2026 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 72-year-old woman with a history of hypertension and hyperlipidemia
presents with a 2-week history of progressive dyspnea on exertion. She reports
difficulty lying flat and wakes up at night gasping for air. On examination, she has
jugular venous distention, bibasilar crackles, and an S3 gallop. Which finding is
most specific for the diagnosis of heart failure?
A. Jugular venous distention
B. Bibasilar crackles
C. S3 gallop
D. Lower extremity edema
Rationale: An S3 gallop is a low-frequency sound heard in early diastole and is highly
specific for volume overload and heart failure. It indicates elevated left ventricular filling
pressures. While JVD, crackles, and edema are suggestive, they can also be seen in other
conditions .
2. A 65-year-old man with a history of coronary artery disease and prior
myocardial infarction presents with a 6-month history of progressive dyspnea and
fatigue. Echocardiogram shows LVEF 25%. He is on carvedilol, lisinopril, and
furosemide. Which medication should be added to reduce mortality?
A. Digoxin
B. Spironolactone
,C. Hydralazine
D. Diltiazem
Rationale: Mineralocorticoid receptor antagonists (spironolactone/eplerenone) reduce
mortality in HFrEF when added to ACE inhibitor and beta-blocker therapy. Diltiazem is
contraindicated in HFrEF due to negative inotropic effects .
3. A 62-year-old woman with a history of hypertension and hyperlipidemia
presents with a 2-day history of substernal chest pressure with exertion and
relieved by rest. No ECG changes at rest. hs-cTnI is 12 ng/L (normal <26). What is
the most appropriate next step?
A. Admit for invasive coronary angiography
B. Perform a stress echocardiogram
C. Start aspirin and clopidogrel
D. Discharge with follow-up
Rationale: Stable angina with normal ECG and troponin warrants noninvasive stress
testing for risk stratification. Stress echocardiography is preferred in patients with baseline
ECG abnormalities .
4. A 58-year-old man presents with acute-onset pleuritic chest pain, dyspnea, and
hypoxia after a long flight. ECG shows sinus tachycardia and S1Q3T3 pattern.
What is the most appropriate diagnostic test?
A. Chest X-ray
B. D-dimer
C. CT pulmonary angiography
D. V/Q scan
Rationale: This patient has high pretest probability for PE. In high-probability patients,
CTPA is the gold standard. D-dimer is not recommended in high-probability patients due
to lower specificity .
,5. A 55-year-old female with palpitations and regular narrow-complex tachycardia
at 165 bpm is hemodynamically stable. What is the first-line therapy?
A. Vagal maneuvers
B. IV adenosine
C. IV amiodarone
D. Synchronized cardioversion
Rationale: Vagal maneuvers are first-line for hemodynamically stable SVT. If vagal
maneuvers fail, adenosine is the drug of choice. Synchronized cardioversion is for unstable
patients .
6. A 75-year-old man with hypertension and type 2 diabetes presents for routine
follow-up. BP 142/86, eGFR 45 mL/min/1.73 m², urine ACR 300 mg/g. What is the
most appropriate BP target?
A. <130/80 mmHg
B. <140/90 mmHg
C. <150/90 mmHg
D. <120/80 mmHg
Rationale: KDIGO 2021 recommends <130/80 mmHg for CKD patients with albuminuria
(ACR ≥30 mg/g). This is also consistent with ACC/AHA hypertension guidelines .
7. A 50-year-old man presents with classic features of acute coronary syndrome.
What is the most appropriate management according to ABIM guidelines?
A. No treatment needed
B. Guideline-directed management for ACS
C. Outdated therapy
D. Non-guideline therapy
Rationale: For ACS, ABIM expects guideline-directed management per ACC/AHA
guidelines. This includes immediate aspirin, ECG, and reperfusion therapy as indicated .
, 8. A 68-year-old man with HFrEF on optimal medical therapy has EF 28% and
NYHA Class II symptoms. Which device is indicated for primary prevention of
sudden cardiac death?
A. Pacemaker
B. ICD
C. CRT
D. CRT-D
Rationale: ICD is a Class I indication for primary prevention in patients with ischemic or
non-ischemic cardiomyopathy with EF ≤35% and NYHA Class II-III symptoms on optimal
medical therapy .
9. A 70-year-old woman with a history of hypertension and diabetes presents with
a 1-hour history of right-sided weakness and aphasia. CT head is negative for
hemorrhage. What is the next step within the thrombolytic window?
A. Aspirin
B. IV tPA
C. Anticoagulation
D. Carotid endarterectomy
Rationale: IV tPA is indicated for acute ischemic stroke within 4.5 hours of symptom onset.
Aspirin is given after 24 hours if no hemorrhage. Anticoagulation is not first-line for acute
stroke .
10. A 70-year-old man with hypertension and CKD presents with progressive
dyspnea and orthopnea. He has JVD, crackles, and edema. Which is the most
appropriate initial therapy?
A. Increase ACE inhibitor
B. Add a loop diuretic
C. Order echocardiogram
D. Refer for angiography
Rationale: Acute decompensated heart failure with volume overload requires diuresis with
a loop diuretic. Symptom relief takes priority over diagnostic studies .
