ABIM Internal Medicine Boards & ITE Exam –
Practice Questions with Verified Answers &
Rationales
ABOUT THIS RESOURCE
This comprehensive question bank is designed to help you prepare for
the American Board of Internal Medicine (ABIM) Certification
Exam and the In-Training Examination (ITE) . The questions are
organized by core content areas and reflect the 2025–2026 ABIM exam
blueprint. Each question includes the correct answer and a detailed,
evidence-based rationale.
ABIM Exam Content Outline:
• Cardiovascular Disease (14–16%)
• Endocrinology, Diabetes & Metabolism (8–10%)
• Gastroenterology & Hepatology (8–10%)
• Infectious Disease (8–10%)
• Nephrology & Urology (8–10%)
• Pulmonary & Critical Care (8–10%)
• Hematology & Oncology (8–10%)
• Rheumatology & Immunology (6–8%)
• Neurology (6–8%)
• Dermatology (3–5%)
• Geriatrics, Palliative Care & Ethics (3–5%)
,SECTION 1: CARDIOVASCULAR DISEASE (Questions 1–
30)
Question 1: A 65-year-old man presents with progressive exertional
dyspnea. On exam, he has bibasilar crackles and an S3 gallop.
Echocardiogram shows an ejection fraction of 35%. Which of the following
is the most appropriate first-line therapy?
A) Hydrochlorothiazide
B) Digoxin
C) ACE inhibitor
D) Amiodarone
Correct Answer: C) ACE inhibitor
Rationale: ACE inhibitors are first-line therapy for systolic heart failure
(HFrEF) as they reduce morbidity and mortality. They decrease afterload and
preload, improve cardiac output, and have been shown to reduce the risk of
hospitalization and death in patients with HFrEF. Digoxin (B) is used for
symptom control but does not reduce mortality. Thiazides (A) are not first-
line for HFrEF. Amiodarone (D) is used for arrhythmias, not as primary
therapy for heart failure.
Question 2: A 55-year-old woman with a history of type 2 diabetes
presents with polyuria and polydipsia. Lab tests show a fasting plasma
glucose of 165 mg/dL and HbA1c of 7.5%. What is the next best step?
A) Start insulin therapy immediately
B) Start metformin therapy
,C) Recommend only lifestyle modification
D) Order an oral glucose tolerance test
Correct Answer: B) Start metformin therapy
Rationale: Metformin is the first-line pharmacologic therapy for type 2
diabetes, along with lifestyle modification. It reduces hepatic glucose
production and improves insulin sensitivity. The patient's HbA1c of 7.5%
indicates that lifestyle modification alone (C) is insufficient. Insulin (A) is not
first-line unless the patient has severe hyperglycemia or is symptomatic. An
OGTT (D) is not needed when the diagnosis is already established.
Question 3: A 62-year-old man presents with exertional chest pain relieved
by rest. ECG shows ST depression in leads V4-V6. What is the next best step
in management?
A) Coronary angiography
B) Start nitrates, beta-blocker, and aspirin
C) Schedule a stress echocardiogram
D) Immediate thrombolysis
Correct Answer: B) Start nitrates, beta-blocker, and aspirin
Rationale: Stable angina is characterized by predictable exertional chest pain
relieved by rest or nitroglycerin. Initial management includes antianginal
therapy (nitrates, beta-blockers), risk factor modification, and aspirin.
Coronary angiography (A) is indicated only if symptoms persist despite
medical therapy or if there is high-risk features on stress testing.
Question 4: A patient with nonischemic cardiomyopathy and LVEF of 35%
on optimal medical therapy for 6 months is being evaluated for primary
, prevention ICD. Recent ECG shows LBBB with QRS duration 150 ms. Which
of the following is the most appropriate next step?
A) Proceed with ICD implantation alone
B) Proceed with CRT-D
C) Continue medical therapy and reassess LVEF in 3 months
D) Perform electrophysiology study to induce ventricular tachycardia
Correct Answer: B) Proceed with CRT-D
Rationale: Current guidelines recommend CRT-D for patients with LVEF
≤35%, LBBB with QRS ≥150 ms, and NYHA class II-III symptoms despite
optimal medical therapy. ICD alone is insufficient because CRT provides
additional mortality benefit. Reassessment is not indicated as the patient is
already on optimal therapy.
Question 5: A 70-year-old man presents with sudden-onset severe left leg
pain. Exam shows a cold, pulseless limb. He has a history of atrial
fibrillation. What is the most likely diagnosis?
A) DVT
B) Acute arterial embolism
C) Peripheral neuropathy
D) Cellulitis
Correct Answer: B) Acute arterial embolism
Rationale: Sudden ischemia in a patient with atrial fibrillation is most
consistent with an acute arterial embolism. The left leg is the most common
site of arterial emboli from the heart. DVT (A) would cause swelling and pain
but not a cold, pulseless limb. Peripheral neuropathy (C) and cellulitis (D) do
not cause acute limb ischemia.
