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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. How to monitor disease activity in SLE
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.
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;
SLE - only minutes; RA; hours;

2. How glucocorticoid leads to bone loss
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
Patello femoral pain syndrome

3. How to prevent glucocorticoid induced bone loss
Coronary atherosclerosis due to SLE
Viral arthritis or RA
Supplementation ca and vitamin D
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

4. patient is having pain when he moves hands above shoulder
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Erythematous-violaceous rash on the eyelids
Osteoarthirit (bouchard at pip - b comes first);

5. Management of HTN during acute gout
Coronary atherosclerosis due to SLE
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

6. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Prophylactic agent to prevent recurrent attack; not given during acute attack

7. carpal tunnel
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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

8. SLE patient p/w MI - vent fibrillation
Xray every 3m
Pt with significant organ involvement and have incomplete response to prednisone alone
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Coronary atherosclerosis due to SLE

9. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
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
Erythematous-violaceous rash on the eyelids
Think about reiter (cannot see - cannot pee - cannot climb a tree)

10. colchicine
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
Symmetrical proximal weakness; increased CPK
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

11. nicotinic acid
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Hypertriglyceridamia and hypercholesterolemia
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

12. management of LBP
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;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

13. Use of allopurinol after kidney transplant
C for c ; crest syndrome
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

14. allpurinol
Xray every 3m
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Supplementation ca and vitamin D
Prophylactic agent to prevent recurrent attack; not given during acute attack

15. pagets in xray
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Measure ca and ALP; increased ALP and normal ca for dx;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
C for c ; crest syndrome

16. right anterior knee pain and provoked by climbing stairs or prolong sitting
C for c ; crest syndrome
AS; sometime only symptom is uveitis;
Increased serum ferritin (acute phase protein)
Patello femoral pain syndrome

17. anterior shoulder pain
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Disseminated gonoccal infection
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

18. caplan syndrom
Prednisone and cyclophosphamide
Nodular lung densitieis with RA;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

19. DIP joint involvement

20. When to start DMARD in RA
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Xray every 3m
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

21. Tx of gout
Symmetrical proximal weakness; increased CPK
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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.

22. primary muscle disease
Osteoarthirit (bouchard at pip - b comes first);
Prednisone and cyclophosphamide
Symmetrical proximal weakness; increased CPK
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

23. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Minocyclin - inhibits metalloproteases and slows joint damage
If person is HLA B27 positive
PMR and giant cell arteritis; can be seen both together;
ESRD

24. mcp and PIP joint involvement
Decrease urate secretion from kidney
Abx -bedrest - exercise
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

25. common valvular abnormalities with AS?
Dorsum of hands and the Achilies tendon
Prednisone and cyclophosphamide
A for aortic regurg; s for prolapSe (MVP)
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

26. Use of antibiotic in RA
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Prednisone and cyclophosphamide
Minocyclin - inhibits metalloproteases and slows joint damage

27. when SLE patient needs steroid
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
SLE - only minutes; RA; hours;
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
A for aortic regurg; s for prolapSe (MVP)

28. carpal tunnel syndrom
Dorsum of hands and the Achilies tendon
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
Pt with significant organ involvement and have incomplete response to prednisone alone

29. heberdeen nodes
If person is HLA B27 positive
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Arthritic sweling of DIP
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

30. probenecid
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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

31. schirmer test
Nodular lung densitieis with RA;
Specific of dx of SLE
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.
Prophylactic agent to prevent recurrent attack; not given during acute attack

32. 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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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

33. Low back pain
High incidence of opportunistitc infection; reactivation of TB;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Measure ca and ALP; increased ALP and normal ca for dx;

34. 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.
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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
AS; sometime only symptom is uveitis;

35. Gait in spinal stenosis
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
Pt with significant organ involvement and have incomplete response to prednisone alone
High incidence of opportunistitc infection; reactivation of TB;

36. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

37. anti-ds DNA antibody
Symmetrical proximal weakness; increased CPK
Specific of dx of 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
Minocyclin - inhibits metalloproteases and slows joint damage

38. complications of anti-cytokine therapy
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
High incidence of opportunistitc infection; reactivation of TB;

39. When to stop statin if cpk elevated
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

40. glucocorticoid therapy
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Decrease urate secretion from kidney

41. who gets reiters syndrome after chlamydia infection
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
If person is HLA B27 positive
Viral arthritis or RA

42. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Measure ca and ALP; increased ALP and normal ca for dx;

43. Tx of reiter
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
Abx -bedrest - exercise
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

44. proximal muscle weakness; decreased tendon reflex; normal creat and ck
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

45. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
Specific of dx of SLE
Abx -bedrest - exercise
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

46. tinel sign
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Minocyclin - inhibits metalloproteases and slows joint damage

47. Raynauds phenomenon
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Xray every 3m

48. Rayanaud's disease vs phenomenon
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

49. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Specific of dx of SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

50. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
PMR and giant cell arteritis; can be seen both together;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
AS; sometime only symptom is uveitis;