ABIM Internal Medicine Boards & ITE Exam –
Practice Questions with Verified Answers &
Rationales 2026
Question 1: A 72-year-old man with a history of hypertension presents
with exertional dyspnea and angina. On examination, he has a systolic
ejection murmur at the right upper sternal border that radiates to the
carotids. The murmur is loudest with squatting and decreases with Valsalva.
Echocardiogram shows a peak gradient of 60 mmHg across the aortic valve.
What is the most appropriate management?
A) Annual echocardiogram surveillance
B) Aortic valve replacement
C) Balloon valvuloplasty
D) Beta-blocker therapy
Correct Answer: B) Aortic valve replacement
Rationale: Symptomatic severe aortic stenosis (peak gradient ≥40 mmHg,
valve area <1.0 cm²) requires aortic valve replacement. The patient has
symptoms of angina and dyspnea, and a peak gradient of 60 mmHg
indicates severe stenosis. Balloon valvuloplasty (C) is a palliative measure for
patients who are not surgical candidates. Beta-blockers (D) do not treat the
underlying valvular obstruction.
Question 2: A 45-year-old woman with a history of mitral valve prolapse
presents with palpitations. Holter monitor shows frequent premature
ventricular contractions (PVCs) with a burden of 15%. Echocardiogram
shows mild mitral regurgitation. What is the most appropriate
management?
,A) Beta-blocker therapy
B) Amiodarone
C) Radiofrequency ablation
D) Observation
Correct Answer: A) Beta-blocker therapy
Rationale: In patients with symptomatic PVCs and normal left ventricular
function, beta-blockers are first-line therapy to reduce symptoms.
Amiodarone (B) has significant toxicity and is not first-line. Radiofrequency
ablation (C) is reserved for patients with high PVC burden (>20%) causing
cardiomyopathy or refractory symptoms. Observation (D) is not appropriate if
the patient is symptomatic.
Question 3: A 65-year-old man presents with progressive shortness of
breath and orthopnea. Echocardiogram shows severe aortic regurgitation
with a dilated left ventricle (LV end-diastolic diameter 70 mm). He is
asymptomatic. What is the most appropriate management?
A) Annual echocardiogram surveillance
B) Aortic valve replacement
C) ACE inhibitor therapy
D) Beta-blocker therapy
Correct Answer: B) Aortic valve replacement
Rationale: Severe aortic regurgitation with LV dilation (LV end-diastolic
diameter >65 mm or LV end-systolic diameter >50 mm) is an indication for
surgery even in asymptomatic patients. This is because the risk of irreversible
LV dysfunction increases beyond these thresholds. ACE inhibitors (C) and
beta-blockers (D) are not definitive treatment for valvular regurgitation.
,Question 4: A 58-year-old man presents with chest pain that is positional
and worse when lying flat. 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 5: A 68-year-old woman with a history of atrial fibrillation on
warfarin presents with acute onset of severe left leg pain and pallor. The leg
is cold and pulseless. What is the most likely diagnosis?
A) Acute arterial embolism
B) Deep vein thrombosis
C) Peripheral neuropathy
D) Cellulitis
Correct Answer: A) Acute arterial embolism
Rationale: Acute ischemia in a patient with atrial fibrillation is most
consistent with an acute arterial embolism. The leg is the most common site
of arterial emboli from the heart. DVT (B) would cause swelling and pain but
not a cold, pulseless limb. Peripheral neuropathy (C) and cellulitis (D) do not
cause acute limb ischemia.
, Question 6: A 62-year-old man with hypertension presents with a BP of
165/95 mmHg on amlodipine 10 mg daily and lisinopril 20 mg daily. His
creatinine is 1.2 mg/dL. What is the most appropriate next step?
A) Add hydrochlorothiazide
B) Increase lisinopril to 40 mg
C) Add spironolactone
D) Switch to an ARB
Correct Answer: A) Add hydrochlorothiazide
Rationale: The patient is on two antihypertensives and is not at goal (BP
<130/80 mmHg). The next step is to add a third agent, such as a thiazide
diuretic. Spironolactone (C) is not first-line for hypertension without heart
failure. Increasing lisinopril (B) may be considered but the patient is already
on a moderate dose. Switching to an ARB (D) is not likely to provide
additional benefit.
Question 7: A 55-year-old man with a history of hypertension and diabetes
presents with a BP of 155/90 mmHg. He is on lisinopril 10 mg daily and
metformin. What is the most appropriate next step?
A) Increase lisinopril to 20 mg
B) Add amlodipine
C) Add hydrochlorothiazide
D) Add spironolactone
Correct Answer: A) Increase lisinopril to 20 mg
Rationale: The dose of the current antihypertensive should be maximized
before adding a second agent. The maximum dose of lisinopril is 40 mg daily.