Practice Questions with Verified Answers &
Rationales
ABOUT THIS RESOURCE
This comprehensive question bank is designed to help you prepare for
the American Board of Internal Medicine (ABIM) Certification
Exam and the In-Training Examination (ITE) . The questions are
organized by core content areas and reflect the 2025–2026 ABIM exam
blueprint. Each question includes the correct answer and a detailed,
evidence-based rationale.
ABIM Exam Content Outline:
• Cardiovascular Disease (14–16%)
• Endocrinology, Diabetes & Metabolism (8–10%)
• Gastroenterology & Hepatology (8–10%)
• Infectious Disease (8–10%)
• Nephrology & Urology (8–10%)
• Pulmonary & Critical Care (8–10%)
• Hematology & Oncology (8–10%)
• Rheumatology & Immunology (6–8%)
• Neurology (6–8%)
• Dermatology (3–5%)
• Geriatrics, Palliative Care & Ethics (3–5%)
,SECTION 1: CARDIOVASCULAR DISEASE (Questions 1–
30)
Question 1: A 65-year-old man presents with progressive exertional
dyspnea. On exam, he has bibasilar crackles and an S3 gallop.
Echocardiogram shows an ejection fraction of 35%. Which of the following
is the most appropriate first-line therapy?
A) Hydrochlorothiazide
B) Digoxin
C) ACE inhibitor
D) Amiodarone
Correct Answer: C) ACE inhibitor
Rationale: ACE inhibitors are first-line therapy for systolic heart failure
(HFrEF) as they reduce morbidity and mortality. They decrease afterload and
preload, improve cardiac output, and have been shown to reduce the risk of
hospitalization and death in patients with HFrEF. Digoxin (B) is used for
symptom control but does not reduce mortality. Thiazides (A) are not first-
line for HFrEF. Amiodarone (D) is used for arrhythmias, not as primary
therapy for heart failure.
Question 2: A 55-year-old woman with a history of type 2 diabetes
presents with polyuria and polydipsia. Lab tests show a fasting plasma
glucose of 165 mg/dL and HbA1c of 7.5%. What is the next best step?
A) Start insulin therapy immediately
B) Start metformin therapy
,C) Recommend only lifestyle modification
D) Order an oral glucose tolerance test
Correct Answer: B) Start metformin therapy
Rationale: Metformin is the first-line pharmacologic therapy for type 2
diabetes, along with lifestyle modification. It reduces hepatic glucose
production and improves insulin sensitivity. The patient's HbA1c of 7.5%
indicates that lifestyle modification alone (C) is insufficient. Insulin (A) is not
first-line unless the patient has severe hyperglycemia or is symptomatic. An
OGTT (D) is not needed when the diagnosis is already established.
Question 3: A 62-year-old man presents with exertional chest pain relieved
by rest. ECG shows ST depression in leads V4-V6. What is the next best step
in management?
A) Coronary angiography
B) Start nitrates, beta-blocker, and aspirin
C) Schedule a stress echocardiogram
D) Immediate thrombolysis
Correct Answer: B) Start nitrates, beta-blocker, and aspirin
Rationale: Stable angina is characterized by predictable exertional chest pain
relieved by rest or nitroglycerin. Initial management includes antianginal
therapy (nitrates, beta-blockers), risk factor modification, and aspirin.
Coronary angiography (A) is indicated only if symptoms persist despite
medical therapy or if there is high-risk features on stress testing.
Question 4: A patient with nonischemic cardiomyopathy and LVEF of 35%
on optimal medical therapy for 6 months is being evaluated for primary
, prevention ICD. Recent ECG shows LBBB with QRS duration 150 ms. Which
of the following is the most appropriate next step?
A) Proceed with ICD implantation alone
B) Proceed with CRT-D
C) Continue medical therapy and reassess LVEF in 3 months
D) Perform electrophysiology study to induce ventricular tachycardia
Correct Answer: B) Proceed with CRT-D
Rationale: Current guidelines recommend CRT-D for patients with LVEF
≤35%, LBBB with QRS ≥150 ms, and NYHA class II-III symptoms despite
optimal medical therapy. ICD alone is insufficient because CRT provides
additional mortality benefit. Reassessment is not indicated as the patient is
already on optimal therapy.
Question 5: A 70-year-old man presents with sudden-onset severe left leg
pain. Exam shows a cold, pulseless limb. He has a history of atrial
fibrillation. What is the most likely diagnosis?
A) DVT
B) Acute arterial embolism
C) Peripheral neuropathy
D) Cellulitis
Correct Answer: B) Acute arterial embolism
Rationale: Sudden ischemia in a patient with atrial fibrillation is most
consistent with an acute arterial embolism. The left leg is the most common
site of arterial emboli from the heart. DVT (A) would cause swelling and pain
but not a cold, pulseless limb. Peripheral neuropathy (C) and cellulitis (D) do
not cause acute limb ischemia.
