Important MCQ’s in Rheumatology For NEET SS Medicine

Q1. A 45-year-old woman with limited scleroderma is admitted to Accident & Emergency in status epilepticus. The previous week she visited her optician with deteriorating vision. Fundoscopy shows cotton wool spots and flame-shaped hemorrhages in both eyes. On examination, her blood pressure was 190/92 mmHg. Urine dipstick revealed protein 3+ and red blood cells 3+. Her fitz is terminated with intramuscular midazolam.

Investigations:

Investigation	Result	Normal range
Haemoglobin	10.6 g/dL	11.5-16.5 g/dL
White blood cells	5.5 x 109/L	4-11 x 109/L
Platelets	155 x 109/L	150-300 x 109/L
Blood film	Polychromasia, helmet cells, reticulocytes
Urea	89.6 mg/dl	15-45 mg/dl
Creatinine	1.92 mg/dl	0.9-1.13 mg/dl

Which of the following is the most appropriate intervention?

1. Intravenous Captopril

2. Intravenous Labetalol

3. Intravenous Methylprednisolone

4. Intravenous Phenytoin

Ans. 1) Intravenous Captopril

Also read: Periarticular Disorders: Soft Tissue Rheumatism & Treatments

Q2. A 27-year-old woman with well-controlled rheumatoid arthritis presents to the clinic. Her disease activity score (DAS28) is 2.2 after starting adalimumab monotherapy six months ago. She completed a 6-month course of isoniazid for TB prophylaxis. She has severe acne, for which she has been taking minocycline for the last year. She now presents with a malar rash and left-sided chest pain, exacerbated by deep inspiration. Investigations reveal:

Investigation	Result	Normal range
C- reactive protein	<10 mg/dl	<10 mg/dl
Erythrocyte Sedimentation rate	75 mm/hr	<30
Complement C3	Low
Complement C4	Low

Which blood test will confirm the diagnosis? 

1. Anti-cardiolipin antibodies

2. Anti-double stranded DNA antibodies

3. Anti-histone antibodies

4. Anti-nuclear antibody 

Ans. 2) Anti-double stranded DNA antibodies 

Q3. Which of the following autoantibodies is associated with the development of renal complications in patients with SLE?

1. Anti-C1q

2. Anti-Histone

3. Anti-hnRNP

4. Anti-La

Ans. 1) Anti-C1q 

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Q4. A 55-year-old man is referred from the acute medical ward with a month-long history of fever, myalgia, arthralgia and abdominal discomfort. Examination reveals no synovitis but diffuse abdominal tenderness and a few scattered subcutaneous nodules. Urine dipstick is positive for blood and protein. Initial investigations are as follows: 

Investigation	Result	Normal range
CRP	95 mg/dl	<5
ESR	72 mm/hr	0-10
WBC	13 x 109/L	4-11 x 109/L
Creatinine	135 umol/L	50-100 umol/L
ANA	Negative

Which of the following is most likely to confirm the diagnosis in this patient? 

1. ANCA

2. Renal and celiac Angiography

3. CT abdomen and pelvis

4. Skin biopsy 

Ans. 2) Renal and celiac Angiography 

Q5. A 24-year-old woman is admitted with sudden onset expressive dysphasia and right-sided hemiplegia. She has suffered from migraine since the age of 16. Clinical examination confirms increased tone in the right arm and leg. Power is graded 4/5 in all muscle groups of the right arm and leg and is 5/5 on the left. There is generalised hyperreflexia and the right plantar is extensor. Sensation to light touch and vibration sense is preserved.

Investigations

CT Brain: Infarct in the left frontal lobe in the territory of the left middle cerebral artery.

Investigation	Result	Normal range
Anti dsDNA	5 U/L	<20 U/L
ESR	32 mm/h	0-10mm/h
CRP	39 mg/L	<7mg/L
Lupus Anticoagulant	Positive
Anti Cardiolipin IgG	45 GPLU/ml	<10
Anti Cardiolipin IgM	50 MPLU/ml	<7
Factor V Leiden mutation:	Not detected.
Protein C activity	118%	76-208%
Protein S activity	111%	62-153%
Anti thrombin III	0.9 kIU/L	0.8-1.2 kIU/L
Homocysteine	5.5 micromol/L	4.9-11.6 micromol/L

ECG: sinus rhythm, 80 beats per minute, normal axis, normal morphology.

