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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. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
Osteoarthirit (bouchard at pip - b comes first);
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
Symmetrical proximal weakness; increased CPK

2. Tx of gout in patient with ESRD or hx GI bleeding
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
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. Gait in spinal stenosis
Abx -bedrest - exercise
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.
Order LFT - heat fractionation (bone burns and liver lives) - GGT

4. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
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.
PMR and giant cell arteritis; can be seen both together;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

5. How to monitor disease activity in SLE
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

6. patient is having pain when he moves hands above shoulder
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Hyper triglyceridemia
Increased serum ferritin (acute phase protein)
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

7. Tx of reiter
Abx -bedrest - exercise
SLE - only minutes; RA; hours;
Minocyclin - inhibits metalloproteases and slows joint damage
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

8. xanthomatous nodule
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Dorsum of hands and the Achilies tendon
PMR and giant cell arteritis; can be seen both together;

9. DIP joint involvement

10. glucocorticoid therapy
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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Disseminated gonoccal infection
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

11. Raynauds phenomenon
Xray every 3m
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Prednisone and cyclophosphamide

12. How glucocorticoid leads to bone loss
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Malignancy - infection - vertebral fracture
Osteoarthirit (bouchard at pip - b comes first);
Primary biliary cirrhosis

13. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
ESRD
Hypertriglyceridamia and hypercholesterolemia
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

14. anterior shoulder pain
PMR and giant cell arteritis; can be seen both together;
High incidence of opportunistitc infection; reactivation of TB;
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

15. inflammatory myositis
Malignancy - infection - vertebral fracture
Coronary atherosclerosis due to SLE
Dorsum of hands and the Achilies tendon
Increased serum ferritin (acute phase protein)

16. allpurinol
Prednisone and cyclophosphamide
Prophylactic agent to prevent recurrent attack; not given during acute attack
Arthritic sweling of DIP
Deposition of cholesterol in the periorbital skin

17. Rayanaud's disease vs phenomenon
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
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

18. Use of allopurinol after kidney transplant
A for aortic regurg; s for prolapSe (MVP)
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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

19. phalen test
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Prednisone and cyclophosphamide
Hyperflexion of both wrists--characteristic pain in one min
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

20. 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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Viral arthritis or RA

21. Tx of gout
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
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Supplementation ca and vitamin D
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

22. 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
Pt with significant organ involvement and have incomplete response to prednisone alone
Decrease urate secretion from kidney
Deposition of cholesterol in the periorbital skin

23. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Pseudogout/hemochromatosis;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Hypertriglyceridamia and hypercholesterolemia

24. What should be chekcked before starting infliximab
High incidence of opportunistitc infection; reactivation of TB;
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
PPD

25. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Hyper triglyceridemia

26. caplan syndrom
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
PPD
Measure ESR; polymyalgia rheumatica; tx prednisone
Nodular lung densitieis with RA;

27. morning stiffness hand joints
Decrease urate secretion from kidney
SLE - only minutes; RA; hours;
Hyperflexion of both wrists--characteristic pain in one min
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

28. Ca oxalate induced arthritis
ESRD
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Nodular lung densitieis with RA;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

29. gemfibrozil
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
C for c ; crest syndrome
Hyper triglyceridemia
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

30. mcp and PIP joint involvement
ESRD
Abx -bedrest - exercise
Viral arthritis or RA
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

31. PIP joint involment
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Xray every 3m
Osteoarthirit (bouchard at pip - b comes first);
Measure ESR; polymyalgia rheumatica; tx prednisone

32. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Specific of dx of SLE
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
ESRD
AS; sometime only symptom is uveitis;

33. xanthelasma
PMR and giant cell arteritis; can be seen both together;
Viral arthritis or RA
Deposition of cholesterol in the periorbital skin
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

34. pain in shoulder and pelvic girdle
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Prednisone and cyclophosphamide
Measure ESR; polymyalgia rheumatica; tx prednisone

35. anti-mitochondrial
Primary biliary cirrhosis
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
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.

36. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Malignancy - infection - vertebral fracture
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

37. cylosporin used after renal transplantation
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Primary biliary cirrhosis
Decrease urate secretion from kidney
Measure ESR; polymyalgia rheumatica; tx prednisone

38. when SLE patient needs steroid
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.
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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
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

39. How to prevent glucocorticoid induced bone loss
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Supplementation ca and vitamin D
Pseudogout/hemochromatosis;
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

40. probenecid
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

41. bouchard nodule
Decrease urate secretion from kidney
A for aortic regurg; s for prolapSe (MVP)
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

42. carpal tunnel syndrom
Coronary atherosclerosis due to SLE
Xray every 3m
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

43. primary muscle disease
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
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Symmetrical proximal weakness; increased CPK
Erythematous-violaceous rash on the eyelids

44. Tx of inflammatory myositis
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Hyper triglyceridemia
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

45. How to differentiate radicular pain with claudication
Decrease urate secretion from kidney
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Check pedal pulses; in claudication pulses should diminish
Pseudogout/hemochromatosis;

46. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Supplementation ca and vitamin D
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Measure ESR; polymyalgia rheumatica; tx prednisone

47. complications of anti-cytokine therapy
ESRD
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Arthritic sweling of DIP
High incidence of opportunistitc infection; reactivation of TB;

48. 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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

49. postoeriod shoulder pain
Hyperflexion of both wrists--characteristic pain in one min
PMR and giant cell arteritis; can be seen both together;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
If person is HLA B27 positive

50. night back pain
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Malignancy - infection - vertebral fracture
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Order LFT - heat fractionation (bone burns and liver lives) - GGT