MRCP Part 1 Rheumatology 1 — Questions and Answers
Question 1: A 45-year-old woman presents with 6 weeks of symmetrical swelling of the MCPs and PIPs, 2-hour morning stiffness, elevated CRP, positive RF, and positive anti-CCP. What is the most appropriate first-line DMARD?
- Hydroxychloroquine
- Methotrexate (Correct answer)
- Sulfasalazine
- Leflunomide
Correct answer: Methotrexate
Methotrexate is the anchor DMARD for rheumatoid arthritis and is recommended as first-line therapy by both NICE and EULAR guidelines.
Question 2: A patient with SLE develops proteinuria 3.5g/24h, haematuria, and cellular casts. Renal biopsy shows endocapillary hypercellularity affecting more than 50% of glomeruli. According to ISN/RPS classification, which class of lupus nephritis is this?
- Class II
- Class III
- Class IV (Correct answer)
- Class V
Correct answer: Class IV
Class IV (diffuse proliferative) lupus nephritis involves more than 50% of glomeruli and is the most severe form, requiring aggressive immunosuppression with cyclophosphamide or mycophenolate.
Question 3: A 65-year-old man taking hydrochlorothiazide presents with acute severe pain in the right first metatarsophalangeal joint. Joint aspirate reveals needle-shaped crystals that are strongly negatively birefringent under polarised light. What is the deposited substance?
- Calcium pyrophosphate
- Monosodium urate (Correct answer)
- Hydroxyapatite
- Calcium oxalate
Correct answer: Monosodium urate
Monosodium urate crystals are negatively birefringent and needle-shaped, causing gout; thiazide diuretics reduce renal urate excretion, raising serum urate levels.
Question 4: A 28-year-old man presents with 4 months of insidious lower back pain and stiffness lasting more than 1 hour each morning, relieved by exercise but not rest. X-ray shows bilateral sacroiliac joint erosions. HLA-B27 is positive. What is the most likely diagnosis?
- Diffuse idiopathic skeletal hyperostosis
- Ankylosing spondylitis (Correct answer)
- Psoriatic spondyloarthropathy
- Reactive arthritis
Correct answer: Ankylosing spondylitis
Ankylosing spondylitis is characterised by bilateral sacroiliitis, inflammatory back pain that improves with exercise (not rest), and strong association with HLA-B27 in young men.
Question 5: A 52-year-old woman presents with a 2-year history of dry eyes, dry mouth, and arthralgia. Schirmer's test confirms reduced lacrimation. Which antibody is most characteristically associated with primary Sjögren's syndrome?
- Anti-Jo-1
- Anti-Scl-70
- Anti-Ro (SSA) (Correct answer)
- Anti-dsDNA
Correct answer: Anti-Ro (SSA)
Anti-Ro (SSA) antibodies are present in approximately 70% of patients with primary Sjögren's syndrome and are the hallmark serological finding.
Question 6: A 40-year-old man with known psoriasis develops diffuse swelling of the entire right index finger, giving it a sausage-like appearance. What is the correct term for this finding?
- Heberden's node
- Swan-neck deformity
- Dactylitis (Correct answer)
- Boutonnière deformity
Correct answer: Dactylitis
Dactylitis (sausage digit) results from simultaneous inflammation of all compartments of a digit including tendons and joints, and is a hallmark feature of psoriatic arthritis.
Question 7: A 58-year-old woman with active rheumatoid arthritis is about to start methotrexate. Which baseline investigation is most critical before initiating this drug?
- Echocardiogram
- Pulmonary function tests
- Liver function tests and full blood count (Correct answer)
- Dual-energy X-ray absorptiometry
Correct answer: Liver function tests and full blood count
Methotrexate is hepatotoxic and myelosuppressive; baseline liver function tests and full blood count are mandatory before starting therapy, with regular monitoring every 4–12 weeks thereafter.
MRCP Part 1 Rheumatology 1
A 45-year-old woman presents with 6 weeks of symmetrical swelling of the MCPs and PIPs, 2-hour morning stiffness, elevated CRP, positive RF, and positive anti-CCP.
What is the most appropriate first-line DMARD?