ABIM-Style Internal Medicine Board Certification Exam 2026:
Comprehensive Physician Practice Test — Cardiovascular Disease,
Endocrinology, Gastroenterology, Infectious Disease, Pulmonary
Medicine & Multisystem Clinical Reasoning — 194 Multiple-Choice
Questions with Answers & Detailed Rationales
CARDIOVASCULAR DISEASE
Question 1
A 58-year-old man with a history of hypertension and hyperlipidemia presents with 30
minutes of substernal chest pressure that radiates to his left arm. ECG shows ST-segment
elevation in leads V1-V4. The nearest PCI-capable hospital is 45 minutes away by ambulance.
Which of the following is the most appropriate next step?
A. Administer fibrinolytic therapy immediately
B. Transfer for primary PCI without fibrinolysis
C. Obtain a bedside echocardiogram to confirm regional wall motion abnormalities
D. Administer aspirin, heparin, and nitroglycerin, then reassess in 30 minutes
Correct Answer: B
Explanation: Primary PCI is preferred when achievable within 120 minutes of first medical
contact; fibrinolysis is reserved for when PCI is unavailable within that window. This patient
has a 45-minute transport time, making PCI the superior reperfusion strategy .
Question 2
,A 72-year-old woman with a history of heart failure with reduced ejection fraction (EF 30%)
presents with worsening dyspnea and a 5-kg weight gain over 2 weeks. She is currently on
carvedilol, lisinopril, and furosemide. Which of the following medication additions has been
shown to reduce mortality in this population?
A. Digoxin
B. Spironolactone
C. Hydralazine
D. Amlodipine
Correct Answer: B
Explanation: Mineralocorticoid receptor antagonists (spironolactone, eplerenone) reduce
mortality in HFrEF. Digoxin reduces hospitalizations but not mortality; hydralazine is reserved
for specific populations; amlodipine is neutral .
Question 3
A 65-year-old man presents with acute onset of tearing chest pain radiating to the back. His
blood pressure is 180/95 mmHg in the right arm and 140/80 mmHg in the left arm. CT
angiography demonstrates an intimal flap involving the ascending aorta. Which of the
following is the most appropriate management?
A. Immediate surgical consultation for repair
B. Intravenous labetalol and observation
C. Beta-blocker followed by nitroprusside, then surgical repair
D. Endovascular stent grafting of the descending aorta
Correct Answer: A
,Explanation: Stanford Type A aortic dissection requires emergent surgical repair. Type B
dissections are managed medically. Blood pressure control is important but does not replace
surgery for ascending involvement.
Question 4
A 45-year-old woman reports palpitations. ECG shows a narrow-complex tachycardia at 180
bpm with a regular rhythm. She is hemodynamically stable. Vagal maneuvers are
unsuccessful. Which of the following is the most appropriate next step?
A. Synchronized cardioversion
B. Intravenous adenosine
C. Intravenous amiodarone
D. Oral metoprolol
Correct Answer: B
Explanation: Adenosine is first-line for stable narrow-complex regular tachycardia (suspected
AVNRT). Cardioversion is reserved for instability; amiodarone is for wide-complex or
refractory arrhythmias.
Question 5
A 70-year-old man with a history of myocardial infarction presents with fatigue and dyspnea.
Echocardiogram shows an ejection fraction of 25% and a QRS duration of 160 ms with left
bundle branch block. He remains symptomatic despite optimal medical therapy. Which of
the following is the most appropriate intervention?
A. Implantable cardioverter-defibrillator alone
B. Cardiac resynchronization therapy with defibrillator
C. Left ventricular assist device
, D. Heart transplantation evaluation
Correct Answer: B
Explanation: CRT-D is indicated for symptomatic HFrEF with QRS ≥150 ms and LBBB. ICD
alone does not improve symptoms; LVAD and transplant are reserved for advanced
refractory disease .
Question 6
A 62-year-old woman presents with progressive exertional dyspnea. Echocardiogram shows
a mean gradient of 50 mmHg across the aortic valve and a valve area of 0.7 cm². She is
asymptomatic. Which of the following findings would most strongly indicate the need for
aortic valve replacement?
A. Left ventricular ejection fraction of 55%
B. Abnormal exercise test with symptom development
C. Mild mitral regurgitation
D. Left atrial enlargement
Correct Answer: B
Explanation: In asymptomatic severe aortic stenosis, an abnormal exercise test (symptoms,
blood pressure fall) is a Class I indication for valve replacement. Normal EF does not trigger
surgery .
Question 7
A 55-year-old man with atrial fibrillation has a CHA₂DS₂-VASc score of 4. He has no
contraindications to anticoagulation. Which of the following is the most appropriate stroke
prevention strategy?
Comprehensive Physician Practice Test — Cardiovascular Disease,
Endocrinology, Gastroenterology, Infectious Disease, Pulmonary
Medicine & Multisystem Clinical Reasoning — 194 Multiple-Choice
Questions with Answers & Detailed Rationales
CARDIOVASCULAR DISEASE
Question 1
A 58-year-old man with a history of hypertension and hyperlipidemia presents with 30
minutes of substernal chest pressure that radiates to his left arm. ECG shows ST-segment
elevation in leads V1-V4. The nearest PCI-capable hospital is 45 minutes away by ambulance.
Which of the following is the most appropriate next step?
A. Administer fibrinolytic therapy immediately
B. Transfer for primary PCI without fibrinolysis
C. Obtain a bedside echocardiogram to confirm regional wall motion abnormalities
D. Administer aspirin, heparin, and nitroglycerin, then reassess in 30 minutes
Correct Answer: B
Explanation: Primary PCI is preferred when achievable within 120 minutes of first medical
contact; fibrinolysis is reserved for when PCI is unavailable within that window. This patient
has a 45-minute transport time, making PCI the superior reperfusion strategy .
Question 2
,A 72-year-old woman with a history of heart failure with reduced ejection fraction (EF 30%)
presents with worsening dyspnea and a 5-kg weight gain over 2 weeks. She is currently on
carvedilol, lisinopril, and furosemide. Which of the following medication additions has been
shown to reduce mortality in this population?
A. Digoxin
B. Spironolactone
C. Hydralazine
D. Amlodipine
Correct Answer: B
Explanation: Mineralocorticoid receptor antagonists (spironolactone, eplerenone) reduce
mortality in HFrEF. Digoxin reduces hospitalizations but not mortality; hydralazine is reserved
for specific populations; amlodipine is neutral .
Question 3
A 65-year-old man presents with acute onset of tearing chest pain radiating to the back. His
blood pressure is 180/95 mmHg in the right arm and 140/80 mmHg in the left arm. CT
angiography demonstrates an intimal flap involving the ascending aorta. Which of the
following is the most appropriate management?
A. Immediate surgical consultation for repair
B. Intravenous labetalol and observation
C. Beta-blocker followed by nitroprusside, then surgical repair
D. Endovascular stent grafting of the descending aorta
Correct Answer: A
,Explanation: Stanford Type A aortic dissection requires emergent surgical repair. Type B
dissections are managed medically. Blood pressure control is important but does not replace
surgery for ascending involvement.
Question 4
A 45-year-old woman reports palpitations. ECG shows a narrow-complex tachycardia at 180
bpm with a regular rhythm. She is hemodynamically stable. Vagal maneuvers are
unsuccessful. Which of the following is the most appropriate next step?
A. Synchronized cardioversion
B. Intravenous adenosine
C. Intravenous amiodarone
D. Oral metoprolol
Correct Answer: B
Explanation: Adenosine is first-line for stable narrow-complex regular tachycardia (suspected
AVNRT). Cardioversion is reserved for instability; amiodarone is for wide-complex or
refractory arrhythmias.
Question 5
A 70-year-old man with a history of myocardial infarction presents with fatigue and dyspnea.
Echocardiogram shows an ejection fraction of 25% and a QRS duration of 160 ms with left
bundle branch block. He remains symptomatic despite optimal medical therapy. Which of
the following is the most appropriate intervention?
A. Implantable cardioverter-defibrillator alone
B. Cardiac resynchronization therapy with defibrillator
C. Left ventricular assist device
, D. Heart transplantation evaluation
Correct Answer: B
Explanation: CRT-D is indicated for symptomatic HFrEF with QRS ≥150 ms and LBBB. ICD
alone does not improve symptoms; LVAD and transplant are reserved for advanced
refractory disease .
Question 6
A 62-year-old woman presents with progressive exertional dyspnea. Echocardiogram shows
a mean gradient of 50 mmHg across the aortic valve and a valve area of 0.7 cm². She is
asymptomatic. Which of the following findings would most strongly indicate the need for
aortic valve replacement?
A. Left ventricular ejection fraction of 55%
B. Abnormal exercise test with symptom development
C. Mild mitral regurgitation
D. Left atrial enlargement
Correct Answer: B
Explanation: In asymptomatic severe aortic stenosis, an abnormal exercise test (symptoms,
blood pressure fall) is a Class I indication for valve replacement. Normal EF does not trigger
surgery .
Question 7
A 55-year-old man with atrial fibrillation has a CHA₂DS₂-VASc score of 4. He has no
contraindications to anticoagulation. Which of the following is the most appropriate stroke
prevention strategy?
