ABIM INTERNAL MEDICINE BOARDS & ITE
EXAM 2026/2027 | HIGH-YIELD PRACTICE
QUESTIONS & VERIFIED ANSWERS WITH
RATIONALES | COMPLETE STUDY GUIDE
ABIM INTERNAL MEDICINE BOARDS & ITE EXAM 2026/2027 | HIGH-YIELD
PRACTICE QUESTIONS & VERIFIED ANSWERS WITH RATIONALES | COMPLETE
STUDY GUIDE
DOCUMENT OVERVIEW
• Comprehensive high-yield practice bank: clinically relevant questions spanning
all major internal medicine subspecialties tested on the ABIM boards, designed to
identify knowledge gaps and build diagnostic reasoning skills through varied clinical
scenarios.
• Evidence-based study approach: Master each question by reviewing the detailed
rationale, then revisit incorrect answers to understand the pathophysiology and
clinical decision-making process—this active recall method strengthens retention
and test-taking confidence.
PRACTICE QUESTIONS
QUESTION 1
A 68-year-old man with a 40-pack-year smoking history presents with
exertional chest pain and dyspnea. Troponin is negative, but an exercise
stress test shows 2-mm ST-segment depression in leads II, III, and aVF. He has
a past medical history of hypertension and diabetes. What is the most
appropriate next step in management?
A) Admit for overnight observation with serial troponins
B) Start aspirin and discharge home with cardiology follow-up
C) Refer for coronary angiography
,D) Obtain echocardiogram and stress test with imaging
E) Start high-dose beta-blocker and repeat stress test
CORRECT ANSWER: C) Refer for coronary angiography
RATIONALE: This patient has an abnormal stress test with significant ST-segment
depression (≥2 mm) in multiple territories, indicating moderate-to-high risk for
coronary artery disease. In the setting of a positive stress test, coronary
angiography is indicated for risk stratification and to establish whether
revascularization is needed. The negative troponin does not rule out significant
CAD, especially with this substantial ischemic burden on the stress test. Options A,
B, and E delay appropriate diagnosis. Echocardiography alone (option D) would not
address the underlying ischemic disease.
QUESTION 2
A 45-year-old woman with bipolar disorder complains of progressive polyuria,
polydipsia, and a 5-lb weight loss over 3 weeks. She takes lithium carbonate
900 mg daily. Lab results: serum glucose 118 mg/dL (fasting), serum sodium
148 mEq/L, serum creatinine 1.4 mg/dL (baseline 0.9), and urine osmolality 210
mOsm/kg despite serum osmolality of 310 mOsm/kg. What is the most likely
diagnosis?
A) Type 2 diabetes mellitus
B) Lithium-induced nephrogenic diabetes insipidus
C) Central diabetes insipidus
D) Hyperglycemia-induced osmotic diuresis
E) Acute kidney injury
CORRECT ANSWER: B) Lithium-induced nephrogenic diabetes insipidus
RATIONALE: Lithium causes nephrogenic diabetes insipidus by interfering with
aquaporin-2 water channel expression in the collecting duct. The clinical
presentation—polyuria, polydipsia, hypernatremia, and dilute urine (osmolality 210)
,despite elevated serum osmolality—is classic for NDI. The normal fasting glucose
excludes type 2 diabetes. Central DI presents similarly but would respond to
desmopressin administration (not mentioned here). The elevated creatinine
suggests chronic lithium nephrotoxicity. Management includes adequate hydration,
NSAIDs or thiazide diuretics, and consideration of lithium discontinuation if
possible.
QUESTION 3
A 52-year-old man with a 20-year history of GERD refractory to proton pump
inhibitor therapy presents with progressive dysphagia to solids and weight
loss of 8 lb over 2 months. Endoscopy reveals a salmon-colored, friable
mucosa with intestinal-type metaplasia confirmed on biopsy. The
gastroenterologist notes the metaplastic segment extends 6 cm proximally
from the gastroesophageal junction. What is the major risk associated with
this diagnosis?
