Rheumatology RACP MCQs Flashcards
What is the greatest predictor of future thrombosis in patients with anti-phospholipid syndrome?
A. Annexin Ab
B. Anticardiolipin Ab
C. Lupus anticoagulant
D. Beta 2 glycoprotein 1 Ab
E. Anti-prothrombin Ab
C Lupus anticoagulant
The presence of LA or triple aPL positivity are the main risk factors for recurrence.
A 27 year old lady with SLE presents with recurrent miscarriage. Which antibody predicts further miscarriages?
A. Anti-SSa
B. Anti-histone
C. Anti-cardiolipin
D. Anti-dsDNA
E. Anti-Smith
C - Anticardiolipin
History suggestive of obstetric APS -defined by recurrent miscarriages, late (>10 wks) foetal demise and premature births due to eclampsia/pre-eclampsia and placental insufficiency. Lupus anticoagulant, anti cardiolipin ab and beta2glycoprotein1 ab are characteristic of APS.
In a 75-year-old woman presenting with a unilateral temporal headache, which of the following clinical features is most specific for a diagnosis of temporal arteritis?
A. Temporal artery tenderness.
B. Blurred vision.
C. Jaw (masseter) claudication.
D. Pain and stiffness around the shoulders and hips.
E. Fever.
C. Jaw (masseter) claudication.
50% of patients with GCA have jaw claudication and is the feature most highly associated with a positive biopsy for GCA.
Which of these features has the highest likelihood ratio for giant cell arteritis (GCA)?
A. Headache
B. Diplopia
C. Jaw claudication
D. Joint synovitis
E. Proximal myalgia
C. Jaw claudication
Which of the following cells is most important in the pathogenesis of vasculitis in temporal arteritis?
A. Multinucleate giant cell
B. Macrophage
C. CD8+ T cell
D. CD4+ T cell
E. Dendritic cell
C. CD4+ T cell
Is the cell that initiates differentiation and activation of macrophages and the subsequent granulomatous inflammation.
A 72-year-old man presents with a right sided headache for two weeks. On examination he is tender over the temporal artery. His erythrocyte sedimentation rate (ESR) is 82 mm/hr [0-22].
Which is the most appropriate next investigation?
A. Ultrasound of temporal artery.
B. Temporal artery biopsy.
C. Platelet count.
D. Retinal photography.
E. Serum protein electrophoresis.
B. Temporal artery biopsy.
CDUS of the head, neck, and upper extremities can serve as a diagnostic surrogate for temporal artery biopsy when performed by clinicians skilled in this technique. In the absence of extensive experience with this technology in routine clinical practice, however, temporal artery biopsy remains an essential diagnostic measure for the evaluation of suspected GCA.
A 70-year-old woman, weighing 45 kg, presents with polymyalgia rheumatica and headache. There is a history of osteoporosis with a previous vertebral wedge fracture. Past history also includes hysterectomy.
Temporal artery biopsy reveals giant cell arteritis. A bone mineral density test shows T scores for the lumbar spine and the femoral neck as -3.0 and -2.5 respectively. A chest X-ray shows wedging of the thoracic vertebra on the lateral view.
The most appropriate initial management is:
A. prednis(ol)one 40 mg daily and alendronate 10 mg daily.
B. prednis(ol)one 10 mg daily and azathioprine 100 mg daily.
C. prednis(ol)one 40 mg twice daily and calcitriol 0.25 μg twice daily.
D. prednis(ol)one 15 mg daily and methotrexate 10 mg weekly.
E. prednis(ol)one 40 mg daily and hormone replacement therapy
A. prednis(ol)one 40 mg daily and alendronate 10 mg daily.
GCA treatment - high dose glucocorticoids (40-60 mg) daily
First line treatment of osteoporosis, esp. that caused by steroids - alendronate
A 35 yo woman presents with a 3-day history of headaches and vomiting. She was diagnosed gastrooesophageal reflux disease 12 months ago and Raynaud’s henomenon 2 years ago. On examination her blood pressure is elevated at 225/145 mmHg, her pulse is 80/min. She has changes of sclerodactyly affecting her fingers, dorsum of hands and has evidence of thickened, tight skin over the anterior chest wall.
Relevant investigations are shown below
Hb 110 g/L
WCC 8.5 x 109/L
Platelets 75 x 109/L
Blood film Schistocytes, low platelets
Urea 10 mmol/L
Creatinine 140 umol/L (eGFR 42 ml/min)
U/A: Protein ++, blood and other markers all –ve
Which of the following is the most appropriate treatment?
A. Captopril
B. Sodium nitroprusside
C. Pulse methylprednisolone
D. Cyclophosphamide
A. Captopril
Patient has scleroderma renal crisis - hypertensive crisis, thrombocytopenia, MAHA (micorangiopathic haemolytic anaemia) and proteinuria.
Treatment:
- Rapid correction with Captopril (this is the ACEi of choice because of extensive clinical experience and its short onset and duration of action, which permit rapid dose escalation)
- Intravenous Nitroprusside in ADDTION if there is CNS symptoms
- Dialysis ( 2/3 patients require this)
- Eculizumab (complement pathway antagonist)
- Renal transplant (if unable to wean dialysis >2 yrs)
In systemic sclerosis, which of the following autoantibodies is associated with scleroderma renal crisis?
A. Anti-centromere
B. Anti-topoisomerase
C. Anti-RNA polymerase III
D. Anti-Smith
C. Anti-RNA polymerase III - assc. with diffuse SSc and scleroderma renal crisis
- Anti-centroemere - specific for localised SSc and pulmonary artery hypertension
- Anti-topoisomerase (Anti Scl 70) - specific for diffuse SSc but associated with ILD
Anti-Smith - associated with SLE and MCTD
A 64yo lady presents with sicca symptoms. She has also noted difficult with dorsiflexion of
her right foot, and a tingling sensation in her fingers.
Investigations show :
ANA : 1: 2560
ENAs : positive for SSA(Anti-Ro) and SSB (Anti-La) , negative for dsDNA
RF 85
What is the diagnosis?
A. Rheumatoid arthritis
B. SLE
C. Primary Sjogrens syndrome
D. Overlap syndrome
E. Scleroderma
C. Primary Sjogrens syndrome
ANA - positive in SLE, RA and Sjogrens
Anti Ro/SSA and Anti La/SSB positive in SLE and Sjogrens
dsDNA - specific for SLE
RF positive in RA, SLE and Sjogrens
RACP 2022a Q4
65F with background of Sjogren’s disease. New rash on the lower limbs
(photo given, purpuric, macular, irregular shaped patches mostly <1cm x 1cm in each section, did not look urticarial; looked vasculitic). Associated with loss of sensation over the foot. Investigations list: ANA/SSA/SSB Positive; RF
300; ACPA Neg; p ANCA weak positive. MPO/PR3 neg. HIV/HepB/C negative. Complement (3/4) both low.
a. Hypocomplimentaemic urticarial vasculitis
b. rheumatoid vasculitis
c. mixed cryoglobulinemia
d. microscopic polyangiitis
Answer D Microscopic polyangitis
RACP 2022a Q9
45 year old man developed myopathy on atorvastatin 6 months ago. His CK was normal at the time and his symptoms improved after cessation of the statin. He now presents with worsening proximal myopathy with a CK of
4000. Muscle biopsy demonstrates necrosis, macrophage infiltration and MH1 staining. What is the most likely cause?
a. Immune mediated necrotic myositis
b. Statin toxic myopathy
c. Inclusion body myositis
d. Polymyositis
Answer A IMNM
Initial reaction to statin was likely toxic myopathy
Following this - current reaction with elevated CK, necrosis, macrophage infiltrate and MHC I staining in keeping with immune mediated necrotising myopathy - caused by abs against HMGCR
RACP 2022a Q13
13.A 56 year old woman has autoimmune hepatitis, hypertension and hyperlipidemia on azathioprine, perindopril and atorvastatin. She develops acute joint pain in her left MTP. Joint aspirate showed calcium pyrophosphate (?) crystals. What is your initial management?
a. Allopurinol
b. Probenicid
c. Feboxustat
d. Benzbromarone
Answer B Probenecid
Allopurinol and febuxostat interfere with the metabolism of azathioprine, increasing plasma levels of 6-mercaptopurine which may result in potentially fatal blood dyscrasias.
Benzbromarone reduces hyperuricaemia by blocking renal tubular reabsorption of uric acid. It is also hepatotoxic.
