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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. How to differentiate radicular pain with claudication
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Check pedal pulses; in claudication pulses should diminish
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

2. anti-ds DNA antibody
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Prophylactic agent to prevent recurrent attack; not given during acute attack
Erythematous-violaceous rash on the eyelids
Specific of dx of SLE

3. inflamed tendons in wrist - ankle - arms; sexual history
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Disseminated gonoccal infection
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

4. Tx of gout
Decrease urate secretion from kidney
PMR and giant cell arteritis; can be seen both together;
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
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

5. carpal tunnel
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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.
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

6. How to monitor disease activity in SLE
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
PPD
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Xray every 3m

7. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Deposition of cholesterol in the periorbital skin
PMR and giant cell arteritis; can be seen both together;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Pt with significant organ involvement and have incomplete response to prednisone alone

8. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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

9. Tx of lupus nephritis
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
Supplementation ca and vitamin D
Prednisone and cyclophosphamide

10. neck mass in sjogren patient
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
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
Viral arthritis or RA

11. How glucocorticoid leads to bone loss
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Prednisone and cyclophosphamide
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

12. Tx of inflammatory myositis
Supplementation ca and vitamin D
Dorsum of hands and the Achilies tendon
If symptoms persist >6weeks
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

13. How often disease activity is monitored in AS?
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.
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Xray every 3m

14. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
Erythematous-violaceous rash on the eyelids
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

15. xanthomatous nodule
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
High incidence of opportunistitc infection; reactivation of TB;
Dorsum of hands and the Achilies tendon
Primary biliary cirrhosis

16. When to start DMARD in RA
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
Measure ESR; polymyalgia rheumatica; tx prednisone
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

17. What should be chekcked before starting infliximab
PPD
Pseudogout/hemochromatosis;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

18. MCP joint involvement
Nodular lung densitieis with RA;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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

19. bouchard nodule
If person is HLA B27 positive
C for c ; crest syndrome
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

20. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Check pedal pulses; in claudication pulses should diminish
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

21. 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
Xray every 3m
Increased serum ferritin (acute phase protein)
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

22. anterior shoulder pain
Symmetrical proximal weakness; increased CPK
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Minocyclin - inhibits metalloproteases and slows joint damage
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

23. allpurinol
Nodular lung densitieis with RA;
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
Prophylactic agent to prevent recurrent attack; not given during acute attack

24. Rayanaud's disease vs phenomenon
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Erythematous-violaceous rash on the eyelids
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
ESRD

25. conjunctivitis - urethritis - and spondyloarthopathy

26. Raynauds phenomenon
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
SLE - only minutes; RA; hours;
ESRD

27. Finding of MRI in stenosis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Decrease urate secretion from kidney
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

28. complications of anti-cytokine therapy
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Hyper triglyceridemia
Check pedal pulses; in claudication pulses should diminish
High incidence of opportunistitc infection; reactivation of TB;

29. anti-mitochondrial
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Primary biliary cirrhosis
A for aortic regurg; s for prolapSe (MVP)

30. management of LBP
Hyperflexion of both wrists--characteristic pain in one min
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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

31. Use of allopurinol after kidney transplant
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Minocyclin - inhibits metalloproteases and slows joint damage
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

32. Low back pain
Measure ESR; polymyalgia rheumatica; tx prednisone
ESRD
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

33. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Malignancy - infection - vertebral fracture
AS; sometime only symptom is uveitis;
Arthritic sweling of DIP
Specific of dx of SLE

34. heberdeen nodes
If symptoms persist >6weeks
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Malignancy - infection - vertebral fracture
Arthritic sweling of DIP

35. when SLE patient needs steroid
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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

36. How to perform schober test
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

37. phalen test
Patello femoral pain syndrome
Hyperflexion of both wrists--characteristic pain in one min
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Supplementation ca and vitamin D

38. pagets in xray
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Measure ca and ALP; increased ALP and normal ca for dx;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Increased serum ferritin (acute phase protein)

39. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

40. Tx of RA
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;
Check pedal pulses; in claudication pulses should diminish
Prophylactic agent to prevent recurrent attack; not given during acute attack

41. SLE patient p/w MI - vent fibrillation
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Coronary atherosclerosis due to SLE
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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

42. Tx of reiter
Abx -bedrest - exercise
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

43. schirmer test
Viral arthritis or RA
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.
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

44. caplan syndrom
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Xray every 3m
Nodular lung densitieis with RA;
Decrease urate secretion from kidney

45. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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
High incidence of opportunistitc infection; reactivation of TB;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

46. How to differential lumbar spinal stenosis and disc herniation pain?
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Disseminated gonoccal infection

47. painless ulcer over glans penis and inflammatory arthritis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Hyper triglyceridemia
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

48. Management of HTN during acute gout
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

49. SLE with pleural effusion
Symmetrical proximal weakness; increased CPK
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
Hypertriglyceridamia and hypercholesterolemia

50. Tx of gout in patient with ESRD or hx GI bleeding
Hyperflexion of both wrists--characteristic pain in one min
Erythematous-violaceous rash on the eyelids
Specific of dx of SLE
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