LATEST RHEUMATOLOGY CERTIFICATION
EXAM FOR THE AMERICAN BOARD OF
INTERNAL MEDICINE (ABIM) | COMPLETE
EXAM Q&A WITH RATIONALES
1. A 45-year-old female presents with symmetric
polyarthritis of the hands, wrists, and knees for 6
weeks. She has morning stiffness lasting 90 minutes.
Rheumatoid factor is positive, anti-CCP is positive.
What is the most appropriate next step?
A) Start methotrexate
B) Start prednisone alone
C) Start hydroxychloroquine
D) Observation
Correct answer: A
Rationale: Methotrexate is first-line disease-
modifying antirheumatic drug (DMARD) for moderate
to severe rheumatoid arthritis. Early aggressive
therapy improves outcomes.
2. A 35-year-old female presents with photosensitive
facial rash, oral ulcers, and arthralgias. ANA is
positive 1:640, anti-dsDNA is positive. What is the
most appropriate initial treatment?
,A) Hydroxychloroquine
B) Prednisone
C) Mycophenolate mofetil
D) Belimumab
Correct answer: A
Rationale: Hydroxychloroquine is first-line for all SLE
patients without major organ involvement (skin,
joints). Reduces flares.
3. A 55-year-old male presents with new-onset severe
headache, jaw claudication, and vision loss. ESR is
95 mm/hr. What is the most appropriate next step?
A) High-dose prednisone (40-60 mg daily)
immediately
B) Temporal artery biopsy
C) MRI brain
D) Observation
Correct answer: A
Rationale: Giant cell arteritis with vision loss requires
immediate high-dose corticosteroids to prevent
further vision loss. Biopsy can be done within days
while on steroids.
,4. A 32-year-old male presents with acute onset of
red, hot, swollen right great toe. He has a history of
hypertension on hydrochlorothiazide. What is the
most appropriate next step?
A) Colchicine or NSAID for acute gout
B) Discontinue hydrochlorothiazide
C) Allopurinol
D) Joint aspiration
Correct answer: D
Rationale: Joint aspiration for polarized light
microscopy to confirm gout (negatively birefringent
crystals) is essential before treating acute flare.
5. A 48-year-old female with rheumatoid arthritis on
methotrexate 20 mg weekly presents with new-onset
shortness of breath and dry cough. Chest X-ray
shows bilateral interstitial infiltrates. What is the most
likely diagnosis?
A) Methotrexate-induced pneumonitis
B) Rheumatoid arthritis-associated ILD
C) Infection
D) Pulmonary embolism
Correct answer: A
, Rationale: Methotrexate pneumonitis
(hypersensitivity) presents with fever, cough,
dyspnea, and infiltrates. Stop methotrexate;
corticosteroids.
6. A 28-year-old female presents with malar rash, oral
ulcers, and pleuritic chest pain. She has a positive
ANA and anti-Smith antibody. Urinalysis shows
proteinuria (1.5 g/day). What is the most appropriate
next step?
A) Mycophenolate mofetil plus prednisone
B) Hydroxychloroquine alone
C) Belimumab
D) Cyclophosphamide
Correct answer: A
Rationale: Class III or IV lupus nephritis (proteinuria)
requires immunosuppression (mycophenolate mofetil
or cyclophosphamide) plus corticosteroids.
7. A 55-year-old male presents with symmetric
polyarthritis, sclerodactyly, Raynaud phenomenon,
and dysphagia. ANA is positive with anti-Scl-70
antibody. What is the most likely diagnosis?
A) Diffuse systemic sclerosis
EXAM FOR THE AMERICAN BOARD OF
INTERNAL MEDICINE (ABIM) | COMPLETE
EXAM Q&A WITH RATIONALES
1. A 45-year-old female presents with symmetric
polyarthritis of the hands, wrists, and knees for 6
weeks. She has morning stiffness lasting 90 minutes.
Rheumatoid factor is positive, anti-CCP is positive.
What is the most appropriate next step?
A) Start methotrexate
B) Start prednisone alone
C) Start hydroxychloroquine
D) Observation
Correct answer: A
Rationale: Methotrexate is first-line disease-
modifying antirheumatic drug (DMARD) for moderate
to severe rheumatoid arthritis. Early aggressive
therapy improves outcomes.
2. A 35-year-old female presents with photosensitive
facial rash, oral ulcers, and arthralgias. ANA is
positive 1:640, anti-dsDNA is positive. What is the
most appropriate initial treatment?
,A) Hydroxychloroquine
B) Prednisone
C) Mycophenolate mofetil
D) Belimumab
Correct answer: A
Rationale: Hydroxychloroquine is first-line for all SLE
patients without major organ involvement (skin,
joints). Reduces flares.
3. A 55-year-old male presents with new-onset severe
headache, jaw claudication, and vision loss. ESR is
95 mm/hr. What is the most appropriate next step?
A) High-dose prednisone (40-60 mg daily)
immediately
B) Temporal artery biopsy
C) MRI brain
D) Observation
Correct answer: A
Rationale: Giant cell arteritis with vision loss requires
immediate high-dose corticosteroids to prevent
further vision loss. Biopsy can be done within days
while on steroids.
,4. A 32-year-old male presents with acute onset of
red, hot, swollen right great toe. He has a history of
hypertension on hydrochlorothiazide. What is the
most appropriate next step?
A) Colchicine or NSAID for acute gout
B) Discontinue hydrochlorothiazide
C) Allopurinol
D) Joint aspiration
Correct answer: D
Rationale: Joint aspiration for polarized light
microscopy to confirm gout (negatively birefringent
crystals) is essential before treating acute flare.
5. A 48-year-old female with rheumatoid arthritis on
methotrexate 20 mg weekly presents with new-onset
shortness of breath and dry cough. Chest X-ray
shows bilateral interstitial infiltrates. What is the most
likely diagnosis?
A) Methotrexate-induced pneumonitis
B) Rheumatoid arthritis-associated ILD
C) Infection
D) Pulmonary embolism
Correct answer: A
, Rationale: Methotrexate pneumonitis
(hypersensitivity) presents with fever, cough,
dyspnea, and infiltrates. Stop methotrexate;
corticosteroids.
6. A 28-year-old female presents with malar rash, oral
ulcers, and pleuritic chest pain. She has a positive
ANA and anti-Smith antibody. Urinalysis shows
proteinuria (1.5 g/day). What is the most appropriate
next step?
A) Mycophenolate mofetil plus prednisone
B) Hydroxychloroquine alone
C) Belimumab
D) Cyclophosphamide
Correct answer: A
Rationale: Class III or IV lupus nephritis (proteinuria)
requires immunosuppression (mycophenolate mofetil
or cyclophosphamide) plus corticosteroids.
7. A 55-year-old male presents with symmetric
polyarthritis, sclerodactyly, Raynaud phenomenon,
and dysphagia. ANA is positive with anti-Scl-70
antibody. What is the most likely diagnosis?
A) Diffuse systemic sclerosis
