Stanford University MD INDE 201 Practice of Medicine I –
Stanford Medical School Study Guide, Original Practice
Questions & Answers, INDE 201 Exam Preparation,
Comprehensive Practice of Medicine Review, Medical
Interviewing, Physical Examination, Clinical Skills,
Patient Communication, Clinical Reasoning, Information
Literacy, Nutrition, Clinical Epidemiology, Biostatistics,
Evidence-Based Medicine, Psychiatry, Biomedical Ethics,
Health Policy & Population Health
Question 1: A 72-year-old male with a history of hypertension and type 2
diabetes presents with a 2-day history of severe, tearing chest pain that
radiates to his back. His blood pressure is 180/110 mmHg in the right arm and
130/80 mmHg in the left arm. What is the most appropriate next step in
management?
A. Administer sublingual nitroglycerin and observe for relief
B. Urgent surgical consultation for possible aortic dissection
C. Obtain a high-resolution CT angiography of the chest
D. Administer a loading dose of clopidogrel and aspirin for acute coronary syndrome
CORRECT ANSWER: C. Obtain a high-resolution CT angiography of the chest
Rationale: The patient’s presentation of acute, severe, tearing chest pain radiating to the
back, combined with a significant inter-arm blood pressure differential, is highly
suspicious for an acute aortic dissection. While surgical consultation is often indicated
for Type A dissections, the immediate diagnostic step to confirm the diagnosis is a CT
angiography. Nitroglycerin could worsen hypotension and is not the primary
management. Antiplatelet therapy is contraindicated in the setting of a suspected
dissection.
Question 2: A 45-year-old female with a BMI of 34 presents with irregular
menstrual cycles, hirsutism, and acne. Laboratory studies reveal an elevated
free testosterone and a normal 17-hydroxyprogesterone level. What is the most
likely diagnosis?
A. Cushing's syndrome
B. Androgen-secreting adrenal tumor
C. Polycystic ovarian syndrome (PCOS)
D. Late-onset congenital adrenal hyperplasia
CORRECT ANSWER: C. Polycystic ovarian syndrome (PCOS)
Rationale: PCOS is a common endocrine disorder characterized by hyperandrogenism
(hirsutism, acne), ovulatory dysfunction (irregular menses), and metabolic issues
(obesity). The diagnosis is supported by elevated free testosterone. A normal 17-
hydroxyprogesterone level effectively rules out late-onset congenital adrenal
hyperplasia. Cushing's syndrome typically presents with central obesity, striae, and
,proximal muscle weakness. An androgen-secreting tumor is rare and usually presents
with very rapid onset and markedly elevated testosterone.
Question 3: A 28-year-old medical student presents with a 6-week history of
persistent, generalized anxiety, difficulty concentrating, and irritability. He
reports difficulty falling asleep and frequent episodes of muscle tension. He
has not experienced any panic attacks or depressive episodes. What is the
most appropriate pharmacologic therapy to initiate?
A. Alprazolam (a benzodiazepine) as needed for anxiety
B. Sertraline (a selective serotonin reuptake inhibitor)
C. Propranolol (a beta-blocker)
D. Buspirone (a 5-HT1A receptor agonist)
CORRECT ANSWER: B. Sertraline (a selective serotonin reuptake inhibitor)
Rationale: The patient meets criteria for generalized anxiety disorder (GAD). First-line
pharmacologic treatment for GAD includes SSRIs (e.g., sertraline, escitalopram) or
SNRIs. Benzodiazepines (alprazolam) are effective but are generally reserved for acute,
short-term use due to risk of tolerance and dependence. Buspirone is an option but can
take several weeks to work and is less effective in patients with prior benzodiazepine
use. Propranolol is used for performance anxiety or situational anxiety, not as a first-line
for chronic GAD.
Question 4: A 60-year-old male presents to the emergency department with
acute onset of left-sided weakness, facial droop, and dysarthria. His symptoms
began 2 hours ago. His blood pressure is 185/100 mmHg. A non-contrast head
CT shows no evidence of intracranial hemorrhage. Which clinical finding
would be a contraindication to the administration of intravenous tissue
plasminogen activator (tPA)?
A. Age over 60 years
B. Blood pressure of 185/100 mmHg
C. History of a myocardial infarction 2 years ago
D. Use of warfarin with a current INR of 1.2
CORRECT ANSWER: D. Use of warfarin with a current INR of 1.2
Rationale: The primary contraindications to IV tPA include a current INR > 1.7 in
patients on warfarin, active internal bleeding, or recent intracranial hemorrhage. An INR
of 1.2 is actually below the threshold and is acceptable. While a BP of 185/100 is
elevated, it must be carefully controlled to <185/110 before tPA administration; it is not
an absolute contraindication if treatable. Age over 60 is not a contraindication.
Question 5: A 55-year-old male with end-stage renal disease on hemodialysis
presents with severe, bilateral knee pain. Laboratory studies show a serum
phosphate of 6.5 mg/dL and a calcium of 8.2 mg/dL. A plain X-ray of the knee
shows vascular calcifications and periarticular soft tissue calcifications. What
is the most likely etiology of his pain?
,A. Gouty arthritis
B. Osteoarthritis
C. Calciphylaxis
D. Calcium pyrophosphate deposition disease (CPPD)
CORRECT ANSWER: C. Calciphylaxis
Rationale: Calciphylaxis is a rare but serious syndrome of vascular calcification,
thrombosis, and skin necrosis, often seen in patients with end-stage renal disease and
secondary hyperparathyroidism. It typically presents with painful, violaceous skin
lesions, but can manifest with periarticular calcifications and joint pain. The combination
of renal failure, hyperphosphatemia, and vascular calcifications strongly points to
calciphylaxis. Gout and CPPD are also crystalline arthropathies but are not typically
associated with the systemic vascular calcifications seen here.
Question 6: A 35-year-old female with a history of systemic lupus
erythematosus (SLE) presents with progressive shortness of breath and a non-
productive cough. A chest X-ray reveals bilateral interstitial infiltrates. Her
vital capacity has decreased by 20% from her baseline last month. A high-
resolution CT shows diffuse ground-glass opacities. What is the most likely
pulmonary manifestation of her SLE?
A. Pulmonary embolism
B. Diffuse alveolar hemorrhage
C. Acute lupus pneumonitis
D. Primary pulmonary hypertension
CORRECT ANSWER: C. Acute lupus pneumonitis
Rationale: Acute lupus pneumonitis is a rare but severe manifestation of SLE
characterized by the acute onset of dyspnea, dry cough, hypoxemia, and bilateral
infiltrates on imaging. Diffuse alveolar hemorrhage can also present similarly but is often
accompanied by a drop in hematocrit and hemoptysis. Pulmonary embolism is less
likely without risk factors, and primary pulmonary hypertension typically presents with a
more insidious onset and evidence of right heart strain.
Question 7: A 42-year-old male is evaluated for a new diagnosis of
hypertension. He is noted to have hypokalemia (K+ 3.0 mEq/L) and a
metabolic alkalosis. His plasma renin activity is suppressed, and his
aldosterone level is elevated. What is the most likely underlying cause of his
hypertension?
A. Renal artery stenosis
B. Primary aldosteronism (Conn's syndrome)
C. Cushing's syndrome
D. Pheochromocytoma
CORRECT ANSWER: B. Primary aldosteronism (Conn's syndrome)
, Rationale: Primary aldosteronism is characterized by hypertension, hypokalemia,
metabolic alkalosis, and suppressed plasma renin activity with elevated aldosterone.
Renal artery stenosis typically presents with elevated renin and aldosterone (secondary
hyperaldosteronism). Cushing's syndrome presents with cortisol excess, and
pheochromocytoma presents with episodic hypertension, palpitations, and diaphoresis.
Conn’s syndrome is the most common cause of secondary hypertension.
