ABIM IM BOARDS ITE EXAMQUESTIONS &
VERIFIED ANSWERS | INTERNAL MEDICINE
BOARD PREP (GRADED A+)
Page 1 of 121
,Question 1
Morphine should be avoided in renal failure. Alternative pain medications is
Correct Answer
Dilaudid, which is metabolized in the liver.
Question 1: A 65-year-old man with a history of heart failure with reduced
ejection fraction (HFrEF) is currently taking lisinopril, carvedilol, and
spironolactone. His blood pressure is 115/75 mm Hg, heart rate is 68 bpm,
and potassium is 4.4 mEq/L. He remains symptomatic with NYHA class II
symptoms. His eGFR is 55 mL/min/1.73 m2. Which of the following is the
most appropriate next step in his pharmacologic management?
A. Add digoxin
B. Switch lisinopril to sacubitril-valsartan
C. Add amlodipine
D. Add isosorbide dinitrate
CORRECT ANSWER: B. Switch lisinopril to sacubitril-valsartan
Rationale: In patients with HFrEF who remain symptomatic on an ACE
inhibitor, beta-blocker, and MRA, replacing the ACE inhibitor with an ARNI
(sacubitril-valsartan) is recommended to further reduce morbidity and
mortality. A 36-hour washout period is required when switching from an ACE
inhibitor to an ARNI to prevent angioedema.
Question 2: A 58-year-old woman with a history of hypertension and type
2 diabetes is evaluated for routine care. Her blood pressure is 138/84 mm
Hg on lisinopril. Her HbA1c is 7.2%. Her 10-year ASCVD risk is 12%. Which
of the following lipid-lowering therapies is most appropriate?
A. No lipid-lowering therapy is indicated
B. Moderate-intensity statin
C. High-intensity statin
D. Ezetimibe
CORRECT ANSWER: C. High-intensity statin
Rationale: Patients aged 40 to 75 with diabetes mellitus and an ASCVD risk
≥7.5% should be started on a high-intensity statin (e.g., atorvastatin 40-80
mg or rosuvastatin 20-40 mg) to reduce the risk of cardiovascular events.
Question 3: A 72-year-old man presents to the emergency department
with sudden onset of severe, tearing chest pain radiating to his back. His
blood pressure is 190/110 mm Hg in the right arm and 160/90 mm Hg in
the left arm. A chest x-ray shows a widened mediastinum. What is the
most appropriate initial medical therapy?
A. Intravenous labetalol
Page 2 of 121
,B. Intravenous nitroprusside
C. Oral captopril
D. Intravenous heparin
CORRECT ANSWER: A. Intravenous labetalol
Rationale: The patient likely has an acute aortic dissection. Initial medical
management requires rapid reduction of blood pressure and heart rate to
decrease aortic wall shear stress (dP/dt). Intravenous beta-blockers (like
labetalol or esmolol) should be given before vasodilators (like nitroprusside)
to prevent reflex tachycardia, which would worsen the dissection.
Question 4: A 68-year-old woman presents with a 2-month history of
progressive dyspnea on exertion and two episodes of near-syncope while
walking. On exam, her carotid upstroke is delayed, and a harsh, crescendo-
decrescendo systolic murmur is heard at the right upper sternal border.
What is the most appropriate initial diagnostic test?
A. Electrocardiogram
B. Transthoracic echocardiogram
C. Exercise stress test
D. Cardiac magnetic resonance imaging
CORRECT ANSWER: B. Transthoracic echocardiogram
Rationale: The clinical presentation is classic for severe aortic stenosis. A
transthoracic echocardiogram is the initial test of choice to confirm the
diagnosis, assess valve morphology, and measure the transvalvular gradient
and valve area. Stress testing is contraindicated in symptomatic severe aortic
stenosis.
Question 5: A 24-year-old man presents with sharp, pleuritic chest pain
that improves when he leans forward. He had a viral upper respiratory
infection 1 week ago. ECG shows diffuse ST-segment elevations and PR-
segment depressions. Which of the following is the most appropriate
treatment?
A. High-dose corticosteroids
B. Ibuprofen and colchicine
C. Sublingual nitroglycerin
D. Heparin infusion
CORRECT ANSWER: B. Ibuprofen and colchicine
Rationale: The patient has acute pericarditis. First-line therapy is high-dose
NSAIDs (like ibuprofen or aspirin) plus colchicine to speed resolution and
prevent recurrence. Corticosteroids are reserved for refractory cases or
specific etiologies as they increase the risk of recurrence.
