A 44-year-old man has had 2 weeks of low back pain radiating down the posterior left leg to the lateral foot after lifting furniture. He has no bowel or bladder symptoms, fever, weight loss, intravenous drug use, or history of cancer. Ibuprofen gives partial relief. Straight-leg raise on the left reproduces leg pain at 40 degrees. Strength is normal throughout, the left ankle reflex is diminished, and sensation is mildly reduced over the lateral foot. Saddle sensation and rectal tone are normal. Which of the following is the most appropriate next step in management?

Continue NSAID therapy and remain active

Epidural glucocorticoid injection now

MRI of the lumbar spine without contrast

A 68-year-old man with heart failure with reduced ejection fraction (LVEF 30%) and NYHA class III symptoms is evaluated for fatigue despite guideline-directed medical therapy. Colonoscopy and upper endoscopy performed 1 year ago were normal, and stool testing for occult blood is negative. Hemoglobin is 11.6 g/dL, mean corpuscular volume 86 fL, ferritin 82 ng/mL [24-336], transferrin saturation 13%, and eGFR 55 mL/min/1.73 m2. Which of the following is the most appropriate treatment?

Intravenous ferric carboxymaltose

No treatment; anemia of inflammation

A 46-year-old woman is evaluated for a mole on her upper back that her husband says has darkened and enlarged over 6 months. She has fair skin, many nevi and a history of blistering sunburns. The lesion is a 9-mm asymmetric macule with irregular borders and brown, black and pink areas, and it looks different from her other nevi. There is no palpable lymphadenopathy. Which of the following is the most appropriate next step in management?

Excisional biopsy with 1- to 3-mm margins

Superficial shave biopsy of the lesion

Punch biopsy of the darkest central area

Dermoscopy with photographs repeated in 3 months

Wide local excision with 2-cm margins

A 61-year-old man undergoes sigmoid colectomy for adenocarcinoma. Pathology shows tumor invading through the muscularis propria into pericolic fat, with 3 of 18 lymph nodes positive and negative margins. Staging CT of the chest, abdomen, and pelvis shows no distant metastases. Postoperative CEA is normal. The tumor is mismatch repair–proficient. He has recovered well from surgery, is fully active, and has normal kidney function. Which of the following is the most appropriate next step in management?

Adjuvant oxaliplatin-based chemotherapy

Adjuvant pelvic external-beam radiation

Adjuvant bevacizumab-based therapy

Adjuvant pembrolizumab immunotherapy

Surveillance with serial CEA and CT scans

A 27-year-old woman with systemic lupus erythematosus diagnosed 2 years ago, maintained on hydroxychloroquine, has new ankle swelling. Blood pressure is 142/90 mm Hg. Creatinine is 1.0 mg/dL (baseline 0.7). Urinalysis shows 2+ protein, 15 to 20 erythrocytes/hpf with dysmorphic forms, and erythrocyte casts. Urine protein-to-creatinine ratio is 1.6 g/g. Anti–double-stranded DNA titer has risen, and C3 and C4 levels are low. Platelet count and coagulation studies are normal. Which of the following is the most appropriate next step in management?

Empiric intravenous cyclophosphamide

Increase hydroxychloroquine dose

A 70-year-old man hospitalized for pneumonia receives subcutaneous unfractionated heparin for thromboprophylaxis. On hospital day 7, his platelet count has fallen from 210,000/µL to 78,000/µL, and he has new left calf swelling; ultrasonography shows a popliteal vein thrombosis. He has received no new medications, and there is no sepsis or DIC. Serum creatinine is 3.4 mg/dL (estimated creatinine clearance 18 mL/min), and liver chemistries are normal. Which of the following is the most appropriate management?

Stop heparin and start argatroban

Continue heparin pending serotonin release assay

Stop heparin and start warfarin

Stop heparin and start fondaparinux

Switch to therapeutic enoxaparin

A 56-year-old man with untreated hypertension is brought to the emergency department with 1 day of severe headache, vomiting, and progressive confusion. Blood pressure is 228/138 mm Hg, pulse 96/min. He is disoriented but moves all limbs symmetrically. Funduscopic examination shows bilateral papilledema with flame hemorrhages. Noncontrast head CT shows no hemorrhage or infarct. Creatinine is 1.8 mg/dL [0.7–1.3]; urinalysis shows 2+ protein. Which of the following is the most appropriate management?

Intravenous nicardipine to lower mean arterial pressure by about 25% in the first hour

Intravenous labetalol only if blood pressure remains above 220/120 mm Hg in 6 hours

Oral clonidine every hour until blood pressure is below 160/100 mm Hg

Intravenous hydralazine boluses to lower blood pressure below 130/80 mm Hg today

Intravenous nicardipine to lower blood pressure below 140/90 mm Hg within the first hour

A 52-year-old woman has a 2.8-cm, node-positive, HER2-positive, hormone receptor–negative invasive breast cancer. Neoadjuvant therapy with docetaxel, carboplatin, trastuzumab, and pertuzumab is planned. She has hypertension treated with lisinopril, no cardiac symptoms, and no history of anthracycline exposure or chest radiation. Blood pressure is 134/82 mm Hg, and cardiac examination is normal. Electrocardiogram is normal. She has never had an echocardiogram. Which of the following is the most appropriate test before starting therapy?

Serum B-type natriuretic peptide

Exercise treadmill stress testing

Coronary artery calcium scoring

ABIM Internal Medicine Certification Exam

Free ABIM Internal Medicine Practice Questions

10 sample questions for the ABIM Internal Medicine Certification Exam, with the correct answer and an explanation for each. No account needed. Try each one before you open the answer.

Sections covered on the exam: Cardiovascular Disease, Nephrology and Urology, Gastroenterology, Rheumatology and Orthopedics, Obstetrics and Gynecology, Ophthalmology, Otolaryngology and Dental Medicine, Hematology, Allergy and Immunology, Medical Oncology, Miscellaneous, Pulmonary Disease, Psychiatry, Dermatology.

