2026-2027 ABIM Internal Medicine In-Training Examination (ITE)
– Practice Questions with Verified Answers & Clinical Rationales |
High-Yield Board Review Study Guide
Exceed your target percentile rank on your residency milestone assessment with this
definitive ABIM Internal Medicine In-Training Examination (ITE) practice test bank. This
comprehensive preparation guide features high-yield clinical vignette questions paired
with 100% verified answers and rigorous, evidence-based rationales tracking the latest
ABIM blueprint domains, including cardiology, gastroenterology, nephrology, oncology,
and infectious diseases. It is an indispensable study tool for internal medicine residents
and fellows looking to optimize their study routines, identify knowledge gaps, and
confidently prepare for the final board certification.
1. A 62-year-old man with a history of hypertension, type 2 diabetes (HbA1c
7.8%), and hyperlipidemia presents with progressive dyspnea on exertion,
orthopnea, and weight gain. His medications include lisinopril, metformin,
atorvastatin, and furosemide. On examination, JVP is 12 cm H₂O, S3 gallop is
audible, and there is 2+ pitting edema. Echocardiogram shows LVEF 28%.
Creatinine is 1.4 mg/dL, potassium 4.8 mEq/L, BNP 1,200 pg/mL. Which represents
the most appropriate comprehensive pharmacotherapeutic escalation?
A. Increase furosemide to 80 mg daily, add spironolactone 25 mg daily, and initiate
dapagliflozin 10 mg daily
B. Transition lisinopril to sacubitril/valsartan, increase furosemide to 80 mg daily,
and add dapagliflozin 10 mg daily with close renal function monitoring
C. Add hydralazine 75 mg three times daily and isosorbide dinitrate 40 mg three times
daily
D. Increase lisinopril to 40 mg daily, add carvedilol 12.5 mg twice daily, and schedule for
ICD evaluation
Rationale: This patient has worsening HFrEF despite GDMT. Sacubitril/valsartan (ARNI)
has demonstrated superior mortality benefit over ACE inhibitors in PARADIGM-HF and
should replace lisinopril. Dapagliflozin (SGLT2i) has Class I evidence for HFrEF regardless
of diabetes status. Loop diuretic intensification is needed for volume management.
Spironolactone is appropriate but requires careful monitoring given creatinine of 1.4
,mg/dL. Hydralazine/nitrates are indicated in African American patients or those intolerant
to ACEi/ARB/ARNI .
2. A 48-year-old woman with no significant past medical history presents to the
emergency department with acute onset of severe, ripping chest pain that radiates
to her back and interscapular region. Blood pressure is 190/110 mmHg in the right
arm and 110/70 mmHg in the left arm. HR 102 bpm. What is the most appropriate
initial imaging study?
A. Echocardiogram
B. CT angiography of the chest
C. Chest X-ray
D. Transesophageal echocardiogram
Rationale: Acute aortic dissection is a life-threatening emergency. CT angiography is the
imaging modality of choice for diagnosis. It can identify the intimal flap and extent of
dissection. The blood pressure differential between arms is a classic finding of aortic
dissection. Type A dissections involving the ascending aorta require emergent surgical
repair .
3. A patient with acute decompensated heart failure presents with severe dyspnea,
cool extremities, and a blood pressure of 85/50 mm Hg. Which hemodynamic
profile is most consistent with these findings?
A. Warm and wet
B. Cold and wet
C. Cold and dry
D. Warm and dry
Rationale: The "cold and wet" profile indicates low cardiac output (cold extremities) and
congestion (wet). This patient requires inotropic support and vasodilators if tolerated, but
hypotension limits vasodilator use. The Forrester classification helps guide hemodynamic
management in acute heart failure .
,4. A 70-year-old woman with a history of hypertension presents with a 3-hour
history of severe, tearing chest pain. Blood pressure is 200/110 mmHg in both
arms. CT angiography reveals a type A aortic dissection. What is the most
appropriate immediate management?
A. Medical management with beta-blockers
B. Surgical repair
C. Endovascular stent grafting
D. Thrombolytic therapy
Rationale: Type A aortic dissection (involving the ascending aorta) is a surgical emergency
requiring emergent operative repair. Medical management with beta-blockers is the initial
step but does not replace surgical intervention. Type B dissections may be managed
medically or with endovascular stenting .
5. A patient presents with acute-onset chest pain, dyspnea, and hypotension. ECG
shows low voltage and electrical alternans. What is the most likely diagnosis?
