ABIM Internal Medicine Boards & ITE Exam | 200
Practice Questions & Verified Answers with Rationales |
Latest Update 2026/2027 | A+ Graded
Question 1
A 65yearold man with a history of hypertension and type 2 diabetes presents with progressive
exertional dyspnea and orthopnea. On examination, he has bibasilar crackles, an S3 gallop, and 2+
pitting edema in the lower extremities. Echocardiogram shows an ejection fraction of 30%. Which of the
following is the most appropriate firstline therapy?
A. Metoprolol succinate
B. Furosemide
C. Lisinopril
D. Digoxin
Correct Answer: C
Rationale: The patient has heart failure with reduced ejection fraction (HFrEF). ACE inhibitors (lisinopril)
are firstline therapy for HFrEF along with betablockers. ACE inhibitors reduce afterload and preload,
improving cardiac output and decreasing mortality. Betablockers (metoprolol succinate) should be
added but are typically started after ACE inhibitors. Furosemide is for symptom management of fluid
overload. Digoxin is not firstline therapy.
Question 2
A 55yearold man with chronic stable angina is started on a statin for hyperlipidemia. Which of the
following is the most important adverse effect to monitor?
A. Hepatotoxicity
B. Myopathy and rhabdomyolysis
,C. Nephrotoxicity
D. Pancreatitis
Correct Answer: B
Rationale: Statins can cause myopathy and rhabdomyolysis, which are the most important adverse
effects to monitor. Patients should be advised to report any muscle pain, tenderness, or weakness.
Hepatotoxicity is also possible but less common. Liver function tests should be checked at baseline and
as clinically indicated.
Question 3
A 72yearold woman presents with acute onset of severe chest pain radiating to her back. On
examination, blood pressure is 100/60 mmHg in the right arm and 130/80 mmHg in the left arm. Which
of the following is the most likely diagnosis?
A. Acute myocardial infarction
B. Pulmonary embolism
C. Aortic dissection
D. Pericarditis
Correct Answer: C
Rationale: The patient's presentation of acute severe chest pain radiating to the back with a blood
pressure differential between arms is classic for aortic dissection. Aortic dissection is a medical
emergency requiring immediate imaging (CT angiography) and surgical or medical management. MI, PE,
and pericarditis do not typically present with blood pressure differentials.
Question 4
,A 60yearold man with a history of COPD presents with worsening dyspnea and cough productive of
yellow sputum. On examination, he has wheezing and prolonged expiration. Arterial blood gas shows pH
7.32, PaCO2 58 mmHg, PaO2 55 mmHg, HCO3 28 mEq/L. Which of the following is the most appropriate
initial management?
A. Intubation and mechanical ventilation
B. Noninvasive positive pressure ventilation (NIPPV)
C. Highflow oxygen via nonrebreather mask
D. Nebulized albuterol and ipratropium
Correct Answer: D
Rationale: The patient has an acute exacerbation of COPD with respiratory acidosis. Initial management
includes bronchodilators (nebulized albuterol and ipratropium) and corticosteroids. Oxygen should be
titrated to maintain SpO2 8892% (higher oxygen can suppress hypoxic drive). NIPPV is indicated if the
patient fails to improve with medical therapy or has worsening respiratory acidosis. Intubation is
reserved for severe cases.
Question 5
A 45yearold woman presents with fatigue, weight gain, cold intolerance, and constipation. On
examination, she has a slow heart rate and dry skin. Thyroid function tests show TSH 15 µIU/mL (normal
0.44.0) and free T4 0.5 ng/dL (normal 0.81.8). Which of the following is the most appropriate treatment?
A. Methimazole
B. Levothyroxine
C. Propylthiouracil
D. Radioactive iodine
Correct Answer: B
, Rationale: The patient has hypothyroidism, confirmed by elevated TSH and low free T4. Levothyroxine is
the treatment of choice. Methimazole and propylthiouracil are used for hyperthyroidism. Radioactive
iodine is used for hyperthyroidism, not hypothyroidism.
Question 6
A 68yearold man presents with acute shortness of breath and pleuritic chest pain. He recently had a
total knee replacement surgery 2 weeks ago. On examination, heart rate is 110 bpm, respiratory rate is
28, and oxygen saturation is 89% on room air. Which of the following is the most appropriate diagnostic
test?
A. Chest Xray
B. Ddimer
C. CT pulmonary angiography
D. Ventilationperfusion (V/Q) scan
Correct Answer: C
Rationale: The patient has a high pretest probability for pulmonary embolism (recent surgery,
tachycardia, hypoxia, pleuritic chest pain). CT pulmonary angiography is the diagnostic test of choice for
PE. Ddimer is useful for low to moderate pretest probability but is less specific. Chest Xray may show
alternative diagnoses but is not diagnostic for PE. V/Q scan is an alternative but less commonly used.
Question 7
A 55yearold man with a history of alcohol use disorder presents with jaundice, abdominal distension,
and confusion. On examination, he has spider angiomas, palmar erythema, and asterixis. Laboratory
tests show elevated bilirubin, low albumin, and prolonged PT/INR. Which of the following is the most
likely diagnosis?
