Test your basic knowledge |

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. anti-ds DNA antibody
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Viral arthritis or RA
Specific of dx of SLE

2. xanthelasma
Decrease urate secretion from kidney
Hypertriglyceridamia and hypercholesterolemia
Nodular lung densitieis with RA;
Deposition of cholesterol in the periorbital skin

3. Finding of MRI in stenosis
Arthritic sweling of DIP
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Deposition of cholesterol in the periorbital skin
Dorsum of hands and the Achilies tendon

4. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Deposition of cholesterol in the periorbital skin
AS; sometime only symptom is uveitis;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Viral arthritis or RA

5. PIP joint involment
If symptoms persist >6weeks
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Osteoarthirit (bouchard at pip - b comes first);
Abx -bedrest - exercise

6. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Minocyclin - inhibits metalloproteases and slows joint damage
Erythematous-violaceous rash on the eyelids
Check pedal pulses; in claudication pulses should diminish

7. Raynauds phenomenon
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Arthritic sweling of DIP
Coronary atherosclerosis due to SLE

8. schirmer test
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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.
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
C for c ; crest syndrome

9. Use of antibiotic in RA
Viral arthritis or RA
Minocyclin - inhibits metalloproteases and slows joint damage
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

10. postoeriod shoulder pain
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Check pedal pulses; in claudication pulses should diminish
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

11. Low back pain
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.
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;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

12. Gait in spinal stenosis
Hyperflexion of both wrists--characteristic pain in one min
Pt with significant organ involvement and have incomplete response to prednisone alone
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
High incidence of opportunistitc infection; reactivation of TB;

13. MCP joint involvement
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Hypertriglyceridamia and hypercholesterolemia
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Hyper triglyceridemia

14. Rayanaud's disease vs phenomenon
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Deposition of cholesterol in the periorbital skin
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

15. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Arthritic sweling of DIP
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Deposition of cholesterol in the periorbital skin
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

16. colchicine
Nodular lung densitieis with RA;
Coronary atherosclerosis due to SLE
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

17. common valvular abnormalities with AS?
Coronary atherosclerosis due to 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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
A for aortic regurg; s for prolapSe (MVP)

18. 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
Supplementation ca and vitamin D
If person is HLA B27 positive
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

19. anti-mitochondrial
Symmetrical proximal weakness; increased CPK
Nodular lung densitieis with RA;
Abx -bedrest - exercise
Primary biliary cirrhosis

20. allpurinol
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
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
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

21. Tx of lupus nephritis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Prednisone and cyclophosphamide
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
If person is HLA B27 positive

22. Tx of gout in patient with ESRD or hx GI bleeding
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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
C for c ; crest syndrome
PMR and giant cell arteritis; can be seen both together;

23. caplan syndrom
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
Nodular lung densitieis with RA;
PMR and giant cell arteritis; can be seen both together;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

24. morning stiffness hand joints
Hyperflexion of both wrists--characteristic pain in one min
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
PMR and giant cell arteritis; can be seen both together;
SLE - only minutes; RA; hours;

25. How to perform schober test
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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
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

26. Tx of 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
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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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

27. tinel sign
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Pseudogout/hemochromatosis;
AS; sometime only symptom is uveitis;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

28. patient pw groin pain; on steroid
High incidence of opportunistitc infection; reactivation of TB;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

29. neck mass in sjogren patient
PMR and giant cell arteritis; can be seen both together;
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
If person is HLA B27 positive
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

30. primary muscle disease
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Decrease urate secretion from kidney
Symmetrical proximal weakness; increased CPK

31. pain in shoulder and pelvic girdle
Pseudogout/hemochromatosis;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Measure ESR; polymyalgia rheumatica; tx prednisone
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

32. Tx of reiter
Abx -bedrest - exercise
AS; sometime only symptom is uveitis;
Pt with significant organ involvement and have incomplete response to prednisone alone
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

33. probenecid
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
Symmetrical proximal weakness; increased CPK
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Dorsum of hands and the Achilies tendon

34. How often disease activity is monitored in AS?
Xray every 3m
Supplementation ca and vitamin D
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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

35. conjunctivitis - urethritis - and spondyloarthopathy

36. carpal tunnel syndrom
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

37. Management of HTN during acute gout
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
Viral arthritis or RA
Erythematous-violaceous rash on the eyelids
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

38. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Malignancy - infection - vertebral fracture
Hyperflexion of both wrists--characteristic pain in one min
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Coronary atherosclerosis due to SLE

39. Tx of gout
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
Erythematous-violaceous rash on the eyelids
ESRD

40. When to give methotrexate in SLE
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Pt with significant organ involvement and have incomplete response to prednisone alone
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

41. complications of anti-cytokine therapy
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
High incidence of opportunistitc infection; reactivation of TB;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Deposition of cholesterol in the periorbital skin

42. How glucocorticoid leads to bone loss
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Primary biliary cirrhosis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Prednisone and cyclophosphamide

43. What should be chekcked before starting infliximab
PPD
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
Xray every 3m

44. How to differential lumbar spinal stenosis and disc herniation pain?
Specific of dx of SLE
Deposition of cholesterol in the periorbital skin
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Malignancy - infection - vertebral fracture

45. bouchard nodule
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Prophylactic agent to prevent recurrent attack; not given during acute attack
If symptoms persist >6weeks

46. What marker is used to follow up disease activity in 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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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

47. role HLA B27 in dx of ankylosing spondylitis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

48. cylosporin used after renal transplantation
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Decrease urate secretion from kidney
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

49. SLE with pleural effusion
Measure ESR; polymyalgia rheumatica; tx prednisone
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

50. anterior shoulder pain
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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