A) Increased risk of esophageal adenocarcinoma
B) Increased risk of gastric ulcer perforation
C) Increased risk of peptic stricture formation
D) Increased risk of acute variceal hemorrhage
E) Increased risk of Boerhaave syndrome
CORRECT ANSWER: A) Increased risk of esophageal adenocarcinoma
RATIONALE: This patient has Barrett esophagus (intestinal metaplasia in the distal
esophagus in the setting of chronic GERD). Barrett esophagus is a premalignant
condition with an annual progression rate to adenocarcinoma of approximately
0.5–1% per year. The presence of intestinal metaplasia and the length of the
segment (>3 cm) are risk factors for progression. While GERD itself can lead to
other complications (options B–E), the critical concern with Barrett esophagus is
malignant transformation. This patient requires endoscopic surveillance and
aggressive acid suppression.
, QUESTION 4
A 34-year-old woman presents with a 6-week history of progressive fatigue,
joint pain, and morning stiffness lasting 90 minutes. She has a rash on her
cheeks and reports photosensitivity. Labs show: hemoglobin 9.2 g/dL, platelet
count 110,000/μL, and strongly positive ANA 1:1280. Which of the following
serologic findings would most strongly support the diagnosis of systemic
lupus erythematosus?
A) Anti-SSA/Ro antibodies alone
B) Anti-histone antibodies
C) Anti-double-stranded DNA and low C3 and C4
D) Rheumatoid factor positivity
E) Anti-centromere antibodies
CORRECT ANSWER: C) Anti-double-stranded DNA and low C3 and C4
RATIONALE: Anti-double-stranded DNA (dsDNA) antibodies are highly specific for
SLE (present in 70% of patients) and indicate active, organ-involving disease,
particularly lupus nephritis. When combined with low complement levels (C3, C4)—
which indicate complement consumption from immune complex formation—this
pattern is virtually pathognomonic for SLE. Anti-SSA/Ro (option A) is associated with
Sjögren syndrome and neonatal lupus. Anti-histone antibodies (option B) suggest
drug-induced lupus. Rheumatoid factor (option D) and anti-centromere antibodies
(option E) are not specific to SLE.
QUESTION 5
A 73-year-old man with chronic obstructive pulmonary disease (COPD) and
pulmonary hypertension presents with acute dyspnea, pleuritic chest pain,
and hemoptysis. He is a former smoker with a 30-pack-year history. Chest X-
ray shows a wedge-shaped opacity in the right lower lobe. D-dimer is elevated
at 2.8 μg/mL. What is the most appropriate next diagnostic test?
EXAM 2026/2027 | HIGH-YIELD PRACTICE
QUESTIONS & VERIFIED ANSWERS WITH
RATIONALES | COMPLETE STUDY GUIDE
ABIM INTERNAL MEDICINE BOARDS & ITE EXAM 2026/2027 | HIGH-YIELD
PRACTICE QUESTIONS & VERIFIED ANSWERS WITH RATIONALES | COMPLETE
STUDY GUIDE
DOCUMENT OVERVIEW
• Comprehensive high-yield practice bank: clinically relevant questions spanning
all major internal medicine subspecialties tested on the ABIM boards, designed to
identify knowledge gaps and build diagnostic reasoning skills through varied clinical
scenarios.
• Evidence-based study approach: Master each question by reviewing the detailed
rationale, then revisit incorrect answers to understand the pathophysiology and
clinical decision-making process—this active recall method strengthens retention
and test-taking confidence.
PRACTICE QUESTIONS
QUESTION 1
A 68-year-old man with a 40-pack-year smoking history presents with
exertional chest pain and dyspnea. Troponin is negative, but an exercise
stress test shows 2-mm ST-segment depression in leads II, III, and aVF. He has
a past medical history of hypertension and diabetes. What is the most
appropriate next step in management?
A) Admit for overnight observation with serial troponins
B) Start aspirin and discharge home with cardiology follow-up
C) Refer for coronary angiography
,D) Obtain echocardiogram and stress test with imaging
E) Start high-dose beta-blocker and repeat stress test
CORRECT ANSWER: C) Refer for coronary angiography
RATIONALE: This patient has an abnormal stress test with significant ST-segment
depression (≥2 mm) in multiple territories, indicating moderate-to-high risk for
coronary artery disease. In the setting of a positive stress test, coronary
angiography is indicated for risk stratification and to establish whether
revascularization is needed. The negative troponin does not rule out significant
CAD, especially with this substantial ischemic burden on the stress test. Options A,
B, and E delay appropriate diagnosis. Echocardiography alone (option D) would not
address the underlying ischemic disease.
