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Free IM Practice Questions

10 free, exam-style Internal Medicine (IM) practice questions with answers and explanations. No signup required. Work through them below, then take the full free IM practice test to study every exam domain.

The IM exam has 240 questions and runs 10 hours.

These 10 free IM questions are organized by exam domain, so you can see how each part of the Internal Medicine blueprint is tested. Reveal the answer and explanation under each question.

Domain 1: Allergy and Immunology 2% of exam

Question 1

A 34-year-old woman has blood pressure of 168/104 mm Hg on three visits despite lifestyle changes. Serum potassium is 3.1 mmol/L (reference 3.5-5.0) with no diuretic use. Plasma aldosterone concentration is elevated and plasma renin activity is suppressed, giving a high aldosterone-to-renin ratio. Which of the following is the most appropriate next step?

  1. Proceed to confirmatory testing, then CT of the adrenal glands or adrenal vein sampling
  2. Add hydrochlorothiazide to her regimen and recheck the potassium level in 2 weeks
  3. Measure fractionated plasma metanephrines to evaluate for a pheochromocytoma
  4. Start an ACE inhibitor and reassess the blood pressure response in 1 month
Show answer & explanation

Correct answer: A - Proceed to confirmatory testing, then CT of the adrenal glands or adrenal vein sampling

Question 2

A 72-year-old man with newly diagnosed nonvalvular atrial fibrillation has hypertension and diabetes but no prior stroke. He asks whether he needs a blood thinner. Using the CHA₂DS₂-VASc score to guide therapy, which of the following is most appropriate?

  1. No antithrombotic therapy is needed because he has never had a stroke or TIA
  2. Aspirin 81 mg daily is preferred because his overall stroke risk remains low
  3. Warfarin titrated to a target INR of 2.5 to 3.5 is the recommended option
  4. A direct oral anticoagulant, because his score indicates elevated stroke risk
Show answer & explanation

Correct answer: D - A direct oral anticoagulant, because his score indicates elevated stroke risk

Question 3

A 68-year-old man reports exertional syncope and worsening dyspnea. Examination reveals a late-peaking crescendo-decrescendo systolic murmur at the right upper sternal border that radiates to the carotids, with a diminished and delayed carotid upstroke. Which of the following is the most likely diagnosis?

  1. Hypertrophic obstructive cardiomyopathy
  2. Aortic stenosis
  3. Chronic mitral regurgitation with volume overload
  4. Chronic aortic regurgitation with a wide pulse pressure
Show answer & explanation

Correct answer: B - Aortic stenosis

Domain 2: Cardiovascular Disease 14% of exam

Question 4

A 41-year-old woman has palpitations, heat intolerance, and a tender, enlarged thyroid following a recent upper respiratory illness. TSH is suppressed and free T4 is elevated. The erythrocyte sedimentation rate is markedly elevated, and radioactive iodine uptake is low. Which of the following is the most likely diagnosis?

  1. Graves disease from stimulating TSH-receptor antibodies
  2. Toxic multinodular goiter with autonomous nodules
  3. Subacute (de Quervain) thyroiditis
  4. Factitious ingestion of exogenous thyroid hormone
Show answer & explanation

Correct answer: C - Subacute (de Quervain) thyroiditis

Question 5

A 60-year-old man with small cell lung cancer has serum sodium of 122 mmol/L (reference 135-145). He is euvolemic. Serum osmolality is low, urine osmolality is inappropriately high, and urine sodium is elevated. Which of the following best distinguishes this condition from cerebral salt wasting?

  1. Volume status is euvolemic here, whereas cerebral salt wasting causes hypovolemia
  2. Urine sodium is elevated in this condition but is characteristically low in salt wasting
  3. Serum osmolality is low in this condition but is typically normal in salt wasting
  4. Urine osmolality is high in this condition but is usually low in salt wasting
Show answer & explanation

Correct answer: A - Volume status is euvolemic here, whereas cerebral salt wasting causes hypovolemia

Domain 3: Dermatology 3% of exam

Question 6

A 55-year-old man with cirrhosis and ascites presents with fever and diffuse abdominal pain. Diagnostic paracentesis shows an ascitic fluid polymorphonuclear (PMN) count of 320 cells/µL. Which of the following is the most appropriate next step?

  1. Repeat the paracentesis in 48 hours to confirm the upward trend before treating
  2. Give oral ciprofloxacin only if the ascitic fluid cultures return positive
  3. Start empiric intravenous cefotaxime for spontaneous bacterial peritonitis
  4. Transfuse intravenous albumin and observe closely without antibiotics
Show answer & explanation

Correct answer: C - Start empiric intravenous cefotaxime for spontaneous bacterial peritonitis

Question 7

An asymptomatic 45-year-old man with no family history of colorectal cancer and no other risk factors asks when he should begin colorectal cancer screening. According to current U.S. screening recommendations for average-risk adults, which of the following is most appropriate?

  1. Begin colorectal cancer screening now, at age 45
  2. Wait and begin screening at age 50
  3. Screen only if he later develops gastrointestinal symptoms
  4. Defer screening until age 60 given his lack of risk factors
Show answer & explanation

Correct answer: A - Begin colorectal cancer screening now, at age 45

Domain 4: Endocrinology, Diabetes, and Metabolism 9% of exam

Question 8

A 38-year-old man with newly diagnosed HIV has a CD4 count of 180 cells/µL and is asymptomatic. In addition to starting antiretroviral therapy, which of the following prophylactic regimens is most appropriate at this time?

  1. Azithromycin prophylaxis against Mycobacterium avium complex infection
  2. Fluconazole prophylaxis against cryptococcal meningitis and candidiasis
  3. Trimethoprim-sulfamethoxazole for Pneumocystis jirovecii pneumonia
  4. Valganciclovir prophylaxis against cytomegalovirus retinitis and colitis
Show answer & explanation

Correct answer: C - Trimethoprim-sulfamethoxazole for Pneumocystis jirovecii pneumonia

Question 9

A 29-year-old woman from Connecticut develops a fever, headache, and an expanding erythematous rash with central clearing at the site of a tick bite two weeks ago. She is otherwise well with no neurologic or cardiac findings. Which of the following is the most appropriate treatment?

  1. Intravenous ceftriaxone for disseminated infection
  2. Oral amoxicillin-clavulanate for 21 days
  3. Await serologic confirmation before starting any therapy
  4. Oral doxycycline for early localized disease
Show answer & explanation

Correct answer: D - Oral doxycycline for early localized disease

Domain 5: Gastroenterology 9% of exam

Question 10

A 62-year-old woman presents with acute pleuritic chest pain and dyspnea 5 days after knee replacement. Heart rate is 112/min and oxygen saturation is 91% on room air. She is hemodynamically stable. A CT pulmonary angiogram confirms a segmental pulmonary embolism. Which of the following is the most appropriate initial treatment?

  1. Systemic thrombolysis with intravenous alteplase
  2. Anticoagulation with a direct oral anticoagulant such as apixaban
  3. Placement of a retrievable inferior vena cava filter
  4. Aspirin therapy with outpatient follow-up in 1 week
Show answer & explanation

Correct answer: B - Anticoagulation with a direct oral anticoagulant such as apixaban

The rest of the IM blueprint

The IM exam also covers these domains. Drill them in the full free practice test:

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