RACP 2022a Q34
34.What is skin lesion associated with antiphospholipid syndrome?
a. Livedo reticularis
b. Digital ulcers
c. Erythema annulare
d. Palpable purpura
Answer A
Livedo is the most common cutaneous manifestation of APS. Although livedo reticularis is nonspecific, livedo racemosa can be associated with arterial lesions and multiple thromboses in APS.
RACP 2022a Q64
64.Testing for which antiphospholipid antibody is affected by warfarin administration?
a. Lupus anticoagulant
b. Anti-cardiolipin
c. Anti-beta2glycoprotein
d. Protein C
Answer A Lupus anticoagulant
aCL and anti-beta2GPI antibody results are unaffected by anticoagulation. By contrast, different anticoagulants have variable effects on laboratory tests used to identify LA, making interpretation of the results more challenging.
RACP 2022b Q25
- A patient on infliximab develops new skin lesions (repeat question - picture shown)
A. Subacute cutaneous lupus
B. Psoriasis
Answer B Psoriasis
The use of infliximab in rheumatoid and inflammatory bowel diseases (IBD) has been associated with a variety of adverse skin reactions, including paradoxical psoriatic lesions.
Not enough information recalled to answer question.
RACP 2022b Q 30
- Neonatal heart block is associated with antibodies anti-Ro/SSA and anti-La/SSB.
What period of gestation does neonatal heart block develop?
A. 12-18 weeks
B. 18-24 weeks
C. 24-30 weeks
D. 30-36 weeks
Answer B 18-24 weeks
Congenital heart block is usually detected when the fetus is between 18 and 24 weeks old.
RACP 2022b Q59
- Neonatal heart block is associated with antibodies anti-Ro/SSA and anti-La/SSB.
What period of gestation does neonatal heart block develop?
A. 12-18 weeks
B. 18-24 weeks
C. 24-30 weeks
D. 30-36 weeks
Answer B 18-24 weeks
Congenital heart block is usually detected when the fetus is between 18 and 24 weeks old.
RACP 2021a Q11
Q11. Which of the following features is most specific clinical sign for psoriatic arthritis?
A. Asymmetrical swelling of DIP joints
B. Dactilitis
C. Nail pitting
D. Enthesisits
Answer A
Distal arthritis and arthritis mutilans are considered most specific for PsA, but they are not the most common patterns seen
RACP 2020a Q41
- 32 yo female with 12 month history of fatigue, arthralgia, sterile dysuria, dry eyes/mouth and
parotid enlargement. CRP: 8, ESR: 90. Had vasculitis screen which showed ANA of 1:640, ENA positive for Anti-Ro/SSa + Anti-La SSb. Rheumatoid factor: 540 and Anti-CCP: 12 (<10).
Lymphopenia and raised globulins. What is the most likely diagnosis?
A) MCTD
B) RA
C) Sjogrens
D) SLE
Answer C Sjogrens
Anti-SSA/Ro and anti-La/SSB are the hallmark antibodies in primary Sjögren’s syndrome (pSS), being present in 60-70% of patients.
RACP 2020a Q77
- Methotrexate used in RA and other inflammatory diseases. Which enzyme does methotrexate
inhibit ?
A) Dihydrofolate reductase
B) Dihyroorotate reductase
C) Inosine monophosphate dehydrogenase
D) Thiopurine methyltransferase
Answer A Dihydrofolate reductase
The inhibition of DHFR by folate antagonists (methotrexate) results in a deficiency in the cellular pools of thymidylate and purines and thus in a decrease in nucleic acid synthesis. Therefore, methotrexate interferes with DNA synthesis, repair, and cellular replication.
RACP 2020
- Recurrent pancreatitis. Enlarged lacrimal glands. Retroperitoneal lymph node enlargement with
dilated bile ducts on imaging. A biopsy of lacrimal glands that shows storiform fibrosis.
A) Sarcoidosis
B) IgG4 disease
C) Lymphoma
D) Sjogren’s Syndrome
Answer B IgG4 disease
The fibrosis associated with IgG4-RD usually has a characteristic “storiform” pattern, typified by a cartwheeling appearance of the arranged fibroblasts and inflammatory cells. The majority of patients have elevated serum levels of IgG4.
RACP 2019a Q4
Question 4
A 35 year old Turkish lady has joint pain, oral and genital ulcers, red painful nodules on legs,
occasional painful red eye. What is the most likely diagnosis?
A. Behcet disease
B. Sarcoidosis
C. Systemic lupus erythematosus
D. Granulomatosis with polyangiitis
Answer A Behcets disease
Behcet disease is an auto-inflammatory systemic vasculitis of unknown etiology. It is characterized by mucocutaneous manifestations, including recurrent oral and genital ulcerations, ocular manifestations, especially chronic relapsing uveitis, and systemic vasculitis involving arteries and veins of all sizes. Tt is observed commonly among populations living along the historic Silk Road, an ancient trading route that spans from Japan and China in the Far East to the Mediterranean Sea, including countries such as Turkey and Iran.
RACP 2019 a Q10
Question 10
Which of the following disease causes predominance of upper lobe pulmonary fibrosis?
A. Rheumatoid arthritis
B. Diffuse scleroderma
C. Mixed connective tissue disease
D. Ankylosing spondylitis
Answer: D Ankylosing spondylitis
RACP 2019a Q38
Question 38
A 36 year old female personal trainer presents with 6 months of right heel pain, worse when weight bearing. Over the last few weeks, she has developed left heel pain. She has a cousin with SLE and her GP checked her ANA (positive with a 1:160 titre). Double-stranded DNA is negative.
What is the most appropriate management?
A. NSAID and physiotherapy
B. Entheseal steroid injection to plantar fascia
C. Hydroxychloroquine
D. Corticosteroid
Answer A
Diagnosis: plantar fasciitis
First line - physiotherapy
Second line: NSAIDs
Third line : steroid injection
RACP 2019a Q58
Question 58
A 40 year old lady is on hydroxychloroquine and prednisolone for SLE. What is the next best agent in
lupus patient with non-renal lupus?
A. Methotrexate
B. Mycophenolate
C. Azathioprine
D. Cyclosporine
Answer A or C
MTX or AZA can be used - MTX has better evidence , but contraindicated in pregnancy.
As this patient is 40yo - consider AZA?
https://ard.bmj.com/content/78/6/736
RACP 2019a Q86
A 62 year old lady presents with a violaceous rash over her face and biopsy confirms lupus pernio.
With which disease is this most commonly associated?
A. Sjogren’s syndrome
B. Sarcoidosis
C. Systemic lupus erythematosus
D. Psoriatic arthritis
Answer B Sarcoidosis
Lupus pernio is a rare cutaneous manifestation of sarcoidosis. It presents as a violaceous lesion or shiny nodules over the head and neck but is predominantly localized to the nose, cheeks, and ears. Lupus pernio is often a predictor of systemic sarcoidosis, which warrants thorough workup. Patients with lupus pernio have a higher risk for pulmonary disease,
RACP 2019a Q90
Question 90
A 25yo personal trainer has presented concerned about the possibility of lupus. Her sister was
recently diagnosed with lupus and her GP performed blood tests demonstrating an ANA of 1:160.
DsDNA and ENA were negative. She describes long standing right heel pain on weight-bearing. What
is the most appropriate next step in management?
A. NSAIDs and physiotherapy
B. Steroid injection
C. Prednisone
D. Hydroxychloroquine
Answer A
RACP 2019a Q99
EMQ 99 and 100
A. C6
B. C7
C. Median elbow
D. Median wrist
E. Radial forearm
F. Radial spiral
G. Ulnar elbow
H. Ulnar wrist
Question 99
A 45 year old bartender presents with severe clawing of the ring and 5th finger.
Answer H Ulnar nerve at wrist
Motor complaints may include weakness/paralysis of the intrinsic muscles of the hand innervated by the ulnar nerve, which may present as a weakening of the handgrip and clawing of the fourth and fifth digits. Hypothenar atrophy may be present in more advanced cases. Differentiation between ulnar nerve compression at Guyon canal (wrist) vs. cubital tunnel (elbow) can be done by testing the strength of intrinsic (hand) vs. extrinsic (forearm) muscles supplied by the ulnar nerve respectively. Sparing of the dorsal surface of ulnar dermatome (dorsal medial hand and two fingers) points to Guyon canal syndrome.
RACP 2019a Q100
EMQ 99 and 100
A. C6
B. C7
C. Median elbow
D. Median wrist
E. Radial forearm
F. Radial spiral
G. Ulnar elbow
H. Ulnar wrist
A 54 year old lady who is a data analyst presents with pain and tingling in her thumb and index finger while driving. This pain also wakes her at night. The symptoms last for minutes and improve with shaking of her hand.
