Osteoarthirit (bouchard at pip - b comes first);

13. How to perform schober test
Patello femoral pain syndrome
Prophylactic agent to prevent recurrent attack; not given during acute attack
Check pedal pulses; in claudication pulses should diminish
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

14. Rayanaud's disease vs phenomenon
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
Decrease urate secretion from kidney
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

15. carpal tunnel
Measure ESR; polymyalgia rheumatica; tx prednisone
AS; sometime only symptom is uveitis;
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

16. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

17. morning stiffness hand joints
SLE - only minutes; RA; hours;
Xray every 3m
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

18. xanthomatous nodule
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Dorsum of hands and the Achilies tendon
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

19. primary muscle disease
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
Symmetrical proximal weakness; increased CPK
Coronary atherosclerosis due to SLE

20. How to differential lumbar spinal stenosis and disc herniation pain?
Primary biliary cirrhosis
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

21. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Hypertriglyceridamia and hypercholesterolemia
ESRD
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

22. bouchard nodule
Hypertriglyceridamia and hypercholesterolemia
Erythematous-violaceous rash on the eyelids
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

23. Tx of gout in patient with ESRD or hx GI bleeding
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Deposition of cholesterol in the periorbital skin
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

24. increased ALP; liver or bone origin?
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Deposition of cholesterol in the periorbital skin
Order LFT - heat fractionation (bone burns and liver lives) - GGT
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

25. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Hyperflexion of both wrists--characteristic pain in one min
PMR and giant cell arteritis; can be seen both together;
Minocyclin - inhibits metalloproteases and slows joint damage
Increased serum ferritin (acute phase protein)

26. anti-ds DNA antibody
Specific of dx of SLE
PPD
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

27. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
High incidence of opportunistitc infection; reactivation of TB;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

28. Tx of RA
Primary biliary cirrhosis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

29. Tx of inflammatory myositis
High incidence of opportunistitc infection; reactivation of TB;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

30. proximal muscle weakness; decreased tendon reflex; normal creat and ck
ESRD
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

31. phalen test
Hyperflexion of both wrists--characteristic pain in one min
PMR and giant cell arteritis; can be seen both together;
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

32. Raynauds phenomenon
Patello femoral pain syndrome
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Osteoarthirit (bouchard at pip - b comes first);
Arthritic sweling of DIP

33. DIP joint involvement

34. patient pw groin pain; on steroid
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Symmetrical proximal weakness; increased CPK
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
High incidence of opportunistitc infection; reactivation of TB;

35. neck mass in sjogren patient
Coronary atherosclerosis due to SLE
A for aortic regurg; s for prolapSe (MVP)
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

36. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

37. gemfibrozil
Primary biliary cirrhosis
Hyper triglyceridemia
Measure ESR; polymyalgia rheumatica; tx prednisone
Hyperflexion of both wrists--characteristic pain in one min

38. How glucocorticoid leads to bone loss
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
ESRD
If symptoms persist >6weeks

39. heberdeen nodes
If symptoms persist >6weeks
Arthritic sweling of DIP
PPD
High incidence of opportunistitc infection; reactivation of TB;

40. Gait in spinal stenosis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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

41. inflammatory myositis
Increased serum ferritin (acute phase protein)
Measure ESR; polymyalgia rheumatica; tx prednisone
Hyper triglyceridemia
Xray every 3m

42. What is heliotrope sign
Erythematous-violaceous rash on the eyelids
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

43. tinel sign
Malignancy - infection - vertebral fracture
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Viral arthritis or RA
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

44. How to prevent glucocorticoid induced bone loss
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Deposition of cholesterol in the periorbital skin
Supplementation ca and vitamin D

45. nicotinic acid
Hyperflexion of both wrists--characteristic pain in one min
Primary biliary cirrhosis
Hypertriglyceridamia and hypercholesterolemia
Check pedal pulses; in claudication pulses should diminish

46. anti-mitochondrial
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)
Coronary atherosclerosis due to SLE
Primary biliary cirrhosis

47. Tx of lupus nephritis
Primary biliary cirrhosis
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Prednisone and cyclophosphamide

48. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Decrease urate secretion from kidney

49. probenecid
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
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

50. Ca oxalate induced arthritis
ESRD
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite