ABIM Ultimate Test 3 — Questions and Answers
Question 1: A 67-year-old man with diabetes and hypertension presents with acute-onset flank pain radiating to the groin, microscopic hematuria, and a 6-mm ureteral stone on CT. He has no fever and his creatinine is at baseline. What is the most appropriate initial management?
- Emergency urologic intervention
- IV antibiotics and admission
- Medical expulsive therapy with tamsulosin and analgesics (Correct answer)
- Immediate extracorporeal shock wave lithotripsy
Correct answer: Medical expulsive therapy with tamsulosin and analgesics
Uncomplicated ureteral stones ≤10 mm without infection or obstruction are managed with medical expulsive therapy; tamsulosin relaxes ureteral smooth muscle to facilitate passage.
Question 2: A 34-year-old woman has episodic hypertension, headaches, diaphoresis, and palpitations. 24-hour urine shows elevated metanephrines and normetanephrines. What is the most important pre-operative medication to initiate?
- Beta-blocker (metoprolol)
- Alpha-blocker (phenoxybenzamine) (Correct answer)
- Calcium channel blocker (amlodipine)
- ACE inhibitor (lisinopril)
Correct answer: Alpha-blocker (phenoxybenzamine)
Alpha-blockade must be established before beta-blockade to prevent unopposed alpha-adrenergic vasoconstriction and hypertensive crisis during pheochromocytoma resection.
Question 3: A 70-year-old woman with atrial fibrillation is on warfarin with a stable INR of 2.4. She is scheduled for a colonoscopy with polypectomy. What is the most appropriate peri-procedural anticoagulation strategy?
- Continue warfarin without interruption
- Hold warfarin 5 days prior; bridge with LMWH if high stroke risk (Correct answer)
- Switch to aspirin 5 days before
- Hold warfarin 1 day prior only
Correct answer: Hold warfarin 5 days prior; bridge with LMWH if high stroke risk
High-bleed-risk procedures like polypectomy require warfarin to be held 5 days prior; bridging with LMWH is indicated for high thromboembolic risk (e.g., CHA₂DS₂-VASc ≥5 or mechanical valve).
Question 4: A 48-year-old man is found to have a fasting glucose of 130 mg/dL on two separate occasions. His HbA1c is 7.4%. He has BMI 31 and no cardiovascular disease. What is the preferred initial pharmacologic therapy?
- Insulin glargine
- Metformin (Correct answer)
- Sulfonylurea (glipizide)
- GLP-1 receptor agonist
Correct answer: Metformin
Metformin is the recommended first-line pharmacologic agent for type 2 diabetes unless contraindicated, given its efficacy, safety profile, low cost, and weight neutrality.
Question 5: A 55-year-old woman with rheumatoid arthritis on methotrexate 20 mg/week presents with progressive dyspnea and a dry cough. HRCT shows bilateral ground-glass opacities and fine reticulations. Her PFTs show a restrictive pattern. What is the most likely diagnosis?
- Rheumatoid arthritis-associated interstitial lung disease
- Methotrexate-induced pneumonitis (Correct answer)
- Community-acquired pneumonia
- Pulmonary embolism
Correct answer: Methotrexate-induced pneumonitis
Methotrexate pneumonitis is a hypersensitivity reaction that can occur at any dose and time; it presents with dry cough, dyspnea, fever, and bilateral infiltrates on imaging.
Question 6: A 29-year-old woman at 32 weeks gestation presents with severe headache, visual changes, and BP 160/110 mmHg on two readings 4 hours apart. Urine protein is 3+ on dipstick. What complication must be urgently prevented?
- Placental abruption
- Eclamptic seizure (Correct answer)
- Preterm labor
- Deep vein thrombosis
Correct answer: Eclamptic seizure
Severe-range preeclampsia requires IV magnesium sulfate for seizure prophylaxis and urgent antihypertensive therapy to prevent eclampsia and end-organ damage.
Question 7: A 75-year-old man presents with progressive fatigue, macrocytic anemia (MCV 110 fL), and symmetric paresthesias of the lower extremities. Serum B12 is 98 pg/mL. Anti-intrinsic factor antibodies are positive. Which finding would confirm the underlying diagnosis?
- Low serum folate level
- Elevated methylmalonic acid and homocysteine (Correct answer)
- Hypersegmented neutrophils only
- Iron deficiency on bone marrow biopsy
Correct answer: Elevated methylmalonic acid and homocysteine
Elevated methylmalonic acid (MMA) and homocysteine confirm functional B12 deficiency and are pathognomonic for pernicious anemia when anti-intrinsic factor antibodies are present.
ABIM Ultimate Test 3
A 67-year-old man with diabetes and hypertension presents with acute-onset flank pain radiating to the groin, microscopic hematuria, and a 6-mm ureteral stone on CT.
He has no fever and his creatinine is at baseline.
What is the most appropriate initial management?