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, Clinical Interviewing, Physical
Examination, Patient Communication, Information
Literacy, Nutrition, Clinical Epidemiology,
Biostatistics, Evidence-Based Medicine, Psychiatry,
Biomedical Ethics, Health Policy, Population Health
& Simulated Clinical Encounters
Question 1: A 72-year-old male with a 40-pack-year smoking history and
known COPD presents with progressive dyspnea and a new dry cough. His
chest X-ray shows a large left-sided pleural effusion. Thoracentesis yields an
exudative fluid with a pH of 7.20, glucose of 40 mg/dL, and a positive cytology
for adenocarcinoma. What is the most appropriate next step in management?
A. Indwelling pleural catheter insertion for outpatient management
B. Chemical pleurodesis with talc via a chest tube
C. Video-assisted thoracoscopic surgery (VATS) for pleural biopsy and talc poudrage
D. Therapeutic thoracentesis and observation
CORRECT ANSWER: C. Video-assisted thoracoscopic surgery (VATS) for
pleural biopsy and talc poudrage
Rationale: This patient has a malignant pleural effusion (MPE) with a trapped lung (pH
<7.20 and glucose <60 mg/dL are poor prognostic indicators). VATS allows for
definitive tissue biopsy, staging, and mechanical talc poudrage, which is the most
effective form of pleurodesis for symptomatic MPE, especially when the lung is not fully
expandable.
Question 2: A 65-year-old female with diabetes and hypertension is started on
lisinopril. Two weeks later, she presents with a dry cough, facial swelling, and
difficulty breathing. Her blood pressure is 90/60 mmHg, and she has stridor.
Which of the following is the first-line therapy for her condition?
A. Intravenous diphenhydramine
B. Nebulized albuterol
C. Intramuscular epinephrine
D. Intravenous methylprednisolone
CORRECT ANSWER: C. Intramuscular epinephrine
Rationale: The patient is experiencing anaphylaxis (angioedema) likely due to ACE
inhibitor-induced angioedema causing laryngeal edema. Intramuscular epinephrine (0.3-
0.5 mg of 1:1000 solution) is the first-line treatment for anaphylaxis due to its rapid
vasoconstrictive and bronchodilatory effects. Airway protection is paramount.
,Question 3: A 58-year-old male with a history of alcohol use disorder presents
with a 2-day history of severe epigastric pain radiating to the back, nausea,
and vomiting. On exam, he has a tender, distended abdomen and hypoactive
bowel sounds. His serum amylase and lipase are markedly elevated. Which of
the following findings on a contrast-enhanced CT of the abdomen is most
specific for a diagnosis of necrotizing pancreatitis?
A. Peripancreatic fluid collections
B. Non-enhancing pancreatic parenchyma
C. Diffuse pancreatic enlargement
D. Thickening of the anterior pararenal fascia
CORRECT ANSWER: B. Non-enhancing pancreatic parenchyma
Rationale: In acute pancreatitis, contrast-enhanced CT is the gold standard for assessing
necrosis. Non-enhancing pancreatic parenchyma indicates lack of perfusion and is the
most specific sign of pancreatic necrosis. Fluid collections (A) are common in interstitial
edematous pancreatitis, while (C) and (D) are non-specific inflammatory changes.
Question 4: A 32-year-old woman in her third trimester of pregnancy presents
with painless vaginal bleeding. Ultrasound reveals a placenta previa. Her vital
signs are stable, and fetal heart rate is reassuring. What is the most
appropriate management?
A. Immediate cesarean section
B. Digital vaginal examination to assess cervical dilation
C. Administration of corticosteroids and expectant management
D. Oxytocin infusion to induce labor
CORRECT ANSWER: C. Administration of corticosteroids and expectant
management
Rationale: In a stable patient with placenta previa and a preterm fetus, expectant
management is indicated. Administering corticosteroids (betamethasone) accelerates
fetal lung maturity. Digital vaginal exams (B) and any manipulation are strictly
contraindicated due to the risk of catastrophic hemorrhage. Delivery is only indicated
for uncontrolled bleeding or fetal distress.
Question 5: A 48-year-old male with no significant medical history presents
with sudden onset of severe, "thunderclap" headache, nausea, and
photophobia. His neurological exam is normal. A non-contrast head CT is
negative for hemorrhage. What is the most appropriate next diagnostic step?
A. Magnetic resonance angiography (MRA) of the brain
B. Lumbar puncture
C. Carotid ultrasound
D. Electroencephalogram (EEG)
CORRECT ANSWER: B. Lumbar puncture
,Rationale: A "thunderclap" headache with a negative non-contrast head CT is highly
suspicious for subarachnoid hemorrhage (SAH). A lumbar puncture is the next step to
evaluate for xanthochromia or red blood cells in the cerebrospinal fluid. CT is less
sensitive after 6-12 hours, and LP is required to rule out SAH.
Question 6: A 76-year-old male with chronic kidney disease stage 3 is started
on allopurinol for gout. Two weeks later, he develops a pruritic,
maculopapular rash, fever, and eosinophilia. His liver function tests show AST
150 U/L and ALT 180 U/L. What is the most likely diagnosis?
A. Stevens-Johnson syndrome
B. Drug-induced liver injury (DILI) with hypersensitivity
C. Acute cholangitis
D. Gout flare with hepatic involvement
CORRECT ANSWER: B. Drug-induced liver injury (DILI) with hypersensitivity
Rationale: Allopurinol can cause a hypersensitivity syndrome (DRESS - Drug Reaction
with Eosinophilia and Systemic Symptoms) characterized by rash, fever, eosinophilia,
and internal organ involvement (hepatitis in this case). Stevens-Johnson syndrome (A) is
a severe mucocutaneous reaction typically involving mucous membranes and skin
detachment, which is not described here.
Question 7: A 55-year-old female with a history of rheumatoid arthritis
presents with progressive shortness of breath and a non-productive cough.
High-resolution CT of the chest reveals diffuse ground-glass opacities and
intralobular septal thickening in a bilateral, symmetric distribution.
Pulmonary function tests show a restrictive pattern with a severely reduced
DLCO. Which medication is most likely responsible for this presentation?
A. Methotrexate
B. Sulfasalazine
C. Hydroxychloroquine
D. Etanercept
CORRECT ANSWER: A. Methotrexate
Rationale: Methotrexate is a common cause of drug-induced interstitial lung disease
(ILD), presenting subacutely with dyspnea, cough, and a restrictive pattern on PFTs. The
HRCT findings of ground-glass opacities and septal thickening are consistent with this.
While all DMARDs can cause lung disease, methotrexate is the most classic agent for
this pattern.
Question 8: A 22-year-old college student presents with a 1-week history of
sore throat, fever, and profound fatigue. Examination reveals exudative
tonsillitis, tender anterior cervical lymphadenopathy, and palpable
splenomegaly. What is the most appropriate confirmatory diagnostic test?
, A. Throat culture for Group A Streptococcus
B. Rapid antigen detection test for Group A Streptococcus
C. Heterophile antibody test (Monospot)
D. Complete blood count with differential
CORRECT ANSWER: C. Heterophile antibody test (Monospot)
Rationale: The presentation of exudative tonsillitis, posterior cervical adenopathy
(though anterior is possible), and splenomegaly is classic for infectious mononucleosis
caused by Epstein-Barr virus. The heterophile antibody test (Monospot) is the rapid,
confirmatory test for acute EBV infection. A negative result may require EBV-specific
serology.
Question 9: A 70-year-old male with a history of hypertension and
hyperlipidemia presents with a 30-minute episode of transient monocular
vision loss (amaurosis fugax) in his right eye that completely resolved. Carotid
ultrasound reveals a 75% stenosis of the right internal carotid artery. What is
the most appropriate management?
A. Aspirin 81 mg daily and aggressive risk factor modification
B. Carotid endarterectomy (CEA)
C. Carotid artery stenting (CAS)
D. Clopidogrel 75 mg daily
CORRECT ANSWER: B. Carotid endarterectomy (CEA)
Rationale: The patient has had a transient ischemic attack (TIA) (amaurosis fugax)
attributable to a >70% symptomatic carotid stenosis. Carotid endarterectomy is
indicated in symptomatic patients with 70-99% stenosis to reduce the risk of future
stroke, provided the surgical risk is <6%. Medical management alone (A) is insufficient.
Question 10: A 28-year-old male is brought to the emergency department after
a generalized tonic-clonic seizure. He has a history of epilepsy and takes
phenytoin. He has been non-adherent for the past week. Serum phenytoin
levels are below therapeutic range. What is the most appropriate loading dose
administration strategy?
A. Intravenous phenytoin 20 mg/kg at 50 mg/min
B. Intravenous fosphenytoin 20 mg PE/kg at 150 mg/min
C. Intravenous phenobarbital 20 mg/kg
D. Oral phenytoin 20 mg/kg in divided doses over 24 hours
CORRECT ANSWER: B. Intravenous fosphenytoin 20 mg PE/kg at 150 mg/min
Rationale: Fosphenytoin is a water-soluble prodrug of phenytoin, allowing for faster
intravenous infusion (up to 150 mg PE/min) with fewer local tissue reactions and less
hypotension compared to intravenous phenytoin (which is limited to 50 mg/min). It is
the preferred agent for acute loading in status epilepticus or acute breakthrough
seizures.
Medicine I – Stanford Medical School Study Guide,
Original Practice Questions & Answers, INDE 201
Exam Preparation, Comprehensive Practice of
Medicine Review, Clinical Interviewing, Physical
Examination, Patient Communication, Information
Literacy, Nutrition, Clinical Epidemiology,
Biostatistics, Evidence-Based Medicine, Psychiatry,
Biomedical Ethics, Health Policy, Population Health
& Simulated Clinical Encounters
Question 1: A 72-year-old male with a 40-pack-year smoking history and
known COPD presents with progressive dyspnea and a new dry cough. His
chest X-ray shows a large left-sided pleural effusion. Thoracentesis yields an
exudative fluid with a pH of 7.20, glucose of 40 mg/dL, and a positive cytology
for adenocarcinoma. What is the most appropriate next step in management?
A. Indwelling pleural catheter insertion for outpatient management
B. Chemical pleurodesis with talc via a chest tube
C. Video-assisted thoracoscopic surgery (VATS) for pleural biopsy and talc poudrage
D. Therapeutic thoracentesis and observation
CORRECT ANSWER: C. Video-assisted thoracoscopic surgery (VATS) for
pleural biopsy and talc poudrage
Rationale: This patient has a malignant pleural effusion (MPE) with a trapped lung (pH
<7.20 and glucose <60 mg/dL are poor prognostic indicators). VATS allows for
definitive tissue biopsy, staging, and mechanical talc poudrage, which is the most
effective form of pleurodesis for symptomatic MPE, especially when the lung is not fully
expandable.
Question 2: A 65-year-old female with diabetes and hypertension is started on
lisinopril. Two weeks later, she presents with a dry cough, facial swelling, and
difficulty breathing. Her blood pressure is 90/60 mmHg, and she has stridor.
Which of the following is the first-line therapy for her condition?
A. Intravenous diphenhydramine
B. Nebulized albuterol
C. Intramuscular epinephrine
D. Intravenous methylprednisolone
CORRECT ANSWER: C. Intramuscular epinephrine
Rationale: The patient is experiencing anaphylaxis (angioedema) likely due to ACE
inhibitor-induced angioedema causing laryngeal edema. Intramuscular epinephrine (0.3-
0.5 mg of 1:1000 solution) is the first-line treatment for anaphylaxis due to its rapid
vasoconstrictive and bronchodilatory effects. Airway protection is paramount.
,Question 3: A 58-year-old male with a history of alcohol use disorder presents
with a 2-day history of severe epigastric pain radiating to the back, nausea,
and vomiting. On exam, he has a tender, distended abdomen and hypoactive
bowel sounds. His serum amylase and lipase are markedly elevated. Which of
the following findings on a contrast-enhanced CT of the abdomen is most
specific for a diagnosis of necrotizing pancreatitis?
A. Peripancreatic fluid collections
B. Non-enhancing pancreatic parenchyma
C. Diffuse pancreatic enlargement
D. Thickening of the anterior pararenal fascia
CORRECT ANSWER: B. Non-enhancing pancreatic parenchyma
Rationale: In acute pancreatitis, contrast-enhanced CT is the gold standard for assessing
necrosis. Non-enhancing pancreatic parenchyma indicates lack of perfusion and is the
most specific sign of pancreatic necrosis. Fluid collections (A) are common in interstitial
edematous pancreatitis, while (C) and (D) are non-specific inflammatory changes.
Question 4: A 32-year-old woman in her third trimester of pregnancy presents
with painless vaginal bleeding. Ultrasound reveals a placenta previa. Her vital
signs are stable, and fetal heart rate is reassuring. What is the most
appropriate management?
A. Immediate cesarean section
B. Digital vaginal examination to assess cervical dilation
C. Administration of corticosteroids and expectant management
D. Oxytocin infusion to induce labor
CORRECT ANSWER: C. Administration of corticosteroids and expectant
management
Rationale: In a stable patient with placenta previa and a preterm fetus, expectant
management is indicated. Administering corticosteroids (betamethasone) accelerates
fetal lung maturity. Digital vaginal exams (B) and any manipulation are strictly
contraindicated due to the risk of catastrophic hemorrhage. Delivery is only indicated
for uncontrolled bleeding or fetal distress.
Question 5: A 48-year-old male with no significant medical history presents
with sudden onset of severe, "thunderclap" headache, nausea, and
photophobia. His neurological exam is normal. A non-contrast head CT is
negative for hemorrhage. What is the most appropriate next diagnostic step?
A. Magnetic resonance angiography (MRA) of the brain
B. Lumbar puncture
C. Carotid ultrasound
D. Electroencephalogram (EEG)
CORRECT ANSWER: B. Lumbar puncture
,Rationale: A "thunderclap" headache with a negative non-contrast head CT is highly
suspicious for subarachnoid hemorrhage (SAH). A lumbar puncture is the next step to
evaluate for xanthochromia or red blood cells in the cerebrospinal fluid. CT is less
sensitive after 6-12 hours, and LP is required to rule out SAH.
Question 6: A 76-year-old male with chronic kidney disease stage 3 is started
on allopurinol for gout. Two weeks later, he develops a pruritic,
maculopapular rash, fever, and eosinophilia. His liver function tests show AST
150 U/L and ALT 180 U/L. What is the most likely diagnosis?
A. Stevens-Johnson syndrome
B. Drug-induced liver injury (DILI) with hypersensitivity
C. Acute cholangitis
D. Gout flare with hepatic involvement
CORRECT ANSWER: B. Drug-induced liver injury (DILI) with hypersensitivity
Rationale: Allopurinol can cause a hypersensitivity syndrome (DRESS - Drug Reaction
with Eosinophilia and Systemic Symptoms) characterized by rash, fever, eosinophilia,
and internal organ involvement (hepatitis in this case). Stevens-Johnson syndrome (A) is
a severe mucocutaneous reaction typically involving mucous membranes and skin
detachment, which is not described here.
Question 7: A 55-year-old female with a history of rheumatoid arthritis
presents with progressive shortness of breath and a non-productive cough.
High-resolution CT of the chest reveals diffuse ground-glass opacities and
intralobular septal thickening in a bilateral, symmetric distribution.
Pulmonary function tests show a restrictive pattern with a severely reduced
DLCO. Which medication is most likely responsible for this presentation?
A. Methotrexate
B. Sulfasalazine
C. Hydroxychloroquine
D. Etanercept
CORRECT ANSWER: A. Methotrexate
Rationale: Methotrexate is a common cause of drug-induced interstitial lung disease
(ILD), presenting subacutely with dyspnea, cough, and a restrictive pattern on PFTs. The
HRCT findings of ground-glass opacities and septal thickening are consistent with this.
While all DMARDs can cause lung disease, methotrexate is the most classic agent for
this pattern.
Question 8: A 22-year-old college student presents with a 1-week history of
sore throat, fever, and profound fatigue. Examination reveals exudative
tonsillitis, tender anterior cervical lymphadenopathy, and palpable
splenomegaly. What is the most appropriate confirmatory diagnostic test?
, A. Throat culture for Group A Streptococcus
B. Rapid antigen detection test for Group A Streptococcus
C. Heterophile antibody test (Monospot)
D. Complete blood count with differential
CORRECT ANSWER: C. Heterophile antibody test (Monospot)
Rationale: The presentation of exudative tonsillitis, posterior cervical adenopathy
(though anterior is possible), and splenomegaly is classic for infectious mononucleosis
caused by Epstein-Barr virus. The heterophile antibody test (Monospot) is the rapid,
confirmatory test for acute EBV infection. A negative result may require EBV-specific
serology.
Question 9: A 70-year-old male with a history of hypertension and
hyperlipidemia presents with a 30-minute episode of transient monocular
vision loss (amaurosis fugax) in his right eye that completely resolved. Carotid
ultrasound reveals a 75% stenosis of the right internal carotid artery. What is
the most appropriate management?
A. Aspirin 81 mg daily and aggressive risk factor modification
B. Carotid endarterectomy (CEA)
C. Carotid artery stenting (CAS)
D. Clopidogrel 75 mg daily
CORRECT ANSWER: B. Carotid endarterectomy (CEA)
Rationale: The patient has had a transient ischemic attack (TIA) (amaurosis fugax)
attributable to a >70% symptomatic carotid stenosis. Carotid endarterectomy is
indicated in symptomatic patients with 70-99% stenosis to reduce the risk of future
stroke, provided the surgical risk is <6%. Medical management alone (A) is insufficient.
Question 10: A 28-year-old male is brought to the emergency department after
a generalized tonic-clonic seizure. He has a history of epilepsy and takes
phenytoin. He has been non-adherent for the past week. Serum phenytoin
levels are below therapeutic range. What is the most appropriate loading dose
administration strategy?
A. Intravenous phenytoin 20 mg/kg at 50 mg/min
B. Intravenous fosphenytoin 20 mg PE/kg at 150 mg/min
C. Intravenous phenobarbital 20 mg/kg
D. Oral phenytoin 20 mg/kg in divided doses over 24 hours
CORRECT ANSWER: B. Intravenous fosphenytoin 20 mg PE/kg at 150 mg/min
Rationale: Fosphenytoin is a water-soluble prodrug of phenytoin, allowing for faster
intravenous infusion (up to 150 mg PE/min) with fewer local tissue reactions and less
hypotension compared to intravenous phenytoin (which is limited to 50 mg/min). It is
the preferred agent for acute loading in status epilepticus or acute breakthrough
seizures.