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 72-year-old woman with a history of hypertension and hyperlipidemia
presents with a 2-week history of progressive dyspnea on exertion. She reports
difficulty lying flat and wakes up at night gasping for air. On examination, she has
jugular venous distention, bibasilar crackles, and an S3 gallop. Which finding is
most specific for the diagnosis of heart failure?
A. Jugular venous distention
B. Bibasilar crackles
C. S3 gallop
D. Lower extremity edema
Rationale: An S3 gallop is a low-frequency sound heard in early diastole and is highly
specific for volume overload and heart failure. It indicates elevated left ventricular filling
pressures. While JVD, crackles, and edema are suggestive, they can also be seen in other
conditions .
2. A 65-year-old man with a history of coronary artery disease and prior
myocardial infarction presents with a 6-month history of progressive dyspnea and
fatigue. Echocardiogram shows LVEF 25%. He is on carvedilol, lisinopril, and
furosemide. Which medication should be added to reduce mortality?
A. Digoxin
B. Spironolactone
,C. Hydralazine
D. Diltiazem
Rationale: Mineralocorticoid receptor antagonists (spironolactone/eplerenone) reduce
mortality in HFrEF when added to ACE inhibitor and beta-blocker therapy. Diltiazem is
contraindicated in HFrEF due to negative inotropic effects .
3. A 62-year-old woman with a history of hypertension and hyperlipidemia
presents with a 2-day history of substernal chest pressure with exertion and
relieved by rest. No ECG changes at rest. hs-cTnI is 12 ng/L (normal <26). What is
the most appropriate next step?
A. Admit for invasive coronary angiography
B. Perform a stress echocardiogram
C. Start aspirin and clopidogrel
D. Discharge with follow-up
Rationale: Stable angina with normal ECG and troponin warrants noninvasive stress
testing for risk stratification. Stress echocardiography is preferred in patients with baseline
ECG abnormalities .
4. A 58-year-old man presents with acute-onset pleuritic chest pain, dyspnea, and
hypoxia after a long flight. ECG shows sinus tachycardia and S1Q3T3 pattern.
What is the most appropriate diagnostic test?
A. Chest X-ray
B. D-dimer
C. CT pulmonary angiography
D. V/Q scan
Rationale: This patient has high pretest probability for PE. In high-probability patients,
CTPA is the gold standard. D-dimer is not recommended in high-probability patients due
to lower specificity .
,5. A 55-year-old female with palpitations and regular narrow-complex tachycardia
at 165 bpm is hemodynamically stable. What is the first-line therapy?
A. Vagal maneuvers
B. IV adenosine
C. IV amiodarone
D. Synchronized cardioversion
Rationale: Vagal maneuvers are first-line for hemodynamically stable SVT. If vagal
maneuvers fail, adenosine is the drug of choice. Synchronized cardioversion is for unstable
patients .
6. A 75-year-old man with hypertension and type 2 diabetes presents for routine
follow-up. BP 142/86, eGFR 45 mL/min/1.73 m², urine ACR 300 mg/g. What is the
most appropriate BP target?
A. <130/80 mmHg
B. <140/90 mmHg
C. <150/90 mmHg
D. <120/80 mmHg
Rationale: KDIGO 2021 recommends <130/80 mmHg for CKD patients with albuminuria
(ACR ≥30 mg/g). This is also consistent with ACC/AHA hypertension guidelines .
7. A 50-year-old man presents with classic features of acute coronary syndrome.
What is the most appropriate management according to ABIM guidelines?
A. No treatment needed
B. Guideline-directed management for ACS
C. Outdated therapy
D. Non-guideline therapy
Rationale: For ACS, ABIM expects guideline-directed management per ACC/AHA
guidelines. This includes immediate aspirin, ECG, and reperfusion therapy as indicated .
, 8. A 68-year-old man with HFrEF on optimal medical therapy has EF 28% and
NYHA Class II symptoms. Which device is indicated for primary prevention of
sudden cardiac death?
A. Pacemaker
B. ICD
C. CRT
D. CRT-D
Rationale: ICD is a Class I indication for primary prevention in patients with ischemic or
non-ischemic cardiomyopathy with EF ≤35% and NYHA Class II-III symptoms on optimal
medical therapy .
9. A 70-year-old woman with a history of hypertension and diabetes presents with
a 1-hour history of right-sided weakness and aphasia. CT head is negative for
hemorrhage. What is the next step within the thrombolytic window?
A. Aspirin
B. IV tPA
C. Anticoagulation
D. Carotid endarterectomy
Rationale: IV tPA is indicated for acute ischemic stroke within 4.5 hours of symptom onset.
Aspirin is given after 24 hours if no hemorrhage. Anticoagulation is not first-line for acute
stroke .
10. A 70-year-old man with hypertension and CKD presents with progressive
dyspnea and orthopnea. He has JVD, crackles, and edema. Which is the most
appropriate initial therapy?
A. Increase ACE inhibitor
B. Add a loop diuretic
C. Order echocardiogram
D. Refer for angiography
Rationale: Acute decompensated heart failure with volume overload requires diuresis with
a loop diuretic. Symptom relief takes priority over diagnostic studies .