Question 1 · Cardiovascular Disease
A 34-year-old man with newly diagnosed Burkitt lymphoma and bulky abdominal disease is to begin chemotherapy tomorrow. Laboratory studies show creatinine 1.4 mg/dL, uric acid 10.8 mg/dL [3.5–7.2], potassium 4.9 mEq/L, phosphorus 4.6 mg/dL [2.5–4.5], calcium 9.0 mg/dL, and lactate dehydrogenase 2,900 U/L [100–220]. Glucose-6-phosphate dehydrogenase activity is normal. Aggressive intravenous isotonic fluids have been started, and urine output is adequate. Which of the following is the most appropriate additional management?
- A.Rasburicase
- B.Prophylactic hemodialysis
- C.Allopurinol
- D.Sodium bicarbonate infusion
- E.Febuxostat
Show answer and explanation
Answer: A. Rasburicase
Burkitt lymphoma with bulky disease, high LDH, elevated uric acid and early kidney injury is at high risk of tumor lysis syndrome. Rasburicase, a recombinant urate oxidase, rapidly lowers existing uric acid and is preferred for high-risk patients or those with hyperuricemia, after excluding G6PD deficiency, which causes hemolysis and methemoglobinemia. Allopurinol and febuxostat only prevent new uric acid formation and do not lower an already elevated level quickly; they suit intermediate risk. Sodium bicarbonate infusion is no longer recommended because alkalinization promotes calcium phosphate precipitation. Prophylactic hemodialysis is not indicated without refractory hyperkalemia, volume overload, or severe kidney failure.
Question 2 · Rheumatology and Orthopedics
A 44-year-old man has had 2 weeks of low back pain radiating down the posterior left leg to the lateral foot after lifting furniture. He has no bowel or bladder symptoms, fever, weight loss, intravenous drug use, or history of cancer. Ibuprofen gives partial relief. Straight-leg raise on the left reproduces leg pain at 40 degrees. Strength is normal throughout, the left ankle reflex is diminished, and sensation is mildly reduced over the lateral foot. Saddle sensation and rectal tone are normal. Which of the following is the most appropriate next step in management?
- A.Referral for lumbar discectomy
- B.Epidural glucocorticoid injection now
- C.Continue NSAID therapy and remain active
- D.MRI of the lumbar spine without contrast
- E.Bed rest for 3 to 5 days
Show answer and explanation
Answer: C. Continue NSAID therapy and remain active
He has an acute left S1 radiculopathy from a likely disc herniation with no red flags and no motor deficit. Most such cases improve within 6 weeks, so the best approach is to continue NSAID therapy and remain active. MRI of the lumbar spine without contrast is indicated for red flags, progressive or severe neurologic deficit, or persistent symptoms after about 6 weeks in a surgical or injection candidate; a reduced reflex and mild sensory change do not qualify. Epidural glucocorticoid injection gives only short-term relief and is not first-line. Bed rest delays recovery. Discectomy is for cauda equina syndrome, progressive weakness, or refractory pain.
Question 3 · Hematology
A 68-year-old man with heart failure with reduced ejection fraction (LVEF 30%) and NYHA class III symptoms is evaluated for fatigue despite guideline-directed medical therapy. Colonoscopy and upper endoscopy performed 1 year ago were normal, and stool testing for occult blood is negative. Hemoglobin is 11.6 g/dL, mean corpuscular volume 86 fL, ferritin 82 ng/mL [24-336], transferrin saturation 13%, and eGFR 55 mL/min/1.73 m2. Which of the following is the most appropriate treatment?
- A.No treatment; anemia of inflammation
- B.Intravenous ferric carboxymaltose
- C.Red blood cell transfusion
- D.Oral ferrous sulfate daily
- E.Darbepoetin alfa
Show answer and explanation
Answer: B. Intravenous ferric carboxymaltose
Ferritin is an acute-phase reactant, so in heart failure iron deficiency is present with ferritin below 100 ng/mL, or up to about 300 ng/mL when transferrin saturation is below 20%. This patient meets that definition, and intravenous ferric carboxymaltose improves symptoms, exercise capacity and heart failure hospitalization in HFrEF. Oral iron is poorly absorbed in heart failure and did not improve exercise capacity in trials. Calling this anemia of inflammation because ferritin is normal is the key trap. Erythropoiesis-stimulating agents increased thrombotic events in heart failure without benefit, and transfusion is not indicated at this hemoglobin.
Question 4 · Dermatology
A 46-year-old woman is evaluated for a mole on her upper back that her husband says has darkened and enlarged over 6 months. She has fair skin, many nevi and a history of blistering sunburns. The lesion is a 9-mm asymmetric macule with irregular borders and brown, black and pink areas, and it looks different from her other nevi. There is no palpable lymphadenopathy. Which of the following is the most appropriate next step in management?
- A.Superficial shave biopsy of the lesion
- B.Punch biopsy of the darkest central area
- C.Dermoscopy with photographs repeated in 3 months
- D.Wide local excision with 2-cm margins
- E.Excisional biopsy with 1- to 3-mm margins
Show answer and explanation
Answer: E. Excisional biopsy with 1- to 3-mm margins
An evolving, asymmetric, multicolored 9-mm lesion that stands out from her other nevi (the ugly duckling sign) requires biopsy for suspected melanoma. Excisional biopsy with 1- to 3-mm margins removes the whole lesion so that Breslow thickness, the main determinant of prognosis, definitive margins and sentinel node decisions, can be measured accurately. A superficial shave may transect the base and understage the tumor. Wide excision with 2-cm margins is definitive treatment chosen after thickness is known. A partial punch biopsy samples only part of a small lesion and risks missing the thickest area. Short-term monitoring is inappropriate for a lesion that is already changing.
Question 5 · Cardiovascular Disease
A 61-year-old man undergoes sigmoid colectomy for adenocarcinoma. Pathology shows tumor invading through the muscularis propria into pericolic fat, with 3 of 18 lymph nodes positive and negative margins. Staging CT of the chest, abdomen, and pelvis shows no distant metastases. Postoperative CEA is normal. The tumor is mismatch repair–proficient. He has recovered well from surgery, is fully active, and has normal kidney function. Which of the following is the most appropriate next step in management?
- A.Adjuvant pelvic external-beam radiation
- B.Adjuvant bevacizumab-based therapy
- C.Adjuvant pembrolizumab immunotherapy
- D.Adjuvant oxaliplatin-based chemotherapy
- E.Surveillance with serial CEA and CT scans
Show answer and explanation
Answer: D. Adjuvant oxaliplatin-based chemotherapy
This is stage III colon cancer (node-positive, no distant disease). Adjuvant oxaliplatin-based chemotherapy, such as capecitabine plus oxaliplatin or FOLFOX, improves overall survival and is standard for fit patients. Surveillance with serial CEA and CT scans is appropriate for most stage I and low-risk stage II tumors, not node-positive disease. Adjuvant pelvic external-beam radiation applies to rectal cancer, not sigmoid colon cancer. Adjuvant pembrolizumab immunotherapy is not standard and is relevant mainly to mismatch repair–deficient metastatic disease; this tumor is proficient. Adjuvant bevacizumab-based therapy failed to improve outcomes in trials of resected colon cancer.
Question 6 · Rheumatology and Orthopedics
A 27-year-old woman with systemic lupus erythematosus diagnosed 2 years ago, maintained on hydroxychloroquine, has new ankle swelling. Blood pressure is 142/90 mm Hg. Creatinine is 1.0 mg/dL (baseline 0.7). Urinalysis shows 2+ protein, 15 to 20 erythrocytes/hpf with dysmorphic forms, and erythrocyte casts. Urine protein-to-creatinine ratio is 1.6 g/g. Anti–double-stranded DNA titer has risen, and C3 and C4 levels are low. Platelet count and coagulation studies are normal. Which of the following is the most appropriate next step in management?
- A.Repeat urinalysis in 3 months
- B.Empiric mycophenolate mofetil
- C.Empiric intravenous cyclophosphamide
- D.Increase hydroxychloroquine dose
- E.Percutaneous kidney biopsy
Show answer and explanation
Answer: E. Percutaneous kidney biopsy
Proteinuria above 0.5 g/day with an active sediment (dysmorphic erythrocytes, erythrocyte casts), rising creatinine and serologic activity indicate lupus nephritis. Percutaneous kidney biopsy is the next step, because ISN/RPS class and activity versus chronicity determine therapy; proliferative class III or IV disease needs induction immunosuppression, while class V and minimal disease are managed differently. Empiric mycophenolate mofetil or intravenous cyclophosphamide skips the classification that guides treatment intensity, and biopsy is safe with normal platelets and coagulation. Repeat urinalysis in 3 months delays treatment of potentially progressive glomerulonephritis. Increasing the hydroxychloroquine dose does not treat nephritis and raises retinal toxicity risk.
Question 7 · Dermatology
A 36-year-old man with Crohn disease in remission on no therapy for 2 years is evaluated for worsening plaque psoriasis. He has well-demarcated scaly plaques on the elbows, knees, scalp and trunk covering about 18% of body surface area despite high-potency topical glucocorticoids and calcipotriene. He has no joint symptoms, heart failure or demyelinating disease. Interferon-gamma release assay and hepatitis B and C serologies are negative. Which of the following is the most appropriate treatment?
- A.Etanercept
- B.Oral prednisone taper
- C.Ustekinumab
- D.Secukinumab
- E.Acitretin
Show answer and explanation
Answer: C. Ustekinumab
Moderate to severe psoriasis uncontrolled on topical therapy warrants a biologic, and coexisting Crohn disease guides the choice. Ustekinumab, which blocks interleukins 12 and 23, is effective for both psoriasis and Crohn disease. Secukinumab and other interleukin-17 inhibitors can provoke or worsen inflammatory bowel disease. Etanercept treats psoriasis but is ineffective for Crohn disease, unlike monoclonal tumor necrosis factor antibodies. Acitretin is less effective than biologics and does not treat bowel disease. Systemic glucocorticoids can trigger pustular flares on withdrawal and are avoided in psoriasis.
Question 8 · Hematology
A 70-year-old man hospitalized for pneumonia receives subcutaneous unfractionated heparin for thromboprophylaxis. On hospital day 7, his platelet count has fallen from 210,000/µL to 78,000/µL, and he has new left calf swelling; ultrasonography shows a popliteal vein thrombosis. He has received no new medications, and there is no sepsis or DIC. Serum creatinine is 3.4 mg/dL (estimated creatinine clearance 18 mL/min), and liver chemistries are normal. Which of the following is the most appropriate management?
- A.Stop heparin and start argatroban
- B.Continue heparin pending serotonin release assay
- C.Stop heparin and start warfarin
- D.Stop heparin and start fondaparinux
- E.Switch to therapeutic enoxaparin
Show answer and explanation
Answer: A. Stop heparin and start argatroban
His 4Ts score is 8 (platelet fall over 50% with nadir above 20,000, onset day 5 to 10, new thrombosis, no other cause), so heparin-induced thrombocytopenia is highly likely. All heparin must be stopped and a non-heparin anticoagulant started without waiting for confirmatory testing. Argatroban is hepatically cleared and is the appropriate choice with severe kidney impairment. Fondaparinux is renally cleared and contraindicated with creatinine clearance below 30 mL/min. Enoxaparin cross-reacts with HIT antibodies. Warfarin started during acute HIT can cause venous limb gangrene and must wait until platelets recover to at least 150,000/µL.
Question 9 · Nephrology and Urology
A 56-year-old man with untreated hypertension is brought to the emergency department with 1 day of severe headache, vomiting, and progressive confusion. Blood pressure is 228/138 mm Hg, pulse 96/min. He is disoriented but moves all limbs symmetrically. Funduscopic examination shows bilateral papilledema with flame hemorrhages. Noncontrast head CT shows no hemorrhage or infarct. Creatinine is 1.8 mg/dL [0.7–1.3]; urinalysis shows 2+ protein. Which of the following is the most appropriate management?
- A.Intravenous nicardipine to lower mean arterial pressure by about 25% in the first hour
- B.Intravenous labetalol only if blood pressure remains above 220/120 mm Hg in 6 hours
- C.Oral clonidine every hour until blood pressure is below 160/100 mm Hg
- D.Intravenous hydralazine boluses to lower blood pressure below 130/80 mm Hg today
- E.Intravenous nicardipine to lower blood pressure below 140/90 mm Hg within the first hour
Show answer and explanation
Answer: A. Intravenous nicardipine to lower mean arterial pressure by about 25% in the first hour
Encephalopathy, papilledema with hemorrhages, and acute kidney injury define hypertensive emergency with hypertensive encephalopathy. A titratable intravenous agent such as nicardipine should lower mean arterial pressure by no more than about 25% in the first hour, then toward 160/100 mm Hg over the next 2 to 6 hours, because cerebral autoregulation is shifted upward. Rapid normalization below 140/90 within an hour risks cerebral, renal, and coronary ischemia. Oral clonidine and unpredictable hydralazine boluses are poorly titratable. Waiting 6 hours with a permissive threshold is the acute ischemic stroke rule, which does not apply here.
Question 10 · Cardiovascular Disease
A 52-year-old woman has a 2.8-cm, node-positive, HER2-positive, hormone receptor–negative invasive breast cancer. Neoadjuvant therapy with docetaxel, carboplatin, trastuzumab, and pertuzumab is planned. She has hypertension treated with lisinopril, no cardiac symptoms, and no history of anthracycline exposure or chest radiation. Blood pressure is 134/82 mm Hg, and cardiac examination is normal. Electrocardiogram is normal. She has never had an echocardiogram. Which of the following is the most appropriate test before starting therapy?
- A.Serum B-type natriuretic peptide
- B.Transthoracic echocardiography
- C.Exercise treadmill stress testing
- D.Baseline bone density by DXA
- E.Coronary artery calcium scoring
Show answer and explanation
Answer: B. Transthoracic echocardiography
Trastuzumab and pertuzumab cause cardiotoxicity through reduced left ventricular ejection fraction, which is usually reversible and not dose-dependent. Baseline transthoracic echocardiography (or multigated acquisition scan) is required, with repeat assessment about every 3 months during HER2-directed therapy, and treatment is held for a significant decline. Serum B-type natriuretic peptide may complement imaging but does not establish baseline ejection fraction. Exercise treadmill stress testing and coronary artery calcium scoring evaluate coronary disease, which is not the mechanism of trastuzumab toxicity. Baseline bone density by DXA is needed before aromatase inhibitors, but this tumor is hormone receptor–negative and the regimen does not cause rapid bone loss.

Keep practicing for the ABIM Internal Medicine

TTP Prep has 200 ABIM Internal Medicine practice questions with explanations, timed and mock-exam modes, 324 flashcards, interactive lessons, a printable cheat sheet and a readiness score. Start free, no card needed.

Take a free Quick 10 See everything in the ABIM Internal Medicine prep