ABIM Internal Medicine Boards & ITE
Exam – Practice Questions with Verified
Answers & Rationales 2026-2027
Question 1: A 55-year-old man presents with progressive dyspnea and
fatigue. Echocardiogram shows concentric left ventricular hypertrophy with
a normal ejection fraction. He has a history of hypertension for 10 years.
Which of the following is the most likely diagnosis?
A) Hypertrophic cardiomyopathy
B) Hypertensive heart disease with diastolic dysfunction
C) Aortic stenosis
D) Restrictive cardiomyopathy
Correct Answer: B) Hypertensive heart disease with diastolic
dysfunction
Rationale: Long-standing hypertension causes concentric left ventricular
hypertrophy and diastolic dysfunction. The ejection fraction is typically
preserved. Hypertrophic cardiomyopathy (A) is a genetic condition with
asymmetric septal hypertrophy. Aortic stenosis (C) would have a systolic
ejection murmur. Restrictive cardiomyopathy (D) is less common.
Question 2: A 60-year-old woman presents with a 3-month history of
fatigue and mild dyspnea. On examination, she has a mid-systolic click and
a late systolic murmur at the apex. What is the most likely diagnosis?
,A) Mitral stenosis
B) Mitral regurgitation due to mitral valve prolapse
C) Aortic stenosis
D) Tricuspid regurgitation
Correct Answer: B) Mitral regurgitation due to mitral valve prolapse
Rationale: A mid-systolic click followed by a late systolic murmur is classic for
mitral valve prolapse with mitral regurgitation. Mitral stenosis (A) causes a
diastolic murmur. Aortic stenosis (C) causes a systolic ejection murmur at the
right upper sternal border. Tricuspid regurgitation (D) causes a murmur at
the left lower sternal border.
Question 3: A 68-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. What is the most likely diagnosis?
A) Acute myocardial infarction
B) Aortic dissection
C) Pulmonary embolism
D) Pericarditis
Correct Answer: B) Aortic dissection
Rationale: Aortic dissection presents with "tearing" chest pain radiating to the
back with a blood pressure difference between arms. Myocardial infarction
(A) has pressure-type pain. Pulmonary embolism (C) has pleuritic pain.
Pericarditis (D) pain is positional.
Question 4: A 45-year-old woman with a history of systemic lupus
erythematosus presents with chest pain and shortness of breath.
,Echocardiogram shows a moderate pericardial effusion. What is the most
likely diagnosis?
A) Pericarditis
B) Myocarditis
C) Endocarditis
D) Pulmonary embolism
Correct Answer: A) Pericarditis
Rationale: Pericarditis is a common complication of SLE. The pericardial
effusion is due to inflammation of the pericardium. Myocarditis (B) would
cause heart failure. Endocarditis (C) would have a heart murmur. Pulmonary
embolism (D) would have pleuritic chest pain and risk factors.
Question 5: A 65-year-old man with a history of hypertension presents
with a BP of 155/95 mmHg. He is on hydrochlorothiazide 25 mg daily. What
is the most appropriate next step?
A) Increase hydrochlorothiazide to 50 mg
B) Add lisinopril
C) Add amlodipine
D) Add spironolactone
Correct Answer: B) Add lisinopril
Rationale: The patient is not at goal BP (<130/80 mmHg). The next step is to
add a second agent. ACE inhibitors (lisinopril) are a good choice for
hypertension, especially in patients with diabetes or CKD. Increasing
hydrochlorothiazide (A) may not provide additional benefit beyond 25 mg.
Amlodipine (C) is also an option but ACE inhibitors are often preferred first.
, Question 6: A 58-year-old man presents with chest pain that occurs at rest
and lasts 15 minutes. ECG shows transient ST depression. Troponin is
negative. What is the most likely diagnosis?
A) Stable angina
B) Unstable angina
C) Non-ST elevation MI
D) ST elevation MI
Correct Answer: B) Unstable angina
Rationale: Unstable angina is characterized by chest pain at rest or with
minimal exertion, lasting >10 minutes. Troponin is negative (no myocardial
necrosis). NSTEMI (C) would have elevated troponin. STEMI (D) would have ST
elevation. Stable angina (A) is exertional and relieved by rest.
Question 7: A 70-year-old man with atrial fibrillation is on apixaban. He
presents with a left-sided stroke. What is the most appropriate
management?
A) Continue apixaban
B) Switch to warfarin
C) Add aspirin
D) Discontinue apixaban
Correct Answer: A) Continue apixaban
Rationale: Apixaban is a DOAC indicated for stroke prevention in atrial
fibrillation. The patient should continue apixaban. Switching to warfarin (B) is
not indicated unless there is a reason to discontinue the DOAC. Adding
aspirin (C) is not recommended. Discontinuing apixaban (D) would increase
the risk of recurrent stroke.
