🎯 Theme 6 Exam Practice

A 49-year-old woman with primary Sjögren syndrome has persistent dry eyes, dry mouth and recurrent dental caries. Investigation reveals anti-Ro positivity and reduced tear production. Which additional investigation is most useful for objectively assessing lacrimal gland dysfunction?

A 28-year-old woman presents with symmetrical small-joint pain, fatigue and mild anemia. Rheumatoid arthritis is initially considered. Further assessment reveals photosensitive facial erythema, recurrent painless oral ulcers, proteinuria, elevated anti-dsDNA antibodies and reduced complement levels. Which diagnosis best explains the overall clinical and laboratory pattern?

A 48-year-old woman with systemic sclerosis has exertional dyspnea that has progressed over several months. She now reports dizziness and near-syncope while walking. Examination demonstrates an accentuated pulmonary component of the second heart sound and a mild right ventricular heave. Which complication should be prioritized for urgent investigation?

A 23-year-old woman presents with fatigue, facial swelling, inflammatory joint pain and a recurrent photosensitive rash. Examination reveals a blood pressure of 152/96 mmHg, bilateral pedal edema and tenderness of the metacarpophalangeal joints. Which combination of findings most strongly suggests active renal involvement rather than isolated musculoskeletal lupus?

A 42-year-old woman with Raynaud phenomenon and sclerodactyly undergoes nailfold capillaroscopy. The examination reveals dilated capillary loops and areas of capillary loss. She also has digital pitting scars and telangiectasias. Which interpretation of these findings is most appropriate?

A 62-year-old woman with longstanding rheumatoid arthritis develops a gradual decline in kidney function. She has been taking NSAIDs regularly for chronic joint pain. Urinalysis reveals mild proteinuria, and autoimmune disease activity is currently low. Which approach is most appropriate for identifying the cause of her renal dysfunction?

A 43-year-old woman with suspected systemic sclerosis is examined for progressive limitation of hand movements. Both hands show shiny, thickened skin extending onto the dorsum, reduced skin creases, difficulty making a complete fist and small depressed scars at the fingertips. Which pathological combination best explains these findings?

A 42-year-old woman with systemic sclerosis, Raynaud phenomenon, esophageal reflux and interstitial lung disease is preparing for long-term outpatient follow-up. Her current symptoms are stable, and she is concerned about future disability and complications. Which follow-up plan best addresses the multisystem nature of her disease?

A 43-year-old woman with systemic sclerosis complains of frequent regurgitation, heartburn and difficulty swallowing solid food. Examination reveals characteristic skin thickening and sclerodactyly. Which mechanism best explains her esophageal symptoms?

A 45-year-old woman being evaluated for progressive skin tightening reports frequent retrosternal burning, particularly after meals and when lying down. She also describes intermittent difficulty swallowing solid food. Examination reveals sclerodactyly and reduced mouth opening. Which underlying mechanism best explains her gastrointestinal symptoms?

A 47-year-old woman presents with progressive skin thickening extending above the elbows, Raynaud phenomenon and exertional dyspnea. High-resolution CT demonstrates bilateral interstitial lung disease. Which autoantibody is most strongly associated with this systemic sclerosis pattern?

A 28-year-old woman with biopsy-confirmed active proliferative lupus nephritis has persistent proteinuria and declining renal function. After assessing disease severity, the treating team plans induction therapy. Which treatment approach most appropriately addresses the underlying renal inflammation?

A 24-year-old woman has a four-month history of inflammatory polyarthralgia, photosensitive facial rash, oral ulcers and alopecia. Examination reveals small-joint tenderness without fixed deformities. Urinalysis demonstrates proteinuria and microscopic hematuria. Which interpretation best integrates these findings?

A 29-year-old woman with suspected lupus nephritis has persistent proteinuria of 2.4 g/g, microscopic hematuria, red-cell casts and serum creatinine of 1.4 mg/dL. Renal ultrasound shows normal-sized kidneys without obstruction. What is the most appropriate next diagnostic step to guide definitive treatment?

A 42-year-old woman with sclerodactyly, digital pitting scars and esophageal reflux is investigated for an autoimmune connective tissue disease. Her ANA is positive at 1:320, and anti-Scl-70 antibodies are detected. Pulmonary function testing also demonstrates reduced forced vital capacity. Which diagnosis best integrates these findings?

A 42-year-old woman has progressive skin tightening of her fingers and hands, Raynaud phenomenon, digital pitting scars and exertional dyspnea. Examination also reveals microstomia and bibasal crackles. There is no documented skin thickening proximal to the elbows or over the trunk. Which assessment is most appropriate?

A 34-year-old woman with systemic lupus erythematosus has persistent inflammatory arthritis despite treatment with hydroxychloroquine. Her physician considers adding methotrexate. Which mechanism best explains the immunosuppressive action of methotrexate?

A 42-year-old woman with progressive hand skin thickening develops breathlessness when climbing stairs. She has an occasional dry cough and no fever or sputum production. Examination reveals fine bilateral basal inspiratory crackles. Which clinical interpretation is most appropriate?

A 45-year-old woman has Raynaud phenomenon, finger skin thickening, digital pitting scars and positive ANA. Further testing identifies anti-Scl-70 antibodies. She has recently developed a dry cough and exertional dyspnea. What is the most important clinical implication of this antibody result in her current presentation?

A 58-year-old woman is diagnosed with dermatomyositis after presenting with proximal muscle weakness, heliotrope rash and Gottron papules. Her muscle enzyme levels are elevated. Which additional clinical assessment is particularly important because of a recognized association with this disorder?

A 43-year-old woman with established systemic sclerosis attends follow-up. She feels clinically stable, and her blood pressure is 126/80 mmHg. Serum creatinine is 0.8 mg/dL, and urinalysis shows no significant proteinuria or hematuria. What is the most appropriate interpretation and next approach?

A 39-year-old woman with established antiphospholipid syndrome develops rapidly progressive renal dysfunction, respiratory failure and neurological deterioration over several days. Investigations demonstrate thrombosis affecting multiple organs. Which complication best explains this presentation?

A 27-year-old woman with lupus nephritis has persistent proteinuria and a blood pressure of 150/94 mmHg. Her serum potassium is normal, and she is not pregnant or planning immediate conception. Alongside treatment of the underlying lupus nephritis, which therapeutic approach would best address both hypertension and proteinuria?

A 24-year-old woman presents with progressive facial puffiness and bilateral ankle swelling for three weeks. She reports frothy urine, intermittent small-joint pain, recurrent mouth ulcers and facial redness following sun exposure. Which additional historical feature would most strongly indicate clinically significant renal involvement?

A 26-year-old woman presents with recurrent oral ulcers, photosensitive rash and inflammatory polyarthritis. Her ANA is positive at a titre of 1:160. However, anti-dsDNA and anti-Sm antibodies are negative, complement levels are normal and there is no evidence of renal or hematological involvement. Which principle is most appropriate when interpreting these findings?

A 25-year-old woman with lupus nephritis has been receiving treatment for several months. Her edema has resolved, blood pressure is controlled and renal function has improved. She asks whether she can discontinue her medications because she now feels well. Which management principle is most appropriate?

A 25-year-old woman with suspected systemic lupus erythematosus has developed proteinuria and hypertension. During history-taking, she reports occasionally taking over-the-counter analgesics for joint pain. Which medication-related history is most important when assessing potentially preventable worsening of renal function?

A 46-year-old woman presents with tight facial skin and progressive difficulty opening her mouth. Examination reveals reduced facial expression, fine radial furrows around the lips and a reduced oral aperture. Her fingers are thickened, and several telangiectasias are visible over her face. What is the most likely explanation for the reduced mouth opening?

A 46-year-old woman with systemic sclerosis develops worsening finger stiffness despite improvement in her Raynaud symptoms following vasodilator treatment. She is increasingly unable to grip objects and perform her work as a tailor. Examination reveals reduced finger flexion and early contractures without active synovitis. Which intervention should be prioritized to preserve her functional independence?

A 54-year-old woman with longstanding limited cutaneous systemic sclerosis develops progressive exertional breathlessness and reduced exercise tolerance. Examination reveals an accentuated pulmonary component of the second heart sound. Echocardiography suggests elevated pulmonary arterial pressure, while significant interstitial lung disease is absent. Which complication is most likely?

A 29-year-old woman with systemic lupus erythematosus and previous lupus nephritis presents with sudden pleuritic chest pain and breathlessness. She reports unilateral calf swelling that developed two days earlier. Her oxygen saturation is 91% on room air. Which complication should be prioritized in the clinical assessment?

A 28-year-old woman receiving glucocorticoids and mycophenolate for proliferative lupus nephritis develops fever and marked weakness. Her urine protein-creatinine ratio has been declining, but her white blood cell count is 2,100/µL. What is the most appropriate immediate clinical response?

A 40-year-old woman with inflammatory myopathy is started on glucocorticoids and a steroid-sparing immunosuppressant. At follow-up, her proximal muscle strength has improved, and serum creatine kinase levels have decreased significantly. What is the most appropriate interpretation of these findings?

A 24-year-old woman with known systemic lupus erythematosus attends follow-up after treatment for proliferative lupus nephritis. Her serum creatinine has remained stable, urine protein-creatinine ratio has decreased from 2.4 to 0.8 g/g and peripheral edema has improved. Anti-dsDNA levels remain mildly elevated. Which interpretation of her treatment response is most appropriate?

A 25-year-old woman with SLE develops persistent proteinuria, microscopic hematuria and impaired renal function. Kidney biopsy reveals focal proliferative glomerulonephritis involving 30% of the glomeruli. Which classification is most appropriate?

A 26-year-old woman with known Class IV lupus nephritis presents with markedly reduced urine output over two days. Her blood pressure is 180/110 mmHg, serum creatinine has risen from 1.2 to 2.6 mg/dL and urinalysis shows persistent red-cell casts. Which interpretation should guide the immediate management decision?

A 26-year-old woman with systemic lupus erythematosus undergoes kidney biopsy because of persistent proteinuria and active urinary sediment. Histology demonstrates diffuse endocapillary proliferative glomerulonephritis involving more than 50% of sampled glomeruli, with immune-complex deposition. Which classification best describes this renal lesion?

A 31-year-old woman with established SLE develops increasing fatigue, facial puffiness and hypertension. Investigations show rising serum creatinine, proteinuria and red blood cell casts. Anti-dsDNA titres have increased and complement levels are reduced. Which pathological process most likely explains her renal deterioration?

A 37-year-old woman with SLE has been taking glucocorticoids for several months. Her disease activity has improved, but she has developed weight gain, hypertension and elevated blood glucose. Which long-term management principle is most appropriate?

A 24-year-old woman has photosensitive rash, non-scarring alopecia, inflammatory arthritis and persistent proteinuria. ANA is positive at 1:640, anti-dsDNA antibodies are elevated and serum C3 and C4 levels are reduced. Which interpretation best explains the immunological findings?

A 44-year-old woman with systemic sclerosis presents to the emergency department with a severe headache, blurred vision and reduced urine output over two days. Her previous blood pressure was 122/78 mmHg, but it is now 198/112 mmHg. Serum creatinine has increased from 0.8 mg/dL to 2.3 mg/dL. Which management decision is most appropriate?

A 26-year-old woman is being assessed for suspected systemic lupus erythematosus. She reports symmetrical pain in the small joints of both hands, photosensitive facial redness and intermittent painless oral ulcers. Her joint pain has persisted for four months. Which additional historical finding would most strongly raise suspicion of active glomerular disease?

A 24-year-old woman with active lupus nephritis is prescribed hydroxychloroquine as part of long-term systemic lupus management. At review, she reports good adherence and asks why periodic ophthalmological assessment is recommended. Which complication is the principal reason for this monitoring?

A 42-year-old woman presents with an 18-month history of progressive tightening of the skin of both hands. She reports that her fingers become pale and painful on cold exposure, followed by bluish discoloration and redness during rewarming. She has recently developed painful fingertip lesions. Which additional historical feature would most strongly support secondary rather than primary Raynaud phenomenon?

A 25-year-old woman presents with facial swelling and frothy urine. Urinalysis reveals protein 3+, microscopic hematuria and red-cell casts. She also has a photosensitive rash and inflammatory joint symptoms. Which interpretation of the urinary findings is most appropriate?

A 51-year-old woman with primary Sjögren syndrome develops recurrent episodes of muscle weakness and fatigue. Investigations reveal hypokalemia and normal anion gap metabolic acidosis. Which renal manifestation best explains these findings?

A 47-year-old woman with systemic sclerosis undergoes routine pulmonary assessment. She reports increasing breathlessness but has no basal crackles. Pulmonary function testing demonstrates a markedly reduced DLCO, with relatively preserved lung volumes. Echocardiography suggests elevated pulmonary artery pressure. Which interpretation is most appropriate?

A 27-year-old woman with suspected systemic lupus erythematosus has facial erythema, small-joint tenderness and mild anemia. She subsequently develops bilateral pedal edema. Her blood pressure is 148/92 mmHg. Which additional examination finding would indicate a potentially serious complication requiring urgent clinical assessment?

A 30-year-old pregnant woman with confirmed obstetric antiphospholipid syndrome has a history of recurrent pregnancy loss but no previous thrombosis. She attends an early antenatal assessment. Which management strategy is most appropriate to reduce pregnancy complications?

A 27-year-old married woman with biopsy-confirmed lupus nephritis has responded well to treatment and is taking hydroxychloroquine, low-dose glucocorticoids and mycophenolate. She wishes to conceive within the next few months. Which counselling recommendation is most appropriate?

A 44-year-old woman has progressive tightening of her fingers, digital pitting scars, microstomia, reflux symptoms and exertional breathlessness. Another patient presents with Raynaud phenomenon and puffy hands but also has prominent inflammatory arthritis and proximal muscle weakness. Which additional finding in the second patient would favor mixed connective tissue disease over systemic sclerosis?

A 42-year-old woman with systemic sclerosis has progressive exertional dyspnea, reduced FVC and HRCT findings consistent with interstitial lung disease. Her respiratory symptoms are gradually worsening, but she is clinically stable and does not require emergency oxygen support. Which management strategy is most appropriate?

A 42-year-old woman with systemic sclerosis develops progressively worsening exertional dyspnea. Pulmonary function tests show FVC 68% of predicted and reduced DLCO. High-resolution CT reveals bilateral basal ground-glass and reticular opacities. Which interpretation best explains the combined findings?

A 44-year-old woman presents with progressive symmetrical proximal muscle weakness and elevated serum creatine kinase. She also reports difficulty swallowing and a persistent dry cough. Chest imaging suggests interstitial lung disease. Which investigation is most useful for supporting the diagnosis of an inflammatory myopathy and assessing muscle inflammation?

A 14-year-old girl with childhood-onset SLE has persistent proteinuria, hypertension and active immunological disease. She requires prolonged immunosuppressive treatment. Which additional consideration is particularly important during her long-term management?

A 45-year-old woman with systemic sclerosis complains of persistent heartburn, particularly after evening meals and when lying down. She has intermittent dysphagia but no significant weight loss or gastrointestinal bleeding. Which initial management approach best addresses her predominant gastrointestinal problem?

A 29-year-old woman with SLE develops generalized edema and heavy proteinuria. Kidney biopsy demonstrates predominantly membranous lupus nephritis without significant proliferative lesions. Which clinical presentation is most closely associated with this pathological pattern?

A 42-year-old woman with systemic sclerosis experiences frequent cold-induced digital pain and color changes despite wearing gloves and avoiding cold exposure. Her blood pressure is 124/78 mmHg, and there is no evidence of critical digital ischemia. Which pharmacological approach is most appropriate for improving her peripheral vascular symptoms?

A 33-year-old woman with established SLE presents with sudden pleuritic chest pain and dyspnea. CT pulmonary angiography confirms pulmonary embolism. She has a history of an unexplained miscarriage, and antiphospholipid antibodies have previously been detected. Which additional laboratory pattern would provide the strongest evidence of a high-risk antiphospholipid antibody profile?

A 25-year-old woman has newly diagnosed systemic lupus erythematosus with biopsy-confirmed Class IV lupus nephritis. She has significant proteinuria, microscopic hematuria and mildly impaired renal function. Which management approach is most appropriate?