ABIM INTERNAL MEDICINE BOARDS ITE – COMPREHENSIVE 2025/2026
STUDY GUIDE WITH QUESTIONS, ANSWERS & EXPLANATIONS
Cardiology
1. A 62-year-old man with hypertension and diabetes presents with
substernal chest pressure radiating to the jaw, occurring at rest and
lasting 15 minutes. ECG shows ST depression in V4-V6. Troponin is
elevated. What is the most appropriate next step?
A. Exercise stress test
B. Aspirin, clopidogrel, heparin, and urgent catheterization
C. Outpatient cardiology referral
D. Nitroglycerin and discharge with aspirin
Answer: B
Rationale: This patient has a non-ST elevation myocardial infarction
(NSTEMI) with high-risk features (diabetes, ongoing symptoms, dynamic ECG
changes). An urgent invasive strategy within 24 hours is indicated .
2. A 55-year-old man reports palpitations. ECG shows an irregularly
irregular rhythm with no P waves and a ventricular rate of 140 bpm.
What is the most appropriate acute management if he is
hemodynamically stable?
A. Immediate synchronized cardioversion
B. Rate control with metoprolol or diltiazem
C. Aspirin 325 mg
D. Amiodarone 150 mg IV push
Answer: B
Rationale: Atrial fibrillation with rapid ventricular response in a stable
patient is managed with rate control using a beta-blocker or
nondihydropyridine calcium channel blocker. Cardioversion is reserved for
unstable patients or after appropriate anticoagulation.
,3. A 72-year-old man with hypertension reports lightheadedness
when standing. BP supine 140/80, HR 72; standing BP 100/60, HR
80. Which medication is most likely contributing?
A. Metoprolol
B. Lisinopril
C. Hydrochlorothiazide
D. Doxazosin
Answer: D
Rationale: Alpha-blockers (doxazosin, terazosin, prazosin) cause significant
orthostatic hypotension. Beta-blockers and ACE inhibitors cause less.
Thiazides can cause volume depletion but less orthostasis than alpha-
blockers .
4. A 65-year-old woman has a new diastolic murmur best heard at
the left sternal border with an opening snap. What is the most likely
diagnosis?
A. Aortic stenosis
B. Mitral stenosis
C. Tricuspid regurgitation
D. Pulmonic stenosis
Answer: B
Rationale: Diastolic murmur with an opening snap at the left sternal border
is classic for mitral stenosis, most commonly due to rheumatic heart disease.
The opening snap occurs when the stenotic mitral valve leaflets open
abruptly in early diastole.
5. A 68-year-old man with heart failure with reduced EF (35%)
presents with worsening dyspnea and orthopnea. He is on lisinopril,
carvedilol, and furosemide. What is the most appropriate next
medication to reduce mortality?
, A. Digoxin
B. Spironolactone
C. Hydralazine/isosorbide dinitrate
D. Ivabradine
Answer: B
Rationale: Spironolactone (a mineralocorticoid receptor antagonist) reduces
mortality in NYHA class III-IV HFrEF patients already on an ACE inhibitor and
beta-blocker. The RALES trial demonstrated significant mortality benefit .
6. A 70-year-old man with atrial fibrillation has a CHA₂DS₂-VASc
score of 4. What is the appropriate anticoagulation strategy?
A. Aspirin 81 mg daily
B. Apixaban or warfarin (target INR 2-3)
C. No anticoagulation
D. Clopidogrel alone
Answer: B
Rationale: A CHA₂DS₂-VASc score ≥2 in men or ≥3 in women indicates oral
anticoagulation (DOAC preferred, or warfarin). Aspirin is no longer
recommended for stroke prevention in AF.
7. A 70-year-old man with Parkinson's disease on carbidopa-
levodopa reports vivid nightmares and hallucinations. What is the
most appropriate next step?
A. Add quetiapine
B. Decrease levodopa dose
C. Add donepezil
D. Switch to dopamine agonist
Answer: B
Rationale: Hallucinations in Parkinson's disease are often medication-
related, especially with levodopa and dopamine agonists. Dose reduction is
first-line. Antipsychotics can be used but may worsen motor symptoms.
STUDY GUIDE WITH QUESTIONS, ANSWERS & EXPLANATIONS
Cardiology
1. A 62-year-old man with hypertension and diabetes presents with
substernal chest pressure radiating to the jaw, occurring at rest and
lasting 15 minutes. ECG shows ST depression in V4-V6. Troponin is
elevated. What is the most appropriate next step?
A. Exercise stress test
B. Aspirin, clopidogrel, heparin, and urgent catheterization
C. Outpatient cardiology referral
D. Nitroglycerin and discharge with aspirin
Answer: B
Rationale: This patient has a non-ST elevation myocardial infarction
(NSTEMI) with high-risk features (diabetes, ongoing symptoms, dynamic ECG
changes). An urgent invasive strategy within 24 hours is indicated .
2. A 55-year-old man reports palpitations. ECG shows an irregularly
irregular rhythm with no P waves and a ventricular rate of 140 bpm.
What is the most appropriate acute management if he is
hemodynamically stable?
A. Immediate synchronized cardioversion
B. Rate control with metoprolol or diltiazem
C. Aspirin 325 mg
D. Amiodarone 150 mg IV push
Answer: B
Rationale: Atrial fibrillation with rapid ventricular response in a stable
patient is managed with rate control using a beta-blocker or
nondihydropyridine calcium channel blocker. Cardioversion is reserved for
unstable patients or after appropriate anticoagulation.
,3. A 72-year-old man with hypertension reports lightheadedness
when standing. BP supine 140/80, HR 72; standing BP 100/60, HR
80. Which medication is most likely contributing?
A. Metoprolol
B. Lisinopril
C. Hydrochlorothiazide
D. Doxazosin
Answer: D
Rationale: Alpha-blockers (doxazosin, terazosin, prazosin) cause significant
orthostatic hypotension. Beta-blockers and ACE inhibitors cause less.
Thiazides can cause volume depletion but less orthostasis than alpha-
blockers .
4. A 65-year-old woman has a new diastolic murmur best heard at
the left sternal border with an opening snap. What is the most likely
diagnosis?
A. Aortic stenosis
B. Mitral stenosis
C. Tricuspid regurgitation
D. Pulmonic stenosis
Answer: B
Rationale: Diastolic murmur with an opening snap at the left sternal border
is classic for mitral stenosis, most commonly due to rheumatic heart disease.
The opening snap occurs when the stenotic mitral valve leaflets open
abruptly in early diastole.
5. A 68-year-old man with heart failure with reduced EF (35%)
presents with worsening dyspnea and orthopnea. He is on lisinopril,
carvedilol, and furosemide. What is the most appropriate next
medication to reduce mortality?
, A. Digoxin
B. Spironolactone
C. Hydralazine/isosorbide dinitrate
D. Ivabradine
Answer: B
Rationale: Spironolactone (a mineralocorticoid receptor antagonist) reduces
mortality in NYHA class III-IV HFrEF patients already on an ACE inhibitor and
beta-blocker. The RALES trial demonstrated significant mortality benefit .
6. A 70-year-old man with atrial fibrillation has a CHA₂DS₂-VASc
score of 4. What is the appropriate anticoagulation strategy?
A. Aspirin 81 mg daily
B. Apixaban or warfarin (target INR 2-3)
C. No anticoagulation
D. Clopidogrel alone
Answer: B
Rationale: A CHA₂DS₂-VASc score ≥2 in men or ≥3 in women indicates oral
anticoagulation (DOAC preferred, or warfarin). Aspirin is no longer
recommended for stroke prevention in AF.
7. A 70-year-old man with Parkinson's disease on carbidopa-
levodopa reports vivid nightmares and hallucinations. What is the
most appropriate next step?
A. Add quetiapine
B. Decrease levodopa dose
C. Add donepezil
D. Switch to dopamine agonist
Answer: B
Rationale: Hallucinations in Parkinson's disease are often medication-
related, especially with levodopa and dopamine agonists. Dose reduction is
first-line. Antipsychotics can be used but may worsen motor symptoms.