Which of the following is the next most appropriate investigation?

1. Anti Beta 2 glycoprotein 1 antibodies

2. Carotid and vertebral artery Doppler scan

3. Echocardiography

4. Lower limb Venous Doppler 

Ans. 3) Echocardiography 

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Q6. A 38-year-old woman diagnosed with limited systemic sclerosis 5 years ago is seen in the clinic. Which of the following examination findings would raise your suspicion of pulmonary arterial hypertension?

1. Bi-basal crackles

2. Double apex beat

3. Loud S2

4. Slow rising pulse

Ans. 3) Loud S2

Q7. A 31-year-old woman presents with a two-month history of cramping pain in her right upper arm, particularly while ironing. She has an approximate one-year history of general malaise and headaches and has lost approximately 5 kg in weight. There is no other past history of note except a miscarriage at 8 weeks. Her only medication is the combined oral contraceptive. On examination, blood pressure is 122/68 mmHg in the left arm, and she is noted to have absent right arm pulses. Initial investigations reveal:

Investigation	Result	Normal range
Haemoglobin	12.3 g/dl	12-16 g/dl
White cell count	6.3 x 109/L	3-10 x 109/L
Platelets	175 x 109/L	150-450 x 109/L
CRP	35 mg/L	< 10 mg/L
ESR	76 mm/hr	1-10
ANA	negative
Rheumatoid Factor	negative
ANCA	negative
Lupus anticoagulant	not detected
IgG Anticardiolipin antibodies	negative
IgM Anticardiolipin antibodies	negative
Beta-2 GP1	negative

Which of the following is the likely diagnosis?

1. Antiphospholipid antibody syndrome

2. Cervical rib

3. Giant cell arteritis

4. Takayasu's arteritis 

Ans. 4) Takayasu's arteritis

Q8. A 17-year-old woman with known SLE presents with a painful swollen left knee and left wrist and feels generally unwell. She had recently returned from a 2 week official tour. She had stopped taking hydroxychloroquine three months previously. Her blood pressure was 120/70 mmHg, pulse 80 bpm and temperature 37.6℃. Examination revealed 2 pustular lesions on her abdomen, a warm effusion of her left knee, and puffy swelling of the extensor tendons of her left wrist.

Investigations are as follows:

Investigation	Result	Normal range
CRP	95 mg/dl	<5
DsDNA	104 iu/ml	<20 iu/ml
C3	0.07 mg/L	0.75-1.65 mg/L
C4	0.50 mg/L	0.14-0.54 mg/L
ESR	17 mm/hr	0-10
WBC	10.8 x 109/L	4-11 x 109/L
Neutrophils	8.0 x 109/L	2.0-7.5 x 109/L
Rheumatoid Factor	36 iu/ml	<20

The most likely diagnosis is: 

1. Generalised flare of SLE

2. Disseminated Gonococcal Infection

3. Staphylococcal joint sepsis

4. Reactive arthritis 

Ans. 2) Disseminated Gonococcal Infection 

Also read: Important MCQ’s For Cardiovascular in NEET SS Medicine

Q9. A 25 year old male with known Behcet's disease, who currently is not receiving any medication, presents with a sudden decrease in visual acuity. Review by the ophthalmologists reveals a posterior uveitis. Careful review of the patient's history reveals this is the first episode of an eye manifestation of his disease. Which of the following treatment regimes would you use to control his symptoms?

