ABIM and ITE INTERNAL MEDICINE
BOARDS ACTUAL EXAM PREP 2026
EDITION 150 Q&AS WITH BOLD
ANSWERS & FULL RATIONALES
1. A 65-year-old man presents with a 2-month history of progressive
dyspnea on exertion and dry cough. He has no history of smoking and
worked as an electrician for 30 years. Physical examination reveals fine,
dry inspiratory crackles at the bases and clubbing of the fingers.
Pulmonary function tests demonstrate a restrictive pattern with
decreased DLCO. A high-resolution CT scan of the chest shows
subpleural, basal-predominant honeycombing and traction
bronchiectasis. Given the most likely diagnosis of Idiopathic Pulmonary
Fibrosis (IPF), which of the following therapeutic options has been
shown to slow the rate of decline in forced vital capacity (FVC)?
Correct Answer: Pirfenidone
Rationale: Pirfenidone and nintedanib are anti-fibrotic agents
approved for the treatment of IPF. Both have been shown to reduce the
rate of FVC decline in clinical trials, although they do not improve
symptoms or mortality. Treatment with steroids and
immunosuppressants can be harmful in IPF.
2. A 45-year-old woman with a history of Graves' disease treated with
radioactive iodine 1 year ago presents with fatigue, constipation, and
weight gain. Laboratory studies show a TSH of 45 mIU/L (normal 0.4–
4.0) and a low free T4. She is diagnosed with hypothyroidism and started
on levothyroxine 100 mcg daily. She has no other medical conditions.
Which of the following is the most appropriate next step in the
management of this patient?
Correct Answer: Recheck TSH levels in 6-8 weeks
Rationale: Levothyroxine therapy for hypothyroidism should be
monitored by checking TSH levels. Because the half-life of T4 is 7 days,
it takes about 5-6 half-lives (roughly 6-8 weeks) to reach a steady state.
Therefore, TSH should not be rechecked sooner than 6 weeks after
initiating therapy or changing the dose.
,3. A 72-year-old man is brought to the emergency department by his
wife due to confusion and decreased oral intake for 3 days. He has a
history of hypertension and dementia. On arrival, he is lethargic. Serum
sodium is 115 mEq/L, serum osmolarity is 245 mOsm/kg, and urine
osmolarity is 500 mOsm/kg. Urine sodium is 50 mEq/L. He appears
euvolemic on examination. What is the most likely cause of his
hyponatremia?
Correct Answer: Syndrome of inappropriate antidiuretic
hormone secretion (SIADH)
Rationale: The patient has hypotonic hyponatremia with high urine
osmolarity and high urine sodium, in the setting of euvolemia, which
defines SIADH. The high urine sodium indicates that the patient is not
volume-depleted, which would typically cause a low urine sodium.
4. A 55-year-old woman with chronic plaque psoriasis presents with a 6-
month history of pain and stiffness in her distal interphalangeal (DIP)
joints, as well as morning stiffness lasting 1 hour. Examination shows
sausage-shaped swelling of the second digit on the right hand (dactylitis)
and pitting of the nails. Radiographs of the hands reveal marginal
erosions and "pencil-in-cup" deformities. What is the most appropriate
initial disease-modifying antirheumatic drug (DMARD) for this patient?
Correct Answer: Methotrexate
Rationale: The patient has psoriatic arthritis, which is commonly
treated with methotrexate as a first-line DMARD, especially when there
is significant skin involvement. TNF inhibitors are also effective, but
methotrexate is typically used first. NSAIDs can help with symptoms
but do not alter the disease course.
5. A 35-year-old woman presents to the clinic for a routine follow-up.
She has a history of systemic lupus erythematosus (SLE) and is currently
taking hydroxychloroquine. She is planning to become pregnant.
Laboratory studies show positive anti-SSA/Ro antibodies. Which of the
following fetal complications is this patient at the highest risk for during
pregnancy?
Correct Answer: Congenital heart block
Rationale: Anti-SSA/Ro (and anti-SSB/La) antibodies are
associated with neonatal lupus, the most serious complication of which
is congenital heart block. These antibodies cross the placenta and can
,damage the fetal cardiac conduction system, usually between 18 and 24
weeks of gestation.
