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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. night back pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Malignancy - infection - vertebral fracture
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

2. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
C for c ; crest syndrome
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
Pseudogout/hemochromatosis;

3. How to differential lumbar spinal stenosis and disc herniation pain?
Xray every 3m
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;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

4. nicotinic acid
Osteoarthirit (bouchard at pip - b comes first);
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Deposition of cholesterol in the periorbital skin
Hypertriglyceridamia and hypercholesterolemia

5. allpurinol
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Prophylactic agent to prevent recurrent attack; not given during acute attack
Pseudogout/hemochromatosis;

6. carpal tunnel syndrom
Prednisone and cyclophosphamide
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
Prophylactic agent to prevent recurrent attack; not given during acute attack

7. patient pw groin pain; on steroid
Xray every 3m
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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

8. Tx of reiter
AS; sometime only symptom is uveitis;
Abx -bedrest - exercise
Minocyclin - inhibits metalloproteases and slows joint damage
Measure ca and ALP; increased ALP and normal ca for dx;

9. probenecid
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
Hypertriglyceridamia and hypercholesterolemia
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

10. proximal muscle weakness; decreased tendon reflex; normal creat and ck
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
AS; sometime only symptom is uveitis;
Abx -bedrest - exercise
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

11. Rayanaud's disease vs phenomenon
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
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
ESRD

12. Tx of lupus nephritis
Prednisone and cyclophosphamide
Coronary atherosclerosis due to SLE
Hyper triglyceridemia
Prophylactic agent to prevent recurrent attack; not given during acute attack

13. increased ALP; liver or bone origin?
Xray every 3m
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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 marker is used to follow up disease activity in SLE
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Prednisone and cyclophosphamide
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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

15. Finding of MRI in stenosis
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

16. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
AS; sometime only symptom is uveitis;
Symmetrical proximal weakness; increased CPK
Primary biliary cirrhosis

17. What is heliotrope sign
Erythematous-violaceous rash on the eyelids
Check pedal pulses; in claudication pulses should diminish
AS; sometime only symptom is uveitis;
Malignancy - infection - vertebral fracture

18. When to stop statin if cpk elevated
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

19. How often disease activity is monitored in AS?
Xray every 3m
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
If person is HLA B27 positive
PPD

20. phalen test
C for c ; crest syndrome
Hyperflexion of both wrists--characteristic pain in one min
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Increased serum ferritin (acute phase protein)

21. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Abx -bedrest - exercise

22. tinel sign
Abx -bedrest - exercise
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
A for aortic regurg; s for prolapSe (MVP)

23. 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
C for c ; crest syndrome
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

24. Gait in spinal stenosis
Decrease urate secretion from kidney
A for aortic regurg; s for prolapSe (MVP)
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Measure ESR; polymyalgia rheumatica; tx prednisone

25. cylosporin used after renal transplantation
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Decrease urate secretion from kidney
Hypertriglyceridamia and hypercholesterolemia
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

26. When to order MRI in LBP
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
If symptoms persist >6weeks
Erythematous-violaceous rash on the eyelids
Patello femoral pain syndrome

27. Raynauds phenomenon
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
If symptoms persist >6weeks
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

28. postoeriod shoulder pain
Symmetrical proximal weakness; increased CPK
If symptoms persist >6weeks
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

29. caplan syndrom
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Viral arthritis or RA
Nodular lung densitieis with RA;
A for aortic regurg; s for prolapSe (MVP)

30. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
Measure ESR; polymyalgia rheumatica; tx prednisone
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Arthritic sweling of DIP

31. mcp and PIP joint involvement
Viral arthritis or RA
Prednisone and cyclophosphamide
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Minocyclin - inhibits metalloproteases and slows joint damage

32. SLE patient p/w MI - vent fibrillation
Erythematous-violaceous rash on the eyelids
SLE - only minutes; RA; hours;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Coronary atherosclerosis due to SLE

33. xanthomatous nodule
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
PMR and giant cell arteritis; can be seen both together;
Dorsum of hands and the Achilies tendon
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

34. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
Measure ca and ALP; increased ALP and normal ca for dx;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

35. How to prevent glucocorticoid induced bone loss
Measure ESR; polymyalgia rheumatica; tx prednisone
Supplementation ca and vitamin D
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
Prophylactic agent to prevent recurrent attack; not given during acute attack

36. spondyloarthopathy
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

37. Tx of inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Pseudogout/hemochromatosis;
ESRD
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

38. carpal tunnel
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
A for aortic regurg; s for prolapSe (MVP)
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
Coronary atherosclerosis due to SLE

39. Use of antibiotic in RA
Check pedal pulses; in claudication pulses should diminish
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
Coronary atherosclerosis due to SLE
Minocyclin - inhibits metalloproteases and slows joint damage

40. schirmer test
High incidence of opportunistitc infection; reactivation of TB;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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.
Erythematous-violaceous rash on the eyelids

41. who gets reiters syndrome after chlamydia infection
Patello femoral pain syndrome
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
If person is HLA B27 positive

42. DIP joint involvement

43. anti-ds DNA antibody
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
Specific of dx of SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

44. pain in shoulder and pelvic girdle
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Measure ESR; polymyalgia rheumatica; tx prednisone
Xray every 3m

45. xanthelasma
Supplementation ca and vitamin D
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
Deposition of cholesterol in the periorbital skin
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

46. complications of anti-cytokine therapy
Check pedal pulses; in claudication pulses should diminish
High incidence of opportunistitc infection; reactivation of TB;
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)

47. colchicine
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Primary biliary cirrhosis
Nodular lung densitieis with RA;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

48. How to perform schober test
A for aortic regurg; s for prolapSe (MVP)
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
Disseminated gonoccal infection
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

49. SLE with pleural effusion
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

50. morning stiffness hand joints
Minocyclin - inhibits metalloproteases and slows joint damage
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Prednisone and cyclophosphamide
SLE - only minutes; RA; hours;