Test your basic knowledge |

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. anti-centromere ab
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
If symptoms persist >6weeks
C for c ; crest syndrome
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

2. bouchard nodule
Prophylactic agent to prevent recurrent attack; not given during acute attack
Minocyclin - inhibits metalloproteases and slows joint damage
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Think about reiter (cannot see - cannot pee - cannot climb a tree)

3. PIP joint involment
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
Minocyclin - inhibits metalloproteases and slows joint damage
Osteoarthirit (bouchard at pip - b comes first);

4. xanthelasma
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
C for c ; crest syndrome
Prophylactic agent to prevent recurrent attack; not given during acute attack
Deposition of cholesterol in the periorbital skin

5. How often disease activity is monitored in AS?
Dorsum of hands and the Achilies tendon
Pseudogout/hemochromatosis;
Xray every 3m
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

6. Tx of inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Osteoarthirit (bouchard at pip - b comes first);
Minocyclin - inhibits metalloproteases and slows joint damage
PMR and giant cell arteritis; can be seen both together;

7. criteria for AS
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Patello femoral pain syndrome

8. How to differential lumbar spinal stenosis and disc herniation pain?
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

9. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

10. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hyper triglyceridemia
AS; sometime only symptom is uveitis;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

11. who gets reiters syndrome after chlamydia infection
Order LFT - heat fractionation (bone burns and liver lives) - GGT
If person is HLA B27 positive
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

12. How to monitor disease activity in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
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
Prednisone and cyclophosphamide

13. anti-ds DNA antibody
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Specific of dx of SLE
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

14. patient is having pain when he moves hands above shoulder
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Osteoarthirit (bouchard at pip - b comes first);
Hyper triglyceridemia

15. Gait in spinal stenosis
Viral arthritis or RA
Coronary atherosclerosis due to SLE
Supplementation ca and vitamin D
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

16. heberdeen nodes
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Arthritic sweling of DIP
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

17. What marker is used to follow up disease activity in SLE
Disseminated gonoccal infection
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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

18. postoeriod shoulder pain
Measure ca and ALP; increased ALP and normal ca for dx;
Nodular lung densitieis with RA;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Pt with significant organ involvement and have incomplete response to prednisone alone

19. Tx of reiter
Viral arthritis or RA
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Supplementation ca and vitamin D
Abx -bedrest - exercise

20. conjunctivitis - urethritis - and spondyloarthopathy

21. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Specific of dx of SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
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

22. SLE patient p/w MI - vent fibrillation
A for aortic regurg; s for prolapSe (MVP)
Coronary atherosclerosis due to SLE
Disseminated gonoccal infection
Arthritic sweling of DIP

23. Management of HTN during acute gout
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

24. Tx of gout in patient with ESRD or hx GI bleeding
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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

25. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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

26. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
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
Hyperflexion of both wrists--characteristic pain in one min
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

27. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

28. painless ulcer over glans penis and inflammatory arthritis
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Coronary atherosclerosis due to SLE
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

29. Finding of MRI in stenosis
Pseudogout/hemochromatosis;
PPD
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

30. anterior shoulder pain
PPD
Osteoarthirit (bouchard at pip - b comes first);
Nodular lung densitieis with RA;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

31. phalen test
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Hyperflexion of both wrists--characteristic pain in one min
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

32. right anterior knee pain and provoked by climbing stairs or prolong sitting
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Patello femoral pain syndrome

33. neck mass in sjogren patient
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
PMR and giant cell arteritis; can be seen both together;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

34. carpal tunnel syndrom
Malignancy - infection - vertebral fracture
Primary biliary cirrhosis
Check pedal pulses; in claudication pulses should diminish
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

35. When to stop statin if cpk elevated
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
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
Symmetrical proximal weakness; increased CPK
Xray every 3m

36. allpurinol
Measure ca and ALP; increased ALP and normal ca for dx;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Minocyclin - inhibits metalloproteases and slows joint damage
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

37. Use of antibiotic in RA
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
Minocyclin - inhibits metalloproteases and slows joint damage
If person is HLA B27 positive

38. Tx of gout
Increased serum ferritin (acute phase protein)
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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

39. gemfibrozil
Hyper triglyceridemia
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
If person is HLA B27 positive
Coronary atherosclerosis due to SLE

40. management of LBP
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

41. What should be chekcked before starting infliximab
PPD
Hyper triglyceridemia
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

42. How to differentiate radicular pain with claudication
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Prophylactic agent to prevent recurrent attack; not given during acute attack

43. Rayanaud's disease vs 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
Prednisone and cyclophosphamide
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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

44. spondyloarthopathy
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

45. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Specific of dx of SLE
Supplementation ca and vitamin D

46. xanthomatous nodule
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Dorsum of hands and the Achilies tendon
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

47. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Pseudogout/hemochromatosis;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

48. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Measure ca and ALP; increased ALP and normal ca for dx;
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Symmetrical proximal weakness; increased CPK

49. Ca oxalate induced arthritis
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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
ESRD
Erythematous-violaceous rash on the eyelids

50. Tx of RA
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Pt with significant organ involvement and have incomplete response to prednisone alone