D Carpal tunnel syndrome - median nerve affected at wrist
Numbness, tingling, burning, and pain — primarily in the thumb and index, middle, and ring fingers. This often wakes people up at night. Many patients find that moving or shaking their hands helps relieve their symptoms. Repeating the same hand and wrist motions or activities over a prolonged period of time may aggravate the tendons in the wrist, causing swelling that puts pressure on the nerve.
RACP 2019b Q24
Question 24
In psoriatic arthritis, methotrexate is most helpful for:
A. Small joint arthritis
B. Axial arthritis
C. Enthesitis
D. Nail psoriasis
Answer : ? A
MTX useful for polyarthritis with/ without dactylitis
https://ard.bmj.com/content/79/6/700.1
RACP 2018a Q1
Febuxostat is a newer urate-lowering therapy than allopurinol. Based on randomised controlled
trial data in chronic gout, what is the main benefit of febuxostat 80 mg daily over allopurinol
300 mg daily?
A. Faster resolution of tophi.
B. Fewer cardiovascular events.
C. Fewer flares of acute gout.
D. Less radiologic articular changes.
E. Lower serum uric acid.
Answer E
In comparison with allopurinol, febuxostat is a more selective xanthine oxidase inhibitor and more potent in lowering serum urate levels.
Also note: febuxostat associated with increased incidence of cardiac events and all cause mortality compared to allopurinol.
RACP 2018a Q34
34.A 72-year-old man presents with a 3-month history of malaise, arthralgias, abdominal pain, and left foot weakness. In addition to left foot drop, examination reveals that he is hypertensive and
has a non-blanching lace-like skin discolouration on his legs.
Laboratory findings:
Normal values
Erythrocyte sedimentation rate (ESR) 102 mm/hr [0–15]
C-reactive protein (CRP) 68 mg/L [< 5]
Creatinine 120 μmol/L [45–90]
MSU 1+ proteinuria
CT scan angiography shows multiple small vessel aneurysms in the renal and mesenteric
arteries.
What is his autoantibody screening most likely to show?
A. c-ANCA.
B. dsDNA autoantibodies.
C. No autoantibodies detected.
D. p-ANCA.
E. Rheumatoid factor.
Answer C
Stem is consistent with polyarteritis nodosa which is not associated with any particular antibodies.
RACP 2018a Q45
- An 83-year-old woman presents with increasing difficulty walking. She develops left buttock
pain after walking approximately 700 m or standing for a prolonged period. The pain radiates to the left calf and is eased by leaning on a shopping trolley or resting for 5 minutes. She has no pain on sitting.
What is the most likely diagnosis?
A. Ankylosing spondylitis.
B. Osteoarthritis of the hip.
C. Peripheral arterial disease.
D. Spinal canal stenosis.
E. Vertebral fracture.
Answer C Spinal canal stenosis
Forward flexion of the back may open up narrowed spinal-canal foraminal spaces in patients with lumbar spinal stenosis and improve their pain symptoms. These patients describe pain relief when leaning forward to push a shopping cart (“shopping cart sign”)
RACP 2018a Q75
- An 86-year-old lady with hypertension, type 2 diabetes and osteoporosis is found to have mild primary hyperparathyroidism. Her usual medications are metformin, quinapril,
hydrochlorothiazide, cholecalciferol and alendronate.
In light of the new diagnosis, which of her medications should be discontinued?
A. Alendronate.
B. Cholecalciferol.
C. Hydrochlorothiazide.
D. Metformin.
E. Quinapril.
Answer C: Hydrochlorothiazide
PTH stimulates osteoclast activity and increases serum calcium.
Hydrochlorothiazide causes increased tubular reabsorption of calcium and may cause hypercalcaemia in patients with hyperparathyroidism
RACP 2018b Q102
102.A 68-year-old man with rheumatoid arthritis for 15 years has the following bone densitometry
results obtained on a dual energy x-ray absorptiometry scan:
T score Z score
Lumbar spine +1.3 +2.0
Femoral neck −2.4 −1.7
What is the most likely explanation for the discrepancy between the femoral neck and lumbar
spine readings?
A. Metastatic bone disease.
B. Osteonecrosis of the hip.
C. Osteophyte formation in the lumbar spine.
D. Paget disease in the lumbar spine.
E. Synovitis in the hip.
Answer C Osteophyte formation in the lumbar spine
RACP 2018 Q125
125.If a patient has strong positive anti-dsDNA antibodies (> 100 IU/mL) and a negative screen for
extractable nuclear antigens (ENA), what is the most likely pattern on antinuclear antibody
(ANA) testing?
A. Centromere.
B. Homogeneous.
C. Negative (no pattern seen).
D. Nucleolar.
E. Speckled.
E Speckled
SLE can be speckled (52%), homogenous (30% ) and nucleolar
RACP 2018 Q128
128.Rheumatoid factor antibodies are directed against which antigenic component?
A. Citrullinated peptides.
B. Deoxyribonucleic acid (DNA).
C. Extractable nuclear proteins.
D. Neutrophil cytoplasmic antigens.
E. The Fc portion of immunoglobulin G.
Answer E
Rheumatoid factors are antibodies directed against the Fc region of immunoglobulin G
RACP 2018 Q129
129.What is the most prevalent neuropsychiatric complication of systemic lupus erythematosus?
A. Anxiety disorder.
B. Cognitive dysfunction.
C. Major depression.
D. Mania.
E. Psychosis.
Answer ?B
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4349748/#:~:text=The%20most%20frequent%20NPSLE%20manifestations%20are%20headaches%2C%20psychiatric%20disorders%20(depression,of%20SLE%20diagnosis%20%5B7%5D.
RACP 2018 Q134
134.What is the most common pattern of interstitial lung disease in rheumatoid arthritis?
A. Acute interstitial pneumonia.
B. Desquamative interstitial pneumonia.
C. Lymphocytic interstitial pneumonia.
D. Organising pneumonia.
E. Usual interstitial pneumonia.
Answer E
The most typical radiological pattern of RA-ILD is usual interstitial pneumonia (UIP), representing more than half of the cases, followed by nonspecific interstitial pneumonia (NSIP), organizing pneumonia (OP), and lymphocytic interstitial pneumonia (LIP)
RACP 2018 Q151
151.Patients should be considered for investigation for secondary causes of osteoporosis if their
z-score is less than −2.0.
Assuming normal distribution, what does a z-score of −2.0 indicate?
A. A patient with this bone mineral density is in the lowest 1% of age-matched peers.
B. A patient with this bone mineral density is in the lowest 2.5% of age-matched peers.
C. A patient with this bone mineral density is in the lowest 5% for age-matched peers.
D. A patient with this bone density is twice as likely to fracture than other women her age.
E. A patient with this bone density is twice as likely to have a secondary cause of osteoporosis
compared with a young female.
Answer C
Z score represents standard deviations compared to age and gender matched means.
Z score of -2 is 2 standard deviations below the mean. Usually 2 standard deviations encompasses 95% of values. Hence Z score < -2 represents a score in the lowest 5% for that population.
RACP 2018 Q163
163.Bisphosphonates primarily act on which cell?
A. Macrophage.
B. Osteoblast.
C. Osteoclast.
D. Osteocyte.
E. Pericyte.
Answer C
By specifically inhibiting osteoclast-mediated bone resorption, bisphosphonates presumptively allow bone-forming osteoblasts more time to promote bone formation, albeit in the setting of abnormal collagen matrix.
RACP 2017a Q11
A 75-year-old Chinese man who is being treated with a TNF inhibitor for Rheumatoid Arthritis
develops fevers, night sweats and a productive cough. You suspect Tuberculosis.The most sensitive test for diagnosing active TB infection is:
a) Three consecutive sputum samples sent for acid fast bacilli staining
b) Three consecutive sputum samples sent for TB culture
c) Transbronchial biopsy
d) Quantiferon Gold Assay
e) Tuberculin Skin Test
Answer B
Mycobacterial culture, has the highest sensitivity for diagnosing and confirming active TB, requires 2 to 6 weeks for interpretation
RACP 2017a Q18
A 72-year-old female has a two-week history of episodes of shooting pain affecting her cheek and
jaw. The episodes last 30 seconds and she had dozens per day. They are brought on by chewing or
talking. She has a normal neurological examination. What is the most likely diagnosis?
a) Giant Cell Arteritis
b) Hemifacial Spasms
c) Migraine
d) Transient Ischaemic Attack
e) Trigeminal Neuralgia
Answer ? A
Jaw claudication caused by GCA, ischemia to the muscles of mastication
RACP 2017a Q20
A 40-year-old lady presents with fatigue, arthralgias, rash to her lower limbs, abdominal pain, fevers,
haematuria. CT angiography demonstrates micro-aneurysms to her renal and mesenteric arteries.
