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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. bouchard nodule
Pt with significant organ involvement and have incomplete response to prednisone alone
Minocyclin - inhibits metalloproteases and slows joint damage
If symptoms persist >6weeks
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

2. right anterior knee pain and provoked by climbing stairs or prolong sitting
If symptoms persist >6weeks
Patello femoral pain syndrome
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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

3. caplan syndrom
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
Nodular lung densitieis with RA;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Minocyclin - inhibits metalloproteases and slows joint damage

4. nicotinic acid
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
Hypertriglyceridamia and hypercholesterolemia
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

5. anti-mitochondrial
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Primary biliary cirrhosis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Check pedal pulses; in claudication pulses should diminish

6. postoeriod shoulder pain
Specific of dx of SLE
Measure ca and ALP; increased ALP and normal ca for dx;
Pseudogout/hemochromatosis;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

7. How to perform schober test
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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.
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

8. Ca oxalate induced arthritis
Disseminated gonoccal infection
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
ESRD
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

9. xanthomatous nodule
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Dorsum of hands and the Achilies tendon
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

10. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Coronary atherosclerosis due to SLE
AS; sometime only symptom is uveitis;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
PMR and giant cell arteritis; can be seen both together;

11. conjunctivitis - urethritis - and spondyloarthopathy

12. primary muscle disease
Prophylactic agent to prevent recurrent attack; not given during acute attack
Symmetrical proximal weakness; increased CPK
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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

13. role HLA B27 in dx of ankylosing spondylitis
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Osteoarthirit (bouchard at pip - b comes first);
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

14. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Prophylactic agent to prevent recurrent attack; not given during acute attack
PPD
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

15. criteria for AS
Pseudogout/hemochromatosis;
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

16. carpal tunnel syndrom
Minocyclin - inhibits metalloproteases and slows joint damage
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

17. patient pw groin pain; on steroid
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Hypertriglyceridamia and hypercholesterolemia
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

18. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Dorsum of hands and the Achilies tendon
Hypertriglyceridamia and hypercholesterolemia
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

19. 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.
Arthritic sweling of DIP
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
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

20. Low back pain
Hypertriglyceridamia and hypercholesterolemia
Patello femoral pain syndrome
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
If person is HLA B27 positive

21. SLE patient p/w MI - vent fibrillation
AS; sometime only symptom is uveitis;
Supplementation ca and vitamin D
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Coronary atherosclerosis due to SLE

22. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
A for aortic regurg; s for prolapSe (MVP)
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
Erythematous-violaceous rash on the eyelids
PMR and giant cell arteritis; can be seen both together;

23. Tx of inflammatory myositis
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Primary biliary cirrhosis
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

24. Rayanaud's disease vs phenomenon
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Increased serum ferritin (acute phase protein)
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

25. night back pain
Malignancy - infection - vertebral fracture
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
Hypertriglyceridamia and hypercholesterolemia
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

26. schirmer test
Arthritic sweling of DIP
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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.
Pt with significant organ involvement and have incomplete response to prednisone alone

27. proximal muscle weakness; decreased tendon reflex; normal creat and ck
ESRD
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

28. anti-centromere ab
Coronary atherosclerosis due to SLE
C for c ; crest syndrome
Prednisone and cyclophosphamide
Order LFT - heat fractionation (bone burns and liver lives) - GGT

29. How often disease activity is monitored in AS?
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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
Xray every 3m
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

30. anti-ds DNA antibody
Abx -bedrest - exercise
Specific of dx of SLE
If symptoms persist >6weeks
Hyperflexion of both wrists--characteristic pain in one min

31. What is heliotrope sign
Erythematous-violaceous rash on the eyelids
Deposition of cholesterol in the periorbital skin
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
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

32. How to prevent glucocorticoid induced bone loss
Erythematous-violaceous rash on the eyelids
Osteoarthirit (bouchard at pip - b comes first);
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Supplementation ca and vitamin D

33. How to differentiate radicular pain with claudication
Check pedal pulses; in claudication pulses should diminish
Deposition of cholesterol in the periorbital skin
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Arthritic sweling of DIP

34. When to start DMARD in RA
Disseminated gonoccal infection
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
C for c ; crest syndrome
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

35. MCP joint involvement
Xray every 3m
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Prophylactic agent to prevent recurrent attack; not given during acute attack
Primary biliary cirrhosis

36. Tx of gout in patient with ESRD or hx GI bleeding
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
C for c ; crest syndrome

37. gemfibrozil
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Dorsum of hands and the Achilies tendon
Hyper triglyceridemia
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

38. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Coronary atherosclerosis due to SLE
Pseudogout/hemochromatosis;
Minocyclin - inhibits metalloproteases and slows joint damage

39. PIP joint involment
C for c ; crest syndrome
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
Osteoarthirit (bouchard at pip - b comes first);

40. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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

41. Tx of reiter
Prednisone and cyclophosphamide
Abx -bedrest - exercise
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

42. What marker is used to follow up disease activity in SLE
Nodular lung densitieis with RA;
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
Patello femoral pain syndrome
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

43. management of LBP
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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

44. tinel sign
Xray every 3m
PPD
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

45. inflammatory myositis
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
Erythematous-violaceous rash on the eyelids
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Increased serum ferritin (acute phase protein)

46. Tx of lupus nephritis
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Decrease urate secretion from kidney
Prednisone and cyclophosphamide
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

47. carpal tunnel
Pt with significant organ involvement and have incomplete response to prednisone alone
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
Check pedal pulses; in claudication pulses should diminish
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

48. Management of HTN during acute gout
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Disseminated gonoccal infection
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

49. patient is having pain when he moves hands above shoulder
Pseudogout/hemochromatosis;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Primary biliary cirrhosis
Hypertriglyceridamia and hypercholesterolemia

50. Raynauds phenomenon
Measure ca and ALP; increased ALP and normal ca for dx;
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine