Morning Rounds · Rheumatology Series
Rheumatology
A Guide to the Morning Rounds Series
A Guide to the Morning Rounds Series
Seven high-yield rounds · 35 clinical cases · NEET-PG and UPSC CMS · +4 / −1 scoring
Rheumatology is examined with a particular kind of cruelty in competitive postgraduate entrance tests. The diseases overlap, the antibodies are plentiful, the drug mechanisms are intricate, and the clinical presentations mimic each other across half a dozen conditions. A young woman with fatigue, joint pain, and a raised ESR could be RA, SLE, Sjogren's, MCTD, or early scleroderma — and the examiner knows you know that. What separates candidates is not pattern recognition alone, but the ability to apply the right diagnostic criterion, the right antibody, the right drug, and the right complication to the right disease under time pressure.
This series of seven Morning Rounds covers the full rheumatology curriculum as tested in NEET-PG and UPSC CMS. The first round on Rheumatology Clinical Reasoning is an existing post on this site and anchors the series — covering crystal arthropathy under polarised light, RA treatment escalation by EULAR criteria, SLE nephritis class and complement consumption, GCA and the visual emergency protocol, and axial SpA with ASAS inflammatory back pain criteria. Rounds Two through Seven build outward from there, with no repeated ground and no repeated question angles.
Each round carries five clinical cases with full debrief explanations and Extra Points — the paragraph after the dashed line that carries the exam-edge material: the criteria table, the drug interaction, the complication that defines the prognosis. The rounds are self-contained and can be taken in any order, but the sequence below is the recommended one: it moves from the most commonly tested conditions outward to the more specialised, and ends with a mixed paper that mirrors the random cross-cutting style of the actual exam.
The Seven Rounds
Round 01 · Rheumatology Series
Rheumatology Clinical Reasoning
The anchor round for this series, covering five high-yield topics drawn from across the rheumatology spectrum. Crystal arthropathy under compensated polarised light microscopy: MSU crystals in a thiazide-treated patient, with the birefringence pattern, the crystal shape, and the trap of a normal serum uric acid during an acute attack. RA treatment escalation: the EULAR 2022 decision to add a TNF inhibitor to methotrexate when poor prognostic markers are present and a cDMARD has failed at adequate dose. SLE Class IV lupus nephritis: the ISN/RPS classification, the mechanism of low C3 and C4 through classical pathway consumption, and induction therapy. GCA with visual threat: the protocol for immediate high-dose prednisolone before biopsy when amaurosis fugax has occurred, and why delaying treatment for histology is the most consequential clinical error in the disease. Axial SpA: the ASAS inflammatory back pain criteria and how this patient satisfies all five features including nocturnal improvement on getting up.
Open Round →
Round 02 · Rheumatology Series
SLE & Antiphospholipid Syndrome
Five cases in depth on systemic lupus erythematosus and its antiphospholipid overlap, with deliberate attention to the distinctions that examiners test rather than the ones textbooks repeat. ANA patterns and disease-specific antibodies: the homogeneous pattern with anti-dsDNA and anti-Sm, versus speckled with anti-RNP and anti-Sm, versus nucleolar with anti-Scl-70 — and why anti-SSA and anti-SSB belong to Sjogren's first and SLE second. The 2019 ACR/EULAR classification criteria with weighted scoring across seven domains, and why renal biopsy is not required for classification. Drug-induced lupus: hydralazine, anti-histone antibody as the hallmark, absent anti-dsDNA, and full reversibility on stopping the drug. Primary APS: the 12-week interval rule for antibody confirmation, the triple-positivity risk, and the warfarin INR target versus why DOACs are avoided. Neonatal lupus: anti-SSA crossing the placenta, the congenital heart block risk, and the fetal echocardiography surveillance window from 16 to 26 weeks.