Which of the following auto-antibodies will likely be positive?
a) c-ANCA
b) Rheumatoid Factor
c) All antibodies are likely to be negative
d) p-ANCA
e) ds-DNA
Answer C
Diagnosis is polyarteritis nodosa, not associated with any specific antibody
RACP 2017a Q45
Calcinosis cutis is most commonly found in what condition?
a) Systemic Sclerosis
b) Systemic Lupus Erythematosus
c) Sarcoidosis
d) Bechet’s Disease
e) Sjogren’s Syndrome
Answer A
Dermatomyositis and systemic sclerosis were the most common ACTDs associated with calcinosis cutis
RACP 2017a Q63
A 79-year-old woman presents with three-month history of dull right thigh pain. She does not recall any injuries to her leg or hip. Her past medical history is significant for COPD, GORD and
Osteoporosis.
A radiograph of her hip is presented below
What is the most likely cause of her thigh pain?
a) Osteoarthritis
b) Paget’s disease involving the femur
c) Osteophyte formation
d) Atypical femoral fracture
e) Avascular Necrosis
Answer D Atypical femoral fracture
Rare complication of bisphosphonate therapy
Initial symptoms are thigh pain
X ray showing cortical thickening with fracture line
RACP 2017 Q80
A 75-year-old woman with back pain has a DEXA scan to investigate for Osteoporosis. The results are shown below:
T-score
Lumbar + 1
Radial - 2.6
Right Hip - 2.5
What is the most correct interpretation of the discordant T-scores?
a) Corticosteroid-induced Osteoporosis
b) Osteoarthritis of the lumbar spine
c) Osteomalacia
d) Osteoporosis
e) Primary Hyperparathyroidism
Answer B OA of the lumbar spine
RACP 2017 Q73
The ultrasound image presented below is that of the femoral condyle in the longitudinal plane. The
area of echogenicity in the cartilage is known as a double contour.
This is imaging finding is pathognomonic for which of the following conditions?
a) Chrondocalcinosis
b) Gout
c) Systemic Lupus Erythematosus
d) Psoriatic Arthritis
e) Rheumatoid Arthritis
Answer B
Double contour sign is a hyperechoic band over the superficial margin of the anechoic hyaline cartilage, which is highly specific for gout. In chondrocalcinosis, calcium deposits appear as hyperechoic foci within the intermediate layer of the cartilage.
RACP 2017 Q 99
a) Psoriatic Arthritis
b) Rheumatoid Arthritis
c) Haemochromatosis
d) Systemic Lupus Erythematosus
e) Ankylosing Spondylitis
f) Osteoarthritis
g) Polymyalgia Rheumatica
h) Sjogren’s Syndrome
i) Gout
Which of the above medical conditions is most likely in a patient who presents with:
Erosive arthritis of the 2nd and 3rd metacarpophalygeal joints.
Answer C Haemochromatosis
Squared-off bone ends and hook-like osteophytes in the MCP joints, particularly if these changes are located in the second and third MCP joints. Such changes are especially common in hemochromatosis [35] and hemochromatosis-associated CPPD disease
RACP 2017 Q100
a) Psoriatic Arthritis
b) Rheumatoid Arthritis
c) Haemochromatosis
d) Systemic Lupus Erythematosus
e) Ankylosing Spondylitis
f) Osteoarthritis
g) Polymyalgia Rheumatica
h) Sjogren’s Syndrome
i) Gout
Which of the above medical conditions is most likely in a
Reducible non-erosive inflammatory polyarthritis of the small joints of the hands
Answer D SLE
The arthritis of SLE is typically nonerosive and is generally different from that of rheumatoid arthritis (RA). The arthritis and arthralgias of SLE tend to be migratory; symptoms in a particular joint may be gone within 24 hours but can often last longer. Although any joint can be involved, the arthritis is usually symmetric and polyarticular, with a predilection for the knees, carpal joints, and joints of the fingers, especially the proximal interphalangeal (PIP) joint. The ankles, elbows, shoulders, and hips are less frequently involved.
RACP 2017b Q10
The Rheumatoid Factor antibody is directed against which of the following?
a) Nuclear antigens
b) Cyclic citrullinated peptides
c) Deoxy-ribonucleic acid
d) Fc portion of IgG
e) Nuclear cytoplasmic antigens
Answer D Fc portion of IgG
RACP 2017b Q43
72-year-old female presents with posterior ankle pain. There is no joint effusion on ultrasound to
aspirate. Dual energy CT shows sodium deposition in the Achilles tendon. What is the most likely
cause of ankle pain?
Below is an image of a dual-energy CT of the foot of the patient. The green areas represent sodium and the purple areas represent calcium. What is the most likely cause of her ankle pain?
a) Degenerative changes
b) Osteoarthritis
c) Gout
d) Rheumatoid Arthritis
e) Psoriatic Arthritis
Answer C Gout
Monosodium urate deposition seen in Achilles and also other common gout sites (first MTP/ podagra).
RACP 2017b Q50
Which of the following describes the target of the monoclonal antibody Denosumab?
a) Osteoblasts
b) Osteoclasts
c) RANK-Ligand
d) Estrogen receptors
e) PTH Receptor
Answer C RANK Ligand
Denusomab targets and binds RANK Ligand, inhibiting osteoclast formation, function, and survival. RANKL is a protein that acts as the primary signal to promote bone removal/resorption
RACP 2017b Q67
Options
a) Systemic Lupus Erythematosus
b) Polyarteritis Nodosa
c) Bechet’s Disease
d) Reactive Arthritis
e) Ankylosing Spondylitis
f) Lofgren Syndrome
g) Osteoarthritis
h) Secondary Syphilis
Which of the above conditions best fits the following clinical vignettes?
A Turkish man with conjunctivitis, arthritis, thrombophlebitis, oral and genital ulcers.
Answer C Bechets disease
RACP 2017b Q68
Options
a) Systemic Lupus Erythematosus
b) Polyarteritis Nodosa
c) Bechet’s Disease
d) Reactive Arthritis
e) Ankylosing Spondylitis
f) Lofgren Syndrome
g) Osteoarthritis
h) Secondary Syphilis
Which of the above conditions best fits the following clinical vignettes?
A 65-year-old woman presents with arthropathy involving several of her distal interphalangeal joints. She had normal ESR and CRP. The CCP is mildly elevated.
Answer G OA
RACP 2016a Q5
Question 5
Defects in apoptosis resulting in delayed elimination of self-proteins is thought to be involved in the pathogenesis of which of the following diseases?
A. Immune thrombocytopenia purpura
B. Multiple Sclerosis
C. SLE
D. Type 1 diabetes mellitus
E. Ulcerative Colitis
RACP 2016a Q50
Question 50
A 42 year old female presents with arthralgia and exertional dyspnoea. She reports episodes of Raynaud’s phenomenon has noticed weakness in both the upper and lower limbs. HRCT of the lungs shows evidence of ILD in
a NSIP pattern.
CK = 1500
ANA = 1: 1600
ENAs = Jo1 positive
RF = 30 (<20)
CCP = negative
What is the most likely diagnosis?
A) Anti-synthetase syndrome
B) SLE
C) RA
D) Polymyositis
E) Sjogren’s syndrome
Answer A
Antisynthetase syndrome
Antibodies to aminoacyl tRNA - anti-Jo-1, PL-7, PL-12 common
Clinical features depend on antibodies involved
Higher risk and greater severity of ILD
Other features – mechanics hand, Raynaud’s phenomenon and arthritis
RACP 2016a Q51
Question 51
An elderly Caucasian man presents with a long sand history of back pain and
stiffness. An x-ray is performed
The most likely diagnosis is
A) DISH
B) Hyperparathyroidism
C) Osteoarthritis
D) Psoriatic arthritis
E) Ankylosing spondylitis
RACP 2016a Q63
A young man presents with ankle swelling bilaterally and a painful red eye. He is also noted to have painful erythematous nodules on his lower limbs. He denies a history of unprotected intercourse. What is to most likely diagnosis?
A) Rheumatoid arthritis
B) Reactive arthritis
C) Sarcoidosis
D) Small vessel vasculitis
E) Psoriatic arthritis
RACP 2016a Q71
Question 71
Eliciting hip joint pathology is best achieved by which of the following
A) Extension, external rotation, abduction
B) Extension internal rotation, abduction
C) Extension, internal rotation, adduction
D) Flexion, external rotation, abduction
E) Flexion, internal rotation, abduction
RACP 2016a Q89
Question 89
34 year oldmale with a 4year history oflower back pain and morning stiffness. Pelvic X-ray reveals bilateral
grade 3 sacroilitis (film not shown). ESR = 34.