1. Oral prednisolone and Azathioprine

2. Oral prednisolone and Etanercept

3. Oral prednisolone and Interferon alpha

4. Oral prednisolone and Methotrexate

Ans. 1) Oral prednisolone and Azathioprine 

Q10. A 20-year-old man with known Behcet's disease presents with hemoptysis. He describes coughing up 2 teaspoons of blood. He is currently not receiving any medication having stopped Azathioprine himself 4 months previously. Examination reveals a blood pressure of 110/55 mmHg and a pulse of 65 bpm. Chest radiograph reveals a number of rounded opacities. A CT scan of the thorax is performed which confirms multiple pulmonary artery aneurysm. Investigations are as follows:

Investigation	Result	Normal range
CRP	18 mg/dl	<3
ESR	23 mm/hr	0-10
WBC	9.5 x 109/L	4-11 x 109/L
Neutrophils	7.4x109/L	2.0-7.5 x 109/L
Haemoglobin	13.6 g/dl	13.5-17.7 g/dl

Which of the following treatment options would you recommend?

1. High dose glucocorticoids

2. High dose glucocorticoids and Anakinra

3. High dose glucocorticoids and Azathioprine

4. High dose glucocorticoids and Cyclophosphamide 

Ans. 4) High dose glucocorticoids and Cyclophosphamide 

Q11. A 72-year-old woman presents with a one-week history of a rash affecting her shins, and an inability to lift up her right foot whilst walking, which now drags along the floor. Her general practitioner has recently commenced her on a nasal steroid spray for symptoms of congestion.

On examination, her rash appears vasculitic in nature and is distributed over both shins and the dorsum of both feet. Neurological examination of both lower limbs revealed a gait with right foot drop, normal tone, isolated reduced power of 1/5 on dorsiflexion of the right foot with power 5/5 in all other myotomes. The sensation is reduced over the anterior of the right shin and dorsum of the right foot. A renal biopsy was performed which revealed that 50% of glomeruli showed crescentic glomerulosclerosis.

Investigations reveal:

Investigation	Result	Normal range
Urine dipstick	Protein 3+, Red blood cells 3+
cANCA	Positive 1:320
PR3 Antibody	positive
Urea	126.3 mg/dl	15-45 mg/dl
Creatinine	2.77 mg/dl	0.7-1.4 mg/dl

Select the most appropriate management for this patient. 

1. Azathioprine

2. Oral prednisolone

3. Plasma exchange

4. Pulsed methylprednisolone and pulsed cyclophosphamide 

Ans. 4) Pulsed methylprednisolone and pulsed cyclophosphamide 

Also read: NEET SS Medicine Most important MCQS

Q12. A 25-year-old woman presents with painful swollen knees and ankles for the last 12 months. Further questioning reveals a history of recurrent episodes of oral ulceration; she has never had an episode of genital ulceration. She reports using the combined oral contraceptive for treatment of acne.

Examination reveals tender ankles and bilateral small knee effusions. She has two small aphthous mouth ulcers and mild acne on her back.

Investigations reveal the following:

Investigation	Result	Normal range
CRP	10 mg/dl	<5
ANA	Positive 1/40
DsDNA	19 iu/ml	<20
C3	0.85 mg/l	0.75-1.65
C4	0.50 mg/L	0.14-0.54 mg/L
ESR	24 mm/hr	0-10
WBC	7.0 x 109/L	4-11 x 109/L
Neutrophils	5.5 xc109/L	2.0-7.5 x 109/L

The most likely diagnosis is: 

1. Behcet's disease

2. Rheumatoid Arthritis

3. SAPHO syndrome

4. Sarcoidosis 

Ans. 1) Behcet's disease 

Q13. A 23-year-old woman with known SLE who is using hydroxychloroquine to manage her condition visits the clinic and discloses she is 7 weeks pregnant. She asks for guidance on how to proceed with her care. Her past discloses that she experienced an unidentified cause miscarriage at 11 weeks three years prior. She has only gotten pregnant once. Investigations in the past have turned up a lupus anticoagulant that was consistently positive. Prior to this, the patient was opposed to long-term low-dose aspirin use. Which one of the following would you suggest, based on the most recent European best practices recommendations?