Open Round →
Round 03 · Rheumatology Series
Seronegative Spondyloarthropathies
Ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and IBD-associated SpA — grouped as they appear in examination papers, which is to say together and with enough overlap to confuse. AS and the radiological progression: the difference between syndesmophytes (thin, vertical, marginal, outer annulus fibrosus) and the osteophytes of DISH, how sacroiliitis is graded from 0 to IV, and why MRI detects active disease years before plain X-ray changes. Reactive arthritis: the post-enteric trigger, the sterile joint, keratoderma blennorrhagica as the pathognomonic skin finding, circinate balanitis, and why a negative Chlamydia swab does not exclude the diagnosis. Psoriatic arthritis: the five clinical patterns including the destructive arthritis mutilans with its pencil-in-cup deformity, the CASPAR criteria, and dactylitis as combined tenosynovitis. AS treatment: why BASDAI ≥4 after two NSAID failures justifies a biologic directly, without a cDMARD bridge — the fundamental distinction from RA. IBD-associated SpA: axial disease runs independently of bowel activity, and IL-17 inhibitors are contraindicated in Crohn's disease.
Open Round →
Round 04 · Rheumatology Series
Crystal Arthropathies
The full spectrum of crystal-induced joint disease, deliberately avoiding the birefringence question already answered in Round One and instead targeting the clinical and pharmacological angles that remain high-yield and under-tested. Gout diagnosis without microscopy: the ACR 2015 classification criteria, the ultrasound double contour sign, dual-energy CT, and the critical fact that a normal serum uric acid during an acute attack does not exclude the diagnosis because SUA falls transiently under cytokine-driven uricosuria. ULT timing and targets: why allopurinol is started two to four weeks after the acute attack resolves, why mobilisation flares require prophylactic colchicine for the first three to six months, and the SUA target of under 6 mg/dL. Gout in CKD: the evidence against the old dose-cap for allopurinol, the uricosuric effect of losartan, the role of SGLT2 inhibitors, and why NSAIDs are avoided and colchicine is dose-reduced when eGFR falls below 30. CPPD and pseudogout: the HATCH metabolic conditions, crowned dens syndrome, and the absence of any urate-lowering equivalent. Milwaukee shoulder: hydroxyapatite invisible on standard polarised light, the triad of large effusion plus rotator cuff tear plus glenohumeral destruction, and the alizarin red S stain.
Open Round →
Round 05 · Rheumatology Series
Vasculitides
The Chapel Hill Consensus classification from large to small vessel, with five cases chosen to represent the most examined entities and the most consequential clinical decisions. Takayasu arteritis: the young woman with BP asymmetry and a subclavian bruit, MR angiography as the investigation of choice, Numano classification types, and the distinction from GCA by age, ethnicity, and biopsy technique. GPA (Wegener's): the pulmonary-renal syndrome as a haematological emergency, pauci-immune crescentic GN with no immune deposits on immunofluorescence, c-ANCA/PR3 positivity, and the choice between cyclophosphamide and rituximab for induction. PAN: the disease that has no glomerulonephritis, no pulmonary involvement, and negative ANCA — the three negatives that define it — with microaneurysms on angiography, mononeuritis multiplex, testicular artery involvement, and antiviral therapy for HBV-associated disease alongside corticosteroids. EGPA (Churg-Strauss): the three-phase progression from asthma through tissue eosinophilia to vasculitis, cardiac eosinophilic myocarditis as the leading cause of death, the Five Factor Score, and mepolizumab for relapsing disease. GCA without cranial symptoms: the PMR overlap, the temporal artery halo sign on ultrasound replacing biopsy in experienced centres, tocilizumab from the GiACTA trial, and large-vessel GCA detected on PET-CT.
Open Round →
Round 06 · Rheumatology Series
Myopathies, Sjogren's & Scleroderma
Five conditions grouped by their shared tendency to produce overlapping clinical pictures and to demand antibody-level discrimination. Dermatomyositis and the antisynthetase syndrome: Gottron's papules and heliotrope rash as the pathognomonic skin findings of DM, anti-Jo-1 as the prototype antisynthetase antibody predicting the full cluster of ILD, inflammatory arthritis, mechanic's hands, and Raynaud's phenomenon, and ILD as the leading cause of mortality. The full myositis-specific antibody table in the Extra Points panel: anti-Mi-2, anti-MDA5 with its rapidly progressive ILD, anti-TIF1-γ with its malignancy association, anti-SRP, and anti-HMGCR. Steroid myopathy as the clinical trap that recurs in every exam diet: normal CK, normal ESR, no spontaneous activity on EMG, and the correct response of reducing the prednisolone dose rather than increasing it. Scleroderma renal crisis: the emergency of acute hypertension with microangiopathic haemolysis in early diffuse SSc, captopril as the treatment regardless of creatinine level, and prednisolone ≥15 mg/day as the precipitating drug. MCTD: high-titre anti-U1-RNP as the defining antibody in the absence of disease-specific antibodies, puffy hands as the underappreciated clinical clue, and pulmonary arterial hypertension as the leading cause of death.
