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Test your basic knowledge |
USMLE Step3 Rheumatology
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Study First
Subjects
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health-sciences
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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. MCP joint involvement
Measure ESR; polymyalgia rheumatica; tx prednisone
C for c ; crest syndrome
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Minocyclin - inhibits metalloproteases and slows joint damage
2. Tx of gout
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
3. When to stop statin if cpk elevated
Malignancy - infection - vertebral fracture
High incidence of opportunistitc infection; reactivation of TB;
Minocyclin - inhibits metalloproteases and slows joint damage
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
4. tinel sign
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Prednisone and cyclophosphamide
Osteoarthirit (bouchard at pip - b comes first);
Hyper triglyceridemia
5. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Pseudogout/hemochromatosis;
ESRD
6. Tx of RA
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
7. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Minocyclin - inhibits metalloproteases and slows joint damage
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
Deposition of cholesterol in the periorbital skin
8. postoeriod shoulder pain
Arthritic sweling of DIP
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Decrease urate secretion from kidney
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
9. SLE with pleural effusion
Measure ca and ALP; increased ALP and normal ca for dx;
Check pedal pulses; in claudication pulses should diminish
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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.
10. 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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Specific of dx of SLE
Arthritic sweling of DIP
11. caplan syndrom
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Nodular lung densitieis with RA;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
12. primary muscle disease
Symmetrical proximal weakness; increased CPK
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
Hypertriglyceridamia and hypercholesterolemia
Measure ca and ALP; increased ALP and normal ca for dx;
13. Tx of lupus nephritis
Pseudogout/hemochromatosis;
Prednisone and cyclophosphamide
Measure ESR; polymyalgia rheumatica; tx prednisone
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
14. inflammatory myositis
Increased serum ferritin (acute phase protein)
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
Primary biliary cirrhosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
15. What marker is used to follow up disease activity in SLE
Hyper triglyceridemia
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
Specific of dx of SLE
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.
16. Tx of gout in patient with ESRD or hx GI bleeding
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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
Viral arthritis or RA
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
17. xanthomatous nodule
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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.
Specific of dx of SLE
18. common valvular abnormalities with AS?
AS; sometime only symptom is uveitis;
ESRD
A for aortic regurg; s for prolapSe (MVP)
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
19. management of LBP
Specific of dx of SLE
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
PPD
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
20. Rayanaud's disease vs phenomenon
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Hyper triglyceridemia
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Primary biliary cirrhosis
21. neck mass in sjogren patient
Think about reiter (cannot see - cannot pee - cannot climb a tree)
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Pseudogout/hemochromatosis;
Patello femoral pain syndrome
22. carpal tunnel syndrom
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Coronary atherosclerosis due to SLE
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
23. proximal muscle weakness; decreased tendon reflex; normal creat and ck
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Supplementation ca and vitamin D
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
24. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
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
Pseudogout/hemochromatosis;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
25. How to differential lumbar spinal stenosis and disc herniation pain?
Dorsum of hands and the Achilies tendon
Xray every 3m
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
26. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Disseminated gonoccal infection
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Prednisone and cyclophosphamide
27. What should be chekcked before starting infliximab
Measure ca and ALP; increased ALP and normal ca for dx;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
PPD
Disseminated gonoccal infection
28. patient pw groin pain; on steroid
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
29. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
30. Management of HTN during acute gout
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Xray every 3m
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
31. How to perform schober test
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
Viral arthritis or RA
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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
32. When to give methotrexate in SLE
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Supplementation ca and vitamin D
Pt with significant organ involvement and have incomplete response to prednisone alone
33. How to prevent glucocorticoid induced bone loss
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
SLE - only minutes; RA; hours;
Supplementation ca and vitamin D
Minocyclin - inhibits metalloproteases and slows joint damage
34. Tx of inflammatory myositis
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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Arthritic sweling of DIP
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
35. How to monitor disease activity in SLE
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Prednisone and cyclophosphamide
36. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
37. probenecid
Nodular lung densitieis with RA;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
38. colchicine
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
39. SLE patient p/w MI - vent fibrillation
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
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
ESRD
Coronary atherosclerosis due to SLE
40. Low back pain
Viral arthritis or RA
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
41. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Hypertriglyceridamia and hypercholesterolemia
AS; sometime only symptom is uveitis;
Supplementation ca and vitamin D
42. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Hypertriglyceridamia and hypercholesterolemia
43. morning stiffness hand joints
SLE - only minutes; RA; hours;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Nodular lung densitieis with RA;
Hyperflexion of both wrists--characteristic pain in one min
44. What is heliotrope sign
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
Erythematous-violaceous rash on the eyelids
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
45. How glucocorticoid leads to bone loss
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
C for c ; crest syndrome
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
46. complications of anti-cytokine therapy
Hyperflexion of both wrists--characteristic pain in one min
High incidence of opportunistitc infection; reactivation of TB;
Deposition of cholesterol in the periorbital skin
Coronary atherosclerosis due to SLE
47. glucocorticoid therapy
Disseminated gonoccal infection
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
48. Tx of reiter
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Abx -bedrest - exercise
Nodular lung densitieis with RA;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
49. anti-ds DNA antibody
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Specific of dx of SLE
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
50. Ca oxalate induced arthritis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Viral arthritis or RA
ESRD
SLE - only minutes; RA; hours;