ABIM INTERNAL MEDICINE BOARDS and
ITE 2026 150 DETAILED CORRECT
ANSWERS WITH RATIONALES CORRECT
VERIFIED ANSWERS GRADE A+ |
INSTANT DOWNLOAD
ABIM Internal Medicine Boards & ITE 2026: Comprehensive
High-Yield Examination
Question 1: A 68-year-old man with a history of ischemic
cardiomyopathy presents for routine follow-up. His left ventricular
ejection fraction (LVEF) is 30%. He is currently taking carvedilol 25 mg
twice daily, lisinopril 20 mg daily, and spironolactone 25 mg daily. He
reports mild dyspnea on exertion (NYHA Class II) but no orthopnea or
edema. His blood pressure is 110/70 mmHg, heart rate is 68 bpm, and
serum potassium is 4.2 mEq/L with a creatinine of 1.1 mg/dL. According
to current guidelines, what is the most appropriate next step in
optimizing his guideline-directed medical therapy (GDMT)? A) Increase
lisinopril to 40 mg daily. B) Switch lisinopril to sacubitril/valsartan and
add dapagliflozin. C) Add digoxin 0.125 mg daily. D) Refer for immediate
cardiac resynchronization therapy (CRT). Correct Answer: B Switch
lisinopril to sacubitril/valsartan and add dapagliflozin.
Rationale: Current heart failure guidelines strongly recommend the
four pillars of GDMT for HFrEF: a beta-blocker, an ARNI (preferred
over ACEi/ARB), an MRA, and an SGLT2 inhibitor. Switching his ACE
inhibitor to an ARNI and adding an SGLT2 inhibitor (like
dapagliflozin) will provide significant mortality and morbidity benefits.
His blood pressure and potassium levels can tolerate these additions.
is a 55-year-old woman who presents to the emergency department with
sudden-onset shortness of breath and pleuritic chest pain. She recently
returned from a 10-hour flight. Her heart rate is 115 bpm, blood pressure
is 105/65 mmHg, and oxygen saturation is 92% on room air. A CT
pulmonary angiogram confirms a large bilateral pulmonary embolism.
Echocardiography shows right ventricular dilation and dysfunction, but
her blood pressure remains stable. Troponin is mildly elevated. What is
,the most appropriate initial management? A) Administer systemic
alteplase (tPA) immediately. B) Initiate therapeutic anticoagulation with
intravenous unfractionated heparin and admit to a monitored unit. C)
Schedule for emergent surgical pulmonary embolectomy. D) Discharge
home on oral rivaroxaban with close outpatient follow-up. Correct
Answer: B Initiate therapeutic anticoagulation with
intravenous unfractionated heparin and admit to a monitored
unit. Rationale: This patient has an intermediate-high risk
(submassive) pulmonary embolism, characterized by right ventricular
dysfunction and elevated biomarkers but without hemodynamic
instability (hypotension). The standard of care is immediate
therapeutic anticoagulation (often with UFH due to its short half-life
and reversibility, allowing for escalation if she decompensates).
Systemic thrombolysis is reserved for high-risk (massive) PE with
hemodynamic instability.
Question 3: A 62-year-old man with a 10-year history of type 2 diabetes
mellitus presents for medication review. His HbA1c is 8.2% despite
maximally tolerated metformin therapy. He has a history of a myocardial
infarction 3 years ago and chronic kidney disease with an eGFR of 45
mL/min/1.73m² and mildly elevated urine albumin-to-creatinine ratio.
Which of the following medications should be added to his regimen to
provide the greatest cardiovascular and renal benefit? A) Glipizide B)
Pioglitazone C) Empagliflozin D) Sitagliptin Correct Answer: C
Empagliflozin Rationale: In patients with type 2 diabetes and
established atherosclerotic cardiovascular disease (ASCVD) or chronic
kidney disease, SGLT2 inhibitors (like empagliflozin) or GLP-1 receptor
agonists with proven cardiovascular benefit are recommended as add-
on therapy regardless of baseline HbA1c. Empagliflozin will improve
his glycemic control while providing proven cardiovascular mortality
reduction and slowing the progression of diabetic nephropathy.
Question 4: A 28-year-old woman with a 4-year history of Crohn's
disease presents with a 3-week history of worsening abdominal pain,
non-bloody diarrhea (6-8 episodes/day), and a 10-pound weight loss.
She is currently on mesalamine, which is no longer effective.
Colonoscopy reveals severe, deep ulcerations in the terminal ileum and
ascending colon. Her CRP is elevated. What is the most appropriate next
step in management? A) Increase the dose of mesalamine and add
loperamide. B) Initiate oral prednisone 40 mg daily and start a biologic
agent such as infliximab. C) Schedule an immediate total colectomy. D)
,Start ciprofloxacin and metronidazole for presumed infectious colitis.
Correct Answer: B Initiate oral prednisone 40 mg daily and
start a biologic agent such as infliximab. Rationale: This patient
has moderate-to-severe Crohn's disease that is refractory to 5-ASA
therapy. The standard of care for inducing remission in moderate-to-
severe disease is systemic corticosteroids, combined with the initiation
of a steroid-sparing maintenance therapy, such as an anti-TNF agent
(infliximab or adalimumab), to achieve mucosal healing and prevent
complications.
Question 5: A 70-year-old man is admitted with acute kidney injury
(AKI). His baseline creatinine was 1.0 mg/dL, and it is now 2.8 mg/dL.
He was recently started on a proton pump inhibitor (PPI) for GERD and
takes ibuprofen for osteoarthritis. Urinalysis shows white blood cell
casts, eosinophiluria, and mild proteinuria. Fractional excretion of
sodium (FeNa) is 1.5%. What is the most likely diagnosis? A) Acute
tubular necrosis (ATN) B) Acute interstitial nephritis (AIN) C) Prerenal
azotemia D) Postrenal obstruction Correct Answer: B Acute
interstitial nephritis (AIN) Rationale: The classic presentation of
AIN includes AKI following the initiation of an offending agent
(commonly PPIs, NSAIDs, or antibiotics), accompanied by urinary
findings of white blood cells, WBC casts, and eosinophiluria. While
NSAIDs can also cause ATN or hemodynamically mediated prerenal
AKI, the presence of WBC casts and eosinophiluria strongly points to an
allergic interstitial nephritis.
Question 6: A 45-year-old man is admitted with Staphylococcus aureus
bacteremia. Blood cultures drawn from two separate sites are positive for
methicillin-susceptible S. aureus (MSSA). A transthoracic
echocardiogram (TTE) is negative for vegetations, but he has a new
murmur and persistent fever after 4 days of appropriate intravenous
cefazolin therapy. What is the most appropriate next step? A) Continue
cefazolin for a total of 14 days and discharge. B) Switch to intravenous
vancomycin. C) Perform a transesophageal echocardiogram (TEE). D)
Add gentamicin for synergy. Correct Answer: C Perform a
transesophageal echocardiogram (TEE). Rationale: In patients
with S. aureus bacteremia, especially those with persistent fever, a new
murmur, or other clinical signs of endocarditis, a TEE is indicated even
if the initial TTE is negative. TEE has a much higher sensitivity for
detecting valvular vegetations and complications like abscesses, which
, would necessitate a longer duration of therapy (4-6 weeks) and
possible surgical evaluation.
Question 7: A 65-year-old woman with rheumatoid arthritis presents
with fatigue. Her complete blood count shows a hemoglobin of 9.5 g/dL,
MCV of 82 fL, serum iron of 30 mcg/dL (low), TIBC of 200 mcg/dL
(low), and ferritin of 250 ng/mL (high). What is the most likely cause of
her anemia? A) Iron deficiency anemia B) Anemia of chronic disease C)
Vitamin B12 deficiency D) Hemolytic anemia Correct Answer: B
Anemia of chronic disease Rationale: Anemia of chronic disease
(also known as anemia of inflammation) is characterized by a low
serum iron, low TIBC, and normal or elevated ferritin. Hepcidin, an
acute-phase reactant elevated in chronic inflammatory states like
rheumatoid arthritis, blocks iron release from macrophages and
intestinal absorption, leading to functional iron deficiency despite
adequate total body iron stores.
Question 8: A 58-year-old man with stage 3 chronic kidney disease
(eGFR 35 mL/min/1.73m²) presents to the clinic with an acute,
exquisitely painful, swollen, and erythematous right first
metatarsophalangeal (MTP) joint. He has a known history of gout.
Which of the following is the most appropriate treatment for this acute
flare? A) Indomethacin 50 mg three times daily B) Colchicine 0.6 mg
twice daily C) Intra-articular triamcinolone injection D) Allopurinol 300
mg daily (initiate now) Correct Answer: C Intra-articular
triamcinolone injection Rationale: For an acute gout flare in a
patient with significant chronic kidney disease, NSAIDs (indomethacin)
and colchicine are relatively or absolutely contraindicated due to the
risk of worsening renal function and colchicine toxicity, respectively.
Intra-articular glucocorticoid injection is highly effective and avoids
systemic side effects. If multiple joints were involved, oral or
intramuscular glucocorticoids would be the preferred systemic option.
Question 9: A 72-year-old man is brought to the emergency
department by his wife due to sudden onset of right-sided weakness and
aphasia that began 2 hours ago. His blood pressure is 195/105 mmHg. A
non-contrast head CT shows no evidence of hemorrhage. He has no
other contraindications to thrombolysis. What is the most appropriate
immediate next step? A) Administer intravenous alteplase immediately.
B) Administer intravenous labetalol to lower blood pressure to <185/110
mmHg, then administer intravenous alteplase. C) Administer aspirin
325 mg and admit to the stroke unit. D) Schedule for emergent
ITE 2026 150 DETAILED CORRECT
ANSWERS WITH RATIONALES CORRECT
VERIFIED ANSWERS GRADE A+ |
INSTANT DOWNLOAD
ABIM Internal Medicine Boards & ITE 2026: Comprehensive
High-Yield Examination
Question 1: A 68-year-old man with a history of ischemic
cardiomyopathy presents for routine follow-up. His left ventricular
ejection fraction (LVEF) is 30%. He is currently taking carvedilol 25 mg
twice daily, lisinopril 20 mg daily, and spironolactone 25 mg daily. He
reports mild dyspnea on exertion (NYHA Class II) but no orthopnea or
edema. His blood pressure is 110/70 mmHg, heart rate is 68 bpm, and
serum potassium is 4.2 mEq/L with a creatinine of 1.1 mg/dL. According
to current guidelines, what is the most appropriate next step in
optimizing his guideline-directed medical therapy (GDMT)? A) Increase
lisinopril to 40 mg daily. B) Switch lisinopril to sacubitril/valsartan and
add dapagliflozin. C) Add digoxin 0.125 mg daily. D) Refer for immediate
cardiac resynchronization therapy (CRT). Correct Answer: B Switch
lisinopril to sacubitril/valsartan and add dapagliflozin.
Rationale: Current heart failure guidelines strongly recommend the
four pillars of GDMT for HFrEF: a beta-blocker, an ARNI (preferred
over ACEi/ARB), an MRA, and an SGLT2 inhibitor. Switching his ACE
inhibitor to an ARNI and adding an SGLT2 inhibitor (like
dapagliflozin) will provide significant mortality and morbidity benefits.
His blood pressure and potassium levels can tolerate these additions.
is a 55-year-old woman who presents to the emergency department with
sudden-onset shortness of breath and pleuritic chest pain. She recently
returned from a 10-hour flight. Her heart rate is 115 bpm, blood pressure
is 105/65 mmHg, and oxygen saturation is 92% on room air. A CT
pulmonary angiogram confirms a large bilateral pulmonary embolism.
Echocardiography shows right ventricular dilation and dysfunction, but
her blood pressure remains stable. Troponin is mildly elevated. What is
,the most appropriate initial management? A) Administer systemic
alteplase (tPA) immediately. B) Initiate therapeutic anticoagulation with
intravenous unfractionated heparin and admit to a monitored unit. C)
Schedule for emergent surgical pulmonary embolectomy. D) Discharge
home on oral rivaroxaban with close outpatient follow-up. Correct
Answer: B Initiate therapeutic anticoagulation with
intravenous unfractionated heparin and admit to a monitored
unit. Rationale: This patient has an intermediate-high risk
(submassive) pulmonary embolism, characterized by right ventricular
dysfunction and elevated biomarkers but without hemodynamic
instability (hypotension). The standard of care is immediate
therapeutic anticoagulation (often with UFH due to its short half-life
and reversibility, allowing for escalation if she decompensates).
Systemic thrombolysis is reserved for high-risk (massive) PE with
hemodynamic instability.
Question 3: A 62-year-old man with a 10-year history of type 2 diabetes
mellitus presents for medication review. His HbA1c is 8.2% despite
maximally tolerated metformin therapy. He has a history of a myocardial
infarction 3 years ago and chronic kidney disease with an eGFR of 45
mL/min/1.73m² and mildly elevated urine albumin-to-creatinine ratio.
Which of the following medications should be added to his regimen to
provide the greatest cardiovascular and renal benefit? A) Glipizide B)
Pioglitazone C) Empagliflozin D) Sitagliptin Correct Answer: C
Empagliflozin Rationale: In patients with type 2 diabetes and
established atherosclerotic cardiovascular disease (ASCVD) or chronic
kidney disease, SGLT2 inhibitors (like empagliflozin) or GLP-1 receptor
agonists with proven cardiovascular benefit are recommended as add-
on therapy regardless of baseline HbA1c. Empagliflozin will improve
his glycemic control while providing proven cardiovascular mortality
reduction and slowing the progression of diabetic nephropathy.
Question 4: A 28-year-old woman with a 4-year history of Crohn's
disease presents with a 3-week history of worsening abdominal pain,
non-bloody diarrhea (6-8 episodes/day), and a 10-pound weight loss.
She is currently on mesalamine, which is no longer effective.
Colonoscopy reveals severe, deep ulcerations in the terminal ileum and
ascending colon. Her CRP is elevated. What is the most appropriate next
step in management? A) Increase the dose of mesalamine and add
loperamide. B) Initiate oral prednisone 40 mg daily and start a biologic
agent such as infliximab. C) Schedule an immediate total colectomy. D)
,Start ciprofloxacin and metronidazole for presumed infectious colitis.
Correct Answer: B Initiate oral prednisone 40 mg daily and
start a biologic agent such as infliximab. Rationale: This patient
has moderate-to-severe Crohn's disease that is refractory to 5-ASA
therapy. The standard of care for inducing remission in moderate-to-
severe disease is systemic corticosteroids, combined with the initiation
of a steroid-sparing maintenance therapy, such as an anti-TNF agent
(infliximab or adalimumab), to achieve mucosal healing and prevent
complications.
Question 5: A 70-year-old man is admitted with acute kidney injury
(AKI). His baseline creatinine was 1.0 mg/dL, and it is now 2.8 mg/dL.
He was recently started on a proton pump inhibitor (PPI) for GERD and
takes ibuprofen for osteoarthritis. Urinalysis shows white blood cell
casts, eosinophiluria, and mild proteinuria. Fractional excretion of
sodium (FeNa) is 1.5%. What is the most likely diagnosis? A) Acute
tubular necrosis (ATN) B) Acute interstitial nephritis (AIN) C) Prerenal
azotemia D) Postrenal obstruction Correct Answer: B Acute
interstitial nephritis (AIN) Rationale: The classic presentation of
AIN includes AKI following the initiation of an offending agent
(commonly PPIs, NSAIDs, or antibiotics), accompanied by urinary
findings of white blood cells, WBC casts, and eosinophiluria. While
NSAIDs can also cause ATN or hemodynamically mediated prerenal
AKI, the presence of WBC casts and eosinophiluria strongly points to an
allergic interstitial nephritis.
Question 6: A 45-year-old man is admitted with Staphylococcus aureus
bacteremia. Blood cultures drawn from two separate sites are positive for
methicillin-susceptible S. aureus (MSSA). A transthoracic
echocardiogram (TTE) is negative for vegetations, but he has a new
murmur and persistent fever after 4 days of appropriate intravenous
cefazolin therapy. What is the most appropriate next step? A) Continue
cefazolin for a total of 14 days and discharge. B) Switch to intravenous
vancomycin. C) Perform a transesophageal echocardiogram (TEE). D)
Add gentamicin for synergy. Correct Answer: C Perform a
transesophageal echocardiogram (TEE). Rationale: In patients
with S. aureus bacteremia, especially those with persistent fever, a new
murmur, or other clinical signs of endocarditis, a TEE is indicated even
if the initial TTE is negative. TEE has a much higher sensitivity for
detecting valvular vegetations and complications like abscesses, which
, would necessitate a longer duration of therapy (4-6 weeks) and
possible surgical evaluation.
Question 7: A 65-year-old woman with rheumatoid arthritis presents
with fatigue. Her complete blood count shows a hemoglobin of 9.5 g/dL,
MCV of 82 fL, serum iron of 30 mcg/dL (low), TIBC of 200 mcg/dL
(low), and ferritin of 250 ng/mL (high). What is the most likely cause of
her anemia? A) Iron deficiency anemia B) Anemia of chronic disease C)
Vitamin B12 deficiency D) Hemolytic anemia Correct Answer: B
Anemia of chronic disease Rationale: Anemia of chronic disease
(also known as anemia of inflammation) is characterized by a low
serum iron, low TIBC, and normal or elevated ferritin. Hepcidin, an
acute-phase reactant elevated in chronic inflammatory states like
rheumatoid arthritis, blocks iron release from macrophages and
intestinal absorption, leading to functional iron deficiency despite
adequate total body iron stores.
Question 8: A 58-year-old man with stage 3 chronic kidney disease
(eGFR 35 mL/min/1.73m²) presents to the clinic with an acute,
exquisitely painful, swollen, and erythematous right first
metatarsophalangeal (MTP) joint. He has a known history of gout.
Which of the following is the most appropriate treatment for this acute
flare? A) Indomethacin 50 mg three times daily B) Colchicine 0.6 mg
twice daily C) Intra-articular triamcinolone injection D) Allopurinol 300
mg daily (initiate now) Correct Answer: C Intra-articular
triamcinolone injection Rationale: For an acute gout flare in a
patient with significant chronic kidney disease, NSAIDs (indomethacin)
and colchicine are relatively or absolutely contraindicated due to the
risk of worsening renal function and colchicine toxicity, respectively.
Intra-articular glucocorticoid injection is highly effective and avoids
systemic side effects. If multiple joints were involved, oral or
intramuscular glucocorticoids would be the preferred systemic option.
Question 9: A 72-year-old man is brought to the emergency
department by his wife due to sudden onset of right-sided weakness and
aphasia that began 2 hours ago. His blood pressure is 195/105 mmHg. A
non-contrast head CT shows no evidence of hemorrhage. He has no
other contraindications to thrombolysis. What is the most appropriate
immediate next step? A) Administer intravenous alteplase immediately.
B) Administer intravenous labetalol to lower blood pressure to <185/110
mmHg, then administer intravenous alteplase. C) Administer aspirin
325 mg and admit to the stroke unit. D) Schedule for emergent