Question 8: A 22-year-old male presents with a 3-day history of watery
diarrhea, fever, and severe abdominal cramping. He reports recently eating
undercooked chicken at a restaurant. A stool culture shows non-lactose
fermenting, gram-negative rods. Which organism is the most likely pathogen?
A. Shigella species
B. Salmonella species
C. Escherichia coli O157:H7
D. Campylobacter jejuni
CORRECT ANSWER: D. Campylobacter jejuni
Rationale: Campylobacter jejuni is one of the most common causes of bacterial
gastroenteritis worldwide, frequently associated with consumption of undercooked
poultry. It causes a prodrome of fever, abdominal cramping, and diarrhea (often bloody).
Shigella and Salmonella are also gram-negative rods, but Campylobacter is the classic
pathogen associated with poultry. E. coli O157:H7 is associated with undercooked
ground beef.
Question 9: A 68-year-old female with known coronary artery disease presents
with a 2-day history of intermittent, severe, substernal chest pain that occurs
at rest and wakes her from sleep. Her troponin I is slightly elevated at 0.1
ng/mL. What is the most appropriate diagnosis?
A. Stable angina
B. Unstable angina
C. Non-ST elevation myocardial infarction (NSTEMI)
D. Prinzmetal's angina
CORRECT ANSWER: C. Non-ST elevation myocardial infarction (NSTEMI)
Rationale: Unstable angina and NSTEMI are both acute coronary syndromes. The
distinction is based on the presence of myocardial necrosis. An elevated troponin level
(even a slight elevation) indicates myocardial necrosis and defines an NSTEMI. Stable
angina is precipitated by exertion and relieved by rest. Prinzmetal's angina is caused by
coronary vasospasm, often occurring at rest, but is not typically associated with elevated
troponin.
Question 10: A 30-year-old female presents with amenorrhea, galactorrhea,
and headaches. She has noticed a bitemporal visual field defect on
examination. Serum prolactin level is 400 ng/mL. What is the most
appropriate initial imaging study?
Stanford Medical School Study Guide, Original Practice
Questions & Answers, INDE 201 Exam Preparation,
Comprehensive Practice of Medicine Review, Medical
Interviewing, Physical Examination, Clinical Skills,
Patient Communication, Clinical Reasoning, Information
Literacy, Nutrition, Clinical Epidemiology, Biostatistics,
Evidence-Based Medicine, Psychiatry, Biomedical Ethics,
Health Policy & Population Health
Question 1: A 72-year-old male with a history of hypertension and type 2
diabetes presents with a 2-day history of severe, tearing chest pain that
radiates to his back. His blood pressure is 180/110 mmHg in the right arm and
130/80 mmHg in the left arm. What is the most appropriate next step in
management?
A. Administer sublingual nitroglycerin and observe for relief
B. Urgent surgical consultation for possible aortic dissection
C. Obtain a high-resolution CT angiography of the chest
D. Administer a loading dose of clopidogrel and aspirin for acute coronary syndrome
CORRECT ANSWER: C. Obtain a high-resolution CT angiography of the chest
Rationale: The patient’s presentation of acute, severe, tearing chest pain radiating to the
back, combined with a significant inter-arm blood pressure differential, is highly
suspicious for an acute aortic dissection. While surgical consultation is often indicated
for Type A dissections, the immediate diagnostic step to confirm the diagnosis is a CT
angiography. Nitroglycerin could worsen hypotension and is not the primary
management. Antiplatelet therapy is contraindicated in the setting of a suspected
dissection.
Question 2: A 45-year-old female with a BMI of 34 presents with irregular
menstrual cycles, hirsutism, and acne. Laboratory studies reveal an elevated
free testosterone and a normal 17-hydroxyprogesterone level. What is the most
likely diagnosis?
