ABIM Ultimate Test 5 — Questions and Answers
Question 1: A 72-year-old man with hypertension and hyperlipidemia presents with sudden painless loss of vision in his left eye. Fundoscopy shows a pale, edematous retina with a 'cherry-red spot' at the macula. What is the most likely diagnosis?
- Central retinal vein occlusion
- Central retinal artery occlusion (Correct answer)
- Acute angle-closure glaucoma
- Anterior ischemic optic neuropathy
Correct answer: Central retinal artery occlusion
Central retinal artery occlusion causes sudden painless monocular vision loss with a pale retina and cherry-red spot due to preserved choroidal circulation at the fovea.
Question 2: A 65-year-old man with COPD on tiotropium presents with an acute exacerbation with increased dyspnea, purulent sputum, and reduced exercise tolerance. SpO₂ is 88% on room air. What is the appropriate target SpO₂ during oxygen supplementation?
- 98–100%
- 88–92% (Correct answer)
- 94–96%
- 80–85%
Correct answer: 88–92%
In COPD exacerbations, controlled oxygen therapy targeting SpO₂ 88–92% prevents hypercapnic respiratory failure by preserving hypoxic drive in CO₂ retainers.
Question 3: A 44-year-old woman presents with proximal muscle weakness, elevated CK of 4,200 U/L, and an erythematous rash over her knuckles (Gottron's papules) and eyelids (heliotrope rash). What malignancy must be screened for?
- Leukemia
- Ovarian cancer (Correct answer)
- Brain tumor
- Multiple myeloma
Correct answer: Ovarian cancer
Dermatomyositis is strongly associated with internal malignancy, most commonly ovarian, lung, breast, and GI cancers; age- and sex-appropriate cancer screening is mandatory at diagnosis.
Question 4: A 55-year-old man with known alcoholic cirrhosis (Child-Pugh B) presents with acute onset abdominal pain and fever. Diagnostic paracentesis shows PMN count of 350 cells/µL. What is the most appropriate treatment?
- IV vancomycin and piperacillin-tazobactam
- IV cefotaxime (or ceftriaxone) plus IV albumin (Correct answer)
- Oral ciprofloxacin and discontinue diuretics
- Repeat paracentesis in 48 hours before starting antibiotics
Correct answer: IV cefotaxime (or ceftriaxone) plus IV albumin
Spontaneous bacterial peritonitis (PMN ≥250/µL) is treated with IV third-generation cephalosporin plus albumin infusion (1.5 g/kg at diagnosis, 1 g/kg on day 3) to prevent hepatorenal syndrome.
Question 5: A 48-year-old man is found to have a serum calcium of 11.4 mg/dL and a PTH of 92 pg/mL (elevated). He is asymptomatic with normal renal function and bone density T-score of -1.8. What is the recommended management?
- Immediate parathyroidectomy
- Observation with annual monitoring (Correct answer)
- Start cinacalcet
- Start alendronate
Correct answer: Observation with annual monitoring
Asymptomatic primary hyperparathyroidism without surgical criteria (Ca <1 mg/dL above ULN, age >50, T-score >-2.5, GFR >60) is managed with surveillance per AAES guidelines.
Question 6: A 38-year-old woman presents with bilateral ankle edema, dyspnea on exertion, and syncope. Echocardiography shows right ventricular dilation, RV systolic pressure of 65 mmHg, and normal left heart. Right heart catheterization confirms mPAP 42 mmHg with PCWP 10 mmHg. What initial therapy is indicated for WHO Group I PAH?
- Loop diuretics only
- Endothelin receptor antagonist (e.g., ambrisentan) or PDE-5 inhibitor (e.g., sildenafil) (Correct answer)
- ACE inhibitor and beta-blocker
- High-dose systemic corticosteroids
Correct answer: Endothelin receptor antagonist (e.g., ambrisentan) or PDE-5 inhibitor (e.g., sildenafil)
WHO Group I PAH with elevated PVR and normal PCWP is treated with pulmonary vasodilators including ERA, PDE-5 inhibitors, or prostacyclin analogs based on risk stratification.
Question 7: A 60-year-old man undergoes colonoscopy and is found to have a 6-mm tubular adenoma. He has no family history of colorectal cancer. When should his next surveillance colonoscopy be performed?
- 1 year
- 3–5 years (Correct answer)
- 7–10 years
- 15 years
Correct answer: 3–5 years
ACG/ACS guidelines recommend repeat colonoscopy in 3–5 years for patients with 1–2 small (<10 mm) tubular adenomas without high-grade dysplasia.
ABIM Ultimate Test 5
A 72-year-old man with hypertension and hyperlipidemia presents with sudden painless loss of vision in his left eye.
Fundoscopy shows a pale, edematous retina with a 'cherry-red spot' at the macula.
What is the most likely diagnosis?