Free practice quiz
ABIM Internal Medicine Prep Course (ABIM IM): free quiz
10 questions from the program. See your score right away, then unlock the explanation of every answer.
- Question 1 of 10
A 64-year-old man presents with 45 minutes of substernal chest pressure at rest with diaphoresis and nausea. He has hypertension, type 2 diabetes, and a 40-pack-year smoking history. Blood pressure is 148/88 mm Hg, heart rate is 96/min, and oxygen saturation is 97% on room air. ECG shows 1.5-mm horizontal ST-segment depressions in V4-V6 without ST-segment elevation. Initial high-sensitivity troponin is elevated above the 99th percentile and rises on repeat testing 2 hours later. Which acute coronary syndrome pattern is most likely?
NSTEMI Pattern
C is correct: plaque rupture with subtotal thrombosis causes ischemic symptoms, ST depression, and rising troponin from myocardial necrosis. D is exertional and predictable with negative biomarkers. B is tempting because rest pain and ST depression overlap, but troponin remains negative. A requires persistent ST elevation or equivalent patterns suggesting transmural injury and urgent reperfusion.
Diagnose NSTEMI with ischemic symptoms plus dynamic troponin elevation; order serial ECGs/troponins; treat with antiplatelet, anticoagulation, anti-ischemic therapy, and high-intensity statin; escalate for early invasive cardiology evaluation if high risk. - Question 2 of 10
A 59-year-old man with chronic HFrEF returns for follow-up after stabilization of his volume status. He currently receives an ARNI, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor. He has no identified contraindication to beta-blocker treatment but has not yet been prescribed one. Which is the most appropriate next step in long-term management?
A: Replacing the ARNI with hydralazine alone would remove an established component of guideline-directed HFrEF therapy. Hydralazine-based treatment has an adjunctive role when indicated rather than routinely replacing foundational therapy.
B: Mineralocorticoid receptor antagonists are one of the four foundational drug classes for HFrEF. Simplifying the regimen by eliminating this class would leave an important treatment component unaddressed.
C: Having three foundational drug classes does not make the regimen complete. The missing beta blocker should be considered when the patient's clinical condition permits its use.
D: Correct. Evidence-based beta blockers are a foundational component of chronic HFrEF treatment. This clinically stable patient already receives the other three medication classes and should have beta-blocker therapy incorporated into the regimen, with appropriate monitoring of blood pressure and volume status.
- Question 3 of 10
A 29-year-old previously healthy man develops headache, fatigue, and dyspnea after rapidly ascending to an elevation of 4,200 meters. Examination reveals tachypnea and an oxygen saturation of 86% while breathing ambient air. His lungs are clear, and his A-a oxygen gradient is normal when calculated using the local barometric pressure. Which mechanism best explains his hypoxemia?
A (Incorrect): Right-to-left shunting causes blood to bypass effective alveolar oxygenation, typically increasing the A-a gradient and producing a relatively poor response to supplemental oxygen. The normal gradient and high-altitude exposure do not support shunting as the primary mechanism.
B (Correct): At high altitude, decreased barometric pressure lowers inspired oxygen partial pressure despite an unchanged fractional oxygen concentration in ambient air. Alveolar and arterial oxygen tensions consequently decrease together, preserving a normal A-a gradient in uncomplicated altitude-related hypoxemia. Supplemental oxygen increases inspired oxygen tension and improves oxygenation.
C (Incorrect): Diffusion limitation results from impaired oxygen movement across the alveolar-capillary membrane and usually increases the A-a gradient. There is no evidence of fibrotic lung disease or abnormal pulmonary gas transfer in this scenario.
D (Incorrect): Regional V/Q mismatch commonly increases the A-a gradient because some perfused lung units are inadequately ventilated. A normal altitude-adjusted gradient favors reduced inspired oxygen tension instead.
- Question 4 of 10
A 42-year-old woman presents with sudden pleuritic right-sided chest pain and mild dyspnea 2 days after a 6-hour flight. She has no cancer, prior venous thromboembolism, hemoptysis, or estrogen use. Temperature is 37.0 °C, blood pressure 122/76 mm Hg, heart rate 104/min, respiratory rate 18/min, and oxygen saturation 97% on room air. Lungs are clear, legs are symmetric, ECG shows sinus tachycardia, and chest radiograph is normal. Clinical gestalt suggests low pretest probability for pulmonary embolism. What is the best next step?
PE Evaluation
Low-pretest-probability PE is excluded by a negative high-sensitivity B-dimer; her tachycardia makes PERC inapplicable, so A is correct. C is tempting because CT angiography confirms PE, but it is reserved for positive B-dimer or high clinical probability. D is appropriate when probability is high or the patient is unstable; she is stable with low probability. A can be used when CT is contraindicated, but no contrast allergy, renal failure, or pregnancy is present.
Diagnose using pretest probability; order B-dimer first when low/intermediate and PERC-positive; treat confirmed PE with anticoagulation; escalate for hypotension or right-heart strain. - Question 5 of 10
A 78-year-old man with benign prostatic hyperplasia presents with suprapubic discomfort and markedly decreased urine output for 18 hours. Serum creatinine is 3.1 mg/dL compared with a baseline of 1.2 mg/dL. Bedside bladder ultrasonography demonstrates approximately 900 mL of retained urine. Which of the following is the most appropriate next step?
A (Incorrect): The immediate problem is urinary outflow obstruction rather than demonstrated volume depletion. Additional fluids without relieving obstruction may worsen bladder distention and fluid accumulation.
B (Correct): Acute urinary retention with a distended bladder and rising creatinine strongly supports postrenal AKI. Prompt catheterization relieves bladder outlet obstruction and is the appropriate initial intervention. Urine output, electrolytes, and renal function should subsequently be monitored.
C (Incorrect): Serologic evaluation is useful when intrinsic inflammatory or glomerular kidney disease is suspected. It should not delay treatment of an identified mechanical obstruction.
D (Incorrect): Kidney biopsy does not address the established cause of kidney injury. Biopsy is reserved for selected cases in which intrinsic renal pathology requires clarification.
- Question 6 of 10
A 70-year-old man presents with rapidly worsening renal function and microscopic hematuria. His creatinine has increased from 1.2 to 4.0 mg/dL over 3 weeks. Kidney biopsy shows necrotizing crescentic glomerulonephritis with little or no immunoglobulin or complement deposition on immunofluorescence, and serum testing is positive for myeloperoxidase-ANCA. Which classification best describes his glomerulonephritis?
A: Correct. ANCA-associated glomerulonephritis typically demonstrates necrotizing crescentic injury with minimal immune deposition, described as pauci-immune. Positive myeloperoxidase-ANCA further supports this diagnosis.
B: Incorrect. Anti-GBM glomerulonephritis is generally characterized by linear IgG staining along the glomerular basement membrane, which is absent here.
C: Incorrect. Immune complex-mediated glomerulonephritis usually demonstrates granular immune deposits, rather than a pauci-immune immunofluorescence pattern.
D: Incorrect. Hemodynamic kidney injury does not produce the necrotizing crescentic glomerular inflammation documented on biopsy.
- Question 7 of 10
A 52-year-old woman presents with 6 months of fatigue, constipation, cold intolerance, and progressive weight gain. Examination reveals dry skin and delayed relaxation of deep tendon reflexes. Laboratory testing shows a TSH of 19.6 mIU/L (reference range, 0.4–4.5) and free T4 of 0.5 ng/dL (reference range, 0.8–1.8). Which of the following best classifies her thyroid dysfunction?
A. Correct. Primary hypothyroidism is characterized by elevated TSH and decreased free T4. Reduced thyroid hormone production removes negative feedback on the pituitary, causing TSH to rise. The patient's symptoms and laboratory findings are consistent with overt primary hypothyroidism.
B. Incorrect. Central hypothyroidism results from hypothalamic or pituitary dysfunction and typically produces low free T4 with a low or inappropriately normal TSH rather than a markedly elevated TSH.
C. Incorrect. Primary hyperthyroidism usually produces suppressed TSH and elevated free T4, the opposite of this patient's laboratory pattern.
D. Incorrect. Subclinical hypothyroidism is characterized by elevated TSH with free T4 remaining within the reference range. The patient's low free T4 establishes overt hypothyroidism.
- Question 8 of 10
A 68-year-old postmenopausal woman undergoes dual-energy X-ray absorptiometry (DXA) as part of fracture risk assessment. Her lumbar spine T-score is -1.8, and her left femoral neck T-score is -2.6. She has no history of fragility fractures, and her calculated 10-year FRAX probability of hip fracture is 2.0%. Which interpretation of these findings is most appropriate?
A: Incorrect. Although the lumbar spine T-score is within the osteopenic range, osteoporosis classification is based on the lowest qualifying T-score at an appropriate skeletal site.
B: Correct. A DXA T-score of -2.5 or lower at the femoral neck, total hip, or lumbar spine establishes densitometric osteoporosis in a postmenopausal woman. The femoral neck T-score of -2.6 meets this criterion independently of the FRAX estimate.
C: Incorrect. FRAX estimates future fracture probability and informs treatment decisions, particularly in osteopenia. A relatively low FRAX probability does not negate a DXA diagnosis of osteoporosis.
D: Incorrect. The available DXA measurements provide sufficient information for classification. Repeat testing is not required solely because different skeletal sites have different T-scores.
- Question 9 of 10
A 58-year-old man with known cirrhosis presents to the emergency department after several episodes of hematemesis. His blood pressure is 88/54 mm Hg, and his heart rate is 118/min. The treating team suspects acute esophageal variceal hemorrhage. Which management strategy is most appropriate?
A: Incorrect. Suspected variceal hemorrhage requires urgent evaluation and endoscopic planning rather than delayed outpatient assessment.
B: Correct. Acute variceal bleeding in a patient with cirrhosis requires immediate attention to hemodynamic instability, initiation of vasoactive therapy and antibiotics, and urgent endoscopic planning. These interventions address the immediate risks of portal hypertensive hemorrhage.
C: Incorrect. Antibiotics are an important component of management but do not replace vasoactive therapy, hemodynamic stabilization, or urgent endoscopic assessment.
D: Incorrect. Observation alone delays interventions recommended for suspected acute variceal bleeding, particularly in a patient with hypotension and tachycardia.
- Question 10 of 10
A 42-year-old man presents with 4 days of fatigue, nausea, and right upper quadrant discomfort. Laboratory studies show AST 540 U/L, ALT 760 U/L, alkaline phosphatase 135 U/L, total bilirubin 1.3 mg/dL, and INR 1.0. Which liver injury pattern best describes these findings?
A: Incorrect. Cholestatic injury is characterized by a disproportionate elevation of alkaline phosphatase relative to aminotransferases. The marked AST and ALT elevations in this patient do not support a predominantly cholestatic pattern.
B: Correct. Hepatocellular injury produces predominantly elevated AST and ALT, with comparatively smaller changes in alkaline phosphatase. This patient's markedly elevated aminotransferases and relatively modest alkaline phosphatase elevation establish a hepatocellular biochemical pattern.
C: Incorrect. A mixed pattern requires substantial contributions from both hepatocellular and cholestatic enzyme abnormalities. Here, aminotransferase elevations clearly predominate.
D: Incorrect. Hepatic synthetic dysfunction is evaluated in part through INR, which is normal in this patient. Marked AST and ALT elevations demonstrate biochemical liver injury rather than isolated synthetic dysfunction.
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