Rheumatology Prometric exam questions with answers

1. Question 1Connective Tissue Diseasesmedium

   A man taking hydralazine for 2 years develops arthralgia, pleuritic pain and a positive ANA with anti-histone antibodies; anti-dsDNA is negative and kidneys are normal. What is the best management?

   1. AStart mycophenolate
   2. BStart high-dose glucocorticoids
   3. CStop hydralazine and observe
   4. DStart cyclophosphamide
   Show answer and explanation▾

   Answer: C. Stop hydralazine and observe

   Drug-induced lupus usually resolves within weeks to months of stopping the drug; short NSAIDs or low-dose steroids may help symptoms. Intensive immunosuppression is not needed without major organ involvement.

2. Question 2Connective Tissue Diseaseshard

   A woman with early diffuse systemic sclerosis and anti-RNA polymerase III antibodies develops BP 200/115 mmHg, rising creatinine and microangiopathic hemolysis. What is the treatment of choice?

   1. AHigh-dose intravenous methylprednisolone
   2. BPlasma exchange as first line
   3. CA beta blocker titrated rapidly
   4. DAn ACE inhibitor titrated rapidly
   Show answer and explanation▾

   Answer: D. An ACE inhibitor titrated rapidly

   ACE inhibitors such as captopril dramatically improved survival in scleroderma renal crisis and are continued even if dialysis is needed. High-dose glucocorticoids are a risk factor for renal crisis and should be avoided.

3. Question 3Crystal Arthropathiesmedium

   A man with recurrent gout without tophi starts allopurinol. What is the recommended serum urate target?

   1. ABelow 360 µmol/L
   2. BBelow 480 µmol/L
   3. CBelow 420 µmol/L
   4. DBelow 200 µmol/L
   Show answer and explanation▾

   Answer: A. Below 360 µmol/L

   A treat-to-target urate of below 360 µmol/L (6 mg/dL) dissolves crystals; below 300 µmol/L is recommended for severe or tophaceous gout. Levels around 420 µmol/L are near saturation and do not dissolve crystals.

4. Question 4Drug Safety, Monitoring and Professional Practicemedium

   A patient on weekly methotrexate is given trimethoprim-sulfamethoxazole for a urinary infection and develops mouth ulcers and pancytopenia. What is the mechanism?

   1. AInduction of hepatic metabolism
   2. BReduced oral absorption of the methotrexate dose
   3. CAdditive antifolate effect and reduced clearance
   4. DImmune-mediated platelet destruction
   Show answer and explanation▾

   Answer: C. Additive antifolate effect and reduced clearance

   Trimethoprim is an antifolate and both drugs compete for renal excretion, causing severe marrow toxicity. The interaction raises, not lowers, methotrexate exposure.

5. Question 5Spondyloarthritiseasy

   Which feature most suggests inflammatory rather than mechanical back pain?

   1. AOnset after age 50 years
   2. BImprovement with exercise, not rest
   3. CPain worse at the end of the day
   4. DShort morning stiffness under 10 minutes
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   Answer: B. Improvement with exercise, not rest

   Inflammatory back pain begins before 40, has insidious onset, improves with exercise but not rest, and causes night pain and prolonged morning stiffness. Pain worse at the end of the day is typical of mechanical pain.

6. Question 6Osteoarthritis, Bone and Soft Tissuemedium

   A 40-year-old has widespread pain for 1 year, fatigue, unrefreshing sleep and normal examination and blood tests. What is the first-line management?

   1. AEducation and graded aerobic exercise
   2. BLong-term opioid analgesia at low dose
   3. COral glucocorticoids
   4. DMethotrexate
   Show answer and explanation▾

   Answer: A. Education and graded aerobic exercise

   Education and graded exercise have the strongest evidence in fibromyalgia, with medications such as amitriptyline or duloxetine as adjuncts. Opioids and glucocorticoids are ineffective and harmful.

7. Question 7Rheumatoid and Psoriatic Arthritishard

   Before starting adalimumab, a patient has a positive interferon-gamma release assay, a normal chest radiograph and no symptoms. What is the best approach?

   1. AStart adalimumab and repeat the IGRA in 1 year
   2. BTreat latent TB before starting the TNF inhibitor
   3. CAvoid all biologic therapy permanently
   4. DStart full four-drug TB treatment first
   Show answer and explanation▾

   Answer: B. Treat latent TB before starting the TNF inhibitor

   Latent TB should be treated before TNF inhibition, which greatly increases reactivation; the biologic usually starts after about a month of preventive therapy. Four-drug therapy is for active TB, which has been excluded.

8. Question 8Vasculitiseasy

   A 28-year-old man has recurrent oral ulcers, genital ulcers, anterior uveitis and a positive pathergy test. What is the most likely diagnosis?

   1. AReactive arthritis
   2. BBehcet disease
   3. CHerpes simplex infection
   4. DCrohn disease
   Show answer and explanation▾

   Answer: B. Behcet disease

   Recurrent oral and genital ulcers with eye disease and pathergy fit the International Criteria for Behcet disease. Herpes ulcers do not cause uveitis with pathergy.

