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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. neck mass in sjogren patient
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Osteoarthirit (bouchard at pip - b comes first);

2. mcp and PIP joint involvement
Viral arthritis or RA
Erythematous-violaceous rash on the eyelids
Pt with significant organ involvement and have incomplete response to prednisone alone
Disseminated gonoccal infection

3. How glucocorticoid leads to bone loss
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Coronary atherosclerosis due to SLE
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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

4. carpal tunnel
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
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Viral arthritis or 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

5. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
Disseminated gonoccal infection
Hyperflexion of both wrists--characteristic pain in one min
Increased serum ferritin (acute phase protein)

6. pain in shoulder and pelvic girdle
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Measure ESR; polymyalgia rheumatica; tx prednisone

7. heberdeen nodes
Coronary atherosclerosis due to SLE
Arthritic sweling of DIP
Pseudogout/hemochromatosis;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

8. Use of antibiotic in RA
Viral arthritis or RA
Minocyclin - inhibits metalloproteases and slows joint damage
Deposition of cholesterol in the periorbital skin
Hyper triglyceridemia

9. caplan syndrom
Nodular lung densitieis with RA;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Increased serum ferritin (acute phase protein)
PMR and giant cell arteritis; can be seen both together;

10. Low back pain
Xray every 3m
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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;

11. What marker is used to follow up disease activity in SLE
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
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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. role HLA B27 in dx of ankylosing spondylitis
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Dorsum of hands and the Achilies tendon
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

13. night back pain
Malignancy - infection - vertebral fracture
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Symmetrical proximal weakness; increased CPK

14. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Disseminated gonoccal infection
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Pt with significant organ involvement and have incomplete response to prednisone alone

15. schirmer test
Disseminated gonoccal infection
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.
Prednisone and cyclophosphamide
Symmetrical proximal weakness; increased CPK

16. pagets in xray
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;
Arthritic sweling of DIP
If symptoms persist >6weeks

17. tx pagets
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Pseudogout/hemochromatosis;

18. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Decrease urate secretion from kidney
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

19. primary muscle disease
ESRD
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

20. Use of allopurinol after kidney transplant
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

21. xanthomatous nodule
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Dorsum of hands and the Achilies tendon
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

22. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Disseminated gonoccal infection
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

23. When to start DMARD in RA
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
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
Hypertriglyceridamia and hypercholesterolemia
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

24. criteria for AS
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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

25. What is heliotrope sign
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
Erythematous-violaceous rash on the eyelids
ESRD
SLE - only minutes; RA; hours;

26. Rayanaud's disease vs phenomenon
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Increased serum ferritin (acute phase protein)

27. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
Measure ESR; polymyalgia rheumatica; tx prednisone
Hyper triglyceridemia
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

28. DIP joint involvement

29. painless ulcer over glans penis and inflammatory arthritis
Coronary atherosclerosis due to SLE
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Nodular lung densitieis with RA;

30. Tx of gout in patient with ESRD or hx GI bleeding
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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

31. Raynauds phenomenon
High incidence of opportunistitc infection; reactivation of TB;
Check pedal pulses; in claudication pulses should diminish
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

32. anti-ds DNA antibody
Hyperflexion of both wrists--characteristic pain in one min
Specific of dx of SLE
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

33. conjunctivitis - urethritis - and spondyloarthopathy

34. Gait in spinal stenosis
Nodular lung densitieis with RA;
Pseudogout/hemochromatosis;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Disseminated gonoccal infection

35. Tx of inflammatory myositis
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Hyper triglyceridemia
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

36. who gets reiters syndrome after chlamydia infection
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
PMR and giant cell arteritis; can be seen both together;
If person is HLA B27 positive

37. glucocorticoid therapy
Nodular lung densitieis with RA;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Arthritic sweling of DIP
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

38. When to stop statin if cpk elevated
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Malignancy - infection - vertebral fracture
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

39. cylosporin used after renal transplantation
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Decrease urate secretion from kidney
Specific of dx of SLE
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

40. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Pseudogout/hemochromatosis;
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.
Minocyclin - inhibits metalloproteases and slows joint damage
PMR and giant cell arteritis; can be seen both together;

41. Tx of lupus nephritis
Prednisone and cyclophosphamide
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Nodular lung densitieis with RA;
Hypertriglyceridamia and hypercholesterolemia

42. Management of HTN during acute gout
Deposition of cholesterol in the periorbital skin
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

43. When to order MRI in LBP
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
If symptoms persist >6weeks
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Symmetrical proximal weakness; increased CPK

44. tinel sign
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
If symptoms persist >6weeks
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

45. How to differentiate radicular pain with claudication
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
Check pedal pulses; in claudication pulses should diminish
ESRD

46. morning stiffness hand joints
Hyper triglyceridemia
C for c ; crest syndrome
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
SLE - only minutes; RA; hours;

47. complications of anti-cytokine therapy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Symmetrical proximal weakness; increased CPK
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
High incidence of opportunistitc infection; reactivation of TB;

48. anti-mitochondrial
Primary biliary cirrhosis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Deposition of cholesterol in the periorbital skin
Increased serum ferritin (acute phase protein)

49. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Viral arthritis or RA
Primary biliary cirrhosis

50. patient pw groin pain; on steroid
Check pedal pulses; in claudication pulses should diminish
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
AS; sometime only symptom is uveitis;