ABIM Internal Medicine Boards & ITE
Exam Questions with Answers| Guaranteed Pass| Latest Update
,Question 1. A 62-year-old man with hypertension presents with
substernal chest pain for 2 hours. ECG shows ST-segment elevation in
leads II, III, and aVF. He is hemodynamically stable. Which of the following
is the most appropriate next step?
A. Administer thrombolytics and observe
B. Immediate coronary angiography with primary PCI
C. Start beta-blocker and discharge with outpatient stress test
D. CT coronary angiography to confirm diagnosis
E. Administer high-dose statin only and reassess in 24 hours
Correct Answer: B
Rationale: This patient has an inferior STEMI. Primary PCI within 90 minutes of
first medical contact is the guideline-recommended reperfusion strategy when
a PCI-capable center is available, as it reduces mortality compared with
fibrinolysis. Fibrinolytics are reserved for centers without timely PCI capability
(transfer time >120 minutes).
Question 2. A 74-year-old woman with a history of paroxysmal atrial
fibrillation and hypertension presents for routine follow-up.
CHA2DS2-VASc score is 3. She has normal renal function. Which of the
following is the most appropriate anticoagulation strategy?
A. Aspirin 81 mg daily
B. No anticoagulation needed
C. Direct oral anticoagulant (e.g., apixaban)
D. Warfarin only if she has a mechanical valve
E. Clopidogrel plus aspirin
Correct Answer: C
Rationale: A CHA2DS2-VASc score 2 in women (1 in men) warrants oral
anticoagulation for stroke prevention. DOACs (apixaban, rivaroxaban,
dabigatran, edoxaban) are preferred over warfarin in nonvalvular atrial
fibrillation due to comparable or superior efficacy, lower intracranial
hemorrhage risk, and no need for routine monitoring. Aspirin alone is
inadequate for this risk level.
,Question 3. A 55-year-old man with heart failure with reduced ejection
fraction (EF 30%) on optimal doses of an ACE inhibitor, beta-blocker, and
mineralocorticoid receptor antagonist continues to have NYHA class II
symptoms. Which of the following changes is most appropriate?
A. Add digoxin as first-line therapy
B. Switch ACE inhibitor to an ARNI (sacubitril/valsartan)
C. Add a calcium channel blocker
D. Discontinue beta-blocker to reduce fatigue
E. Add hydralazine/nitrates only in this patient regardless of race
Correct Answer: B
Rationale: In patients with HFrEF who remain symptomatic despite
guideline-directed medical therapy, switching from an ACE inhibitor/ARB to an
angiotensin receptor-neprilysin inhibitor (ARNI) reduces cardiovascular death
and heart failure hospitalization (PARADIGM-HF trial). A 36-hour washout is
required when switching from an ACE inhibitor to avoid angioedema risk.
Question 4. A 45-year-old woman presents with exertional dyspnea.
Echocardiogram reveals a mid-systolic click and late systolic murmur at
the apex that increases with standing. What is the most likely diagnosis?
A. Aortic stenosis
B. Mitral valve prolapse
C. Hypertrophic cardiomyopathy
D. Mitral stenosis
E. Tricuspid regurgitation
Correct Answer: B
Rationale: Mitral valve prolapse classically presents with a mid-systolic click
followed by a late systolic murmur. Maneuvers that decrease left ventricular
volume (standing, Valsalva) cause the click to occur earlier and the murmur to
lengthen, distinguishing it from other murmurs such as HCM (which also
increases with standing but lacks a click) or mitral stenosis (diastolic, opening
snap).
, Question 5. A 68-year-old man with longstanding hypertension develops
progressive exertional dyspnea. Physical exam reveals a harsh
crescendo-decrescendo systolic murmur at the right upper sternal border
radiating to the carotids, with a delayed and diminished carotid upstroke.
Echocardiogram confirms severe aortic stenosis with an EF of 55%. He
reports occasional exertional syncope. What is the most appropriate
management?
A. Watchful waiting with annual echocardiography
B. Aortic valve replacement (surgical or transcatheter)
C. Balloon aortic valvuloplasty as definitive therapy
D. Aggressive diuresis and afterload reduction
E. Beta-blocker therapy to reduce symptoms
Correct Answer: B
Rationale: Severe symptomatic aortic stenosis (angina, syncope, or heart
failure) is an indication for aortic valve replacement, either surgical (SAVR) or
transcatheter (TAVR) depending on surgical risk and patient factors, since
without intervention the prognosis is poor (average survival <2-3 years after
symptom onset). Balloon valvuloplasty is a bridge therapy, not definitive
treatment, and vasodilators/negative inotropes can be dangerous in
fixed-obstruction states.
Question 6. A 30-year-old woman with no cardiac history presents with
sudden pleuritic chest pain and dyspnea 10 days postpartum. She is
tachycardic and hypoxic. D-dimer is elevated. Which of the following is
the most appropriate next diagnostic step?
A. CT pulmonary angiography
B. V/Q scan only, CTPA is contraindicated postpartum
C. Empiric anticoagulation without imaging
D. Troponin alone to rule out PE
E. Lower extremity Doppler only
Correct Answer: A
Rationale: CT pulmonary angiography is the preferred initial imaging test for
suspected pulmonary embolism in most patients, including postpartum women,
given its high sensitivity/specificity and wide availability; radiation exposure is
Exam Questions with Answers| Guaranteed Pass| Latest Update
,Question 1. A 62-year-old man with hypertension presents with
substernal chest pain for 2 hours. ECG shows ST-segment elevation in
leads II, III, and aVF. He is hemodynamically stable. Which of the following
is the most appropriate next step?