A. Acute myocardial infarction
B. Pulmonary embolism
C. Cardiac tamponade
D. Aortic dissection
Rationale: The triad of hypotension, low voltage, and electrical alternans is classic for
cardiac tamponade. Echocardiography confirms pericardial effusion with right atrial and
right ventricular collapse. Immediate pericardiocentesis may be necessary for
hemodynamically unstable patients .
6. A patient with severe aortic stenosis (valve area 0.8 cm², mean gradient 50 mm
Hg) is asymptomatic. Which finding would be an indication for aortic valve
replacement?
A. Left ventricular ejection fraction 55%
B. Abnormal exercise test with symptoms
C. Moderate mitral regurgitation
D. Left atrial enlargement
, Rationale: In severe aortic stenosis, even if asymptomatic, an abnormal exercise test
(development of symptoms, fall in blood pressure) is a Class I indication for valve
replacement. Other indications include LVEF <50% or severe symptoms .
7. A patient with hypertrophic cardiomyopathy (HCM) has a left ventricular
outflow tract gradient of 80 mm Hg at rest and symptoms of dyspnea and
syncope. Which medication is most likely to exacerbate the gradient?
A. Metoprolol
B. Verapamil
C. Disopyramide
D. Nitroglycerin
Rationale: Nitroglycerin reduces preload and afterload, increasing outflow tract
obstruction in HCM. Beta-blockers and verapamil reduce gradient. Disopyramide is a
negative inotrope used to reduce obstruction .
8. A 68-year-old man with HFrEF on optimal medical therapy including
sacubitril/valsartan, beta-blocker, and spironolactone continues to have NYHA
Class III symptoms. LVEF is 30%. There is no significant coronary disease. Which
intervention has been shown to reduce mortality in this population?
A. Implantable cardioverter-defibrillator (ICD) alone
B. Cardiac resynchronization therapy with defibrillator (CRT-D)
C. Left ventricular assist device (LVAD) as destination therapy
D. Heart transplantation listing
Rationale: In patients with HFrEF, wide QRS (≥150 ms) and LBBB, CRT-D reduces mortality
and hospitalizations. ICD alone does not improve symptoms. LVAD and transplantation
are reserved for advanced disease with refractory symptoms .
9. A patient with an implantable cardioverter-defibrillator (ICD) receives a shock
while awake and asymptomatic. Device interrogation reveals ventricular
fibrillation that was successfully terminated. What is the most appropriate next
– Practice Questions with Verified Answers & Clinical Rationales |
High-Yield Board Review Study Guide
Exceed your target percentile rank on your residency milestone assessment with this
definitive ABIM Internal Medicine In-Training Examination (ITE) practice test bank. This
comprehensive preparation guide features high-yield clinical vignette questions paired
with 100% verified answers and rigorous, evidence-based rationales tracking the latest
ABIM blueprint domains, including cardiology, gastroenterology, nephrology, oncology,
and infectious diseases. It is an indispensable study tool for internal medicine residents
and fellows looking to optimize their study routines, identify knowledge gaps, and
confidently prepare for the final board certification.
1. A 62-year-old man with a history of hypertension, type 2 diabetes (HbA1c
7.8%), and hyperlipidemia presents with progressive dyspnea on exertion,
orthopnea, and weight gain. His medications include lisinopril, metformin,
atorvastatin, and furosemide. On examination, JVP is 12 cm H₂O, S3 gallop is
audible, and there is 2+ pitting edema. Echocardiogram shows LVEF 28%.
Creatinine is 1.4 mg/dL, potassium 4.8 mEq/L, BNP 1,200 pg/mL. Which represents
the most appropriate comprehensive pharmacotherapeutic escalation?
A. Increase furosemide to 80 mg daily, add spironolactone 25 mg daily, and initiate
dapagliflozin 10 mg daily
B. Transition lisinopril to sacubitril/valsartan, increase furosemide to 80 mg daily,
and add dapagliflozin 10 mg daily with close renal function monitoring
C. Add hydralazine 75 mg three times daily and isosorbide dinitrate 40 mg three times
daily
D. Increase lisinopril to 40 mg daily, add carvedilol 12.5 mg twice daily, and schedule for
ICD evaluation
Rationale: This patient has worsening HFrEF despite GDMT. Sacubitril/valsartan (ARNI)
has demonstrated superior mortality benefit over ACE inhibitors in PARADIGM-HF and
should replace lisinopril. Dapagliflozin (SGLT2i) has Class I evidence for HFrEF regardless
of diabetes status. Loop diuretic intensification is needed for volume management.
Spironolactone is appropriate but requires careful monitoring given creatinine of 1.4
,mg/dL. Hydralazine/nitrates are indicated in African American patients or those intolerant
to ACEi/ARB/ARNI .