9. Question 9Rheumatoid and Psoriatic Arthritismedium

   A 45-year-old has 6 weeks of swelling in 4 MCP joints and 2 PIP joints, high-positive anti-CCP and raised CRP. What is her ACR/EULAR 2010 score, and does she meet criteria?

   1. A8 of 10; meets criteria
   2. B6 of 10; meets criteria
   3. C5 of 10; does not meet criteria
   4. D9 of 10; meets criteria
   Show answer and explanation▾

   Answer: A. 8 of 10; meets criteria

   Six small joints (4-10 small joints) score 3, high-positive anti-CCP scores 3, raised CRP scores 1 and symptoms of 6 weeks or more score 1, giving 8. A score of 6 or more classifies definite RA; counting symptom duration as 0 gives the tempting but wrong 7 or less.

10. Question 10Rheumatoid and Psoriatic Arthritismedium

    A patient with 20 years of erosive RA is listed for elective hip replacement and reports neck pain with occipital headaches. What is the most important pre-operative investigation?

    1. AHip MRI with intravenous gadolinium contrast
    2. BFull pulmonary function testing
    3. CDual-energy bone densitometry
    4. DCervical spine flexion-extension imaging
    Show answer and explanation▾

    Answer: D. Cervical spine flexion-extension imaging

    Atlantoaxial instability is common in long-standing RA and can cause cord injury during intubation; flexion-extension films or MRI identify it. Pulmonary function testing is useful for ILD but does not address the intubation risk.

11. Question 11Spondyloarthritismedium

    A patient with active axial spondyloarthritis has persistent high disease activity despite two NSAIDs at full dose for 4 weeks in total. What is the next recommended step?

    1. AStart a TNF or IL-17 inhibitor
    2. BStart methotrexate
    3. CStart sulfasalazine for axial disease
    4. DStart long-term oral prednisolone
    Show answer and explanation▾

    Answer: A. Start a TNF or IL-17 inhibitor

    After failure of two NSAIDs, bDMARDs (TNF or IL-17 inhibitors) or JAK inhibitors are recommended. Conventional DMARDs such as methotrexate and sulfasalazine are not effective for axial disease.

12. Question 12Spondyloarthritismedium

    Three weeks after urethritis, a 25-year-old man develops asymmetric knee and ankle arthritis, conjunctivitis and scaly lesions on the soles. What is the most likely diagnosis?

    1. AReactive arthritis
    2. BDisseminated gonococcal infection
    3. CPsoriatic arthritis
    4. DBehcet disease
    Show answer and explanation▾

    Answer: A. Reactive arthritis

    Asymmetric oligoarthritis after genitourinary infection with conjunctivitis and keratoderma blennorrhagicum is reactive arthritis. Disseminated gonococcal infection presents with tenosynovitis, pustular skin lesions and migratory arthralgia during the infection.

13. Question 13Spondyloarthritismedium

    Which MRI finding indicates active sacroiliitis in suspected axial spondyloarthritis?

    1. AIsolated periarticular fat metaplasia on T1
    2. BJoint space narrowing on T1
    3. CSubchondral sclerosis on T2
    4. DPeriarticular bone marrow edema on STIR
    Show answer and explanation▾

    Answer: D. Periarticular bone marrow edema on STIR

    Active inflammation appears as bone marrow edema (osteitis) on STIR or contrast-enhanced T1 sequences. Fat metaplasia and sclerosis are structural or post-inflammatory changes, not active lesions.

14. Question 14Vasculitismedium

    A 74-year-old has new temporal headache, jaw claudication, scalp tenderness and ESR 90 mm/h. Temporal artery biopsy can be done in 5 days. What is the best immediate step?

    1. AWait for the biopsy before treating
    2. BStart an NSAID and review in 1 week
    3. CStart low-dose prednisolone 10 mg daily
    4. DStart high-dose glucocorticoids now
    Show answer and explanation▾

    Answer: D. Start high-dose glucocorticoids now

    Glucocorticoids should start immediately on suspicion to prevent irreversible visual loss; biopsy remains diagnostic for 1-2 weeks after starting treatment. Low-dose prednisolone is the dose for polymyalgia rheumatica, not GCA.

15. Question 15Vasculitismedium

    A man with adult-onset asthma has eosinophils of 4.5 x 10^9/L, foot drop and palpable purpura. P-ANCA is positive. What is the most likely diagnosis?

    1. AGranulomatosis with polyangiitis (limited)
    2. BMicroscopic polyangiitis with neuropathy
    3. CEosinophilic granulomatosis with polyangiitis
    4. DIdiopathic hypereosinophilic syndrome
    Show answer and explanation▾

    Answer: C. Eosinophilic granulomatosis with polyangiitis

    Asthma, marked eosinophilia, mononeuritis multiplex and MPO-ANCA are characteristic of EGPA. GPA more often has PR3-ANCA with sinus and lung granulomas and no prominent asthma or eosinophilia.

Last reviewed September 2026. Questions are original and written to the published exam blueprint; they are not taken from any real paper.