ABIM Ultimate Test 2 — Questions and Answers
Question 1: A 58-year-old man with type 2 diabetes presents with a serum creatinine of 2.4 mg/dL and a urine albumin-to-creatinine ratio of 450 mg/g. Which medication class provides the greatest kidney-protective benefit beyond blood pressure control in this patient?
- Calcium channel blocker
- SGLT2 inhibitor (Correct answer)
- Beta-blocker
- Thiazide diuretic
Correct answer: SGLT2 inhibitor
SGLT2 inhibitors (e.g., empagliflozin, canagliflozin) have demonstrated significant cardiorenal protection in diabetic kidney disease independent of glycemic control.
Question 2: A 45-year-old woman is found to have a TSH of 0.02 mIU/L and free T4 of 2.8 ng/dL. She reports palpitations, heat intolerance, and a 10-lb weight loss. Thyroid uptake scan shows diffusely increased uptake. What is the most appropriate next step?
- Start methimazole (Correct answer)
- Perform thyroid biopsy
- Start levothyroxine
- Obtain thyroid ultrasound only
Correct answer: Start methimazole
Diffusely increased radioiodine uptake in the setting of hyperthyroidism is consistent with Graves' disease; methimazole is the preferred first-line antithyroid drug in non-pregnant adults.
Question 3: A 72-year-old woman presents with sudden-onset severe headache, neck stiffness, and photophobia. CT head is negative. CSF shows xanthochromia and 8,500 red blood cells/µL that do not clear. What is the most likely diagnosis?
- Bacterial meningitis
- Subarachnoid hemorrhage (Correct answer)
- Viral meningitis
- Hypertensive encephalopathy
Correct answer: Subarachnoid hemorrhage
Xanthochromia with a bloody, non-clearing CSF tap in the context of a thunderclap headache is pathognomonic for subarachnoid hemorrhage.
Question 4: A 55-year-old man with known cirrhosis develops confusion, asterixis, and jaundice. His INR is 2.1, bilirubin 8.4 mg/dL, and creatinine 2.8 mg/dL. By which scoring system is he best stratified for transplant priority?
- Child-Pugh score
- MELD-Na score (Correct answer)
- APACHE II
- Glasgow Coma Scale
Correct answer: MELD-Na score
MELD-Na (Model for End-stage Liver Disease with sodium) is the standard scoring system used by UNOS to prioritize liver transplant candidates.
Question 5: A 38-year-old woman with SLE develops worsening dyspnea and bilateral pleural effusions. Lab work shows complement levels C3 45 mg/dL (low) and anti-dsDNA 1:640. Urine protein is 4.2 g/24h. What is the most likely cause of her effusions?
- Pulmonary embolism
- Nephrotic syndrome with hypoalbuminemia (Correct answer)
- Congestive heart failure
- Tuberculous pleuritis
Correct answer: Nephrotic syndrome with hypoalbuminemia
Markedly elevated proteinuria with low complement in SLE indicates active nephritis causing nephrotic syndrome; hypoalbuminemia from protein loss leads to transudative effusions.
Question 6: A 62-year-old man with a 40 pack-year smoking history presents with a 2.5-cm solid pulmonary nodule. PET scan shows avid FDG uptake (SUV 6.8). He is a surgical candidate. What is the most appropriate next step?
- Bronchoscopy with BAL
- CT-guided biopsy then resection if malignant
- Repeat CT in 3 months
- Proceed directly to surgical resection (Correct answer)
Correct answer: Proceed directly to surgical resection
A solid nodule >8 mm with high pre-test probability and avid PET uptake in a surgical candidate warrants direct resection without prior biopsy per Fleischner Society guidelines.
Question 7: A 50-year-old man presents with recurrent episodes of crampy abdominal pain, non-bloody diarrhea, and a 15-lb weight loss over 6 months. Colonoscopy shows skip lesions with cobblestoning from terminal ileum to ascending colon. Histology reveals non-caseating granulomas. Which medication class is most appropriate for inducing remission?
- 5-aminosalicylates (mesalamine)
- Corticosteroids (prednisone) (Correct answer)
- Antifungals (fluconazole)
- Antibiotics (ciprofloxacin)
Correct answer: Corticosteroids (prednisone)
Corticosteroids remain the standard induction therapy for moderate-to-severe Crohn's disease flares, though they are not used for maintenance.
ABIM Ultimate Test 2
A 58-year-old man with type 2 diabetes presents with a serum creatinine of 2.4 mg/dL and a urine albumin-to-creatinine ratio of 450 mg/g.
Which medication class provides the greatest kidney-protective benefit beyond blood pressure control in this patient?