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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. Rayanaud's disease vs phenomenon
Check pedal pulses; in claudication pulses should diminish
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Deposition of cholesterol in the periorbital skin

2. common valvular abnormalities with AS?
If symptoms persist >6weeks
A for aortic regurg; s for prolapSe (MVP)
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

3. Tx of RA
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

4. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

5. Finding of MRI in stenosis
Pseudogout/hemochromatosis;
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
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

6. Tx of inflammatory myositis
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
PPD

7. carpal tunnel
SLE - only minutes; RA; hours;
Viral arthritis or RA
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

8. Tx of gout in patient with ESRD or hx GI bleeding
Xray every 3m
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Measure ESR; polymyalgia rheumatica; tx prednisone

9. How to monitor disease activity in SLE
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Hyper triglyceridemia
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

10. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Erythematous-violaceous rash on the eyelids
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Dorsum of hands and the Achilies tendon

11. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Osteoarthirit (bouchard at pip - b comes first);
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Patello femoral pain syndrome

12. How glucocorticoid leads to bone loss
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

13. tx pagets
Deposition of cholesterol in the periorbital skin
Arthritic sweling of DIP
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Primary biliary cirrhosis

14. How to differentiate radicular pain with claudication
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Abx -bedrest - exercise
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.
Check pedal pulses; in claudication pulses should diminish

15. gemfibrozil
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
Xray every 3m
Hyper triglyceridemia
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

16. conjunctivitis - urethritis - and spondyloarthopathy

17. xanthelasma
Pt with significant organ involvement and have incomplete response to prednisone alone
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Deposition of cholesterol in the periorbital skin
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

18. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Check pedal pulses; in claudication pulses should diminish
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

19. increased ALP; liver or bone origin?
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
PMR and giant cell arteritis; can be seen both together;
Order LFT - heat fractionation (bone burns and liver lives) - GGT

20. DIP joint involvement

21. anti-centromere ab
If person is HLA B27 positive
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
C for c ; crest syndrome
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

22. Tx of lupus nephritis
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Increased serum ferritin (acute phase protein)
Prednisone and cyclophosphamide
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

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

24. 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
Measure ca and ALP; increased ALP and normal ca for dx;
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
Nodular lung densitieis with RA;

25. Management of HTN during acute gout
Prophylactic agent to prevent recurrent attack; not given during acute attack
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

26. inflammatory myositis
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.
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
Increased serum ferritin (acute phase protein)

27. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Pseudogout/hemochromatosis;
Arthritic sweling of DIP

28. How often disease activity is monitored in AS?
Xray every 3m
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
SLE - only minutes; RA; hours;
Pt with significant organ involvement and have incomplete response to prednisone alone

29. anterior shoulder pain
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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

30. patient pw groin pain; on steroid
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Supplementation ca and vitamin D
Order LFT - heat fractionation (bone burns and liver lives) - GGT

31. cylosporin used after renal transplantation
Decrease urate secretion from kidney
Supplementation ca and vitamin D
Hyperflexion of both wrists--characteristic pain in one min
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

32. allpurinol
PPD
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

33. heberdeen nodes
Arthritic sweling of DIP
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Prednisone and cyclophosphamide

34. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Patello femoral pain syndrome
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
C for c ; crest syndrome

35. criteria for AS
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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
PMR and giant cell arteritis; can be seen both together;

36. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
C for c ; crest syndrome
AS; sometime only symptom is uveitis;
Minocyclin - inhibits metalloproteases and slows joint damage
High incidence of opportunistitc infection; reactivation of TB;

37. morning stiffness hand joints
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
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
SLE - only minutes; RA; hours;

38. Tx of gout
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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;
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. How to perform schober test
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
Measure ESR; polymyalgia rheumatica; tx prednisone
Hyperflexion of both wrists--characteristic pain in one min
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

40. MCP joint involvement
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Xray every 3m
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Coronary atherosclerosis due to SLE

41. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Nodular lung densitieis with RA;
Minocyclin - inhibits metalloproteases and slows joint damage

42. What marker is used to follow up disease activity in SLE
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Prednisone and cyclophosphamide

43. schirmer test
Supplementation ca and vitamin D
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.
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
Pseudogout/hemochromatosis;

44. Tx of reiter
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Increased serum ferritin (acute phase protein)
Specific of dx of SLE
Abx -bedrest - exercise

45. anti-mitochondrial
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina 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
C for c ; crest syndrome
Primary biliary cirrhosis

46. primary muscle disease
Primary biliary cirrhosis
Symmetrical proximal weakness; increased CPK
Disseminated gonoccal infection
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

47. postoeriod shoulder pain
Abx -bedrest - exercise
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
AS; sometime only symptom is uveitis;

48. neck mass in sjogren patient
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

49. How to differential lumbar spinal stenosis and disc herniation pain?
Malignancy - infection - vertebral fracture
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

50. bouchard nodule
Minocyclin - inhibits metalloproteases and slows joint damage
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Specific of dx of SLE