ABIM IM BOARDS ITE EXAM 2026 REAL
QUESTIONS & VERIFIED ANSWERS | INTERNAL
MEDICINE BOARD PREP EXAM QUESTIONS WITH
CHOICES AND WELL DETAILED ANSWERS ALL
WITH RATIONALE
Cardiology
1. A 62-year-old man with hypertension and diabetes presents with
substernal chest pressure radiating to the jaw, occurring at rest and
lasting 15 minutes. ECG shows ST depression in V4-V6. Troponin is
elevated. What is the most appropriate next step?
A. Exercise stress test
B. Aspirin, clopidogrel, heparin, and urgent catheterization
C. Outpatient cardiology referral
D. Nitroglycerin and discharge with aspirin
Answer: B
Rationale: This patient has non-ST elevation myocardial infarction (NSTEMI)
based on symptoms, ECG changes, and elevated troponin. High-risk features
(diabetes, ongoing symptoms) warrant urgent invasive strategy (within 24
hours) with dual antiplatelet therapy (DAPT) and anticoagulation.
2. A 55-year-old man reports palpitations. ECG shows irregularly
irregular rhythm with no P waves and ventricular rate 140 bpm.
,What is the most appropriate acute management if he is
hemodynamically stable?
A. Immediate synchronized cardioversion
B. Rate control with metoprolol or diltiazem
C. Aspirin 325 mg
D. Amiodarone 150 mg IV push
Answer: B
Rationale: Atrial fibrillation with rapid ventricular response in a stable
patient is managed with rate control (beta-blocker or nondihydropyridine
calcium channel blocker). Cardioversion is for unstable patients or after
appropriate anticoagulation.
3. A 70-year-old woman has a blood pressure of 150/92 mmHg. She
has diabetes and chronic kidney disease (eGFR 40 mL/min). What is
the target blood pressure for this patient per recent guidelines?
A. <120/80 mmHg
B. <130/80 mmHg
C. <140/90 mmHg
D. <150/90 mmHg
Answer: B
Rationale: ACC/AHA guidelines recommend BP target <130/80 mmHg for
patients with diabetes, CKD, or established cardiovascular disease.
,4. A patient with chest pain has ECG showing ST elevation in leads
V1-V4. Cardiac catheterization shows 90% proximal LAD stenosis.
What is the most appropriate next step?
A. Medical management with aspirin and statin
B. PCI with drug-eluting stent
C. CABG
D. Thrombolytics
Answer: B
Rationale: STEMI (ST elevation in V1-V4 = anterior MI) requires emergent
reperfusion. PCI is preferred if door-to-balloon time <90 minutes.
Thrombolytics if PCI not available.
5. A 72-year-old man with hypertension reports lightheadedness
when standing. BP supine 140/80, HR 72; standing BP 100/60, HR
80. Which medication is most likely contributing?
A. Metoprolol
B. Lisinopril
C. Hydrochlorothiazide
D. Doxazosin
Answer: D
Rationale: Alpha-blockers (doxazosin, terazosin, prazosin) cause significant
orthostatic hypotension. Beta-blockers and ACE inhibitors cause less.
Thiazides cause volume depletion but less orthostasis.
, 6. A 65-year-old woman has a new diastolic murmur best heard at
the left sternal border with an opening snap. What is the most likely
diagnosis?
A. Aortic stenosis
B. Mitral stenosis
C. Tricuspid regurgitation
D. Pulmonic stenosis
Answer: B
Rationale: Diastolic murmur with opening snap at the left sternal border is
classic for mitral stenosis. Most common cause is rheumatic heart disease.
Opening snap occurs when stenotic mitral valve leaflets open abruptly in
early diastole.
7. A 68-year-old man with a history of heart failure with reduced EF
(35%) presents with worsening dyspnea and orthopnea. He is on
lisinopril, carvedilol, and furosemide. What is the most appropriate
next medication to reduce mortality?
