ABIM INTERNAL MEDICINE
BOARDS & ITE EXAM
COMPLETE PRACTICE TEST
BANK – 300 ORIGINAL
QUESTIONS WITH DETAILED
RATIONALES
## TABLE OF CONTENTS
| Section | Topic | Questions |
|---------|-------|-----------|
| I | Cardiovascular Medicine | 1–45 |
| II | Pulmonary & Critical Care Medicine | 46–75 |
| III | Gastroenterology & Hepatology | 76–105 |
| IV | Endocrinology & Metabolism | 106–130 |
| V | Infectious Disease | 131–155 |
| VI | Nephrology & Electrolytes | 156–175 |
| VII | Hematology & Medical Oncology | 176–205 |
| VIII | Rheumatology & Immunology | 206–230 |
| IX | Neurology | 231–250 |
| X | Preventive Medicine, Geriatrics & Mixed Topics | 251–300 |
---
## EXAM OVERVIEW
**Exam:** ABIM Internal Medicine Board Certification & In-Training Examination (ITE)
,**Format:** Computer-based, multiple-choice, clinical vignettes
**Question Type:** Each question is a clinical vignette with four answer choices followed by the
correct answer and a detailed rationale explaining the clinical reasoning.
---
# SECTION I: CARDIOVASCULAR MEDICINE
## Questions 1–45
---
**Question 1**
A 67-year-old man with a history of hypertension and hyperlipidemia presents to the emergency
department with substernal chest pressure that began 45 minutes ago while shoveling snow. The pain
radiates to his left arm and is associated with diaphoresis and nausea. His ECG shows 2-mm ST-
segment elevation in leads II, III, and aVF. His blood pressure is 105/65 mmHg, and heart rate is 52
bpm. Which of the following is the most appropriate initial management?
A) Administer sublingual nitroglycerin and observe
B) Administer aspirin, morphine, and arrange for urgent PCI
C) Administer fibrinolytic therapy immediately
D) Administer IV metoprolol and start a heparin drip
**Correct Answer: B**
**Rationale:** This patient has an inferior ST-segment elevation myocardial infarction (STEMI) with
bradycardia (a common finding in inferior MI due to vagal stimulation). The standard of care is
emergent reperfusion with percutaneous coronary intervention (PCI). Aspirin and morphine are
appropriate adjuncts. Fibrinolytics are an alternative if PCI is not available within 90 minutes. Beta-
blockers are generally avoided in the acute setting of an inferior MI with bradycardia and
hypotension.
---
**Question 2**
A 75-year-old woman with a history of heart failure with preserved ejection fraction (HFpEF)
presents with worsening exertional dyspnea and peripheral edema over the past 2 weeks. She reports a
5-pound weight gain. Her blood pressure is 152/85 mmHg, and her heart rate is 78 bpm. Jugular
,venous pressure is elevated at 12 cm H₂O. She has bilateral pitting edema to the mid-shins. Which of
the following is the most appropriate initial pharmacologic intervention?
A) Increase her lisinopril dose
B) Start furosemide
C) Start metoprolol succinate
D) Start spironolactone
**Correct Answer: B**
**Rationale:** This patient has acute decompensated heart failure with volume overload. The initial
treatment is diuresis with a loop diuretic (furosemide) to relieve congestion and symptoms. While
ACE inhibitors, beta-blockers, and aldosterone antagonists are part of chronic management, they are
not the first-line for acute volume overload.
---
**Question 3**
A 62-year-old man with a history of paroxysmal atrial fibrillation, hypertension, and diabetes presents
for routine follow-up. His CHA₂DS₂-VASc score is calculated as 4. He is currently on apixaban 5 mg
twice daily. His serum creatinine is 1.6 mg/dL, and his body weight is 58 kg. Which of the following
is the most appropriate adjustment to his anticoagulation regimen?
A) Continue apixaban 5 mg twice daily
B) Reduce apixaban to 2.5 mg twice daily
C) Switch to warfarin with a target INR of 2-3
D) Discontinue apixaban and start aspirin 81 mg daily
**Correct Answer: B**
**Rationale:** Apixaban requires dose reduction to 2.5 mg twice daily in patients with at least two of
the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. This patient meets
two criteria (weight ≤60 kg and Cr ≥1.5 mg/dL), so dose reduction is indicated. DOACs are preferred
over warfarin for non-valvular atrial fibrillation.
---
**Question 4**
, A 58-year-old woman presents with acute onset of sharp, pleuritic chest pain that is worse when lying
flat and improves when leaning forward. She recently recovered from an upper respiratory infection.
Her ECG shows diffuse ST-segment elevation and PR depression. Her troponin is mildly elevated.
Which of the following is the most likely diagnosis?
A) Acute myocardial infarction
B) Acute pericarditis
C) Pulmonary embolism
D) Aortic dissection
**Correct Answer: B**
**Rationale:** The presentation of positional chest pain (worse supine, better leaning forward) with
diffuse ST-segment elevation and PR depression is classic for acute pericarditis, often post-viral.
While troponin can be mildly elevated in pericarditis (due to epicardial inflammation), the ECG
pattern and clinical presentation distinguish it from acute MI, which would show localized ST
elevation with reciprocal changes.
---
**Question 5**
A 70-year-old man with a history of hypertension and diabetes has a blood pressure of 145/85 mmHg
on three separate office visits. His eGFR is 42 mL/min/1.73 m². According to current guidelines, what
is his target blood pressure?
A) <120/80 mmHg
B) <130/80 mmHg
C) <140/90 mmHg
D) <150/90 mmHg
**Correct Answer: B**
**Rationale:** The ACC/AHA and KDIGO guidelines recommend a blood pressure target of
<130/80 mmHg for patients with hypertension and chronic kidney disease (CKD), diabetes, or
established cardiovascular disease.
---
BOARDS & ITE EXAM
COMPLETE PRACTICE TEST
BANK – 300 ORIGINAL
QUESTIONS WITH DETAILED
RATIONALES
## TABLE OF CONTENTS
| Section | Topic | Questions |
|---------|-------|-----------|
| I | Cardiovascular Medicine | 1–45 |
| II | Pulmonary & Critical Care Medicine | 46–75 |
| III | Gastroenterology & Hepatology | 76–105 |
| IV | Endocrinology & Metabolism | 106–130 |
| V | Infectious Disease | 131–155 |
| VI | Nephrology & Electrolytes | 156–175 |
| VII | Hematology & Medical Oncology | 176–205 |
| VIII | Rheumatology & Immunology | 206–230 |
| IX | Neurology | 231–250 |
| X | Preventive Medicine, Geriatrics & Mixed Topics | 251–300 |
---
## EXAM OVERVIEW
**Exam:** ABIM Internal Medicine Board Certification & In-Training Examination (ITE)
,**Format:** Computer-based, multiple-choice, clinical vignettes
**Question Type:** Each question is a clinical vignette with four answer choices followed by the
correct answer and a detailed rationale explaining the clinical reasoning.
---
# SECTION I: CARDIOVASCULAR MEDICINE
## Questions 1–45
---
**Question 1**
A 67-year-old man with a history of hypertension and hyperlipidemia presents to the emergency
department with substernal chest pressure that began 45 minutes ago while shoveling snow. The pain
radiates to his left arm and is associated with diaphoresis and nausea. His ECG shows 2-mm ST-
segment elevation in leads II, III, and aVF. His blood pressure is 105/65 mmHg, and heart rate is 52
bpm. Which of the following is the most appropriate initial management?
