ABIM IM BOARDS ITE EXAM QUESTIONS AND
CORRECT ANSWERS WITH RATIONALES
GRADED A+ LATEST 2026
ABIM Internal Medicine Boards ITE Exam Bank
1. A 62-year-old man presents with exertional chest pain relieved by rest.
ECG shows ST depression in leads V4-V6. What is the next best step in
management?
A. Coronary angiography
B. Start nitrates, beta-blocker, and aspirin
C. Schedule a stress echocardiogram
D. Immediate thrombolysis
Answer: B
Rationale: Stable angina is characterized by predictable exertional chest
pain relieved by rest or nitroglycerin. Initial management includes
antianginal therapy (nitrates, beta-blockers), risk factor modification, and
aspirin. Coronary angiography is indicated only if symptoms persist despite
medical therapy.
2. A 55-year-old woman with type 2 diabetes presents with painful
burning in her feet. Examination shows decreased vibration sense.
What is the most appropriate first-line treatment?
A. Gabapentin
B. Amitriptyline
C. Duloxetine
D. Capsaicin cream
Answer: C
Rationale: Diabetic peripheral neuropathy is best managed with duloxetine
or pregabalin as first-line agents. Duloxetine, an SNRI, provides both
analgesic and antidepressant benefits. Tricyclics like amitriptyline are
effective but have more side effects in older adults.
,3. A 48-year-old man with a history of chronic alcohol use presents with
confusion, ataxia, and ophthalmoplegia. What is the most likely
diagnosis?
A. Hepatic encephalopathy
B. Wernicke encephalopathy
C. Korsakoff psychosis
D. Alcohol withdrawal
Answer: B
Rationale: The triad of confusion, ataxia, and ophthalmoplegia is classic for
Wernicke encephalopathy, due to thiamine deficiency. Always administer
IV thiamine before glucose to prevent worsening neurological injury.
4. A 70-year-old man presents with cough, hemoptysis, and a cavitary
lesion in the upper lobe. He has a 40-pack-year smoking history. Which
organism is most likely responsible?
A. Mycobacterium tuberculosis
B. Klebsiella pneumoniae
C. Aspergillus fumigatus
D. Streptococcus pneumoniae
Answer: A
Rationale: Chronic cavitary lesions in upper lobes with hemoptysis are
strongly suggestive of pulmonary tuberculosis. Smoking history and
chronicity further support this diagnosis.
5. A 67-year-old man presents with dyspnea and orthopnea.
Echocardiography reveals an ejection fraction of 35%. Which
medication improves survival?
A. Furosemide
B. Digoxin
C. Metoprolol succinate
D. Diltiazem
Answer: C
Rationale: Beta-blockers (metoprolol succinate, carvedilol, bisoprolol) and
ACE inhibitors improve mortality in systolic heart failure. Loop diuretics
improve symptoms but not survival.
,6. A 45-year-old man with HIV presents with fever, cough, and dyspnea.
Chest X-ray shows bilateral interstitial infiltrates. CD4 count is 120
cells/mm³. What is the most likely diagnosis?
A. Pneumocystis jirovecii pneumonia
B. Tuberculosis
C. Cryptococcal pneumonia
D. Streptococcal pneumonia
Answer: A
Rationale: In patients with HIV and CD4 <200, Pneumocystis jirovecii is
the most common cause of diffuse interstitial pneumonia. Diagnosis is
confirmed via sputum DFA or bronchoalveolar lavage. Treat with TMP-
SMX and corticosteroids if hypoxemic.
7. A 50-year-old woman presents with fatigue and pruritus. Labs reveal
elevated alkaline phosphatase and positive antimitochondrial
antibodies. What is the diagnosis?
A. Primary sclerosing cholangitis
B. Autoimmune hepatitis
C. Primary biliary cholangitis
D. Chronic hepatitis C
Answer: C
Rationale: Primary biliary cholangitis (PBC) is an autoimmune destruction
of intrahepatic bile ducts, seen in middle-aged women. Key features:
elevated ALP, AMA positivity, and pruritus. Treat with ursodeoxycholic
acid.
