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