2026-2027 ABIM INTERNAL MEDICINE BOARDS & ITE
EXAM – UNIQUE PRACTICE QUESTIONS (SET 7)
Question 1: A 68-year-old man with a history of hypertension presents
with progressive dyspnea on exertion and orthopnea. Echocardiogram
shows concentric left ventricular hypertrophy with an ejection fraction of
55% and evidence of diastolic dysfunction. Which of the following is the
most appropriate initial therapy?
A) Digoxin
B) Spironolactone
C) Loop diuretic
D) ACE inhibitor
Correct Answer: C) Loop diuretic
Rationale: This patient has heart failure with preserved ejection fraction
(HFpEF) with signs of volume overload. Loop diuretics are first-line for
symptom management in HFpEF. ACE inhibitors (D) may be used but are not
the initial therapy for acute symptom management. Digoxin (A) is not
indicated in HFpEF. Spironolactone (B) may be considered for long-term
management but is not first-line for acute symptoms.
Question 2: A 72-year-old man with atrial fibrillation is on warfarin. His INR
is 5.0. He has no bleeding. What is the most appropriate management?
A) Hold warfarin and resume when INR is <3
B) Administer vitamin K 1 mg orally
,C) Administer fresh frozen plasma
D) Continue warfarin at the same dose
Correct Answer: A) Hold warfarin and resume when INR is <3
Rationale: For an asymptomatic patient with an INR of 5.0 (above therapeutic
range but <5.0), the appropriate management is to hold warfarin and resume
when the INR is <3. Vitamin K (B) is indicated for INR >5 or if there is
bleeding. Fresh frozen plasma (C) is for life-threatening bleeding.
Question 3: A 55-year-old woman presents with palpitations and
lightheadedness. ECG shows a regular, narrow-complex tachycardia at 180
bpm. She is hemodynamically stable. Carotid sinus massage fails to
terminate the rhythm. What is the most appropriate next step?
A) Adenosine 6 mg IV push
B) Verapamil 5 mg IV
C) Metoprolol 5 mg IV
D) Amiodarone 150 mg IV
Correct Answer: A) Adenosine 6 mg IV push
Rationale: Adenosine is the first-line agent for stable, regular, narrow-
complex SVT. It is administered as a rapid IV push (6 mg followed by 12 mg if
needed). Verapamil (B) and metoprolol (C) are second-line agents.
Amiodarone (D) is not first-line for SVT.
Question 4: A 60-year-old woman presents with dyspnea on exertion and
fatigue. Echocardiogram shows severe mitral regurgitation. She is
asymptomatic. What is the most appropriate management?
,A) Watchful waiting with annual echocardiograms
B) Mitral valve repair
C) Medical therapy with ACE inhibitors
D) Mitral valve replacement
Correct Answer: A) Watchful waiting with annual echocardiograms
Rationale: Asymptomatic patients with severe mitral regurgitation and
normal LV function can be managed with watchful waiting. Surgery (B, D) is
indicated when symptoms develop, LVEF decreases (<60%), or LV dilation
occurs. Medical therapy (C) is not effective for primary mitral regurgitation.
Question 5: A 45-year-old man presents with acute chest pain. ECG shows
diffuse ST elevation with PR depression. What is the most likely diagnosis?
A) Acute myocardial infarction
B) Pericarditis
C) Pulmonary embolism
D) Aortic dissection
Correct Answer: B) Pericarditis
Rationale: Pericarditis typically presents with diffuse ST elevation (concave
upward) and PR depression. The pain is often pleuritic and positional (worse
lying flat, improved by sitting up). Myocardial infarction (A) causes localized
ST elevation with reciprocal changes. Pulmonary embolism (C) causes
tachycardia and hypoxia. Aortic dissection (D) causes "tearing" chest pain.
Question 6: A 70-year-old man presents with sudden onset of severe chest
pain radiating to the back. His blood pressure is 180/100 mmHg in the right
, arm and 130/80 mmHg in the left arm. Which imaging study is most
appropriate for diagnosis?
A) Chest X-ray
B) CT angiography of the chest
C) Echocardiography
D) ECG
Correct Answer: B) CT angiography of the chest
Rationale: CT angiography of the chest is the imaging study of choice for
diagnosing aortic dissection. It can visualize the intimal flap and determine
the extent of the dissection. Chest X-ray (A) may show a widened
mediastinum but is not diagnostic. Echocardiography (C) may be useful but
CT is more definitive. ECG (D) is useful for MI but not for dissection.
Question 7: A 65-year-old man with hypertension and CKD stage 3 is on
lisinopril 20 mg daily. His BP is 145/85 mmHg. What is the most appropriate
next step?
A) Increase lisinopril to 40 mg
B) Add amlodipine
C) Add hydrochlorothiazide
D) Add spironolactone
Correct Answer: A) Increase lisinopril to 40 mg
Rationale: ACE inhibitors are preferred in patients with CKD due to their
renoprotective effects. The dose should be maximized before adding another
agent. The maximum dose of lisinopril is 40 mg daily. Spironolactone (D)
should be used with caution in CKD due to the risk of hyperkalemia.
EXAM – UNIQUE PRACTICE QUESTIONS (SET 7)
Question 1: A 68-year-old man with a history of hypertension presents
with progressive dyspnea on exertion and orthopnea. Echocardiogram
shows concentric left ventricular hypertrophy with an ejection fraction of
55% and evidence of diastolic dysfunction. Which of the following is the
most appropriate initial therapy?
A) Digoxin
B) Spironolactone
C) Loop diuretic
D) ACE inhibitor
Correct Answer: C) Loop diuretic
Rationale: This patient has heart failure with preserved ejection fraction
(HFpEF) with signs of volume overload. Loop diuretics are first-line for
symptom management in HFpEF. ACE inhibitors (D) may be used but are not
the initial therapy for acute symptom management. Digoxin (A) is not
indicated in HFpEF. Spironolactone (B) may be considered for long-term
management but is not first-line for acute symptoms.
Question 2: A 72-year-old man with atrial fibrillation is on warfarin. His INR
is 5.0. He has no bleeding. What is the most appropriate management?
A) Hold warfarin and resume when INR is <3
B) Administer vitamin K 1 mg orally
,C) Administer fresh frozen plasma
D) Continue warfarin at the same dose
Correct Answer: A) Hold warfarin and resume when INR is <3
Rationale: For an asymptomatic patient with an INR of 5.0 (above therapeutic
range but <5.0), the appropriate management is to hold warfarin and resume
when the INR is <3. Vitamin K (B) is indicated for INR >5 or if there is
bleeding. Fresh frozen plasma (C) is for life-threatening bleeding.
Question 3: A 55-year-old woman presents with palpitations and
lightheadedness. ECG shows a regular, narrow-complex tachycardia at 180
bpm. She is hemodynamically stable. Carotid sinus massage fails to
terminate the rhythm. What is the most appropriate next step?
A) Adenosine 6 mg IV push
B) Verapamil 5 mg IV
C) Metoprolol 5 mg IV
D) Amiodarone 150 mg IV
Correct Answer: A) Adenosine 6 mg IV push
Rationale: Adenosine is the first-line agent for stable, regular, narrow-
complex SVT. It is administered as a rapid IV push (6 mg followed by 12 mg if
needed). Verapamil (B) and metoprolol (C) are second-line agents.
Amiodarone (D) is not first-line for SVT.
Question 4: A 60-year-old woman presents with dyspnea on exertion and
fatigue. Echocardiogram shows severe mitral regurgitation. She is
asymptomatic. What is the most appropriate management?
,A) Watchful waiting with annual echocardiograms
B) Mitral valve repair
C) Medical therapy with ACE inhibitors
D) Mitral valve replacement
Correct Answer: A) Watchful waiting with annual echocardiograms
Rationale: Asymptomatic patients with severe mitral regurgitation and
normal LV function can be managed with watchful waiting. Surgery (B, D) is
indicated when symptoms develop, LVEF decreases (<60%), or LV dilation
occurs. Medical therapy (C) is not effective for primary mitral regurgitation.
Question 5: A 45-year-old man presents with acute chest pain. ECG shows
diffuse ST elevation with PR depression. What is the most likely diagnosis?
A) Acute myocardial infarction
B) Pericarditis
C) Pulmonary embolism
D) Aortic dissection
Correct Answer: B) Pericarditis
Rationale: Pericarditis typically presents with diffuse ST elevation (concave
upward) and PR depression. The pain is often pleuritic and positional (worse
lying flat, improved by sitting up). Myocardial infarction (A) causes localized
ST elevation with reciprocal changes. Pulmonary embolism (C) causes
tachycardia and hypoxia. Aortic dissection (D) causes "tearing" chest pain.
Question 6: A 70-year-old man presents with sudden onset of severe chest
pain radiating to the back. His blood pressure is 180/100 mmHg in the right
, arm and 130/80 mmHg in the left arm. Which imaging study is most
appropriate for diagnosis?
A) Chest X-ray
B) CT angiography of the chest
C) Echocardiography
D) ECG
Correct Answer: B) CT angiography of the chest
Rationale: CT angiography of the chest is the imaging study of choice for
diagnosing aortic dissection. It can visualize the intimal flap and determine
the extent of the dissection. Chest X-ray (A) may show a widened
mediastinum but is not diagnostic. Echocardiography (C) may be useful but
CT is more definitive. ECG (D) is useful for MI but not for dissection.
Question 7: A 65-year-old man with hypertension and CKD stage 3 is on
lisinopril 20 mg daily. His BP is 145/85 mmHg. What is the most appropriate
next step?
A) Increase lisinopril to 40 mg
B) Add amlodipine
C) Add hydrochlorothiazide
D) Add spironolactone
Correct Answer: A) Increase lisinopril to 40 mg
Rationale: ACE inhibitors are preferred in patients with CKD due to their
renoprotective effects. The dose should be maximized before adding another
agent. The maximum dose of lisinopril is 40 mg daily. Spironolactone (D)
should be used with caution in CKD due to the risk of hyperkalemia.
