100+ Free Arab Board IM Final Written Practice Questions

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Sample Arab Board IM Final Written Practice Questions

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1A 64-year-old man presents with recurrent episodes of retrosternal chest pressure occurring at rest over the past 12 hours. His ECG shows 1.5-mm horizontal ST-segment depression in leads V4 through V6 and T-wave inversion in lead aVL. High-sensitivity cardiac troponin I is elevated at 480 ng/L (reference < 14 ng/L). His calculated GRACE risk score is 158. He is hemodynamically stable with a blood pressure of 135/85 mmHg and a heart rate of 76 bpm. Which of the following is the most appropriate next step in management?

A.Early invasive coronary angiography within 24 hours

B.Immediate intravenous thrombolytic therapy with tenecteplase

C.Outpatient exercise treadmill stress electrocardiography

D.Elective myocardial perfusion scintigraphy in 4 to 6 weeks

Explanation: This patient has a high-risk Non-ST-Segment Elevation Acute Coronary Syndrome (NSTE-ACS), evidenced by dynamic ST-segment depression, positive cardiac biomarkers, and a high GRACE risk score (>140). International guidelines (ESC/ACC) strongly recommend an early invasive strategy with coronary angiography within 24 hours of presentation for high-risk NSTE-ACS patients to improve clinical outcomes and reduce recurrent ischemic events. Fibrinolytic therapy is strictly contraindicated in NSTE-ACS because it increases mortality without clinical benefit.

2A 58-year-old woman with ischemic cardiomyopathy and heart failure with reduced ejection fraction (LVEF 28%, NYHA functional class II) is evaluated in the clinic. Her current medications include guideline-target doses of enalapril and bisoprolol. Her vital signs are: BP 118/74 mmHg, HR 64 bpm. Laboratory evaluation shows serum sodium 139 mEq/L, potassium 4.2 mEq/L, and eGFR 68 mL/min/1.73 m2. Which of the following medications should be added next to improve survival according to guideline-directed medical therapy (GDMT)?

A.Empagliflozin

B.Digoxin

C.Amlodipine

D.Furosemide

Explanation: Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) is built upon four foundational pillar classes: RAS inhibitors (preferably ARNI or ACEi/ARB), evidence-based beta-blockers, mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter 2 (SGLT2) inhibitors (such as empagliflozin or dapagliflozin). SGLT2 inhibitors significantly reduce all-cause mortality and heart failure hospitalizations in HFrEF regardless of whether the patient has type 2 diabetes. Digoxin improves symptoms and reduces hospitalizations but does not improve overall mortality.

3A 46-year-old man with active Staphylococcus aureus aortic valve endocarditis suddenly develops acute respiratory distress and severe orthopnea. On examination, his blood pressure is 95/70 mmHg, heart rate is 118 bpm, and respiratory rate is 32 breaths/min. Auscultation reveals a soft, short early diastolic murmur along the left sternal border and bilateral pulmonary rales. Transthoracic echocardiography demonstrates severe acute aortic regurgitation with large mobile vegetations and premature closure of the mitral valve in early diastole. Which of the following is the most appropriate definitive management?

A.Urgent surgical aortic valve replacement

B.Intravenous nitroprusside infusion and conservative medical therapy

C.Insertion of an intra-aortic balloon pump (IABP)

D.Six-week course of intravenous antibiotics prior to elective surgery

Explanation: Acute severe aortic regurgitation presents catastrophically with sudden hemodynamic collapse, flash pulmonary edema, and cardiogenic shock because the unprepared, non-compliant left ventricle cannot accommodate the massive regurgitant volume. Premature closure of the mitral valve on echocardiography is an ominous sign indicating marked elevation of left ventricular end-diastolic pressure exceeding left atrial pressure. Urgent surgical aortic valve intervention is lifesaving and mandatory; delaying surgery for prolonged medical therapy leads to rapid fatal decompensation.

4A 72-year-old woman is diagnosed with newly discovered non-valvular paroxysmal atrial fibrillation. Her medical history includes hypertension, type 2 diabetes mellitus, and a transient ischemic attack (TIA) two years ago. Her serum creatinine is 0.9 mg/dL (eGFR 72 mL/min/1.73 m2). Which of the following is the most appropriate initial therapy for thromboembolic stroke prevention?

A.Apixaban

B.Aspirin monotherapy 100 mg daily

C.Dual antiplatelet therapy with aspirin and clopidogrel

D.Subcutaneous low-molecular-weight heparin bridge to warfarin target INR 1.5-2.0

Explanation: This patient has a CHA2DS2-VASc score of 6 (Age 65-74 = 1, Female sex = 1, Hypertension = 1, Diabetes = 1, Prior TIA = 2), indicating a very high annual stroke risk (>9%). In non-valvular atrial fibrillation, Direct Oral Anticoagulants (DOACs, such as apixaban, dabigatran, rivaroxaban, or edoxaban) are preferred over vitamin K antagonists due to non-inferior or superior efficacy, significantly lower risk of intracranial hemorrhage, and predictable pharmacokinetics. Antiplatelet therapy is ineffective for cardioembolic stroke prevention in atrial fibrillation.

5A 28-year-old previously healthy man presents with sharp, retrosternal chest pain that began 24 hours ago. The pain worsens with deep inspiration and when lying flat on his back, but improves when sitting upright and leaning forward. A 12-lead ECG demonstrates widespread concave-upward ST-segment elevation with PR-segment depression in leads I, II, aVF, and V3 through V6, along with PR-segment elevation in lead aVR. High-sensitivity troponin levels are within normal limits. Which of the following is the first-line pharmacologic treatment for this patient?

A.High-dose ibuprofen plus colchicine

B.Oral prednisone monotherapy

C.Intravenous unfractionated heparin

D.Sublingual nitroglycerin as needed

Explanation: The clinical presentation and ECG findings are pathognomonic for acute pericarditis (pleuritic positional chest pain, widespread concave ST elevation, and PR depression with aVR PR elevation). First-line therapy for acute viral or idiopathic pericarditis is a combination of a nonsteroidal anti-inflammatory drug (NSAID, such as ibuprofen 600-800 mg every 8 hours) or aspirin, plus colchicine (0.5 mg daily or twice daily for 3 months). Colchicine significantly accelerates symptom resolution and halves the rate of recurrent pericarditis. Corticosteroids are reserved for patients with contraindications or refractory symptoms because they increase recurrence risk.

6A 32-year-old man presents with progressive exertional dyspnea and lightheadedness. On physical examination, a harsh crescendo-decrescendo systolic murmur is heard at the left lower sternal border; the murmur intensity increases noticeably during the strain phase of the Valsalva maneuver and decreases during passive leg raise. Transthoracic echocardiography reveals asymmetric septal hypertrophy (interventricular septal thickness 22 mm), systolic anterior motion of the mitral valve, and a resting left ventricular outflow tract (LVOT) gradient of 52 mmHg. Which of the following is the first-line medical therapy for this patient?

A.Metoprolol

B.Digoxin

C.Nitroglycerin

D.Amlodipine

Explanation: This patient has symptomatic Hypertrophic Obstructive Cardiomyopathy (HOCM). Dynamic LVOT obstruction is exacerbated by maneuvers that decrease LV preload (such as the Valsalva strain phase or standing) or increase myocardial contractility. First-line medical therapy consists of non-vasodilating beta-blockers (such as metoprolol or bisoprolol) titrated to symptom control; beta-blockers reduce heart rate, prolong diastolic ventricular filling time, decrease inotropy, and alleviate LVOT obstruction. Non-dihydropyridine calcium channel blockers (verapamil) are alternatives if beta-blockers are contraindicated.

7A 55-year-old woman presents to the emergency department with profound weakness and lightheadedness 10 days after undergoing coronary artery bypass graft surgery. Her blood pressure is 84/60 mmHg with a 16-mmHg inspiratory drop in systolic blood pressure. Heart rate is 120 bpm, and respiratory rate is 24 breaths/min. Jugular venous examination demonstrates prominent distention with a sharp x-descent and absent y-descent. Heart sounds are distant. ECG shows sinus tachycardia with low-voltage QRS complexes and electrical alternans. Which of the following is the immediate management of choice?

A.Emergency bedside pericardiocentesis

B.Aggressive intravenous diuresis with furosemide

C.Intravenous diltiazem for rate control

D.Immediate chest tube placement in the 5th intercostal space

Explanation: The clinical picture demonstrates Beck's triad (hypotension, jugular venous distention, muffled heart sounds), severe pulsus paradoxus (>10 mmHg inspiratory drop in SBP), electrical alternans, and hemodynamic collapse, diagnostic of cardiac tamponade. In tamponade, elevated intrapericardial pressure impairs diastolic filling of all cardiac chambers, leading to equalization of end-diastolic pressures and loss of the jugular y-descent. Immediate pericardiocentesis is lifesaving to relieve intrapericardial pressure and restore venous return and cardiac output.

8A 62-year-old man who presented 4 hours ago with an acute inferior wall ST-elevation myocardial infarction suddenly becomes confused and diaphoresis. His blood pressure drops to 78/48 mmHg and heart rate is 36 bpm. The cardiac monitor reveals complete atrioventricular (AV) dissociation with a regular narrow-complex escape rhythm at 36 bpm and independent P waves at 90 bpm. Which of the following is the most appropriate initial pharmacological and electrical intervention?

A.Intravenous atropine and immediate preparation for transcutaneous pacing

B.Intravenous amiodarone bolus and infusion

C.Intravenous adenosine rapid push

D.Intravenous metoprolol 5 mg bolus

Explanation: This patient has developed symptomatic third-degree (complete) AV block with severe hemodynamic instability (hypotension, confusion) complicating an acute inferior STEMI (often due to right coronary artery occlusion supplying the AV node). The immediate management for unstable bradyarrhythmias/high-grade AV block per ACLS guidelines is intravenous atropine (1 mg IV every 3-5 minutes, up to 3 mg) while immediately preparing for transcutaneous pacing and subsequent transvenous temporary pacing if non-responsive.

9A 40-year-old previously asymptomatic man is brought to the emergency department after experiencing a sudden syncopal episode while resting at home. His physical examination and baseline laboratory investigations are unremarkable. A 12-lead ECG demonstrates coved-type ST-segment elevation of 3 mm followed by a negative T wave in leads V1 and V2 (Type 1 Brugada pattern). Echocardiography reveals normal biventricular size and function with no structural heart disease. Which of the following is the definitive management of choice to prevent sudden cardiac death in this patient?

A.Implantable cardioverter-defibrillator (ICD) placement

B.Chronic oral flecainide therapy

C.Radiofrequency catheter ablation of the AV node

D.Long-term oral verapamil therapy

Explanation: Brugada syndrome is an inherited channelopathy (most commonly involving loss-of-function mutations in the SCN5A gene encoding the cardiac sodium channel) predisposing to polymorphic ventricular tachycardia and ventricular fibrillation. In patients with a spontaneous Type 1 Brugada ECG pattern who present with unexplained syncope or documented sustained ventricular arrhythmias, an implantable cardioverter-defibrillator (ICD) is the only proven therapy for the secondary prevention of sudden cardiac death. Class IC antiarrhythmics like flecainide are contraindicated because they unmask or worsen the arrhythmia.

10A 74-year-old man presents to the clinic with two recent episodes of syncope while climbing stairs. On physical examination, his carotid pulse is parvus et tardus (diminished and delayed), and auscultation reveals a harsh late-peaking systolic ejection murmur at the right upper sternal border radiating to the carotids, with a soft single S2. Transthoracic echocardiography reveals severe calcific aortic stenosis with a peak aortic jet velocity of 4.5 m/s, mean transaortic gradient of 48 mmHg, and an aortic valve area (AVA) of 0.65 cm2. Left ventricular ejection fraction is 55%. What is the most appropriate next step in management?

A.Aortic valve replacement (surgical or transcatheter)

B.Initiation of high-dose oral beta-blockers and reassurance

C.Balloon aortic valvuloplasty as definitive therapy

D.Repeat echocardiography in 12 months

Explanation: This patient has severe symptomatic calcific aortic stenosis (defined by peak velocity >= 4.0 m/s, mean gradient >= 40 mmHg, or AVA < 1.0 cm2 in the presence of classic cardinal symptoms: angina, syncope, or heart failure). Once symptoms such as exertional syncope develop, the 2-year mortality rate exceeds 50% without valve intervention. Aortic valve replacement—either surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVR)—is the only definitive treatment that restores normal hemodynamics, relieves symptoms, and improves survival.

About the Arab Board IM Final Written Exam

The Arab Board Internal Medicine Final Written Examination is the culminating cognitive exit assessment required for specialist board certification by the Arab Board of Health Specializations (ABHS). Spanning all subspecialties of internal medicine—including cardiology, pulmonary medicine, critical care, gastroenterology, hepatology, nephrology, endocrinology, hematology, oncology, infectious diseases, rheumatology, and neurology—this high-stakes examination evaluates senior residents and specialist candidates on complex clinical problem-solving, guideline-directed management, multi-system disease navigation, and therapeutic prioritization.

Assessment

A comprehensive final exit written examination of 120 to 200 A-type best-of-four single-best-answer multiple-choice questions assessing advanced diagnostic reasoning, evidence-based pharmacotherapy, and clinical decision-making across all internal medicine subspecialties.

Time Limit

Approximately 3 hours

Passing Score

60%. The ABHS examination-affairs decisions fix the pass mark at 60% for the primary written, final written and clinical/oral examinations across every scientific council; the Scientific Council of Internal Medicine guidebook adds that the mark is confirmed by criterion-referenced standard setting under the Arab Board bylaws.

Exam Fee

Set by ABHS and national councils (Arab Board of Health Specializations (ABHS) - Scientific Council of Internal Medicine)

Arab Board IM Final Written Exam Content Outline

14%

Cardiology

Risk stratification and timing of invasive coronary angiography in acute coronary syndromes, guideline-directed medical therapy (GDMT) sequencing in HFrEF and HFpEF, advanced valvular interventions, acute aortic syndromes, pericarditis and tamponade hemodynamics, and cardiac pacing/ICD indications.

14%

Pulmonary & Critical Care Medicine

Acute COPD and asthma exacerbation management, interstitial lung disease diagnosis and antifibrotic pharmacotherapy, intermediate- and high-risk pulmonary embolism algorithms, pulmonary arterial hypertension classification and combination vasodilators, ARDS lung-protective mechanical ventilation, and septic shock resuscitation.

12%

Gastroenterology & Hepatology

Multimodal management of acute variceal hemorrhage, spontaneous bacterial peritonitis prophylaxis and therapy, autoimmune liver diseases (PBC, PSC, AIH), acute severe ulcerative colitis rescue therapy, acute pancreatitis fluid and nutritional strategies, and non-alcoholic steatohepatitis (MASH) risk stratification.

12%

Nephrology & Acid-Base Disorders

Acute kidney injury etiology and biomarker evaluation, nephroprotective strategies in diabetic and non-diabetic chronic kidney disease (SGLT2 inhibitors, MRAs, RAS inhibitors), rapidly progressive glomerulonephritis workup and induction, severe electrolyte emergency correction (hyperkalemia, hyponatremia), and complex mixed acid-base analysis.

12%

Endocrinology, Diabetes & Metabolism

Inpatient and outpatient glycemic management, DKA and HHS fluid/insulin/electrolyte protocols, evaluation of hypercalcemia and hypocalcemia, adrenal crisis recognition and cosyntropin stimulation testing, Cushing syndrome step-wise diagnostic pathways, pheochromocytoma alpha/beta-blockade sequencing, and gestational thyroid disorders.

10%

Hematology & Medical Oncology

Differential diagnosis and investigation of anemias, immune thrombocytopenia treatment escalations, thrombotic microangiopathies (TTP ADAMTS13 testing and plasma exchange), chronic myeloproliferative neoplasms (CML TKI therapy, polycythemia vera phlebotomy targets), multiple myeloma diagnostic CRAB criteria, heparin-induced thrombocytopenia (HIT), and febrile neutropenia.

10%

Infectious Diseases & Antimicrobial Stewardship

Empiric and targeted antimicrobial regimens for community- and hospital-acquired infections, bacterial and cryptococcal meningitis induction, prosthetic valve endocarditis regimens, latent and active tuberculosis multi-drug therapy, opportunistic fungal infections (invasive aspergillosis, mucormycosis), and antimicrobial stewardship principles.

Rheumatology & Clinical Immunology

Early rheumatoid arthritis DMARD selection, lupus nephritis classification and immunosuppressive induction, scleroderma renal crisis ACE inhibitor management, giant cell arteritis high-dose corticosteroid urgency, ANCA-associated vasculitides, crystal arthropathy acute flare management in renal impairment, and antiphospholipid syndrome anticoagulation.

Neurology in Internal Medicine

Hyperacute ischemic stroke IV thrombolysis and endovascular thrombectomy candidacy, generalized status epilepticus step-wise medical escalations, myasthenia gravis crisis vs cholinergic crisis, Guillain-Barré syndrome immunotherapy, cerebral vasospasm prevention in subarachnoid hemorrhage, and herpes simplex encephalitis antiviral therapy.

How to Pass the Arab Board IM Final Written Exam

What You Need to Know

Passing score: 60%. The ABHS examination-affairs decisions fix the pass mark at 60% for the primary written, final written and clinical/oral examinations across every scientific council; the Scientific Council of Internal Medicine guidebook adds that the mark is confirmed by criterion-referenced standard setting under the Arab Board bylaws.
Assessment: A comprehensive final exit written examination of 120 to 200 A-type best-of-four single-best-answer multiple-choice questions assessing advanced diagnostic reasoning, evidence-based pharmacotherapy, and clinical decision-making across all internal medicine subspecialties.
Time limit: Approximately 3 hours
Exam fee: Set by ABHS and national councils

Keys to Passing

Work through all 100 available questions
Review every answer and explanation
Track weak areas and revisit them
Use our AI tutor for tough concepts

Arab Board IM Final Written Study Tips from Top Performers

1Focus systematically on high-yield subspecialty scenarios involving multi-system disease, such as cardio-renal syndrome, lupus nephritis, diabetic ketoacidosis with electrolyte derangements, and hepatorenal syndrome.

2Review authoritative international and regional clinical guidelines, including ESC/ACC heart failure and ACS guidelines, KDIGO kidney disease guidelines, ADA standards of diabetes care, IDSA sepsis and antimicrobial guidelines, and EULAR/ACR rheumatology recommendations.

3Master diagnostic test sequencing and management algorithms, paying specific attention to first-line disease-modifying agents, indications for urgent invasive procedures, and contraindications in renal or hepatic impairment.

Frequently Asked Questions

What is the format and structure of the Arab Board Internal Medicine Final Written Examination?

The examination is typically delivered as a single-best-answer multiple-choice question (MCQ) format consisting of approximately 150 questions across two examination papers, lasting about 3 hours in total.

What is the passing standard for the ABHS Internal Medicine Final Written Exam?

While the exact pass mark is determined through criterion-referenced standard-setting methods by the Scientific Council of Internal Medicine for each examination sitting, candidates generally target a benchmark of 60% or higher.

What eligibility requirements must candidates meet prior to sitting for the Final Written Exam?

Candidates must have successfully completed the full accredited residency training curriculum in internal medicine (typically 4 years) at an ABHS-accredited medical center, passed the Part 1 written examination, and completed all required in-training portfolio assessments and logbooks.

How does the Final Written Examination differ from the Part 1 Written Examination?

While the Part 1 examination focuses heavily on foundational pathophysiology, pharmacology, and core medical knowledge, the Final Written Examination evaluates senior clinical decision-making, multi-morbidity management, guideline-directed pharmacotherapy, diagnostic test selection, and critical care emergencies.

100+ Free Arab Board IM Final Written Practice Questions

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