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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. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
Specific of dx of SLE
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

2. Gait in spinal stenosis
Primary biliary cirrhosis
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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;

3. PIP joint involment
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Decrease urate secretion from kidney
Osteoarthirit (bouchard at pip - b comes first);

4. heberdeen nodes
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
AS; sometime only symptom is uveitis;
Arthritic sweling of DIP

5. phalen test
Measure ca and ALP; increased ALP and normal ca for dx;
Hyperflexion of both wrists--characteristic pain in one min
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

6. Tx of gout
SLE - only minutes; RA; hours;
Viral arthritis or RA
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

7. anti-mitochondrial
Measure ESR; polymyalgia rheumatica; tx prednisone
Nodular lung densitieis with RA;
Primary biliary cirrhosis
High incidence of opportunistitc infection; reactivation of TB;

8. probenecid
Viral arthritis or RA
Supplementation ca and vitamin D
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

9. allpurinol
Pseudogout/hemochromatosis;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Decrease urate secretion from kidney
Measure ca and ALP; increased ALP and normal ca for dx;

10. Management of HTN during acute gout
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

11. patient pw groin pain; on steroid
Deposition of cholesterol in the periorbital skin
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

12. mcp and PIP joint involvement
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Viral arthritis or RA
Arthritic sweling of DIP
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

13. How to differential lumbar spinal stenosis and disc herniation pain?
Specific of dx of SLE
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

14. How to perform schober test
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

15. schirmer test
A for aortic regurg; s for prolapSe (MVP)
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
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.

16. caplan syndrom
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
Nodular lung densitieis with RA;
Hyperflexion of both wrists--characteristic pain in one min
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

17. When to start DMARD in RA
Patello femoral pain syndrome
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Primary biliary cirrhosis

18. neck mass in sjogren patient
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
Pseudogout/hemochromatosis;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

19. SLE patient p/w MI - vent fibrillation
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
ESRD
Coronary atherosclerosis due to SLE
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

20. pain in shoulder and pelvic girdle
Coronary atherosclerosis due to SLE
Measure ESR; polymyalgia rheumatica; tx prednisone
Primary biliary cirrhosis
Erythematous-violaceous rash on the eyelids

21. Tx of RA
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Hyper triglyceridemia
Nodular lung densitieis with RA;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

22. How to differentiate radicular pain with claudication
Increased serum ferritin (acute phase protein)
Deposition of cholesterol in the periorbital skin
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Check pedal pulses; in claudication pulses should diminish

23. tinel sign
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
Increased serum ferritin (acute phase protein)
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

24. bouchard nodule
Disseminated gonoccal infection
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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

25. increased ALP; liver or bone origin?
Prednisone and cyclophosphamide
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Order LFT - heat fractionation (bone burns and liver lives) - GGT

26. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT

27. Tx of lupus nephritis
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
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

28. patient is having pain when he moves hands above shoulder
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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
Dorsum of hands and the Achilies tendon
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

29. xanthomatous nodule
Dorsum of hands and the Achilies tendon
PPD
Think about reiter (cannot see - cannot pee - cannot climb a tree)
If symptoms persist >6weeks

30. cylosporin used after renal transplantation
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Arthritic sweling of DIP
Decrease urate secretion from kidney
Hyperflexion of both wrists--characteristic pain in one min

31. inflammatory myositis
Increased serum ferritin (acute phase protein)
AS; sometime only symptom is uveitis;
Nodular lung densitieis with RA;
Deposition of cholesterol in the periorbital skin

32. painless ulcer over glans penis and inflammatory arthritis
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
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)
Arthritic sweling of DIP

33. tx pagets
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Deposition of cholesterol in the periorbital skin

34. How often disease activity is monitored in AS?
Malignancy - infection - vertebral fracture
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.
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Xray every 3m

35. What should be chekcked before starting infliximab
PMR and giant cell arteritis; can be seen both together;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Primary biliary cirrhosis
PPD

36. Ca oxalate induced arthritis
ESRD
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

37. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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

38. When to stop statin if cpk elevated
If person is HLA B27 positive
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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
Increased serum ferritin (acute phase protein)

39. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

40. who gets reiters syndrome after chlamydia infection
Supplementation ca and vitamin D
SLE - only minutes; RA; hours;
If person is HLA B27 positive
Hyper triglyceridemia

41. gemfibrozil
C for c ; crest syndrome
Hyper triglyceridemia
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Disseminated gonoccal infection

42. when SLE patient needs steroid
A for aortic regurg; s for prolapSe (MVP)
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
Pseudogout/hemochromatosis;
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

43. When to order MRI in LBP
Measure ca and ALP; increased ALP and normal ca for dx;
Increased serum ferritin (acute phase protein)
If symptoms persist >6weeks
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

44. role HLA B27 in dx of ankylosing spondylitis
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

45. xanthelasma
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
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.

46. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Pseudogout/hemochromatosis;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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.

47. SLE with pleural effusion
Supplementation ca and vitamin D
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Minocyclin - inhibits metalloproteases and slows joint damage

48. anti-centromere ab
High incidence of opportunistitc infection; reactivation of TB;
C for c ; crest syndrome
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
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.

49. nicotinic acid
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Hypertriglyceridamia and hypercholesterolemia
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

50. primary muscle disease
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Prophylactic agent to prevent recurrent attack; not given during acute attack
Symmetrical proximal weakness; increased CPK