ABIM IM BOARDS ITE EXAM 2026-2027 - 200 Questions and
Answers Already Graded A+ Premium Exam Tested And
Verified
Subject Area Internal Medicine Board Review
Description This rigorous exam simulates the American Board of Internal Medicine (ABIM)
Initial Certification (ITE) examination, covering core internal medicine topics
including cardiology, gastroenterology, pulmonology, nephrology, infectious
disease, endocrinology, rheumatology, hematology, oncology, and general
internal medicine. It tests advanced clinical reasoning, evidence-based
management, and interpretation of diagnostic data at the level expected of a
graduating internal medicine resident.
Expected Grade A+
Total Questions 200
Duration 4 hours
Learning Outcomes 1. Apply evidence-based guidelines to diagnose and manage complex medical
conditions.
2. Interpret advanced diagnostic tests and imaging to guide clinical
decision-making.
3. Integrate pathophysiology, pharmacology, and epidemiology to solve clinical
problems.
4. Recognize atypical presentations and rare complications of common diseases.
5. Demonstrate proficiency in high-stakes, time-pressured clinical reasoning.
Accreditation This examination adheres to the standards set by the Accreditation Council for
Graduate Medical Education (ACGME) and the American Board of Internal
Medicine (ABIM) for initial certification.
Page 1
,1. A 55-year-old man with a history of hypertension and type 2 diabetes presents
with acute onset of severe, tearing chest pain radiating to the back. Blood pressure is
200/110 mm Hg in the right arm and 150/90 mm Hg in the left arm. Chest X-ray
shows a widened mediastinum. What is the most appropriate initial management
step before surgical intervention?
Answer: Intravenous labetalol
In acute aortic dissection, the goal is to reduce heart rate and blood pressure to
decrease aortic wall stress. Beta-blockers (e.g., labetalol or esmolol) are first-line to
reduce dP/dt. Labetalol is preferred because it also provides alpha-blockade for
vasodilation. Nitroprusside alone can cause reflex tachycardia, worsening dissection.
Hydralazine is not recommended. Esmolol is an alternative but requires titration.
2. A 48-year-old woman is found to have a serum calcium of 11.2 mg/dL (normal
8.5-10.2) on routine labs. Intact PTH is 65 pg/mL (normal 10-65). 24-hour urinary
calcium is 400 mg (normal <250). Which of the following is the most likely
diagnosis?
Answer: Primary hyperparathyroidism
Primary hyperparathyroidism typically presents with elevated calcium, elevated or
inappropriately normal PTH, and high urinary calcium. Familial hypocalciuric
hypercalcemia (FHH) has low urinary calcium (usually <100 mg/day) and is benign.
Malignancy-associated hypercalcemia usually has suppressed PTH. Sarcoidosis causes
hypercalcemia via increased 1,25-dihydroxyvitamin D, with low PTH.
3. A 62-year-old man with cirrhosis due to nonalcoholic steatohepatitis is admitted
with hematemesis. Emergent upper endoscopy reveals esophageal varices with active
bleeding. After endoscopic band ligation, which pharmacologic agent should be
initiated to reduce portal pressure?
Answer: Octreotide
Octreotide, a somatostatin analogue, is commonly used in acute variceal bleeding to
reduce splanchnic blood flow and portal pressure. Terlipressin is not available in the
US. Propranolol is used for secondary prophylaxis after bleeding is controlled, not in
the acute setting. Somatostatin itself is not used clinically; octreotide is the preferred
agent.
Page 2
,4. A 70-year-old woman with a history of atrial fibrillation on warfarin presents with
acute onset of right flank pain and hematuria. CT urogram reveals a 2 cm left
ureteral stone. INR is 3.5. What is the most appropriate management?
Answer: Reverse anticoagulation with vitamin K and fresh frozen plasma, then
proceed with ureteroscopy
In a patient with an INR of 3.5 and an active bleeding complication (hematuria)
requiring urgent intervention, reversal of anticoagulation is indicated. Vitamin K and
fresh frozen plasma (or prothrombin complex concentrate) can rapidly reverse
warfarin effect. Elective ureteroscopy is not appropriate because the stone is causing
symptoms and may lead to obstruction. Bridging is not needed after reversal.
Desmopressin is used for uremic bleeding, not warfarin reversal.
5. A 35-year-old woman presents with acute onset of dyspnea and pleuritic chest
pain. CT pulmonary angiography shows a segmental pulmonary embolism. Her vital
signs are normal, and echocardiogram shows no right ventricular strain. She has no
contraindications to anticoagulation. What is the most appropriate initial
anticoagulant?
Answer: Direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban
For acute pulmonary embolism without hemodynamic instability or right ventricular
dysfunction, current guidelines recommend DOACs (apixaban, rivaroxaban) as
first-line therapy due to ease of use and favorable safety profile. LMWH followed by
warfarin is an alternative but less convenient. Unfractionated heparin is reserved for
patients with hemodynamic instability or severe renal impairment. Fondaparinux is an
option but not preferred over DOACs.
6. A 45-year-old man with HIV (CD4 count 120 cells/L, not on antiretroviral
therapy) presents with fever, headache, and confusion. MRI brain shows multiple
ring-enhancing lesions. Lumbar puncture is contraindicated due to
thrombocytopenia. Which of the following is the most likely diagnosis?
Answer: Toxoplasma encephalitis
In HIV patients with low CD4 counts (<100-200), ring-enhancing brain lesions are most
commonly due to Toxoplasma gondii encephalitis. Primary CNS lymphoma (often
Epstein-Barr virus associated) can also present with ring-enhancing lesions but is less
common. CMV encephalitis typically presents with ventriculitis. PML (JC virus)
presents with non-enhancing white matter lesions.
Page 3
, 7. A 50-year-old woman with a history of hypothyroidism on levothyroxine presents
with fatigue, weight gain, and constipation. Labs show TSH 20 mIU/L (normal
0.5-4.5) and free T4 0.6 ng/dL (normal 0.8-1.8). She reports taking her medication
with breakfast. What is the most likely cause of her persistent hypothyroidism?
Answer: Drug interaction with calcium supplements
Levothyroxine absorption is impaired by food, especially calcium and iron
supplements. Taking it with breakfast reduces absorption. Malabsorption (e.g., celiac) is
less common. Poor adherence is possible but the patient reports taking it. Incorrect
dosing is a consideration, but the most likely cause given her history is the timing with
food. Calcium supplements are a common culprit.
8. A 60-year-old man with chronic obstructive pulmonary disease (COPD) presents
with progressive dyspnea and cough. Spirometry shows FEV1/FVC 0.55, FEV1 40%
predicted. He is on long-acting beta-agonist/inhaled corticosteroid combination.
Which of the following interventions has been shown to reduce mortality in patients
with this severity of COPD?
Answer: Long-term oxygen therapy
Long-term oxygen therapy (>15 hours/day) reduces mortality in patients with COPD
and severe resting hypoxemia (PaO2 55 mm Hg or SpO2 88%). This patient has severe
COPD (GOLD 3) and likely qualifies. Roflumilast reduces exacerbations but not
mortality. Pulmonary rehabilitation improves quality of life but not mortality.
Azithromycin reduces exacerbations but has no mortality benefit and risk of hearing
loss.
9. A 65-year-old woman with rheumatoid arthritis on methotrexate and adalimumab
presents with a 2-day history of fever, cough, and dyspnea. Chest X-ray shows a left
upper lobe infiltrate. She is admitted and started on broad-spectrum antibiotics.
Sputum culture grows Pseudomonas aeruginosa. Which of the following is the most
appropriate antibiotic regimen?
Answer: Piperacillin-tazobactam plus ciprofloxacin
For healthcare-associated pneumonia (HCAP) or hospital-acquired pneumonia (HAP)
due to Pseudomonas, dual antipseudomonal therapy is recommended to reduce
resistance risk. Piperacillin-tazobactam plus ciprofloxacin provides adequate coverage.
Ceftazidime plus tobramycin is also effective but tobramycin is nephrotoxic.
Ciprofloxacin monotherapy risks resistance. Imipenem-cilastatin plus vancomycin
covers MRSA but not necessarily Pseudomonas well unless combined with an
antipseudomonal.