6. A 60-year-old man with a 30 pack-year smoking history presents with
a 3-week history of worsening cough and hemoptysis. A chest X-ray
reveals a 4-cm right hilar mass. Laboratory studies are significant for a
serum calcium level of 13.5 mg/dL. PTH level is low, and PTHrP is
elevated. Which type of lung cancer is most likely?
Correct Answer: Squamous cell carcinoma
Rationale: Squamous cell carcinoma of the lung is classically
associated with the production of parathyroid hormone-related peptide
(PTHrP), causing hypercalcemia. It is often centrally located and
associated with smoking.
7. A 28-year-old woman with a history of Crohn's disease presents with a
2-day history of right lower quadrant abdominal pain, fever, and
vomiting. A CT scan of the abdomen reveals a 4-cm abscess near the
terminal ileum, associated with thickened bowel wall. She is currently
taking infliximab. Which of the following is the most appropriate initial
management?
Correct Answer: Bowel rest, intravenous antibiotics, and
percutaneous drainage
Rationale: Initial management of a Crohn's-related intra-
abdominal abscess involves bowel rest, IV antibiotics, and image-
guided percutaneous drainage. Surgical resection is generally reserved
for patients who do not respond to these measures or who develop
complications like free perforation.
8. A 58-year-old man with a history of cirrhosis due to hepatitis C
presents with increasing abdominal girth. Paracentesis shows an
albumin level of 1.2 g/dL and a serum albumin of 3.2 g/dL, resulting in
an SAAG (serum-ascites albumin gradient) of 2.0 g/dL. The ascitic fluid
polymorphonuclear (PMN) cell count is 300 cells/mm³. What is the
most appropriate next step in management?
Correct Answer: Start empiric intravenous cefotaxime
Rationale: The SAAG is >1.1 g/dL, indicating portal hypertension.
The PMN count is >250 cells/mm³, which is diagnostic of spontaneous
bacterial peritonitis (SBP). Immediate treatment with third-generation
cephalosporins is necessary.
, 9. A 65-year-old woman with a history of hypertension and diabetes
presents with sudden onset of right-sided weakness and aphasia.
Symptoms started 90 minutes ago. Her blood pressure is 170/90 mmHg.
Non-contrast CT head shows no hemorrhage. She has no
contraindications to thrombolysis. What is the most appropriate next
step?
Correct Answer: Intravenous alteplase (tPA)
administration
Rationale: The patient is within the 4.5-hour window for IV tPA
administration, which is indicated for acute ischemic stroke. Blood
pressure is below the threshold for immediate treatment before tPA.
10. A 40-year-old man with a history of HIV, with a CD4 count of 50
cells/µL, presents with headache and fever. Lumbar puncture reveals
high opening pressure, and India ink stain is positive. Which of the
following is the best initial therapy?
Correct Answer: Amphotericin B and flucytosine
Rationale: Cryptococcal meningitis in an AIDS patient is treated
with induction therapy using amphotericin B and flucytosine, followed
by consolidation and maintenance therapy with fluconazole.
11. A 70-year-old man with chronic atrial fibrillation, who is on warfarin
with a therapeutic INR, presents with a new onset of severe, diffuse
abdominal pain that is out of proportion to physical exam findings. He
has not had a bowel movement in 2 days. What is the most likely
diagnosis?
Correct Answer: Acute mesenteric ischemia
Rationale: Acute mesenteric ischemia should be suspected in a
patient with atrial fibrillation (risk of embolus) who presents with
severe abdominal pain out of proportion to the physical exam. Early
diagnosis with CT angiography is critical.
12. A 25-year-old woman presents to the clinic with a 3-month history of
fatigue, joint pains, and a rash on her face that worsens with sun
exposure. She also reports hair loss. Laboratory tests show a positive
ANA, positive anti-dsDNA, and low complement levels (C3, C4). What is
the most likely diagnosis?
Correct Answer: Systemic lupus erythematosus (SLE)
Rationale: The combination ofmalar rash, arthritis, alopecia, and
BOARDS ACTUAL EXAM PREP 2026
EDITION 150 Q&AS WITH BOLD
ANSWERS & FULL RATIONALES
1. A 65-year-old man presents with a 2-month history of progressive
dyspnea on exertion and dry cough. He has no history of smoking and
worked as an electrician for 30 years. Physical examination reveals fine,
dry inspiratory crackles at the bases and clubbing of the fingers.
Pulmonary function tests demonstrate a restrictive pattern with
decreased DLCO. A high-resolution CT scan of the chest shows
subpleural, basal-predominant honeycombing and traction
bronchiectasis. Given the most likely diagnosis of Idiopathic Pulmonary
Fibrosis (IPF), which of the following therapeutic options has been
shown to slow the rate of decline in forced vital capacity (FVC)?
Correct Answer: Pirfenidone
Rationale: Pirfenidone and nintedanib are anti-fibrotic agents
approved for the treatment of IPF. Both have been shown to reduce the
rate of FVC decline in clinical trials, although they do not improve
symptoms or mortality. Treatment with steroids and
immunosuppressants can be harmful in IPF.
2. A 45-year-old woman with a history of Graves' disease treated with
radioactive iodine 1 year ago presents with fatigue, constipation, and
weight gain. Laboratory studies show a TSH of 45 mIU/L (normal 0.4–
4.0) and a low free T4. She is diagnosed with hypothyroidism and started
on levothyroxine 100 mcg daily. She has no other medical conditions.
Which of the following is the most appropriate next step in the
management of this patient?
Correct Answer: Recheck TSH levels in 6-8 weeks
Rationale: Levothyroxine therapy for hypothyroidism should be
monitored by checking TSH levels. Because the half-life of T4 is 7 days,
it takes about 5-6 half-lives (roughly 6-8 weeks) to reach a steady state.
Therefore, TSH should not be rechecked sooner than 6 weeks after
initiating therapy or changing the dose.
,3. A 72-year-old man is brought to the emergency department by his
wife due to confusion and decreased oral intake for 3 days. He has a
history of hypertension and dementia. On arrival, he is lethargic. Serum
sodium is 115 mEq/L, serum osmolarity is 245 mOsm/kg, and urine
osmolarity is 500 mOsm/kg. Urine sodium is 50 mEq/L. He appears
euvolemic on examination. What is the most likely cause of his
hyponatremia?
Correct Answer: Syndrome of inappropriate antidiuretic
hormone secretion (SIADH)
Rationale: The patient has hypotonic hyponatremia with high urine
osmolarity and high urine sodium, in the setting of euvolemia, which
defines SIADH. The high urine sodium indicates that the patient is not
volume-depleted, which would typically cause a low urine sodium.
4. A 55-year-old woman with chronic plaque psoriasis presents with a 6-
month history of pain and stiffness in her distal interphalangeal (DIP)
joints, as well as morning stiffness lasting 1 hour. Examination shows
sausage-shaped swelling of the second digit on the right hand (dactylitis)
and pitting of the nails. Radiographs of the hands reveal marginal
erosions and "pencil-in-cup" deformities. What is the most appropriate
initial disease-modifying antirheumatic drug (DMARD) for this patient?
Correct Answer: Methotrexate
Rationale: The patient has psoriatic arthritis, which is commonly
treated with methotrexate as a first-line DMARD, especially when there
is significant skin involvement. TNF inhibitors are also effective, but
methotrexate is typically used first. NSAIDs can help with symptoms
but do not alter the disease course.
5. A 35-year-old woman presents to the clinic for a routine follow-up.
She has a history of systemic lupus erythematosus (SLE) and is currently
taking hydroxychloroquine. She is planning to become pregnant.
Laboratory studies show positive anti-SSA/Ro antibodies. Which of the
following fetal complications is this patient at the highest risk for during
pregnancy?
Correct Answer: Congenital heart block
Rationale: Anti-SSA/Ro (and anti-SSB/La) antibodies are
associated with neonatal lupus, the most serious complication of which
is congenital heart block. These antibodies cross the placenta and can
,damage the fetal cardiac conduction system, usually between 18 and 24
weeks of gestation.