QUESTION 2
A 45-year-old woman with bipolar disorder complains of progressive polyuria,
polydipsia, and a 5-lb weight loss over 3 weeks. She takes lithium carbonate
900 mg daily. Lab results: serum glucose 118 mg/dL (fasting), serum sodium
148 mEq/L, serum creatinine 1.4 mg/dL (baseline 0.9), and urine osmolality 210
mOsm/kg despite serum osmolality of 310 mOsm/kg. What is the most likely
diagnosis?
A) Type 2 diabetes mellitus
B) Lithium-induced nephrogenic diabetes insipidus
C) Central diabetes insipidus
D) Hyperglycemia-induced osmotic diuresis
E) Acute kidney injury
CORRECT ANSWER: B) Lithium-induced nephrogenic diabetes insipidus
RATIONALE: Lithium causes nephrogenic diabetes insipidus by interfering with
aquaporin-2 water channel expression in the collecting duct. The clinical
presentation—polyuria, polydipsia, hypernatremia, and dilute urine (osmolality 210)
,despite elevated serum osmolality—is classic for NDI. The normal fasting glucose
excludes type 2 diabetes. Central DI presents similarly but would respond to
desmopressin administration (not mentioned here). The elevated creatinine
suggests chronic lithium nephrotoxicity. Management includes adequate hydration,
NSAIDs or thiazide diuretics, and consideration of lithium discontinuation if
possible.
QUESTION 3
A 52-year-old man with a 20-year history of GERD refractory to proton pump
inhibitor therapy presents with progressive dysphagia to solids and weight
loss of 8 lb over 2 months. Endoscopy reveals a salmon-colored, friable
mucosa with intestinal-type metaplasia confirmed on biopsy. The
gastroenterologist notes the metaplastic segment extends 6 cm proximally
from the gastroesophageal junction. What is the major risk associated with
this diagnosis?
A) Increased risk of esophageal adenocarcinoma
B) Increased risk of gastric ulcer perforation
C) Increased risk of peptic stricture formation
D) Increased risk of acute variceal hemorrhage
E) Increased risk of Boerhaave syndrome
CORRECT ANSWER: A) Increased risk of esophageal adenocarcinoma
RATIONALE: This patient has Barrett esophagus (intestinal metaplasia in the distal
esophagus in the setting of chronic GERD). Barrett esophagus is a premalignant
condition with an annual progression rate to adenocarcinoma of approximately
0.5–1% per year. The presence of intestinal metaplasia and the length of the
segment (>3 cm) are risk factors for progression. While GERD itself can lead to
other complications (options B–E), the critical concern with Barrett esophagus is
malignant transformation. This patient requires endoscopic surveillance and
aggressive acid suppression.
, QUESTION 4
A 34-year-old woman presents with a 6-week history of progressive fatigue,
joint pain, and morning stiffness lasting 90 minutes. She has a rash on her
cheeks and reports photosensitivity. Labs show: hemoglobin 9.2 g/dL, platelet
count 110,000/μL, and strongly positive ANA 1:1280. Which of the following
serologic findings would most strongly support the diagnosis of systemic
lupus erythematosus?
A) Anti-SSA/Ro antibodies alone
B) Anti-histone antibodies
C) Anti-double-stranded DNA and low C3 and C4
D) Rheumatoid factor positivity
E) Anti-centromere antibodies
CORRECT ANSWER: C) Anti-double-stranded DNA and low C3 and C4
RATIONALE: Anti-double-stranded DNA (dsDNA) antibodies are highly specific for
SLE (present in 70% of patients) and indicate active, organ-involving disease,
particularly lupus nephritis. When combined with low complement levels (C3, C4)—
which indicate complement consumption from immune complex formation—this
pattern is virtually pathognomonic for SLE. Anti-SSA/Ro (option A) is associated with
Sjögren syndrome and neonatal lupus. Anti-histone antibodies (option B) suggest
drug-induced lupus. Rheumatoid factor (option D) and anti-centromere antibodies
(option E) are not specific to SLE.
QUESTION 5
A 73-year-old man with chronic obstructive pulmonary disease (COPD) and
pulmonary hypertension presents with acute dyspnea, pleuritic chest pain,
and hemoptysis. He is a former smoker with a 30-pack-year history. Chest X-
ray shows a wedge-shaped opacity in the right lower lobe. D-dimer is elevated
at 2.8 μg/mL. What is the most appropriate next diagnostic test?