Page 4
Answers Already Graded A+ Premium Exam Tested And
Verified
Subject Area Internal Medicine Board Review
Description This rigorous exam simulates the American Board of Internal Medicine (ABIM)
Initial Certification (ITE) examination, covering core internal medicine topics
including cardiology, gastroenterology, pulmonology, nephrology, infectious
disease, endocrinology, rheumatology, hematology, oncology, and general
internal medicine. It tests advanced clinical reasoning, evidence-based
management, and interpretation of diagnostic data at the level expected of a
graduating internal medicine resident.
Expected Grade A+
Total Questions 200
Duration 4 hours
Learning Outcomes 1. Apply evidence-based guidelines to diagnose and manage complex medical
conditions.
2. Interpret advanced diagnostic tests and imaging to guide clinical
decision-making.
3. Integrate pathophysiology, pharmacology, and epidemiology to solve clinical
problems.
4. Recognize atypical presentations and rare complications of common diseases.
5. Demonstrate proficiency in high-stakes, time-pressured clinical reasoning.
Accreditation This examination adheres to the standards set by the Accreditation Council for
Graduate Medical Education (ACGME) and the American Board of Internal
Medicine (ABIM) for initial certification.
Page 1
,1. A 55-year-old man with a history of hypertension and type 2 diabetes presents
with acute onset of severe, tearing chest pain radiating to the back. Blood pressure is
200/110 mm Hg in the right arm and 150/90 mm Hg in the left arm. Chest X-ray
shows a widened mediastinum. What is the most appropriate initial management
step before surgical intervention?
Answer: Intravenous labetalol
In acute aortic dissection, the goal is to reduce heart rate and blood pressure to
decrease aortic wall stress. Beta-blockers (e.g., labetalol or esmolol) are first-line to
reduce dP/dt. Labetalol is preferred because it also provides alpha-blockade for
vasodilation. Nitroprusside alone can cause reflex tachycardia, worsening dissection.
Hydralazine is not recommended. Esmolol is an alternative but requires titration.
2. A 48-year-old woman is found to have a serum calcium of 11.2 mg/dL (normal
8.5-10.2) on routine labs. Intact PTH is 65 pg/mL (normal 10-65). 24-hour urinary
calcium is 400 mg (normal <250). Which of the following is the most likely
diagnosis?
Answer: Primary hyperparathyroidism
Primary hyperparathyroidism typically presents with elevated calcium, elevated or
inappropriately normal PTH, and high urinary calcium. Familial hypocalciuric
hypercalcemia (FHH) has low urinary calcium (usually <100 mg/day) and is benign.
Malignancy-associated hypercalcemia usually has suppressed PTH. Sarcoidosis causes
hypercalcemia via increased 1,25-dihydroxyvitamin D, with low PTH.
3. A 62-year-old man with cirrhosis due to nonalcoholic steatohepatitis is admitted
with hematemesis. Emergent upper endoscopy reveals esophageal varices with active
bleeding. After endoscopic band ligation, which pharmacologic agent should be
initiated to reduce portal pressure?
Answer: Octreotide
Octreotide, a somatostatin analogue, is commonly used in acute variceal bleeding to
reduce splanchnic blood flow and portal pressure. Terlipressin is not available in the
US. Propranolol is used for secondary prophylaxis after bleeding is controlled, not in
the acute setting. Somatostatin itself is not used clinically; octreotide is the preferred
agent.
Page 2
,4. A 70-year-old woman with a history of atrial fibrillation on warfarin presents with
acute onset of right flank pain and hematuria. CT urogram reveals a 2 cm left
ureteral stone. INR is 3.5. What is the most appropriate management?
Answer: Reverse anticoagulation with vitamin K and fresh frozen plasma, then
proceed with ureteroscopy
In a patient with an INR of 3.5 and an active bleeding complication (hematuria)
requiring urgent intervention, reversal of anticoagulation is indicated. Vitamin K and
fresh frozen plasma (or prothrombin complex concentrate) can rapidly reverse
warfarin effect. Elective ureteroscopy is not appropriate because the stone is causing
symptoms and may lead to obstruction. Bridging is not needed after reversal.