Apart from commencinghim on anexercise program what would be your next step?
A. Etanacept
B. Methotrexate
C. NSAIDs
D. Paracetamol
E. Prednisone
RACP 2016b Q13
Question 13
Which of the following drugs can precipitate a scleroderma renal crisis?
A. Prednisone
B. Hydroxychloroquine
C. Irbesartan
D. Adenosine
E. Amlodipine
RACP 2016b Q23
Question 23
54 year old man presents with bilateral proximal muscle weakness. His CK is elevated at 3400 U/L (<250 U/L).
Muscle biopsy demonstrates muscle necrosis without inflammation.
What is the most likely diagnosis?
A. Dermatomyositis
B. Mitochondrial myopathy
C. Necrotising autoimmune myopathy
D. Polymyositis
E. Viral myositis
Answer C Necrotising myopathy
Rapidly progressing proximal muscle weakness
Myalgia
Limited extra-muscular features and systemic involvement
Significantly elevated CK
Biopsy shows myonecrosis without inflammation
RACP 2016b Q26
Question 26
Which of the following antibodies is related with ILD and scleroderma
A. Anti smith
B. Anti-topoisomerase I
C. Anti RNA polymerase III
D. Anti centromere
E. Ds-DNA
RACP 2016b Q32
A 68 year old woman presents to your office with a history of long standing pain in her feet. A radiograph of her
feet shows lateral deviation of both feet with erosions in the proximal and distal intertarsal joints.
What is the most likely diagnosis
A) Charcot’s Arthropathy
B) Rheumatoid Arthritis
C) Osteoarthritis
D) Systemic Lupus Erythamatosis
E) Psoriatic Athritis
RACP 2016b Q53
Question 53
When given orally what is the comparative dose of prednisone to hydrocortisone 100mg?
A) 4mg
B) 10mg
C) 25mg
D) 40mg
E) 100mg
RACP 2016b Q62
Question 62
What is a contraindication to treatment with an anti-TNF alpha agent?
A) History of a demyelinating condition
B) Pancreatitis
C) Liver failure
D) Kidney failure
E) Previously treated TB
RACP 2015a Q23
Question 23
What is the mechanism of action of Teriparatide?
A. Increases osteoblast action
B. Reduces osteoclast action
C. Increases gastrointestinal absorption of calcium
D. Increases hydroxyl-vitamin D
E. Increases calcium secretion
RACP 2015a Q25
Question 25
What is most associated with rheumatoid arthritis severity?
A. Rheumatoid factor
B. Age
C. Smoking
D. Obesity
E. Rhubarb
RACP 2015a Q41
Question 41
A man has anterior uveitis treated with topical corticosteroids. Which is the most important
musculoskeletal abnormality to examine?
A. Shoulders
B. Lumbar spine
C. Achilles tendon
D. Hands
E. Knees
RACP 2015a Q43
Question 43
Which complication leads to greatest mortality in scleroderma patients?
A. GI disease
B. Cardiac disease
C. Renal disease
D. Drug toxicity
E. Respiratory disease
RACP 2015a Q51
Question 51
A 46 year old lady presents to the clinic, complaining of hand numbness. She is known to have seropositive rheumatoid arthritis and is treated with methotrexate, leflunomide and
prednisone. On examination, she is found to have sensory loss over the palmar aspect of
the thumb, index, middle and radial surface of the ring finger. She also has weakness of wrist flexion.
The most likely cause of her symptoms is:
A. Carpal tunnel syndrome
B. C6 radiculopathy
C. Pronator syndrome
D. Drug related neuropathy
E. Vasculitis
RACP 2015a Q92
Question 92
Which antibody is most specific for SLE?
A. Anti-CCP
B. Anti-Smith
C. Anti-dsDNA
D. Anti-Ro
E. Anticardiolipin IgG
RACP 2015b Q69
Question 92
Which antibody is most specific for SLE?
A. Anti-CCP
B. Anti-Smith
C. Anti-dsDNA
D. Anti-Ro
E. Anticardiolipin IgG
RACP 2015b Q70
Extended Matching Questions: Question 69-70
A. Scl70
B. Anti centromere
C. ANCA
D. anti-CCP
E. anti-SSA
F. anti-SSB
G. anti dsDNA
Question 70:
32 year old female, 12 weeks pregnant, has sicca symptoms.
Which antibody predicts development of neonatal heart-block?
RACP 2015
An older man presents with gout. He is on frusemide and hydrochlorothiazide. You
commence him on allopurinol.
What is the best endpoint to assess the efficacy of his allopurinol dose?
A. Urate level
B. Swollen joint count
C. CRP
D. Rhubarb
E. Rhubarb
Answer A Urate/Uric acid level
Urate lowering therapy is commenced with treat to target uric acid level:
< 0.36mmol/L for non-severe gout
<0.30 mmol/L for severe/ tophaceous gout
RACP 2014a Q28
79 year old lady presents to hospital with an acute sore, swollen R shoulder. She has a background history of rheumatoid arthritis treated with adalimumab/steroids. She is febrile to 39.5C and has tenderness, swelling and limited range of movement with the right shoulder. Joint aspirate reveals a cell count of 120 000 (90% neutrophils) and negative gram stain. What
is it most likely to be
a. RA
b. Gout
c. OA
d. Septic arthritis
Answer D
Reasons pointing to septic arthritis:
- High WBC count with high neutrophil percentage (non-infectious inflammation have WBc counts upto 50,000 max, non- inflammatory should be < 2000 WBC)
- High grade fevers
Immunosuppression for RA treatment
-Gram stains are negative in about 50% of cases of bacterial arthritis, but (in the absence of antibiotics) cultures are positive in about 90%
RACP 2014b Q5
Question 5:
A 76 year old female is evaluated for osteoporosis. She is currently on vitamin D and calcium medications. She states that she drinks milk regularly and exercises 20 minutes a day. She completed menopause at the age of 46 and never had any HRT. Her UEC, CMP and vitamin D are all normal. Her DEXA scan results are shown below:
T score:
Lumbar spine -1.5
Hip -1.2
What is the management plan?
1. Continue calcium and vitamin D
2. Commence HRT
3. Commence strontium
4. Commence bisphosphonate
5. Commence raloxifene
RACP 2014b Q7
Question 7
A 43 year old woman presents with painful dysaesthesias of both hands, as well as weakness of
dorsiflexion of the left foot. She also reports sicca symptoms and arthralgia. Results of some of her blood tests are outlined below:
ANA positive 1:2560
Anti-SSA and SSB antibodies positive
Rheumatoid factor positive
ANCA negative
Normal C3 and C4
What is the most likely underlying pathology?
a. Rheumatoid arthritis
b. Primary Sjogren’s syndrome
c. Mixed connective tissue disease
d. SLE
e. Cryoglobulinaemic vasculitis
Answer B Primary Sjogrens
RACP 2014b Q14
A 76 y.o female presents with difficulty forming a fist bilaterally. She has been having progressive difficulty with using a key over the last 12 months. She was wasting of the distal forearms and hands with associated weakness of the hands. She is ANA and ANCA –ve and has
a normal FBC, LFT and CK.
What is the likely diagnosis?
A. Hypothyroidism
B. Inclusion body myosotis
C. Polymyositis
D. SLE
E. Viral myopathy
RACP 2014b Q37
A 35 year old overweight woman (BMI 28) presents with 12 month history of bilateral shoulder
pain, dry eyes, face flushing after alcohol and urinary frequency.
Investigations showed ANA 1:160, ENA, RF negative. Full blood count, creatinine, liver function
tests and inflammatory markers were unremarkable.
What is the most likely diagnosis?
A. Fibromyalgia
B. Sjogrens
C. Systemic lupus erythematosis
D. Polymyositis
E. Polymyalgia rheumatica
RACP 2014 Q41
A 58 year old gentleman presents with a two week history of right shoulder pain, worse at night time. He has restricted ROM both to passive and active movement. His ESR, CRP
are normal and hisANA is negative. What is the most likely diagnosis?
A. Osteoarthritis
B. Rheumatoid arthritis
C. Gout
D. Adhesive Capsulitis
E. Septic arthritis
Answer D: Adhesive capsulitis
Clinical features:
Severe restriction of both active and passive range of motion of the glenohumeral joint in all planes, especially:
- External rotation
- Passive abduction (restricted to < 90°)
RACP 2013a Q2
Question 2
Which is the best clinical feature to differentiate ankylosing spondylitis from mechanical back pain?