A. Cushing's syndrome
B. Androgen-secreting adrenal tumor
C. Polycystic ovarian syndrome (PCOS)
D. Late-onset congenital adrenal hyperplasia
CORRECT ANSWER: C. Polycystic ovarian syndrome (PCOS)
Rationale: PCOS is a common endocrine disorder characterized by hyperandrogenism
(hirsutism, acne), ovulatory dysfunction (irregular menses), and metabolic issues
(obesity). The diagnosis is supported by elevated free testosterone. A normal 17-
hydroxyprogesterone level effectively rules out late-onset congenital adrenal
hyperplasia. Cushing's syndrome typically presents with central obesity, striae, and
,proximal muscle weakness. An androgen-secreting tumor is rare and usually presents
with very rapid onset and markedly elevated testosterone.
Question 3: A 28-year-old medical student presents with a 6-week history of
persistent, generalized anxiety, difficulty concentrating, and irritability. He
reports difficulty falling asleep and frequent episodes of muscle tension. He
has not experienced any panic attacks or depressive episodes. What is the
most appropriate pharmacologic therapy to initiate?
A. Alprazolam (a benzodiazepine) as needed for anxiety
B. Sertraline (a selective serotonin reuptake inhibitor)
C. Propranolol (a beta-blocker)
D. Buspirone (a 5-HT1A receptor agonist)
CORRECT ANSWER: B. Sertraline (a selective serotonin reuptake inhibitor)
Rationale: The patient meets criteria for generalized anxiety disorder (GAD). First-line
pharmacologic treatment for GAD includes SSRIs (e.g., sertraline, escitalopram) or
SNRIs. Benzodiazepines (alprazolam) are effective but are generally reserved for acute,
short-term use due to risk of tolerance and dependence. Buspirone is an option but can
take several weeks to work and is less effective in patients with prior benzodiazepine
use. Propranolol is used for performance anxiety or situational anxiety, not as a first-line
for chronic GAD.
Question 4: A 60-year-old male presents to the emergency department with
acute onset of left-sided weakness, facial droop, and dysarthria. His symptoms
began 2 hours ago. His blood pressure is 185/100 mmHg. A non-contrast head
CT shows no evidence of intracranial hemorrhage. Which clinical finding
would be a contraindication to the administration of intravenous tissue
plasminogen activator (tPA)?
A. Age over 60 years
B. Blood pressure of 185/100 mmHg
C. History of a myocardial infarction 2 years ago
D. Use of warfarin with a current INR of 1.2
CORRECT ANSWER: D. Use of warfarin with a current INR of 1.2
Rationale: The primary contraindications to IV tPA include a current INR > 1.7 in
patients on warfarin, active internal bleeding, or recent intracranial hemorrhage. An INR
of 1.2 is actually below the threshold and is acceptable. While a BP of 185/100 is
elevated, it must be carefully controlled to <185/110 before tPA administration; it is not
an absolute contraindication if treatable. Age over 60 is not a contraindication.
Question 5: A 55-year-old male with end-stage renal disease on hemodialysis
presents with severe, bilateral knee pain. Laboratory studies show a serum
phosphate of 6.5 mg/dL and a calcium of 8.2 mg/dL. A plain X-ray of the knee
shows vascular calcifications and periarticular soft tissue calcifications. What
is the most likely etiology of his pain?
,A. Gouty arthritis
B. Osteoarthritis
C. Calciphylaxis
D. Calcium pyrophosphate deposition disease (CPPD)
CORRECT ANSWER: C. Calciphylaxis
Rationale: Calciphylaxis is a rare but serious syndrome of vascular calcification,
thrombosis, and skin necrosis, often seen in patients with end-stage renal disease and
secondary hyperparathyroidism. It typically presents with painful, violaceous skin
lesions, but can manifest with periarticular calcifications and joint pain. The combination
of renal failure, hyperphosphatemia, and vascular calcifications strongly points to
calciphylaxis. Gout and CPPD are also crystalline arthropathies but are not typically
associated with the systemic vascular calcifications seen here.
