Medical Council of Canada Qualifying Exam — Questions and Answers

Question 1: A woman delivers a healthy infant but her placenta fails to deliver after 40 minutes of active management. On manual exploration, the placenta cannot be separated from the uterine wall. What is the most likely diagnosis?

Placenta previa
Placenta accreta (Correct answer)
Retained placental cotyledon
Uterine inversion

Correct answer: Placenta accreta

Placenta accreta is characterized by abnormal adherence of placental villi to the myometrium, preventing normal separation and delivery.

Question 2: A 45-year-old with MDD has failed two adequate antidepressant trials. Which augmentation strategy has the strongest evidence base for treatment-resistant depression?

Adding a benzodiazepine
Adding lithium or atypical antipsychotic (Correct answer)
Switching to an MAOI without washout
Adding methylphenidate

Correct answer: Adding lithium or atypical antipsychotic

Lithium augmentation and atypical antipsychotic augmentation (e.g., quetiapine, aripiprazole) have the best evidence for treatment-resistant depression.

Question 3: How many attempts at MCCQE Part I does the MCC currently allow a candidate over their lifetime?

A maximum of 2 attempts
A maximum of 5 attempts (Correct answer)
Unlimited attempts
A maximum of 3 attempts

Correct answer: A maximum of 5 attempts

The MCC limits candidates to a maximum of 5 lifetime attempts at MCCQE Part I.

Question 4: Which antibiotic requires dose adjustment in patients with renal failure but NOT in patients with hepatic failure?

Clindamycin
Metronidazole
Azithromycin
Gentamicin (Correct answer)

Correct answer: Gentamicin

Gentamicin is almost entirely renally excreted without hepatic metabolism, requiring dose reduction in renal failure but not in hepatic impairment.

Question 5: A 55-year-old man undergoes elective right hemicolectomy. On post-operative day 3 he develops fever, tachycardia, and worsening abdominal pain with peritoneal signs. CT shows free air and fluid. What is the most likely diagnosis and appropriate next step?

C. difficile colitis — oral vancomycin
Wound infection — open wound and antibiotics
Anastomotic leak — return to OR for washout and stoma creation (Correct answer)
Ileus — nasogastric decompression

Correct answer: Anastomotic leak — return to OR for washout and stoma creation

Post-operative peritonitis with free air on POD 3 after bowel resection is anastomotic leak until proven otherwise, requiring urgent surgical re-exploration, washout, and fecal diversion.

Question 6: What distinguishes therapeutic privilege from withholding information inappropriately?

Therapeutic privilege allows withholding information whenever the physician feels it is best
Therapeutic privilege is rarely justified and applies only when disclosure itself would directly cause serious harm (Correct answer)
Therapeutic privilege is standard practice for all bad-news disclosures
Therapeutic privilege requires family consent before withholding information

Correct answer: Therapeutic privilege is rarely justified and applies only when disclosure itself would directly cause serious harm

Therapeutic privilege is a narrow exception permitting non-disclosure only when the disclosure itself (not the diagnosis) would directly harm the patient.

Question 7: Which reflex is abnormal if still present at 6 months of age?

Moro reflex (Correct answer)
Parachute reflex
Plantar grasp reflex
Babinski reflex

Correct answer: Moro reflex

The Moro (startle) reflex normally disappears by 4–6 months; persistence beyond 6 months suggests central nervous system pathology.

Question 8: A candidate takes the MCCQE Part I but experiences a documented medical emergency during the exam. What outcome is most likely per MCC protocol?

The candidate's score is extrapolated from completed questions to generate a full estimate
The partial exam is automatically scored and passed if 50% is completed
The MCC may grant a medical withdrawal, preserving eligibility without counting the attempt (Correct answer)
The candidate forfeits that sitting and must reregister and repay fees at the next opportunity

Correct answer: The MCC may grant a medical withdrawal, preserving eligibility without counting the attempt

The MCC can grant a medical withdrawal when a documented emergency prevents exam completion, which typically does not count as a failed attempt.

Question 9: A 22-year-old college student fears being watched or judged in social situations, avoids classes, and has impaired daily functioning for over 6 months. What is the first-line pharmacological treatment?

Selective serotonin reuptake inhibitor (SSRI) (Correct answer)
Bupropion
Diazepam
Haloperidol

Correct answer: Selective serotonin reuptake inhibitor (SSRI)

SSRIs (e.g., paroxetine, sertraline) are first-line pharmacotherapy for social anxiety disorder, with evidence for both acute and long-term treatment.

Question 10: A 48-year-old man presents with a painful erythematous and edematous right lower leg with rapidly spreading erythema, crepitus on palpation, and systemic sepsis. Blood glucose is 22 mmol/L. What is the diagnosis and immediate treatment?

Cellulitis — IV penicillin
Deep vein thrombosis — anticoagulation
Gas gangrene (myonecrosis) — hyperbaric oxygen first
Necrotizing fasciitis — emergent surgical debridement and broad-spectrum antibiotics (Correct answer)

Correct answer: Necrotizing fasciitis — emergent surgical debridement and broad-spectrum antibiotics

Crepitus, rapidly advancing erythema, and sepsis in a diabetic patient indicate necrotizing fasciitis requiring immediate aggressive surgical debridement, which is life-saving and cannot be delayed.

Question 11: At which age would you expect a child to begin stranger anxiety?

2–3 months
12–15 months
6–9 months (Correct answer)
4–5 months

Correct answer: 6–9 months

Stranger anxiety typically emerges between 6 and 9 months as the infant develops object permanence and preferential attachment to caregivers.

Question 12: At what age do most children achieve daytime bladder control (daytime continence)?

3–4 years
4–5 years
2–3 years (Correct answer)
18–24 months

Correct answer: 2–3 years

Most children achieve reliable daytime bladder control between ages 2 and 3 years, though nighttime dryness may take longer.

Question 13: A physician inadvertently makes a medication error that causes patient harm. What is the ethical obligation regarding disclosure?

Proactively disclose the error, apologize, and explain the steps taken to prevent recurrence (Correct answer)
Disclose only if the patient directly asks
Document the error in the chart without informing the patient
Disclose only to the hospital risk management team

Correct answer: Proactively disclose the error, apologize, and explain the steps taken to prevent recurrence

The duty of candour requires physicians to proactively disclose adverse events, including errors, to affected patients.

Question 14: In an outbreak investigation, the epidemic curve shows a sharp peak with cases clustered within one incubation period. This pattern most suggests:

A common-source point exposure (Correct answer)
A continuous common source
Propagated (person-to-person) spread
Vector-borne transmission

Correct answer: A common-source point exposure

A sharp unimodal peak with cases within one incubation period is characteristic of a point-source outbreak with simultaneous exposure.

Question 15: A 75-year-old patient has been deemed incapable of making medical decisions due to advanced dementia. He does not have a power of attorney for personal care or an advance directive. According to the typical hierarchy of substitute decision-makers (SDMs) in most Canadian provinces, who should the medical team approach first for consent?

A court-appointed guardian.
The patient's eldest adult child.
A close friend who has known the patient for 40 years.
The patient's spouse. (Correct answer)

Correct answer: The patient's spouse.

Most provinces and territories in Canada have legislation that specifies a ranked hierarchy of automatic substitute decision-makers (SDMs) for patients who are incapable of consenting to treatment and have not legally appointed someone. [2, 20] While the exact order can vary slightly, the spouse or partner is consistently ranked at or near the top of the list, above adult children, parents, or siblings. [8, 20] A court-appointed guardian would only be sought if no one higher on the list is available or willing to act. A close friend is typically much lower on the hierarchy, if included at all. [8]

Question 16: A researcher finds an odds ratio of 2.5 (95% CI: 0.9–6.8) for the association between a dietary factor and colon cancer. What is the correct interpretation?

The study has insufficient external validity
The result is not statistically significant at the 0.05 level (Correct answer)
There is a statistically significant association
The dietary factor is definitively protective

Correct answer: The result is not statistically significant at the 0.05 level

Because the 95% CI crosses 1.0, the result is not statistically significant at α = 0.05.

Question 17: A woman at 36 weeks presents with pruritus affecting palms and soles, worse at night, without rash. Liver enzymes are mildly elevated and bile acids are 48 µmol/L. What is the most serious fetal risk?

Preterm birth from premature rupture of membranes
Fetal hydrops
Intrauterine fetal death (Correct answer)
Meconium aspiration syndrome

Correct answer: Intrauterine fetal death

Intrahepatic cholestasis of pregnancy (ICP) is associated with sudden unexplained stillbirth, particularly when bile acids exceed 40 µmol/L.

Question 18: Which organization is responsible for setting the passing standard for the MCCQE?

Canadian Medical Association
College of Family Physicians of Canada
Royal College of Physicians and Surgeons of Canada
Medical Council of Canada (Correct answer)

Correct answer: Medical Council of Canada

The Medical Council of Canada (MCC) administers and sets the passing standard for both MCCQE Part I and Part II.

Question 19: A 55-year-old woman on phenelzine for depression eats aged cheese and develops severe hypertensive crisis. What is the mechanism?

Histamine toxicity from fermentation
Tyramine-induced norepinephrine surge due to MAO inhibition (Correct answer)
Serotonin syndrome from cheese-induced 5-HT release
Direct vasopressin release from casein

Correct answer: Tyramine-induced norepinephrine surge due to MAO inhibition

MAO inhibitors block tyramine breakdown; dietary tyramine triggers massive norepinephrine release from sympathetic terminals, causing hypertensive crisis.

Question 20: Which of the following study designs is most prone to the ecological fallacy?

Case-control study
Cohort study
Ecological study (Correct answer)
Cross-sectional study

Correct answer: Ecological study

Ecological studies use group-level data; applying group associations to individuals risks the ecological fallacy.

Question 21: What credential is verified through physiciansapply.ca for MCCQE eligibility?

A clinical practice report.
A medical residency certificate.
A board certification letter.
Medical degree and supporting documents. (Correct answer)

Correct answer: Medical degree and supporting documents.

The physiciansapply.ca platform is used to verify a candidate's medical degree and all supporting academic documents. This crucial step confirms the authenticity and equivalence of their medical education, ensuring they meet the necessary standards for MCCQE eligibility.

Question 22: Which of the following is the primary goal of initiating a rhythm-control strategy in a symptomatic patient with atrial fibrillation, according to current Canadian cardiovascular guidelines?

To improve quality of life and reduce AF-related symptoms. (Correct answer)
To eliminate the need for long-term oral anticoagulation.
To reduce the risk of stroke and systemic embolism.
To decrease the risk of heart failure development.

Correct answer: To improve quality of life and reduce AF-related symptoms.

The primary indication for a rhythm-control strategy (using antiarrhythmic drugs or ablation) in patients with atrial fibrillation is to reduce AF-related symptoms and improve quality of life. While rhythm control can have other benefits, symptom improvement is the main goal. Stroke prevention with anticoagulation is still required based on the patient's risk profile, irrespective of the rhythm-control strategy.

Question 23: Which doctrine requires physicians to disclose information that a reasonable patient in the same circumstances would want to know before consenting to treatment?

Therapeutic privilege
Modified objective standard (Correct answer)
Subjective patient standard
Professional practice standard

Correct answer: Modified objective standard

The modified objective standard requires disclosure of what a reasonable patient would want to know, as established in Reibl v. Hughes.

Question 24: A 60-year-old man presents with a 3-week history of depressed mood, anhedonia, psychomotor retardation, and 10 lb weight loss following his wife's death 2 months ago. Which finding most supports a diagnosis of MDD rather than normal bereavement?

Marked functional impairment and suicidal ideation (Correct answer)
Persistent tearfulness
Feeling sad on anniversaries
Dreaming about the deceased

Correct answer: Marked functional impairment and suicidal ideation

Marked functional impairment and suicidal ideation distinguish major depressive disorder from normal grief, which typically does not involve suicidality.

Question 25: At what age does a child typically develop the pincer grasp (thumb-forefinger apposition)?

4 months
9 months (Correct answer)
6 months
12 months

Correct answer: 9 months

The mature pincer grasp develops around 9–10 months, allowing precise grasping of small objects between thumb and index finger.

Question 26: A 55-year-old woman develops sudden severe headache ('thunderclap'), neck stiffness, and photophobia. Non-contrast CT head is negative for hemorrhage. What is the next critical step?

CT angiography for aneurysm
Lumbar puncture to look for xanthochromia (Correct answer)
Start empiric acyclovir for herpes encephalitis
MRI brain with gadolinium

Correct answer: Lumbar puncture to look for xanthochromia

A negative CT does not exclude subarachnoid hemorrhage; lumbar puncture must be performed to detect xanthochromia or elevated RBCs, as CT sensitivity drops significantly after 6–12 hours.

Question 27: A 10-year-old girl begins breast development. This is considered precocious puberty. What is the most common underlying cause?

Central (gonadotropin-dependent) precocious puberty — idiopathic (Correct answer)
Congenital adrenal hyperplasia
Adrenal tumor
McCune-Albright syndrome

Correct answer: Central (gonadotropin-dependent) precocious puberty — idiopathic

Wait — precocious puberty in girls is defined as onset before age 8, so a 10-year-old with breast development is normal; however if the question intends age 7, the most common cause of true precocious puberty is idiopathic central precocious puberty.

Question 28: Which official document published by the Medical Council of Canada serves as the primary blueprint for MCCQE Part 1 content?

CanMEDS Physician Competency Framework
AFMC Undergraduate Medical Education Report
MCC Objectives for the Qualifying Examination (Correct answer)
Canadian Residency Matching Service (CaRMS) Guide

Correct answer: MCC Objectives for the Qualifying Examination

The MCC Objectives for the Qualifying Examination outlines the clinical presentations, disciplines, and competencies that form the basis of all MCCQE Part 1 content.

Question 29: A physician suspects that an elderly patient is being financially abused by a family caregiver. The patient denies abuse and asks the physician to stay out of it. What is the most appropriate action?

Discharge the patient from the practice
Respect the patient's wishes entirely and take no action
Assess capacity, document concerns, provide resources, and consider mandatory reporting if legally required in the province (Correct answer)
Immediately report to police without patient knowledge

Correct answer: Assess capacity, document concerns, provide resources, and consider mandatory reporting if legally required in the province

Suspected elder abuse requires assessment of capacity, thorough documentation, offering resources, and following provincial mandatory reporting obligations where they exist.

Question 30: Spaced repetition is best applied to MCCQE preparation by:

Reviewing incorrect and flagged Qbank questions at increasing intervals (e.g., 1 day, 3 days, 7 days) (Correct answer)
Reading the same chapter three times in one day before moving on
Studying each organ system sequentially without returning to earlier systems
Taking one full-length practice exam every week regardless of performance

Correct answer: Reviewing incorrect and flagged Qbank questions at increasing intervals (e.g., 1 day, 3 days, 7 days)

Spaced repetition exploits the spacing effect by re-encountering material at optimal forgetting intervals, maximizing retention efficiency.

Question 31: A 29-year-old woman at 20 weeks is found to have cervical length of 18 mm on transvaginal ultrasound during routine anatomy scan. She had a second-trimester loss last pregnancy. What is the most appropriate management?

Cervical cerclage placement (Correct answer)
Immediate induction of labour
Bed rest and pelvic rest only
Progesterone suppositories alone

Correct answer: Cervical cerclage placement

Women with prior second-trimester loss and short cervix benefit from cervical cerclage to reduce the risk of recurrent preterm birth.

Question 32: A 72-year-old male with a new diagnosis of non-valvular atrial fibrillation has a CHADS2 score of 3. He is being started on anticoagulation for stroke prevention. Which of the following is a key component of his management plan according to the Canadian Cardiovascular Society (CCS) guidelines?

Screening for and managing modifiable cardiovascular risk factors such as hypertension and obesity. (Correct answer)
Scheduling an elective cardioversion within the first month of diagnosis.
Prescribing a reduced dose of a direct oral anticoagulant (DOAC) to minimize bleeding risk, regardless of specific criteria.
Initiating dual antiplatelet therapy in addition to oral anticoagulation.

Correct answer: Screening for and managing modifiable cardiovascular risk factors such as hypertension and obesity.

The 2020 CCS/CHRS Atrial Fibrillation Guidelines emphasize a comprehensive approach to management. A crucial part of this is the management of modifiable cardiovascular risk factors (e.g., hypertension, obesity, sleep apnea) to reduce cardiovascular events and decrease the burden of atrial fibrillation.

Question 33: A 78-year-old female with a history of atrial fibrillation presents with the sudden onset of severe, diffuse abdominal pain. On examination, her abdomen is soft and non-tender with normal bowel sounds. Laboratory tests reveal a significant metabolic acidosis and a markedly elevated lactate level. Which of the following is the most likely diagnosis?

Acute pancreatitis
Perforated diverticulitis
Ruptured abdominal aortic aneurysm
Acute mesenteric ischemia (Correct answer)

Correct answer: Acute mesenteric ischemia

The classic presentation of acute mesenteric ischemia is 'pain out of proportion to physical exam findings'. The severe pain with a benign abdominal exam, combined with risk factors (atrial fibrillation, a source of emboli) and evidence of tissue hypoperfusion (metabolic acidosis, high lactate), is highly suggestive of this diagnosis. The other options would typically present with more pronounced physical findings like tenderness, guarding, or a pulsatile mass.

Question 34: A 52-year-old man with a recent NSTEMI has LDL of 3.2 mmol/L despite maximum-dose rosuvastatin and ezetimibe. What is the next best lipid-lowering option?

Add a fibrate
Add a PCSK9 inhibitor (evolocumab or alirocumab) (Correct answer)
Add omega-3 fatty acids
Switch to atorvastatin

Correct answer: Add a PCSK9 inhibitor (evolocumab or alirocumab)

PCSK9 inhibitors added to maximally tolerated statin plus ezetimibe further reduce LDL by 50–60% and reduce CV events in high-risk patients (FOURIER, ODYSSEY OUTCOMES).

Question 35: Which of the following is NOT listed as an eligibility requirement for MCCQE Part I?

Holding a valid license to practice medicine in any jurisdiction (Correct answer)
Obtaining an MCC identification number
Paying the applicable examination fee
Enrollment in or graduation from a recognized medical school

Correct answer: Holding a valid license to practice medicine in any jurisdiction

A license to practice medicine is not required for MCCQE Part I; candidates are typically students or recent graduates who have not yet been licensed.

Question 36: Standardized mortality ratio (SMR) is used to:

Estimate the life expectancy of a cohort
Calculate the case fatality rate of a disease
Measure absolute mortality in a study population
Compare observed deaths in a study population to expected deaths based on a reference population (Correct answer)

Correct answer: Compare observed deaths in a study population to expected deaths based on a reference population

SMR = observed deaths / expected deaths × 100; an SMR > 100 indicates excess mortality compared to the reference population.

Question 37: A 24-year-old woman presents with periods of depressed mood for 2 weeks every month beginning a week before menstruation and resolving within a few days of its onset, with significant functional impairment. What is the diagnosis?

Major depressive disorder with seasonal pattern
Dysthymia
Premenstrual dysphoric disorder (PMDD) (Correct answer)
Premenstrual syndrome (PMS)

Correct answer: Premenstrual dysphoric disorder (PMDD)

PMDD is distinguished from PMS by marked functional impairment and mood symptoms (not just physical) confirmed prospectively across at least two cycles.

Question 38: A factory worker cohort has higher lung disease rates than the general population. Comparing to the general population introduces which bias?

Recall bias
Hawthorne effect
Healthy worker effect (Correct answer)
Berkson bias

Correct answer: Healthy worker effect

The healthy worker effect occurs because employed populations are generally healthier than the general population, underestimating occupational risks.

Question 39: Under what circumstance would the MCC invalidate a candidate's MCCQE Part I result after it has been released?

If the candidate scores in the bottom 5th percentile
If the candidate fails to register for Part II within 12 months
If evidence of exam misconduct or irregularity is confirmed post-hoc (Correct answer)
If a medical school requests a score review

Correct answer: If evidence of exam misconduct or irregularity is confirmed post-hoc

The MCC can invalidate results if post-hoc evidence of misconduct or testing irregularities is confirmed.

Question 40: Under MCC policy, which of the following correctly describes the citizenship or residency requirement for MCCQE Part I eligibility?

There is no citizenship or residency requirement (Correct answer)
Applicants must be Canadian citizens or permanent residents
Applicants must hold a Canadian study permit
Applicants must reside in Canada at the time of the exam

Correct answer: There is no citizenship or residency requirement

The MCC does not impose any citizenship or residency requirement for MCCQE Part I eligibility.

Question 41: Which of the following best describes a systematic review?

A single large observational study
A narrative literature review without defined search criteria
An expert opinion on a clinical question
A comprehensive synthesis of all relevant studies on a topic using explicit methods (Correct answer)

Correct answer: A comprehensive synthesis of all relevant studies on a topic using explicit methods

Systematic reviews use pre-specified, reproducible search and selection criteria to synthesize evidence from multiple studies.

Question 42: A 34-year-old woman at 39 weeks undergoes caesarean section. During closure, brisk bleeding is noted from the uterine incision edges that does not stop with suture. She receives oxytocin, ergometrine, and carboprost without effect. Estimated blood loss is 3 L. What is the next surgical step?

Uterine curettage to remove retained products
Internal iliac artery ligation
B-Lynch compression suture (Correct answer)
Peripartum hysterectomy immediately

Correct answer: B-Lynch compression suture

B-Lynch compression suture is a uterine-preserving surgical option for refractory uterine atony after medical management fails, compressing the uterus to reduce bleeding.

Question 43: A 38-year-old G3P2 woman at 34 weeks gestation presents with painless, bright red vaginal bleeding. She has had two previous Cesarean sections. A transabdominal ultrasound reveals a placenta completely covering the internal cervical os. What is the most likely diagnosis?

Placenta previa (Correct answer)
Placental abruption
Uterine rupture
Vasa previa

Correct answer: Placenta previa

The classic presentation of placenta previa is painless, bright red vaginal bleeding in the third trimester. The diagnosis is confirmed by ultrasound showing the placenta covering the internal cervical os. Her history of two previous Cesarean sections is a significant risk factor. Placental abruption typically presents with painful bleeding and uterine tenderness. Vasa previa involves fetal vessels running over the os and bleeding would occur with membrane rupture. Uterine rupture is a rare, catastrophic event usually associated with labor in a scarred uterus.

Question 44: A 24-year-old female has a history of multiple tumultuous relationships that end abruptly, recurrent acts of self-harm during periods of stress, and chronic feelings of emptiness. She often makes frantic efforts to avoid perceived abandonment by her partners. This clinical picture is most characteristic of which core feature of Borderline Personality Disorder?

Grandiose sense of self-importance
Instability in relationships, self-image, and affects (Correct answer)
Social inhibition and feelings of inadequacy
Pervasive distrust and suspiciousness

Correct answer: Instability in relationships, self-image, and affects

A pervasive pattern of instability is the hallmark of Borderline Personality Disorder, as defined by the DSM-5. This includes instability in interpersonal relationships (e.g., alternating between idealization and devaluation), unstable self-image, and affective instability (intense mood swings). The patient's presentation directly reflects these core features. Distrust is characteristic of Paranoid PD, grandiosity of Narcissistic PD, and social inhibition of Avoidant PD.

Question 45: A 33-year-old woman presents with 2 years of hypomanic episodes (lasting 4+ days) alternating with depressive episodes, never meeting full criteria for mania or major depression. What is the diagnosis?

Persistent depressive disorder (dysthymia)
Bipolar II disorder
Bipolar I disorder
Cyclothymic disorder (Correct answer)

Correct answer: Cyclothymic disorder

Cyclothymic disorder requires at least 2 years of hypomanic and depressive symptoms that never meet full criteria for a hypomanic or major depressive episode.

Question 46: Fluconazole is effective against Candida albicans but often ineffective against Candida krusei. Which mechanism explains this intrinsic resistance?

C. krusei overexpresses efflux pumps constitutively
C. krusei produces a fluconazole-inactivating acetylase
C. krusei has an intrinsically less susceptible CYP51 target enzyme (Correct answer)
C. krusei produces beta-glucan that prevents fluconazole entry

Correct answer: C. krusei has an intrinsically less susceptible CYP51 target enzyme

Candida krusei has intrinsic resistance to fluconazole primarily due to reduced affinity of its lanosterol 14α-demethylase (CYP51) target for the drug.

Question 47: A 50-year-old woman presents with right iliac fossa pain, fever, and a palpable mass. CT shows a perforated appendicitis with a 4 cm periappendiceal abscess and no free perforation. What is the preferred management in a stable patient?

Immediate laparoscopic appendectomy
IV antibiotics alone without drainage
IV antibiotics and CT-guided percutaneous drainage, followed by interval appendectomy (Correct answer)
Open drainage with primary appendectomy

Correct answer: IV antibiotics and CT-guided percutaneous drainage, followed by interval appendectomy

A well-contained periappendiceal abscess in a stable patient is best managed with percutaneous drainage and antibiotics, followed by interval appendectomy at 6–8 weeks to rule out underlying malignancy.

Question 48: Which developmental screening tool is validated for use in Canadian primary care settings for children 0–5 years?

Griffiths Mental Development Scales
Ages and Stages Questionnaires (ASQ) (Correct answer)
Bayley Scales of Infant Development
Denver Developmental Screening Test II (Denver II)

Correct answer: Ages and Stages Questionnaires (ASQ)

The Ages and Stages Questionnaires (ASQ) is a widely validated, parent-completed screening tool recommended for use in Canadian primary care for children aged 0–66 months.

Question 49: In a screening program, the positive predictive value of a test is most influenced by which of the following?

Test specificity
Sample size of the study
Test sensitivity
Prevalence of the disease in the screened population (Correct answer)

Correct answer: Prevalence of the disease in the screened population

Positive predictive value depends heavily on disease prevalence; a highly specific test still has low PPV in low-prevalence populations.

Question 50: At which point in a Canadian physician's career is the MCCQE Part I typically taken?

Only after obtaining provincial licensure
After completing a full residency program
Near the end of or shortly after completing medical school (Correct answer)
During the first year of medical school

Correct answer: Near the end of or shortly after completing medical school

Most Canadian medical graduates sit MCCQE Part I near graduation or within a year of completing their MD program, before entering residency.

Question 51: What is a recommended resource for studying for the MCCQE Part I?

Clinical placement reports.
Hospital work experience.
Textbooks on healthcare management.
Practice Tests and Self-Assessment Tools (SAE). (Correct answer)

Correct answer: Practice Tests and Self-Assessment Tools (SAE).

Practice Tests and Self-Assessment Tools (SAE) are highly recommended resources for studying for the MCCQE Part I. These tools simulate the exam format and content, allowing candidates to familiarize themselves with question types and assess their knowledge gaps effectively.

Question 52: A 55-year-old man with schizophrenia requires clozapine due to treatment resistance. What mandatory monitoring is required due to clozapine's most dangerous adverse effect?

Absolute neutrophil count (ANC) monitoring per registry protocol (Correct answer)
Thyroid function tests biweekly
Liver function tests weekly
Serum creatinine monthly

Correct answer: Absolute neutrophil count (ANC) monitoring per registry protocol

Clozapine carries a risk of potentially fatal agranulocytosis, requiring mandatory ANC monitoring through a national registry (e.g., weekly for 26 weeks, then biweekly).

Question 53: Which of the following situations creates a mandatory reporting obligation for a Canadian physician regardless of patient consent?

A patient with poorly controlled diabetes who drives
A patient with untreated epileptic seizures who holds a commercial driver's licence (Correct answer)
A patient with depression who walks to work
A patient with hypertension on medication

Correct answer: A patient with untreated epileptic seizures who holds a commercial driver's licence

Physicians in most provinces have a legal duty to report patients with seizure disorders who drive, particularly commercial drivers, to the relevant transport authority.

Question 54: A pharmaceutical company offers a physician an all-expenses-paid trip to a resort in exchange for prescribing their medication. This arrangement is best described as:

A standard industry practice permitted by the CMA
Acceptable if the physician discloses it to patients
An inappropriate conflict of interest and potential bribery (Correct answer)
Acceptable continuing medical education

Correct answer: An inappropriate conflict of interest and potential bribery

Accepting inducements from industry in exchange for prescribing constitutes a serious conflict of interest and violates professional and legal standards.

Question 55: A 19-year-old man presents with a 6-month history of social withdrawal, flat affect, disorganized speech, and auditory hallucinations. He has no prior psychiatric history and no substance use. What is the most likely diagnosis?

Delusional disorder
Brief psychotic disorder
Schizophreniform disorder
Schizophrenia (Correct answer)

Correct answer: Schizophrenia

Schizophrenia requires at least 6 months of symptoms including at least 1 month of active-phase symptoms; this patient meets full criteria.

Question 56: A 32-year-old G2P1 at 36 weeks presents with sudden onset severe epigastric pain, vomiting, and jaundice. Labs show AST 850 U/L, ALT 920 U/L, bilirubin 6.2 mg/dL, platelets 48,000, and PT prolonged. What is the most likely diagnosis?

Viral hepatitis
HELLP syndrome
Intrahepatic cholestasis of pregnancy
Acute fatty liver of pregnancy (Correct answer)

Correct answer: Acute fatty liver of pregnancy

Acute fatty liver of pregnancy (AFLP) presents with jaundice, coagulopathy, and markedly elevated transaminases in late pregnancy, distinguishable from HELLP by the degree of liver failure.

Question 57: A 32-year-old woman with bipolar I disorder is stable on lithium and becomes pregnant. What is the primary concern regarding lithium use in the first trimester?

Ebstein's anomaly risk (Correct answer)
Neonatal seizures
Placental abruption
Neonatal hypothyroidism

Correct answer: Ebstein's anomaly risk

Lithium use in the first trimester carries a small but increased risk of Ebstein's anomaly, a cardiac malformation of the tricuspid valve.

Question 58: A community-based intervention reduces hypertension prevalence by 5 percentage points (from 30% to 25%). What is the absolute risk reduction?

17%
20%
5% (Correct answer)
25%

Correct answer: 5%

Absolute risk reduction = 30% − 25% = 5 percentage points.

Question 59: A 60-year-old man presents with left lower quadrant pain, fever, and leukocytosis. CT shows pericolic fat stranding and a small extraluminal air bubble adjacent to the sigmoid colon (Hinchey Stage II). He is stable. What is the standard management?

IV antibiotics and CT-guided drainage of any abscess, with elective sigmoid resection later (Correct answer)
Oral antibiotics as outpatient
Primary sigmoid resection with anastomosis immediately
Emergent Hartmann's procedure

Correct answer: IV antibiotics and CT-guided drainage of any abscess, with elective sigmoid resection later

Hinchey II diverticulitis (pericolic or pelvic abscess without free perforation) is managed with IV antibiotics and percutaneous drainage if the abscess is ≥3 cm, followed by elective resection.

Question 60: A physician is treating a long-term patient who is also a close personal friend. Which ethical risk does this relationship most create?

Conflict with substitute decision-maker hierarchy
Violation of mandatory reporting duties
Boundary violation and compromised objectivity (Correct answer)
Breach of research ethics

Correct answer: Boundary violation and compromised objectivity

Dual relationships can compromise clinical objectivity, impair professional judgment, and create boundary violations.

Question 61: Which of the following best represents secondary prevention?

Mammography screening for breast cancer (Correct answer)
Occupational safety regulations
Influenza vaccination campaign
Cardiac rehabilitation after myocardial infarction

Correct answer: Mammography screening for breast cancer

Secondary prevention involves screening to detect disease at an early, asymptomatic stage, enabling earlier treatment.

Question 62: Which score metric reported on the MCCQE Part I result allows candidates to compare their performance to previous cohorts?

Standard score (scaled score) (Correct answer)
Percentile rank
Z-score
Raw score

Correct answer: Standard score (scaled score)

The standard (scaled) score allows comparison across different exam administrations by accounting for variation in item difficulty.

Question 63: What is the minimum passing score for the MCCQE Part I?

226. (Correct answer)
250.
300.
210.

Correct answer: 226.

