1|Page
American Board of Internal Medicine (ABIM)
Certification Exam | Latest Verified Questions and
Detailed Answers
OVERVIEW DESCRIPTION:
This comprehensive set of multiple-choice questions is designed for the American Board of
Internal Medicine (ABIM) Certification Exam. The questions span all major internal
medicine subspecialties, including cardiology, pulmonology, gastroenterology, nephrology,
endocrinology, rheumatology, infectious diseases, hematology-oncology, neurology, and
critical care. Each question follows a clinical vignette format, testing the ability to
synthesize patient presentations, diagnostic reasoning, and evidence-based management
decisions. The answer key is accompanied by a concise expert rationale that explains the
correct choice and reinforces key clinical pearls.
QUESTION 1
A 68-year-old man with hypertension and type 2 diabetes presents with acute-onset
severe left flank pain radiating to the groin, nausea, and hematuria. Urinalysis shows
many red blood cells. Which test is most appropriate for initial imaging?
A) Abdominal X-ray
B) Renal ultrasonography
C) Noncontrast helical CT
D) Intravenous pyelography
CORRECT ANSWER: C
EXPERT RATIONALE: Noncontrast helical CT is the gold standard for diagnosing acute
nephrolithiasis, with high sensitivity for stones regardless of composition or
radiodensity.
,2|Page
QUESTION 2
A 55-year-old woman with rheumatoid arthritis on methotrexate develops dyspnea and
nonproductive cough over 2 weeks. HRCT shows diffuse ground-glass opacities and
reticulation. Which test is most likely to confirm the diagnosis?
A) Serum rheumatoid factor
B) Bronchoalveolar lavage with lymphocytosis
C) Surgical lung biopsy showing organizing pneumonia
D) Methotrexate discontinuation with clinical improvement
CORRECT ANSWER: D
EXPERT RATIONALE: Methotrexate-induced pneumonitis is a diagnosis of exclusion
often confirmed by improvement after drug withdrawal, as histopathology is
nonspecific.
QUESTION 3
A 72-year-old man with heart failure with reduced ejection fraction (HFrEF) on lisinopril,
metoprolol, and furosemide presents with creatinine rising from 1.0 to 1.9 mg/dL over 3
days. Blood pressure is 110/70 mm Hg. What is the best next step?
A) Discontinue lisinopril
B) Increase furosemide dose
C) Add intravenous fluids
D) Obtain renal artery duplex ultrasound
CORRECT ANSWER: A
EXPERT RATIONALE: Worsening renal function in a euvolemic patient on ACE inhibitor
suggests possible renal artery stenosis or prerenal physiology; stopping the ACE
inhibitor is first step.
,3|Page
QUESTION 4
A 45-year-old obese woman presents with episodic palpitations, sweating, and
hypertension. Plasma metanephrines are elevated. A CT abdomen shows a 4 cm right
adrenal mass. Which test should be done next?
A) Adrenal vein sampling
B) Iodine-131 MIBG scintigraphy
C) Plasma aldosterone/renin ratio
D) 24-hour urinary cortisol
CORRECT ANSWER: B
EXPERT RATIONALE: MIBG scan localizes pheochromocytoma to adrenal or extra-
adrenal sites and rules out metastatic disease before surgery.
QUESTION 5
A 62-year-old man with cirrhosis and ascites develops fever and abdominal pain.
Paracentesis reveals neutrophil count 750/mm³, protein 1.2 g/dL, and cultures pending.
What is the appropriate initial antibiotic regimen?
A) Oral norfloxacin
B) Intravenous cefotaxime
C) Intravenous vancomycin plus piperacillin-tazobactam
D) Intravenous metronidazole alone
CORRECT ANSWER: B
EXPERT RATIONALE: Spontaneous bacterial peritonitis requires empiric third-generation
cephalosporin (e.g., cefotaxime) to cover gram-negative enteric organisms.
QUESTION 6
A 28-year-old woman with systemic lupus erythematosus presents with acute dyspnea
, 4|Page
and pleuritic chest pain. CXR shows bilateral infiltrates. She is hypoxemic. Which
diagnostic test is most specific for acute lupus pneumonitis?
A) Bronchoscopy with transbronchial biopsy
B) High-resolution CT chest
C) Serum anti-dsDNA antibody
D) Echocardiogram
CORRECT ANSWER: C
EXPERT RATIONALE: Acute lupus pneumonitis is a clinical diagnosis often associated
with high anti-dsDNA titers; lung biopsy is rarely needed and may show nonspecific
inflammation.
QUESTION 7
A 70-year-old man with atrial fibrillation on warfarin presents with INR 9.2, no bleeding.
What is the appropriate management?
A) Oral vitamin K 2.5 mg
B) Intravenous vitamin K 10 mg
C) Fresh frozen plasma
D) Hold warfarin and recheck INR next day
CORRECT ANSWER: A
EXPERT RATIONALE: For INR >9 without bleeding, oral vitamin K (1-2.5 mg) is safe and
effective to reduce INR without overcorrection.
QUESTION 8
A 34-year-old man presents with intermittent abdominal pain, diarrhea, and weight loss.
Upper endoscopy shows scalloping of duodenal folds. Serologic test is positive for anti-
tissue transglutaminase IgA. What is the next best step?
American Board of Internal Medicine (ABIM)
Certification Exam | Latest Verified Questions and
Detailed Answers
OVERVIEW DESCRIPTION:
This comprehensive set of multiple-choice questions is designed for the American Board of
Internal Medicine (ABIM) Certification Exam. The questions span all major internal
medicine subspecialties, including cardiology, pulmonology, gastroenterology, nephrology,
endocrinology, rheumatology, infectious diseases, hematology-oncology, neurology, and
critical care. Each question follows a clinical vignette format, testing the ability to
synthesize patient presentations, diagnostic reasoning, and evidence-based management
decisions. The answer key is accompanied by a concise expert rationale that explains the
correct choice and reinforces key clinical pearls.
QUESTION 1
A 68-year-old man with hypertension and type 2 diabetes presents with acute-onset
severe left flank pain radiating to the groin, nausea, and hematuria. Urinalysis shows
many red blood cells. Which test is most appropriate for initial imaging?
A) Abdominal X-ray
B) Renal ultrasonography
C) Noncontrast helical CT
D) Intravenous pyelography
CORRECT ANSWER: C
EXPERT RATIONALE: Noncontrast helical CT is the gold standard for diagnosing acute
nephrolithiasis, with high sensitivity for stones regardless of composition or
radiodensity.
,2|Page
QUESTION 2
A 55-year-old woman with rheumatoid arthritis on methotrexate develops dyspnea and
nonproductive cough over 2 weeks. HRCT shows diffuse ground-glass opacities and
reticulation. Which test is most likely to confirm the diagnosis?
A) Serum rheumatoid factor
B) Bronchoalveolar lavage with lymphocytosis
C) Surgical lung biopsy showing organizing pneumonia
D) Methotrexate discontinuation with clinical improvement
CORRECT ANSWER: D
EXPERT RATIONALE: Methotrexate-induced pneumonitis is a diagnosis of exclusion
often confirmed by improvement after drug withdrawal, as histopathology is
nonspecific.
QUESTION 3
A 72-year-old man with heart failure with reduced ejection fraction (HFrEF) on lisinopril,
metoprolol, and furosemide presents with creatinine rising from 1.0 to 1.9 mg/dL over 3
days. Blood pressure is 110/70 mm Hg. What is the best next step?
A) Discontinue lisinopril
B) Increase furosemide dose
C) Add intravenous fluids
D) Obtain renal artery duplex ultrasound
CORRECT ANSWER: A
EXPERT RATIONALE: Worsening renal function in a euvolemic patient on ACE inhibitor
suggests possible renal artery stenosis or prerenal physiology; stopping the ACE
inhibitor is first step.
,3|Page
QUESTION 4
A 45-year-old obese woman presents with episodic palpitations, sweating, and
hypertension. Plasma metanephrines are elevated. A CT abdomen shows a 4 cm right
adrenal mass. Which test should be done next?
A) Adrenal vein sampling
B) Iodine-131 MIBG scintigraphy
C) Plasma aldosterone/renin ratio
D) 24-hour urinary cortisol
CORRECT ANSWER: B
EXPERT RATIONALE: MIBG scan localizes pheochromocytoma to adrenal or extra-
adrenal sites and rules out metastatic disease before surgery.
QUESTION 5
A 62-year-old man with cirrhosis and ascites develops fever and abdominal pain.
Paracentesis reveals neutrophil count 750/mm³, protein 1.2 g/dL, and cultures pending.
What is the appropriate initial antibiotic regimen?
A) Oral norfloxacin
B) Intravenous cefotaxime
C) Intravenous vancomycin plus piperacillin-tazobactam
D) Intravenous metronidazole alone
CORRECT ANSWER: B
EXPERT RATIONALE: Spontaneous bacterial peritonitis requires empiric third-generation
cephalosporin (e.g., cefotaxime) to cover gram-negative enteric organisms.
QUESTION 6
A 28-year-old woman with systemic lupus erythematosus presents with acute dyspnea
, 4|Page
and pleuritic chest pain. CXR shows bilateral infiltrates. She is hypoxemic. Which
diagnostic test is most specific for acute lupus pneumonitis?
A) Bronchoscopy with transbronchial biopsy
B) High-resolution CT chest
C) Serum anti-dsDNA antibody
D) Echocardiogram
CORRECT ANSWER: C
EXPERT RATIONALE: Acute lupus pneumonitis is a clinical diagnosis often associated
with high anti-dsDNA titers; lung biopsy is rarely needed and may show nonspecific
inflammation.
QUESTION 7
A 70-year-old man with atrial fibrillation on warfarin presents with INR 9.2, no bleeding.
What is the appropriate management?
A) Oral vitamin K 2.5 mg
B) Intravenous vitamin K 10 mg
C) Fresh frozen plasma
D) Hold warfarin and recheck INR next day
CORRECT ANSWER: A
EXPERT RATIONALE: For INR >9 without bleeding, oral vitamin K (1-2.5 mg) is safe and
effective to reduce INR without overcorrection.
QUESTION 8
A 34-year-old man presents with intermittent abdominal pain, diarrhea, and weight loss.
Upper endoscopy shows scalloping of duodenal folds. Serologic test is positive for anti-
tissue transglutaminase IgA. What is the next best step?