Open Round →
Round 07 · Rheumatology Series
Mixed High-Yield Round — Exam Simulation
Five cases drawn from across the full rheumatology spectrum, designed to replicate the cross-cutting, unpredictable style of the actual NEET-PG and UPSC CMS paper. Felty's syndrome: the triad of seropositive RA with splenomegaly and neutropaenia, the mechanism of neutrophil destruction through splenic sequestration and anti-neutrophil antibodies, the requirement to exclude large granular lymphocyte leukaemia before attributing the picture to Felty's, and G-CSF for recurrent infection. Hydroxychloroquine dosing and toxicity: the revised maximum dose of 5 mg/kg of actual body weight (not the older 6.5 mg/kg of ideal body weight), annual retinal screening with SD-OCT from year five, bull's-eye maculopathy as the indication to stop, and why retinal damage is largely irreversible. Raynaud's phenomenon primary versus secondary: nail-fold capillaroscopy as the single best discriminating investigation, the scleroderma capillaroscopic pattern predicting CTD development, and the LeRoy-Medsger very early SSc criteria. Methotrexate pneumonitis: the idiosyncratic hypersensitivity mechanism, BAL CD4+ lymphocytosis, the fact that folic acid does not prevent pneumonitis, and the firm instruction not to restart MTX after confirmed pneumonitis. An integrated autoantibody case across four CTDs: which antibody in which patient predicts PAH as the leading cause of death — testing the anti-centromere versus anti-Scl-70 versus anti-U1-RNP distinction that resolves the majority of rheumatology prognosis questions.
Open Round →
Closing the Series
Summative Revision · Rheumatology Series
Rheumatology Summative Revision Notes
A structured revision document covering all seven rounds. Includes the ACR/EULAR criteria for RA, SLE, and GCA; the ISN/RPS lupus nephritis classification; the ASAS biologic threshold for axial SpA; the three-crystal comparison table for MSU, CPPD, and hydroxyapatite; the Chapel Hill vasculitis classification by vessel size; the myositis-specific antibody table; the scleroderma subtype and antibody grid; the leading-cause-of-death table by CTD; and the complete autoantibody master reference. Read this after working through the rounds, not before.
Open Notes →
Topics not covered in this series
This series is thorough for NEET-PG and UPSC CMS purposes but is not a comprehensive rheumatology textbook. Areas outside these seven rounds include juvenile idiopathic arthritis (JIA) and its subtypes, adult-onset Still's disease, Behcet's disease, relapsing polychondritis, familial Mediterranean fever and other autoinflammatory syndromes, fibromyalgia and chronic pain syndromes, and orthopaedic rheumatology (osteoarthritis, osteoporosis, metabolic bone disease). These topics carry lighter but non-zero examination weight and are better addressed through a dedicated supplementary round or a targeted question bank after this series has been completed.
A note for doctor-examinees
Rheumatology is genuinely difficult to teach well at the examination level because the diseases are defined by patterns — antibody patterns, clinical overlap patterns, therapeutic response patterns — rather than by a single pathognomonic finding. The cases in this series have been written to test those patterns rather than isolated facts, and the distractors have been written to be genuinely plausible rather than easily eliminated. If you found a case that was unfair, inaccurate, or misjudged in difficulty — or if you found one that taught you something you did not expect to find in a quiz format — the contact page is always open. That feedback shapes the next series.
Morning Rounds · atsixty.com · Rheumatology Series · Seven rounds · 35 high-yield clinical cases · +4 / −1 scoring · NEET-PG and UPSC CMS