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 68-year-old man with heart failure with reduced ejection fraction (HFrEF, EF
28%) is on optimal medical therapy including an ARNI and a beta-blocker. His
potassium is 4.8 mEq/L and eGFR is 45 mL/min. Which medication should be
added to reduce mortality?
A. Digoxin
B. Spironolactone
C. Hydralazine/isosorbide dinitrate
D. Furosemide
Rationale: In patients with HFrEF, mineralocorticoid receptor antagonists (MRAs) like
spironolactone reduce mortality. This is part of the four-pillar therapy (ARNI, beta-blocker,
MRA, SGLT2i). Potassium and renal function must be monitored closely .
2. A 72-year-old female with a history of hypertension, diabetes, and a prior
ischemic stroke presents for routine follow-up. Her CHA₂DS₂-VASc score is 6. She
has been on warfarin but reports difficulty with INR monitoring. Which is the most
appropriate anticoagulation strategy?
A. Continue warfarin with more frequent INR checks
,B. Aspirin 81 mg daily
C. Apixaban 5 mg twice daily
D. Apixaban 2.5 mg twice daily
Rationale: This patient has a high CHA₂DS₂-VASc score (≥2 in males, ≥3 in females) and
requires oral anticoagulation. DOACs are preferred over warfarin for stroke prevention in
non-valvular atrial fibrillation. Apixaban 5 mg BID is the standard dose; 2.5 mg is used for
patients with at least two criteria: age ≥80, weight ≤60 kg, or creatinine ≥1.5 mg/dL .
3. A 55-year-old male presents with sudden onset of severe, tearing chest pain
radiating to his back. Blood pressure is 190/110 mmHg in both arms. Which of the
following 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, extent of
dissection, and involvement of branch vessels .
4. A 45-year-old female presents with palpitations and a heart rate of 165 bpm.
ECG shows a regular, narrow-complex tachycardia. She is hemodynamically stable.
Which is the first-line therapy to terminate this rhythm?
A. Vagal maneuvers
B. IV adenosine 6 mg rapid push
C. IV amiodarone 150 mg bolus
D. Synchronized cardioversion
Rationale: For hemodynamically stable patients with regular narrow-complex tachycardia
(likely supraventricular tachycardia, SVT), vagal maneuvers are first-line. If vagal
maneuvers fail, adenosine is the drug of choice. Synchronized cardioversion is indicated for
unstable patients .
,5. A 62-year-old woman with a history of hypertension and hyperlipidemia
presents with a 2-day history of substernal chest pressure that occurs with
exertion and is relieved by rest. She has no ECG changes at rest. Her high-
sensitivity cardiac troponin I is 12 ng/L (normal <26 ng/L). What is the most
appropriate next step?
A. Admit for invasive coronary angiography
B. Perform a stress echocardiogram
C. Start aspirin and clopidogrel and discharge home
D. Perform a treadmill exercise stress test
Rationale: This patient has stable angina with a normal resting ECG and normal troponin.
Noninvasive testing is indicated for risk stratification. Stress echocardiography is preferred
in patients with baseline ECG abnormalities or inability to exercise adequately .
6. A 75-year-old man with hypertension and type 2 diabetes presents for routine
follow-up. BP is 142/86 mmHg. eGFR is 45 mL/min/1.73 m². Urine albumin-to-
creatinine ratio is 300 mg/g. What is the most appropriate blood pressure target?
A. <130/80 mmHg
B. <140/90 mmHg
C. <150/90 mmHg
D. <120/80 mmHg
Rationale: The 2021 KDIGO guideline recommends a BP target of <130/80 mmHg for
patients with CKD, especially those with albuminuria (ACR ≥30 mg/g). This is also
consistent with the ACC/AHA hypertension guideline for adults with hypertension and
CKD .
7. A 58-year-old man presents with acute-onset chest pain that is sharp, pleuritic,
and associated with dyspnea. He recently returned from a long international flight.
Oxygen saturation is 90% on room air. ECG shows sinus tachycardia and S1Q3T3
pattern. What is the most appropriate next diagnostic test?
A. Chest X-ray
B. D-dimer
C. CT pulmonary angiography
D. Ventilation-perfusion (V/Q) scan
, Rationale: This patient has high pretest probability for PE given pleuritic chest pain,
dyspnea, hypoxia, and recent travel. In high-probability patients, CTPA is the gold
standard imaging modality. D-dimer is not recommended in high-probability patients due
to lower specificity .
8. A 70-year-old woman with a history of hypertension and hyperlipidemia
presents with a 2-week history of progressive dyspnea on exertion. On
examination, she has JVD, 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 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 .
9. A 70-year-old man with a history of hypertension and chronic kidney disease
presents with progressive dyspnea and orthopnea. He has JVD, crackles, and
peripheral edema. Which of the following is the most appropriate initial therapy?
A. Increase ACE inhibitor dose
B. Add a loop diuretic
C. Order an echocardiogram
D. Refer for coronary angiography
Rationale: The patient has signs of acute decompensated heart failure with volume
overload. The immediate priority is diuresis with a loop diuretic to relieve congestive
symptoms. While an echocardiogram is important for long-term management, symptom
relief takes priority .
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 68-year-old man with heart failure with reduced ejection fraction (HFrEF, EF
28%) is on optimal medical therapy including an ARNI and a beta-blocker. His
potassium is 4.8 mEq/L and eGFR is 45 mL/min. Which medication should be
added to reduce mortality?
A. Digoxin
B. Spironolactone
C. Hydralazine/isosorbide dinitrate
D. Furosemide
Rationale: In patients with HFrEF, mineralocorticoid receptor antagonists (MRAs) like
spironolactone reduce mortality. This is part of the four-pillar therapy (ARNI, beta-blocker,
MRA, SGLT2i). Potassium and renal function must be monitored closely .
2. A 72-year-old female with a history of hypertension, diabetes, and a prior
ischemic stroke presents for routine follow-up. Her CHA₂DS₂-VASc score is 6. She
has been on warfarin but reports difficulty with INR monitoring. Which is the most
appropriate anticoagulation strategy?
A. Continue warfarin with more frequent INR checks
,B. Aspirin 81 mg daily
C. Apixaban 5 mg twice daily
D. Apixaban 2.5 mg twice daily
Rationale: This patient has a high CHA₂DS₂-VASc score (≥2 in males, ≥3 in females) and
requires oral anticoagulation. DOACs are preferred over warfarin for stroke prevention in
non-valvular atrial fibrillation. Apixaban 5 mg BID is the standard dose; 2.5 mg is used for
patients with at least two criteria: age ≥80, weight ≤60 kg, or creatinine ≥1.5 mg/dL .
3. A 55-year-old male presents with sudden onset of severe, tearing chest pain
radiating to his back. Blood pressure is 190/110 mmHg in both arms. Which of the
following 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, extent of
dissection, and involvement of branch vessels .
4. A 45-year-old female presents with palpitations and a heart rate of 165 bpm.
ECG shows a regular, narrow-complex tachycardia. She is hemodynamically stable.
Which is the first-line therapy to terminate this rhythm?
A. Vagal maneuvers
B. IV adenosine 6 mg rapid push
C. IV amiodarone 150 mg bolus
D. Synchronized cardioversion
Rationale: For hemodynamically stable patients with regular narrow-complex tachycardia
(likely supraventricular tachycardia, SVT), vagal maneuvers are first-line. If vagal
maneuvers fail, adenosine is the drug of choice. Synchronized cardioversion is indicated for
unstable patients .
,5. A 62-year-old woman with a history of hypertension and hyperlipidemia
presents with a 2-day history of substernal chest pressure that occurs with
exertion and is relieved by rest. She has no ECG changes at rest. Her high-
sensitivity cardiac troponin I is 12 ng/L (normal <26 ng/L). What is the most
appropriate next step?
A. Admit for invasive coronary angiography
B. Perform a stress echocardiogram
C. Start aspirin and clopidogrel and discharge home
D. Perform a treadmill exercise stress test
Rationale: This patient has stable angina with a normal resting ECG and normal troponin.
Noninvasive testing is indicated for risk stratification. Stress echocardiography is preferred
in patients with baseline ECG abnormalities or inability to exercise adequately .
6. A 75-year-old man with hypertension and type 2 diabetes presents for routine
follow-up. BP is 142/86 mmHg. eGFR is 45 mL/min/1.73 m². Urine albumin-to-
creatinine ratio is 300 mg/g. What is the most appropriate blood pressure target?
A. <130/80 mmHg
B. <140/90 mmHg
C. <150/90 mmHg
D. <120/80 mmHg
Rationale: The 2021 KDIGO guideline recommends a BP target of <130/80 mmHg for
patients with CKD, especially those with albuminuria (ACR ≥30 mg/g). This is also
consistent with the ACC/AHA hypertension guideline for adults with hypertension and
CKD .
7. A 58-year-old man presents with acute-onset chest pain that is sharp, pleuritic,
and associated with dyspnea. He recently returned from a long international flight.
Oxygen saturation is 90% on room air. ECG shows sinus tachycardia and S1Q3T3
pattern. What is the most appropriate next diagnostic test?
A. Chest X-ray
B. D-dimer
C. CT pulmonary angiography
D. Ventilation-perfusion (V/Q) scan
, Rationale: This patient has high pretest probability for PE given pleuritic chest pain,
dyspnea, hypoxia, and recent travel. In high-probability patients, CTPA is the gold
standard imaging modality. D-dimer is not recommended in high-probability patients due
to lower specificity .
8. A 70-year-old woman with a history of hypertension and hyperlipidemia
presents with a 2-week history of progressive dyspnea on exertion. On
examination, she has JVD, 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 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 .
9. A 70-year-old man with a history of hypertension and chronic kidney disease
presents with progressive dyspnea and orthopnea. He has JVD, crackles, and
peripheral edema. Which of the following is the most appropriate initial therapy?
A. Increase ACE inhibitor dose
B. Add a loop diuretic
C. Order an echocardiogram
D. Refer for coronary angiography
Rationale: The patient has signs of acute decompensated heart failure with volume
overload. The immediate priority is diuresis with a loop diuretic to relieve congestive
symptoms. While an echocardiogram is important for long-term management, symptom
relief takes priority .
