BIM Internal Medicine ITE Exam Actual Exam
2026/2027 | Complete Test Bank with Verified
Questions & Explanations | Updated In-Training
Exam Prep | A+ Graded
1. A 62-year-old man with a history of hypertension and type 2 diabetes presents with acute
dyspnea and orthopnea. On examination, jugular venous pressure is elevated, bibasilar crackles
are present, and an S3 gallop is heard. Blood pressure is 110/70 mm Hg, heart rate 105 bpm.
Echocardiogram shows left ventricular ejection fraction of 35% with global hypokinesis. Recent
coronary angiography revealed nonobstructive coronary artery disease. Which of the following
pharmacologic interventions has been shown to reduce mortality in this patient population?
A. Sacubitril/valsartan
B. Ivabradine
C. Digoxin
D. Metoprolol tartrate
Answer: A
Rationale: PARADIGM-HF demonstrated that sacubitril/valsartan reduces cardiovascular death and
heart failure hospitalization compared to enalapril in patients with HFrEF. Ivabradine is approved only
for stable HFrEF patients in sinus rhythm with resting HR 70 bpm on maximally tolerated beta-blocker;
digoxin reduces hospitalizations but not mortality; metoprolol succinate (not tartrate) is evidence-based
for mortality reduction.
2. A 45-year-old woman with no significant medical history presents with acute onset of pleuritic
chest pain and dyspnea. CT pulmonary angiography confirms a pulmonary embolism involving
the right main pulmonary artery. She is hemodynamically stable with normal blood pressure.
Which of the following is the most appropriate next step in management?
A. Initiate unfractionated heparin with a bolus and continuous infusion
B. Administer systemic thrombolysis
C. Start rivaroxaban 15 mg twice daily for 21 days, then 20 mg daily
D. Place an inferior vena cava filter
Answer: C
Rationale: Current guidelines recommend direct oral anticoagulants (DOACs) such as rivaroxaban or
apixaban as first-line therapy for acute PE in hemodynamically stable patients. Rivaroxaban is given 15
mg BID for 21 days then 20 mg daily. Unfractionated heparin is an alternative but not preferred;
thrombolysis is reserved for patients with hemodynamic instability; IVC filters are indicated only if
anticoagulation is contraindicated.
Page 1
,3. A 58-year-old man with chronic obstructive pulmonary disease (COPD) presents with worsening
dyspnea and cough productive of green sputum for 3 days. He has a 40-pack-year smoking history.
Temperature is 38.5°C, heart rate 100 bpm, respiratory rate 24/min, oxygen saturation 88% on
room air. Chest X-ray shows hyperinflation but no consolidation. Which of the following sets of
laboratory findings is most consistent with acute respiratory acidosis?
A. pH 7.25, PaCO2 60 mm Hg, PaO2 55 mm Hg, HCO3- 24 mEq/L
B. pH 7.35, PaCO2 50 mm Hg, PaO2 60 mm Hg, HCO3- 28 mEq/L
C. pH 7.45, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3- 22 mEq/L
D. pH 7.50, PaCO2 25 mm Hg, PaO2 90 mm Hg, HCO3- 20 mEq/L
Answer: A
Rationale: Acute respiratory acidosis is characterized by a low pH, elevated PaCO2, and normal HCO3-
(no renal compensation). Option A shows pH 7.25, PaCO2 60, HCO3- 24, indicating acute hypercapnia.
Option B shows partially compensated respiratory acidosis (elevated HCO3-). Option C is respiratory
alkalosis, and option D is acute respiratory alkalosis.
4. A 34-year-old woman presents with fatigue, arthralgias, and a malar rash. Laboratory studies
show positive antinuclear antibody (ANA) at 1:640, anti-double-stranded DNA antibody elevated,
and low complement C3 and C4. Urinalysis reveals proteinuria (2+) and red blood cell casts. Renal
biopsy shows class IV lupus nephritis. Which of the following is the most appropriate initial
induction therapy?
A. Hydroxychloroquine alone
B. Mycophenolate mofetil plus high-dose corticosteroids
C. Azathioprine plus low-dose corticosteroids
D. Cyclophosphamide pulse therapy alone
Answer: B
Rationale: For class III/IV lupus nephritis, current guidelines recommend mycophenolate mofetil (MMF)
or cyclophosphamide combined with corticosteroids as first-line induction. MMF is preferred due to
similar efficacy and better safety profile. Hydroxychloroquine is adjunctive but insufficient alone.
Azathioprine is used for maintenance, not induction. Cyclophosphamide alone without steroids is not
standard.
5. A 72-year-old man with a history of chronic kidney disease stage 3 (eGFR 45 mL/min) presents
with confusion and muscle cramps. Serum sodium is 125 mEq/L, potassium 5.8 mEq/L, chloride 95
mEq/L, bicarbonate 18 mEq/L, BUN 80 mg/dL, creatinine 3.0 mg/dL, glucose 120 mg/dL. Serum
osmolality is 265 mOsm/kg. Urine osmolality is 350 mOsm/kg, urine sodium 40 mEq/L. Which of
the following is the most likely cause of his hyponatremia?
A. Primary polydipsia
B. Syndrome of inappropriate antidiuretic hormone (SIADH)
C. Hypovolemic hyponatremia
D. Hypervolemic hyponatremia due to renal failure
Answer: B
Rationale: The patient has euvolemic hyponatremia with low serum osmolality, urine osmolality >100
(inappropriately concentrated), and urine sodium >30, consistent with SIADH. Primary polydipsia
would have maximally dilute urine (urine osmolality <100). Hypovolemic hyponatremia typically has
Page 2
,urine sodium <10 (unless on diuretics). Hypervolemic states (CHF, cirrhosis) usually have edema; renal
failure alone does not typically cause such severe hyponatremia.
6. A 55-year-old man with a history of alcoholic cirrhosis presents with hematemesis and melena.
He is hypotensive and tachycardic. After resuscitation with packed red blood cells, an emergent
upper endoscopy shows actively bleeding esophageal varices. Which of the following is the most
appropriate immediate pharmacologic therapy to reduce portal pressure and control bleeding?
A. Octreotide
B. Propranolol
C. Terlipressin
D. Vasopressin
Answer: A
Rationale: Octreotide is a somatostatin analog that reduces splanchnic blood flow and portal pressure; it
is the preferred vasoactive agent for acute variceal bleeding in many centers due to better safety profile.
Terlipressin is also effective but not available in all countries. Propranolol is used for primary
prophylaxis, not acute bleeding. Vasopressin is less used due to systemic side effects.
7. A 65-year-old woman with diabetes and hypertension presents with acute onset of severe
abdominal pain and vomiting. Serum lipase is 1200 U/L. CT abdomen shows peripancreatic fat
stranding and a 3 cm pseudocyst. She is started on aggressive intravenous fluids. On hospital day
3, she develops increasing abdominal pain, distension, and fever. Repeat CT shows a new
gas-containing collection in the retroperitoneum. Which of the following is the most appropriate
next step in management?
A. Continue conservative management with antibiotics
B. Percutaneous catheter drainage
C. Surgical necrosectomy
D. Endoscopic cystogastrostomy
Answer: C
Rationale: The presence of gas in a pancreatic fluid collection indicates infected necrotizing pancreatitis.
Current guidelines recommend surgical necrosectomy or step-up approach (percutaneous drainage
followed by minimally invasive necrosectomy) for infected necrosis. However, given the patient's clinical
deterioration and gas on CT, surgical intervention is often required. Percutaneous drainage may be
considered but is less definitive for solid necrosis. Endoscopic cystogastrostomy is for pseudocysts
without necrosis.
8. A 28-year-old woman presents with palpitations, weight loss, and heat intolerance. Thyroid
function tests show TSH <0.01 mIU/L, free T4 3.5 ng/dL, free T3 8.0 pg/mL. Thyroid scan shows
diffusely increased uptake. She has no ophthalmopathy. Which of the following is the most
appropriate first-line treatment?
A. Radioactive iodine ablation
B. Methimazole
C. Propylthiouracil
D. Subtotal thyroidectomy
Page 3
, Answer: B
Rationale: Methimazole is the preferred first-line antithyroid drug for Graves' disease in non-pregnant
patients due to better efficacy and safety compared to propylthiouracil (which carries risk of
hepatotoxicity). Radioactive iodine and surgery are second-line options. Propylthiouracil is reserved for
first trimester pregnancy or thyroid storm.
9. A 60-year-old man with a history of hypertension presents with sudden onset of severe headache,
nausea, and visual disturbances. Blood pressure is 220/130 mm Hg. Funduscopic examination
reveals papilledema, hemorrhages, and exudates. Serum creatinine is 2.0 mg/dL. Which of the
following is the most appropriate initial antihypertensive agent to reduce blood pressure in this
patient?
A. Intravenous nitroprusside
B. Intravenous labetalol
C. Intravenous nicardipine
D. Intravenous hydralazine
Answer: B
Rationale: In hypertensive emergency with papilledema (malignant hypertension), current guidelines
recommend intravenous labetalol, nicardipine, or clevidipine as first-line agents. Labetalol is often
preferred due to its rapid onset and lack of reflex tachycardia. Nitroprusside is effective but carries risk
of cyanide toxicity with prolonged use or renal impairment. Hydralazine is less predictable and may
cause reflex tachycardia.
10. A 50-year-old woman with a history of recurrent urinary tract infections presents with acute
onset of fever, flank pain, and nausea. Urinalysis shows pyuria and bacteriuria. Urine culture
grows Escherichia coli resistant to ampicillin and ciprofloxacin but sensitive to ceftriaxone and
nitrofurantoin. She has no known drug allergies. Which of the following is the most appropriate
empiric antibiotic for this patient?
A. Ciprofloxacin
B. Ceftriaxone
C. Nitrofurantoin
D. Amoxicillin-clavulanate
Answer: B
Rationale: This patient has acute pyelonephritis, requiring antibiotics with high renal parenchymal
penetration. Ceftriaxone is appropriate given sensitivity and once-daily dosing. Ciprofloxacin is
resistant, so not appropriate. Nitrofurantoin is not effective for pyelonephritis due to poor tissue levels.
Amoxicillin-clavulanate is not recommended as empiric therapy due to high resistance rates.
11. A 45-year-old man with a history of hypertension and chronic kidney disease stage 3 presents
with acute-onset dyspnea and orthopnea. On examination, he has bibasilar crackles, elevated
jugular venous pressure, and an S3 gallop. Chest radiograph shows pulmonary edema. Which of
the following is the most appropriate initial pharmacologic therapy for this patient?
A. Intravenous furosemide 40 mg bolus
B. Intravenous metoprolol 5 mg
Page 4
2026/2027 | Complete Test Bank with Verified
Questions & Explanations | Updated In-Training
Exam Prep | A+ Graded
1. A 62-year-old man with a history of hypertension and type 2 diabetes presents with acute
dyspnea and orthopnea. On examination, jugular venous pressure is elevated, bibasilar crackles
are present, and an S3 gallop is heard. Blood pressure is 110/70 mm Hg, heart rate 105 bpm.
Echocardiogram shows left ventricular ejection fraction of 35% with global hypokinesis. Recent
coronary angiography revealed nonobstructive coronary artery disease. Which of the following
pharmacologic interventions has been shown to reduce mortality in this patient population?
A. Sacubitril/valsartan
B. Ivabradine
C. Digoxin
D. Metoprolol tartrate
Answer: A
Rationale: PARADIGM-HF demonstrated that sacubitril/valsartan reduces cardiovascular death and
heart failure hospitalization compared to enalapril in patients with HFrEF. Ivabradine is approved only
for stable HFrEF patients in sinus rhythm with resting HR 70 bpm on maximally tolerated beta-blocker;
digoxin reduces hospitalizations but not mortality; metoprolol succinate (not tartrate) is evidence-based
for mortality reduction.
2. A 45-year-old woman with no significant medical history presents with acute onset of pleuritic
chest pain and dyspnea. CT pulmonary angiography confirms a pulmonary embolism involving
the right main pulmonary artery. She is hemodynamically stable with normal blood pressure.
Which of the following is the most appropriate next step in management?
A. Initiate unfractionated heparin with a bolus and continuous infusion
B. Administer systemic thrombolysis
C. Start rivaroxaban 15 mg twice daily for 21 days, then 20 mg daily
D. Place an inferior vena cava filter
Answer: C
Rationale: Current guidelines recommend direct oral anticoagulants (DOACs) such as rivaroxaban or
apixaban as first-line therapy for acute PE in hemodynamically stable patients. Rivaroxaban is given 15
mg BID for 21 days then 20 mg daily. Unfractionated heparin is an alternative but not preferred;
thrombolysis is reserved for patients with hemodynamic instability; IVC filters are indicated only if
anticoagulation is contraindicated.
Page 1
,3. A 58-year-old man with chronic obstructive pulmonary disease (COPD) presents with worsening
dyspnea and cough productive of green sputum for 3 days. He has a 40-pack-year smoking history.
Temperature is 38.5°C, heart rate 100 bpm, respiratory rate 24/min, oxygen saturation 88% on
room air. Chest X-ray shows hyperinflation but no consolidation. Which of the following sets of
laboratory findings is most consistent with acute respiratory acidosis?
A. pH 7.25, PaCO2 60 mm Hg, PaO2 55 mm Hg, HCO3- 24 mEq/L
B. pH 7.35, PaCO2 50 mm Hg, PaO2 60 mm Hg, HCO3- 28 mEq/L
C. pH 7.45, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3- 22 mEq/L
D. pH 7.50, PaCO2 25 mm Hg, PaO2 90 mm Hg, HCO3- 20 mEq/L
Answer: A
Rationale: Acute respiratory acidosis is characterized by a low pH, elevated PaCO2, and normal HCO3-
(no renal compensation). Option A shows pH 7.25, PaCO2 60, HCO3- 24, indicating acute hypercapnia.
Option B shows partially compensated respiratory acidosis (elevated HCO3-). Option C is respiratory
alkalosis, and option D is acute respiratory alkalosis.
4. A 34-year-old woman presents with fatigue, arthralgias, and a malar rash. Laboratory studies
show positive antinuclear antibody (ANA) at 1:640, anti-double-stranded DNA antibody elevated,
and low complement C3 and C4. Urinalysis reveals proteinuria (2+) and red blood cell casts. Renal
biopsy shows class IV lupus nephritis. Which of the following is the most appropriate initial
induction therapy?
A. Hydroxychloroquine alone
B. Mycophenolate mofetil plus high-dose corticosteroids
C. Azathioprine plus low-dose corticosteroids
D. Cyclophosphamide pulse therapy alone
Answer: B
Rationale: For class III/IV lupus nephritis, current guidelines recommend mycophenolate mofetil (MMF)
or cyclophosphamide combined with corticosteroids as first-line induction. MMF is preferred due to
similar efficacy and better safety profile. Hydroxychloroquine is adjunctive but insufficient alone.
Azathioprine is used for maintenance, not induction. Cyclophosphamide alone without steroids is not
standard.
5. A 72-year-old man with a history of chronic kidney disease stage 3 (eGFR 45 mL/min) presents
with confusion and muscle cramps. Serum sodium is 125 mEq/L, potassium 5.8 mEq/L, chloride 95
mEq/L, bicarbonate 18 mEq/L, BUN 80 mg/dL, creatinine 3.0 mg/dL, glucose 120 mg/dL. Serum
osmolality is 265 mOsm/kg. Urine osmolality is 350 mOsm/kg, urine sodium 40 mEq/L. Which of
the following is the most likely cause of his hyponatremia?
A. Primary polydipsia
B. Syndrome of inappropriate antidiuretic hormone (SIADH)
C. Hypovolemic hyponatremia
D. Hypervolemic hyponatremia due to renal failure
Answer: B
Rationale: The patient has euvolemic hyponatremia with low serum osmolality, urine osmolality >100
(inappropriately concentrated), and urine sodium >30, consistent with SIADH. Primary polydipsia
would have maximally dilute urine (urine osmolality <100). Hypovolemic hyponatremia typically has
Page 2
,urine sodium <10 (unless on diuretics). Hypervolemic states (CHF, cirrhosis) usually have edema; renal
failure alone does not typically cause such severe hyponatremia.
6. A 55-year-old man with a history of alcoholic cirrhosis presents with hematemesis and melena.
He is hypotensive and tachycardic. After resuscitation with packed red blood cells, an emergent
upper endoscopy shows actively bleeding esophageal varices. Which of the following is the most
appropriate immediate pharmacologic therapy to reduce portal pressure and control bleeding?
A. Octreotide
B. Propranolol
C. Terlipressin
D. Vasopressin
Answer: A
Rationale: Octreotide is a somatostatin analog that reduces splanchnic blood flow and portal pressure; it
is the preferred vasoactive agent for acute variceal bleeding in many centers due to better safety profile.
Terlipressin is also effective but not available in all countries. Propranolol is used for primary
prophylaxis, not acute bleeding. Vasopressin is less used due to systemic side effects.
7. A 65-year-old woman with diabetes and hypertension presents with acute onset of severe
abdominal pain and vomiting. Serum lipase is 1200 U/L. CT abdomen shows peripancreatic fat
stranding and a 3 cm pseudocyst. She is started on aggressive intravenous fluids. On hospital day
3, she develops increasing abdominal pain, distension, and fever. Repeat CT shows a new
gas-containing collection in the retroperitoneum. Which of the following is the most appropriate
next step in management?
A. Continue conservative management with antibiotics
B. Percutaneous catheter drainage
C. Surgical necrosectomy
D. Endoscopic cystogastrostomy
Answer: C
Rationale: The presence of gas in a pancreatic fluid collection indicates infected necrotizing pancreatitis.
Current guidelines recommend surgical necrosectomy or step-up approach (percutaneous drainage
followed by minimally invasive necrosectomy) for infected necrosis. However, given the patient's clinical
deterioration and gas on CT, surgical intervention is often required. Percutaneous drainage may be
considered but is less definitive for solid necrosis. Endoscopic cystogastrostomy is for pseudocysts
without necrosis.
8. A 28-year-old woman presents with palpitations, weight loss, and heat intolerance. Thyroid
function tests show TSH <0.01 mIU/L, free T4 3.5 ng/dL, free T3 8.0 pg/mL. Thyroid scan shows
diffusely increased uptake. She has no ophthalmopathy. Which of the following is the most
appropriate first-line treatment?
A. Radioactive iodine ablation
B. Methimazole
C. Propylthiouracil
D. Subtotal thyroidectomy
Page 3
, Answer: B
Rationale: Methimazole is the preferred first-line antithyroid drug for Graves' disease in non-pregnant
patients due to better efficacy and safety compared to propylthiouracil (which carries risk of
hepatotoxicity). Radioactive iodine and surgery are second-line options. Propylthiouracil is reserved for
first trimester pregnancy or thyroid storm.
9. A 60-year-old man with a history of hypertension presents with sudden onset of severe headache,
nausea, and visual disturbances. Blood pressure is 220/130 mm Hg. Funduscopic examination
reveals papilledema, hemorrhages, and exudates. Serum creatinine is 2.0 mg/dL. Which of the
following is the most appropriate initial antihypertensive agent to reduce blood pressure in this
patient?
A. Intravenous nitroprusside
B. Intravenous labetalol
C. Intravenous nicardipine
D. Intravenous hydralazine
Answer: B
Rationale: In hypertensive emergency with papilledema (malignant hypertension), current guidelines
recommend intravenous labetalol, nicardipine, or clevidipine as first-line agents. Labetalol is often
preferred due to its rapid onset and lack of reflex tachycardia. Nitroprusside is effective but carries risk
of cyanide toxicity with prolonged use or renal impairment. Hydralazine is less predictable and may
cause reflex tachycardia.
10. A 50-year-old woman with a history of recurrent urinary tract infections presents with acute
onset of fever, flank pain, and nausea. Urinalysis shows pyuria and bacteriuria. Urine culture
grows Escherichia coli resistant to ampicillin and ciprofloxacin but sensitive to ceftriaxone and
nitrofurantoin. She has no known drug allergies. Which of the following is the most appropriate
empiric antibiotic for this patient?
A. Ciprofloxacin
B. Ceftriaxone
C. Nitrofurantoin
D. Amoxicillin-clavulanate
Answer: B
Rationale: This patient has acute pyelonephritis, requiring antibiotics with high renal parenchymal
penetration. Ceftriaxone is appropriate given sensitivity and once-daily dosing. Ciprofloxacin is
resistant, so not appropriate. Nitrofurantoin is not effective for pyelonephritis due to poor tissue levels.
Amoxicillin-clavulanate is not recommended as empiric therapy due to high resistance rates.
11. A 45-year-old man with a history of hypertension and chronic kidney disease stage 3 presents
with acute-onset dyspnea and orthopnea. On examination, he has bibasilar crackles, elevated
jugular venous pressure, and an S3 gallop. Chest radiograph shows pulmonary edema. Which of
the following is the most appropriate initial pharmacologic therapy for this patient?
A. Intravenous furosemide 40 mg bolus
B. Intravenous metoprolol 5 mg
Page 4
