ABIM INTERNAL MEDICINE BOARDS & ITE
Question 1 – Cardiology
A 68-year-old man with hypertension and diabetes presents with exertional
dyspnea. Echocardiography reveals concentric left ventricular hypertrophy, normal
ejection fraction, and impaired relaxation. BNP is mildly elevated. Which finding
most strongly supports the diagnosis of heart failure with preserved ejection
fraction (HFpEF)?
A. Reduced left ventricular end-diastolic volume
B. Elevated pulmonary capillary wedge pressure during exercise
C. QRS prolongation on ECG
D. Reduced stroke volume at rest
E. Global hypokinesis on echocardiography
Correct Answer: B
Rationale:
HFpEF is characterized by normal systolic function but impaired diastolic filling.
Hemodynamic testing often reveals elevated filling pressures during exertion,
even when resting pressures are normal. Reduced EF or global hypokinesis would
suggest HFrEF. QRS prolongation and reduced stroke volume are nonspecific.
Question 2 – Pulmonology
A 55-year-old woman with progressive dyspnea has pulmonary function tests
showing reduced TLC, reduced DLCO, and a normal FEV1/FVC ratio. HRCT
demonstrates subpleural reticulation and honeycombing. What is the most likely
diagnosis?
A. Hypersensitivity pneumonitis
B. Sarcoidosis
C. Idiopathic pulmonary fibrosis
D. Chronic eosinophilic pneumonia
E. Bronchiolitis obliterans
,Correct Answer: C
Rationale:
Subpleural reticulation with honeycombing and restrictive physiology is classic for
idiopathic pulmonary fibrosis (UIP pattern). Sarcoidosis typically has upper-
lobe and nodular involvement. Hypersensitivity pneumonitis has ground-glass
opacities and centrilobular nodules.
Question 3 – Gastroenterology
A 42-year-old man presents with chronic diarrhea, weight loss, and iron-deficiency
anemia. Duodenal biopsy reveals villous atrophy and crypt hyperplasia. Which
additional finding is most likely?
A. Positive anti-mitochondrial antibodies
B. Elevated fecal calprotectin
C. IgA anti-tissue transglutaminase antibodies
D. Elevated gastrin level
E. Decreased pancreatic elastase
Correct Answer: C
Rationale:
This presentation is classic for celiac disease, which is associated with IgA anti-
tissue transglutaminase antibodies. Anti-mitochondrial antibodies are seen in
primary biliary cholangitis. Elevated fecal calprotectin suggests inflammatory
bowel disease.
Question 4 – Endocrinology
A patient with type 2 diabetes is started on an SGLT2 inhibitor. Which additional
benefit is most strongly supported by evidence?
A. Reduced risk of pancreatitis
B. Increased bone mineral density
C. Reduced progression of chronic kidney disease
D. Improved postprandial glucose only
E. Prevention of diabetic neuropathy
Correct Answer: C
,Rationale:
SGLT2 inhibitors have demonstrated renal protective effects, including slowing
progression of CKD and reducing albuminuria, independent of glycemic control.
They may slightly increase fracture risk rather than improve bone density.
Question 5 – Nephrology
A 63-year-old man with long-standing hypertension presents with progressive
renal insufficiency. Urinalysis shows minimal proteinuria and bland sediment.
Renal ultrasound reveals bilaterally small kidneys. What is the most likely
diagnosis?
A. Diabetic nephropathy
B. Hypertensive nephrosclerosis
C. Membranous nephropathy
D. Polycystic kidney disease
E. Acute interstitial nephritis
Correct Answer: B
Rationale:
Hypertensive nephrosclerosis presents with slowly progressive CKD, minimal
proteinuria, bland urine sediment, and small kidneys. Diabetic nephropathy
typically has significant proteinuria.
Question 6 – Infectious Diseases
A hospitalized patient receiving broad-spectrum antibiotics develops watery
diarrhea. Stool testing is positive for C. difficile toxin. What is the preferred initial
treatment for non-severe disease?
A. Metronidazole
B. Fidaxomicin or oral vancomycin
C. IV vancomycin
D. Loperamide
E. Probiotics alone
Correct Answer: B
Rationale:
Current guidelines recommend fidaxomicin or oral vancomycin as first-line
, therapy for initial non-severe C. difficile infection. Metronidazole is no longer first
line.
Question 7 – Hematology
A 30-year-old woman presents with fatigue. Labs show hemoglobin 8.5 g/dL,
MCV 72 fL, ferritin 6 ng/mL. Which additional finding is most likely?
A. Elevated reticulocyte count
B. Increased transferrin saturation
C. Decreased total iron-binding capacity
D. Reactive thrombocytosis
E. Hypersegmented neutrophils
Correct Answer: D
Rationale:
Iron-deficiency anemia commonly causes reactive thrombocytosis. Ferritin is
low, TIBC is increased, and transferrin saturation is decreased.
Question 8 – Oncology
A patient with small cell lung cancer develops hyponatremia with low serum
osmolality and inappropriately concentrated urine. What is the mechanism?
A. Renal sodium wasting
B. Aldosterone deficiency
C. Syndrome of inappropriate ADH secretion
D. Cerebral salt wasting
E. Hypothyroidism
Correct Answer: C
Rationale:
Small cell lung cancer is classically associated with SIADH, causing euvolemic
hyponatremia with inappropriately concentrated urine.
