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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. pagets in xray
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Measure ca and ALP; increased ALP and normal ca for dx;
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

2. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Increased serum ferritin (acute phase protein)
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

3. colchicine
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Deposition of cholesterol in the periorbital skin

4. When to give methotrexate in SLE
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Pt with significant organ involvement and have incomplete response to prednisone alone

5. criteria for AS
PMR and giant cell arteritis; can be seen both together;
Dorsum of hands and the Achilies tendon
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Pseudogout/hemochromatosis;

6. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
AS; sometime only symptom is uveitis;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
PMR and giant cell arteritis; can be seen both together;

7. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
PPD
ESRD
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

8. anti-ds DNA antibody
Specific of dx of SLE
Disseminated gonoccal infection
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

9. who gets reiters syndrome after chlamydia infection
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
If person is HLA B27 positive
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

10. painless ulcer over glans penis and inflammatory arthritis
If symptoms persist >6weeks
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)
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

11. When to order MRI in LBP
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
If symptoms persist >6weeks
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Check pedal pulses; in claudication pulses should diminish

12. DIP joint involvement

13. Tx of reiter
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
Abx -bedrest - exercise
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
A for aortic regurg; s for prolapSe (MVP)

14. inflammatory myositis
Pseudogout/hemochromatosis;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Erythematous-violaceous rash on the eyelids
Increased serum ferritin (acute phase protein)

15. Management of HTN during acute gout
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

16. gemfibrozil
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Prednisone and cyclophosphamide
Primary biliary cirrhosis
Hyper triglyceridemia

17. SLE with pleural effusion
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
Xray every 3m
Malignancy - infection - vertebral fracture

18. heberdeen nodes
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Arthritic sweling of DIP
Hypertriglyceridamia and hypercholesterolemia
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

19. anti-centromere ab
AS; sometime only symptom is uveitis;
C for c ; crest syndrome
PMR and giant cell arteritis; can be seen both together;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

20. carpal tunnel syndrom
Prophylactic agent to prevent recurrent attack; not given during acute attack
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

21. increased ALP; liver or bone origin?
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

22. Tx of gout
Viral arthritis or RA
Nodular lung densitieis with RA;
If symptoms persist >6weeks
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

23. cylosporin used after renal transplantation
Decrease urate secretion from kidney
Prophylactic agent to prevent recurrent attack; not given during acute attack
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

24. PIP joint involment
Prophylactic agent to prevent recurrent attack; not given during acute attack
If person is HLA B27 positive
Viral arthritis or RA
Osteoarthirit (bouchard at pip - b comes first);

25. 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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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

26. Gait in spinal stenosis
If person is HLA B27 positive
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

27. allpurinol
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
A for aortic regurg; s for prolapSe (MVP)
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

28. What is heliotrope sign
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
Erythematous-violaceous rash on the eyelids
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
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

29. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Measure ca and ALP; increased ALP and normal ca for dx;
Abx -bedrest - exercise

30. anterior shoulder pain
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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.
Coronary atherosclerosis due to SLE
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

31. 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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

32. 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
Dorsum of hands and the Achilies tendon
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Pseudogout/hemochromatosis;

33. night back pain
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Malignancy - infection - vertebral fracture
Minocyclin - inhibits metalloproteases and slows joint damage

34. 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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Erythematous-violaceous rash on the eyelids
Dorsum of hands and the Achilies tendon

35. How to differentiate radicular pain with claudication
High incidence of opportunistitc infection; reactivation of TB;
Nodular lung densitieis with RA;
Check pedal pulses; in claudication pulses should diminish
Disseminated gonoccal infection

36. inflamed tendons in wrist - ankle - arms; sexual history
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Hyper triglyceridemia
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Disseminated gonoccal infection

37. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
If person is HLA B27 positive
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
Supplementation ca and vitamin D

38. Tx of RA
Nodular lung densitieis with RA;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
ESRD

39. Tx of inflammatory myositis
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Patello femoral pain syndrome
High incidence of opportunistitc infection; reactivation of TB;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

40. How to prevent glucocorticoid induced bone loss
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
Supplementation ca and vitamin D
Hypertriglyceridamia and hypercholesterolemia
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

41. caplan syndrom
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Nodular lung densitieis with RA;
Xray every 3m
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

42. phalen test
Hyperflexion of both wrists--characteristic pain in one min
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

43. Raynauds phenomenon
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
Check pedal pulses; in claudication pulses should diminish

44. Rayanaud's disease vs phenomenon
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
If person is HLA B27 positive
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

45. Tx of gout in patient with ESRD or hx GI bleeding
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Hyper triglyceridemia
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
Xray every 3m

46. When to stop statin if cpk elevated
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
If person is HLA B27 positive
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

47. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Symmetrical proximal weakness; increased CPK
AS; sometime only symptom is uveitis;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

48. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
Measure ca and ALP; increased ALP and normal ca for dx;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

49. Ca oxalate induced arthritis
ESRD
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
A for aortic regurg; s for prolapSe (MVP)
Minocyclin - inhibits metalloproteases and slows joint damage

50. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat