1
BIM Internal Medicine ITE Exam Actual Exam
2026/2027 | Complete Test Bank with Verified
Questions & Explanations | Updated In-Training
Exam Prep | A+ Graded
SECTION 1: CARDIOVASCULAR MEDICINE (Questions 1-35)
Q1: A 68-year-old man with a history of hypertension and type 2 diabetes presents to the
emergency department with acute-onset substernal chest pressure radiating to his left arm,
associated with diaphoresis and nausea. Symptoms began 2 hours ago. His blood pressure is
145/90 mmHg, heart rate 98 bpm, respiratory rate 18, oxygen saturation 97% on room air. ECG
reveals 2-mm ST-segment elevations in leads V1-V4. Which intervention should be performed
NEXT?
A. Obtain serial troponin measurements
B. Administer sublingual nitroglycerin
C. Prepare for emergent coronary angiography [CORRECT]
D. Start intravenous heparin infusion
Rationale: This patient presents with acute STEMI (ST elevations in V1-V4 with typical
symptoms). The next priority is emergent reperfusion therapy. Given symptom onset within 2
hours, emergent coronary angiography with percutaneous coronary intervention (PCI) is
indicated if available within 90-120 minutes. While nitroglycerin (B) may be given for symptom
relief and heparin (D) is part of standard therapy, they should not delay preparation for
reperfusion. Troponin (A) will confirm diagnosis but should not delay emergent reperfusion.
Q2: A 72-year-old woman with a history of atrial fibrillation on warfarin presents with sudden-
onset right-sided weakness and aphasia. Her last known well was 90 minutes ago. CT head
shows no hemorrhage. INR is 2.8. Blood pressure is 175/105 mmHg. What is the most
appropriate next step?
A. Administer intravenous tPA immediately
B. Lower blood pressure to <140/90 mmHg with IV labetalol
C. Check fibrinogen level and administer 4-factor PCC followed by IV tPA [CORRECT]
D. Observe for 24 hours and repeat CT imaging
,2
Rationale: This patient has acute ischemic stroke with symptom onset <4.5 hours ago. However,
she is on warfarin with INR 2.8, which is a relative contraindication to tPA. Current guidelines
recommend reversing warfarin anticoagulation with 4-factor prothrombin complex concentrate
(PCC) before administering tPA. Simply lowering blood pressure (B) does not address the need
for reperfusion therapy. Observation (D) would miss the therapeutic window.
Q3: A 58-year-old man with hypertension presents for routine follow-up. His home blood
pressure log shows averages of 142/88 mmHg on lisinopril 20 mg daily. He is otherwise
asymptomatic. Labs show creatinine 1.1 mg/dL, potassium 4.2 mEq/L. What is the most
appropriate next step in management?
A. Increase lisinopril to 40 mg daily
B. Add amlodipine 5 mg daily [CORRECT]
C. Add hydrochlorothiazide 25 mg daily
D. Continue current regimen and reassess in 6 months
Rationale: The patient has uncontrolled hypertension (Stage 1, average >130/80 per ACC/AHA
guidelines) on ACE inhibitor monotherapy. The preferred second-line agent is a calcium channel
blocker (amlodipine) or thiazide diuretic. Amlodipine is preferred in this case as it has
complementary mechanisms and is well-tolerated. Increasing lisinopril (A) to maximum dose
before adding second agent is less effective than combination therapy. Continuing current
regimen (D) is inappropriate given uncontrolled hypertension.
Q4: A 65-year-old man with a history of heart failure with reduced ejection fraction (HFrEF,
LVEF 35%) presents with worsening dyspnea and lower extremity edema. He is currently on
lisinopril, metoprolol succinate, and furosemide. Vital signs: BP 110/70, HR 72. Labs: creatinine
1.4 mg/dL, potassium 4.8 mEq/L, BNP 800 pg/mL. What medication should be added to his
regimen?
A. Sacubitril/valsartan [CORRECT]
B. Digoxin
C. Hydralazine/isosorbide dinitrate
D. Ivabradine
Rationale: For HFrEF patients already on ACE inhibitor/ARB and beta-blocker who remain
symptomatic, guideline-directed medical therapy includes addition of sacubitril/valsartan
(ARNI), which has shown mortality benefit over enalapril alone. Hydralazine/nitrate (C) is
reserved for African American patients or those intolerant to ACE/ARB. Ivabradine (D) is for
patients in sinus rhythm with HR >70 despite beta-blocker. Digoxin (B) is for symptom control
only, not mortality benefit.
,3
Q5: A 45-year-old woman presents with palpitations and lightheadedness. ECG shows irregularly
irregular rhythm with no discernible P waves and variable QRS complexes. Ventricular rate is
120 bpm. She is hemodynamically stable. What is the next best step in management?
A. Immediate synchronized cardioversion
B. Rate control with IV metoprolol or diltiazem [CORRECT]
C. Anticoagulation with heparin and immediate catheter ablation
D. Adenosine 6 mg rapid IV push
Rationale: This patient has new-onset atrial fibrillation with rapid ventricular response (RVR) but
is hemodynamically stable. The initial priority is rate control with beta-blocker or non-
dihydropyridine calcium channel blocker. Synchronized cardioversion (A) is reserved for
unstable patients. Catheter ablation (C) is not first-line for new-onset AF. Adenosine (D) is used
for SVT, not AF with RVR.
Q6: A 70-year-old man with severe aortic stenosis (valve area 0.7 cm², mean gradient 45 mmHg)
presents with syncope. He has no other medical problems. Echocardiogram shows normal LVEF.
What is the definitive management?
A. Medical management with beta-blockers
B. Transcatheter aortic valve replacement (TAVR) [CORRECT]
C. Surgical aortic valve replacement only
D. Balloon valvuloplasty as definitive therapy
Rationale: Severe symptomatic aortic stenosis (syncope, angina, or heart failure) requires valve
replacement. TAVR is now approved for low-risk patients and is preferred in many elderly
patients due to less invasive approach. Medical management (A) alone has poor prognosis.
Balloon valvuloplasty (D) is only a bridge to surgery. Surgical AVR (C) is appropriate but TAVR
is now first-line for many patients.
Q7: A 55-year-old man with diabetes and hyperlipidemia presents with stable angina. Stress test
shows reversible anterior wall ischemia. Coronary angiography reveals 70% stenosis of the
proximal LAD. LVEF is normal. What is the optimal management?
A. Optimal medical therapy alone
B. PCI with drug-eluting stent [CORRECT]
C. Coronary artery bypass grafting
D. Lifestyle modification only
, 4
Rationale: For stable coronary artery disease with significant proximal LAD disease and
symptoms despite medical therapy, PCI with DES improves angina and has been shown to
reduce major adverse cardiovascular events compared to medical therapy alone in appropriate
patients. CABG (C) is reserved for more complex disease (e.g., three-vessel disease, left main).
Medical therapy alone (A) is insufficient for proximal LAD disease with symptoms.
Q8: A 62-year-old woman presents with acute dyspnea and hypoxia. CT pulmonary angiography
shows bilateral pulmonary emboli. Blood pressure is 85/50 mmHg, heart rate 120 bpm.
Echocardiogram shows RV dilation and hypokinesis. What is the most appropriate management?
A. Therapeutic anticoagulation with heparin alone
B. Systemic thrombolysis [CORRECT]
C. Inferior vena cava filter placement
D. Surgical embolectomy
Rationale: This patient has massive PE with hemodynamic compromise (hypotension) and RV
strain, which constitutes high-risk PE. Systemic thrombolysis is indicated in the absence of
contraindications. Anticoagulation alone (A) has high mortality in massive PE. IVC filter (C) is
for patients with contraindications to anticoagulation. Surgical embolectomy (D) is reserved for
failed thrombolysis or contraindications to lysis.
Q9: A 48-year-old man with no prior cardiac history presents with chest pain. ECG shows ST
depressions in leads V4-V6 and T-wave inversions in leads I and aVL. Troponin I is 2.5 ng/mL.
He is hemodynamically stable. What is the next best step?
A. Immediate coronary angiography within 24-72 hours [CORRECT]
B. Stress testing prior to invasive strategy
C. Medical management with aspirin, clopidogrel, and heparin only
D. Thrombolytic therapy
Rationale: This patient has non-ST elevation myocardial infarction (NSTEMI) with high-risk
features (elevated troponin, ST changes). Current guidelines recommend an invasive strategy
with coronary angiography within 24-72 hours for high-risk NSTEMI. Stress testing (B) is
inappropriate in the setting of active NSTEMI. Medical management alone (C) is inferior to
invasive strategy in high-risk patients. Thrombolytics (D) are contraindicated in NSTEMI.
Q10: A 75-year-old man with heart failure presents with bradycardia and syncope. ECG shows
third-degree AV block with junctional escape rhythm at 35 bpm. What is the definitive
management?
A. Atropine 0.5 mg IV
BIM Internal Medicine ITE Exam Actual Exam
2026/2027 | Complete Test Bank with Verified
Questions & Explanations | Updated In-Training
Exam Prep | A+ Graded
SECTION 1: CARDIOVASCULAR MEDICINE (Questions 1-35)
Q1: A 68-year-old man with a history of hypertension and type 2 diabetes presents to the
emergency department with acute-onset substernal chest pressure radiating to his left arm,
associated with diaphoresis and nausea. Symptoms began 2 hours ago. His blood pressure is
145/90 mmHg, heart rate 98 bpm, respiratory rate 18, oxygen saturation 97% on room air. ECG
reveals 2-mm ST-segment elevations in leads V1-V4. Which intervention should be performed
NEXT?
A. Obtain serial troponin measurements
B. Administer sublingual nitroglycerin
C. Prepare for emergent coronary angiography [CORRECT]
D. Start intravenous heparin infusion
Rationale: This patient presents with acute STEMI (ST elevations in V1-V4 with typical
symptoms). The next priority is emergent reperfusion therapy. Given symptom onset within 2
hours, emergent coronary angiography with percutaneous coronary intervention (PCI) is
indicated if available within 90-120 minutes. While nitroglycerin (B) may be given for symptom
relief and heparin (D) is part of standard therapy, they should not delay preparation for
reperfusion. Troponin (A) will confirm diagnosis but should not delay emergent reperfusion.
Q2: A 72-year-old woman with a history of atrial fibrillation on warfarin presents with sudden-
onset right-sided weakness and aphasia. Her last known well was 90 minutes ago. CT head
shows no hemorrhage. INR is 2.8. Blood pressure is 175/105 mmHg. What is the most
appropriate next step?
A. Administer intravenous tPA immediately
B. Lower blood pressure to <140/90 mmHg with IV labetalol
C. Check fibrinogen level and administer 4-factor PCC followed by IV tPA [CORRECT]
D. Observe for 24 hours and repeat CT imaging
,2
Rationale: This patient has acute ischemic stroke with symptom onset <4.5 hours ago. However,
she is on warfarin with INR 2.8, which is a relative contraindication to tPA. Current guidelines
recommend reversing warfarin anticoagulation with 4-factor prothrombin complex concentrate
(PCC) before administering tPA. Simply lowering blood pressure (B) does not address the need
for reperfusion therapy. Observation (D) would miss the therapeutic window.
Q3: A 58-year-old man with hypertension presents for routine follow-up. His home blood
pressure log shows averages of 142/88 mmHg on lisinopril 20 mg daily. He is otherwise
asymptomatic. Labs show creatinine 1.1 mg/dL, potassium 4.2 mEq/L. What is the most
appropriate next step in management?
A. Increase lisinopril to 40 mg daily
B. Add amlodipine 5 mg daily [CORRECT]
C. Add hydrochlorothiazide 25 mg daily
D. Continue current regimen and reassess in 6 months
Rationale: The patient has uncontrolled hypertension (Stage 1, average >130/80 per ACC/AHA
guidelines) on ACE inhibitor monotherapy. The preferred second-line agent is a calcium channel
blocker (amlodipine) or thiazide diuretic. Amlodipine is preferred in this case as it has
complementary mechanisms and is well-tolerated. Increasing lisinopril (A) to maximum dose
before adding second agent is less effective than combination therapy. Continuing current
regimen (D) is inappropriate given uncontrolled hypertension.
Q4: A 65-year-old man with a history of heart failure with reduced ejection fraction (HFrEF,
LVEF 35%) presents with worsening dyspnea and lower extremity edema. He is currently on
lisinopril, metoprolol succinate, and furosemide. Vital signs: BP 110/70, HR 72. Labs: creatinine
1.4 mg/dL, potassium 4.8 mEq/L, BNP 800 pg/mL. What medication should be added to his
regimen?
A. Sacubitril/valsartan [CORRECT]
B. Digoxin
C. Hydralazine/isosorbide dinitrate
D. Ivabradine
Rationale: For HFrEF patients already on ACE inhibitor/ARB and beta-blocker who remain
symptomatic, guideline-directed medical therapy includes addition of sacubitril/valsartan
(ARNI), which has shown mortality benefit over enalapril alone. Hydralazine/nitrate (C) is
reserved for African American patients or those intolerant to ACE/ARB. Ivabradine (D) is for
patients in sinus rhythm with HR >70 despite beta-blocker. Digoxin (B) is for symptom control
only, not mortality benefit.
,3
Q5: A 45-year-old woman presents with palpitations and lightheadedness. ECG shows irregularly
irregular rhythm with no discernible P waves and variable QRS complexes. Ventricular rate is
120 bpm. She is hemodynamically stable. What is the next best step in management?
A. Immediate synchronized cardioversion
B. Rate control with IV metoprolol or diltiazem [CORRECT]
C. Anticoagulation with heparin and immediate catheter ablation
D. Adenosine 6 mg rapid IV push
Rationale: This patient has new-onset atrial fibrillation with rapid ventricular response (RVR) but
is hemodynamically stable. The initial priority is rate control with beta-blocker or non-
dihydropyridine calcium channel blocker. Synchronized cardioversion (A) is reserved for
unstable patients. Catheter ablation (C) is not first-line for new-onset AF. Adenosine (D) is used
for SVT, not AF with RVR.
Q6: A 70-year-old man with severe aortic stenosis (valve area 0.7 cm², mean gradient 45 mmHg)
presents with syncope. He has no other medical problems. Echocardiogram shows normal LVEF.
What is the definitive management?
A. Medical management with beta-blockers
B. Transcatheter aortic valve replacement (TAVR) [CORRECT]
C. Surgical aortic valve replacement only
D. Balloon valvuloplasty as definitive therapy
Rationale: Severe symptomatic aortic stenosis (syncope, angina, or heart failure) requires valve
replacement. TAVR is now approved for low-risk patients and is preferred in many elderly
patients due to less invasive approach. Medical management (A) alone has poor prognosis.
Balloon valvuloplasty (D) is only a bridge to surgery. Surgical AVR (C) is appropriate but TAVR
is now first-line for many patients.
Q7: A 55-year-old man with diabetes and hyperlipidemia presents with stable angina. Stress test
shows reversible anterior wall ischemia. Coronary angiography reveals 70% stenosis of the
proximal LAD. LVEF is normal. What is the optimal management?
A. Optimal medical therapy alone
B. PCI with drug-eluting stent [CORRECT]
C. Coronary artery bypass grafting
D. Lifestyle modification only
, 4
Rationale: For stable coronary artery disease with significant proximal LAD disease and
symptoms despite medical therapy, PCI with DES improves angina and has been shown to
reduce major adverse cardiovascular events compared to medical therapy alone in appropriate
patients. CABG (C) is reserved for more complex disease (e.g., three-vessel disease, left main).
Medical therapy alone (A) is insufficient for proximal LAD disease with symptoms.
Q8: A 62-year-old woman presents with acute dyspnea and hypoxia. CT pulmonary angiography
shows bilateral pulmonary emboli. Blood pressure is 85/50 mmHg, heart rate 120 bpm.
Echocardiogram shows RV dilation and hypokinesis. What is the most appropriate management?
A. Therapeutic anticoagulation with heparin alone
B. Systemic thrombolysis [CORRECT]
C. Inferior vena cava filter placement
D. Surgical embolectomy
Rationale: This patient has massive PE with hemodynamic compromise (hypotension) and RV
strain, which constitutes high-risk PE. Systemic thrombolysis is indicated in the absence of
contraindications. Anticoagulation alone (A) has high mortality in massive PE. IVC filter (C) is
for patients with contraindications to anticoagulation. Surgical embolectomy (D) is reserved for
failed thrombolysis or contraindications to lysis.
Q9: A 48-year-old man with no prior cardiac history presents with chest pain. ECG shows ST
depressions in leads V4-V6 and T-wave inversions in leads I and aVL. Troponin I is 2.5 ng/mL.
He is hemodynamically stable. What is the next best step?
A. Immediate coronary angiography within 24-72 hours [CORRECT]
B. Stress testing prior to invasive strategy
C. Medical management with aspirin, clopidogrel, and heparin only
D. Thrombolytic therapy
Rationale: This patient has non-ST elevation myocardial infarction (NSTEMI) with high-risk
features (elevated troponin, ST changes). Current guidelines recommend an invasive strategy
with coronary angiography within 24-72 hours for high-risk NSTEMI. Stress testing (B) is
inappropriate in the setting of active NSTEMI. Medical management alone (C) is inferior to
invasive strategy in high-risk patients. Thrombolytics (D) are contraindicated in NSTEMI.
Q10: A 75-year-old man with heart failure presents with bradycardia and syncope. ECG shows
third-degree AV block with junctional escape rhythm at 35 bpm. What is the definitive
management?
A. Atropine 0.5 mg IV