The minimum passing score for the MCCQE Part I is 226 on a scaled score. This specific threshold is determined through a rigorous standard-setting process to ensure that all candidates who pass possess the necessary level of competence for entry into supervised medical practice in Canada.

Question 64: A 33-year-old G2P1 at 37 weeks with known HIV on HAART has a viral load of 450 copies/mL at 36 weeks. What is the recommended mode of delivery?

Elective caesarean section at 38 weeks
Vaginal delivery with IV zidovudine intrapartum only
Elective caesarean section at 37-38 weeks to reduce vertical transmission (Correct answer)
Vaginal delivery is safe as viral load is below 1000 copies/mL

Correct answer: Elective caesarean section at 37-38 weeks to reduce vertical transmission

Elective caesarean section is recommended for HIV-positive women with viral load >400 copies/mL at 36 weeks to reduce vertical transmission risk.

Question 65: A physician has a personal moral objection to prescribing medical assistance in dying (MAID). What is their legal obligation in Canada?

They may refuse without any further duty
They must provide an effective referral to a willing provider (Correct answer)
They must provide MAID regardless of personal beliefs
They must transfer the patient's care entirely

Correct answer: They must provide an effective referral to a willing provider

Under Bill C-14 and professional guidelines, conscientious objectors must provide timely and effective referrals so patients can access MAID.

Question 66: Which of the following is an example of tertiary prevention?

Stroke rehabilitation to minimize disability (Correct answer)
Hepatitis B vaccination
Water fluoridation to prevent dental caries
Cervical cancer screening (Pap smear)

Correct answer: Stroke rehabilitation to minimize disability

Tertiary prevention reduces the impact of established disease by restoring function and minimizing complications.

Question 67: A 45-year-old woman with moderate depression and comorbid chronic pain is seeking pharmacotherapy that addresses both conditions. Which antidepressant class is most appropriate?

Tricyclic antidepressant at full antidepressant dose
Bupropion
SSRI (e.g., fluoxetine)
SNRI (e.g., duloxetine) (Correct answer)

Correct answer: SNRI (e.g., duloxetine)

SNRIs such as duloxetine have evidence for both depression and neuropathic/chronic pain through noradrenergic and serotonergic mechanisms.

Question 68: A patient with Clostridium difficile infection fails metronidazole therapy. What is the most appropriate next step?

Start oral vancomycin (Correct answer)
Initiate intravenous vancomycin
Add rifaximin to current metronidazole
Switch to intravenous metronidazole at higher doses

Correct answer: Start oral vancomycin

Oral vancomycin is recommended for patients who fail or are intolerant to metronidazole for C. difficile infection, as it achieves high luminal concentrations.

Question 69: What type of feedback do candidates receive after completing MCCQE Part I?

Scaled total score and performance profiles by discipline area (Correct answer)
Item-by-item correct/incorrect breakdown
Only a pass or fail notification with no score
A percentile rank compared to all other candidates that sitting

Correct answer: Scaled total score and performance profiles by discipline area

Candidates receive their scaled total score along with performance profiles showing relative strengths and weaknesses across discipline areas.

Question 70: A 7-year-old boy is brought in for short stature. He is growing at 4 cm/year. Bone age is 7 years. Thyroid function and IGF-1 are normal. What is the most likely diagnosis?

Constitutional growth delay
Hypothyroidism
Familial short stature (Correct answer)
Growth hormone deficiency

Correct answer: Familial short stature

Familial short stature features a bone age matching chronological age, normal growth velocity, and a family history of short stature, distinguishing it from constitutional delay where bone age is delayed.

Question 71: A 31-year-old woman with Type 1 diabetes at 36 weeks has her glucose poorly controlled (HbA1c 9.2%). Which neonatal complication is most directly related to maternal hyperglycemia during the third trimester?

Neonatal hypoglycemia from fetal hyperinsulinism (Correct answer)
Neonatal hypothyroidism from iodine deficiency
Neonatal polycythemia from erythropoietin deficiency
Neonatal seizures from cerebral hypoxia

Correct answer: Neonatal hypoglycemia from fetal hyperinsulinism

Maternal hyperglycemia causes fetal hyperglycemia, which stimulates fetal pancreatic beta cells to produce excess insulin; after birth, this hyperinsulinism causes neonatal hypoglycemia.

Question 72: A patient on isoniazid (INH) for latent TB prophylaxis develops peripheral neuropathy. Which supplement should be co-administered with INH to prevent this complication?

Vitamin B12 (cyanocobalamin)
Vitamin D
Folic acid
Vitamin B6 (pyridoxine) (Correct answer)

Correct answer: Vitamin B6 (pyridoxine)

INH competitively inhibits pyridoxal phosphate (active vitamin B6) metabolism, causing deficiency that leads to peripheral neuropathy; pyridoxine supplementation prevents this.

Question 73: What is a key benefit of the MCC Practice Tests?

Provides detailed case studies.
Focuses on clinical rotations.
Offers free certification.
Simulates the exam environment. (Correct answer)

Correct answer: Simulates the exam environment.

A key benefit of the MCC Practice Tests is their ability to simulate the actual exam environment, including the format, timing, and types of questions. This helps candidates become comfortable with the testing conditions and manage their time effectively during the real examination.

Question 74: A screening test for colorectal cancer is applied to 10,000 people; 200 test positive, 50 have true disease (all test positive), and 150 are false positives. What is the specificity?

75%
25%
98.4% (Correct answer)
100%

Correct answer: 98.4%

Specificity = TN / (TN + FP) = 9,800 / (9,800 + 150) = 9,800/9,950 ≈ 98.5%.

Question 75: A research participant enrolled in a clinical trial develops an unexpected serious adverse event. What is the researcher's immediate obligation?

Withdraw the participant silently to protect trial data
Inform only the sponsor and continue
Complete the trial before reporting to minimize bias
Immediately report the event to the Research Ethics Board and consider stopping the trial (Correct answer)

Correct answer: Immediately report the event to the Research Ethics Board and consider stopping the trial

Serious adverse events must be promptly reported to the REB; participant safety takes precedence over data integrity.

Question 76: A 38-year-old G4P3 at 32 weeks presents with sudden onset severe abdominal pain and uterine rigidity. She denies bleeding. BP is 150/98. On CTG, late decelerations are noted. What is the most likely diagnosis?

Preterm labour
Uterine rupture
Placental abruption (Correct answer)
Placenta previa

Correct answer: Placental abruption

Placental abruption classically presents with painful uterine rigidity, may have concealed hemorrhage, and is associated with hypertension.

Question 77: Which of the following is a key principle, as originally described by Wilson and Jungner, for a condition to be suitable for a population-based screening program?

The condition must have a recognizable latent or early symptomatic stage. (Correct answer)
The condition must have a high prevalence in the target population.
The treatment for the disease must be inexpensive and easily accessible.
The screening test must have 100% specificity to avoid false positives.

Correct answer: The condition must have a recognizable latent or early symptomatic stage.

A core Wilson-Jungner criterion is that the natural history of the condition should be understood, including a detectable early stage (latent or early symptomatic) during which treatment is more effective than if applied later. This allows the screening program to identify and treat the disease early, thereby improving the outcome.

Question 78: A 26-year-old G1P0 at 34 weeks presents with painless, bright red vaginal bleeding. She denies contractions. Ultrasound shows placenta previa. What is the most appropriate next step?

Admit for observation, IV access, crossmatch, and corticosteroids (Correct answer)
Digital cervical exam to assess dilation
Immediate caesarean delivery
Amniotomy to hasten delivery

Correct answer: Admit for observation, IV access, crossmatch, and corticosteroids

Stable placenta previa at 34 weeks warrants expectant management with hospitalization, corticosteroids for fetal lung maturity, and avoidance of digital exam to prevent further hemorrhage.

Question 79: A 60-year-old woman with known gallstones presents with fever, right upper quadrant pain, and jaundice (Charcot's triad). She then develops hypotension and altered consciousness (Reynolds' pentad). What is the diagnosis and priority management?

Mirizzi syndrome — hepaticojejunostomy
Choledocholithiasis — elective ERCP as outpatient
Ascending cholangitis — IV antibiotics, urgent biliary decompression via ERCP (Correct answer)
Acute cholecystitis — laparoscopic cholecystectomy within 24 hours

Correct answer: Ascending cholangitis — IV antibiotics, urgent biliary decompression via ERCP

Reynolds' pentad (Charcot's triad plus shock and confusion) indicates acute suppurative cholangitis requiring urgent biliary decompression via ERCP and IV broad-spectrum antibiotics.

Question 80: A 28-year-old G1P0 at 26 weeks is found to have a 1-hour 50g GCT of 8.9 mmol/L. A 2-hour 75g OGTT shows fasting 5.4, 1-hour 11.2, and 2-hour 9.0 mmol/L. What is the most appropriate initial management?

Start metformin and dietary counselling
Start insulin immediately given OGTT results
Repeat OGTT in 4 weeks to confirm diagnosis
Medical nutrition therapy (MNT) and lifestyle modification for 2 weeks before pharmacotherapy (Correct answer)

Correct answer: Medical nutrition therapy (MNT) and lifestyle modification for 2 weeks before pharmacotherapy

Newly diagnosed gestational diabetes mellitus (GDM) is initially managed with medical nutrition therapy and lifestyle modification; pharmacotherapy is added if targets are not met within 1-2 weeks.

Question 81: You are plotting the growth of a 4-year-old girl on a WHO growth chart. Her weight has been consistently tracking along the 50th percentile, but her height has just dropped from the 25th percentile to below the 3rd percentile over the last year. What is the most appropriate next step?

Schedule a follow-up visit in one year to re-evaluate.
Advise a high-calorie diet to promote catch-up growth.
Initiate an investigation for an underlying cause of growth failure. (Correct answer)
Reassure the parents that this is a normal growth variation.

Correct answer: Initiate an investigation for an underlying cause of growth failure.

A significant drop in height percentile, especially crossing two or more major percentile lines (e.g., from the 25th to below the 3rd), is a major red flag for growth failure. This warrants a thorough investigation to rule out underlying medical conditions such as endocrine disorders, chronic illness, or malnutrition. Reassurance is inappropriate given the significant change. While nutrition is important, simply advising a high-calorie diet without investigating the cause is insufficient. Delaying follow-up for a year could be detrimental.

Question 82: The MCCQE Part II uses which primary format to assess clinical competence for scoring purposes?

Written long-answer clinical vignettes
Standardized oral examination with physician examiners
Computer-based multiple-choice questions
Objective Structured Clinical Examination (OSCE) stations (Correct answer)

Correct answer: Objective Structured Clinical Examination (OSCE) stations

The MCCQE Part II is delivered as an OSCE with multiple clinical stations where candidates interact with standardized patients.

Question 83: A 27-year-old G3P2 delivers a 4.2 kg infant vaginally. The anterior shoulder is delivered but the body does not follow despite gentle downward traction. The turtle sign is noted. What manoeuvre should be performed first?

Zavanelli manoeuvre
McRoberts manoeuvre with suprapubic pressure (Correct answer)
Internal rotation (Woods screw)
Fundal pressure (Kristeller manoeuvre)

Correct answer: McRoberts manoeuvre with suprapubic pressure

McRoberts manoeuvre (hyperflexion of maternal thighs) combined with suprapubic pressure is the first-line management for shoulder dystocia.

Question 84: A 15-year-old girl has not yet had her first menstrual period but has Tanner stage 4 breast development and pubic hair. What is the most appropriate next step?

Reassure; primary amenorrhea is defined as no menses by age 16 with secondary sexual characteristics (Correct answer)
Refer to genetics for Turner syndrome workup
Start oral contraceptive pills
Order pelvic ultrasound and hormone panel now

Correct answer: Reassure; primary amenorrhea is defined as no menses by age 16 with secondary sexual characteristics

Primary amenorrhea is defined as no menses by age 15 in the presence of secondary sexual characteristics, so this 15-year-old does not yet meet diagnostic criteria.

Question 85: Gray baby syndrome associated with chloramphenicol in neonates is caused by which mechanism?

Neonatal erythrocytes lack G6PD, sensitizing to oxidative hemolysis
Immature hepatic UDP-glucuronosyltransferase causes toxic drug accumulation (Correct answer)
Immature blood-brain barrier allows CNS accumulation
Renal tubular immaturity prevents adequate chloramphenicol excretion

Correct answer: Immature hepatic UDP-glucuronosyltransferase causes toxic drug accumulation

Neonates have immature hepatic glucuronidation (UDP-glucuronosyltransferase), causing chloramphenicol to accumulate to toxic levels, resulting in cardiovascular collapse.

Question 86: A 34-year-old woman reports re-experiencing a car accident through flashbacks and nightmares, hypervigilance, emotional numbing, and avoidance of driving for 3 months. What is the first-line pharmacotherapy?

Alprazolam
Sertraline (SSRI) (Correct answer)
Bupropion
Propranolol

Correct answer: Sertraline (SSRI)

SSRIs (sertraline, paroxetine) are first-line pharmacotherapy for PTSD, targeting mood, anxiety, and intrusion symptoms.

Question 87: A 28-year-old woman presents with recurrent episodes of binge eating followed by self-induced vomiting, dental erosions, and parotid gland enlargement. Which electrolyte abnormality is most likely?

Hypokalemia (Correct answer)
Hypernatremia
Hyperkalemia
Hypercalcemia

Correct answer: Hypokalemia

Repeated purging in bulimia nervosa causes loss of gastric acid, leading to hypokalemic, hypochloremic metabolic alkalosis.

Question 88: A 25-year-old man sustains a stab wound to the left chest at the 5th intercostal space, midclavicular line. He is hypotensive with distended neck veins and muffled heart sounds. Trachea is midline. What is the immediate intervention?

Bilateral chest tubes
Needle decompression at 2nd ICS midclavicular line
Pericardiocentesis or emergency thoracotomy for cardiac tamponade (Correct answer)
Emergency chest X-ray

Correct answer: Pericardiocentesis or emergency thoracotomy for cardiac tamponade

Beck's triad (hypotension, JVD, muffled heart sounds) with a penetrating chest wound indicates cardiac tamponade, treated emergently with pericardiocentesis or left anterolateral thoracotomy.

Question 89: A new mother is concerned about her 4-month-old infant's fine motor skills. Which of the following observations would be an expected and appropriate milestone for this age?

Brings hands to midline and to the mouth. (Correct answer)
Transfers an object from one hand to the other.
Demonstrates a mature pincer grasp to pick up a small object.
Builds a tower of two blocks.

Correct answer: Brings hands to midline and to the mouth.

By 4 months, an infant should be able to bring their hands together at the midline and bring them to their mouth. Transferring objects hand-to-hand typically develops around 6 months. The pincer grasp (using thumb and index finger) matures later, around 9-12 months. Building a tower of blocks is a skill that emerges around 12-15 months.

Question 90: A 68-year-old woman with atrial fibrillation presents with sudden severe periumbilical pain out of proportion to physical exam findings, followed by bloody diarrhea 6 hours later. CT angiography shows filling defect in the superior mesenteric artery. What is the priority management?

Immediate exploratory laparotomy
IV heparin anticoagulation and urgent surgical or endovascular revascularization (Correct answer)
Broad-spectrum antibiotics and bowel rest
Vasopressin infusion via angiography catheter

Correct answer: IV heparin anticoagulation and urgent surgical or endovascular revascularization

Acute mesenteric ischemia from embolic occlusion requires immediate anticoagulation with heparin and urgent revascularization (surgical embolectomy or endovascular therapy) to prevent bowel infarction.

Question 91: A 3-year-old girl has a bone age of 5 years, elevated LH/FSH, and advanced pubertal staging. MRI of the brain is most likely to show:

Craniopharyngioma
Normal MRI
Pineal gland cyst
Hypothalamic hamartoma (Correct answer)

Correct answer: Hypothalamic hamartoma

Hypothalamic hamartoma is the most common identifiable CNS cause of central precocious puberty in young children, causing premature GnRH pulsatility.

Question 92: A 45-year-old man with dilated cardiomyopathy (EF 25%) on optimal medical therapy has LBBB with QRS 155 ms. What device therapy should be considered?

Implantable loop recorder
Implantable cardioverter-defibrillator alone
Cardiac resynchronization therapy (CRT) (Correct answer)
Permanent pacemaker

Correct answer: Cardiac resynchronization therapy (CRT)

CRT is indicated in HFrEF with LVEF ≤35%, LBBB, and QRS ≥150 ms on optimal medical therapy to improve symptoms and reduce mortality.

Question 93: Rifampin is a potent inducer of CYP3A4. Which clinical consequence is most important when co-administering rifampin with oral contraceptives?

Increased hepatotoxicity risk from competitive CYP3A4 binding
Increased estrogen toxicity due to reduced first-pass metabolism
Rifampin absorption is reduced by estrogen chelation
Contraceptive failure due to accelerated estrogen and progestin metabolism (Correct answer)

Correct answer: Contraceptive failure due to accelerated estrogen and progestin metabolism

Rifampin induces CYP3A4 and accelerates metabolism of estrogen and progestin, reducing oral contraceptive plasma levels and causing contraceptive failure.

Question 94: Which mechanism explains why beta-lactam antibiotics are most effective against rapidly dividing bacteria?

Actively dividing bacteria overexpress PBPs, increasing drug binding sites
Rapidly dividing bacteria have thinner cell walls that are more permeable to beta-lactams
Cell wall synthesis only occurs during active bacterial growth, requiring PBP activity (Correct answer)
Beta-lactams upregulate autolysins only during the logarithmic growth phase

Correct answer: Cell wall synthesis only occurs during active bacterial growth, requiring PBP activity

Beta-lactams inhibit transpeptidation of peptidoglycan, a process that only occurs during active cell wall synthesis in growing bacteria.

Question 95: A 14-year-old girl is at Tanner stage 1 with no signs of puberty. Her karyotype returns 45,X. Which additional finding is most likely?

Normal bone age
Low FSH and LH
Elevated FSH and LH (Correct answer)
Elevated estrogen

Correct answer: Elevated FSH and LH

Turner syndrome (45,X) causes primary ovarian insufficiency; without negative feedback from estrogen, FSH and LH are markedly elevated (hypergonadotropic hypogonadism).

Question 96: A 58-year-old male is receiving intravenous vancomycin for MRSA osteomyelitis. Partway through the infusion, he develops intense flushing of his face and neck, pruritus, and an erythematous rash on his upper torso. His vital signs are stable. What is the most likely mechanism responsible for this reaction?

Non-immunologic mast cell degranulation (Correct answer)
Immune complex deposition (Type III)
T-cell mediated delayed hypersensitivity (Type IV)
IgE-mediated type I hypersensitivity

Correct answer: Non-immunologic mast cell degranulation

The clinical presentation is classic for Vancomycin Infusion Reaction, also known as Red Man Syndrome. This is an anaphylactoid reaction, not a true allergy, caused by the rapid infusion of vancomycin leading to direct, non-immunologic degranulation of mast cells and basophils, which releases histamine. [3, 5, 12] It is rate-dependent and can be managed by slowing the infusion and administering antihistamines. [20]

Question 97: Which of the following Qbank features is most important when selecting a MCCQE-specific preparation resource?

The largest total number of questions regardless of content alignment
A mobile app with offline mode for studying without internet access
Questions organized by MCC Objective clinical presentations with Canadian guideline-based explanations (Correct answer)
Questions sourced exclusively from USMLE Step 2 CK question pools

Correct answer: Questions organized by MCC Objective clinical presentations with Canadian guideline-based explanations

MCCQE questions are organized around MCC Objective clinical presentations and Canadian clinical standards, so content alignment is the critical differentiator among Qbanks.

Question 98: A 24-year-old G1P0 at 12 weeks presents with severe nausea, vomiting, and weight loss of 5 kg. Her urine shows large ketones. Beta-hCG is markedly elevated and ultrasound shows a 'snowstorm' appearance without a fetal pole. What is the diagnosis?

Complete hydatidiform mole (Correct answer)
Missed abortion with choriocarcinoma
Hyperemesis gravidarum with normal twin pregnancy
Partial hydatidiform mole

Correct answer: Complete hydatidiform mole

A complete hydatidiform mole presents with markedly elevated hCG, hyperemesis, snowstorm ultrasound, and absence of fetal tissue.

Question 99: A hospital-based study aims to determine if smoking is a risk factor for pancreatitis. Cases are recruited from the hospital's gastroenterology ward. Controls are recruited from the hospital's pulmonary ward, which treats many patients with smoking-related diseases. This study design is most susceptible to which type of bias?

Recall bias
Confounding
Selection bias (Correct answer)
Observer bias

Correct answer: Selection bias

This is a form of selection bias, specifically Berkson's bias. The control group is not representative of the general population from which the cases arose. Because the control group (pulmonary patients) has a much higher prevalence of smoking than the general population, the association between smoking and pancreatitis may be artificially weakened or missed entirely.

Question 100: A 29-year-old woman with recurrent major depression is started on fluoxetine. After 2 weeks, she reports increased energy but has not yet experienced mood improvement. What is the most appropriate counselling at this point?

Advise that increased energy before mood improvement may transiently increase suicide risk (Correct answer)
Stop fluoxetine due to lack of response
Reassure that full response is expected within 2 weeks
Add a second antidepressant immediately

Correct answer: Advise that increased energy before mood improvement may transiently increase suicide risk

During early antidepressant treatment, returning energy before mood improvement can increase the risk of acting on suicidal ideation, requiring close monitoring.

Question 101: A 16-month-old child is not yet walking. Which factor most strongly indicates a need for urgent neurological evaluation rather than watchful waiting?

Loss of previously achieved motor milestones (Correct answer)
Age-appropriate language development
Family history of late walking
Premature birth at 34 weeks

Correct answer: Loss of previously achieved motor milestones

Regression (loss) of previously acquired motor milestones is always a red flag requiring urgent neurological investigation regardless of age.

Question 102: A 38-year-old woman presents with persistent medically unexplained neurological symptoms including paralysis and blindness following a stressful event. Neurological examination is inconsistent. What is the most likely diagnosis?

Somatic symptom disorder
Factitious disorder
Functional neurological symptom disorder (conversion disorder) (Correct answer)
Malingering

Correct answer: Functional neurological symptom disorder (conversion disorder)

Functional neurological symptom disorder (conversion disorder) presents with neurological symptoms that are incompatible with recognized neurological disease and occur after psychological stress.

Question 103: A 31-year-old G1P0 at 28 weeks presents with preterm prelabour rupture of membranes (PPROM). Speculum exam confirms rupture. She has no signs of chorioamnionitis. What antibiotic regimen is most appropriate?

No antibiotics unless fever develops
Amoxicillin-clavulanate for 10 days
Metronidazole alone for 7 days
Erythromycin and ampicillin for 48 hours then oral erythromycin for 5 days (Correct answer)

Correct answer: Erythromycin and ampicillin for 48 hours then oral erythromycin for 5 days

The standard regimen for PPROM without chorioamnionitis is IV ampicillin plus erythromycin for 48 hours followed by oral erythromycin for 5 days (avoiding amoxicillin-clavulanate due to NEC risk).

Question 104: Which finding on developmental assessment at 12 months is the most concerning red flag?

No pincer grasp
Does not point to show objects (Correct answer)
No single words
No walking independently

Correct answer: Does not point to show objects

Absence of declarative pointing (pointing to share interest) by 12 months is a red flag for autism spectrum disorder and requires urgent developmental assessment.

Question 105: A 17-year-old boy presents with a 9-month history of inattention, hyperactivity, and impulsivity in multiple settings since early childhood, causing academic failure. After diagnosis of ADHD, what is first-line pharmacotherapy in Canada?

Clonidine
Atomoxetine
Bupropion
Stimulant medication (methylphenidate or amphetamine) (Correct answer)

Correct answer: Stimulant medication (methylphenidate or amphetamine)

Stimulant medications (methylphenidate or mixed amphetamine salts) are first-line pharmacotherapy for ADHD across all age groups in Canadian guidelines.

Question 106: A 36-year-old G2P1 at 32 weeks presents with sudden onset dyspnea, hypoxia (SpO2 82%), hypotension, and cardiovascular collapse immediately after an amniotomy. She develops DIC. What is the most likely diagnosis?

Tension pneumothorax
Massive pulmonary embolism
Amniotic fluid embolism (Correct answer)
Severe septic shock

Correct answer: Amniotic fluid embolism

Amniotic fluid embolism (AFE) is characterized by sudden cardiovascular collapse, hypoxia, and DIC following amniotic fluid entry into maternal circulation, classically triggered by amniotomy or delivery.

Question 107: Which of the following findings most strongly suggests that an incarcerated inguinal hernia has progressed to strangulation?

The patient develops fever, tachycardia, and erythema over the hernia. (Correct answer)
The hernia can no longer be manually reduced.
The patient experiences nausea and constipation.
The patient reports a recent increase in the size of the bulge.

Correct answer: The patient develops fever, tachycardia, and erythema over the hernia.

Incarceration means the hernia is non-reducible. Strangulation implies compromised blood flow to the herniated contents, leading to ischemia. Systemic signs of infection/inflammation (fever, tachycardia) and localized skin changes (erythema, extreme tenderness) are red flags for strangulation, which is a surgical emergency. Nausea and constipation can occur with simple incarceration due to obstruction, but the systemic signs point specifically to strangulation.

Question 108: A 50-year-old man with Crohn's disease presents with severe right lower quadrant pain, fever, and a palpable mass. CT reveals a 5 cm phlegmon/abscess in the right iliac fossa with no free perforation. What is the preferred initial management?

Immediate surgical resection of terminal ileum
Colonoscopy and mucosal biopsy
High-dose systemic corticosteroids
CT-guided percutaneous drainage and IV antibiotics, with interval resection (Correct answer)

Correct answer: CT-guided percutaneous drainage and IV antibiotics, with interval resection

A Crohn's-related abscess without free perforation is best managed initially with CT-guided percutaneous drainage and antibiotics, followed by elective bowel resection after inflammation resolves.

Question 109: A 78-year-old woman presents with acute onset confusion, abdominal distension, and obstipation. AXR shows a grossly dilated sigmoid colon in an inverted U-shape pointing to the right upper quadrant. What is the diagnosis and first-line treatment?

Large bowel obstruction from carcinoma — CT then surgery
Ogilvie's syndrome — neostigmine administration
Sigmoid volvulus — endoscopic detorsion via flexible sigmoidoscopy (Correct answer)
Cecal volvulus — right hemicolectomy

Correct answer: Sigmoid volvulus — endoscopic detorsion via flexible sigmoidoscopy

The 'coffee bean sign' on AXR is pathognomonic of sigmoid volvulus, and endoscopic decompression is the initial treatment of choice unless there are signs of ischemia or perforation.

Question 110: During the final two weeks before MCCQE Part 1, a candidate's performance on timed practice blocks has plateaued at 72%. The most appropriate response is:

Accept the plateau as normal, focus on reviewing weak-area explanations, and maintain sleep and routine (Correct answer)
Stop all practice questions and exclusively re-read content to consolidate knowledge
Dramatically increase daily study hours to break through the plateau
Switch to a completely different Qbank for fresh questions to jolt performance

Correct answer: Accept the plateau as normal, focus on reviewing weak-area explanations, and maintain sleep and routine

Performance plateaus near exam day are normal; maintaining cognitive function through adequate sleep and targeted review is more effective than unsustainable intensity increases.

Question 111: A 35-year-old G3P2 at 38 weeks with no prenatal care presents with BP 165/110, headache, and 3+ proteinuria. Labs show platelets 95,000, LDH 650, and creatinine 1.3. She seizes on the ward. What medication should be given first?

Magnesium sulfate 4-6 g IV bolus (Correct answer)
Diazepam 10 mg IV
Phenytoin 15 mg/kg IV
Lorazepam 2 mg IV

Correct answer: Magnesium sulfate 4-6 g IV bolus

Magnesium sulfate is the drug of choice for both treatment and prevention of eclamptic seizures in obstetric patients.

Question 112: A 20-year-old male presents after a motor vehicle collision with hypotension, tachycardia, and abdominal distension. FAST ultrasound shows free fluid in Morrison's pouch and the splenorenal space. He remains hypotensive despite 2 L IV crystalloid. What is the next step?

CT abdomen with contrast for injury characterization
Angioembolization of splenic artery
Diagnostic peritoneal lavage
Emergent exploratory laparotomy (Correct answer)

Correct answer: Emergent exploratory laparotomy

A hemodynamically unstable trauma patient with FAST-positive free fluid requires emergent exploratory laparotomy; CT is contraindicated in the unstable patient.

Question 113: A medical student performing a supervised procedure causes harm due to a technical error. Who bears the primary legal responsibility?

The medical student alone
The hospital administration only
No one, as student errors are exempt from liability
The supervising physician and the institution (Correct answer)

Correct answer: The supervising physician and the institution

The supervising physician holds primary responsibility for the actions of supervised trainees, and the institution may also bear vicarious liability.

Question 114: A 50-year-old man presents with grandiose delusions that he has been chosen to lead the country, decreased need for sleep, pressured speech, and reckless spending for 10 days. He has no insight. What is the acute treatment of choice?

Antipsychotic with or without a mood stabilizer (Correct answer)
Lithium monotherapy for acute mania
Start an SSRI alone
Cognitive behavioural therapy alone

Correct answer: Antipsychotic with or without a mood stabilizer

Acute mania with psychotic features requires an antipsychotic, often combined with a mood stabilizer such as lithium or valproate, for rapid symptom control.

Question 115: A 27-year-old woman presents after an argument with her partner. She describes intense fear of abandonment, unstable relationships, impulsive self-harm, and chronic feelings of emptiness. What is the most likely diagnosis?

Histrionic personality disorder
Cyclothymic disorder
Bipolar II disorder
Borderline personality disorder (Correct answer)

Correct answer: Borderline personality disorder

Borderline personality disorder is characterized by fear of abandonment, unstable relationships, impulsivity, self-harm, and chronic emptiness.

Question 116: A 65-year-old man develops confusion, agitation, and disorientation 2 days after hip replacement surgery. He has fluctuating consciousness and is worse at night. What is the most likely diagnosis?

New-onset schizophrenia
Postoperative delirium (Correct answer)
Dementia with Lewy bodies
Bipolar disorder with psychosis

Correct answer: Postoperative delirium

Postoperative delirium is common in elderly patients, characterized by acute onset, fluctuating consciousness, and disorientation, often precipitated by surgery, anesthesia, and pain medications.

Question 117: Candidate Dr. X passes MCCQE Part I in 2022. He completes residency and wishes to write Part II in 2028. What concern arises?

He must revalidate his medical degree before registering for Part II
He must submit a provincial license application before Part II registration
Part I results expired, so he must rewrite Part I before attempting Part II (Correct answer)
No concern; Part I results have no expiry for Part II eligibility

Correct answer: Part I results expired, so he must rewrite Part I before attempting Part II

MCCQE Part I results have a validity period, and candidates must complete Part II within that window or risk needing to rewrite Part I.

Question 118: A 45-year-old man is brought to the ER after a high-speed MVC. He is hemodynamically stable. CT scan shows a grade III splenic laceration with a small perisplenic hematoma but no active extravasation. What is the appropriate management?

Emergent splenectomy
Diagnostic laparoscopy
Non-operative management with angioembolization
Non-operative management with admission, serial abdominal exams, and bed rest (Correct answer)

Correct answer: Non-operative management with admission, serial abdominal exams, and bed rest

Hemodynamically stable patients with grade I–III splenic lacerations and no active extravasation are candidates for non-operative management with ICU admission, serial exams, and serial hemoglobin monitoring.

Question 119: A 72-year-old woman with AF on warfarin (INR 2.5) undergoes elective knee replacement. What is the recommended perioperative anticoagulation strategy for low-to-moderate thromboembolic risk?

Stop warfarin 5 days pre-op with heparin bridging
Stop warfarin 5 days pre-op without bridging (Correct answer)
Continue warfarin throughout surgery
Switch to aspirin perioperatively

Correct answer: Stop warfarin 5 days pre-op without bridging

For AF patients with low-to-moderate thromboembolic risk (CHA₂DS₂-VASc <4), warfarin is held 5 days pre-op without bridging anticoagulation to reduce bleeding.

