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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. schirmer test
If person is HLA B27 positive
Minocyclin - inhibits metalloproteases and slows joint damage
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.
Arthritic sweling of DIP

2. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Symmetrical proximal weakness; increased CPK
Patello femoral pain syndrome
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

3. postoeriod shoulder pain
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

4. morning stiffness hand joints
SLE - only minutes; RA; hours;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

5. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

6. colchicine
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Primary biliary cirrhosis

7. caplan syndrom
Dorsum of hands and the Achilies tendon
Symmetrical proximal weakness; increased CPK
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Nodular lung densitieis with RA;

8. SLE with pleural effusion
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

9. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
A for aortic regurg; s for prolapSe (MVP)
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
AS; sometime only symptom is uveitis;

10. Tx of RA
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 methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Dorsum of hands and the Achilies tendon
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

11. Finding of MRI in stenosis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
AS; sometime only symptom is uveitis;
Hyperflexion of both wrists--characteristic pain in one min
Supplementation ca and vitamin D

12. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Increased serum ferritin (acute phase protein)
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

13. gemfibrozil
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Hyperflexion of both wrists--characteristic pain in one min
Hyper triglyceridemia

14. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Disseminated gonoccal infection
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Patello femoral pain syndrome

15. MCP joint involvement
Patello femoral pain syndrome
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
PPD

16. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Osteoarthirit (bouchard at pip - b comes first);
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
Prednisone and cyclophosphamide

17. inflammatory myositis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Disseminated gonoccal infection
Erythematous-violaceous rash on the eyelids
Increased serum ferritin (acute phase protein)

18. pagets in xray
Osteoarthirit (bouchard at pip - b comes first);
Pseudogout/hemochromatosis;
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;

19. pain in shoulder and pelvic girdle
Osteoarthirit (bouchard at pip - b comes first);
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Erythematous-violaceous rash on the eyelids
Measure ESR; polymyalgia rheumatica; tx prednisone

20. nicotinic acid
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Hypertriglyceridamia and hypercholesterolemia
Prednisone and cyclophosphamide

21. anti-ds DNA antibody
Hyper triglyceridemia
Specific of dx of SLE
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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.

22. How to monitor disease activity in SLE
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
High incidence of opportunistitc infection; reactivation of TB;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
AS; sometime only symptom is uveitis;

23. cylosporin used after renal transplantation
C for c ; crest syndrome
Arthritic sweling of DIP
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Decrease urate secretion from kidney

24. anterior shoulder pain
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
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

25. when SLE patient needs steroid
Primary biliary cirrhosis
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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

26. How to perform schober test
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Pseudogout/hemochromatosis;
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

27. primary muscle disease
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Symmetrical proximal weakness; increased CPK

28. What should be chekcked before starting infliximab
Xray every 3m
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Dorsum of hands and the Achilies tendon
PPD

29. role HLA B27 in dx of ankylosing spondylitis
Disseminated gonoccal infection
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Pt with significant organ involvement and have incomplete response to prednisone alone
Symmetrical proximal weakness; increased CPK

30. Tx of inflammatory myositis
Prednisone and cyclophosphamide
C for c ; crest syndrome
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

31. Tx of reiter
Hyper triglyceridemia
Arthritic sweling of DIP
Abx -bedrest - exercise
Think about reiter (cannot see - cannot pee - cannot climb a tree)

32. conjunctivitis - urethritis - and spondyloarthopathy

33. Rayanaud's disease vs phenomenon
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Disseminated gonoccal infection

34. carpal tunnel syndrom
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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

35. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Disseminated gonoccal infection
PPD
Erythematous-violaceous rash on the eyelids

36. night back pain
Coronary atherosclerosis due to SLE
Malignancy - infection - vertebral fracture
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Minocyclin - inhibits metalloproteases and slows joint damage

37. patient is having pain when he moves hands above shoulder
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Arthritic sweling of DIP
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

38. DIP joint involvement

39. When to order MRI in LBP
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Pseudogout/hemochromatosis;
If symptoms persist >6weeks
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

40. Gait in spinal stenosis
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Dorsum of hands and the Achilies tendon
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

41. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Pseudogout/hemochromatosis;
Minocyclin - inhibits metalloproteases and slows joint damage
PMR and giant cell arteritis; can be seen both together;

42. inflamed tendons in wrist - ankle - arms; sexual history
Increased serum ferritin (acute phase protein)
Disseminated gonoccal infection
Arthritic sweling of DIP
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

43. xanthomatous nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Minocyclin - inhibits metalloproteases and slows joint damage
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Dorsum of hands and the Achilies tendon

44. What is heliotrope sign
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Erythematous-violaceous rash on the eyelids
Coronary atherosclerosis due to SLE

45. anti-centromere ab
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
C for c ; crest syndrome
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Prophylactic agent to prevent recurrent attack; not given during acute attack

46. How to differentiate radicular pain with claudication
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Check pedal pulses; in claudication pulses should diminish
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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

47. mcp and PIP joint involvement
Viral arthritis or RA
Nodular lung densitieis with RA;
If person is HLA B27 positive
Hypertriglyceridamia and hypercholesterolemia

48. Management of HTN during acute gout
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

49. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
Supplementation ca and vitamin D
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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

50. anti-mitochondrial
Primary biliary cirrhosis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA