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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. gemfibrozil
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
PPD
Hyper triglyceridemia
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

2. spondyloarthopathy
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Measure ca and ALP; increased ALP and normal ca for dx;
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
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;
Increased serum ferritin (acute phase protein)
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

4. anti-mitochondrial
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Viral arthritis or RA
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Primary biliary cirrhosis

5. conjunctivitis - urethritis - and spondyloarthopathy

6. primary muscle disease
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Symmetrical proximal weakness; increased CPK
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
Malignancy - infection - vertebral fracture

7. How to prevent glucocorticoid induced bone loss
Minocyclin - inhibits metalloproteases and slows joint damage
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Supplementation ca and vitamin D
Check pedal pulses; in claudication pulses should diminish

8. bouchard nodule
AS; sometime only symptom is uveitis;
Decrease urate secretion from kidney
High incidence of opportunistitc infection; reactivation of TB;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

9. pain in shoulder and pelvic girdle
Check pedal pulses; in claudication pulses should diminish
Hyper triglyceridemia
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Measure ESR; polymyalgia rheumatica; tx prednisone

10. When to give methotrexate in SLE
Check pedal pulses; in claudication pulses should diminish
Pt with significant organ involvement and have incomplete response to prednisone alone
Specific of dx of SLE
A for aortic regurg; s for prolapSe (MVP)

11. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

12. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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
Check pedal pulses; in claudication pulses should diminish

13. Low back pain
Arthritic sweling of DIP
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Prednisone and cyclophosphamide
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

14. SLE patient p/w MI - vent fibrillation
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

15. MCP joint involvement
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Hyper triglyceridemia
Hypertriglyceridamia and hypercholesterolemia

16. caplan syndrom
Xray every 3m
Nodular lung densitieis with RA;
Patello femoral pain syndrome
SLE - only minutes; RA; hours;

17. What marker is used to follow up disease activity in SLE
Measure ESR; polymyalgia rheumatica; tx prednisone
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Check pedal pulses; in claudication pulses should diminish
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. What is heliotrope sign
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
Erythematous-violaceous rash on the eyelids
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Order LFT - heat fractionation (bone burns and liver lives) - GGT

19. criteria for AS
Arthritic sweling of DIP
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Pt with significant organ involvement and have incomplete response to prednisone alone
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

20. management of LBP
Pt with significant organ involvement and have incomplete response to prednisone alone
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Xray every 3m
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

21. carpal tunnel
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Nodular lung densitieis with RA;
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

22. role HLA B27 in dx of ankylosing spondylitis
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Osteoarthirit (bouchard at pip - b comes first);
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

23. How often disease activity is monitored in AS?
Hyperflexion of both wrists--characteristic pain in one min
Prednisone and cyclophosphamide
Xray every 3m
Decrease urate secretion from kidney

24. 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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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

25. Ca oxalate induced arthritis
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
ESRD

26. 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
Deposition of cholesterol in the periorbital skin
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Supplementation ca and vitamin D

27. inflamed tendons in wrist - ankle - arms; sexual history
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Disseminated gonoccal infection
Xray every 3m
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

28. common valvular abnormalities with AS?
Prophylactic agent to prevent recurrent attack; not given during acute attack
Malignancy - infection - vertebral fracture
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;

29. Finding of MRI in stenosis
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Decrease urate secretion from kidney
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

30. tinel sign
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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. Management of HTN during acute gout
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Measure ESR; polymyalgia rheumatica; tx prednisone
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.

32. nicotinic acid
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Hypertriglyceridamia and hypercholesterolemia
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

33. PIP joint involment
Disseminated gonoccal 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
Osteoarthirit (bouchard at pip - b comes first);
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

34. patient pw groin pain; on steroid
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Hyper triglyceridemia
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

35. patient is having pain when he moves hands above shoulder
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.
A for aortic regurg; s for prolapSe (MVP)
Measure ESR; polymyalgia rheumatica; tx prednisone

36. What should be chekcked before starting infliximab
PPD
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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
Hyper triglyceridemia

37. Use of antibiotic in RA
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
If symptoms persist >6weeks
Minocyclin - inhibits metalloproteases and slows joint damage

38. pagets in xray
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Pseudogout/hemochromatosis;
Measure ca and ALP; increased ALP and normal ca for dx;
Coronary atherosclerosis due to SLE

39. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
AS; sometime only symptom is uveitis;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

40. Tx of gout
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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
Symmetrical proximal weakness; increased CPK

41. neck mass in sjogren patient
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
ESRD
Osteoarthirit (bouchard at pip - b comes first);

42. anti-centromere ab
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
C for c ; crest syndrome
Disseminated gonoccal infection
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

43. allpurinol
If person is HLA B27 positive
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Patello femoral pain syndrome
Prophylactic agent to prevent recurrent attack; not given during acute attack

44. Tx of gout in patient with ESRD or hx GI bleeding
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Pseudogout/hemochromatosis;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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

45. How to differentiate radicular pain with claudication
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Supplementation ca and vitamin D

46. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Prophylactic agent to prevent recurrent attack; not given during acute attack
A for aortic regurg; s for prolapSe (MVP)
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

47. when SLE patient needs steroid
Xray every 3m
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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

48. colchicine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
If symptoms persist >6weeks
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

49. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

50. DIP joint involvement