Question 9 – Rheumatology
A 48-year-old woman presents with morning stiffness lasting 90 minutes,
symmetric MCP and PIP joint swelling, and positive anti-CCP antibodies. What is
Question 1 – Cardiology
A 68-year-old man with hypertension and diabetes presents with exertional
dyspnea. Echocardiography reveals concentric left ventricular hypertrophy, normal
ejection fraction, and impaired relaxation. BNP is mildly elevated. Which finding
most strongly supports the diagnosis of heart failure with preserved ejection
fraction (HFpEF)?
A. Reduced left ventricular end-diastolic volume
B. Elevated pulmonary capillary wedge pressure during exercise
C. QRS prolongation on ECG
D. Reduced stroke volume at rest
E. Global hypokinesis on echocardiography
Correct Answer: B
Rationale:
HFpEF is characterized by normal systolic function but impaired diastolic filling.
Hemodynamic testing often reveals elevated filling pressures during exertion,
even when resting pressures are normal. Reduced EF or global hypokinesis would
suggest HFrEF. QRS prolongation and reduced stroke volume are nonspecific.
Question 2 – Pulmonology
A 55-year-old woman with progressive dyspnea has pulmonary function tests
showing reduced TLC, reduced DLCO, and a normal FEV1/FVC ratio. HRCT
demonstrates subpleural reticulation and honeycombing. What is the most likely
diagnosis?
A. Hypersensitivity pneumonitis
B. Sarcoidosis
C. Idiopathic pulmonary fibrosis
D. Chronic eosinophilic pneumonia
E. Bronchiolitis obliterans
,Correct Answer: C
Rationale:
Subpleural reticulation with honeycombing and restrictive physiology is classic for
idiopathic pulmonary fibrosis (UIP pattern). Sarcoidosis typically has upper-
lobe and nodular involvement. Hypersensitivity pneumonitis has ground-glass
opacities and centrilobular nodules.
Question 3 – Gastroenterology
A 42-year-old man presents with chronic diarrhea, weight loss, and iron-deficiency
anemia. Duodenal biopsy reveals villous atrophy and crypt hyperplasia. Which
additional finding is most likely?
A. Positive anti-mitochondrial antibodies
B. Elevated fecal calprotectin
C. IgA anti-tissue transglutaminase antibodies
D. Elevated gastrin level
E. Decreased pancreatic elastase
Correct Answer: C
Rationale:
This presentation is classic for celiac disease, which is associated with IgA anti-
tissue transglutaminase antibodies. Anti-mitochondrial antibodies are seen in
primary biliary cholangitis. Elevated fecal calprotectin suggests inflammatory
bowel disease.
Question 4 – Endocrinology
A patient with type 2 diabetes is started on an SGLT2 inhibitor. Which additional
benefit is most strongly supported by evidence?
A. Reduced risk of pancreatitis
B. Increased bone mineral density
C. Reduced progression of chronic kidney disease
D. Improved postprandial glucose only
E. Prevention of diabetic neuropathy
Correct Answer: C
,Rationale:
SGLT2 inhibitors have demonstrated renal protective effects, including slowing
progression of CKD and reducing albuminuria, independent of glycemic control.
They may slightly increase fracture risk rather than improve bone density.
Question 5 – Nephrology
A 63-year-old man with long-standing hypertension presents with progressive
renal insufficiency. Urinalysis shows minimal proteinuria and bland sediment.
Renal ultrasound reveals bilaterally small kidneys. What is the most likely
diagnosis?
A. Diabetic nephropathy
B. Hypertensive nephrosclerosis
C. Membranous nephropathy
D. Polycystic kidney disease
E. Acute interstitial nephritis
Correct Answer: B
Rationale:
Hypertensive nephrosclerosis presents with slowly progressive CKD, minimal
proteinuria, bland urine sediment, and small kidneys. Diabetic nephropathy
typically has significant proteinuria.
Question 6 – Infectious Diseases
A hospitalized patient receiving broad-spectrum antibiotics develops watery
diarrhea. Stool testing is positive for C. difficile toxin. What is the preferred initial
treatment for non-severe disease?
A. Metronidazole
B. Fidaxomicin or oral vancomycin
C. IV vancomycin
D. Loperamide
E. Probiotics alone
Correct Answer: B
Rationale:
Current guidelines recommend fidaxomicin or oral vancomycin as first-line
, therapy for initial non-severe C. difficile infection. Metronidazole is no longer first
line.
Question 7 – Hematology
A 30-year-old woman presents with fatigue. Labs show hemoglobin 8.5 g/dL,
MCV 72 fL, ferritin 6 ng/mL. Which additional finding is most likely?
A. Elevated reticulocyte count
B. Increased transferrin saturation
C. Decreased total iron-binding capacity
D. Reactive thrombocytosis
E. Hypersegmented neutrophils
Correct Answer: D
Rationale:
Iron-deficiency anemia commonly causes reactive thrombocytosis. Ferritin is
low, TIBC is increased, and transferrin saturation is decreased.
Question 8 – Oncology
A patient with small cell lung cancer develops hyponatremia with low serum
osmolality and inappropriately concentrated urine. What is the mechanism?
A. Renal sodium wasting
B. Aldosterone deficiency
C. Syndrome of inappropriate ADH secretion
D. Cerebral salt wasting
E. Hypothyroidism
Correct Answer: C
Rationale:
Small cell lung cancer is classically associated with SIADH, causing euvolemic
hyponatremia with inappropriately concentrated urine.
Question 9 – Rheumatology
A 48-year-old woman presents with morning stiffness lasting 90 minutes,
symmetric MCP and PIP joint swelling, and positive anti-CCP antibodies. What is
