Q1. Which feature most suggests INFLAMMATORY rather than mechanical joint pain? A. Pain worse after activity B. Morning stiffness lasting over an hour, improving with movement C. Brief stiffness relieved by rest D. Bony hard swelling ANSWER: B. Why: prolonged morning stiffness that eases with use is the hallmark of inflammatory disease. Mechanical pain worsens with use and settles with rest. LEARNING POINT: "better with movement" is the single most useful question in the rheumatology history.

Q2. Gout crystals on polarised microscopy are: A. Rhomboid and positively birefringent B. Needle-shaped and negatively birefringent C. Spherical and non-birefringent D. Absent in acute attacks ANSWER: B — needle-shaped, negatively birefringent. Why: monosodium urate crystals are needle-shaped with negative birefringence. Calcium pyrophosphate (pseudogout) is rhomboid and positively birefringent. LEARNING POINT: needle/negative for urate; rhomboid/positive for CPPD.

Q3. A patient with rheumatoid arthritis on methotrexate has one acutely hot, swollen knee for 24 hours. Temperature 37.1°C. The correct action is: A. Treat as a rheumatoid flare with steroids B. Urgent joint aspiration; treat as septic arthritis until excluded C. Reassure and review in a week D. Increase the methotrexate ANSWER: B — aspirate urgently. Why: a single acutely hot joint is septic until proven otherwise, and this patient has two major risk factors — pre-existing joint disease and immunosuppression. RA flares are typically polyarticular, and immunosuppressed patients often do not mount a fever. LEARNING POINT: a near-normal temperature is not reassurance in this group.

Q4. A man on a thiazide has an acute painful first MTP joint. Serum urate is within the normal range. This means: A. Gout is excluded B. Urate often falls during an acute attack, so gout is not excluded C. He must have septic arthritis D. The urate assay is unreliable ANSWER: B. Why: serum urate frequently falls during a flare, so a normal level mid-attack is common and excludes nothing. The presentation and the thiazide both support gout. LEARNING POINT: recheck urate after the attack settles, and review the diuretic.

Q5. A newly diagnosed rheumatoid patient is started on NSAIDs alone with a plan to review in six months. The main problem with this plan is: A. NSAIDs are contraindicated in RA B. NSAIDs relieve symptoms but do not prevent erosion — DMARDs should start early C. Six months is too short an interval D. NSAIDs cause rheumatoid nodules ANSWER: B. Why: joint erosion is irreversible and occurs early. DMARDs modify the disease; NSAIDs only relieve symptoms. Delaying disease-modifying treatment allows permanent damage while the patient feels adequately treated. LEARNING POINT: comfort is not disease control.

Q6. A joint aspirate shows urate crystals. The patient is febrile, systemically unwell, and the joint is very hot. The correct interpretation is: A. Gout is confirmed; infection is excluded B. Crystals do not exclude coexisting septic arthritis — treat as septic pending cultures C. Send home on colchicine D. Repeat the aspirate in a week ANSWER: B. Why: crystal arthritis and septic arthritis can occur in the same joint simultaneously. In a systemically unwell patient with a hot joint, the safe course is to treat as septic while awaiting culture. LEARNING POINT: a positive finding for one diagnosis does not exclude a more dangerous one.

Q7. A rheumatoid patient's methotrexate is transcribed on admission as a DAILY dose. Three days later she has mucositis and neutropenia. This represents: A. An expected side effect at normal dosing B. Methotrexate toxicity from incorrect daily rather than weekly administration C. Septic arthritis D. Disease flare ANSWER: B — a dosing error. Why: methotrexate for rheumatological disease is dosed WEEKLY. Daily administration produces severe myelosuppression and mucositis, and is a recognised and sometimes fatal prescribing error, typically occurring at transitions of care. LEARNING POINT: check the frequency on every methotrexate prescription, and co-prescribe folic acid on a different day.