ABIM Ultimate Test 4 — Questions and Answers
Question 1: A 66-year-old woman with heart failure (EF 25%) presents with worsening dyspnea. She is already on carvedilol, lisinopril, and furosemide. Her potassium is 4.2 mEq/L. What additional medication most reduces mortality in this patient?
- Digoxin
- Spironolactone (aldosterone antagonist) (Correct answer)
- Amlodipine
- Hydralazine
Correct answer: Spironolactone (aldosterone antagonist)
Aldosterone antagonists (spironolactone or eplerenone) are a pillar of HFrEF therapy with proven mortality benefit in patients with EF ≤35% and adequate renal function/potassium.
Question 2: A 40-year-old man with HIV (CD4 count 85/µL, not on ART) develops subacute fever, headache, and altered mental status over 3 weeks. CSF India ink preparation is positive. What is the best initial treatment?
- Fluconazole monotherapy
- Liposomal amphotericin B plus flucytosine induction (Correct answer)
- Voriconazole
- Caspofungin
Correct answer: Liposomal amphotericin B plus flucytosine induction
Cryptococcal meningitis in HIV is treated with liposomal amphotericin B plus flucytosine for at least 2 weeks induction before transitioning to fluconazole consolidation.
Question 3: A 52-year-old woman presents with a 3-month history of early satiety, dysphagia to solids and liquids, and regurgitation of undigested food. Esophageal manometry shows absent peristalsis and failure of LES relaxation. What is the diagnosis?
- Diffuse esophageal spasm
- Achalasia (Correct answer)
- Scleroderma esophagus
- GERD with peptic stricture
Correct answer: Achalasia
Achalasia is characterized by aperistalsis and incomplete lower esophageal sphincter relaxation on manometry, causing progressive dysphagia to both solids and liquids.
Question 4: A 68-year-old man is found to have a monoclonal IgG spike of 3.8 g/dL, bone marrow plasma cells 25%, serum calcium 11.8 mg/dL, and multiple lytic bone lesions on skeletal survey. Creatinine is 1.9 mg/dL. What is the diagnosis?
- Monoclonal gammopathy of undetermined significance (MGUS)
- Multiple myeloma (Correct answer)
- Waldenstrom macroglobulinemia
- Solitary plasmacytoma
Correct answer: Multiple myeloma
Multiple myeloma is diagnosed by ≥10% clonal plasma cells plus at least one CRAB criterion (hyperCalcemia, Renal insufficiency, Anemia, Bone lesions).
Question 5: A 45-year-old man presents with sudden onset of tearing chest pain radiating to the back. BP is 180/100 mmHg in right arm and 140/80 mmHg in left arm. CXR shows widened mediastinum. What is the most appropriate immediate management?
- IV nitroglycerin infusion
- IV labetalol to target HR <60 and SBP <120 mmHg (Correct answer)
- Thrombolytic therapy
- Emergent pericardiocentesis
Correct answer: IV labetalol to target HR <60 and SBP <120 mmHg
Type A aortic dissection management begins with IV beta-blockade (labetalol) to reduce aortic wall stress by lowering heart rate and blood pressure before urgent surgery.
Question 6: A 58-year-old woman with no prior cardiac history presents with acute chest pain. ECG shows ST depressions in V4-V6 and elevated troponin. Angiography reveals 95% stenosis of the left circumflex artery. She is hemodynamically stable. What is the optimal timing for PCI?
- Immediate PCI within 2 hours
- PCI within 24–72 hours (early invasive strategy) (Correct answer)
- Medical therapy alone without PCI
- PCI only if she develops hemodynamic instability
Correct answer: PCI within 24–72 hours (early invasive strategy)
NSTEMI with high-risk features (elevated troponin, ST changes) is managed with an early invasive strategy with PCI within 24–72 hours per ACC/AHA guidelines.
Question 7: A 30-year-old woman presents with polyuria, polydipsia, and a serum sodium of 148 mEq/L. Her urine osmolality is 95 mOsm/kg after overnight water deprivation. After desmopressin (DDAVP) administration, urine osmolality increases to 680 mOsm/kg. What is the diagnosis?
- Nephrogenic diabetes insipidus
- Central diabetes insipidus (Correct answer)
- Primary polydipsia
- Syndrome of inappropriate ADH
Correct answer: Central diabetes insipidus
A robust response to exogenous desmopressin (urine osmolality >50% increase) confirms central diabetes insipidus, where the kidney is intact but ADH secretion is deficient.
ABIM Ultimate Test 4
A 66-year-old woman with heart failure (EF 25%) presents with worsening dyspnea.
She is already on carvedilol, lisinopril, and furosemide.
Her potassium is 4.2 mEq/L.
What additional medication most reduces mortality in this patient?