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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. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Patello femoral pain syndrome
Disseminated gonoccal infection
Arthritic sweling of DIP

2. Tx of gout in patient with ESRD or hx GI bleeding
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;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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

3. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
AS; sometime only symptom is uveitis;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Hyper triglyceridemia

4. SLE with pleural effusion
ESRD
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

5. bouchard nodule
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Supplementation ca and vitamin D
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

6. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Malignancy - infection - vertebral fracture
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

7. patient is having pain when he moves hands above shoulder
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
ESRD
Decrease urate secretion from kidney

8. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Hyper triglyceridemia
Measure ESR; polymyalgia rheumatica; tx prednisone

9. Ca oxalate induced arthritis
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Increased serum ferritin (acute phase protein)
ESRD
Pt with significant organ involvement and have incomplete response to prednisone alone

10. role HLA B27 in dx of ankylosing spondylitis
SLE - only minutes; RA; hours;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
C for c ; crest syndrome
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

11. PIP joint involment
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
Primary biliary cirrhosis
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Osteoarthirit (bouchard at pip - b comes first);

12. caplan syndrom
Nodular lung densitieis with RA;
Supplementation ca and vitamin D
Primary biliary cirrhosis
Xray every 3m

13. when SLE patient needs steroid
Nodular lung densitieis with RA;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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

14. What should be chekcked before starting infliximab
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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

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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Nodular lung densitieis with RA;

16. increased ALP; liver or bone origin?
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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
Primary biliary cirrhosis
Order LFT - heat fractionation (bone burns and liver lives) - GGT

17. MCP joint involvement
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Erythematous-violaceous rash on the eyelids
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Pseudogout/hemochromatosis;

18. When to start DMARD in RA
Minocyclin - inhibits metalloproteases and slows joint damage
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Pt with significant organ involvement and have incomplete response to prednisone alone
Hypertriglyceridamia and hypercholesterolemia

19. How often disease activity is monitored in AS?
Xray every 3m
ESRD
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
PPD

20. How to perform schober test
Decrease urate secretion from kidney
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.
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

21. How to differentiate radicular pain with claudication
Check pedal pulses; in claudication pulses should diminish
SLE - only minutes; RA; hours;
PPD
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

22. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PPD
PMR and giant cell arteritis; can be seen both together;
Decrease urate secretion from kidney
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

23. Tx of inflammatory myositis
Arthritic sweling of DIP
Symmetrical proximal weakness; increased CPK
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Primary biliary cirrhosis

24. How glucocorticoid leads to bone loss
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Hypertriglyceridamia and hypercholesterolemia
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

25. phalen test
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Hyperflexion of both wrists--characteristic pain in one min
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);

26. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
SLE - only minutes; RA; hours;
Hyper triglyceridemia
AS; sometime only symptom is uveitis;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

27. primary muscle disease
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
Symmetrical proximal weakness; increased CPK
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

28. conjunctivitis - urethritis - and spondyloarthopathy

29. painless ulcer over glans penis and inflammatory arthritis
Specific of dx of SLE
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Increased serum ferritin (acute phase protein)
Coronary atherosclerosis due to SLE

30. What marker is used to follow up disease activity in SLE
Abx -bedrest - exercise
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
ESRD

31. right anterior knee pain and provoked by climbing stairs or prolong sitting
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
Abx -bedrest - exercise
Patello femoral pain syndrome

32. complications of anti-cytokine therapy
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Hypertriglyceridamia and hypercholesterolemia
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

33. carpal tunnel
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
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
Hyper triglyceridemia

34. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Patello femoral pain syndrome
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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

35. xanthelasma
Deposition of cholesterol in the periorbital skin
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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

36. tinel sign
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Arthritic sweling of DIP
Erythematous-violaceous rash on the eyelids
ESRD

37. What is heliotrope sign
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Erythematous-violaceous rash on the eyelids
Check pedal pulses; in claudication pulses should diminish
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

38. Use of allopurinol after kidney transplant
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
Primary biliary cirrhosis
Coronary atherosclerosis due to SLE
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

39. How to monitor disease activity in SLE
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
A for aortic regurg; s for prolapSe (MVP)

40. heberdeen nodes
Supplementation ca and vitamin D
Arthritic sweling of DIP
Increased serum ferritin (acute phase protein)
ESRD

41. gemfibrozil
Xray every 3m
Hyper triglyceridemia
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

42. night back pain
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Malignancy - infection - vertebral fracture
Supplementation ca and vitamin D

43. Tx of reiter
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Symmetrical proximal weakness; increased CPK
Abx -bedrest - exercise

44. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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

45. spondyloarthopathy
Deposition of cholesterol in the periorbital skin
A for aortic regurg; s for prolapSe (MVP)
Measure ESR; polymyalgia rheumatica; tx prednisone
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

46. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Osteoarthirit (bouchard at pip - b comes first);
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

47. colchicine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Measure ESR; polymyalgia rheumatica; tx prednisone
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

48. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hyperflexion of both wrists--characteristic pain in one min
Nodular lung densitieis with RA;
Deposition of cholesterol in the periorbital skin

49. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Minocyclin - inhibits metalloproteases and slows joint damage
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

50. Tx of RA
Pseudogout/hemochromatosis;
SLE - only minutes; RA; hours;
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