Question 6: A 35-year-old female with a history of systemic lupus
erythematosus (SLE) presents with progressive shortness of breath and a non-
productive cough. A chest X-ray reveals bilateral interstitial infiltrates. Her
vital capacity has decreased by 20% from her baseline last month. A high-
resolution CT shows diffuse ground-glass opacities. What is the most likely
pulmonary manifestation of her SLE?
A. Pulmonary embolism
B. Diffuse alveolar hemorrhage
C. Acute lupus pneumonitis
D. Primary pulmonary hypertension
CORRECT ANSWER: C. Acute lupus pneumonitis
Rationale: Acute lupus pneumonitis is a rare but severe manifestation of SLE
characterized by the acute onset of dyspnea, dry cough, hypoxemia, and bilateral
infiltrates on imaging. Diffuse alveolar hemorrhage can also present similarly but is often
accompanied by a drop in hematocrit and hemoptysis. Pulmonary embolism is less
likely without risk factors, and primary pulmonary hypertension typically presents with a
more insidious onset and evidence of right heart strain.
Question 7: A 42-year-old male is evaluated for a new diagnosis of
hypertension. He is noted to have hypokalemia (K+ 3.0 mEq/L) and a
metabolic alkalosis. His plasma renin activity is suppressed, and his
aldosterone level is elevated. What is the most likely underlying cause of his
hypertension?
A. Renal artery stenosis
B. Primary aldosteronism (Conn's syndrome)
C. Cushing's syndrome
D. Pheochromocytoma
CORRECT ANSWER: B. Primary aldosteronism (Conn's syndrome)
, Rationale: Primary aldosteronism is characterized by hypertension, hypokalemia,
metabolic alkalosis, and suppressed plasma renin activity with elevated aldosterone.
Renal artery stenosis typically presents with elevated renin and aldosterone (secondary
hyperaldosteronism). Cushing's syndrome presents with cortisol excess, and
pheochromocytoma presents with episodic hypertension, palpitations, and diaphoresis.
Conn’s syndrome is the most common cause of secondary hypertension.
Question 8: A 22-year-old male presents with a 3-day history of watery
diarrhea, fever, and severe abdominal cramping. He reports recently eating
undercooked chicken at a restaurant. A stool culture shows non-lactose
fermenting, gram-negative rods. Which organism is the most likely pathogen?
A. Shigella species
B. Salmonella species
C. Escherichia coli O157:H7
D. Campylobacter jejuni
CORRECT ANSWER: D. Campylobacter jejuni
Rationale: Campylobacter jejuni is one of the most common causes of bacterial
gastroenteritis worldwide, frequently associated with consumption of undercooked
poultry. It causes a prodrome of fever, abdominal cramping, and diarrhea (often bloody).
Shigella and Salmonella are also gram-negative rods, but Campylobacter is the classic
pathogen associated with poultry. E. coli O157:H7 is associated with undercooked
ground beef.
Question 9: A 68-year-old female with known coronary artery disease presents
with a 2-day history of intermittent, severe, substernal chest pain that occurs
at rest and wakes her from sleep. Her troponin I is slightly elevated at 0.1
ng/mL. What is the most appropriate diagnosis?
A. Stable angina
B. Unstable angina
C. Non-ST elevation myocardial infarction (NSTEMI)
D. Prinzmetal's angina
CORRECT ANSWER: C. Non-ST elevation myocardial infarction (NSTEMI)
Rationale: Unstable angina and NSTEMI are both acute coronary syndromes. The
distinction is based on the presence of myocardial necrosis. An elevated troponin level
(even a slight elevation) indicates myocardial necrosis and defines an NSTEMI. Stable
angina is precipitated by exertion and relieved by rest. Prinzmetal's angina is caused by
coronary vasospasm, often occurring at rest, but is not typically associated with elevated
troponin.
Question 10: A 30-year-old female presents with amenorrhea, galactorrhea,
and headaches. She has noticed a bitemporal visual field defect on
examination. Serum prolactin level is 400 ng/mL. What is the most
appropriate initial imaging study?
