ABIM Internal Medicine Board Exam Prep | Comprehensive
Practice Questions, Clinical Cases & Detailed Rationales
2026/2027
Question 1
A 28-year-old man presents with sharp, retrosternal chest pain that
worsens when lying flat and improves when sitting up and leaning
forward. He had a mild viral upper respiratory infection a week ago. A
friction rub is heard along the left sternal border. Electrocardiogram
reveals diffuse concave ST-segment elevations and PR-segment
depressions. Which of the following is the most appropriate initial
medical therapy?
A. High-dose aspirin or NSAIDs plus colchicine
B. Intravenous unfractionated heparin
C. Emergency coronary angiography
D. Systemic corticosteroids as first-line monotherapy
Correct Answer: A. High-dose aspirin or NSAIDs plus colchicine
Detailed Rationale: Acute pericarditis is treated primarily with high-
dose NSAIDs (or aspirin) combined with colchicine to reduce symptoms
and prevent recurrence. Corticosteroids are reserved for refractory
cases or specific secondary etiologies.
Question 2
A 45-year-old man is evaluated for progressive fatigue, joint pains, and
elevated liver enzymes. Physical examination reveals skin
,hyperpigmentation ("bronze diabetes"). Laboratory workup shows a
serum ferritin of 1,200 ng/mL, transferrin saturation of 65%, and
genetic testing confirms homozygosity for the C282Y mutation in the
HFE gene. Which of the following is the most appropriate initial
management?
A. Chelation therapy with deferoxamine
B. Therapeutic phlebotomy
C. Orthotopic liver transplantation
D. Low-iron dietary restriction alone
Correct Answer: B. Therapeutic phlebotomy
Detailed Rationale: Hereditary hemochromatosis is managed primarily
with therapeutic phlebotomy to systematically deplete excess iron
stores and prevent end-organ damage such as cirrhosis and
cardiomyopathy.
Question 3
A 52-year-old man with type 2 diabetes mellitus and a history of
myocardial infarction 2 years ago has a hemoglobin A1c of 8.4% despite
maximal doses of metformin. He has no chronic kidney disease or heart
failure. Which of the following classes of medications should be added
next to reduce major adverse cardiovascular events?
A. Sulfonylurea (e.g., glipizide)
B. Dipeptidyl peptidase-4 (DPP-4) inhibitor (e.g., sitagliptin)
C. Sodium-glucose cotransporter-2 (SGLT2) inhibitor or GLP-1 receptor
agonist with proven cardiovascular benefit
,D. Basal insulin glargine
Correct Answer: C. Sodium-glucose cotransporter-2 (SGLT2) inhibitor or
GLP-1 receptor agonist with proven cardiovascular benefit
Detailed Rationale: In patients with type 2 diabetes and established
atherosclerotic cardiovascular disease, SGLT2 inhibitors or GLP-1
receptor agonists with proven cardiovascular benefits are
recommended independently of baseline A1c.
Question 4
A 60-year-old man with a 40 pack-year smoking history and chronic
bronchitis presents with a 4-day history of increased dyspnea, increased
sputum volume, and purulent sputum production. Spirometry
historically shows an FEV1/FVC ratio of 0.62. Which of the following is
the most appropriate initial management?
A. Short-acting bronchodilators, systemic corticosteroids, and antibiotics
B. Intravenous vancomycin monotherapy
C. Maintenance long-acting muscarinic antagonist (LAMA) monotherapy
alone
D. Urgent mechanical ventilation
Correct Answer: A. Short-acting bronchodilators, systemic
corticosteroids, and antibiotics
Detailed Rationale: Acute exacerbations of COPD characterized by
increased dyspnea, sputum volume, and sputum purulence are
managed with short-acting bronchodilators, systemic corticosteroids,
and targeted antibiotic therapy.
, Question 5
A 35-year-old woman is evaluated for acute onset of macroscopic
hematuria, hemoptysis, and rapidly progressive glomerulonephritis.
Renal biopsy demonstrates linear IgG deposition along the glomerular
basement membrane. Which of the following is the most likely
diagnosis?
A. Goodpasture syndrome (Anti-GBM disease)
B. IgA nephropathy
C. Systemic lupus erythematosus
D. Granulomatosis with polyangiitis
Correct Answer: A. Goodpasture syndrome (Anti-GBM disease)
Detailed Rationale: Anti-GBM disease (Goodpasture syndrome) is
characterized by antibodies against the alpha-3 chain of type IV
collagen, presenting as rapidly progressive glomerulonephritis and
alveolar hemorrhage with classic linear IgG immunofluorescence.
Question 6
A 50-year-old man with a history of intravenous drug use presents with
persistent fever, weight loss, and a new grade 3/6 holosystolic murmur
at the apex. Blood cultures grow methicillin-resistant Staphylococcus
aureus (MRSA). Transesophageal echocardiography reveals a 1.5 cm
vegetation on the mitral valve with moderate regurgitation. Which of
the following is the appropriate duration of intravenous antimicrobial
therapy?
