Free practice quiz
ABIM Rheumatology Prep Course (Rheum): free quiz
10 questions from the program. See your score right away, then unlock the explanation of every answer.
- Question 1 of 10
A 34-year-old woman has recurrent 2-day fevers, migratory urticarial rash, and arthralgias since adolescence. Examination between attacks shows no synovitis. During flares, ESR and CRP are markedly elevated; ANA, rheumatoid factor, anti-CCP, and blood cultures are negative, and complement levels are normal. Symptoms improve dramatically after starting anakinra. Which immune pathway best explains this presentation?
Innate Autoinflammation and IL-1
Autoinflammatory syndromes arise from dysregulated innate immunity, often inflammasome activation with IL-1β excess; fever, urticarial rash, high CRP, negative autoantibodies, and anakinra response support A. D is tempting in lupus or serum sickness, but normal complements and absent immune-complex features argue against it. A can drive psoriasis/spondyloarthritis, but this episodic fever pattern and IL-1 response discriminate. A fits adaptive autoimmunity such as rheumatoid arthritis, but there is no persistent synovitis or autoantibody signal.
Diagnose autoinflammatory IL-1 disease; order inflammatory markers and infection exclusion; treat with IL-1 blockade; escalate for organ-threatening inflammation.Review Innate Autoinflammation — focus on inflammasome-driven IL-1β.
- Question 2 of 10
A 34-year-old woman has 3 weeks of daily spiking fevers, sore throat, evanescent salmon-colored rash, and symmetric wrist and knee pain. Examination shows synovitis of both wrists and a faint rash during fever. Labs: leukocytes 18,500/µL with 86% neutrophils, hemoglobin 10.8 g/dL, platelets 510,000/µL, ESR 82 mm/h, CRP 14 mg/dL, ferritin 18,700 ng/mL. ANA and rheumatoid factor are negative; blood cultures are negative. Which diagnosis best explains this pattern?
Marked ferritin with quotidian fever
Adult-onset Still disease causes innate immune activation with quotidian fever, evanescent rash, neutrophilic leukocytosis, arthritis, negative ANA/RF, and often very high ferritin. Treat initially with glucocorticoids/NSAIDs when appropriate; IL-1 or IL-6 blockade is used for severe or refractory disease. SLE can cause fever, rash, and arthritis, but typically has ANA positivity, leukopenia, low complement, and less striking CRP/ferritin. Polymyalgia rheumatica causes shoulder/hip girdle pain in older adults, not rash or neutrophilic leukocytosis. Seronegative RA causes chronic synovitis but not quotidian fever or ferritin near 20,000. Diagnose AOSD; order infection/malignancy exclusion and ferritin trend; treat inflammation; escalate urgently if cytopenias, hepatitis, or hypofibrinogenemia suggest macrophage activation.
- Question 3 of 10
A 52-year-old woman has 10 weeks of symmetric pain and swelling in the MCP and PIP joints with 90 minutes of morning stiffness. Examination shows synovitis in 4 small joints. ESR is 42 mm/h, CRP is 18 mg/L, RF and anti-CCP antibodies are negative, and hand radiographs show no erosions. She has no psoriasis, inflammatory bowel disease, viral prodrome, or preceding genitourinary infection. Her 2010 ACR/EULAR classification score is below the research threshold. What is the best next step?
Classification criteria are not diagnostic rules
Early seronegative RA can fail classification thresholds; persistent symmetric small-joint synovitis supports clinical diagnosis once mimics are excluded. B is correct: treat early inflammatory RA with a DMARD, usually methotrexate if safe. A is wrong because classification criteria standardize research cohorts, not exclusion of disease. D is wrong because waiting for erosions permits preventable damage. C is tempting due to seronegativity, but no preceding infection or typical asymmetric lower-extremity pattern supports reactive arthritis.
Diagnose persistent inflammatory small-joint synovitis clinically; order baseline DMARD labs and mimic evaluation; treat early with methotrexate when appropriate; escalate or refer urgently for organ-threatening features. - Question 4 of 10
A 46-year-old woman presents with 4 months of pain and swelling in both hands and wrists. She reports morning stiffness lasting 90 minutes and fatigue. Examination shows boggy tenderness and swelling of the bilateral second and third metacarpophalangeal joints, proximal interphalangeal joints, and wrists; distal interphalangeal joints are spared. ESR is elevated. Rheumatoid factor and anti-CCP antibody are negative. Hand radiographs show periarticular osteopenia without erosions. Which diagnosis is most likely?
