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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. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)

2. What is heliotrope sign
Erythematous-violaceous rash on the eyelids
Disseminated gonoccal infection
If symptoms persist >6weeks
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

3. who gets reiters syndrome after chlamydia infection
Erythematous-violaceous rash on the eyelids
Primary biliary cirrhosis
If person is HLA B27 positive
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

4. management of LBP
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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

5. inflamed tendons in wrist - ankle - arms; sexual history
Arthritic sweling of DIP
Hyperflexion of both wrists--characteristic pain in one min
Specific of dx of SLE
Disseminated gonoccal infection

6. increased ALP; liver or bone origin?
High incidence of opportunistitc infection; reactivation of TB;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Nodular lung densitieis with RA;

7. anterior shoulder pain
Patello femoral pain syndrome
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Minocyclin - inhibits metalloproteases and slows joint damage

8. Management of HTN during acute gout
Check pedal pulses; in claudication pulses should diminish
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
PPD

9. Use of allopurinol after kidney transplant
Increased serum ferritin (acute phase protein)
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Disseminated gonoccal infection
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

10. xanthomatous nodule
Deposition of cholesterol in the periorbital skin
Coronary atherosclerosis due to SLE
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Dorsum of hands and the Achilies tendon

11. Ca oxalate induced arthritis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
ESRD
If symptoms persist >6weeks
Think about reiter (cannot see - cannot pee - cannot climb a tree)

12. Tx of gout
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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
Decrease urate secretion from kidney
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

13. tinel sign
AS; sometime only symptom is uveitis;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

14. Tx of gout in patient with ESRD or hx GI bleeding
Check pedal pulses; in claudication pulses should diminish
Deposition of cholesterol in the periorbital skin
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
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

15. Tx of reiter
Supplementation ca and vitamin D
Abx -bedrest - exercise
Symmetrical proximal weakness; increased CPK
Order LFT - heat fractionation (bone burns and liver lives) - GGT

16. carpal tunnel syndrom
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Symmetrical proximal weakness; increased CPK

17. Low back 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
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
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

18. What marker is used to follow up disease activity in SLE
SLE - only minutes; RA; hours;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

19. glucocorticoid therapy
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Osteoarthirit (bouchard at pip - b comes first);
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

20. Gait in spinal stenosis
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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
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

21. SLE with pleural effusion
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
Increased serum ferritin (acute phase protein)
SLE - only minutes; RA; hours;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

22. How often disease activity is monitored in AS?
Hyperflexion of both wrists--characteristic pain in one min
Arthritic sweling of DIP
Hyper triglyceridemia
Xray every 3m

23. when SLE patient needs steroid
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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
PMR and giant cell arteritis; can be seen both together;

24. tx pagets
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
Malignancy - infection - vertebral fracture
ESRD
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

26. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

27. conjunctivitis - urethritis - and spondyloarthopathy

28. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Patello femoral pain syndrome
Supplementation ca and vitamin D
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

29. nicotinic acid
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Hypertriglyceridamia and hypercholesterolemia
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

30. anti-centromere ab
Minocyclin - inhibits metalloproteases and slows joint damage
C for c ; crest syndrome
Specific of dx of SLE
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

31. morning stiffness hand joints
Disseminated gonoccal infection
SLE - only minutes; RA; hours;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
If person is HLA B27 positive

32. anti-mitochondrial
Primary biliary cirrhosis
C for c ; crest syndrome
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Arthritic sweling of DIP

33. What should be chekcked before starting infliximab
A for aortic regurg; s for prolapSe (MVP)
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Prophylactic agent to prevent recurrent attack; not given during acute attack
PPD

34. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
PMR and giant cell arteritis; can be seen both together;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

35. pain in shoulder and pelvic girdle
Abx -bedrest - exercise
Arthritic sweling of DIP
Decrease urate secretion from kidney
Measure ESR; polymyalgia rheumatica; tx prednisone

36. criteria for AS
If symptoms persist >6weeks
Hypertriglyceridamia and hypercholesterolemia
Erythematous-violaceous rash on the eyelids
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

37. right anterior knee pain and provoked by climbing stairs or prolong sitting
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Primary biliary cirrhosis
Patello femoral pain syndrome
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

38. How to prevent glucocorticoid induced bone loss
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
Supplementation ca and vitamin D
Symmetrical proximal weakness; increased CPK

39. cylosporin used after renal transplantation
Decrease urate secretion from kidney
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
AS; sometime only symptom is uveitis;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

40. MCP joint involvement
Pt with significant organ involvement and have incomplete response to prednisone alone
Hyper triglyceridemia
Measure ca and ALP; increased ALP and normal ca for dx;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

41. colchicine
PMR and giant cell arteritis; can be seen both together;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

42. primary muscle disease
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Symmetrical proximal weakness; increased CPK
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

43. patient pw groin pain; on steroid
If person is HLA B27 positive
PMR and giant cell arteritis; can be seen both together;
AS; sometime only symptom is uveitis;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

44. schirmer test
Minocyclin - inhibits metalloproteases and slows joint damage
Coronary atherosclerosis due to 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.
A for aortic regurg; s for prolapSe (MVP)

45. painless ulcer over glans penis and inflammatory arthritis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Coronary atherosclerosis due to SLE
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

46. probenecid
Malignancy - infection - vertebral fracture
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
PMR and giant cell arteritis; can be seen both together;

47. 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
Deposition of cholesterol in the periorbital skin
Minocyclin - inhibits metalloproteases and slows joint damage
Increased serum ferritin (acute phase protein)

48. PIP joint involment
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
If symptoms persist >6weeks
ESRD
Osteoarthirit (bouchard at pip - b comes first);

49. Tx of inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
AS; sometime only symptom is uveitis;
Hypertriglyceridamia and hypercholesterolemia

50. xanthelasma
Deposition of cholesterol in the periorbital skin
Hyper triglyceridemia
Malignancy - infection - vertebral fracture
Dermatomyositis - in adult 2ndary to malignancy eg lung ca