Question 120: A cohort study followed a group of 5,000 factory workers for 10 years. Among 2,000 workers exposed to a chemical, 100 developed bladder cancer. Among the 3,000 unexposed workers, 60 developed bladder cancer. What is the relative risk (RR) of developing bladder cancer for the exposed workers compared to the unexposed workers?

30.0
2.50 (Correct answer)
0.60
1.67

Correct answer: 2.50

First, calculate the incidence in each group. Incidence in exposed = 100/2000 = 0.05. Incidence in unexposed = 60/3000 = 0.02. The Relative Risk (RR) is the ratio of the incidence in the exposed group to the incidence in the unexposed group. RR = 0.05 / 0.02 = 2.50. This means the exposed workers were 2.5 times as likely to develop bladder cancer as the unexposed workers.

Question 121: A 55-year-old male with a history of NSAID use for arthritis presents to the emergency department with a sudden onset of severe, diffuse abdominal pain. On examination, he is tachycardic, hypotensive, and has a rigid, board-like abdomen with guarding and rebound tenderness. Which of the following is the most appropriate initial imaging modality to confirm the suspected diagnosis?

Upright chest X-ray (Correct answer)
HIDA scan
CT scan with oral contrast
Abdominal ultrasound

Correct answer: Upright chest X-ray

The clinical presentation is highly suggestive of peritonitis from a perforated viscus (e.g., peptic ulcer). An upright chest X-ray is the fastest and most appropriate initial imaging test to look for free air under the diaphragm (pneumoperitoneum), which would confirm the diagnosis. While a CT scan is more sensitive, the chest X-ray is a crucial and rapid first step, especially in a potentially unstable patient.

Question 122: A 29-year-old at 34 weeks develops fever (38.8°C), uterine tenderness, maternal tachycardia, and fetal tachycardia (baseline 175 bpm) after PPROM 36 hours ago. What is the correct management?

Repeat amniocentesis to confirm infection before delivery
Broad-spectrum antibiotics and expectant management until 37 weeks
Immediate delivery regardless of gestational age plus broad-spectrum antibiotics (Correct answer)
Tocolysis to delay delivery while completing antibiotic course

Correct answer: Immediate delivery regardless of gestational age plus broad-spectrum antibiotics

Clinical chorioamnionitis is an indication for immediate delivery at any gestational age, combined with broad-spectrum intrapartum antibiotics, as expectant management risks maternal sepsis and fetal death.

Question 123: A 70-year-old man presents with sudden onset painless bright red rectal bleeding causing hemodynamic instability. He has no abdominal pain. Nasogastric aspirate is bile-stained without blood. What is the most appropriate next diagnostic and therapeutic step?

Upper GI endoscopy
Colonoscopy after rapid bowel prep
Emergent sigmoidoscopy
CT angiography followed by interventional radiology embolization (Correct answer)

Correct answer: CT angiography followed by interventional radiology embolization

Hemodynamically significant lower GI bleeding in an elderly patient warrants CT angiography (if actively bleeding at ≥0.3 mL/min) to localize the source, followed by angioembolization.

Question 124: A 9-month-old infant cannot sit without support and does not transfer objects between hands. Which developmental domain is most delayed?

Fine motor
Social-emotional
Language
Gross motor (Correct answer)

Correct answer: Gross motor

Sitting without support is a gross motor milestone expected by 6–7 months; failure to achieve this by 9 months indicates gross motor delay.

Question 125: How is the MCCQE Part I scored?

Curved grading against peers.
Pass or fail only.
Randomized scoring.
Criterion-referenced scoring. (Correct answer)

Correct answer: Criterion-referenced scoring.

The MCCQE Part I uses criterion-referenced scoring, meaning candidates are evaluated against a predetermined standard of competence, not against the performance of other test-takers. This ensures that all successful candidates meet a minimum level of medical knowledge and clinical decision-making ability required for safe practice.

Question 126: A 33-year-old man presents with testicular pain and swelling that began 4 hours ago. The testis is high-riding with a horizontal lie. Doppler ultrasound shows absent blood flow. What is the time window for salvage with surgical detorsion?

Within 1 hour — near 100% salvage
Within 12 hours — approximately 50% salvage
Within 24 hours — approximately 10% salvage
Within 6 hours — approximately 90–100% salvage (Correct answer)

Correct answer: Within 6 hours — approximately 90–100% salvage

Testicular salvage rates approach 90–100% if surgical detorsion is performed within 6 hours of onset; rates drop to ~50% at 12 hours and <10% at 24 hours.

Question 127: A 40-year-old woman presents with colicky right flank pain radiating to the groin, hematuria, and nausea. CT KUB shows a 7 mm stone at the ureterovesical junction with mild hydronephrosis. She is afebrile and pain-controlled. What is the management?

Extracorporeal shock wave lithotripsy (ESWL) immediately
Emergency ureteroscopy
Percutaneous nephrostomy
Medical expulsive therapy with tamsulosin and close follow-up (Correct answer)

Correct answer: Medical expulsive therapy with tamsulosin and close follow-up

A 7 mm ureteral stone without infection or renal failure can be managed conservatively with medical expulsive therapy (alpha-blocker) and analgesia, as spontaneous passage is likely with close monitoring.

Question 128: A 42-year-old woman undergoes laparoscopic cholecystectomy. On POD 1 she has right upper quadrant pain, rising bilirubin, and bile drain output. HIDA scan shows biliary leak. What is the most common bile duct injury in laparoscopic cholecystectomy?

Injury to the cystic duct—CBD junction (Correct answer)
Cautery injury to the right hepatic duct
Clip occlusion of the common hepatic duct
Transection of the common bile duct

Correct answer: Injury to the cystic duct—CBD junction

The most common bile duct injury in laparoscopic cholecystectomy is a cystic duct stump leak or clip misplacement at the cystic duct–CBD junction due to misidentification of structures.

Question 129: A 33-year-old G2P1 with a previous low transverse caesarean section is labouring at 39 weeks. At 8 cm dilation, she reports severe sudden abdominal pain and the CTG shows prolonged bradycardia. Her previous scar is tender on palpation. What is the most feared complication?

Scar ectopic pregnancy rupture
Placental abruption over the scar
Complete uterine rupture (Correct answer)
Uterine dehiscence without rupture

Correct answer: Complete uterine rupture

Uterine rupture during trial of labour after caesarean (TOLAC) presents with sudden pain, scar tenderness, and acute fetal distress, requiring immediate emergency caesarean.

Question 130: A physician prescribes a beta-blocker to a patient with a known and clearly documented allergy to this class of medication. The pharmacy's computer system flags the error before the medication is dispensed, and the patient suffers no physical harm. What is the physician's primary ethical obligation in this situation?

Do not inform the patient, as no harm occurred and disclosure would only cause unnecessary anxiety.
Only document the event in the hospital's internal incident reporting system.
Thank the pharmacist for their diligence but take no further action regarding the patient.
Disclose the near miss to the patient, apologize, and explain the corrective measures being implemented. (Correct answer)

Correct answer: Disclose the near miss to the patient, apologize, and explain the corrective measures being implemented.

Ethical guidelines from the Canadian Medical Association and provincial colleges emphasize a duty of candour and transparency with patients. This includes the disclosure of medical errors, even when they do not result in harm (i.e., 'near misses'). The physician has an ethical obligation to inform the patient about what happened, apologize for the error, and explain what steps will be taken to prevent it from happening again. This approach respects patient autonomy and helps to maintain trust in the patient-physician relationship. Relying solely on internal reporting is insufficient as it omits the crucial step of communicating with the patient.

Question 131: A 25-year-old primigravida at 10 weeks with hyperemesis gravidarum is found to have thyroid-stimulating hormone (TSH) of 0.02 mIU/L and free T4 elevated. She has no goiter and no personal history of thyroid disease. What is the most appropriate management?

Start propylthiouracil to prevent fetal thyrotoxicosis
Perform radioactive iodine scan to exclude autonomous nodule
Reassure that this is gestational transient hyperthyroidism; treat hyperemesis (Correct answer)
Start methimazole immediately for Graves disease

Correct answer: Reassure that this is gestational transient hyperthyroidism; treat hyperemesis

Gestational transient thyrotoxicosis (GTT) is caused by TSH receptor stimulation by hCG in early pregnancy; it resolves spontaneously and antithyroid drugs are not indicated.

Question 132: A community health centre implements a program offering regular foot care, retinal screening, and self-management education workshops for individuals already diagnosed with type 2 diabetes. This initiative is an example of which level of prevention?

Tertiary prevention (Correct answer)
Primordial prevention
Primary prevention
Secondary prevention

Correct answer: Tertiary prevention

Tertiary prevention aims to soften the impact of an ongoing illness or injury that has lasting effects. These activities for patients with established diabetes are designed to prevent complications (like foot ulcers, blindness) and improve quality of life, which is the goal of tertiary prevention.

Question 133: A 66-year-old female with a history of myocardial infarction 3 years ago presents for follow-up. She is on aspirin, a beta-blocker, and a high-intensity statin. Her blood pressure is well-controlled. She asks if she should stop her statin now that she feels well. According to secondary prevention guidelines for cardiovascular disease, what is the most appropriate advice?

Continue the high-intensity statin indefinitely. (Correct answer)
Reduce the statin to a low-intensity dose for maintenance.
Switch from the statin to a fibrate for long-term management.
Stop the statin as it is no longer needed for secondary prevention after 3 years.

Correct answer: Continue the high-intensity statin indefinitely.

For patients with established atherosclerotic cardiovascular disease (secondary prevention), high-intensity statin therapy should be continued indefinitely, unless not tolerated. Statins are a cornerstone of secondary prevention to reduce the risk of recurrent cardiovascular events, and their benefit is long-term.

Question 134: A 28-year-old male with Bipolar I Disorder is being maintained on lithium. He complains of increased thirst and frequent urination. Due to the known side-effect profile of his medication, long-term monitoring must include regular assessment of:

Thyroid function and renal function (Correct answer)
Liver function tests and platelet count
Serum glucose and lipid profile
Complete blood count and vitamin B12

Correct answer: Thyroid function and renal function

Lithium is known to have significant long-term effects on the kidneys and thyroid gland. It can cause nephrogenic diabetes insipidus (leading to polyuria and polydipsia) and hypothyroidism. Therefore, regular monitoring of renal function (e.g., creatinine) and thyroid function (e.g., TSH) is mandatory for patients on chronic lithium therapy.

Question 135: A capable adult patient refuses a blood transfusion on religious grounds despite life-threatening hemorrhage. What is the physician's ethical obligation?

Override the refusal to save the patient's life
Transfer care to another physician immediately
Seek emergency court authorization
Respect the refusal and provide alternative management (Correct answer)

Correct answer: Respect the refusal and provide alternative management

Capable adults have the right to refuse any treatment, including life-saving interventions, and physicians must respect this autonomy.

Question 136: Which of the following is the most common cause of postpartum hemorrhage?

Retained placental tissue
Genital tract lacerations
Coagulopathy
Uterine atony (Correct answer)

Correct answer: Uterine atony

Uterine atony accounts for approximately 70-80% of postpartum hemorrhage cases.

Question 137: During a well-child visit for a 13-year-old male, you note the presence of coarse, dark, curly pubic hair spread over the pubis, increased penile length and width, and testicular volume of approximately 12 mL. According to the Tanner stages, which stage of pubertal development does this describe?

Tanner Stage 2
Tanner Stage 5
Tanner Stage 3 (Correct answer)
Tanner Stage 4

Correct answer: Tanner Stage 3

Tanner Stage 3 in males is characterized by the continued growth of the penis and testes, with testicular volume typically between 9-12 mL. The pubic hair becomes coarser, darker, and curlier, spreading over the pubic symphysis. Stage 2 involves the initial enlargement of the testes and sparse, straight pubic hair. Stage 4 involves further growth, darkening of the scrotal skin, and adult-quality hair that has not yet spread to the thighs. Stage 5 represents full adult genitalia and pubic hair distribution.

Question 138: A 40-year-old man presents with persistent worry about multiple life domains, muscle tension, irritability, and sleep disturbance for more than 6 months. What is the first-line psychotherapy?

Hypnotherapy
Cognitive behavioural therapy (CBT) (Correct answer)
Interpersonal therapy
Psychodynamic therapy

Correct answer: Cognitive behavioural therapy (CBT)

CBT is the most evidence-based psychotherapy for generalized anxiety disorder, targeting maladaptive worry and avoidance behaviours.

Question 139: Which study technique has the strongest evidence for improving performance on clinical vignette-based exams like the MCCQE?

Creating elaborate concept maps for every disease entity
Highlighting key facts in review books during first read-through
Passive re-reading of textbook chapters multiple times
Retrieval practice through answering practice questions under exam conditions (Correct answer)

Correct answer: Retrieval practice through answering practice questions under exam conditions

Retrieval practice (the testing effect) consistently outperforms passive study strategies in both knowledge retention and transfer to novel exam questions.

Question 140: During a vacuum-assisted vaginal delivery, a pop is heard and the cup detaches. After reapplication, another pop occurs. What is the recommended course of action?

Apply forceps immediately to complete delivery
Increase vacuum pressure and continue
Allow up to 5 cup detachments if fetal descent is occurring
Abandon vacuum and proceed to caesarean delivery (Correct answer)

Correct answer: Abandon vacuum and proceed to caesarean delivery

Two cup detachments (pop-offs) are an indication to abandon vacuum delivery and proceed to caesarean to prevent fetal injury.

Question 141: A 55-year-old man with stable ischemic heart disease has undergone coronary angiography showing 70% mid-LAD stenosis. FFR is 0.85. What is the recommended management?

Proceed with PCI of the LAD lesion
Optimal medical therapy without revascularization (Correct answer)
Repeat angiography in 6 months
Refer for CABG

Correct answer: Optimal medical therapy without revascularization

FFR >0.80 indicates hemodynamically non-significant stenosis; PCI of non-flow-limiting lesions does not improve outcomes compared to optimal medical therapy (FAME trials).

Question 142: A physician prescribes an antibiotic that acts by inhibiting bacterial DNA gyrase and topoisomerase IV, thereby preventing DNA replication and repair. Which of the following antibiotic classes utilizes this mechanism of action?

Macrolides
Fluoroquinolones (Correct answer)
Aminoglycosides
Beta-lactams

Correct answer: Fluoroquinolones

Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) exert their bactericidal effect by inhibiting bacterial DNA gyrase (topoisomerase II) and topoisomerase IV. [4, 11] These enzymes are essential for bacterial DNA replication, transcription, and repair, and their inhibition leads to bacterial cell death. [23]

Question 143: A 42-year-old man with bipolar disorder on lithium reports polyuria, polydipsia, and fine tremor. His lithium level is 0.7 mEq/L (therapeutic). What is the most appropriate management for polyuria?

Add amiloride or reduce lithium dose if clinically appropriate (Correct answer)
Switch to valproate immediately
Start desmopressin only
Increase lithium dose

Correct answer: Add amiloride or reduce lithium dose if clinically appropriate

Lithium-induced nephrogenic diabetes insipidus is managed by reducing the lithium dose (if safe) and/or adding amiloride, which reduces lithium reabsorption in collecting ducts.

Question 144: A male infant's testicular volume is 4 mL bilaterally. At what Tanner stage is he, and what is the typical age for this stage?

Tanner 2; age 9–11 years (Correct answer)
Tanner 3; age 11–13 years
Tanner 1; age 8–10 years
Tanner 4; age 13–15 years

Correct answer: Tanner 2; age 9–11 years

Tanner stage 2 in males is defined by testicular volume ≥4 mL (or length >2.5 cm), typically occurring between ages 9 and 11 years.

Question 145: Which physical examination finding best differentiates hypertrophic obstructive cardiomyopathy (HOCM) from aortic stenosis?