Symmetric small-joint inflammatory polyarthritis
RA causes chronic synovitis, classically symmetric MCP/PIP/wrist swelling with prolonged morning stiffness; seronegative RA is common, and erosions may appear later. C is tempting because attacks can involve small joints, but palindromic rheumatism is episodic with complete resolution between flares. A can mimic RA, but psoriasis, nail disease, dactylitis, DIP-predominance, or asymmetric oligoarthritis would support psoriatic arthritis. A may affect PIP/DIP joints, but MCP/wrist synovitis and 90-minute stiffness favor inflammatory RA over erosive osteoarthritis.
Diagnose RA clinically; order RF, anti-CCP, ESR/CRP, and baseline radiographs; treat early with a csDMARD such as methotrexate; escalate urgently for extra-articular organ-threatening disease. - Question 5 of 10
A 42-year-old man with plaque psoriasis reports 4 months of right knee swelling, left ankle pain, and painful swelling of an entire right second toe. Examination shows nail pitting, tenderness at the Achilles insertion, and swelling of the right second and third distal interphalangeal joints. Rheumatoid factor and anti-CCP antibodies are negative; serum urate is 6.1 mg/dL. Which diagnosis best explains this pattern?
Review Psoriatic Arthritis Domains
Psoriatic arthritis is driven by seronegative spondyloarthritis inflammation involving peripheral joints, entheses, digits, axial skeleton, and skin/nails. B is correct: psoriasis, asymmetric oligoarthritis, DIP involvement, nail pitting, enthesitis, and dactylitis are classic. C is tempting because RF/anti-CCP can be negative, but rheumatoid arthritis usually causes symmetric MCP/PIP synovitis and spares DIP joints. D can cause episodic mono/oligoarthritis, but normal urate, nail disease, and dactylitis favor psoriatic arthritis. A causes DIP pain and erosions but not Achilles enthesitis, dactylitis, or inflammatory oligoarthritis.
Clinician Action: Diagnose by domain pattern; order targeted radiographs/ultrasound if uncertain; treat based on dominant domain; escalate for axial or erosive disease. - Question 6 of 10
A 29-year-old woman has 3 weeks of daily fevers to 39.5°C that spike in the evening, severe sore throat, wrist and knee pain, and a faint salmon-colored rash that appears during fevers. Examination shows synovitis of both wrists and knees and no focal infection. Laboratory studies show leukocytes 18,000/µL with neutrophil predominance, ESR 88 mm/h, ferritin 12,500 ng/mL, AST 92 U/L, negative ANA, and negative rheumatoid factor. Blood cultures and chest radiograph are unrevealing. Which diagnosis best explains this presentation?
Adult-onset Still disease
Adult-onset Still disease causes IL-1/IL-6–driven systemic inflammation with quotidian fever, evanescent salmon rash, arthritis, neutrophilic leukocytosis, transaminitis, negative ANA/RF, and very high ferritin. B is tempting because fever and arthritis occur in SLE, but ANA negativity and neutrophilic leukocytosis argue against it. A shares symmetric synovitis, but quotidian fever, rash, and ferritin elevation are not typical RA. A may cause rash and elevated AST, but proximal weakness and myositis-specific findings are absent.
Diagnose after excluding infection and malignancy; order ferritin, CBC, LFTs, cultures as indicated; treat with glucocorticoids and consider IL-1 or IL-6 blockade for severe or refractory disease; escalate urgently if macrophage activation syndrome is suspected. - Question 7 of 10
A 28-year-old woman presents with 3 months of fatigue, swollen hand joints, photosensitive facial rash, and painless oral ulcers. Examination shows malar erythema sparing the nasolabial folds and synovitis of the MCP and PIP joints. Laboratory studies show leukocytes 2800/µL, platelets 105,000/µL, urine protein-creatinine ratio 1.1 g/g with RBC casts, ANA 1:640, anti-dsDNA positive, and low C3/C4. Which diagnosis best explains these findings?