6. A 60-year-old man with a 30 pack-year smoking history presents with
a 3-week history of worsening cough and hemoptysis. A chest X-ray
reveals a 4-cm right hilar mass. Laboratory studies are significant for a
serum calcium level of 13.5 mg/dL. PTH level is low, and PTHrP is
elevated. Which type of lung cancer is most likely?
Correct Answer: Squamous cell carcinoma
Rationale: Squamous cell carcinoma of the lung is classically
associated with the production of parathyroid hormone-related peptide
(PTHrP), causing hypercalcemia. It is often centrally located and
associated with smoking.
7. A 28-year-old woman with a history of Crohn's disease presents with a
2-day history of right lower quadrant abdominal pain, fever, and
vomiting. A CT scan of the abdomen reveals a 4-cm abscess near the
terminal ileum, associated with thickened bowel wall. She is currently
taking infliximab. Which of the following is the most appropriate initial
management?
Correct Answer: Bowel rest, intravenous antibiotics, and
percutaneous drainage
Rationale: Initial management of a Crohn's-related intra-
abdominal abscess involves bowel rest, IV antibiotics, and image-
guided percutaneous drainage. Surgical resection is generally reserved
for patients who do not respond to these measures or who develop
complications like free perforation.
8. A 58-year-old man with a history of cirrhosis due to hepatitis C
presents with increasing abdominal girth. Paracentesis shows an
albumin level of 1.2 g/dL and a serum albumin of 3.2 g/dL, resulting in
an SAAG (serum-ascites albumin gradient) of 2.0 g/dL. The ascitic fluid
polymorphonuclear (PMN) cell count is 300 cells/mm³. What is the
most appropriate next step in management?
Correct Answer: Start empiric intravenous cefotaxime
Rationale: The SAAG is >1.1 g/dL, indicating portal hypertension.
The PMN count is >250 cells/mm³, which is diagnostic of spontaneous
bacterial peritonitis (SBP). Immediate treatment with third-generation
cephalosporins is necessary.
, 9. A 65-year-old woman with a history of hypertension and diabetes
presents with sudden onset of right-sided weakness and aphasia.
Symptoms started 90 minutes ago. Her blood pressure is 170/90 mmHg.
Non-contrast CT head shows no hemorrhage. She has no
contraindications to thrombolysis. What is the most appropriate next
step?
Correct Answer: Intravenous alteplase (tPA)
administration
Rationale: The patient is within the 4.5-hour window for IV tPA
administration, which is indicated for acute ischemic stroke. Blood
pressure is below the threshold for immediate treatment before tPA.
10. A 40-year-old man with a history of HIV, with a CD4 count of 50
cells/µL, presents with headache and fever. Lumbar puncture reveals
high opening pressure, and India ink stain is positive. Which of the
following is the best initial therapy?
Correct Answer: Amphotericin B and flucytosine
Rationale: Cryptococcal meningitis in an AIDS patient is treated
with induction therapy using amphotericin B and flucytosine, followed
by consolidation and maintenance therapy with fluconazole.
11. A 70-year-old man with chronic atrial fibrillation, who is on warfarin
with a therapeutic INR, presents with a new onset of severe, diffuse
abdominal pain that is out of proportion to physical exam findings. He
has not had a bowel movement in 2 days. What is the most likely
diagnosis?
Correct Answer: Acute mesenteric ischemia
Rationale: Acute mesenteric ischemia should be suspected in a
patient with atrial fibrillation (risk of embolus) who presents with
severe abdominal pain out of proportion to the physical exam. Early
diagnosis with CT angiography is critical.
12. A 25-year-old woman presents to the clinic with a 3-month history of
fatigue, joint pains, and a rash on her face that worsens with sun
exposure. She also reports hair loss. Laboratory tests show a positive
ANA, positive anti-dsDNA, and low complement levels (C3, C4). What is
the most likely diagnosis?
Correct Answer: Systemic lupus erythematosus (SLE)
Rationale: The combination ofmalar rash, arthritis, alopecia, and