Exam – Practice Questions with Verified
Answers & Rationales 2026-2027
Question 1: A 55-year-old man presents with progressive dyspnea and
fatigue. Echocardiogram shows concentric left ventricular hypertrophy with
a normal ejection fraction. He has a history of hypertension for 10 years.
Which of the following is the most likely diagnosis?
A) Hypertrophic cardiomyopathy
B) Hypertensive heart disease with diastolic dysfunction
C) Aortic stenosis
D) Restrictive cardiomyopathy
Correct Answer: B) Hypertensive heart disease with diastolic
dysfunction
Rationale: Long-standing hypertension causes concentric left ventricular
hypertrophy and diastolic dysfunction. The ejection fraction is typically
preserved. Hypertrophic cardiomyopathy (A) is a genetic condition with
asymmetric septal hypertrophy. Aortic stenosis (C) would have a systolic
ejection murmur. Restrictive cardiomyopathy (D) is less common.
Question 2: A 60-year-old woman presents with a 3-month history of
fatigue and mild dyspnea. On examination, she has a mid-systolic click and
a late systolic murmur at the apex. What is the most likely diagnosis?
,A) Mitral stenosis
B) Mitral regurgitation due to mitral valve prolapse
C) Aortic stenosis
D) Tricuspid regurgitation
Correct Answer: B) Mitral regurgitation due to mitral valve prolapse
Rationale: A mid-systolic click followed by a late systolic murmur is classic for
mitral valve prolapse with mitral regurgitation. Mitral stenosis (A) causes a
diastolic murmur. Aortic stenosis (C) causes a systolic ejection murmur at the
right upper sternal border. Tricuspid regurgitation (D) causes a murmur at
the left lower sternal border.
Question 3: A 68-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. What is the most likely diagnosis?
A) Acute myocardial infarction
B) Aortic dissection
C) Pulmonary embolism
D) Pericarditis
Correct Answer: B) Aortic dissection
Rationale: Aortic dissection presents with "tearing" chest pain radiating to the
back with a blood pressure difference between arms. Myocardial infarction
(A) has pressure-type pain. Pulmonary embolism (C) has pleuritic pain.
Pericarditis (D) pain is positional.
Question 4: A 45-year-old woman with a history of systemic lupus
erythematosus presents with chest pain and shortness of breath.
,Echocardiogram shows a moderate pericardial effusion. What is the most
likely diagnosis?
A) Pericarditis
B) Myocarditis
C) Endocarditis
D) Pulmonary embolism
Correct Answer: A) Pericarditis
Rationale: Pericarditis is a common complication of SLE. The pericardial
effusion is due to inflammation of the pericardium. Myocarditis (B) would
cause heart failure. Endocarditis (C) would have a heart murmur. Pulmonary
embolism (D) would have pleuritic chest pain and risk factors.
Question 5: A 65-year-old man with a history of hypertension presents
with a BP of 155/95 mmHg. He is on hydrochlorothiazide 25 mg daily. What
is the most appropriate next step?
A) Increase hydrochlorothiazide to 50 mg
B) Add lisinopril
C) Add amlodipine
D) Add spironolactone
Correct Answer: B) Add lisinopril
Rationale: The patient is not at goal BP (<130/80 mmHg). The next step is to
add a second agent. ACE inhibitors (lisinopril) are a good choice for
hypertension, especially in patients with diabetes or CKD. Increasing
hydrochlorothiazide (A) may not provide additional benefit beyond 25 mg.
Amlodipine (C) is also an option but ACE inhibitors are often preferred first.
, Question 6: A 58-year-old man presents with chest pain that occurs at rest
and lasts 15 minutes. ECG shows transient ST depression. Troponin is
negative. What is the most likely diagnosis?
A) Stable angina
B) Unstable angina
C) Non-ST elevation MI
D) ST elevation MI
Correct Answer: B) Unstable angina
Rationale: Unstable angina is characterized by chest pain at rest or with
minimal exertion, lasting >10 minutes. Troponin is negative (no myocardial
necrosis). NSTEMI (C) would have elevated troponin. STEMI (D) would have ST
elevation. Stable angina (A) is exertional and relieved by rest.
Question 7: A 70-year-old man with atrial fibrillation is on apixaban. He
presents with a left-sided stroke. What is the most appropriate
management?
A) Continue apixaban
B) Switch to warfarin
C) Add aspirin
D) Discontinue apixaban
Correct Answer: A) Continue apixaban
Rationale: Apixaban is a DOAC indicated for stroke prevention in atrial
fibrillation. The patient should continue apixaban. Switching to warfarin (B) is
not indicated unless there is a reason to discontinue the DOAC. Adding
aspirin (C) is not recommended. Discontinuing apixaban (D) would increase
the risk of recurrent stroke.