Page 3 of 121
, Question 6: A 75-year-old man is evaluated in the clinic. He has a history of
atrial fibrillation, hypertension, and type 2 diabetes. His current
medications include apixaban, lisinopril, and metformin. His CHA2DS2-
VASc score is 4. He asks if he can stop taking apixaban because he feels
well. What is the most appropriate response?
A. Discontinue apixaban and start aspirin
B. Continue apixaban indefinitely
C. Discontinue apixaban and monitor with a Holter monitor
D. Switch apixaban to clopidogrel
CORRECT ANSWER: B. Continue apixaban indefinitely
Rationale: Patients with nonvalvular atrial fibrillation and a CHA2DS2-VASc
score ≥2 in men or ≥3 in women should receive oral anticoagulation to
prevent stroke. Apixaban is a direct oral anticoagulant (DOAC) and is
preferred over warfarin. Aspirin and clopidogrel are not adequate for stroke
prevention in atrial fibrillation.
Question 7: A 75-year-old man presents with fatigue and lightheadedness.
His heart rate is 38 bpm. ECG shows complete dissociation between P
waves and QRS complexes. The QRS duration is 140 ms. What is the most
appropriate definitive treatment?
A. Atropine
B. Transvenous pacing
C. Permanent pacemaker implantation
D. Isoproterenol infusion
CORRECT ANSWER: C. Permanent pacemaker implantation
Rationale: The patient has third-degree (complete) AV block with a wide QRS
escape rhythm, indicating infranodal disease. This is a class I indication for
permanent pacemaker implantation. Atropine is often ineffective for
infranodal blocks and can paradoxically worsen the block.
Question 8: A 60-year-old woman is evaluated for a routine physical. She
feels well. Her blood pressure is 146/90 mm Hg, confirmed on repeat
measurement. She has no other medical conditions. Her BMI is 28. Fasting
glucose and lipids are normal. Which of the following is the most
appropriate first-line antihypertensive medication?
A. Lisinopril
B. Amlodipine
C. Metoprolol
D. Losartan
CORRECT ANSWER: B. Amlodipine
Rationale: For a patient without compelling indications (like diabetes, CKD, or
heart failure), first-line antihypertensive options include thiazide diuretics,
Page 4 of 121
VERIFIED ANSWERS | INTERNAL MEDICINE
BOARD PREP (GRADED A+)
Page 1 of 121
,Question 1
Morphine should be avoided in renal failure. Alternative pain medications is
Correct Answer
Dilaudid, which is metabolized in the liver.
Question 1: A 65-year-old man with a history of heart failure with reduced
ejection fraction (HFrEF) is currently taking lisinopril, carvedilol, and
spironolactone. His blood pressure is 115/75 mm Hg, heart rate is 68 bpm,
and potassium is 4.4 mEq/L. He remains symptomatic with NYHA class II
symptoms. His eGFR is 55 mL/min/1.73 m2. Which of the following is the
most appropriate next step in his pharmacologic management?
A. Add digoxin
B. Switch lisinopril to sacubitril-valsartan
C. Add amlodipine
D. Add isosorbide dinitrate
CORRECT ANSWER: B. Switch lisinopril to sacubitril-valsartan
Rationale: In patients with HFrEF who remain symptomatic on an ACE
inhibitor, beta-blocker, and MRA, replacing the ACE inhibitor with an ARNI
(sacubitril-valsartan) is recommended to further reduce morbidity and
mortality. A 36-hour washout period is required when switching from an ACE
inhibitor to an ARNI to prevent angioedema.
Question 2: A 58-year-old woman with a history of hypertension and type
2 diabetes is evaluated for routine care. Her blood pressure is 138/84 mm
Hg on lisinopril. Her HbA1c is 7.2%. Her 10-year ASCVD risk is 12%. Which
of the following lipid-lowering therapies is most appropriate?
A. No lipid-lowering therapy is indicated
B. Moderate-intensity statin
C. High-intensity statin
D. Ezetimibe
CORRECT ANSWER: C. High-intensity statin
Rationale: Patients aged 40 to 75 with diabetes mellitus and an ASCVD risk
≥7.5% should be started on a high-intensity statin (e.g., atorvastatin 40-80
mg or rosuvastatin 20-40 mg) to reduce the risk of cardiovascular events.
Question 3: A 72-year-old man presents to the emergency department
with sudden onset of severe, tearing chest pain radiating to his back. His
blood pressure is 190/110 mm Hg in the right arm and 160/90 mm Hg in
the left arm. A chest x-ray shows a widened mediastinum. What is the
most appropriate initial medical therapy?
