ABIM Test 3 — Questions and Answers
Question 1: A 66-year-old man with atrial fibrillation and CHA₂DS₂-VASc score of 4 is on warfarin (INR 2.4). He develops hematuria and hemoglobin drops from 13 to 10 g/dL. What is the most appropriate management of anticoagulation?
- Permanently discontinue warfarin
- Hold warfarin and reverse with vitamin K; resume after source identified and treated (Correct answer)
- Continue warfarin at the same dose
- Switch to aspirin only
Correct answer: Hold warfarin and reverse with vitamin K; resume after source identified and treated
Significant bleeding warrants holding anticoagulation and identifying the source; warfarin should be resumed once hemostasis is achieved given his high stroke risk.
Question 2: A 29-year-old woman presents with amenorrhea, galactorrhea, and a serum prolactin of 180 ng/mL. MRI shows a 12-mm pituitary lesion. Which treatment is most appropriate?
- Transsphenoidal surgery
- Cabergoline (Correct answer)
- Bromocriptine
- Observation only
Correct answer: Cabergoline
Cabergoline is the preferred dopamine agonist for macroprolactinomas due to superior efficacy and tolerability compared to bromocriptine.
Question 3: A 70-year-old man with COPD (FEV₁ 45% predicted) is admitted with acute exacerbation. After 48 hours of bronchodilators and systemic corticosteroids, he remains hypercapnic (PaCO₂ 68 mmHg, pH 7.28). Which intervention has been shown to reduce mortality and need for intubation in this setting?
- High-flow nasal cannula oxygen
- Noninvasive positive-pressure ventilation (NIPPV) (Correct answer)
- Immediate intubation and mechanical ventilation
- Inhaled helium-oxygen mixture
Correct answer: Noninvasive positive-pressure ventilation (NIPPV)
NIPPV reduces intubation rates, ICU length of stay, and mortality in COPD exacerbations with hypercapnic respiratory failure.
Question 4: A 48-year-old woman with rheumatoid arthritis on methotrexate and prednisone presents with subacute onset of fever, non-productive cough, and dyspnea. CT shows bilateral ground-glass opacities. LDH is elevated. Which pathogen is most likely?
- Mycobacterium tuberculosis
- Pneumocystis jirovecii (Correct answer)
- Cytomegalovirus
- Aspergillus fumigatus
Correct answer: Pneumocystis jirovecii
Immunosuppressed patients on chronic corticosteroids are at high risk for Pneumocystis jirovecii pneumonia, which presents with bilateral ground-glass opacities and elevated LDH.
Question 5: A 55-year-old man with known coronary artery disease has an LDL of 95 mg/dL on high-intensity statin therapy. What is the most appropriate next step to further reduce his cardiovascular risk?
- Add niacin
- Add ezetimibe (Correct answer)
- Switch to a moderate-intensity statin plus fibrate
- No additional therapy needed
Correct answer: Add ezetimibe
Ezetimibe added to statin therapy was shown in IMPROVE-IT to further reduce major cardiovascular events in high-risk patients, making it the preferred add-on agent.
Question 6: A 34-year-old woman presents with symmetric proximal muscle weakness, elevated CK (3,200 U/L), and a heliotrope rash. EMG shows myopathic changes. What is the most important next diagnostic step?
- Muscle biopsy
- Malignancy screening (Correct answer)
- Anti-Jo-1 antibody testing
- MRI of affected muscles
Correct answer: Malignancy screening
Dermatomyositis is strongly associated with occult malignancy (especially in adults >40), making cancer screening a priority after diagnosis.
Question 7: A 61-year-old man with type 2 diabetes (HbA1c 8.4%) and CKD stage 3 (eGFR 42 mL/min) presents for glucose management optimization. Which agent provides cardiovascular and renoprotective benefits supported by outcomes trials in this population?
- Glipizide
- Sitagliptin
- Empagliflozin (Correct answer)
- Pioglitazone
Correct answer: Empagliflozin
SGLT2 inhibitors like empagliflozin have demonstrated cardiovascular mortality reduction and slowed CKD progression in outcome trials (EMPA-REG, CREDENCE, DAPA-CKD).
ABIM Test 3
A 66-year-old man with atrial fibrillation and CHA₂DS₂-VASc score of 4 is on warfarin (INR 2.4).
He develops hematuria and hemoglobin drops from 13 to 10 g/dL.
What is the most appropriate management of anticoagulation?