Pulse pressure is widened in HOCM
Murmur radiates to carotids in HOCM
Valsalva maneuver increases HOCM murmur and decreases AS murmur (Correct answer)
S4 gallop is absent in HOCM

Correct answer: Valsalva maneuver increases HOCM murmur and decreases AS murmur

Valsalva (reduces preload) increases HOCM obstruction and murmur intensity while decreasing AS murmur, a key clinical differentiator.

Question 146: Which of the following is the primary goal of primary prevention?

Preventing the occurrence of disease in healthy individuals (Correct answer)
Minimizing disability after disease onset
Early detection of disease before symptoms appear
Reducing the prevalence of an established disease

Correct answer: Preventing the occurrence of disease in healthy individuals

Primary prevention targets risk factor reduction to prevent disease from ever occurring in at-risk populations.

Question 147: A 30-year-old woman presents with recurrent, unexpected panic attacks and has developed a significant fear of having another attack, leading her to avoid crowded public spaces. Which of the following represents a first-line, evidence-based treatment for her condition?

Propranolol as needed
Psychoanalytic psychotherapy
Cognitive-Behavioural Therapy (CBT) (Correct answer)
Buspirone monotherapy

Correct answer: Cognitive-Behavioural Therapy (CBT)

Both Cognitive-Behavioural Therapy (CBT) and SSRI antidepressants are considered first-line, evidence-based treatments for panic disorder with agoraphobia. CBT is highly effective for helping patients understand and manage the cognitive and behavioural aspects of the disorder. Propranolol may manage some physical symptoms but is not a first-line treatment for the core disorder. Buspirone is generally not effective for panic disorder. Psychoanalytic psychotherapy is not considered a first-line, evidence-based treatment.

Question 148: A public health intervention reduces the relative risk of stroke from 0.40 to 0.20. What is the relative risk reduction?

20%
80%
50% (Correct answer)
60%

Correct answer: 50%

Relative risk reduction = (RR_old − RR_new) / RR_old = (0.40 − 0.20) / 0.40 = 50%.

Question 149: A 45-year-old man presents with sudden onset severe epigastric pain radiating to the back, nausea, and vomiting after a heavy meal. Serum lipase is 1200 U/L. CT shows peripancreatic fat stranding but no necrosis. What is the Ranson criterion at admission that most strongly predicts severity?

LDH > 350 IU/L
Age > 55 years
Serum glucose > 11 mmol/L (Correct answer)
WBC > 16 x10⁹/L

Correct answer: Serum glucose > 11 mmol/L

Serum glucose > 11 mmol/L (200 mg/dL) at admission is one of the five Ranson criteria assessed on presentation and is a key predictor of severe pancreatitis.

Question 150: A 72-year-old woman is brought in by her family due to progressive memory loss over 3 years, difficulty with word finding, and getting lost in familiar places. Examination shows no focal deficits. Which diagnosis best fits this presentation?

Normal pressure hydrocephalus
Vascular dementia
Lewy body dementia
Alzheimer's disease (Correct answer)

Correct answer: Alzheimer's disease

Alzheimer's disease presents with insidious progressive memory loss, language difficulties, and spatial disorientation over years without focal neurological deficits.

Question 151: Which medication is most appropriate for long-term secondary prevention in a patient with peripheral artery disease (PAD) and no history of AF or MI?

Aspirin 325 mg daily alone
Clopidogrel plus aspirin indefinitely
Aspirin 81 mg plus rivaroxaban 2.5 mg BID (Correct answer)
Warfarin anticoagulation

Correct answer: Aspirin 81 mg plus rivaroxaban 2.5 mg BID

The COMPASS trial showed aspirin 100 mg plus low-dose rivaroxaban 2.5 mg BID significantly reduces MACE and MALE in PAD patients.

Question 152: A 2-year-old with Down syndrome has a height at the 50th percentile on standard WHO growth charts. What is the correct interpretation?

Cannot be interpreted without bone age
Normal growth for Down syndrome
Tall stature for Down syndrome (Correct answer)
Short stature for Down syndrome

Correct answer: Tall stature for Down syndrome

Children with Down syndrome have shorter expected stature; their growth should be plotted on Down syndrome–specific growth charts, where the 50th percentile on standard charts would represent tall stature.

Question 153: Free online resources such as the MCC's sample questions are most appropriately used for which purpose during MCCQE preparation?

Familiarizing oneself with official question style, interface, and difficulty calibration (Correct answer)
Comprehensive coverage of all MCC Objective clinical presentations
As the primary Qbank replacing commercial question banks
Daily practice drilling throughout the entire study period

Correct answer: Familiarizing oneself with official question style, interface, and difficulty calibration

MCC sample questions provide authentic interface experience and style calibration, but their limited number means they supplement rather than replace comprehensive commercial Qbanks.

Question 154: Which mechanism explains the synergy between penicillin and an aminoglycoside in treating Enterococcus faecalis endocarditis?

Aminoglycosides inhibit beta-lactamase, protecting penicillin from degradation
Penicillin disrupts cell wall integrity, enhancing aminoglycoside entry into the bacterial cell (Correct answer)
Penicillin upregulates aminoglycoside efflux pump inhibitors
Both drugs inhibit the same PBP isoform, producing additive killing

Correct answer: Penicillin disrupts cell wall integrity, enhancing aminoglycoside entry into the bacterial cell

Penicillin disrupts the enterococcal cell wall, enabling greater aminoglycoside uptake, which overcomes intrinsic low-level aminoglycoside resistance in Enterococcus.

Question 155: What happens if a candidate fails MCCQE Part I — how many attempts are allowed?

Only one retake is permitted, with a mandatory 2-year wait
Candidates may retake with restrictions on number and timing per MCC policy (Correct answer)
Unlimited attempts with no waiting period
A maximum of 3 attempts lifetime

Correct answer: Candidates may retake with restrictions on number and timing per MCC policy

The MCC sets specific limits on the number of attempts and requires waiting periods between retakes, with policies subject to periodic revision.

Question 156: A 65-year-old man presents with painless obstructive jaundice, a palpable non-tender gallbladder, and 15 kg weight loss over 3 months. CT shows a mass in the head of the pancreas with dilated biliary and pancreatic ducts. What eponymous sign describes the palpable gallbladder?

Murphy's sign
Trousseau's sign
Courvoisier's sign (Correct answer)
Grey Turner's sign

Correct answer: Courvoisier's sign

Courvoisier's sign is a palpable non-tender gallbladder in the setting of painless jaundice, classically indicating malignant biliary obstruction (pancreatic head carcinoma) rather than gallstone disease.

Question 157: What is the significance of 'clinical presentations' in the MCC Objectives?

They describe research presentations at conferences
They define minimum consultation hours required
They list all drugs required for licensure
They organize the exam blueprint around how patients present to physicians (Correct answer)

Correct answer: They organize the exam blueprint around how patients present to physicians

The MCC Objectives are organized around clinical presentations to reflect the real-world approach of diagnosing and managing patients based on their symptoms.

Question 158: Which of the following is a mandatory eligibility criterion for a person to receive Medical Assistance in Dying (MAID) under current federal legislation in Canada?

The person must have a grievous and irremediable medical condition. (Correct answer)
The person's natural death must be reasonably foreseeable.
The person's sole underlying medical condition can be a mental illness.
The request must be co-signed and approved by their substitute decision-maker.

Correct answer: The person must have a grievous and irremediable medical condition.

Under Canada's federal legislation, a core eligibility criterion for MAID is that the person must have a 'grievous and irremediable medical condition'. [7] This is defined as a serious and incurable illness, disease, or disability, being in an advanced state of irreversible decline in capability, and experiencing enduring and intolerable suffering. While there are different procedural safeguards depending on whether natural death is reasonably foreseeable, a foreseeable death is not a universal eligibility requirement. [1, 7] The request for MAID must be made by a capable person for themselves, not by a substitute decision-maker. [7] As of early 2026, persons suffering solely from a mental illness are not eligible for MAID. [1, 21, 23]

Question 159: A patient with MRSA bacteremia is started on vancomycin. Therapeutic drug monitoring is performed. Which pharmacokinetic/pharmacodynamic parameter best predicts vancomycin efficacy against MRSA?

Peak/MIC ratio >10
Trough concentration >15 mg/L
AUC24/MIC ratio of 400-600 (Correct answer)
Time above MIC >40%

Correct answer: AUC24/MIC ratio of 400-600

Current guidelines recommend targeting an AUC24/MIC ratio of 400-600 mg·h/L as the best PK/PD predictor of vancomycin efficacy for serious MRSA infections.

Question 160: Following a large company picnic, 45 of the 100 employees who ate potato salad developed gastroenteritis, while 10 of the 200 employees who did not eat the potato salad developed the same symptoms. What is the primary purpose of calculating the attack rates for these two groups?

To establish the incubation period of the pathogen.
To determine the case-fatality rate of the illness.
To identify the likely source of the foodborne outbreak. (Correct answer)
To calculate the odds ratio of the exposure.

Correct answer: To identify the likely source of the foodborne outbreak.

Calculating and comparing attack rates between exposed and unexposed groups is a fundamental step in an outbreak investigation to identify the source. In this case, the attack rate for those who ate the salad is 45/100 (45%), and for those who did not, it's 10/200 (5%). The significantly higher attack rate in the exposed group strongly implicates the potato salad as the source of the outbreak.

Question 161: A 45-year-old woman with known HIV presents with headache, fever, and confusion over 5 days. CSF India ink preparation shows encapsulated yeast. What is the most appropriate treatment?

Amphotericin B plus flucytosine (Correct answer)
Ceftriaxone plus vancomycin
Acyclovir
Fluconazole monotherapy

Correct answer: Amphotericin B plus flucytosine

Cryptococcal meningitis (seen on India ink as encapsulated yeast) is treated with induction therapy using amphotericin B plus flucytosine for at least 2 weeks.

Question 162: Which antiviral agent used for influenza inhibits viral neuraminidase and should be given within 48 hours of symptom onset for maximum benefit?

Oseltamivir (Correct answer)
Ribavirin
Amantadine
Acyclovir

Correct answer: Oseltamivir

Oseltamivir inhibits influenza neuraminidase, preventing viral release from infected cells, and is most effective when initiated within 48 hours of symptom onset.

Question 163: A 55-year-old man presents with resting tremor, bradykinesia, and cogwheel rigidity more prominent on the right side. He has a shuffling gait. Which dopaminergic pathway is primarily affected in this condition?

Mesocortical pathway
Tuberoinfundibular pathway
Mesolimbic pathway
Nigrostriatal pathway (Correct answer)

Correct answer: Nigrostriatal pathway

Parkinson's disease results from degeneration of dopaminergic neurons in the substantia nigra pars compacta, affecting the nigrostriatal pathway and causing motor deficits.

Question 164: Which of the following documents does the MCC require to verify graduation from a medical school for MCCQE Part I eligibility?

A letter from the dean confirming enrollment
Official medical school transcript sent directly to the MCC (Correct answer)
A notarized personal statement
A photocopy of the medical degree submitted by the applicant

Correct answer: Official medical school transcript sent directly to the MCC

The MCC requires official transcripts or graduation verification sent directly from the medical institution to confirm eligibility.

Question 165: How are MCCQE Part II examiners trained to ensure inter-rater reliability?

Examiners undergo structured training with calibration sessions and benchmark videos (Correct answer)
Only standardized patients rate candidate performance
Examiners are replaced each exam cycle to prevent bias
Examiners are self-trained using published rubrics

Correct answer: Examiners undergo structured training with calibration sessions and benchmark videos

MCC trains examiners with calibration exercises and reference videos so ratings are consistent across different examiners and sites.

Question 166: A 72-year-old man with a known 5.5 cm abdominal aortic aneurysm presents with sudden onset severe back and flank pain, hypotension, and a pulsatile abdominal mass. BP is 80/50. What is the immediate management priority?

Endovascular aortic repair (EVAR) as first-line
CT angiography to confirm rupture
IV fluid resuscitation to normalize blood pressure before surgery
Permissive hypotension targeting SBP 50-70 mmHg and emergent surgical repair (Correct answer)

Correct answer: Permissive hypotension targeting SBP 50-70 mmHg and emergent surgical repair

Ruptured AAA is a surgical emergency; permissive hypotension (SBP 50–70 mmHg) is maintained to reduce further hemorrhage while rushing the patient to the OR for open or endovascular repair.

Question 167: A 23-year-old primigravida at 22 weeks presents with painless cervical dilation of 3 cm and bulging membranes. There are no contractions and no signs of infection. What is the most appropriate intervention?

Bed rest in Trendelenburg position only
Emergency caesarean delivery
Emergency cervical cerclage (Correct answer)
Induction of labour given lethal fetal prognosis

Correct answer: Emergency cervical cerclage

Physical (emergency) cerclage placed for cervical incompetence with dilated cervix and bulging membranes at pre-viable gestational age can prolong pregnancy significantly.

Question 168: A 35-year-old pregnant woman (32 weeks) presents with right upper quadrant pain and elevated liver enzymes. WBC is 14. Ultrasound shows gallbladder wall thickening and pericholecystic fluid. What is the management?

Percutaneous cholecystostomy tube only
Laparoscopic cholecystectomy during the second trimester only
Conservative management until delivery, then cholecystectomy
Laparoscopic cholecystectomy regardless of trimester for acute cholecystitis (Correct answer)

Correct answer: Laparoscopic cholecystectomy regardless of trimester for acute cholecystitis

Acute cholecystitis in pregnancy is treated with laparoscopic cholecystectomy regardless of trimester, as conservative management has high recurrence and risk of preterm labor.

Question 169: A 28-year-old primigravida at 39 weeks in active labour has fetal bradycardia to 80 bpm lasting 3 minutes after a strong contraction, with slow return to baseline. On exam, the cervix is 7 cm dilated and you palpate the umbilical cord. What is the immediate management?

Manually elevate the presenting part and proceed to emergency caesarean section (Correct answer)
Perform amnioinfusion
Administer oxygen and reposition to left lateral
Apply fetal scalp electrode for continuous monitoring

Correct answer: Manually elevate the presenting part and proceed to emergency caesarean section

Cord prolapse requires immediate digital elevation of the presenting part to relieve cord compression while preparing for emergency caesarean delivery.

Question 170: An international medical graduate (IMG) applies for MCCQE Part I and requests test accommodations for a disability. When must this request be submitted?

On the day of the examination at the test center
At any time before the exam date
Only after receiving the examination scheduling permit
During the registration process, by the accommodation request deadline (Correct answer)

Correct answer: During the registration process, by the accommodation request deadline

Accommodation requests must be submitted during registration by the MCC's published deadline; late requests may not be granted.

Question 171: A 52-year-old woman presents with a fixed, unshakeable belief that her intestines have rotted away, despite normal investigations. She is otherwise alert and oriented. What is this symptom called, and in what condition is it classically seen?

Somatic delusion in delusional disorder
Thought insertion in schizophrenia
Capgras syndrome in dementia
Cotard's delusion (nihilistic delusion) in severe depression with psychotic features (Correct answer)

Correct answer: Cotard's delusion (nihilistic delusion) in severe depression with psychotic features

Cotard's delusion (nihilistic delusion of body decay or non-existence) is classically associated with severe psychotic depression.

Question 172: In an intention-to-treat analysis, participants are analyzed according to:

The outcome they experienced
Their actual treatment received
Whether they completed the study protocol
Their randomized group assignment regardless of adherence (Correct answer)

Correct answer: Their randomized group assignment regardless of adherence

Intention-to-treat preserves the benefits of randomization by analyzing participants in their originally assigned groups.

Question 173: What does the number needed to harm (NNH) represent?

The absolute risk difference between two groups
The number of patients who must be treated for one additional patient to experience harm (Correct answer)
The relative risk increase due to an intervention
The probability that a given patient will experience harm

Correct answer: The number of patients who must be treated for one additional patient to experience harm

NNH = 1 / absolute risk increase; it quantifies how many patients need treatment before one additional harmful event occurs.

Question 174: A 65-year-old diabetic man presents with a perianal abscess. After incision and drainage, a fistula-in-ano is suspected. Which classification system is used to guide surgical management?

Milligan-Morgan classification
Hinchey classification
Parks classification (Correct answer)
Lockhart-Mummery classification

Correct answer: Parks classification

The Parks classification categorizes fistulas-in-ano as intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric, guiding surgical strategy to preserve continence.

