ABIM INTERNAL MEDICINE BOARDS & ITE EXAM PRACTICE | COMPREHENSIVE
STUDY GUIDE | ADVANCED TESTBANK WITH PRACTICE QUESTIONS & ANSWERS
| LATEST UPDATE 2026/2027
TABLE OF CONTENTS
i. Cardiovascular Medicine
ii. Pulmonary and Critical Care Medicine
iii. Gastroenterology and Hepatology
iv. Nephrology and Electrolyte Disorders
v. Endocrinology and Metabolism
vi. Infectious Diseases
vii. Hematology and Oncology
viii. Rheumatology and Musculoskeletal Medicine
ix. Neurology
x. Geriatrics, Ethics, and General Internal Medicine
INTRODUCTION
This advanced ABIM Internal Medicine Boards and In-Training Examination practice
set emphasizes clinical reasoning, diagnostic interpretation, evidence-based
management, and prioritization of competing risks across the major domains of
internal medicine. The questions are designed for residents and physicians
preparing for high-level professional assessment, with emphasis on challenging
clinical vignettes rather than simple factual recall. Expect scenarios requiring
integration of history, examination findings, laboratory and imaging results,
probability-based diagnosis, treatment selection, adverse-effect recognition, and
appropriate next-step decision making. Topics span cardiovascular, pulmonary,
gastrointestinal, renal, endocrine, infectious, hematologic, oncologic,
rheumatologic, neurologic, and general internal medicine. Questions emphasize
situations in which the best answer depends on recognizing subtle clinical
distinctions or applying established management principles.
Question 1
A 68-year-old man with ischemic cardiomyopathy has a left ventricular ejection
fraction of 30%. He has hypertension, type 2 diabetes, and chronic kidney disease
,with an estimated GFR of 42 mL/min/1.73 m². He takes carvedilol,
sacubitril/valsartan, and furosemide. Despite adherence, he remains NYHA class III
with recurrent volume overload. Potassium is 4.5 mEq/L and creatinine is stable.
Which additional therapy provides a mortality benefit in this patient?
A. Digoxin
B. Spironolactone
C. Diltiazem
D. Hydrochlorothiazide
🔴 Correct Answer: B. Spironolactone.
🔵 Explanation: A mineralocorticoid receptor antagonist such as spironolactone
reduces morbidity and mortality in appropriately selected patients with symptomatic
heart failure with reduced ejection fraction. Renal function and potassium should be
monitored because hyperkalemia and worsening kidney function are important
adverse effects.
Question 2
A 59-year-old woman presents with sudden dyspnea and pleuritic chest pain 5 days
after hip replacement. She is tachycardic and mildly hypoxemic. CT pulmonary
angiography demonstrates a segmental pulmonary embolus. She has no active
bleeding, severe renal impairment, or hemodynamic instability. Which treatment
strategy is most appropriate?
A. Aspirin alone
B. Immediate systemic thrombolysis
C. Therapeutic anticoagulation
D. Inferior vena cava filter placement without anticoagulation
🔴 Correct Answer: C. Therapeutic anticoagulation.
🔵 Explanation: A hemodynamically stable patient with confirmed acute pulmonary
embolism should receive therapeutic anticoagulation unless contraindicated. Systemic
thrombolysis is generally reserved for patients with high-risk PE and hemodynamic
compromise, whereas an IVC filter is primarily considered when anticoagulation is
contraindicated.
Question 3
,A 47-year-old man with cirrhosis from alcohol-associated liver disease presents with
hematemesis and hypotension. After airway assessment and initial resuscitation,
upper endoscopy demonstrates actively bleeding esophageal varices. Which
combination is most appropriate as part of initial management?
A. Proton pump inhibitor and aspirin
B. Octreotide and prophylactic antibiotic therapy with endoscopic variceal
treatment
C. Heparin and urgent colonoscopy
D. Warfarin and balloon tamponade as first-line therapy
🔴 Correct Answer: B. Octreotide and prophylactic antibiotic therapy with
endoscopic variceal treatment.
🔵 Explanation: Acute variceal hemorrhage requires vasoactive therapy such as
octreotide, antibiotic prophylaxis, and urgent endoscopic variceal ligation when
feasible. Antibiotic prophylaxis decreases infectious complications and improves
outcomes in patients with cirrhosis and upper gastrointestinal bleeding.
Question 4
A 72-year-old woman with chronic kidney disease is taking lisinopril and
spironolactone. She develops weakness. Laboratory testing shows potassium of 7.1
mEq/L. ECG demonstrates peaked T waves and QRS widening. Which intervention
should be performed first?
A. Intravenous calcium gluconate
B. Oral sodium polystyrene sulfonate
C. Intravenous furosemide
D. Sodium-restricted diet
🔴 Correct Answer: A. Intravenous calcium gluconate.
🔵 Explanation: Severe hyperkalemia with ECG abnormalities requires immediate
cardiac membrane stabilization with intravenous calcium. Calcium does not lower
serum potassium, so additional therapies to shift and remove potassium are
subsequently required.
Question 5
, A 34-year-old woman has weight loss, tremor, heat intolerance, and palpitations.
TSH is suppressed and free T4 is elevated. Radioactive iodine uptake is diffusely
increased throughout the thyroid gland. Which diagnosis is most likely?
A. Subacute thyroiditis
B. Graves disease
C. Toxic multinodular goiter
D. Exogenous thyroid hormone use
🔴 Correct Answer: B. Graves disease.
🔵 Explanation: Graves disease causes hyperthyroidism with diffuse increased
radioactive iodine uptake because of stimulation of the TSH receptor. Thyroiditis and
exogenous hormone use generally produce low uptake, while toxic multinodular
goiter produces heterogeneous focal uptake.
Question 6
A 63-year-old man with fever, confusion, hypotension, and tachypnea presents to
the emergency department. Lactate is elevated, and examination suggests a urinary
source of infection. Blood cultures are obtained. Which management strategy is
most appropriate?
A. Delay antibiotics until culture results return
B. Administer prompt empiric antimicrobial therapy and initiate appropriate
resuscitation
C. Give corticosteroids before antimicrobial therapy in every patient
D. Restrict intravenous fluids because pulmonary edema is inevitable
🔴 Correct Answer: B. Administer prompt empiric antimicrobial therapy and
initiate appropriate resuscitation.
🔵 Explanation: Suspected septic shock requires rapid recognition, appropriate
cultures when they do not substantially delay therapy, prompt antimicrobial
treatment, source control when indicated, and hemodynamic resuscitation. Treatment
should not be delayed while awaiting microbiologic confirmation.
Question 7
STUDY GUIDE | ADVANCED TESTBANK WITH PRACTICE QUESTIONS & ANSWERS
| LATEST UPDATE 2026/2027
TABLE OF CONTENTS
i. Cardiovascular Medicine
ii. Pulmonary and Critical Care Medicine
iii. Gastroenterology and Hepatology
iv. Nephrology and Electrolyte Disorders
v. Endocrinology and Metabolism
vi. Infectious Diseases
vii. Hematology and Oncology
viii. Rheumatology and Musculoskeletal Medicine
ix. Neurology
x. Geriatrics, Ethics, and General Internal Medicine
INTRODUCTION
This advanced ABIM Internal Medicine Boards and In-Training Examination practice
set emphasizes clinical reasoning, diagnostic interpretation, evidence-based
management, and prioritization of competing risks across the major domains of
internal medicine. The questions are designed for residents and physicians
preparing for high-level professional assessment, with emphasis on challenging
clinical vignettes rather than simple factual recall. Expect scenarios requiring
integration of history, examination findings, laboratory and imaging results,
probability-based diagnosis, treatment selection, adverse-effect recognition, and
appropriate next-step decision making. Topics span cardiovascular, pulmonary,
gastrointestinal, renal, endocrine, infectious, hematologic, oncologic,
rheumatologic, neurologic, and general internal medicine. Questions emphasize
situations in which the best answer depends on recognizing subtle clinical
distinctions or applying established management principles.
Question 1
A 68-year-old man with ischemic cardiomyopathy has a left ventricular ejection
fraction of 30%. He has hypertension, type 2 diabetes, and chronic kidney disease
,with an estimated GFR of 42 mL/min/1.73 m². He takes carvedilol,
sacubitril/valsartan, and furosemide. Despite adherence, he remains NYHA class III
with recurrent volume overload. Potassium is 4.5 mEq/L and creatinine is stable.
Which additional therapy provides a mortality benefit in this patient?
A. Digoxin
B. Spironolactone
C. Diltiazem
D. Hydrochlorothiazide
🔴 Correct Answer: B. Spironolactone.