A. Digoxin
B. Spironolactone
C. Hydralazine/isosorbide dinitrate
D. Ivabradine
Answer: B
QUESTIONS & VERIFIED ANSWERS | INTERNAL
MEDICINE BOARD PREP EXAM QUESTIONS WITH
CHOICES AND WELL DETAILED ANSWERS ALL
WITH RATIONALE
Cardiology
1. A 62-year-old man with hypertension and diabetes presents with
substernal chest pressure radiating to the jaw, occurring at rest and
lasting 15 minutes. ECG shows ST depression in V4-V6. Troponin is
elevated. What is the most appropriate next step?
A. Exercise stress test
B. Aspirin, clopidogrel, heparin, and urgent catheterization
C. Outpatient cardiology referral
D. Nitroglycerin and discharge with aspirin
Answer: B
Rationale: This patient has non-ST elevation myocardial infarction (NSTEMI)
based on symptoms, ECG changes, and elevated troponin. High-risk features
(diabetes, ongoing symptoms) warrant urgent invasive strategy (within 24
hours) with dual antiplatelet therapy (DAPT) and anticoagulation.
2. A 55-year-old man reports palpitations. ECG shows irregularly
irregular rhythm with no P waves and ventricular rate 140 bpm.
,What is the most appropriate acute management if he is
hemodynamically stable?
A. Immediate synchronized cardioversion
B. Rate control with metoprolol or diltiazem
C. Aspirin 325 mg
D. Amiodarone 150 mg IV push
Answer: B
Rationale: Atrial fibrillation with rapid ventricular response in a stable
patient is managed with rate control (beta-blocker or nondihydropyridine
calcium channel blocker). Cardioversion is for unstable patients or after
appropriate anticoagulation.
3. A 70-year-old woman has a blood pressure of 150/92 mmHg. She
has diabetes and chronic kidney disease (eGFR 40 mL/min). What is
the target blood pressure for this patient per recent guidelines?
A. <120/80 mmHg
B. <130/80 mmHg
C. <140/90 mmHg
D. <150/90 mmHg
Answer: B
Rationale: ACC/AHA guidelines recommend BP target <130/80 mmHg for
patients with diabetes, CKD, or established cardiovascular disease.
,4. A patient with chest pain has ECG showing ST elevation in leads
V1-V4. Cardiac catheterization shows 90% proximal LAD stenosis.
What is the most appropriate next step?
A. Medical management with aspirin and statin
B. PCI with drug-eluting stent
C. CABG
D. Thrombolytics
Answer: B
Rationale: STEMI (ST elevation in V1-V4 = anterior MI) requires emergent
reperfusion. PCI is preferred if door-to-balloon time <90 minutes.
Thrombolytics if PCI not available.
5. A 72-year-old man with hypertension reports lightheadedness
when standing. BP supine 140/80, HR 72; standing BP 100/60, HR
80. Which medication is most likely contributing?
A. Metoprolol
B. Lisinopril
C. Hydrochlorothiazide
D. Doxazosin
Answer: D
Rationale: Alpha-blockers (doxazosin, terazosin, prazosin) cause significant
orthostatic hypotension. Beta-blockers and ACE inhibitors cause less.
Thiazides cause volume depletion but less orthostasis.
, 6. A 65-year-old woman has a new diastolic murmur best heard at
the left sternal border with an opening snap. What is the most likely
diagnosis?
A. Aortic stenosis
B. Mitral stenosis
C. Tricuspid regurgitation
D. Pulmonic stenosis
Answer: B
Rationale: Diastolic murmur with opening snap at the left sternal border is
classic for mitral stenosis. Most common cause is rheumatic heart disease.
Opening snap occurs when stenotic mitral valve leaflets open abruptly in
early diastole.
7. A 68-year-old man with a history of heart failure with reduced EF
(35%) presents with worsening dyspnea and orthopnea. He is on
lisinopril, carvedilol, and furosemide. What is the most appropriate
next medication to reduce mortality?
A. Digoxin
B. Spironolactone
C. Hydralazine/isosorbide dinitrate
D. Ivabradine
Answer: B