Question 175: A candidate has 6 weeks remaining before MCCQE Part 1 and has completed only 40% of his Qbank. What is the most strategic approach?

Prioritize high-yield, high-frequency MCC Objective presentations and complete targeted Qbank blocks for untested areas (Correct answer)
Rush through the remaining 60% of questions without reviewing explanations to maximize question exposure
Focus exclusively on reviewing his incorrect questions from the completed 40%
Stop Qbank practice and focus solely on reading Toronto Notes for the remaining weeks

Correct answer: Prioritize high-yield, high-frequency MCC Objective presentations and complete targeted Qbank blocks for untested areas

With limited time, prioritizing high-yield clinical presentations from the MCC Objectives while selectively tackling untested Qbank content maximizes score impact per study hour.

Question 176: Which of the following clinical features is most characteristic of a small bowel obstruction (SBO) rather than a large bowel obstruction (LBO)?

Obstipation as a primary presenting feature
Marked abdominal distension appearing early in the course
A plain abdominal radiograph showing significant colonic gas with haustra
Profuse, early-onset bilious vomiting (Correct answer)

Correct answer: Profuse, early-onset bilious vomiting

Early and frequent vomiting, often bilious, is a hallmark of a proximal SBO due to the rapid accumulation of fluid and gas proximal to the obstruction. In LBO, vomiting is typically a late feature, and prominent distension is more characteristic. Obstipation is common to both. Haustra are specific to the large bowel.

Question 177: The attributable fraction in exposed individuals measures which of the following?

The absolute risk difference between exposed and unexposed
The proportion of disease in the population due to the exposure
The proportion of disease among exposed individuals attributable to the exposure (Correct answer)
The ratio of disease risk in exposed vs. unexposed

Correct answer: The proportion of disease among exposed individuals attributable to the exposure

Attributable fraction in exposed = (RR − 1) / RR, representing the proportion of exposed cases due to the exposure.

Question 178: Which type of clinical presentation framework does the MCCQE Part I CDM component primarily use?

Laboratory-result-driven scenarios
Symptom/problem-based clinical presentation (Correct answer)
Disease-based presentation
Imaging-only vignettes

Correct answer: Symptom/problem-based clinical presentation

CDM cases are organized around presenting symptoms or clinical problems (e.g., chest pain, shortness of breath), mirroring real clinical encounters.

Question 179: Which study resource type is most effective for rapidly reviewing high-yield clinical presentations listed in the MCC Objectives?

Annotated clinical vignette Qbanks with detailed explanations (Correct answer)
Full subspecialty textbooks (e.g., Harrison's Principles of Internal Medicine)
Research journal articles from CMAJ and NEJM
Medical school lecture slides from first and second year

Correct answer: Annotated clinical vignette Qbanks with detailed explanations

Annotated Qbanks directly train pattern recognition for clinical vignettes while providing high-yield summaries that map to exam-tested presentations.

Question 180: A 24-year-old male presents with 12 hours of right flank pain and dysuria. He has a low-grade fever and mild tenderness in the right lower quadrant, but also significant right costovertebral angle (CVA) tenderness. A urinalysis shows 5-10 WBCs and 5-10 RBCs. What is the most likely diagnosis?

Ureteral Colic
Retrocecal Appendicitis (Correct answer)
Testicular Torsion
Acute Pyelonephritis

Correct answer: Retrocecal Appendicitis

A retrocecal appendix can irritate the adjacent psoas muscle, ureter, and bladder, leading to atypical symptoms that mimic a urinary tract or renal pathology, such as flank pain, CVA tenderness, and sterile pyuria. The presence of right lower quadrant tenderness should maintain a high index of suspicion for appendicitis despite the urinary symptoms.

Question 181: A 60-year-old woman with Wolff-Parkinson-White syndrome develops AF. Which drug is contraindicated?

Amiodarone IV
Procainamide
DC cardioversion
Digoxin (Correct answer)

Correct answer: Digoxin

Digoxin (and verapamil, diltiazem) are contraindicated in WPW with AF because blocking the AV node increases conduction through the accessory pathway, risking VF.

Question 182: What is the format of the MCCQE Part II?

Objective Structured Clinical Examination (OSCE). (Correct answer)
Case study presentations.
Essay-based assessment.
Multiple-choice format.

Correct answer: Objective Structured Clinical Examination (OSCE).

The MCCQE Part II is structured as an Objective Structured Clinical Examination (OSCE). This format involves candidates rotating through a series of stations where they interact with standardized patients or perform specific clinical tasks, allowing for a standardized assessment of their practical clinical skills.

Question 183: A 58-year-old man presents with hematemesis and melena. He is hemodynamically stable after resuscitation. Upper endoscopy reveals a duodenal ulcer with a visible vessel (Forrest Ia). What is the endoscopic treatment of choice?

Endoscopic band ligation
Combination therapy: epinephrine injection plus thermal coagulation or hemoclip (Correct answer)
Argon plasma coagulation alone
Epinephrine injection alone

Correct answer: Combination therapy: epinephrine injection plus thermal coagulation or hemoclip

High-risk peptic ulcer stigmata (Forrest Ia/Ib/IIa) require combination endoscopic therapy—epinephrine injection plus a second modality (thermal coagulation or mechanical clips)—to reduce rebleeding risk.

Question 184: A candidate fails MCCQE Part 1 on the first attempt. Before registering for a re-attempt, the most important preparatory step is:

Extending the study period by at least 12 months regardless of the score gap
Purchasing every available new Qbank to maximize question exposure
Obtaining the MCC performance feedback report to identify specific weak clinical presentation areas (Correct answer)
Switching all study materials to USMLE-focused resources for a different perspective

Correct answer: Obtaining the MCC performance feedback report to identify specific weak clinical presentation areas

The MCC provides performance feedback by content category after a failed attempt, enabling targeted remediation rather than undirected re-studying of all content.

Question 185: Which ECG finding is most specific for right ventricular strain in acute pulmonary embolism?

Sinus tachycardia
New right bundle branch block
S1Q3T3 pattern (Correct answer)
ST elevation in V1

Correct answer: S1Q3T3 pattern

The S1Q3T3 pattern (S wave in lead I, Q wave and T-wave inversion in lead III) is the classic though not highly sensitive ECG finding for acute RV strain in PE.

Question 186: According to DSM-5 criteria, for a diagnosis of Generalized Anxiety Disorder (GAD), excessive anxiety and worry must be present more days than not for a minimum duration of:

2 weeks
1 month
3 months
6 months (Correct answer)

Correct answer: 6 months

The core time criterion for a diagnosis of Generalized Anxiety Disorder in the DSM-5 is the presence of excessive anxiety and worry occurring more days than not for at least 6 months. This chronicity distinguishes GAD from more transient or situational anxiety.

Question 187: A 35-year-old man with schizophrenia develops high fever, muscle rigidity, diaphoresis, and altered consciousness after starting haloperidol. What is the most appropriate immediate management?

Discontinue antipsychotic and provide supportive care (Correct answer)
Increase haloperidol dose
Add benztropine only
Switch to clozapine immediately

Correct answer: Discontinue antipsychotic and provide supportive care

Neuroleptic malignant syndrome (NMS) requires immediate discontinuation of the offending antipsychotic and aggressive supportive care including IV fluids and cooling.

Question 188: Which of the following statements best reflects the guidance from the Canadian Medical Association (CMA) and provincial regulatory bodies regarding physicians providing ongoing medical care to their close family members?

It is permissible without restriction, provided the family member gives explicit consent.
It is only prohibited for prescribing controlled substances, but is acceptable for all other care.
It should be strictly limited to minor conditions or emergencies when no other physician is available. (Correct answer)
It is encouraged, as it improves access to care and convenience for the family.

Correct answer: It should be strictly limited to minor conditions or emergencies when no other physician is available.

The CMA Code of Ethics and Professionalism, along with standards from provincial colleges, strongly advises against physicians treating themselves or close family members. [4, 9, 11] The rationale is that personal relationships can compromise professional objectivity, affect clinical judgment, and create difficulties in areas like taking a sensitive history or performing intimate examinations. [4, 15] The explicit exception is for minor problems or in an emergency situation where another physician is not readily available. [4, 16] Even in these cases, care should be transferred to another physician as soon as practical. This guidance extends beyond just prescribing controlled substances and applies to routine and ongoing care in general. [15]

Question 189: A patient receiving amphotericin B develops rigors, fever, and hypokalemia. Which intervention reduces infusion-related reactions to amphotericin B?

Switching to liposomal amphotericin B
Pre-treating with IV corticosteroids and slowing the infusion rate (Correct answer)
Adding flucytosine to allow dose reduction of amphotericin B
Administering diphenhydramine alone prior to infusion

Correct answer: Pre-treating with IV corticosteroids and slowing the infusion rate

Pre-medicating with acetaminophen, diphenhydramine, and corticosteroids combined with slower infusion rates significantly reduces amphotericin B infusion-related reactions.

Question 190: Loss to follow-up in a cohort study is most problematic when:

Those lost differ from those retained in both exposure and outcome risk (Correct answer)
The follow-up period is very short
It affects both exposed and unexposed groups equally
The sample size is very large

Correct answer: Those lost differ from those retained in both exposure and outcome risk

Differential loss to follow-up creates selection bias when dropout is related to both the exposure and the outcome.

Question 191: A patient with terminal cancer has a valid advance directive refusing resuscitation. During a hospital admission for pneumonia, the patient becomes unconscious. Family members demand full resuscitation. What should the physician do?

Consult ethics committee before making any decision
Follow the family's wishes to avoid conflict
Attempt resuscitation as a compromise
Honor the advance directive and explain its legal status to the family (Correct answer)

Correct answer: Honor the advance directive and explain its legal status to the family

A valid advance directive reflects the patient's autonomous wishes and is legally binding; family preferences do not override it.

Question 192: The MCC's own practice test (Physician Test Preparation, or PTP) is best used as:

A daily drill tool to be repeated throughout the study period
A baseline assessment at the very beginning of preparation
A final simulation tool to gauge readiness close to exam day (Correct answer)
A substitute for commercial Qbanks due to identical question formats

Correct answer: A final simulation tool to gauge readiness close to exam day

The MCC's official practice test most closely mirrors the real exam interface and difficulty, making it ideal for a late-stage simulation rather than a daily drill.

Question 193: A 16-year-old girl is brought in by her parents due to refusal to maintain a minimally normal body weight, intense fear of gaining weight, and distorted body image. Her BMI is 15.5. What medical complication is most life-threatening?

Amenorrhea
Lanugo hair
Constipation
Cardiac arrhythmias from electrolyte imbalance (Correct answer)

Correct answer: Cardiac arrhythmias from electrolyte imbalance

Cardiac arrhythmias due to electrolyte disturbances (especially hypokalemia and hypophosphatemia) are the leading cause of death in anorexia nervosa.

Question 194: A 15-year-old presents alone requesting contraception and demonstrates clear understanding of the treatment. Under the mature minor doctrine, what should the physician do?

Notify parents before any treatment
Provide treatment after assessing capacity (Correct answer)
Refuse treatment without parental consent
Refer to a specialist only

Correct answer: Provide treatment after assessing capacity

Adolescents who demonstrate capacity to understand and appreciate treatment decisions may consent independently under the mature minor doctrine.

Question 195: A patient with schizophrenia on long-term haloperidol develops repetitive lip-smacking movements and tongue protrusion that persist after medication dose reduction. What is this condition?

Tardive dyskinesia (Correct answer)
Acute dystonia
Akathisia
Parkinsonism

Correct answer: Tardive dyskinesia

Tardive dyskinesia is a late-onset, potentially irreversible movement disorder caused by dopamine receptor supersensitivity from chronic antipsychotic use.

Question 196: A 3-year-old boy is at the 5th percentile for height. His growth velocity over the past year was 5 cm. Which finding would most suggest constitutional growth delay over growth hormone deficiency?

Height below the third percentile for mid-parental height
Low IGF-1 level
Bone age delayed by 2 years with normal growth velocity (Correct answer)
Bone age equal to chronological age

Correct answer: Bone age delayed by 2 years with normal growth velocity

Constitutional growth delay is characterized by delayed bone age with a normal growth velocity and a family history of late puberty.

Question 197: Which measure of disease frequency accounts for the time each individual is at risk?

Period prevalence
Incidence rate (person-time) (Correct answer)
Point prevalence
Cumulative incidence

Correct answer: Incidence rate (person-time)

Incidence rate (incidence density) uses person-time denominators to account for variable follow-up periods.

Question 198: A 30-year-old man with alcohol use disorder has his last drink 48 hours ago. He now presents with agitation, tremor, diaphoresis, tachycardia, and a witnessed tonic-clonic seizure. What is the most appropriate immediate treatment?

IV lorazepam (Correct answer)
Haloperidol IM
Oral naltrexone
IV phenytoin

Correct answer: IV lorazepam

IV benzodiazepines (e.g., lorazepam, diazepam) are first-line treatment for alcohol withdrawal seizures and delirium tremens by enhancing GABA-A activity.

Question 199: A 25-year-old woman presents with ascending weakness that began in her feet 2 weeks after a gastrointestinal illness. Deep tendon reflexes are absent bilaterally. CSF shows elevated protein with normal cell count. What is the most likely diagnosis?

Guillain-Barré syndrome (Correct answer)
Multiple sclerosis
Transverse myelitis
Botulism

Correct answer: Guillain-Barré syndrome

Guillain-Barré syndrome presents with ascending flaccid paralysis, areflexia, and albuminocytologic dissociation (high CSF protein, normal cells) often following infection.

Question 200: A physician learns that a colleague is practicing while impaired by alcohol. What is the primary professional obligation?

Inform the hospital administrator only
Confront the colleague privately and take no further action if they deny it
Document observations and wait for a formal complaint
Report to the regulatory college or appropriate authority (Correct answer)

Correct answer: Report to the regulatory college or appropriate authority

Physicians have a professional and ethical duty to report a colleague whose impairment poses a risk to patient safety to the appropriate regulatory body.

Question 201: A 30-year-old man presents 3 days after a cat bite to the right hand with fever, ascending lymphangitis, and purulent wound discharge. He is penicillin-allergic (anaphylaxis). Blood cultures are pending. Which antibiotic covers Pasteurella multocida in a penicillin-anaphylaxis patient?

First-generation cephalosporin (cephalexin)
Doxycycline or a fluoroquinolone (e.g., ciprofloxacin) (Correct answer)
Metronidazole
Clindamycin

Correct answer: Doxycycline or a fluoroquinolone (e.g., ciprofloxacin)

Pasteurella multocida, the key pathogen in cat bites, is resistant to clindamycin; doxycycline or a fluoroquinolone (ciprofloxacin) provides coverage in true penicillin-allergic patients.

Question 202: What does the MCCQE Part II assess in its scoring?

Knowledge of theoretical medical sciences.
Written case analysis.
Hospital management abilities.
Clinical skills and communication. (Correct answer)

Correct answer: Clinical skills and communication.

The MCCQE Part II, being an OSCE, specifically assesses a candidate's practical clinical skills, including history-taking, physical examination, diagnosis, management, and crucial communication abilities. It evaluates how effectively candidates interact with patients and apply their knowledge in a clinical setting.

Question 203: A psychiatrist is treating a patient who reveals a credible and detailed plan to cause serious physical harm to his former supervisor. The patient has a history of violent outbursts. According to Canadian legal and ethical principles, the psychiatrist's primary duty is to:

Take reasonable steps to protect the potential victim, which may include warning them and/or notifying the police. (Correct answer)
Immediately discharge the patient from care to sever professional responsibility.
Maintain absolute patient confidentiality to preserve the therapeutic relationship.
Document the threat thoroughly in the patient's chart and increase the frequency of therapy sessions.

Correct answer: Take reasonable steps to protect the potential victim, which may include warning them and/or notifying the police.