A. Loss of lumbar lordosis
B. Morning stiffness
C. Pain radiating to thigh
D. Age of onset
E. Reduced lumbar movement
Answer B Morning stiffness
Ankylosing spondylitis causes inflammatory back pain characterised by:
- slow insidious onset
- nocturnal pain
- morning stiffness that improves with activity
- persisting of pain at rest
RACP 2013a Q12
Question 12
A 60 year old male presents with a background of left knee osteoarthritis presents with new onset left knee
and posterior lower leg pain. The pain is worse on dorsiflexion.
What is the most likely pathology?
A) Meniscal Tear
B) A ruptured baker's cyst
C) DVT
D) S1 radiculopathy
E) Achilles tendon rupture
RACP 2013a Q62
Question 62
A 76 year old woman suffers a vertebral fracture due to osteoporosis. She is treated with IV zolendronate.
In addition to reducing rate of refracture, what is the benefit of bisphosphonates?
A. Improvement in mobility
B. Decreased bone pain
C. Improved QOL
D. Decrease mortality
E. Improved muscle strength
RACP 2013b Q6
Question 6
A middle aged patient presents with headache, lethargy, lymphadenopathy and a purpuric rash on his feet. Bloods demonstrate
Cryocrit 75%
EPG paraprotein 2g/L
IEPG monoclonal IgM
C4 low limit of normal
RF elevated
What is the most likely diagnosis?
a) Hepatitis C infection
b) Rheumatoid arthritis
c) Sjogren syndrome
d) Waldenstrom’s macroglobulinemia
e) Systemic lupus erythematous
RACP 2013b Q15
Question 15
A 30 year old woman presents with bilateral proximal muscle weakness. She is noted to have blanching of
the fingers, especially in cold weather.
Anti-Jo: positive
ANA positive
CK 2000s
ESR 60
EMG: myopathic changes
The presence of which of the following conveys the worst prognosis?
A) Dysphagia
B) Skin rash
C) CK > 2000 ( or >10xULN)
D) ILD
E) Raynaud’s Phenomenon
RACP 2013b Q39
Question 39
A 60 year old diagnosed with polymyositis which has been well controlled for the last six months with prednisolone 30mg daily and methotrexate 15mg daily. For the last two weeks he has reported worsening proximal weakness and trouble walking up the stairs. Creatine phosphokinase and liver function tests are normal.
What would be the most appropriate next step in management:
A) Commence cyclosporin
B) Increase methotrexate dose
C) Muscle biopsy
D) Physiotherapy
E) Decrease prednisolone dose
RACP 2013b Q51
Extended match questions
Options:
a) Anti CCP
b) Anti Sm
c) Anti ANCA
d) Anti Scl 70
e) Anti DNA
f) Rh factor
g) Anti-centromere
h) Anti-Jo
i) Anti-RNP
What is the most diagnostic test for the conditions below?
Question 51
41 year old woman presents with tightening of fingers, mild difficulty swallowing, and mild shortness of
breath on exertion. She takes somac for reflux. On examination there is tightening of skin in her fingers,
however the rest of the skin is normal. Her joints are not inflamed. The rest of her examination was normal
(including chest examination). Her CXR is also normal. There is mild decrease in DLCO on lung function tests
RACP 2013b Q52
Extended match questions
Options:
a) Anti CCP
b) Anti Sm
c) Anti ANCA
d) Anti Scl 70
e) Anti DNA
f) Rh factor
g) Anti-centromere
h) Anti-Jo
i) Anti-RNP
What is the most diagnostic test for the conditions below?
Question 52
A 30 year old woman presents with fatigue, weight loss and swelling of the small joints of her hands, worst
in the morning, improves with exercise, present for several months. There was no swelling or erythema on
examination, but tenderness on mobilising the small joints of her hands. Her urinalysis is clear and her
respiratory function tests are normal. She also has a rash on her trunk and arms. What is the most useful
test to establish her diagnosis?
RACP 2013b Q55
30F presents with polyarthralgia and fatigue. Which of the following conditions is a negative ANA most
useful for ruling out?
A. Fibromyalgia
B. Adult onset Still's disease
C. Systemic lupus erythematosus
D. Scleroderma
E. Rheumatoid arthritis
RACP 2013b Q67
A 66yo female presents with hand pain. This is an x-ray. What is the diagnosis?
A) Osteoarthritis
B) Rheumatoid arthritis
C) Chronic tophaceous gout
D) Psoriatic arthritis
E) Scleroderma
RACP 2013b Q82
Question 82
With respect to osteoarthritis of the knee, which of the following is most effective in long-term
management of pain?
A. Arthroscopic lavage
B. Glucosamine
C. Muscle strengthening exercises
D. Paracetamol
E. NSAIDs
RACP 2012a Q35
QUESTION 35
Which of the following clinical features is most useful in differentiating between ankylosing spondylitis and mechanical lower back pain?
A. Age
B. Early morning back stiffness
C. Loss of lumbar lordosis
D. Loss of lumbar flexion
E. Pain radiating from the back to posterior thighs
Answer ?B
RACP 2012b Q48
QUESTION 48
Corticosteroid induced osteoporosis, as compared to postmenopausal
osteoporosis, is more likely to be associated with which of the following?
A. Asymptomatic vertebral fractures
B. Fractures at a higher BMD
C. Decreased response to calcium
D. Decreased response to bisphosphonates
E. Sub trochanteric fractures
RACP 2012b Q32
A lady presents with polyarthralgia, fever and rashes on her hands. An example of
her rash is below. What is the condition likely to be?
A. SLE
B. MCTD
C. Scleroderma
D. Cryoglobulinemia
E. RA
RACP 2012b Q78
A lady with rheumatoid arthritis presents with the following signs when attempting to
extend her fingers:
The most likely diagnosis is:
A. Rupture of extensor tendons
B. Dupytrens contracture
C. Arthritis of MCP joints
D. Radial nerve palsy
E. Subluxation of MCP joints
RACP 2012b Q88
A patient presents with painful hands with the appearance shown below:
What type of arthritis commonly presents with this finding?
A. Enteropathic arthritis
B. Psoriatic arthritis
C. Reactive arthritis
D. Rheumatoid arthritis
E. SLE
RACP 2011b Q29
A 54 year old male presents with an 18 month history of pain and swelling in the
distal interphalangeal joint of his right index finger. An X-ray is shown:
The most likely diagnosis is:
A. Calcium pyrophosphate deposition disease
B. Gout
C. Osteoarthritis
D. Psoriatic arthritis
E. Septic arthritis
RACP 2011b Q48
A male patient with a history of intravenous drug use presents with a rash, myalgias, arthralgias. He is afebrile. He is positive to hepatitis C antibody and rheumatoid factor. He C4 complement level is reduced with normal C3 levels. His ANA is positive
at 1:160 speckled. His rash is shown below:
What is the most likely diagnosis?
A. Cryoglobulinaemic vasculitis
B. Henosch-schonlein purpura
C. Rheumatoid vasculitis
D. Subacute bacterial endocarditis
E. Meningococcal disease
RACP 2011b Q51
Question 51
A 65 year old male with longstanding asthma presents with cough, dypsnoea and a
right 6 th cranial nerve palsy. A CT scan shows diffuse and patchy ground glass
changes.
His blood tests are shown:
Hb 109 [130-180]
WCC 14 [4-11]
Plt 480 [150-400]
ANCA positive
RPA2011_Paper B Page 25/17
Anti-myeloperoxidase (MPO) 99 [<5]
ESR 100 [0-5]
CRP 30 [0-5]
Anti-dsDNA 5 [0-6]
ANA 1:160 speckled
Urinalysis trace blood, no protein
The most likely diagnosis is:
A. Allergic bronchopulmonary aspergillosis (ABPA)
B. Churg-Strauss syndrome
C. Primary hypereosinophilic syndrome
D. Systemic lupus erythematosus
E. Wegener’s granulomatosis
RACP 2011b Q66
A 30 year old man presents with pain and swelling at his heel as shown below.
The most likely cause is:
A. Achilles tendonitis
B. Achilles enthesopathy
C. Acute gout
D. Achilles tendon rupture
E. Posterior ankle impingement
RACP 2011b Q92
A 40 year old man with a 20 year history oftype one diabetesmellitus presents with
difficulty flexing and extending his fingers. There is thickened skin over the dorsum
of the hands with palpable thickened tendon sheaths. There is no digital pitting or
loss of distal finger subcutaneous tissue. What is the most likely diagnosis?