A) Administer sublingual nitroglycerin and observe
B) Administer aspirin, morphine, and arrange for urgent PCI
C) Administer fibrinolytic therapy immediately
D) Administer IV metoprolol and start a heparin drip
**Correct Answer: B**
**Rationale:** This patient has an inferior ST-segment elevation myocardial infarction (STEMI) with
bradycardia (a common finding in inferior MI due to vagal stimulation). The standard of care is
emergent reperfusion with percutaneous coronary intervention (PCI). Aspirin and morphine are
appropriate adjuncts. Fibrinolytics are an alternative if PCI is not available within 90 minutes. Beta-
blockers are generally avoided in the acute setting of an inferior MI with bradycardia and
hypotension.
---
**Question 2**
A 75-year-old woman with a history of heart failure with preserved ejection fraction (HFpEF)
presents with worsening exertional dyspnea and peripheral edema over the past 2 weeks. She reports a
5-pound weight gain. Her blood pressure is 152/85 mmHg, and her heart rate is 78 bpm. Jugular
,venous pressure is elevated at 12 cm H₂O. She has bilateral pitting edema to the mid-shins. Which of
the following is the most appropriate initial pharmacologic intervention?
A) Increase her lisinopril dose
B) Start furosemide
C) Start metoprolol succinate
D) Start spironolactone
**Correct Answer: B**
**Rationale:** This patient has acute decompensated heart failure with volume overload. The initial
treatment is diuresis with a loop diuretic (furosemide) to relieve congestion and symptoms. While
ACE inhibitors, beta-blockers, and aldosterone antagonists are part of chronic management, they are
not the first-line for acute volume overload.
---
**Question 3**
A 62-year-old man with a history of paroxysmal atrial fibrillation, hypertension, and diabetes presents
for routine follow-up. His CHA₂DS₂-VASc score is calculated as 4. He is currently on apixaban 5 mg
twice daily. His serum creatinine is 1.6 mg/dL, and his body weight is 58 kg. Which of the following
is the most appropriate adjustment to his anticoagulation regimen?
A) Continue apixaban 5 mg twice daily
B) Reduce apixaban to 2.5 mg twice daily
C) Switch to warfarin with a target INR of 2-3
D) Discontinue apixaban and start aspirin 81 mg daily
**Correct Answer: B**
**Rationale:** Apixaban requires dose reduction to 2.5 mg twice daily in patients with at least two of
the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. This patient meets
two criteria (weight ≤60 kg and Cr ≥1.5 mg/dL), so dose reduction is indicated. DOACs are preferred
over warfarin for non-valvular atrial fibrillation.
---
**Question 4**
, A 58-year-old woman presents with acute onset of sharp, pleuritic chest pain that is worse when lying
flat and improves when leaning forward. She recently recovered from an upper respiratory infection.
Her ECG shows diffuse ST-segment elevation and PR depression. Her troponin is mildly elevated.
Which of the following is the most likely diagnosis?
A) Acute myocardial infarction
B) Acute pericarditis
C) Pulmonary embolism
D) Aortic dissection
**Correct Answer: B**
**Rationale:** The presentation of positional chest pain (worse supine, better leaning forward) with
diffuse ST-segment elevation and PR depression is classic for acute pericarditis, often post-viral.
While troponin can be mildly elevated in pericarditis (due to epicardial inflammation), the ECG
pattern and clinical presentation distinguish it from acute MI, which would show localized ST
elevation with reciprocal changes.
---
**Question 5**
A 70-year-old man with a history of hypertension and diabetes has a blood pressure of 145/85 mmHg
on three separate office visits. His eGFR is 42 mL/min/1.73 m². According to current guidelines, what
is his target blood pressure?
A) <120/80 mmHg
B) <130/80 mmHg
C) <140/90 mmHg
D) <150/90 mmHg
**Correct Answer: B**
**Rationale:** The ACC/AHA and KDIGO guidelines recommend a blood pressure target of
<130/80 mmHg for patients with hypertension and chronic kidney disease (CKD), diabetes, or
established cardiovascular disease.
---