A. Intravenous labetalol
Page 2 of 121
,B. Intravenous nitroprusside
C. Oral captopril
D. Intravenous heparin
CORRECT ANSWER: A. Intravenous labetalol
Rationale: The patient likely has an acute aortic dissection. Initial medical
management requires rapid reduction of blood pressure and heart rate to
decrease aortic wall shear stress (dP/dt). Intravenous beta-blockers (like
labetalol or esmolol) should be given before vasodilators (like nitroprusside)
to prevent reflex tachycardia, which would worsen the dissection.
Question 4: A 68-year-old woman presents with a 2-month history of
progressive dyspnea on exertion and two episodes of near-syncope while
walking. On exam, her carotid upstroke is delayed, and a harsh, crescendo-
decrescendo systolic murmur is heard at the right upper sternal border.
What is the most appropriate initial diagnostic test?
A. Electrocardiogram
B. Transthoracic echocardiogram
C. Exercise stress test
D. Cardiac magnetic resonance imaging
CORRECT ANSWER: B. Transthoracic echocardiogram
Rationale: The clinical presentation is classic for severe aortic stenosis. A
transthoracic echocardiogram is the initial test of choice to confirm the
diagnosis, assess valve morphology, and measure the transvalvular gradient
and valve area. Stress testing is contraindicated in symptomatic severe aortic
stenosis.
Question 5: A 24-year-old man presents with sharp, pleuritic chest pain
that improves when he leans forward. He had a viral upper respiratory
infection 1 week ago. ECG shows diffuse ST-segment elevations and PR-
segment depressions. Which of the following is the most appropriate
treatment?
A. High-dose corticosteroids
B. Ibuprofen and colchicine
C. Sublingual nitroglycerin
D. Heparin infusion
CORRECT ANSWER: B. Ibuprofen and colchicine
Rationale: The patient has acute pericarditis. First-line therapy is high-dose
NSAIDs (like ibuprofen or aspirin) plus colchicine to speed resolution and
prevent recurrence. Corticosteroids are reserved for refractory cases or
specific etiologies as they increase the risk of recurrence.
Page 3 of 121
, Question 6: A 75-year-old man is evaluated in the clinic. He has a history of
atrial fibrillation, hypertension, and type 2 diabetes. His current
medications include apixaban, lisinopril, and metformin. His CHA2DS2-
VASc score is 4. He asks if he can stop taking apixaban because he feels
well. What is the most appropriate response?
A. Discontinue apixaban and start aspirin
B. Continue apixaban indefinitely
C. Discontinue apixaban and monitor with a Holter monitor
D. Switch apixaban to clopidogrel
CORRECT ANSWER: B. Continue apixaban indefinitely
Rationale: Patients with nonvalvular atrial fibrillation and a CHA2DS2-VASc
score ≥2 in men or ≥3 in women should receive oral anticoagulation to
prevent stroke. Apixaban is a direct oral anticoagulant (DOAC) and is
preferred over warfarin. Aspirin and clopidogrel are not adequate for stroke
prevention in atrial fibrillation.
Question 7: A 75-year-old man presents with fatigue and lightheadedness.
His heart rate is 38 bpm. ECG shows complete dissociation between P
waves and QRS complexes. The QRS duration is 140 ms. What is the most
appropriate definitive treatment?
A. Atropine
B. Transvenous pacing
C. Permanent pacemaker implantation
D. Isoproterenol infusion
CORRECT ANSWER: C. Permanent pacemaker implantation
Rationale: The patient has third-degree (complete) AV block with a wide QRS
escape rhythm, indicating infranodal disease. This is a class I indication for
permanent pacemaker implantation. Atropine is often ineffective for
infranodal blocks and can paradoxically worsen the block.
Question 8: A 60-year-old woman is evaluated for a routine physical. She
feels well. Her blood pressure is 146/90 mm Hg, confirmed on repeat
measurement. She has no other medical conditions. Her BMI is 28. Fasting
glucose and lipids are normal. Which of the following is the most
appropriate first-line antihypertensive medication?
A. Lisinopril
B. Amlodipine
C. Metoprolol
D. Losartan
CORRECT ANSWER: B. Amlodipine
Rationale: For a patient without compelling indications (like diabetes, CKD, or
heart failure), first-line antihypertensive options include thiazide diuretics,
Page 4 of 121