Practice Questions with Verified Answers &
Rationales 2026
Question 1: A 72-year-old man with a history of hypertension presents
with exertional dyspnea and angina. On examination, he has a systolic
ejection murmur at the right upper sternal border that radiates to the
carotids. The murmur is loudest with squatting and decreases with Valsalva.
Echocardiogram shows a peak gradient of 60 mmHg across the aortic valve.
What is the most appropriate management?
A) Annual echocardiogram surveillance
B) Aortic valve replacement
C) Balloon valvuloplasty
D) Beta-blocker therapy
Correct Answer: B) Aortic valve replacement
Rationale: Symptomatic severe aortic stenosis (peak gradient ≥40 mmHg,
valve area <1.0 cm²) requires aortic valve replacement. The patient has
symptoms of angina and dyspnea, and a peak gradient of 60 mmHg
indicates severe stenosis. Balloon valvuloplasty (C) is a palliative measure for
patients who are not surgical candidates. Beta-blockers (D) do not treat the
underlying valvular obstruction.
Question 2: A 45-year-old woman with a history of mitral valve prolapse
presents with palpitations. Holter monitor shows frequent premature
ventricular contractions (PVCs) with a burden of 15%. Echocardiogram
shows mild mitral regurgitation. What is the most appropriate
management?
,A) Beta-blocker therapy
B) Amiodarone
C) Radiofrequency ablation
D) Observation
Correct Answer: A) Beta-blocker therapy
Rationale: In patients with symptomatic PVCs and normal left ventricular
function, beta-blockers are first-line therapy to reduce symptoms.
Amiodarone (B) has significant toxicity and is not first-line. Radiofrequency
ablation (C) is reserved for patients with high PVC burden (>20%) causing
cardiomyopathy or refractory symptoms. Observation (D) is not appropriate if
the patient is symptomatic.
Question 3: A 65-year-old man presents with progressive shortness of
breath and orthopnea. Echocardiogram shows severe aortic regurgitation
with a dilated left ventricle (LV end-diastolic diameter 70 mm). He is
asymptomatic. What is the most appropriate management?
A) Annual echocardiogram surveillance
B) Aortic valve replacement
C) ACE inhibitor therapy
D) Beta-blocker therapy
Correct Answer: B) Aortic valve replacement
Rationale: Severe aortic regurgitation with LV dilation (LV end-diastolic
diameter >65 mm or LV end-systolic diameter >50 mm) is an indication for
surgery even in asymptomatic patients. This is because the risk of irreversible
LV dysfunction increases beyond these thresholds. ACE inhibitors (C) and
beta-blockers (D) are not definitive treatment for valvular regurgitation.
,Question 4: A 58-year-old man presents with chest pain that is positional
and worse when lying flat. 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 5: A 68-year-old woman with a history of atrial fibrillation on
warfarin presents with acute onset of severe left leg pain and pallor. The leg
is cold and pulseless. What is the most likely diagnosis?
A) Acute arterial embolism
B) Deep vein thrombosis
C) Peripheral neuropathy
D) Cellulitis
Correct Answer: A) Acute arterial embolism
Rationale: Acute ischemia in a patient with atrial fibrillation is most
consistent with an acute arterial embolism. The leg is the most common site
of arterial emboli from the heart. DVT (B) would cause swelling and pain but
not a cold, pulseless limb. Peripheral neuropathy (C) and cellulitis (D) do not
cause acute limb ischemia.
, Question 6: A 62-year-old man with hypertension presents with a BP of
165/95 mmHg on amlodipine 10 mg daily and lisinopril 20 mg daily. His
creatinine is 1.2 mg/dL. What is the most appropriate next step?
A) Add hydrochlorothiazide
B) Increase lisinopril to 40 mg
C) Add spironolactone
D) Switch to an ARB
Correct Answer: A) Add hydrochlorothiazide
Rationale: The patient is on two antihypertensives and is not at goal (BP
<130/80 mmHg). The next step is to add a third agent, such as a thiazide
diuretic. Spironolactone (C) is not first-line for hypertension without heart
failure. Increasing lisinopril (B) may be considered but the patient is already
on a moderate dose. Switching to an ARB (D) is not likely to provide
additional benefit.
Question 7: A 55-year-old man with a history of hypertension and diabetes
presents with a BP of 155/90 mmHg. He is on lisinopril 10 mg daily and
metformin. What is the most appropriate next step?
A) Increase lisinopril to 20 mg
B) Add amlodipine
C) Add hydrochlorothiazide
D) Add spironolactone
Correct Answer: A) Increase lisinopril to 20 mg
Rationale: The dose of the current antihypertensive should be maximized
before adding a second agent. The maximum dose of lisinopril is 40 mg daily.
