ABIM Test 5 — Questions and Answers
Question 1: A 44-year-old woman presents with fatigue, constipation, and hypercalcemia (Ca 11.8 mg/dL). PTH is 98 pg/mL (elevated). Renal function is normal and she is asymptomatic. Which criterion would make parathyroidectomy indicated per current guidelines?
- Serum calcium >1 mg/dL above the upper limit of normal
- T-score of -1.8 at the femoral neck
- Age under 50 years (Correct answer)
- 24-hour urine calcium >350 mg/day
Correct answer: Age under 50 years
Current AACE/AAES guidelines recommend parathyroidectomy for asymptomatic primary hyperparathyroidism in patients under 50 years of age.
Question 2: A 71-year-old man with cirrhosis (Child-Pugh B) presents with confusion, asterixis, and a serum ammonia of 140 µmol/L. He recently started a high-protein diet. What is the most appropriate treatment?
- Neomycin and metronidazole
- Lactulose titrated to 2–3 soft stools per day (Correct answer)
- Rifaximin alone
- Protein restriction to <40 g/day indefinitely
Correct answer: Lactulose titrated to 2–3 soft stools per day
Lactulose is first-line for acute hepatic encephalopathy, acidifying colonic contents and trapping ammonia for fecal excretion; rifaximin is added for secondary prophylaxis.
Question 3: A 48-year-old woman presents with a 3-week history of productive cough, night sweats, and 12-pound weight loss. She emigrated from Southeast Asia 2 years ago. Chest X-ray shows right upper lobe cavitary infiltrate. AFB smear of sputum is positive. How many negative sputum cultures are required before she can be removed from airborne isolation?
- One negative smear on consecutive days
- Two negative smears collected 8 hours apart
- Three consecutive negative smears collected 8 hours apart (Correct answer)
- One negative culture
Correct answer: Three consecutive negative smears collected 8 hours apart
CDC guidelines require three consecutive negative AFB smears from respiratory specimens collected at least 8 hours apart before discontinuing airborne infection isolation.
Question 4: A 55-year-old man with a history of peptic ulcer disease presents with melena and hemodynamic instability. After resuscitation, upper endoscopy reveals a Forrest Ia (active spurting) duodenal ulcer. What is the most appropriate endoscopic therapy?
- Injection of epinephrine alone
- Thermal coagulation alone
- Combination therapy: epinephrine injection plus thermal coagulation or clip (Correct answer)
- Hemostatic spray only
Correct answer: Combination therapy: epinephrine injection plus thermal coagulation or clip
Combination endoscopic therapy (epinephrine injection plus a second modality such as thermal coagulation or hemoclip) is superior to monotherapy for high-risk stigmata including active spurting.
Question 5: A 64-year-old man with long-standing hypertension presents with sudden severe tearing chest pain radiating to the back. BP is 180/100 mmHg in the right arm and 140/85 in the left. CT angiography shows a type A aortic dissection. What is the definitive management?
- Intravenous labetalol and sodium nitroprusside targeting systolic BP <120 mmHg
- Emergency surgical repair (Correct answer)
- Endovascular stent grafting
- Thrombolytic therapy
Correct answer: Emergency surgical repair
Stanford type A aortic dissection involving the ascending aorta is a surgical emergency; medical management alone carries a mortality of approximately 1–2% per hour.
Question 6: A 38-year-old man with systemic lupus erythematosus presents with pleuritic chest pain and a friction rub. Echo shows a small pericardial effusion with no tamponade physiology. ESR is 88 mm/hr and CRP is elevated. What is the first-line treatment?
- High-dose prednisone 1 mg/kg/day
- NSAIDs plus colchicine (Correct answer)
- Pericardiocentesis
- Hydroxychloroquine dose increase
Correct answer: NSAIDs plus colchicine
NSAIDs combined with colchicine are first-line for acute pericarditis regardless of etiology, with corticosteroids reserved for refractory or autoimmune-specific cases.
Question 7: A 52-year-old woman with obesity and type 2 diabetes is found to have persistently elevated ALT (3× ULN) and AST (2× ULN) on two measurements 6 months apart. Liver biopsy shows macrovesicular steatosis, lobular inflammation, and ballooning hepatocyte degeneration. What pharmacologic agent has FDA approval for this condition?
- Pioglitazone
- Vitamin E
- Resmetirom (Rezdiffra) (Correct answer)
- Obeticholic acid
Correct answer: Resmetirom (Rezdiffra)
Resmetirom (Rezdiffra) received FDA approval in March 2024 as the first pharmacologic treatment specifically approved for metabolic dysfunction-associated steatohepatitis (MASH) with moderate-to-advanced fibrosis.
ABIM Test 5
A 44-year-old woman presents with fatigue, constipation, and hypercalcemia (Ca 11.8 mg/dL).
PTH is 98 pg/mL (elevated).
Renal function is normal and she is asymptomatic.
Which criterion would make parathyroidectomy indicated per current guidelines?