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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. gemfibrozil
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Hyper triglyceridemia
AS; sometime only symptom is uveitis;

2. carpal tunnel
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
AS; sometime only symptom is uveitis;
Minocyclin - inhibits metalloproteases and slows joint damage
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

3. spondyloarthopathy
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Specific of dx of SLE
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

4. bouchard nodule
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Osteoarthirit (bouchard at pip - b comes first);
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

5. management of LBP
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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
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

6. colchicine
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
PPD

7. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
AS; sometime only symptom is uveitis;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

8. mcp and PIP joint involvement
Osteoarthirit (bouchard at pip - b comes first);
Viral arthritis or RA
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Abx -bedrest - exercise

9. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Malignancy - infection - vertebral fracture
ESRD
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

10. conjunctivitis - urethritis - and spondyloarthopathy

11. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

12. Tx of RA
Disseminated gonoccal infection
Malignancy - infection - vertebral fracture
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Measure ESR; polymyalgia rheumatica; tx prednisone

13. Tx of inflammatory myositis
Patello femoral pain syndrome
A for aortic regurg; s for prolapSe (MVP)
If person is HLA B27 positive
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

14. complications of anti-cytokine therapy
PMR and giant cell arteritis; can be seen both together;
High incidence of opportunistitc infection; reactivation of TB;
Primary biliary cirrhosis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

15. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Supplementation ca and vitamin D

16. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Supplementation ca and vitamin D
Patello femoral pain syndrome
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

17. Tx of gout in patient with ESRD or hx GI bleeding
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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);
PMR and giant cell arteritis; can be seen both together;

18. PIP joint involment
C for c ; crest syndrome
Osteoarthirit (bouchard at pip - b comes first);
A for aortic regurg; s for prolapSe (MVP)
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

19. How to differential lumbar spinal stenosis and disc herniation pain?
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

20. who gets reiters syndrome after chlamydia infection
Increased serum ferritin (acute phase protein)
If person is HLA B27 positive
Primary biliary cirrhosis
Minocyclin - inhibits metalloproteases and slows joint damage

21. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
Minocyclin - inhibits metalloproteases and slows joint damage
PMR and giant cell arteritis; can be seen both together;
C for c ; crest syndrome

22. How to differentiate radicular pain with claudication
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Pt with significant organ involvement and have incomplete response to prednisone alone
Check pedal pulses; in claudication pulses should diminish
A for aortic regurg; s for prolapSe (MVP)

23. tinel sign
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

24. Raynauds phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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

25. Use of antibiotic in RA
Hyperflexion of both wrists--characteristic pain in one min
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
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

26. patient pw groin pain; on steroid
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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.
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
ESRD

27. inflammatory myositis
Increased serum ferritin (acute phase protein)
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

28. allpurinol
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Prophylactic agent to prevent recurrent attack; not given during acute attack
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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

29. anti-centromere ab
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
C for c ; crest syndrome
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

30. SLE patient p/w MI - vent fibrillation
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Coronary atherosclerosis due to SLE
Check pedal pulses; in claudication pulses should diminish

31. Tx of reiter
A for aortic regurg; s for prolapSe (MVP)
Abx -bedrest - exercise
Pt with significant organ involvement and have incomplete response to prednisone alone
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

32. anterior shoulder pain
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
If person is HLA B27 positive
Dorsum of hands and the Achilies tendon

33. neck mass in sjogren patient
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

34. heberdeen nodes
Arthritic sweling of DIP
Dorsum of hands and the Achilies tendon
Symmetrical proximal weakness; increased CPK
Hyperflexion of both wrists--characteristic pain in one min

35. What should be chekcked before starting infliximab
A for aortic regurg; s for prolapSe (MVP)
PPD
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Viral arthritis or RA

36. anti-ds DNA antibody
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Specific of dx of SLE
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Think about reiter (cannot see - cannot pee - cannot climb a tree)

37. increased ALP; liver or bone origin?
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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

38. 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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Patello femoral pain syndrome
Arthritic sweling of DIP

39. schirmer test
Patello femoral pain syndrome
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.
Prednisone and cyclophosphamide
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

40. anti-mitochondrial
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.
Primary biliary cirrhosis
Abx -bedrest - exercise
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

41. inflamed tendons in wrist - ankle - arms; sexual history
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Disseminated gonoccal infection
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

42. When to start DMARD in RA
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Prednisone and cyclophosphamide
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

43. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Increased serum ferritin (acute phase protein)
C for c ; crest syndrome

44. Ca oxalate induced arthritis
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
ESRD
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

45. caplan syndrom
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Nodular lung densitieis with RA;
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
Erythematous-violaceous rash on the eyelids

46. xanthelasma
Supplementation ca and vitamin D
Measure ESR; polymyalgia rheumatica; tx prednisone
Deposition of cholesterol in the periorbital skin
Arthritic sweling of DIP

47. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
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.
High incidence of opportunistitc infection; reactivation of TB;
ESRD

48. How to monitor disease activity in SLE
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

49. xanthomatous nodule
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.
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Erythematous-violaceous rash on the eyelids

50. Low back pain
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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;