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. patient pw groin pain; on steroid
Erythematous-violaceous rash on the eyelids
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
If symptoms persist >6weeks
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

2. Low back pain
Patello femoral pain syndrome
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
PPD

3. gemfibrozil
Hyper triglyceridemia
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Prophylactic agent to prevent recurrent attack; not given during acute attack

4. colchicine
PPD
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

5. Raynauds phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Symmetrical proximal weakness; increased CPK
PMR and giant cell arteritis; can be seen both together;
If person is HLA B27 positive

6. phalen test
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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

7. Use of antibiotic in RA
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Measure ca and ALP; increased ALP and normal ca for dx;
Minocyclin - inhibits metalloproteases and slows joint damage

8. xanthomatous nodule
Dorsum of hands and the Achilies tendon
AS; sometime only symptom is uveitis;
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT

9. pain in shoulder and pelvic girdle
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Hyper triglyceridemia
Measure ESR; polymyalgia rheumatica; tx prednisone
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

10. Tx of gout
Specific of dx of SLE
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
Abx -bedrest - exercise
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

11. Ca oxalate induced arthritis
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
ESRD
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

12. How glucocorticoid leads to bone loss
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Pseudogout/hemochromatosis;

13. glucocorticoid therapy
Supplementation ca and vitamin D
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

14. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Increased serum ferritin (acute phase protein)
Erythematous-violaceous rash on the eyelids
PMR and giant cell arteritis; can be seen both together;

15. spondyloarthopathy
SLE - only minutes; RA; hours;
Arthritic sweling of DIP
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Primary biliary cirrhosis

16. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Xray every 3m
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

17. cylosporin used after renal transplantation
Decrease urate secretion from kidney
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Arthritic sweling of DIP

18. night back pain
Malignancy - infection - vertebral fracture
SLE - only minutes; RA; hours;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

19. When to start DMARD in RA
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
High incidence of opportunistitc infection; reactivation of TB;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

20. painless ulcer over glans penis and inflammatory arthritis
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
Increased serum ferritin (acute phase protein)
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

21. anti-mitochondrial
Primary biliary cirrhosis
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
PPD
Think about reiter (cannot see - cannot pee - cannot climb a tree)

22. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
C for c ; crest syndrome
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

23. anti-centromere ab
Osteoarthirit (bouchard at pip - b comes first);
Xray every 3m
Abx -bedrest - exercise
C for c ; crest syndrome

24. allpurinol
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

25. MCP joint involvement
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Increased serum ferritin (acute phase protein)
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

26. 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
If person is HLA B27 positive
Disseminated gonoccal infection

27. What marker is used to follow up disease activity in SLE
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
Patello femoral pain syndrome
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
Disseminated gonoccal infection

28. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw 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.
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
PMR and giant cell arteritis; can be seen both together;
If person is HLA B27 positive

29. caplan syndrom
Specific of dx of SLE
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
Nodular lung densitieis with RA;
Coronary atherosclerosis due to SLE

30. heberdeen nodes
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Prophylactic agent to prevent recurrent attack; not given during acute attack
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Arthritic sweling of DIP

31. How to differential lumbar spinal stenosis and disc herniation pain?
Malignancy - infection - vertebral fracture
Xray every 3m
Coronary atherosclerosis due to SLE
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

32. schirmer test
Hypertriglyceridamia and hypercholesterolemia
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.
Check pedal pulses; in claudication pulses should diminish
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

33. Tx of lupus nephritis
Prednisone and cyclophosphamide
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
C for c ; crest syndrome
Pt with significant organ involvement and have incomplete response to prednisone alone

34. anti-ds DNA antibody
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Measure ESR; polymyalgia rheumatica; tx prednisone
Specific of dx of SLE
ESRD

35. pagets in xray
Viral arthritis or RA
Measure ca and ALP; increased ALP and normal ca for dx;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

36. Tx of reiter
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
SLE - only minutes; RA; hours;
Hypertriglyceridamia and hypercholesterolemia
Abx -bedrest - exercise

37. How to perform schober test
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Primary biliary cirrhosis
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

38. SLE with pleural effusion
Prophylactic agent to prevent recurrent attack; not given during acute attack
Disseminated gonoccal infection
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Malignancy - infection - vertebral fracture

39. Tx of inflammatory myositis
Osteoarthirit (bouchard at pip - b comes first);
AS; sometime only symptom is uveitis;
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.

40. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
If symptoms persist >6weeks
Specific of dx of 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

41. proximal muscle weakness; decreased tendon reflex; normal creat and ck
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
Arthritic sweling of DIP

42. Finding of MRI in stenosis
Decrease urate secretion from kidney
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Pt with significant organ involvement and have incomplete response to prednisone alone

43. patient is having pain when he moves hands above shoulder
Decrease urate secretion from kidney
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Supplementation ca and vitamin D
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

44. mcp and PIP joint involvement
Viral arthritis or RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Xray every 3m
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. When to give methotrexate in SLE
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Increased serum ferritin (acute phase protein)
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Pt with significant organ involvement and have incomplete response to prednisone alone

46. morning stiffness hand joints
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
SLE - only minutes; RA; hours;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Deposition of cholesterol in the periorbital skin

47. How often disease activity is monitored in AS?
Xray every 3m
Nodular lung densitieis with 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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

48. Management of HTN during acute gout
Prednisone and cyclophosphamide
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
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Malignancy - infection - vertebral fracture

49. increased ALP; liver or bone origin?
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
Abx -bedrest - exercise
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

50. DIP joint involvement