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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. inflamed tendons in wrist - ankle - arms; sexual history
Erythematous-violaceous rash on the eyelids
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
Disseminated gonoccal infection

2. Use of antibiotic in RA
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Hyper triglyceridemia
Minocyclin - inhibits metalloproteases and slows joint damage

3. colchicine
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Xray every 3m

4. Raynauds phenomenon
PMR and giant cell arteritis; can be seen both together;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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.
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

5. Tx of inflammatory myositis
Xray every 3m
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
A for aortic regurg; s for prolapSe (MVP)
Symmetrical proximal weakness; increased CPK

6. bouchard nodule
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Minocyclin - inhibits metalloproteases and slows joint damage
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

7. Finding of MRI in stenosis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Hyper triglyceridemia
Measure ca and ALP; increased ALP and normal ca for dx;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

8. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
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.
Erythematous-violaceous rash on the eyelids

9. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
ESRD
PMR and giant cell arteritis; can be seen both together;

10. complications of anti-cytokine therapy
Primary biliary cirrhosis
High incidence of opportunistitc infection; reactivation of TB;
Decrease urate secretion from kidney
Increased serum ferritin (acute phase protein)

11. How to monitor disease activity in SLE
Osteoarthirit (bouchard at pip - b comes first);
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

12. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
AS; sometime only symptom is uveitis;
Check pedal pulses; in claudication pulses should diminish
SLE - only minutes; RA; hours;

13. primary muscle disease
Symmetrical proximal weakness; increased CPK
Deposition of cholesterol in the periorbital skin
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Check pedal pulses; in claudication pulses should diminish

14. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
PMR and giant cell arteritis; can be seen both together;
PPD
Pseudogout/hemochromatosis;

15. 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
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
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

16. Rayanaud's disease vs phenomenon
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Hypertriglyceridamia and hypercholesterolemia

17. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
PPD
Measure ESR; polymyalgia rheumatica; tx prednisone
AS; sometime only symptom is uveitis;
Erythematous-violaceous rash on the eyelids

18. xanthelasma
If person is HLA B27 positive
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Pseudogout/hemochromatosis;
Deposition of cholesterol in the periorbital skin

19. When to give methotrexate in SLE
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Pt with significant organ involvement and have incomplete response to prednisone alone
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Arthritic sweling of DIP

20. glucocorticoid therapy
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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

21. Use of allopurinol after kidney transplant
Hyperflexion of both wrists--characteristic pain in one min
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

22. neck mass in sjogren patient
Xray every 3m
PMR and giant cell arteritis; can be seen both together;
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

23. pain in shoulder and pelvic girdle
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Measure ESR; polymyalgia rheumatica; tx prednisone
Deposition of cholesterol in the periorbital skin

24. Tx of reiter
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Abx -bedrest - exercise
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Symmetrical proximal weakness; increased CPK

25. phalen test
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Patello femoral pain syndrome
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Hyperflexion of both wrists--characteristic pain in one min

26. How to perform schober test
Deposition of cholesterol in the periorbital skin
High incidence of opportunistitc infection; reactivation of TB;
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
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

27. anti-ds DNA antibody
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Specific of dx of SLE
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

28. common valvular abnormalities with AS?
Malignancy - infection - vertebral fracture
A for aortic regurg; s for prolapSe (MVP)
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

29. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
AS; sometime only symptom is uveitis;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
High incidence of opportunistitc infection; reactivation of TB;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

30. inflammatory myositis
Pseudogout/hemochromatosis;
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Increased serum ferritin (acute phase protein)

31. carpal tunnel syndrom
Supplementation ca and vitamin D
C for c ; crest syndrome
Symmetrical proximal weakness; increased CPK
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

32. Gait in spinal stenosis
A for aortic regurg; s for prolapSe (MVP)
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Check pedal pulses; in claudication pulses should diminish

33. How glucocorticoid leads to bone loss
Hyper triglyceridemia
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
PPD
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.

34. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Check pedal pulses; in claudication pulses should diminish
Pseudogout/hemochromatosis;
SLE - only minutes; RA; hours;

35. patient is having pain when he moves hands above shoulder
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Hypertriglyceridamia and hypercholesterolemia
Check pedal pulses; in claudication pulses should diminish
Decrease urate secretion from kidney

36. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Disseminated gonoccal infection
Prednisone and cyclophosphamide
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

37. DIP joint involvement

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38. How to differentiate radicular pain with claudication
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Check pedal pulses; in claudication pulses should diminish
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Hyperflexion of both wrists--characteristic pain in one min

39. Ca oxalate induced arthritis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
ESRD
A for aortic regurg; s for prolapSe (MVP)
If person is HLA B27 positive

40. anterior shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Patello femoral pain syndrome
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

41. heberdeen nodes
Arthritic sweling of DIP
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Dorsum of hands and the Achilies tendon
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

42. What marker is used to follow up disease activity in SLE
Symmetrical proximal weakness; increased CPK
Coronary atherosclerosis due to SLE
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
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

43. Tx of gout
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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
High incidence of opportunistitc infection; reactivation of TB;

44. anti-centromere ab
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
C for c ; crest syndrome
Supplementation ca and vitamin D
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

45. gemfibrozil
Pseudogout/hemochromatosis;
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;
Hyper triglyceridemia

46. How often disease activity is monitored in AS?
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
PMR and giant cell arteritis; can be seen both together;
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

47. cylosporin used after renal transplantation
Viral arthritis or RA
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
Decrease urate secretion from kidney
Prednisone and cyclophosphamide

48. pagets in xray
Erythematous-violaceous rash on the eyelids
Measure ca and ALP; increased ALP and normal ca for dx;
Check pedal pulses; in claudication pulses should diminish
If symptoms persist >6weeks

49. patient pw groin pain; on steroid
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
High incidence of opportunistitc infection; reactivation of TB;
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

50. Tx of lupus nephritis
Measure ESR; polymyalgia rheumatica; tx prednisone
Measure ca and ALP; increased ALP and normal ca for dx;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Prednisone and cyclophosphamide