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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. carpal tunnel syndrom
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
Coronary atherosclerosis due to SLE
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

2. xanthelasma
Minocyclin - inhibits metalloproteases and slows joint damage
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
Deposition of cholesterol in the periorbital skin
Supplementation ca and vitamin D

3. Rayanaud's disease vs phenomenon
SLE - only minutes; RA; hours;
Check pedal pulses; in claudication pulses should diminish
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Hypertriglyceridamia and hypercholesterolemia

4. What is heliotrope sign
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Erythematous-violaceous rash on the eyelids
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

5. anterior shoulder pain
Deposition of cholesterol in the periorbital skin
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Xray every 3m

6. allpurinol
Erythematous-violaceous rash on the eyelids
Prophylactic agent to prevent recurrent attack; not given during acute attack
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Pseudogout/hemochromatosis;

7. What should be chekcked before starting infliximab
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
Pseudogout/hemochromatosis;
PPD
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

8. carpal tunnel
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
PPD
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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

9. MCP joint involvement
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Arthritic sweling of DIP

10. inflamed tendons in wrist - ankle - arms; sexual history
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Disseminated gonoccal infection
Supplementation ca and vitamin D
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

11. common valvular abnormalities with AS?
C for c ; crest syndrome
A for aortic regurg; s for prolapSe (MVP)
Check pedal pulses; in claudication pulses should diminish
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

12. phalen test
Increased serum ferritin (acute phase protein)
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Hyperflexion of both wrists--characteristic pain in one min
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

13. morning stiffness hand joints
Decrease urate secretion from kidney
Abx -bedrest - exercise
High incidence of opportunistitc infection; reactivation of TB;
SLE - only minutes; RA; hours;

14. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Minocyclin - inhibits metalloproteases and slows joint damage
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Measure ca and ALP; increased ALP and normal ca for dx;

15. SLE with pleural effusion
C for c ; crest syndrome
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Measure ca and ALP; increased ALP and normal ca for dx;

16. inflammatory myositis
Increased serum ferritin (acute phase protein)
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
SLE - only minutes; RA; hours;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

17. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Primary biliary cirrhosis
Measure ca and ALP; increased ALP and normal ca for dx;

18. caplan syndrom
Nodular lung densitieis with RA;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Think about reiter (cannot see - cannot pee - cannot climb a tree)

19. primary muscle disease
Symmetrical proximal weakness; increased CPK
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hypertriglyceridamia and hypercholesterolemia

20. tinel sign
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Order LFT - heat fractionation (bone burns and liver lives) - GGT

21. Tx of reiter
A for aortic regurg; s for prolapSe (MVP)
Abx -bedrest - exercise
Increased serum ferritin (acute phase protein)
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

22. What marker is used to follow up disease activity in SLE
If symptoms persist >6weeks
Dorsum of hands and the Achilies tendon
Arthritic sweling of DIP
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

23. Use of antibiotic in RA
Patello femoral pain syndrome
PPD
Minocyclin - inhibits metalloproteases and slows joint damage
Decrease urate secretion from kidney

24. proximal muscle weakness; decreased tendon reflex; normal creat and ck
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
ESRD
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

25. How to differentiate radicular pain with claudication
Hyper triglyceridemia
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.
Check pedal pulses; in claudication pulses should diminish

26. anti-centromere ab
Erythematous-violaceous rash on the eyelids
C for c ; crest syndrome
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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

27. painless ulcer over glans penis and inflammatory arthritis
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Disseminated gonoccal infection
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Specific of dx of SLE

28. 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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
If symptoms persist >6weeks
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

29. DIP joint involvement

30. neck mass in sjogren patient
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.
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
A for aortic regurg; s for prolapSe (MVP)
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

31. Raynauds phenomenon
Measure ca and ALP; increased ALP and normal ca for dx;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Minocyclin - inhibits metalloproteases and slows joint damage
Measure ESR; polymyalgia rheumatica; tx prednisone

32. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Measure ca and ALP; increased ALP and normal ca for dx;
Nodular lung densitieis with RA;
Pseudogout/hemochromatosis;
C for c ; crest syndrome

33. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
Disseminated gonoccal infection
Decrease urate secretion from kidney
Patello femoral pain syndrome

34. When to order MRI in LBP
Patello femoral pain syndrome
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 symptoms persist >6weeks
Supplementation ca and vitamin D

35. role HLA B27 in dx of ankylosing spondylitis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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.
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

36. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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.
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

37. anti-ds DNA antibody
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.
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Specific of dx of SLE

38. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Erythematous-violaceous rash on the eyelids
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
AS; sometime only symptom is uveitis;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

39. Tx of lupus nephritis
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
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
Prednisone and cyclophosphamide
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

40. probenecid
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Hyper triglyceridemia
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

41. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Hyper triglyceridemia
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Deposition of cholesterol in the periorbital skin

42. postoeriod shoulder pain
A for aortic regurg; s for prolapSe (MVP)
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
AS; sometime only symptom is uveitis;

43. tx pagets
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Abx -bedrest - exercise
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Malignancy - infection - vertebral fracture

44. PIP joint involment
Erythematous-violaceous rash on the eyelids
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Osteoarthirit (bouchard at pip - b comes first);
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

45. Use of allopurinol after kidney transplant
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
If symptoms persist >6weeks
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

46. xanthomatous nodule
Dorsum of hands and the Achilies tendon
C for c ; crest syndrome
A for aortic regurg; s for prolapSe (MVP)
Deposition of cholesterol in the periorbital skin

47. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Check pedal pulses; in claudication pulses should diminish

48. 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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Check pedal pulses; in claudication pulses should diminish

49. patient pw groin pain; on steroid
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
High incidence of opportunistitc infection; reactivation of TB;
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.

50. When to give methotrexate in SLE
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
PMR and giant cell arteritis; can be seen both together;
Pt with significant organ involvement and have incomplete response to prednisone alone
A for aortic regurg; s for prolapSe (MVP)