ABIM Internal Medicine Certification Examination | Complete
Practice Questions, Answers & Detailed Rationales
(2026/2027)
Question 1
A 65-year-old man with a history of heart failure with reduced ejection
fraction (HFrEF, EF 30%) is evaluated for persistent dyspnea on exertion.
Current medications include lisinopril, metoprolol succinate, and
furosemide. Blood pressure is 115/75 mm Hg, and heart rate is 68/min.
Physical examination reveals mild jugular venous distension and trace
pedal edema. Laboratory studies show a serum creatinine of 1.1 mg/dL
and potassium of 4.4 mEq/L. Which of the following is the most
appropriate next step in medical therapy?
A. Increase the dose of furosemide.
B. Add sacubitril-valsartan in place of lisinopril.
C. Add digoxin.
D. Add amlodipine.
Correct Answer: B. Add sacubitril-valsartan in place of lisinopril.
Detailed Rationale: Guidelines recommend replacing an ACE inhibitor
(lisinopril) or ARB with an angiotensin receptor-neprilysin inhibitor
(ARNI, sacubitril-valsartan) to further reduce morbidity and mortality in
patients with symptomatic HFrEF.
Question 2
,A 72-year-old woman is evaluated for exertional syncope. On physical
examination, a harsh systolic crescendo-decrescendo murmur is heard
best at the second right intercostal space with radiation to the carotids.
Echocardiography reveals a calculated aortic valve area of 0.8 cm² and a
mean gradient of 45 mm Hg. Which of the following is the most
appropriate management?
A. Medical management with beta-blockers.
B. Annual surveillance echocardiography.
C. Aortic valve replacement.
D. Percutaneous balloon valvuloplasty.
Correct Answer: C. Aortic valve replacement.
Detailed Rationale: This patient has severe, symptomatic aortic stenosis
(exertional syncope). Symptomatic severe aortic stenosis has a poor
prognosis and is an absolute indication for valve replacement (surgical
or transcatheter).
Question 3
A 54-year-old man with type 2 diabetes mellitus has a hemoglobin A1c
of 8.2% despite maximal doses of metformin. His medical history is
significant for atherosclerotic cardiovascular disease (prior myocardial
infarction). He has no history of heart failure or chronic kidney disease.
Which of the following anti-hyperglycemic agents has the best evidence
for reducing cardiovascular events in this patient?
A. Sulfonylurea (e.g., glipizide)
B. Dipeptidyl peptidase-4 (DPP-4) inhibitor (e.g., sitagliptin)
,C. Sodium-glucose cotransporter-2 (SGLT2) inhibitor (e.g., empagliflozin)
D. Basal insulin glargine
Correct Answer: C. Sodium-glucose cotransporter-2 (SGLT2) inhibitor
(e.g., empagliflozin)
Detailed Rationale: In patients with type 2 diabetes and established
ASCVD, SGLT2 inhibitors or GLP-1 receptor agonists with proven
cardiovascular benefit are recommended to reduce major adverse
cardiovascular events.
Question 4
A 45-year-old woman presents with fatigue, cold intolerance, weight
gain, and constipation over the past 4 months. Laboratory evaluation
reveals a thyroid-stimulating hormone (TSH) level of 12.5 mIU/L (normal
0.4–4.0) and a free T4 level of 0.6 ng/dL (normal 0.8–1.8). Which of the
following is the most likely cause of her condition?
A. Graves disease
B. Hashimoto thyroiditis
C. Subacute granulomatous thyroiditis
D. Toxic multinodular goiter
Correct Answer: B. Hashimoto thyroiditis
Detailed Rationale: Hashimoto thyroiditis is the most common cause of
primary hypothyroidism in iodine-sufficient regions, characterized by
elevated TSH, low free T4, and often positive anti-thyroid peroxidase
antibodies.
Question 5
, A 60-year-old man is brought to the emergency department with a 3-
hour history of hematemesis and melena. He has a history of heavy
alcohol use and chronic cirrhosis. His blood pressure is 88/52 mm Hg
and heart rate is 115/min. Resuscitation with crystalloids and blood
products is initiated. Which of the following pharmacological agents
should be administered immediately as part of the initial management
of suspected variceal hemorrhage?
A. Pantoprazole
B. Octreotide
C. Metoclopramide
D. Sucralfate
Correct Answer: B. Octreotide
Detailed Rationale: Octreotide is a somatostatin analog that causes
splanchnic vasoconstriction, reducing portal pressure and acute variceal
bleeding. It should be started immediately along with antibiotic
prophylaxis and endoscopy preparation.
Question 6
A 28-year-old man presents with chronic, nonbloody diarrhea, low-
grade fever, and right lower quadrant abdominal pain for 6 months,
along with a 10-lb weight loss. Colonoscopy reveals skipped lesions,
cobblestoning, and deep ulcerations in the terminal ileum, with
mucosal biopsies demonstrating transmural inflammation and
noncaseating granulomas. Which of the following is the most likely
diagnosis?