2. A 48-year-old woman with no significant past medical history presents to the
emergency department with acute onset of severe, ripping chest pain that radiates
to her back and interscapular region. Blood pressure is 190/110 mmHg in the right
arm and 110/70 mmHg in the left arm. HR 102 bpm. What is the most appropriate
initial imaging study?
A. Echocardiogram
B. CT angiography of the chest
C. Chest X-ray
D. Transesophageal echocardiogram
Rationale: Acute aortic dissection is a life-threatening emergency. CT angiography is the
imaging modality of choice for diagnosis. It can identify the intimal flap and extent of
dissection. The blood pressure differential between arms is a classic finding of aortic
dissection. Type A dissections involving the ascending aorta require emergent surgical
repair .
3. A patient with acute decompensated heart failure presents with severe dyspnea,
cool extremities, and a blood pressure of 85/50 mm Hg. Which hemodynamic
profile is most consistent with these findings?
A. Warm and wet
B. Cold and wet
C. Cold and dry
D. Warm and dry
Rationale: The "cold and wet" profile indicates low cardiac output (cold extremities) and
congestion (wet). This patient requires inotropic support and vasodilators if tolerated, but
hypotension limits vasodilator use. The Forrester classification helps guide hemodynamic
management in acute heart failure .
,4. A 70-year-old woman with a history of hypertension presents with a 3-hour
history of severe, tearing chest pain. Blood pressure is 200/110 mmHg in both
arms. CT angiography reveals a type A aortic dissection. What is the most
appropriate immediate management?
A. Medical management with beta-blockers
B. Surgical repair
C. Endovascular stent grafting
D. Thrombolytic therapy
Rationale: Type A aortic dissection (involving the ascending aorta) is a surgical emergency
requiring emergent operative repair. Medical management with beta-blockers is the initial
step but does not replace surgical intervention. Type B dissections may be managed
medically or with endovascular stenting .
5. A patient presents with acute-onset chest pain, dyspnea, and hypotension. ECG
shows low voltage and electrical alternans. What is the most likely diagnosis?
A. Acute myocardial infarction
B. Pulmonary embolism
C. Cardiac tamponade
D. Aortic dissection
Rationale: The triad of hypotension, low voltage, and electrical alternans is classic for
cardiac tamponade. Echocardiography confirms pericardial effusion with right atrial and
right ventricular collapse. Immediate pericardiocentesis may be necessary for
hemodynamically unstable patients .
6. A patient with severe aortic stenosis (valve area 0.8 cm², mean gradient 50 mm
Hg) is asymptomatic. Which finding would be an indication for aortic valve
replacement?
A. Left ventricular ejection fraction 55%
B. Abnormal exercise test with symptoms
C. Moderate mitral regurgitation
D. Left atrial enlargement
, Rationale: In severe aortic stenosis, even if asymptomatic, an abnormal exercise test
(development of symptoms, fall in blood pressure) is a Class I indication for valve
replacement. Other indications include LVEF <50% or severe symptoms .
7. A patient with hypertrophic cardiomyopathy (HCM) has a left ventricular
outflow tract gradient of 80 mm Hg at rest and symptoms of dyspnea and
syncope. Which medication is most likely to exacerbate the gradient?
A. Metoprolol
B. Verapamil
C. Disopyramide
D. Nitroglycerin
Rationale: Nitroglycerin reduces preload and afterload, increasing outflow tract
obstruction in HCM. Beta-blockers and verapamil reduce gradient. Disopyramide is a
negative inotrope used to reduce obstruction .
8. A 68-year-old man with HFrEF on optimal medical therapy including
sacubitril/valsartan, beta-blocker, and spironolactone continues to have NYHA
Class III symptoms. LVEF is 30%. There is no significant coronary disease. Which
intervention has been shown to reduce mortality in this population?
A. Implantable cardioverter-defibrillator (ICD) alone
B. Cardiac resynchronization therapy with defibrillator (CRT-D)
C. Left ventricular assist device (LVAD) as destination therapy
D. Heart transplantation listing
Rationale: In patients with HFrEF, wide QRS (≥150 ms) and LBBB, CRT-D reduces mortality
and hospitalizations. ICD alone does not improve symptoms. LVAD and transplantation
are reserved for advanced disease with refractory symptoms .
9. A patient with an implantable cardioverter-defibrillator (ICD) receives a shock
while awake and asymptomatic. Device interrogation reveals ventricular
fibrillation that was successfully terminated. What is the most appropriate next