8. A 70-year-old man develops acute painless loss of vision in one eye.
Fundoscopy reveals a pale retina with a cherry-red spot. What is the
most likely cause?
A. Central retinal vein occlusion
B. Central retinal artery occlusion
C. Retinal detachment
D. Temporal arteritis
Answer: B
Rationale: Central retinal artery occlusion results from embolism or
, thrombosis, producing retinal pallor and a cherry-red macula. Immediate
management includes ocular massage and lowering intraocular pressure.
9. A 60-year-old woman presents with hypercalcemia, constipation, and
kidney stones. PTH is elevated. What is the next diagnostic step?
A. Bone scan
B. Neck ultrasound
C. Sestamibi scan
D. 24-hour urinary calcium
Answer: C
Rationale: The most common cause of hypercalcemia with elevated PTH is
primary hyperparathyroidism due to adenoma. Sestamibi scan helps localize
the parathyroid lesion prior to surgical excision.
10. A 32-year-old woman presents with fatigue, pallor, and pica. Labs show
microcytic anemia and low ferritin. Which finding best confirms the
cause?
A. Elevated total iron-binding capacity
B. Normal MCV
C. Low transferrin saturation
D. Elevated ferritin
Answer: A
Rationale: Iron deficiency anemia shows microcytosis, low ferritin, high
TIBC, and low transferrin saturation. Pica and fatigue are classic symptoms.
Evaluate for occult GI bleeding.
11. A 40-year-old man with a history of IV drug use presents with new
murmur, fever, and Janeway lesions. Blood cultures are positive for
Staphylococcus aureus. Which valve is most commonly affected?
A. Aortic
B. Mitral
C. Pulmonic
D. Tricuspid
Answer: D
Rationale: In IV drug users, tricuspid valve endocarditis is most common.
CORRECT ANSWERS WITH RATIONALES
GRADED A+ LATEST 2026
ABIM Internal Medicine Boards ITE Exam Bank
1. A 62-year-old man presents with exertional chest pain relieved by rest.
ECG shows ST depression in leads V4-V6. What is the next best step in
management?
A. Coronary angiography
B. Start nitrates, beta-blocker, and aspirin
C. Schedule a stress echocardiogram
D. Immediate thrombolysis
Answer: B
Rationale: Stable angina is characterized by predictable exertional chest
pain relieved by rest or nitroglycerin. Initial management includes
antianginal therapy (nitrates, beta-blockers), risk factor modification, and
aspirin. Coronary angiography is indicated only if symptoms persist despite
medical therapy.
2. A 55-year-old woman with type 2 diabetes presents with painful
burning in her feet. Examination shows decreased vibration sense.
What is the most appropriate first-line treatment?
A. Gabapentin
B. Amitriptyline
C. Duloxetine
D. Capsaicin cream
Answer: C
Rationale: Diabetic peripheral neuropathy is best managed with duloxetine
or pregabalin as first-line agents. Duloxetine, an SNRI, provides both
analgesic and antidepressant benefits. Tricyclics like amitriptyline are
effective but have more side effects in older adults.
,3. A 48-year-old man with a history of chronic alcohol use presents with
confusion, ataxia, and ophthalmoplegia. What is the most likely
diagnosis?
A. Hepatic encephalopathy
B. Wernicke encephalopathy
C. Korsakoff psychosis
D. Alcohol withdrawal
Answer: B
Rationale: The triad of confusion, ataxia, and ophthalmoplegia is classic for
Wernicke encephalopathy, due to thiamine deficiency. Always administer
IV thiamine before glucose to prevent worsening neurological injury.
4. A 70-year-old man presents with cough, hemoptysis, and a cavitary
lesion in the upper lobe. He has a 40-pack-year smoking history. Which
organism is most likely responsible?
A. Mycobacterium tuberculosis
B. Klebsiella pneumoniae
C. Aspergillus fumigatus
D. Streptococcus pneumoniae
Answer: A
Rationale: Chronic cavitary lesions in upper lobes with hemoptysis are
strongly suggestive of pulmonary tuberculosis. Smoking history and
chronicity further support this diagnosis.
5. A 67-year-old man presents with dyspnea and orthopnea.
Echocardiography reveals an ejection fraction of 35%. Which
medication improves survival?
A. Furosemide
B. Digoxin
C. Metoprolol succinate
D. Diltiazem
Answer: C
Rationale: Beta-blockers (metoprolol succinate, carvedilol, bisoprolol) and
ACE inhibitors improve mortality in systolic heart failure. Loop diuretics
improve symptoms but not survival.
,6. A 45-year-old man with HIV presents with fever, cough, and dyspnea.
Chest X-ray shows bilateral interstitial infiltrates. CD4 count is 120
cells/mm³. What is the most likely diagnosis?
A. Pneumocystis jirovecii pneumonia
B. Tuberculosis
C. Cryptococcal pneumonia
D. Streptococcal pneumonia
Answer: A
Rationale: In patients with HIV and CD4 <200, Pneumocystis jirovecii is
the most common cause of diffuse interstitial pneumonia. Diagnosis is
confirmed via sputum DFA or bronchoalveolar lavage. Treat with TMP-
SMX and corticosteroids if hypoxemic.
7. A 50-year-old woman presents with fatigue and pruritus. Labs reveal
elevated alkaline phosphatase and positive antimitochondrial
antibodies. What is the diagnosis?
A. Primary sclerosing cholangitis
B. Autoimmune hepatitis
C. Primary biliary cholangitis
D. Chronic hepatitis C
Answer: C
Rationale: Primary biliary cholangitis (PBC) is an autoimmune destruction
of intrahepatic bile ducts, seen in middle-aged women. Key features:
elevated ALP, AMA positivity, and pruritus. Treat with ursodeoxycholic
acid.
8. A 70-year-old man develops acute painless loss of vision in one eye.
Fundoscopy reveals a pale retina with a cherry-red spot. What is the
most likely cause?
A. Central retinal vein occlusion
B. Central retinal artery occlusion
C. Retinal detachment
D. Temporal arteritis
Answer: B
Rationale: Central retinal artery occlusion results from embolism or
, thrombosis, producing retinal pallor and a cherry-red macula. Immediate
management includes ocular massage and lowering intraocular pressure.
9. A 60-year-old woman presents with hypercalcemia, constipation, and
kidney stones. PTH is elevated. What is the next diagnostic step?
A. Bone scan
B. Neck ultrasound
C. Sestamibi scan
D. 24-hour urinary calcium
Answer: C
Rationale: The most common cause of hypercalcemia with elevated PTH is
primary hyperparathyroidism due to adenoma. Sestamibi scan helps localize
the parathyroid lesion prior to surgical excision.
10. A 32-year-old woman presents with fatigue, pallor, and pica. Labs show
microcytic anemia and low ferritin. Which finding best confirms the
cause?
A. Elevated total iron-binding capacity
B. Normal MCV
C. Low transferrin saturation
D. Elevated ferritin
Answer: A
Rationale: Iron deficiency anemia shows microcytosis, low ferritin, high
TIBC, and low transferrin saturation. Pica and fatigue are classic symptoms.
Evaluate for occult GI bleeding.
11. A 40-year-old man with a history of IV drug use presents with new
murmur, fever, and Janeway lesions. Blood cultures are positive for
Staphylococcus aureus. Which valve is most commonly affected?
A. Aortic
B. Mitral
C. Pulmonic
D. Tricuspid
Answer: D
Rationale: In IV drug users, tricuspid valve endocarditis is most common.