RPA2011_Paper B Page 43/17
A. Hypothyroidism
B. Limited scleroderma
C. Haemachromatosis
D. Diabetic cheiroarthropathy
E. Amyloidosis
RACP 2010b Q47
A 54-year-old man with an 18 month history of pain and swelling in the DIP joint of the right index finger has the following x-ray. What is the likely diagnosis? The XR is shown below.
This is the closest XR I could find to the actual exam. The main differences are: 1. The DIP instead of PIP was involved. 2. There was significant osteopenia without any significant evidence of punchout lesions. (X-ray shows a hand, with some sort of intraosseous abnormality which some interpreted as
a subchondral cyst but which others have suggested as a tophus)
A. Gout
B. Pseudogout
C. Osteoarthritis
D. Psoriatic arthritis
E. Septic arthritis
RACP 2008b QUESTION 7
When aspirating a small effusion in the knee joint, where should the needle be inserted (see below)?
A. 1 cm medial to the junction of the upper and middle third of the patella.
B. 3 cm medial to the lower pole of the patella.
C. 1 cm medial to the mid point of the patella tendon.
D. 1 cm lateral to the lower pole of the patella.
E. 3 cm lateral to the junction of the upper and middle third of the patella.
RACP 2008b QUESTION 29
A week after a flu like illness, a 22-year-old presents with a haemorrhagic rash on the lower extremities (as shown in the figure below), and generalised arthralgia. The serum creatinine is elevated (125 μmol/L, [<110 μmol/L]) and there is blood and protein in the urine.
The most likely finding on renal biopsy is:
A. glomerular microangiopathy (haemolytic-uraemic syndrome).
B. mesangiocapillary glomerulonephritis.
C. Henoch-Schönlein nephropathy.
D. antineutrophil cytoplasmic antibody (ANCA) positive vasculitis.
E. lupus nephropathy.
RACP 2008b Q 44
A 43-year-old man with human immunodeficiency virus (HIV), first diagnosed 20 years previously,
presents with a gradual onset of right-sided hip pain. He is on tenofovir, emtracitabine and efavirenz. He has had no acquired immunodeficiency syndrome (AIDS) defining illnesses in the past. On examination he has evidence of facial lipoatrophy and there is limitation of the range of movement of
the right hip because of pain. All other joints are normal. There are no skin rashes. An X-ray of his hip is shown below.
Laboratory results show:
CD4 count 0.41 x 109/L [0.45 – 1.1 x 109/L]
HIV viral load undetectable
Full blood count (FBC) within normal limits
Uric acid 0.55 mmol/L [0.18 – 0.48 mmol/L]
Antinuclear antibodies not detected
Rheumatoid factor not detected
What is the most likely diagnosis?
A. Avascular necrosis.
B. Psoriatic arthritis.
C. Osteoarthritis.
D. Rheumatoid arthritis.
E. Gout.
RACP 2007b QUESTION 69
A 49-year-old woman with a 25 year history of type 1 diabetes mellitus presents with progressive mid foot pain and swelling over six months. An X-ray of the affected foot is shown below.
The most likely diagnosis is:
A. Osteoarthrititis.
B. Neuropathic arthropathy.
C. Osteomyelitis.
D. Gout.
E. Rheumatoid arthritis.
RACP 2006b QUESTION 38
A 70-year-old woman has been on haemodialysis for 11 years. She complains of painful shoulders and knees and wrists and cannot raise her arms beyond 90°. She has noted a gradual deterioration in
her arthralgias over a period of 12 months. A radiograph of her wrist is shown below. Which of the following is most likely to explain her symptoms?
A. Pseudogout.
B. Proximal myopathy.
C. Dialysis related amyloidosis.
D. Gout.
E. Osteoarthritis.
RACP 2005a Q24
A 54-year-old man presents with neck pain. Examination reveals a limited range of movement of the neck. Which feature on the X-ray shown above best explains the limited range of movement?
A. Zygoapophyseal joint fusion.
B. Diffuse disc degeneration.
C. Upper cervical spine instability.
D. Calcification of the posterior longitudinal ligament.
E. Diffuse idiopathic skeletal hyperostosis.
RACP 2005 Q22
A 52-year-old female presents with a 12-month history of painful swollen fingers. X-rays of her hands are shown above. For which of the following conditions are these findings most characteristic?
A. Rheumatoid arthritis.
B. Systemic lupus erythematosus.
C. Psoriatic arthritis.
D. Gout.
E. Scleroderma.
RACP 2005b QUESTION 99
A 65-year-old woman presents with six months of worsening left knee pain. The knee pain is worse
during and after walking and improved by rest. On examination she has a body mass index (BMI) of
36 kg/m2
[18-25]. Her left knee is not swollen and has a painful but full range of movement.
Her X-ray is as shown below.
The most appropriate initial management, in addition to simple analgesia with paracetamol, is:
A. commence non-steroidal anti-inflammatory medications.
B. inject the left knee with a depot corticosteroid.
C. refer the patient for quadriceps muscle strengthening exercises.
D. refer to a dietician for a weight-loss program.
E. refer to an orthopedic surgeon for arthroscopy.
RACP 2004a QUESTION 18
Which of the following conditions is most likely to be present in a patient with the nailfold lesions
shown above?
A. Polymyositis.
B. Systemic sclerosis.
C. Systemic lupus erythematosus (SLE).
D. Seropositive rheumatoid arthritis.
E. Multicentric reticulohistiocytosis.
RACP 2004b QUESTION 30
A frail 88-year-old woman is admitted to hospital within a few hours of having developed sudden,
severe and disabling pain in the lower back and right buttock. She has previously been well aside
from well-controlled hypertension and the resection of a sigmoid colon cancer 15 years ago.
Examination is difficult because of pain. There is considerable but poorly localised tenderness around
the sacral area and buttock, pain on movement of either hip and no obvious neurological deficit. X-rays of the lumbo-sacral spine, pelvis and hips reveal degenerative changes in the lumbosacral spine of a degree expected in a woman of her age. A bone scan, performed on the afternoon of her admission, is shown below.
The most likely diagnosis is:
A. prolapsed intervertebral disc causing sciatic pain.
B. stress fracture of the sacrum or pelvis.
C. metastatic bone disease.
D. musculo-ligamentous low back strain.
E. referred pain from pelvic recurrence of colonic neoplasm.
RACP 2004b QUESTION 64
A 60-year-old Polynesian man presents with a 12-month history of pain and swelling in the left third proximal interphalangeal joint. X-rays of the hand and affected finger are shown below.
The X-rays are most consistent with which of the following?
A. Gout.
B. Tuberculous arthritis.
C. Chronic septic arthritis.
D. Hyperparathyroidism.
E. Psoriatic arthritis.
QUESTION 94
A 45-year-old woman is referred following relocation from interstate. Her accompanying medical records list her major diagnosis as systemic lupus erythematosus (SLE). You elicit a history of three
to four years of polyarthritis, Raynaud’s phenomenon, myalgia and proximal muscular weakness and
recently, increasing shortness of breath on exertion. Examination reveals a blood pressure of 120/70 mmHg, a single prominent second heart sound, diffuse puffiness of the digits, mild proximal weakness and mild synovitis of the wrists and small joints of the hands. Which of the following would be the most likely cause of death in this woman?
A. Diffuse proliferative glomerulonephritis.
B. Myocarditis.
C. Renovascular hypertension.
D. Pulmonary hypertension.
E. Cerebral vasculitis.
RACP 2003a Q30
The condition shown in the X-rays above is most likely to be seen with which one of the following?
A. Haemochromatotic arthropathy.
B. Osteoarthritis secondary to trauma.
C. Primary osteoarthritis.
D. Haemophilic arthropathy.
E. Ochronotic arthropathy.
RACP 2003a Q61
A 64-year-old woman undergoes a dual-energy X-ray absorptiometry scan. The report is shown below. According to World Health Organisation (WHO) definitions, the patient’s lumbar spine bone density is:
A. high normal.
B. normal.
C. osteopenic.
D. osteoporotic.
E. severely osteoporotic.
RACP 2003b QUESTION 15
A 19-year-old man, who is sexually active and admits to occasional recreational drug use, presents with a
three-day history of severe pain over the left sacroiliac area. Examination reveals a temperature of 38°C,
pulse rate of 80/minute and blood pressure of 120/80 mmHg. The only other findings are ridged nails and
pain on movement of the spine or when pressure is applied to the sacroiliac joints.
Investigations show:
white cell count 12.5 x 109 /L [3.5-11.0]
haemoglobin normal
platelet count normal
erythrocyte sedimentation rate (ESR) 50 mm/h [<10]
C-reactive protein 170 mg/L [<10]
X-rays of the spine and pelvis are normal. The bone scan is shown below.