SLE with immune-complex activity
SLE causes immune-complex inflammation; anti-dsDNA positivity with low complement supports active disease, and proteinuria with RBC casts suggests lupus nephritis. C is tempting because MCTD causes inflammatory arthritis, but high-titer anti-U1 RNP, Raynaud phenomenon, and swollen hands dominate, not dsDNA/low-complement nephritis. B may cause fatigue and arthralgia, but sicca and anti-SSA/SSB predominate; renal RBC casts are atypical. D is correct. A causes photosensitive rash, but proximal weakness and elevated muscle enzymes are expected, not cytopenias and nephritic urine. Clinician Action: Diagnose SLE; order renal evaluation/biopsy for suspected nephritis; treat urgently with rheumatology-nephrology co-management.
- Question 8 of 10
A 52-year-old woman presents with 18 months of gritty eyes, dry mouth requiring water to swallow crackers, fatigue, and episodic arthralgia. Examination shows dental caries, mild bilateral parotid enlargement without fever, and no synovitis. Schirmer testing shows 3 mm wetting in 5 minutes. Laboratory studies show ANA 1:320, anti-Ro/SSA positive, anti-La/SSB negative, rheumatoid factor positive, normal IgG4 level, and negative hepatitis C antibody. Which diagnosis best explains her presentation?
Review Sjögren Syndrome Features
Primary Sjögren syndrome causes lymphocytic exocrinopathy: objective keratoconjunctivitis sicca, xerostomia, parotid enlargement, arthralgia, RF, and anti-Ro/SSA support D; anti-La/SSB is helpful but not required. Persistent parotid swelling, cryoglobulins, low C4, or lymphadenopathy should prompt lymphoma evaluation. B is tempting because salivary glands enlarge, but IgG4-related disease usually has high IgG4, tumefactive multiorgan disease, and often less severe ocular dryness. A can cause uveitis/parotitis, but pulmonary disease, hilar adenopathy, or granulomatous features are absent. A mimics Sjögren with RF and sicca, but hepatitis C testing is negative.
Diagnose with sicca plus objective dryness/SSA; order salivary testing if unclear; treat dryness and systemic disease; escalate for lymphoma red flags. - Question 9 of 10
A 52-year-old woman presents with 3 months of difficulty rising from chairs and combing her hair. She has no sensory symptoms. Examination shows symmetric proximal arm and hip flexor weakness, violaceous periorbital discoloration, and scaly erythematous papules over the metacarpophalangeal and proximal interphalangeal joints. Creatine kinase is 4200 U/L. She takes amlodipine only. Which diagnosis best explains these findings?
Dermatomyositis recognition
Dermatomyositis is a complement-mediated inflammatory myopathy causing symmetric proximal weakness, high CK, heliotrope rash, and Gottron papules; B fits. D is tempting because weakness and CK elevation overlap, but true polymyositis lacks pathognomonic rash. A can cause severe proximal weakness and CK elevation, usually with statin exposure and anti-HMGCR antibodies, but not heliotrope or Gottron lesions. A causes painless proximal weakness with normal or mildly elevated CK after glucocorticoid exposure.
Diagnose dermatomyositis; order CK trend, myositis antibodies, EMG/MRI as needed, and malignancy screening. Treat with glucocorticoids plus steroid-sparing immunosuppression; escalate for dysphagia, ILD, or cancer concern. - Question 10 of 10
A 29-year-old man reports 9 months of low back pain. He has no fever, weight loss, neurologic deficits, trauma, or cancer history. Lumbar flexion is mildly limited; straight-leg raise is negative. C-reactive protein is mildly elevated. Which additional history most strongly supports inflammatory back pain associated with axial spondyloarthritis?
Inflammatory Back Pain Features
Inflammatory back pain reflects sacroiliac or spinal enthesitis: young onset, night pain, prolonged morning stiffness, alternating buttock pain, and improvement with activity support axial spondyloarthritis. B is tempting but favors mechanical stenosis or degeneration because rest relieves it. A suggests disc radiculopathy; dermatomal symptoms and Valsalva worsening discriminate. C is correct because the combined pattern is classic, though not diagnostic alone. A fits acute lumbar strain with exertional onset and rapid rest response. Review Inflammatory Back Pain Features — focus on improvement with activity rather than rest.
DIAGNOSE by inflammatory pattern; ORDER HLA-B27 and pelvic imaging when suspicion persists; TREAT likely axial disease with exercise and NSAIDs; REFER/ESCALATE for MRI or biologic consideration.
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