Desmopressin is used for uremic bleeding, not warfarin reversal.
5. A 35-year-old woman presents with acute onset of dyspnea and pleuritic chest
pain. CT pulmonary angiography shows a segmental pulmonary embolism. Her vital
signs are normal, and echocardiogram shows no right ventricular strain. She has no
contraindications to anticoagulation. What is the most appropriate initial
anticoagulant?
Answer: Direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban
For acute pulmonary embolism without hemodynamic instability or right ventricular
dysfunction, current guidelines recommend DOACs (apixaban, rivaroxaban) as
first-line therapy due to ease of use and favorable safety profile. LMWH followed by
warfarin is an alternative but less convenient. Unfractionated heparin is reserved for
patients with hemodynamic instability or severe renal impairment. Fondaparinux is an
option but not preferred over DOACs.
6. A 45-year-old man with HIV (CD4 count 120 cells/L, not on antiretroviral
therapy) presents with fever, headache, and confusion. MRI brain shows multiple
ring-enhancing lesions. Lumbar puncture is contraindicated due to
thrombocytopenia. Which of the following is the most likely diagnosis?
Answer: Toxoplasma encephalitis
In HIV patients with low CD4 counts (<100-200), ring-enhancing brain lesions are most
commonly due to Toxoplasma gondii encephalitis. Primary CNS lymphoma (often
Epstein-Barr virus associated) can also present with ring-enhancing lesions but is less
common. CMV encephalitis typically presents with ventriculitis. PML (JC virus)
presents with non-enhancing white matter lesions.
Page 3
, 7. A 50-year-old woman with a history of hypothyroidism on levothyroxine presents
with fatigue, weight gain, and constipation. Labs show TSH 20 mIU/L (normal
0.5-4.5) and free T4 0.6 ng/dL (normal 0.8-1.8). She reports taking her medication
with breakfast. What is the most likely cause of her persistent hypothyroidism?
Answer: Drug interaction with calcium supplements
Levothyroxine absorption is impaired by food, especially calcium and iron
supplements. Taking it with breakfast reduces absorption. Malabsorption (e.g., celiac) is
less common. Poor adherence is possible but the patient reports taking it. Incorrect
dosing is a consideration, but the most likely cause given her history is the timing with
food. Calcium supplements are a common culprit.
8. A 60-year-old man with chronic obstructive pulmonary disease (COPD) presents
with progressive dyspnea and cough. Spirometry shows FEV1/FVC 0.55, FEV1 40%
predicted. He is on long-acting beta-agonist/inhaled corticosteroid combination.
Which of the following interventions has been shown to reduce mortality in patients
with this severity of COPD?
Answer: Long-term oxygen therapy
Long-term oxygen therapy (>15 hours/day) reduces mortality in patients with COPD
and severe resting hypoxemia (PaO2 55 mm Hg or SpO2 88%). This patient has severe
COPD (GOLD 3) and likely qualifies. Roflumilast reduces exacerbations but not
mortality. Pulmonary rehabilitation improves quality of life but not mortality.
Azithromycin reduces exacerbations but has no mortality benefit and risk of hearing
loss.
9. A 65-year-old woman with rheumatoid arthritis on methotrexate and adalimumab
presents with a 2-day history of fever, cough, and dyspnea. Chest X-ray shows a left
upper lobe infiltrate. She is admitted and started on broad-spectrum antibiotics.
Sputum culture grows Pseudomonas aeruginosa. Which of the following is the most
appropriate antibiotic regimen?
Answer: Piperacillin-tazobactam plus ciprofloxacin
For healthcare-associated pneumonia (HCAP) or hospital-acquired pneumonia (HAP)
due to Pseudomonas, dual antipseudomonal therapy is recommended to reduce
resistance risk. Piperacillin-tazobactam plus ciprofloxacin provides adequate coverage.
Ceftazidime plus tobramycin is also effective but tobramycin is nephrotoxic.
Ciprofloxacin monotherapy risks resistance. Imipenem-cilastatin plus vancomycin
covers MRSA but not necessarily Pseudomonas well unless combined with an
antipseudomonal.
Page 4
