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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. Tx of inflammatory myositis
If symptoms persist >6weeks
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Symmetrical proximal weakness; increased CPK
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

2. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Symmetrical proximal weakness; increased CPK
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Decrease urate secretion from kidney

3. gemfibrozil
Dorsum of hands and the Achilies tendon
Hyper triglyceridemia
Osteoarthirit (bouchard at pip - b comes first);
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

4. What is heliotrope sign
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
C for c ; crest syndrome
Erythematous-violaceous rash on the eyelids
ESRD

5. painless ulcer over glans penis and inflammatory arthritis
Decrease urate secretion from kidney
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Coronary atherosclerosis due to SLE

6. Rayanaud's disease vs phenomenon
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

7. What should be chekcked before starting infliximab
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Viral arthritis or RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
PPD

8. How often disease activity is monitored in AS?
Measure ESR; polymyalgia rheumatica; tx prednisone
Xray every 3m
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

9. patient pw groin pain; on steroid
Coronary atherosclerosis due to SLE
A for aortic regurg; s for prolapSe (MVP)
Prednisone and cyclophosphamide
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

10. SLE with pleural effusion
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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.
C for c ; crest syndrome

11. common valvular abnormalities with AS?
Coronary atherosclerosis due to SLE
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
ESRD
A for aortic regurg; s for prolapSe (MVP)

12. Tx of gout in patient with ESRD or hx GI bleeding
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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

13. pagets in xray
Abx -bedrest - exercise
Measure ca and ALP; increased ALP and normal ca for dx;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Hyper triglyceridemia

14. colchicine
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Check pedal pulses; in claudication pulses should diminish
Pseudogout/hemochromatosis;

15. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
Pseudogout/hemochromatosis;
If symptoms persist >6weeks
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

16. complications of anti-cytokine therapy
Minocyclin - inhibits metalloproteases and slows joint damage
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
High incidence of opportunistitc infection; reactivation of TB;
Disseminated gonoccal infection

17. When to start DMARD in RA
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
High incidence of opportunistitc infection; reactivation of TB;

18. nicotinic acid
Minocyclin - inhibits metalloproteases and slows joint damage
Hypertriglyceridamia and hypercholesterolemia
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

19. DIP joint involvement

20. glucocorticoid therapy
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Order LFT - heat fractionation (bone burns and liver lives) - GGT
A for aortic regurg; s for prolapSe (MVP)
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

21. cylosporin used after renal transplantation
Check pedal pulses; in claudication pulses should diminish
Decrease urate secretion from kidney
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
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

22. criteria for AS
Measure ca and ALP; increased ALP and normal ca for dx;
Coronary atherosclerosis due to SLE
PPD
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

23. pain in shoulder and pelvic girdle
Symmetrical proximal weakness; increased CPK
Hypertriglyceridamia and hypercholesterolemia
Prophylactic agent to prevent recurrent attack; not given during acute attack
Measure ESR; polymyalgia rheumatica; tx prednisone

24. anti-ds DNA antibody
Specific of dx of SLE
Nodular lung densitieis with RA;
Abx -bedrest - exercise
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

25. Ca oxalate induced arthritis
Prednisone and cyclophosphamide
Measure ESR; polymyalgia rheumatica; tx prednisone
ESRD
Deposition of cholesterol in the periorbital skin

26. Management of HTN during acute gout
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
If symptoms persist >6weeks

27. carpal tunnel
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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
Primary biliary cirrhosis
Hyperflexion of both wrists--characteristic pain in one min

28. How to prevent glucocorticoid induced bone loss
Check pedal pulses; in claudication pulses should diminish
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Supplementation ca and vitamin D
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

29. How glucocorticoid leads to bone loss
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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

30. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
SLE - only minutes; RA; hours;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

31. role HLA B27 in dx of ankylosing spondylitis
Specific of dx of SLE
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Deposition of cholesterol in the periorbital skin

32. Raynauds phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Patello femoral pain syndrome
If person is HLA B27 positive

33. PIP joint involment
Prednisone and cyclophosphamide
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Supplementation ca and vitamin D
Osteoarthirit (bouchard at pip - b comes first);

34. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Deposition of cholesterol in the periorbital skin
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
PMR and giant cell arteritis; can be seen both together;

35. conjunctivitis - urethritis - and spondyloarthopathy

36. proximal muscle weakness; decreased tendon reflex; normal creat and ck
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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
Pt with significant organ involvement and have incomplete response to prednisone alone

37. phalen test
Measure ca and ALP; increased ALP and normal ca for dx;
Hyperflexion of both wrists--characteristic pain in one min
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

38. Finding of MRI in stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Dorsum of hands and the Achilies tendon
Hyper triglyceridemia
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

39. xanthelasma
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Deposition of cholesterol in the periorbital skin
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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

40. right anterior knee pain and provoked by climbing stairs or prolong sitting
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Patello femoral pain syndrome
ESRD

41. tinel sign
AS; sometime only symptom is uveitis;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

42. heberdeen nodes
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Arthritic sweling of DIP
Coronary atherosclerosis due to SLE
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

43. anti-centromere ab
C for c ; crest syndrome
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
Hyper triglyceridemia

44. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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
Hyper triglyceridemia

45. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

46. How to differentiate radicular pain with claudication
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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
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

47. When to order MRI in LBP
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
If symptoms persist >6weeks
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

48. MCP joint involvement
Deposition of cholesterol in the periorbital skin
SLE - only minutes; RA; hours;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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

49. inflammatory myositis
Pt with significant organ involvement and have incomplete response to prednisone alone
Increased serum ferritin (acute phase protein)
Osteoarthirit (bouchard at pip - b comes first);
Specific of dx of SLE

50. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Pseudogout/hemochromatosis;
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA