Questions

Just like the actual exam

Aligned with the American Board of Internal Medicine format. Authored & peer-reviewed by faculty, clinicians, and program directors.

Each question is written to resemble the format and topics on the exam, meaning you won’t see any negatively phrased questions, no “all of the following except,” no “A and B”…you know what we mean. Most importantly, all questions include selective distractors (incorrect answer choices), which will help you think critically.

  • Must address important content
  • Must be well structured

Question

A 50-year-old man presents to his primary care physician complaining of intermittent episodes of tachycardia, hypertension, sweats, and headache. An extensive workup reveals increased 24-hour urinary fractionated metanephrines. A 3 cm adrenal mass consistent with a pheochromocytoma without malignant features is visualized on CT scan. After surgical consultation, a laparoscopic adrenalectomy is planned in 10 days. He has no significant past medical history and does not take any medications. Which of the following is the most appropriate next step in management?

A Initiate both metoprolol and phenoxybenzamine now
B Initiate metoprolol now and phenoxybenzamine 3 days prior to surgery
C Initiate phenoxybenzamine now and metoprolol 3 days prior to surgery
D No medication therapy is necessary

The most appropriate next step is to initiate phenoxybenzamine now and metoprolol 3 days prior to surgery. A pheochromocytoma is a neuroendocrine tumor originating from the chromaffin cells of the adrenal medulla. Pheochromocytomas are rare tumors that can arise sporadically from a de novo mutation or can be associated with a familial syndrome, such as von Hippel-Lindau syndrome or multiple endocrine neoplasia type 2. Pheochromocytomas produce at least one catecholamine (epinephrine, norepinephrine, or dopamine). Classic presentation involves intermittent tachycardia, sweats, headaches, and episodic or persistent hypertension. Radiologic evaluation with CT or MRI should be performed in patients whose biochemical testing with either plasma metanephrines or 24-hour urinary metanephrines is indicative of a pheochromocytoma. Patients with pheochromocytomas should undergo surgical resection, with laparoscopic adrenalectomy preferred for patients with single, small intra-adrenal tumors without malignant features. Preoperative medical therapy is necessary to manage tachycardia and hypertension (preventing a hypertensive crisis in surgery) and to expand volume prior to surgery. An alpha-adrenergic blocker, such as phenoxybenzamine, is recommended for 7–10 days prior to surgery. A beta-blocker, such as metoprolol, is started 2–3 days prior to surgery, but only after alpha-adrenergic blockade has been established to prevent unopposed alpha-adrenergic receptor stimulation.

Initiate both metoprolol and phenoxybenzamine now (A), initiate metoprolol now and phenoxybenzamine 3 days prior to surgery (B), and no medication therapy is necessary (D) are incorrect. This patient requires medical therapy prior to surgery. Preoperative beta-blockers should not be administered until alpha-adrenergic blockade has been achieved. Worsening hypertension can develop if vasodilatory peripheral beta-adrenergic receptors are blocked while there is unopposed alpha-adrenergic receptor stimulation.


Explanations

Written with a purpose

Understanding why an answer choice is incorrect is just as important as knowing why one is correct. That’s why every Rosh Review question includes detailed explanations for the correct and incorrect answer choices. These comprehensive summaries link the most important components of a topic—from risk factors to diagnostics and treatment—giving you the context to build relationships between them.

  • Created for optimal learning and recall
  • Help reinforce your knowledge
  • Focus on the essential information

Illustrations

Created to enhance learning

Custom illustrations and tables help further clarify the core concepts. When information is presented visually, you can focus on meaning, easily reorganize and group similar ideas, and make better use of your memory.

Pheochromocytoma

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One Step Further

Taking your learning to the next level

After each explanation is a straightforward question with a simple, memorizable answer that reinforces the corresponding topic.

  • Strengthens your knowledge
  • Stands alone from the main explanation so you’re not rereading content

Q: What are metanephrines?

REVEAL ANSWER

A: Metabolic products from catecholamine breakdown (metanephrine and normetanephrine).

Pheochromocytoma

  • Patient will be complaining of headaches, diaphoresis, tremors, and vision changes
  • PE will show hypertension
  • Diagnosis is made by assay of urinary catecholamines and metanephrines, and plasma metanephrine levels
  • Most commonly caused by catecholamine-secreting tumor located in the adrenal glands
  • Treatment is surgery, alpha-blocker (i.e., phentolamine, phenoxybenzamine) prior to beta-blockade to prevent unopposed alpha-agonism

Rapid Review

Keeping things simple

These bulleted reviews focus on condensed, high-yield concepts about the main topic, from patient presentation to preferred management.

  • Cover the fundamentals in one list
  • Allow you to quickly scan the must-know information
I scored the highest raw score in my program’s history. Big thanks to everyone at Rosh Review. Y’all rock.

FAQs

Get a little more clarification

Where can I find free IM-ITE practice questions?
You can access free practice questions with a free trial for the In-Training Exam Qbank—no billing information required. The free trial includes practice questions that align with the IM-ITE blueprint and include comprehensive answer explanations and beautiful teaching images.

After practicing with these questions, if you decide you're ready for thousands of additional questions to help you confidently prep for the IM-ITE, you can easily upgrade to a full Qbank subscription.
How many questions are on the IM-ITE?
The exam has 300 questions, 260 of which are scored and 40 of which are unscored. The topics follow the blueprint for the ABIM board exam (see them here).

The IM-ITE Qbank contains thousands of questions covering all the topics you need to know, so you'll be prepared and confident for exam day.
How do I prepare for the IM-ITE?
Targeting your "unknown unknowns" is one of our favorite study tips for both the IM-ITE and the ABIM board exam. Here's how you do it:

  • Answer a question from a Qbank
  • If you answer incorrectly, read the explanation
  • Take notes about why the correct answer is correct, and make sure to take notes on anything in the explanation that you didn’t already know
If you do this for every question you answer incorrectly, and if you regularly review your notes and add information to topics as you do more questions, you’ll eventually determine your unknown unknowns. In return, you’ll uncover most of your blind spots that questions on the exam can ask about.

Read more about this strategy (plus tips for what to pay attention to on test day) in How to Boost Your Internal Medicine Exam Score.
Do IM-ITE scores matter?
While there is no passing score for the IM-ITE, your results tell you valuable information for self-assessment.

Your report will show the percent of questions you answered correctly and your percentile rank within your PGY level. This report tells you and your program how your knowledge is progressing during residency. You can use this information to guide future study plans (especially for the internal medicine boards) and target topics that need extra attention.
When is the IM-ITE in 2021?
August 19–September 8, 2021 (except September 6).

Looking for a study strategy? Learn how to target your "unknown unknowns" in How to Boost Your Internal Medicine Exam Score.
How can internal medicine programs use self-directed learning?
There are many ways programs can use remote learning platforms to keep their residents engaged. From delivering conferences online to providing custom assessments to track resident progress, you have many options!

Read How Internal Medicine Residencies Can Integrate Self-Directed Learning for details about how a Qbank can help your residents with self-directed learning, how you can keep track of their progress with the Program Director Dashboard, and how to conduct a virtual review session and easily provide remediation.
How do I get started?
Whether you have a trial account or you purchased a subscription, access Rosh Review by logging in at app.roshreview.com.



To access the Qbank, go to the Create Exam tab to begin making and taking exams made up of questions from the Qbank.

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Once you've completed and submitted a few exams, you can see your statistics under the Performance Analysis tab.
Who writes the questions and explanations?
The finest people around! Question writers are board-certified clinicians who have all performed well on their certification exams. Answer explanations are derived from the specialty’s authoritative resources with some personal input to simplify the material and synthesize it for greatest comprehension and recall.

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Absolutely! You can try out a number of sample questions in the actual app by creating a free account (no billing information required—we promise). You will get a fully functional account, forever, with a limited number of questions. If you love it, you can easily purchase a full content subscription. You won't be charged at any point during your trial until you make a purchase.

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