1. Combined low dose aspirin and low molecular heparin

2. Low dose aspirin

3. Low molecular weight heparin

4. Unfractionated heparin

Ans. 1) Combined low dose aspirin and low molecular heparin 

Also read: NEET SS Medicine Clinical Questions

Q14. A 47-year-old man with chronic renal impairment secondary to Wegener's Granulomatosis returns for follow-up in rheumatology outpatient feeling rather lethargic and tired. Twelve months ago, he was treated with intravenous pulsed cyclophosphamide following a severe flare but subsequently improved. One week ago, he developed pain in his left great toe, and his GP prescribed a new tablet for him, but the patient cannot recall what it was called. He does, however, hand you his latest repeat prescription which includes: 1 alfacalcidol, Azathioprine 150 mg daily, Allopurinol 200 mg daily and Salbutamol 100 mcg inhaler. His blood monitoring results over the past 3 months have been satisfactory. His creatinine has been stable over the past 6 months around 170 micromol/L (50-100). On examination he has slight swelling of his left first MTP joint, but no tenderness. There is no lymphadenopathy or splenomegaly.

Investigations reveal:

Investigation	Result	Normal range
Hb	6.4 g/dL	13-15 g/dL
MCV	82 fL	80-99 fL
WBC	2.2 x 106/L	4-11 x 106/L
Neutrophils	0.8 x 106/L	2.0-7.5 x 106/L
Platelets	138 x 106/L	150-400 x 106/L
Sodium	136 meQl/L	135-145 meQ/L
Potassium	4.9 meQ/L	3.5-5.1 meQ/L
Urea	22.4 mg/dl	7-21 mg/dlL
Creatinine	1.75 mg/dl	0.89-1.13 mg/dl
ANCA	negative

Which of the following is the likely explanation of this patient's presentation and results? 

1. Anaemia of chronic renal failure

2. Anaemia secondary to cyclophosphamide

3. Flare of Wegener

4. Interaction between azathioprine and allopurinol

Ans. 4) Interaction between azathioprine and allopurinol 

Q15. A 43-year-old man is admitted under the general medical intake with generalized progressive weakness of his arms and legs. During the preceding five days, he complained of flu-like symptoms and muscle aches. There is no change in his symptoms after exercise, such as walking up a flight of stairs. He compares the discomfort in his legs to a "swarm of bees crawling over his thighs". He has noticed difficulty swallowing but no nasal regurgitation of liquids. His speech and facial expression remain unchanged. There is no family history of muscle disorders. On examination, he displays marked truncal weakness and has difficulty even sitting upright. He has difficulty holding his head up. The muscle bulk of his arms and legs appears normal, with no wasting or hypertrophy. There is no fasciculation of the muscles. His limb tone is reduced, and he was power graded 3/5 on hip flexion and shoulder abduction. A cranial nerve examination is normal. Respiratory examination is unremarkable.

Investigation	Result	Normal range
CK	13,000 U/L	30-200 U/L
CRP	120 mg/L	<5 mg/L
ESR	87 mm/h	<10 mm/h
Urine dipstick: No abnormality detected.
Urine myoglobin: Not detected.

Sodium	135 meQ/L	135-145 meQ/L
Potassium	4.3 meQ/L	3.5-5.0 meQ/L
Urea	16.5 mg/dl	7-21 mg/dl
Creatinine	1.19 mg/dl	0.7-1.39 mg/dl
25OHVit D	52 ng/L	Desirable levels > 30 ng/L
Free T4	20.8 pmol/L	9.8 - 23.8 pmol/L
TSH	2.2 mu/L	0.5-4.5 mu/L

Electromyography is reported as:

Myopathic potentials: low amplitude, short duration polyphasic units on voluntary activation. Increased spontaneous activity with fibrillations and complex repetitive discharges.

Which is the most likely diagnosis?

 1. Limb Girdle Muscular Dystrophy

2. McArdle's Syndrome

3. Motor Neurone Disease

4. Polymyositis

Ans. 4) Polymyositis

Also read: Reactive Arthritis- Etiology, Diagnosis And Treatment

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