🔵 Explanation: A mineralocorticoid receptor antagonist such as spironolactone
reduces morbidity and mortality in appropriately selected patients with symptomatic
heart failure with reduced ejection fraction. Renal function and potassium should be
monitored because hyperkalemia and worsening kidney function are important
adverse effects.
Question 2
A 59-year-old woman presents with sudden dyspnea and pleuritic chest pain 5 days
after hip replacement. She is tachycardic and mildly hypoxemic. CT pulmonary
angiography demonstrates a segmental pulmonary embolus. She has no active
bleeding, severe renal impairment, or hemodynamic instability. Which treatment
strategy is most appropriate?
A. Aspirin alone
B. Immediate systemic thrombolysis
C. Therapeutic anticoagulation
D. Inferior vena cava filter placement without anticoagulation
🔴 Correct Answer: C. Therapeutic anticoagulation.
🔵 Explanation: A hemodynamically stable patient with confirmed acute pulmonary
embolism should receive therapeutic anticoagulation unless contraindicated. Systemic
thrombolysis is generally reserved for patients with high-risk PE and hemodynamic
compromise, whereas an IVC filter is primarily considered when anticoagulation is
contraindicated.
Question 3
,A 47-year-old man with cirrhosis from alcohol-associated liver disease presents with
hematemesis and hypotension. After airway assessment and initial resuscitation,
upper endoscopy demonstrates actively bleeding esophageal varices. Which
combination is most appropriate as part of initial management?
A. Proton pump inhibitor and aspirin
B. Octreotide and prophylactic antibiotic therapy with endoscopic variceal
treatment
C. Heparin and urgent colonoscopy
D. Warfarin and balloon tamponade as first-line therapy
🔴 Correct Answer: B. Octreotide and prophylactic antibiotic therapy with
endoscopic variceal treatment.
🔵 Explanation: Acute variceal hemorrhage requires vasoactive therapy such as
octreotide, antibiotic prophylaxis, and urgent endoscopic variceal ligation when
feasible. Antibiotic prophylaxis decreases infectious complications and improves
outcomes in patients with cirrhosis and upper gastrointestinal bleeding.
Question 4
A 72-year-old woman with chronic kidney disease is taking lisinopril and
spironolactone. She develops weakness. Laboratory testing shows potassium of 7.1
mEq/L. ECG demonstrates peaked T waves and QRS widening. Which intervention
should be performed first?
A. Intravenous calcium gluconate
B. Oral sodium polystyrene sulfonate
C. Intravenous furosemide
D. Sodium-restricted diet
🔴 Correct Answer: A. Intravenous calcium gluconate.
🔵 Explanation: Severe hyperkalemia with ECG abnormalities requires immediate
cardiac membrane stabilization with intravenous calcium. Calcium does not lower
serum potassium, so additional therapies to shift and remove potassium are
subsequently required.
Question 5
, A 34-year-old woman has weight loss, tremor, heat intolerance, and palpitations.
TSH is suppressed and free T4 is elevated. Radioactive iodine uptake is diffusely
increased throughout the thyroid gland. Which diagnosis is most likely?
A. Subacute thyroiditis
B. Graves disease
C. Toxic multinodular goiter
D. Exogenous thyroid hormone use
🔴 Correct Answer: B. Graves disease.
🔵 Explanation: Graves disease causes hyperthyroidism with diffuse increased
radioactive iodine uptake because of stimulation of the TSH receptor. Thyroiditis and
exogenous hormone use generally produce low uptake, while toxic multinodular
goiter produces heterogeneous focal uptake.
Question 6
A 63-year-old man with fever, confusion, hypotension, and tachypnea presents to
the emergency department. Lactate is elevated, and examination suggests a urinary
source of infection. Blood cultures are obtained. Which management strategy is
most appropriate?
A. Delay antibiotics until culture results return
B. Administer prompt empiric antimicrobial therapy and initiate appropriate
resuscitation
C. Give corticosteroids before antimicrobial therapy in every patient
D. Restrict intravenous fluids because pulmonary edema is inevitable
🔴 Correct Answer: B. Administer prompt empiric antimicrobial therapy and
initiate appropriate resuscitation.
🔵 Explanation: Suspected septic shock requires rapid recognition, appropriate
cultures when they do not substantially delay therapy, prompt antimicrobial
treatment, source control when indicated, and hemodynamic resuscitation. Treatment
should not be delayed while awaiting microbiologic confirmation.
Question 7
