Free ABIM Practice Test

The American Board of Internal Medicine (ABIM) examination is designed to assess the knowledge and skills of doctors who seek to practice in certain specialty areas. The exams are all-day events, and are renowned for their rigor.

ABIM exams are broken up into sessions: each exam session contains a maximum of sixty multiple-choice questions. A time allotment of two hours will be granted for completion of each exam session. You will also receive a one-hour lunch break.

The ABIM program includes initial certification exams and exams for the maintenance of the specific medical certification. Initial certification exams are offered in the following specialty areas: internal medicine; adolescent medicine, advanced heart failure and transparent cardiology; allergy and immunology; cardiovascular disease; clinical cardiac electrophysiology; critical care medicine; endocrinology, diabetes, and metabolism; gastroenterology; geriatric medicine; hematology; hospice and palliative medicine; infectious disease; interventional cardiology; medical oncology; nephrology; pulmonary disease; rheumatology; sleep medicine; sports medicine; and transplant hepatology. ABIM maintenance certification exams are offered in the following specialty areas: internal medicine; adolescent medicine; cardiovascular disease; clinical cardiac electrophysiology; critical care medicine; endocrinology, diabetes, and metabolism; gastroenterology; geriatric medicine; hematology; infectious disease; interventional cardiology; medical oncology; nephrology; pulmonary disease; rheumatology; and sports medicine.

All of the ABIM examinations are administered via computer. The computer screen will display the time remaining in each section. You will get a warning when you have five minutes left in each section.

Practice Questions

1. Your middle-aged female patient reports recurrent chest pain and two or three brief syncopal episodes. Clinical findings include a mid-systolic ejection murmur, with a prominent apex pulse, an S4 gallop, and a diminished carotid pulse. Her EKG shows a sinus rhythm with left ventricular hypertrophy. Choose the most likely diagnosis and appropriate treatment:

  1. Coronary artery disease and angioplasty
  2. Calcific aortic stenosis and balloon aortic valvotomy
  3. Calcific aortic stenosis and aortic valve replacement
  4. Calcific aortic stenosis and medical therapy

2. Your patient is a 65-year-old woman, who complains of intermittent chest pain and dyspnea on exertion. She takes a diuretic and an ACE inhibitor for hypertension. Her stress test indicated some septal reversibility. The Catheterization Laboratory reported an 80% obstruction in her LAD with collaterals from the RCA, and a 30% obstruction in her dominant RCA. Her left ventricular ejection fraction was 60%. Therefore, a surgeon performed angioplasty and inserted a stent for her. Shortly after returning to the CCU, your patient developed severe dyspnea, hypoxemia, hypotension, and chest discomfort. You observe no evidence of bleeding at her catheterization site. The Coagulation Laboratory reports her platelet count is 550,000/mm3, and her INR and PTT are normal, but her Ddimer is elevated to 6.0 ?g/mL (normal <0.50 ?g/mL). You start her on nasal oxygen. Choose the most appropriate treatment option now:

  1. Switch to unfractionated heparin intravenously
  2. Vascular surgery consults to install a vena caval filter
  3. Thrombolytic therapy with recombinant tissue-type plasminogen activator (TPA)
  4. Cardiovascular surgical consult for emergency coronary bypass

3. Your patient is a 40-year old woman, who was brought to your ER complaining of acute, severe upper and mid-abdominal pain, radiating from her epigastrium to her mid-back. She guards her abdomen. She denies alcohol abuse or prior abdominal surgery. She denies a recent change in her bowel habits, but her bowel sounds are markedly diminished. Choose the most likely diagnosis and the laboratory or imaging test to establish it:

  1. Acute pancreatitis established by serum amylase
  2. Small bowel obstruction established by plain films of the abdomen
  3. Acute cholecystitis established by ultrasound of the gall bladder
  4. Acute appendicitis established by CT of the abdomen

4. A 70-year-old man presents with brisk, maroon-color bleeding from his rectum. He has no history of bowel disease or previous gastrointestinal bleeding. He reports mild left lower quadrant pain for the past few days. His blood pressure is 140/70 mm/Hg, and his hemoglobin is 12 gm/dL. Identify the most likely source of his bleeding and your initial diagnostic step:

  1. Diverticular source diagnosed by barium enema
  2. Diverticular source diagnosed by colonoscopy
  3. Acute colitis diagnosed by colonoscopy
  4. Cancer of the ascending colon diagnosed by colonoscopy

5. A 30-year-old man has a history of cramping, mid-to-lower abdominal pain, frequent diarrhea that is occasionally bloody, and a 12 lb. weight loss over the past six months. His gastrointestinal work-up disclosed Crohn's disease involving his terminal ileum, and scattered colonic lesions. You started him on prednisone 40 mg/day and he enjoyed considerable improvement in his symptoms over the next two weeks. However, when you tapered his dose to 20 mg/day, his disease flared up again. Identify your next step for managing this patient:

  1. Increase the prednisone and maintain him on this higher dose indefinitely
  2. Temporarily increase the prednisone, add azathioprine, and then taper the steroid again
  3. Segmental resection of his terminal ileum
  4. Begin a 5-aminosalicylic acid containing drug
Answers

1. C: Calcific aortic stenosis and aortic valve replacement. Twenty-five percent of older adults suffer hardening and narrowing of the heart valves, and 3% develop more serious calcific aortic stenosis with obstruction. Trileaflet stenosis from aging causes 50% of cases; congenital bicuspid stenosis causes 40% of cases; only 10% of cases result from rheumatic fever. Signs and symptoms start between ages 40 and 60. Angina, syncope, and sometimes left ventricular failure occur when the valve opening narrows to one-third of normal, (Normal aortic valves measure 3 to 4 cm2). A geometric increase in the left ventricularaortic gradient occurs. Echocardiography estimates the gradient size by Doppler measurement of the flow velocity (gradient = 4 x velocity2). Cardiac catheterization is required for hemodynamic assessment, and to determine if coronary disease is present. Surgical valve replacement is indicated for all symptomatic patients able to undergo surgery. Balloon aortic valvotomy is inappropriate for non-surgical patients. Percutaneous aortic valve replacement holds future promise.

2. C: Thrombolytic therapy with recombinant tissue-type plasminogen activator (TPA). Your patient has a life-threatening situation, with a presumptive clinical diagnosis of massive pulmonary embolus. Heparin can prevent further clot formation, and allows the thrombolytic system to work more efficiently, but it may not be effective in dissolving a large thrombus. A vena caval filter is indicated for those patients with recurrent thromboemboli who receive adequate anticoagulant therapy, but a filter is useless for a pulmonary embolus that has already occurred. Pressor support with dopamine or norepinephrine is indicated, since she is hypotensive. Since there was evidence of only moderate coronary obstruction and good collaterals, and an angioplasty was performed, bypass surgery is not indicated. Her situation is dire, so start thrombolytic therapy with streptokinase (SK) or TPA immediately, even without imaging confirmation of the embolus.

3. A: Acute pancreatitis established by serum amylase. Your female patient's signs and symptoms are typical of acute pancreatitis, but you must consider other causes of acute, severe abdominal pain. The most likely cause of pancreatitis in this woman, who has no history of alcoholism, is gallstones with ductal hypertension and pancreatic enzyme activation. Serum amylase and lipase are nearly always markedly elevated, but lipase tends to remain elevated longer. Ultrasound of her abdomen may disclose gallstones, and a CT could reveal pancreatic edema. Acute cholecystitis is a possibility, but can usually be ruled out by ultrasonography. Bowel obstruction would be unlikely because she has no history of prior abdominal surgery leading to adhesions, diminished bowel sounds, and no change in her usual bowel movement pattern. Her pain pattern is unusual for appendicitis, but rule out that the anatomic position of her appendix is not causing atypical pain, by abdominal CT.

4. B: Diverticular source diagnosed by colonoscopy. Lower gastrointestinal bleeding is a common emergency, arising from many sources, including: Colon cancer; colitis; angiodysplasia; diverticula; and hemorrhoids. Bright red hematochezia is from the anus, rectum, or sigmoid. Maroon hematochezia of sudden onset is more likely from diverticula in the transverse or right colon, with mixed arterial and venous blood. Black melena is from the stomach or duodenum. Colonoscopy is the appropriate initial diagnostic test for all lower gastrointestinal bleeding, except when transfusion and emergency surgery are needed to prevent hypovolemic shock. Do not perform barium enemas for acute bleeding. Inflammatory bowel disease (ulcerative colitis or Crohn's disease) causes lower gastrointestinal bleeding, but usually in younger patients with prodromal diarrhea or abdominal pain. Cancer of the ascending colon in older adults produces occult blood with asymptomatic iron deficiency anemia, and is diagnosed by a positive Hemoccult test during routine screening.

5. B: Temporarily increase the prednisone, add azathioprine, and then taper the steroid again. Oral and intravenous corticosteroids induce remission in Crohn's disease. However, do not continue steroids indefinitely because of their considerable side-effects. Appropriate initial therapy may include antibiotics, such as metronidazole and/or ciprofloxacin. If a flare-up of Crohn's disease occurs while tapering steroids, then temporarily increase the steroid dose, and subsequently add an immunosuppressant. After several weeks on the anti-immune drug, try steroid tapering again. Only perform surgery early in Crohn's disease if your patient is refractory to medical therapy, or develops a fistula, abscess, or intestinal obstruction. You may use drugs containing 5-amino-salicylic acid (e.g., sulfasalazine and olsalazine) as maintenance therapy for Crohn's patients in remission. However, they are more useful for ulcerative colitis. Powdered opium and belladonna are antidiarrheal and antispasmodic medications for symptom relief, but they do not slow or cure Crohn's disease.

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Last Updated: 09/21/2017


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