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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. SLE patient p/w MI - vent fibrillation
C for c ; crest syndrome
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Coronary atherosclerosis due to SLE
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

2. How often disease activity is monitored in AS?
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Xray every 3m
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

3. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Specific of dx of SLE
C for c ; crest syndrome
Patello femoral pain syndrome

4. Tx of gout
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
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

5. 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.
Viral arthritis or RA
Dorsum of hands and the Achilies tendon
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

6. complications of anti-cytokine therapy
Pt with significant organ involvement and have incomplete response to prednisone alone
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
High incidence of opportunistitc infection; reactivation of TB;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

7. When to stop statin if cpk elevated
Xray every 3m
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Hyperflexion of both wrists--characteristic pain in one min
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

8. pagets in xray
Measure ESR; polymyalgia rheumatica; tx prednisone
Hypertriglyceridamia and hypercholesterolemia
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Measure ca and ALP; increased ALP and normal ca for dx;

9. heberdeen nodes
Coronary atherosclerosis due to SLE
Minocyclin - inhibits metalloproteases and slows joint damage
Arthritic sweling of DIP
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

10. postoeriod shoulder pain
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
PPD
Prednisone and cyclophosphamide

11. right anterior knee pain and provoked by climbing stairs or prolong sitting
Xray every 3m
Patello femoral pain syndrome
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

12. increased ALP; liver or bone origin?
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Pt with significant organ involvement and have incomplete response to prednisone alone

13. What marker is used to follow up disease activity in SLE
Decrease urate secretion from kidney
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
Abx -bedrest - exercise
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

14. pain in shoulder and pelvic girdle
High incidence of opportunistitc infection; reactivation of TB;
Measure ESR; polymyalgia rheumatica; tx prednisone
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

15. SLE with pleural effusion
C for c ; crest syndrome
Increased serum ferritin (acute phase protein)
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

16. bouchard nodule
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
Disseminated gonoccal infection
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

17. What should be chekcked before starting infliximab
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
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.
Disseminated gonoccal infection
PPD

18. anti-ds DNA antibody
Specific of dx of SLE
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

19. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

20. primary muscle disease
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
If symptoms persist >6weeks

21. conjunctivitis - urethritis - and spondyloarthopathy

22. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Erythematous-violaceous rash on the eyelids
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

23. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
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
A for aortic regurg; s for prolapSe (MVP)
AS; sometime only symptom is uveitis;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

24. common valvular abnormalities with AS?
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
A for aortic regurg; s for prolapSe (MVP)
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

25. Tx of inflammatory myositis
Xray every 3m
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
Deposition of cholesterol in the periorbital skin

26. colchicine
SLE - only minutes; RA; hours;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

27. anti-centromere ab
Hyperflexion of both wrists--characteristic pain in one min
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
C for c ; crest syndrome
Hypertriglyceridamia and hypercholesterolemia

28. neck mass in sjogren patient
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Coronary atherosclerosis due to SLE
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

29. Tx of RA
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

30. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
C for c ; crest syndrome
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
SLE - only minutes; RA; hours;
Pseudogout/hemochromatosis;

31. when SLE patient needs steroid
If person is HLA B27 positive
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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

32. mcp and PIP joint involvement
Viral arthritis or 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.
SLE - only minutes; RA; hours;
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

33. Use of allopurinol after kidney transplant
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Measure ESR; polymyalgia rheumatica; tx prednisone

34. inflammatory myositis
Increased serum ferritin (acute phase protein)
A for aortic regurg; s for prolapSe (MVP)
If person is HLA B27 positive
Specific of dx of SLE

35. 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
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
Arthritic sweling of DIP
Hypertriglyceridamia and hypercholesterolemia

36. Tx of lupus nephritis
Minocyclin - inhibits metalloproteases and slows joint damage
Prednisone and cyclophosphamide
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

37. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Deposition of cholesterol in the periorbital skin
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

38. xanthomatous nodule
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Dorsum of hands and the Achilies tendon
If person is HLA B27 positive

39. schirmer test
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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.
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
PPD

40. cylosporin used after renal transplantation
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Decrease urate secretion from kidney

41. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
PPD

42. Ca oxalate induced arthritis
Check pedal pulses; in claudication pulses should diminish
PMR and giant cell arteritis; can be seen both together;
ESRD
Hypertriglyceridamia and hypercholesterolemia

43. tx pagets
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Supplementation ca and vitamin D
Nodular lung densitieis with RA;

44. carpal tunnel
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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

45. tinel sign
High incidence of opportunistitc infection; reactivation of TB;
Nodular lung densitieis with RA;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

46. When to give methotrexate in SLE
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Pt with significant organ involvement and have incomplete response to prednisone alone
Nodular lung densitieis with RA;
Prophylactic agent to prevent recurrent attack; not given during acute attack

47. Raynauds phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
If person is HLA B27 positive
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

48. How to monitor disease activity in 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.
Malignancy - infection - vertebral fracture
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Osteoarthirit (bouchard at pip - b comes first);

49. When to order MRI in LBP
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
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

50. Tx of gout in patient with ESRD or hx GI bleeding
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
PPD
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`