A. 2 weeks
Practice Questions, Clinical Cases & Detailed Rationales
2026/2027
Question 1
A 28-year-old man presents with sharp, retrosternal chest pain that
worsens when lying flat and improves when sitting up and leaning
forward. He had a mild viral upper respiratory infection a week ago. A
friction rub is heard along the left sternal border. Electrocardiogram
reveals diffuse concave ST-segment elevations and PR-segment
depressions. Which of the following is the most appropriate initial
medical therapy?
A. High-dose aspirin or NSAIDs plus colchicine
B. Intravenous unfractionated heparin
C. Emergency coronary angiography
D. Systemic corticosteroids as first-line monotherapy
Correct Answer: A. High-dose aspirin or NSAIDs plus colchicine
Detailed Rationale: Acute pericarditis is treated primarily with high-
dose NSAIDs (or aspirin) combined with colchicine to reduce symptoms
and prevent recurrence. Corticosteroids are reserved for refractory
cases or specific secondary etiologies.
Question 2
A 45-year-old man is evaluated for progressive fatigue, joint pains, and
elevated liver enzymes. Physical examination reveals skin
,hyperpigmentation ("bronze diabetes"). Laboratory workup shows a
serum ferritin of 1,200 ng/mL, transferrin saturation of 65%, and
genetic testing confirms homozygosity for the C282Y mutation in the
HFE gene. Which of the following is the most appropriate initial
management?
A. Chelation therapy with deferoxamine
B. Therapeutic phlebotomy
C. Orthotopic liver transplantation
D. Low-iron dietary restriction alone
Correct Answer: B. Therapeutic phlebotomy
Detailed Rationale: Hereditary hemochromatosis is managed primarily
with therapeutic phlebotomy to systematically deplete excess iron
stores and prevent end-organ damage such as cirrhosis and
cardiomyopathy.
Question 3
A 52-year-old man with type 2 diabetes mellitus and a history of
myocardial infarction 2 years ago has a hemoglobin A1c of 8.4% despite
maximal doses of metformin. He has no chronic kidney disease or heart
failure. Which of the following classes of medications should be added
next to reduce major adverse cardiovascular events?
A. Sulfonylurea (e.g., glipizide)
B. Dipeptidyl peptidase-4 (DPP-4) inhibitor (e.g., sitagliptin)
C. Sodium-glucose cotransporter-2 (SGLT2) inhibitor or GLP-1 receptor
agonist with proven cardiovascular benefit
,D. Basal insulin glargine
Correct Answer: C. Sodium-glucose cotransporter-2 (SGLT2) inhibitor or
GLP-1 receptor agonist with proven cardiovascular benefit
Detailed Rationale: In patients with type 2 diabetes and established
atherosclerotic cardiovascular disease, SGLT2 inhibitors or GLP-1
receptor agonists with proven cardiovascular benefits are
recommended independently of baseline A1c.
Question 4
A 60-year-old man with a 40 pack-year smoking history and chronic
bronchitis presents with a 4-day history of increased dyspnea, increased
sputum volume, and purulent sputum production. Spirometry
historically shows an FEV1/FVC ratio of 0.62. Which of the following is
the most appropriate initial management?
A. Short-acting bronchodilators, systemic corticosteroids, and antibiotics
B. Intravenous vancomycin monotherapy
C. Maintenance long-acting muscarinic antagonist (LAMA) monotherapy
alone
D. Urgent mechanical ventilation
Correct Answer: A. Short-acting bronchodilators, systemic
corticosteroids, and antibiotics
Detailed Rationale: Acute exacerbations of COPD characterized by
increased dyspnea, sputum volume, and sputum purulence are
managed with short-acting bronchodilators, systemic corticosteroids,
and targeted antibiotic therapy.
, Question 5
A 35-year-old woman is evaluated for acute onset of macroscopic
hematuria, hemoptysis, and rapidly progressive glomerulonephritis.
Renal biopsy demonstrates linear IgG deposition along the glomerular
basement membrane. Which of the following is the most likely
diagnosis?
A. Goodpasture syndrome (Anti-GBM disease)
B. IgA nephropathy
C. Systemic lupus erythematosus
D. Granulomatosis with polyangiitis
Correct Answer: A. Goodpasture syndrome (Anti-GBM disease)
Detailed Rationale: Anti-GBM disease (Goodpasture syndrome) is
characterized by antibodies against the alpha-3 chain of type IV
collagen, presenting as rapidly progressive glomerulonephritis and
alveolar hemorrhage with classic linear IgG immunofluorescence.
Question 6
A 50-year-old man with a history of intravenous drug use presents with
persistent fever, weight loss, and a new grade 3/6 holosystolic murmur
at the apex. Blood cultures grow methicillin-resistant Staphylococcus
aureus (MRSA). Transesophageal echocardiography reveals a 1.5 cm
vegetation on the mitral valve with moderate regurgitation. Which of
the following is the appropriate duration of intravenous antimicrobial
therapy?
A. 2 weeks