A. Administer thrombolytics and observe
B. Immediate coronary angiography with primary PCI
C. Start beta-blocker and discharge with outpatient stress test
D. CT coronary angiography to confirm diagnosis
E. Administer high-dose statin only and reassess in 24 hours
Correct Answer: B
Rationale: This patient has an inferior STEMI. Primary PCI within 90 minutes of
first medical contact is the guideline-recommended reperfusion strategy when
a PCI-capable center is available, as it reduces mortality compared with
fibrinolysis. Fibrinolytics are reserved for centers without timely PCI capability
(transfer time >120 minutes).
Question 2. A 74-year-old woman with a history of paroxysmal atrial
fibrillation and hypertension presents for routine follow-up.
CHA2DS2-VASc score is 3. She has normal renal function. Which of the
following is the most appropriate anticoagulation strategy?
A. Aspirin 81 mg daily
B. No anticoagulation needed
C. Direct oral anticoagulant (e.g., apixaban)
D. Warfarin only if she has a mechanical valve
E. Clopidogrel plus aspirin
Correct Answer: C
Rationale: A CHA2DS2-VASc score 2 in women (1 in men) warrants oral
anticoagulation for stroke prevention. DOACs (apixaban, rivaroxaban,
dabigatran, edoxaban) are preferred over warfarin in nonvalvular atrial
fibrillation due to comparable or superior efficacy, lower intracranial
hemorrhage risk, and no need for routine monitoring. Aspirin alone is
inadequate for this risk level.
,Question 3. A 55-year-old man with heart failure with reduced ejection
fraction (EF 30%) on optimal doses of an ACE inhibitor, beta-blocker, and
mineralocorticoid receptor antagonist continues to have NYHA class II
symptoms. Which of the following changes is most appropriate?
A. Add digoxin as first-line therapy
B. Switch ACE inhibitor to an ARNI (sacubitril/valsartan)
C. Add a calcium channel blocker
D. Discontinue beta-blocker to reduce fatigue
E. Add hydralazine/nitrates only in this patient regardless of race
Correct Answer: B
Rationale: In patients with HFrEF who remain symptomatic despite
guideline-directed medical therapy, switching from an ACE inhibitor/ARB to an
angiotensin receptor-neprilysin inhibitor (ARNI) reduces cardiovascular death
and heart failure hospitalization (PARADIGM-HF trial). A 36-hour washout is
required when switching from an ACE inhibitor to avoid angioedema risk.
Question 4. A 45-year-old woman presents with exertional dyspnea.
Echocardiogram reveals a mid-systolic click and late systolic murmur at
the apex that increases with standing. What is the most likely diagnosis?
A. Aortic stenosis
B. Mitral valve prolapse
C. Hypertrophic cardiomyopathy
D. Mitral stenosis
E. Tricuspid regurgitation
Correct Answer: B
Rationale: Mitral valve prolapse classically presents with a mid-systolic click
followed by a late systolic murmur. Maneuvers that decrease left ventricular
volume (standing, Valsalva) cause the click to occur earlier and the murmur to
lengthen, distinguishing it from other murmurs such as HCM (which also
increases with standing but lacks a click) or mitral stenosis (diastolic, opening
snap).
, Question 5. A 68-year-old man with longstanding hypertension develops
progressive exertional dyspnea. Physical exam reveals a harsh
crescendo-decrescendo systolic murmur at the right upper sternal border
radiating to the carotids, with a delayed and diminished carotid upstroke.
Echocardiogram confirms severe aortic stenosis with an EF of 55%. He
reports occasional exertional syncope. What is the most appropriate
management?
A. Watchful waiting with annual echocardiography
B. Aortic valve replacement (surgical or transcatheter)
C. Balloon aortic valvuloplasty as definitive therapy
D. Aggressive diuresis and afterload reduction
E. Beta-blocker therapy to reduce symptoms
Correct Answer: B
Rationale: Severe symptomatic aortic stenosis (angina, syncope, or heart
failure) is an indication for aortic valve replacement, either surgical (SAVR) or
transcatheter (TAVR) depending on surgical risk and patient factors, since
without intervention the prognosis is poor (average survival <2-3 years after
symptom onset). Balloon valvuloplasty is a bridge therapy, not definitive
treatment, and vasodilators/negative inotropes can be dangerous in
fixed-obstruction states.
Question 6. A 30-year-old woman with no cardiac history presents with
sudden pleuritic chest pain and dyspnea 10 days postpartum. She is
tachycardic and hypoxic. D-dimer is elevated. Which of the following is
the most appropriate next diagnostic step?
A. CT pulmonary angiography
B. V/Q scan only, CTPA is contraindicated postpartum
C. Empiric anticoagulation without imaging
D. Troponin alone to rule out PE
E. Lower extremity Doppler only
Correct Answer: A
Rationale: CT pulmonary angiography is the preferred initial imaging test for
suspected pulmonary embolism in most patients, including postpartum women,
given its high sensitivity/specificity and wide availability; radiation exposure is