A. Acute viral hepatitis
Practice Questions & Verified Answers with Rationales |
Latest Update 2026/2027 | A+ Graded
Question 1
A 65yearold man with a history of hypertension and type 2 diabetes presents with progressive
exertional dyspnea and orthopnea. On examination, he has bibasilar crackles, an S3 gallop, and 2+
pitting edema in the lower extremities. Echocardiogram shows an ejection fraction of 30%. Which of the
following is the most appropriate firstline therapy?
A. Metoprolol succinate
B. Furosemide
C. Lisinopril
D. Digoxin
Correct Answer: C
Rationale: The patient has heart failure with reduced ejection fraction (HFrEF). ACE inhibitors (lisinopril)
are firstline therapy for HFrEF along with betablockers. ACE inhibitors reduce afterload and preload,
improving cardiac output and decreasing mortality. Betablockers (metoprolol succinate) should be
added but are typically started after ACE inhibitors. Furosemide is for symptom management of fluid
overload. Digoxin is not firstline therapy.
Question 2
A 55yearold man with chronic stable angina is started on a statin for hyperlipidemia. Which of the
following is the most important adverse effect to monitor?
A. Hepatotoxicity
B. Myopathy and rhabdomyolysis
,C. Nephrotoxicity
D. Pancreatitis
Correct Answer: B
Rationale: Statins can cause myopathy and rhabdomyolysis, which are the most important adverse
effects to monitor. Patients should be advised to report any muscle pain, tenderness, or weakness.
Hepatotoxicity is also possible but less common. Liver function tests should be checked at baseline and
as clinically indicated.
Question 3
A 72yearold woman presents with acute onset of severe chest pain radiating to her back. On
examination, blood pressure is 100/60 mmHg in the right arm and 130/80 mmHg in the left arm. Which
of the following is the most likely diagnosis?
A. Acute myocardial infarction
B. Pulmonary embolism
C. Aortic dissection
D. Pericarditis
Correct Answer: C
Rationale: The patient's presentation of acute severe chest pain radiating to the back with a blood
pressure differential between arms is classic for aortic dissection. Aortic dissection is a medical
emergency requiring immediate imaging (CT angiography) and surgical or medical management. MI, PE,
and pericarditis do not typically present with blood pressure differentials.
Question 4
,A 60yearold man with a history of COPD presents with worsening dyspnea and cough productive of
yellow sputum. On examination, he has wheezing and prolonged expiration. Arterial blood gas shows pH
7.32, PaCO2 58 mmHg, PaO2 55 mmHg, HCO3 28 mEq/L. Which of the following is the most appropriate
initial management?
A. Intubation and mechanical ventilation
B. Noninvasive positive pressure ventilation (NIPPV)
C. Highflow oxygen via nonrebreather mask
D. Nebulized albuterol and ipratropium
Correct Answer: D
Rationale: The patient has an acute exacerbation of COPD with respiratory acidosis. Initial management
includes bronchodilators (nebulized albuterol and ipratropium) and corticosteroids. Oxygen should be
titrated to maintain SpO2 8892% (higher oxygen can suppress hypoxic drive). NIPPV is indicated if the
patient fails to improve with medical therapy or has worsening respiratory acidosis. Intubation is
reserved for severe cases.
Question 5
A 45yearold woman presents with fatigue, weight gain, cold intolerance, and constipation. On
examination, she has a slow heart rate and dry skin. Thyroid function tests show TSH 15 µIU/mL (normal
0.44.0) and free T4 0.5 ng/dL (normal 0.81.8). Which of the following is the most appropriate treatment?
A. Methimazole
B. Levothyroxine
C. Propylthiouracil
D. Radioactive iodine
Correct Answer: B
, Rationale: The patient has hypothyroidism, confirmed by elevated TSH and low free T4. Levothyroxine is
the treatment of choice. Methimazole and propylthiouracil are used for hyperthyroidism. Radioactive
iodine is used for hyperthyroidism, not hypothyroidism.
Question 6
A 68yearold man presents with acute shortness of breath and pleuritic chest pain. He recently had a
total knee replacement surgery 2 weeks ago. On examination, heart rate is 110 bpm, respiratory rate is
28, and oxygen saturation is 89% on room air. Which of the following is the most appropriate diagnostic
test?
A. Chest Xray
B. Ddimer
C. CT pulmonary angiography
D. Ventilationperfusion (V/Q) scan
Correct Answer: C
Rationale: The patient has a high pretest probability for pulmonary embolism (recent surgery,
tachycardia, hypoxia, pleuritic chest pain). CT pulmonary angiography is the diagnostic test of choice for
PE. Ddimer is useful for low to moderate pretest probability but is less specific. Chest Xray may show
alternative diagnoses but is not diagnostic for PE. V/Q scan is an alternative but less commonly used.
Question 7
A 55yearold man with a history of alcohol use disorder presents with jaundice, abdominal distension,
and confusion. On examination, he has spider angiomas, palmar erythema, and asterixis. Laboratory
tests show elevated bilirubin, low albumin, and prolonged PT/INR. Which of the following is the most
likely diagnosis?
A. Acute viral hepatitis