A. Ulcerative colitis
Practice Questions, Answers & Detailed Rationales
(2026/2027)
Question 1
A 65-year-old man with a history of heart failure with reduced ejection
fraction (HFrEF, EF 30%) is evaluated for persistent dyspnea on exertion.
Current medications include lisinopril, metoprolol succinate, and
furosemide. Blood pressure is 115/75 mm Hg, and heart rate is 68/min.
Physical examination reveals mild jugular venous distension and trace
pedal edema. Laboratory studies show a serum creatinine of 1.1 mg/dL
and potassium of 4.4 mEq/L. Which of the following is the most
appropriate next step in medical therapy?
A. Increase the dose of furosemide.
B. Add sacubitril-valsartan in place of lisinopril.
C. Add digoxin.
D. Add amlodipine.
Correct Answer: B. Add sacubitril-valsartan in place of lisinopril.
Detailed Rationale: Guidelines recommend replacing an ACE inhibitor
(lisinopril) or ARB with an angiotensin receptor-neprilysin inhibitor
(ARNI, sacubitril-valsartan) to further reduce morbidity and mortality in
patients with symptomatic HFrEF.
Question 2
,A 72-year-old woman is evaluated for exertional syncope. On physical
examination, a harsh systolic crescendo-decrescendo murmur is heard
best at the second right intercostal space with radiation to the carotids.
Echocardiography reveals a calculated aortic valve area of 0.8 cm² and a
mean gradient of 45 mm Hg. Which of the following is the most
appropriate management?
A. Medical management with beta-blockers.
B. Annual surveillance echocardiography.
C. Aortic valve replacement.
D. Percutaneous balloon valvuloplasty.
Correct Answer: C. Aortic valve replacement.
Detailed Rationale: This patient has severe, symptomatic aortic stenosis
(exertional syncope). Symptomatic severe aortic stenosis has a poor
prognosis and is an absolute indication for valve replacement (surgical
or transcatheter).
Question 3
A 54-year-old man with type 2 diabetes mellitus has a hemoglobin A1c
of 8.2% despite maximal doses of metformin. His medical history is
significant for atherosclerotic cardiovascular disease (prior myocardial
infarction). He has no history of heart failure or chronic kidney disease.
Which of the following anti-hyperglycemic agents has the best evidence
for reducing cardiovascular events in this patient?
A. Sulfonylurea (e.g., glipizide)
B. Dipeptidyl peptidase-4 (DPP-4) inhibitor (e.g., sitagliptin)
,C. Sodium-glucose cotransporter-2 (SGLT2) inhibitor (e.g., empagliflozin)
D. Basal insulin glargine
Correct Answer: C. Sodium-glucose cotransporter-2 (SGLT2) inhibitor
(e.g., empagliflozin)
Detailed Rationale: In patients with type 2 diabetes and established
ASCVD, SGLT2 inhibitors or GLP-1 receptor agonists with proven
cardiovascular benefit are recommended to reduce major adverse
cardiovascular events.
Question 4
A 45-year-old woman presents with fatigue, cold intolerance, weight
gain, and constipation over the past 4 months. Laboratory evaluation
reveals a thyroid-stimulating hormone (TSH) level of 12.5 mIU/L (normal
0.4–4.0) and a free T4 level of 0.6 ng/dL (normal 0.8–1.8). Which of the
following is the most likely cause of her condition?
A. Graves disease
B. Hashimoto thyroiditis
C. Subacute granulomatous thyroiditis
D. Toxic multinodular goiter
Correct Answer: B. Hashimoto thyroiditis
Detailed Rationale: Hashimoto thyroiditis is the most common cause of
primary hypothyroidism in iodine-sufficient regions, characterized by
elevated TSH, low free T4, and often positive anti-thyroid peroxidase
antibodies.
Question 5
, A 60-year-old man is brought to the emergency department with a 3-
hour history of hematemesis and melena. He has a history of heavy
alcohol use and chronic cirrhosis. His blood pressure is 88/52 mm Hg
and heart rate is 115/min. Resuscitation with crystalloids and blood
products is initiated. Which of the following pharmacological agents
should be administered immediately as part of the initial management
of suspected variceal hemorrhage?
A. Pantoprazole
B. Octreotide
C. Metoclopramide
D. Sucralfate
Correct Answer: B. Octreotide
Detailed Rationale: Octreotide is a somatostatin analog that causes
splanchnic vasoconstriction, reducing portal pressure and acute variceal
bleeding. It should be started immediately along with antibiotic
prophylaxis and endoscopy preparation.
Question 6
A 28-year-old man presents with chronic, nonbloody diarrhea, low-
grade fever, and right lower quadrant abdominal pain for 6 months,
along with a 10-lb weight loss. Colonoscopy reveals skipped lesions,
cobblestoning, and deep ulcerations in the terminal ileum, with
mucosal biopsies demonstrating transmural inflammation and
noncaseating granulomas. Which of the following is the most likely
diagnosis?
A. Ulcerative colitis