The most likely diagnosis is:
A. reactive arthritis following Chlamydia trachomatis infection.
B. psoriatic arthritis.
C. gonococcal arthritis.
D. septic sacroiliitis.
E. undifferentiated spondylarthropathy.
RACP 2002b QUESTION 28
A 45-year-old diabetic man presents with ‘arthritis in his hands’. X-rays of the left hand are shown below.
The most likely diagnosis is:
A. gout.
B. primary osteoarthritis.
C. hyperparathyroidism.
D. haemochromatosis.
E. rheumatoid arthritis.
RACP 2002b QUESTION 55
A 37-year-old woman who has had rheumatoid arthritis for five years attends for follow-up. She is currently
on treatment with methotrexate 7.5 mg once weekly, folic acid 10 mg once weekly, ketoprofen 200 mg daily
and prednis(ol)one 7.5 mg daily. She says that she is doing ‘very well’, with little pain or morning stiffness
and that her function is much better than it was two years previously. Examination reveals soft tissue
swelling in the wrists and most metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints with
subluxation of the 2nd MCP joint bilaterally.
Blood investigations show:
haemoglobin 105 g/L [115-165]
erythrocyte sedimentation rate (ESR) 45 mm/h [0-15]
C-reactive protein 42 mg/L [<10]
X-rays taken two years ago showed early erosions in the right 2nd MCP joint and the left carpus. The
current X-ray of her right hand is shown below.
The most appropriate treatment would be to:
A. add leflunomide (Arava) to current therapy.
B. increase the methotrexate dose.
C. replace methotrexate with cyclosporin.
D. reduce the prednis(ol)one dose to 5 mg daily.
E. temporarily increase the prednis(ol)one dose to 10 mg twice daily.
RACP 2001a Question 35
Which one of the following is the most common association of the abnormality shown in the X-ray above?
A. Haemochromatosis.
B. Hypomagnesaemia.
C. Old age.
D. Hyperparathyroidism.
E. Osteoporosis.
RACP 2001b Q10
A 25-year-old man presents with a five-year history of low back pain and stiffness. Symptoms are generally worse in the morning with some improvement following activity. Over the past three years he has also had episodes of Achilles tendonitis. Examination reveals marked limitation of lumbar spine movements in all planes.
Investigations shown (in picture)
X-rays of the patient’s pelvis and lumbar spine are shown above.
What is the most appropriate initial management?
A. Paracetamol 1 g qid.
B. Indomethacin 25 mg tds.
C. Indomethacin 25 mg tds and a physical therapy programme.
D. A physical therapy programme and hydrotherapy.
E. Sulphasalazine 1 g bd and hydrotherapy.
RACP 2001b Question 80
A 56-year-old woman with longstanding rheumatoid arthritis presents with a three-month history of increasing groin pain radiating to the knees. Her magnetic resonance imaging (MRI) scan is shown below.
The most likely cause of the pain is:
A. synovitis.
B. osteoarthritis.
C. avascular necrosis.
D. pigmented villonodular synovitis.
E. psoas abscess
RACP 2000a Question 56
A 68-year-old man with rheumatoid arthritis for 15 years has the following bone densitometry results on dual energy X-ray absorptiometry scan:
The most likely explanation for the discrepancy between the femoral neck and lumbar spine readings is:
A. technical error.
B. Paget’s disease in lumbar spine.
C. lumbar spondylosis.
D. secondary osteoarthritis in the hip.
E. synovitis in the hip
RACP 2000a Question 13
A 22-year-old woman presents with an eight-week history of erythematous rash on the arms and malar region, mild arthralgia and malaise.
Investigations show:
The most appropriate initial treatment is:
A. paracetamol.
B. naproxen.
C. hydroxychloroquine.
D. prednis(ol)one 15 mg/day.
E. pulse cyclophosphamide.
RACP 2000 Question 68
A 58-year-old man presents with a two-month history of knee and wrist pain. He has mild local tenderness with no soft tissue swelling or joint effusion. The physical examination is otherwise unremarkable.
An X-ray of his knee is shown below.
Which one of the following is the most appropriate next investigation?
A. Chest X-ray.
B. Joint aspiration.
C. Isotope bone scan.
D. Serum rheumatoid factor.
E. Serum calcium and parathyroid hormone
RACP 2000b Question 77
A 72-year-old man with longstanding diabetes presents with a three-month history of discomfort and swelling in the midtarsal region.
Investigations show:
FBC normal
ESR 22 [2-14]
EUC normal
Serum Uric acid 0.49 [0.20-0.47 mmol/L]
Glycosylated haemoglobin 7.9% [<6.1%]
RF 22U/mL [0-20]
The X-ray of his foot is shown below.
The most likely cause of the foot pain is:
A. osteoarthritis.
B. gout.
C. septic arthritis.
D. neuropathic arthropathy.
E. rheumatoid arthritis.
RACP 2000b Question 87
A 44-year-old man presents with a four-day history of acute right knee pain. He has a 10-year history of episodic pain and swelling of his toes, ankles and wrists. Examination reveals a warm, swollen right knee with an effusion. There is soft tissue swelling in both wrists, the left elbow and the right ankle and forefoot. A previous X-ray of his foot is shown below.
Investigations show:
Hb 150 [130-180]
WCC 12 x10 ^9 [4-11]
ESR 90[1-10]
CRP 186 [0-8]
Which one of the following is the most likely diagnosis?
A. Rheumatoid arthritis.
B. Gout.
C. Chondrocalcinosis.
D. Seronegative arthritis.
E. Septic arthritis.
RACP 2000b Question 97
A 64-year-old woman has painful swelling, pallor and blue discolouration of her fingers when cold.
An X-ray of one of her hands is shown below.
Which one of the following autoantibodies is most likely to be present?
A. Anti-RNP.
B. Anti-Pm-Scl.
C. Anti-centromere.
D. Anti-topoisomerase 1 (Scl 70).
E. Anti-filaggarin.
RACP 1999a A 68-year-old man with rheumatoid arthritis for 15 years has the following bone densitometry results on dual energy X-ray absorptiometry scan:
The most likely explanation for the discrepancy between the femoral neck and lumbar spine readings is:
A. technical error.
B. Paget’s disease in lumbar spine.
C. lumbar spondylosis.
D. secondary osteoarthritis in the hip.
E. synovitis in the hip
RACP 1999b PAPER 2
Question 3
A 25-year-old woman presents with a three-month history of aching and stiffness of her joints. She also reports fatigue and Raynaud’s phenomenon. Her only medication is minocycline for acne.
The appearance of the patient’s hands is shown.
The following blood results are obtained:
Which of the following is the most likely diagnosis?
A. Rheumatoid arthritis.
B. Systemic lupus erythematosus.
C. Drug induced lupus erythematosus.
D. Mixed connective tissue disease.
E. Systemic sclerosis.
RACP 1999b Question 6
A 37-year-old woman presents with a two-week history of pain in the region of the right hip. She has a five-year history of systemic lupus erythematosus with diffuse proliferative glomerulonephritis which was treated initially with high dose prednis(ol)one (1 mg/kg/day), but has recently been controlled by hydroxychloroquine 200 mg/day and prednis(ol)one 7.5 mg/day.
Examination of the right hip reveals moderate painful restriction of movement without local tenderness. Other joints are not painful or inflamed.
X-ray of the right hip shows no abnormality. A technetium 99m MDP bone scan of the right hip is shown below.
Which one of the following is the most likely diagnosis?
A. Acute synovitis.
B. Septic arthritis.
C. Osteoarthritis.
D. Femoral neck fracture.
E. Avascular necrosis.
RACP 1999b Question 10
A 42-year-old woman with severe progressive systemic sclerosis presents with a three-week history of malaise, severe headaches and dyspnoea. Examination findings include a blood pressure of 180/115 mmHg, cardiomegaly, basal lung crepitations, retinal haemorrhages, and widespread skin tethering.
Investigations show:
The most appropriate initial treatment is:
A. pulse intravenous methyl prednis(ol)one.
B. plasmapheresis.
C. frusemide.
D. captopril.
E. renal dialysis.
RACP 1999b Question 83
A 72-year-old woman has rheumatoid arthritis treated with prednis(ol)one 5 mg per day and methotrexate 12.5 mg per week. She is admitted to hospital because of cellulitis in her leg, and treated with intravenous flucloxacillin.
The last dose of methotrexate was on the day before admission.
Investigations on admission show:
The most appropriate additional treatment at this stage is:
A. none.
B. increase prednis(ol)one.
C. granulocyte colony stimulating factor.
D. folic acid.
E. folinic acid (leucovorin calcium).