While patient confidentiality is a cornerstone of medical ethics, it is not absolute. The Supreme Court of Canada decision in Smith v. Jones established a 'public safety' exception. [19] When there is a clear, serious, and imminent risk of harm to an identifiable person or group, the physician's duty to protect the public outweighs the duty of confidentiality. [5, 12, 19] The physician has a duty to take reasonable steps to prevent the harm, which can include warning the potential victim and/or contacting the police. [19] Simply documenting the threat is insufficient, and discharging the patient is an abdication of responsibility. Maintaining absolute confidentiality in this scenario would be a breach of the duty to protect.

Question 204: A 25-year-old woman presents with acute right lower quadrant pain and a positive pregnancy test (beta-hCG 2500 IU/L). Transvaginal ultrasound shows no intrauterine pregnancy and free fluid in the pelvis. She is hemodynamically stable. What is the next step?

Serial ultrasound every 2 weeks
Single-dose methotrexate
Diagnostic laparoscopy to confirm and treat ectopic pregnancy (Correct answer)
Repeat beta-hCG in 48 hours only

Correct answer: Diagnostic laparoscopy to confirm and treat ectopic pregnancy

Free fluid with no IUP and a positive beta-hCG is ectopic pregnancy until proven otherwise; diagnostic and therapeutic laparoscopy is indicated even in stable patients when the tube cannot be visualized as intact.

Question 205: Which population of medical graduates must pass the MCCQE Part I before being eligible for postgraduate training in Canada?

International medical graduates only
Only graduates from Quebec medical schools
Canadian medical graduates only
Both Canadian and international medical graduates (Correct answer)

Correct answer: Both Canadian and international medical graduates

Both Canadian and international medical graduates must pass MCCQE Part I as a requirement to obtain a full license and enter postgraduate training in Canada.

Question 206: In a patient with non-valvular atrial fibrillation and CHA₂DS₂-VASc score of 3, what is the most appropriate anticoagulation strategy?

A direct oral anticoagulant (DOAC) (Correct answer)
Aspirin 81 mg daily
No anticoagulation needed
Warfarin with INR target 2.0–3.0

Correct answer: A direct oral anticoagulant (DOAC)

DOACs (e.g., rivaroxaban, apixaban) are preferred over warfarin for non-valvular AF with CHA₂DS₂-VASc ≥2 due to better efficacy and safety profile.

Question 207: A 40-year-old man presents with a painful, irreducible bulge in the right groin below and lateral to the pubic tubercle that appeared during heavy lifting. He has nausea but no vomiting. What type of hernia is most likely and what is the next step?

Femoral hernia — urgent surgical repair due to high strangulation risk (Correct answer)
Indirect inguinal hernia — elective repair
Direct inguinal hernia — conservative management with truss
Spigelian hernia — CT confirmation then repair

Correct answer: Femoral hernia — urgent surgical repair due to high strangulation risk

A femoral hernia presents below and lateral to the pubic tubercle and carries a high risk of incarceration and strangulation, warranting urgent operative repair.

Question 208: When should a candidate take their first full-length MCCQE Part 1 simulation exam?

At the midpoint of preparation and again in the final week (Correct answer)
After completing 60–70% of their content review and Qbank preparation
On day 1 of preparation as a diagnostic to identify all knowledge gaps
Only in the 48 hours immediately before the actual exam

Correct answer: At the midpoint of preparation and again in the final week

A midpoint simulation identifies remaining gaps while time remains to address them, and a final-week simulation calibrates exam-day pacing and confidence.

Question 209: A candidate is deciding between using AMBOSS or a dedicated MCCQE Qbank for exam preparation. The primary advantage of a dedicated MCCQE Qbank is:

Its questions are mapped directly to MCC Objectives and reflect Canadian clinical practice patterns (Correct answer)
AMBOSS questions are written at a lower difficulty level than MCCQE questions
It has higher total question count than AMBOSS
Dedicated MCCQE Qbanks include free access to Toronto Notes

Correct answer: Its questions are mapped directly to MCC Objectives and reflect Canadian clinical practice patterns

Dedicated MCCQE resources align question stems and answers with Canadian guidelines (e.g., Health Canada drug approvals, Canadian screening recommendations) rather than US-based standards.

Question 210: What is the primary purpose of the MCCQE Part II?

Testing basic science knowledge
Assessing clinical and communication skills (Correct answer)
Examining pharmaceutical knowledge
Evaluating research methodology

Correct answer: Assessing clinical and communication skills

MCCQE Part II uses an OSCE format to assess clinical skills including history-taking, physical examination, and communication with standardized patients.

Question 211: An IMG holds a degree from a school listed in AVICENNA and has passed MCCQE Part I, but has been working as a researcher (not in clinical training) for 3 years. Which eligibility concern is most relevant for their MCCQE Part II application?

Their Part I result may have expired due to the 10-year window starting to elapse
They do not yet meet the 12-month accredited postgraduate clinical training requirement (Correct answer)
Their researcher role disqualifies them from future clinical examinations
They must retake Part I since more than 2 years have elapsed

Correct answer: They do not yet meet the 12-month accredited postgraduate clinical training requirement

Research work does not substitute for accredited postgraduate clinical training; the candidate still lacks the required 12 months of clinical postgraduate training for Part II eligibility.

Question 212: A 55-year-old man with a history of alcoholism presents with hematemesis. Endoscopy reveals bleeding esophageal varices. After band ligation, he remains hemodynamically unstable. What is the appropriate next intervention?

Repeat endoscopic band ligation
Emergent esophageal transection
Vasopressin infusion alone
Sengstaken-Blakemore tube placement as a bridge to TIPS (Correct answer)

Correct answer: Sengstaken-Blakemore tube placement as a bridge to TIPS

Persistent variceal hemorrhage uncontrolled by endoscopy requires balloon tamponade (Sengstaken-Blakemore tube) as a temporary bridge while arranging TIPS (transjugular intrahepatic portosystemic shunt).

Question 213: A 30-year-old woman presents with right lower quadrant pain, low-grade fever, and elevated WBC. Ultrasound is non-diagnostic. CT with contrast shows a 9 mm appendix with periappendiceal fat stranding. She has no perforation or abscess. What is standard of care?

Interval appendectomy in 6 weeks
IV antibiotics alone with outpatient follow-up
Laparoscopic appendectomy (Correct answer)
Open appendectomy via McBurney incision

Correct answer: Laparoscopic appendectomy

Uncomplicated acute appendicitis confirmed on CT is treated with laparoscopic appendectomy, which is the current standard of care offering lower morbidity and faster recovery than open surgery.

Question 214: A patient discloses that they are HIV-positive and refuses to inform their regular sexual partner. The physician determines the partner is at serious risk. What is the most appropriate next step?

Immediately notify the partner without further discussion
Continue counselling the patient and consider public health notification (Correct answer)
Discharge the patient from care for non-compliance
Document and take no action to protect patient confidentiality

Correct answer: Continue counselling the patient and consider public health notification

The physician should continue counselling the patient and, if risk persists, may report to public health authorities under duty-to-warn principles while following provincial guidelines.

Question 215: A terminally ill patient asks their physician to write a prescription for a lethal dose of medication to end their life on their own terms (assisted suicide). The patient does not qualify for MAID under current criteria. What should the physician do?

Write the prescription as requested to respect autonomy
Decline, explain the legal limits, and explore palliative and MAID eligibility options (Correct answer)
Refer the patient to a psychiatrist only
Report the patient to authorities for requesting illegal assistance

Correct answer: Decline, explain the legal limits, and explore palliative and MAID eligibility options

Assisted suicide outside MAID criteria remains illegal in Canada; the physician should decline, explore eligibility, and optimize palliative care.

Question 216: Researchers wish to investigate a potential link between a rare form of cancer and exposure to a specific industrial solvent. They identify 100 individuals with this cancer and a comparison group of 200 individuals without the cancer, matched for age and sex. They then proceed to collect detailed occupational histories from all participants to determine past exposure to the solvent. Which study design does this best describe?

Cross-Sectional Study
Case-Control Study (Correct answer)
Prospective Cohort Study
Randomized Controlled Trial

Correct answer: Case-Control Study

This is a case-control study. The design starts by identifying individuals with the disease (cases) and a group without the disease (controls), and then looks back retrospectively to compare the frequency of past exposure to a risk factor. This approach is particularly efficient for studying rare diseases.

Question 217: In Bradford Hill's criteria, which criterion addresses the plausibility of the cause-effect relationship based on current biological knowledge?

Coherence
Specificity
Biological plausibility (Correct answer)
Temporality

Correct answer: Biological plausibility

Biological plausibility requires that the association makes sense given existing biological and medical knowledge.

Question 218: A candidate scores 65% overall but notices she consistently scores below 50% on ethics and professionalism questions. The most appropriate resource to address this gap is:

The CanMEDS framework document paired with MCCQE practice vignettes on professional/ethical scenarios (Correct answer)
Memorizing the Canadian Medical Association Code of Ethics word-for-word
A medical ethics textbook covering philosophical frameworks (utilitarianism, deontology)
Skipping these questions as they represent a small fraction of total MCCQE questions

Correct answer: The CanMEDS framework document paired with MCCQE practice vignettes on professional/ethical scenarios

MCCQE ethics questions are based on the CanMEDS Professional role and Canadian medical law/ethics context; vignette practice using this framework directly trains the reasoning pattern tested.

Question 219: A 26-year-old man presents with recurrent, intrusive thoughts about contamination and compulsive hand washing that takes 3 hours daily. He finds the thoughts distressing and ego-dystonic. What is the first-line treatment?

CBT with exposure and response prevention (ERP) and/or SSRI (Correct answer)
Psychodynamic therapy alone
Benzodiazepine monotherapy
Antipsychotic monotherapy

Correct answer: CBT with exposure and response prevention (ERP) and/or SSRI

CBT with exposure and response prevention (ERP) combined with an SSRI is first-line treatment for OCD, targeting both behavioral and neurochemical mechanisms.

Question 220: A 45-year-old man with no other medical history is diagnosed with a first episode of moderate Major Depressive Disorder. According to the Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines, which of the following is the most appropriate initial pharmacological treatment?

Lithium
Lorazepam
Quetiapine
Sertraline (Correct answer)

Correct answer: Sertraline

According to CANMAT guidelines, second-generation antidepressants, including Selective Serotonin Reuptake Inhibitors (SSRIs) like sertraline, are recommended as first-line pharmacotherapy for moderate to severe Major Depressive Disorder. Quetiapine, an atypical antipsychotic, is considered a second-line agent or for adjunctive use. Lithium is a mood stabilizer primarily used for bipolar disorder. Lorazepam is a benzodiazepine used for short-term management of anxiety and is not a primary treatment for depression.

Question 221: A 45-year-old female presents with a 12-hour history of constant right upper quadrant (RUQ) pain, fever, and nausea after a fatty meal. Examination reveals a temperature of 38.5°C, localized RUQ tenderness, and a positive Murphy's sign. Ultrasound confirms gallstones, a thickened gallbladder wall, and pericholecystic fluid. In addition to intravenous fluids and analgesia, what is the most appropriate next step in management?

Arrange for an outpatient cholecystectomy in 6-8 weeks
Schedule an urgent ERCP
Administer broad-spectrum intravenous antibiotics (Correct answer)
Discharge with oral antibiotics and follow-up

Correct answer: Administer broad-spectrum intravenous antibiotics

The patient has a clear diagnosis of acute cholecystitis. Initial management involves supportive care (NPO, IV fluids, analgesia) and the administration of broad-spectrum intravenous antibiotics to cover common biliary pathogens. This stabilizes the patient and treats the infectious component in preparation for an early cholecystectomy, which is the definitive treatment.

Question 222: Which body issues the Medical Council of Canada (MCC) identification number required to register for the MCCQE Part I?

Provincial medical licensing authority
Royal College of Physicians and Surgeons
Medical Council of Canada (Correct answer)
Association of Faculties of Medicine of Canada

Correct answer: Medical Council of Canada

The MCC itself issues the unique MCC identification number needed for all MCC examination registrations.

Question 223: What document must candidates provide to confirm their eligibility for the MCCQE Part II?

A reference letter from a supervisor.
Proof of practice in a clinical setting.
A residency completion certificate.
A valid MCC student or graduate number. (Correct answer)

Correct answer: A valid MCC student or graduate number.

To confirm eligibility for the MCCQE Part II, candidates must provide a valid MCC student or graduate number. This number is assigned after successful credential verification and passing the MCCQE Part I, signifying their progress through the Canadian medical licensure pathway.

Question 224: A 65-year-old patient with enterococcal endocarditis is started on a parenteral antibiotic regimen that includes gentamicin for synergy. Due to the known toxicities of this medication, which of the following parameters must be closely monitored throughout the course of therapy?

Complete blood count with differential
Serum creatinine and drug trough levels (Correct answer)
Liver function tests (ALT, AST)
Prothrombin time (PT/INR)

Correct answer: Serum creatinine and drug trough levels

Gentamicin is an aminoglycoside antibiotic, a class of drugs well-known for causing nephrotoxicity (kidney damage) and ototoxicity (hearing and vestibular damage). [7, 19] Monitoring renal function via serum creatinine and ensuring appropriate drug clearance by measuring trough levels are essential to minimize the risk of these serious, dose-dependent adverse effects. [24, 29]

Question 225: A 55-year-old man presents post-thyroidectomy with stridor, voice hoarseness, and respiratory distress 2 hours after surgery. Neck is swelling. What is the immediate bedside intervention?

Bedside wound opening to evacuate hematoma (Correct answer)
Racemic epinephrine nebulization
IV dexamethasone
Emergent reintubation with video laryngoscopy

Correct answer: Bedside wound opening to evacuate hematoma

Post-thyroidectomy neck hematoma causing airway compromise requires immediate bedside wound opening to decompress the hematoma before definitive airway management or return to OR.

Question 226: An 18-month-old boy has no words and does not point to objects. He previously said 'mama' and 'dada' at 12 months but has stopped. What is the most important next step?

Evaluate for autism spectrum disorder (Correct answer)
Start iron supplementation
Reassure and recheck at 24 months
Order chromosomal microarray

Correct answer: Evaluate for autism spectrum disorder

Language regression combined with loss of pointing and no words at 18 months are red flags for autism spectrum disorder requiring immediate evaluation.

Question 227: A 22-year-old is brought to the clinic by his family due to a 7-month history of progressive social withdrawal, disorganized speech, and a firm belief that his thoughts are being broadcasted by a local radio station. He also reports hearing a voice that provides a running commentary on his actions. His functioning at university has declined significantly. What is the most likely diagnosis?

Schizophrenia (Correct answer)
Delusional disorder
Brief psychotic disorder
Schizophreniform disorder

Correct answer: Schizophrenia

The diagnosis of schizophrenia requires the presence of characteristic symptoms for at least one month, with continuous signs of the disturbance persisting for at least six months. This patient's 7-month history of psychotic symptoms (delusions, hallucinations) and functional decline fits the criteria for schizophrenia. Schizophreniform disorder has a duration of 1 to 6 months. Brief psychotic disorder lasts less than one month. Delusional disorder is characterized by delusions without the other prominent symptoms of schizophrenia like disorganized speech and significant negative symptoms.

Question 228: A 25-year-old woman presents to the emergency department with 6 weeks of amenorrhea, right lower quadrant pain, and light vaginal spotting. Her serum β-hCG is 1800 IU/L. A transvaginal ultrasound shows an empty uterus and a complex adnexal mass. She is hemodynamically stable. According to Canadian guidelines, which of the following is an appropriate management option?

Uterine curettage to rule out a non-viable intrauterine pregnancy
Intramuscular methotrexate (Correct answer)
Expectant management with serial β-hCG monitoring
Immediate diagnostic laparoscopy

Correct answer: Intramuscular methotrexate

This patient has a suspected ectopic pregnancy. Given that she is hemodynamically stable, has a β-hCG less than 5000 IU/L, and no evidence of fetal cardiac activity on ultrasound, she is a suitable candidate for medical management with intramuscular methotrexate. Immediate laparoscopy is reserved for hemodynamically unstable patients or those who do not meet the criteria for medical management. Expectant management is typically considered for patients with very low and declining β-hCG levels. Uterine curettage is not the first-line diagnostic or therapeutic step in this clear clinical picture.

Question 229: If a candidate's medical degree is issued in a language other than English or French, what must accompany the official documents submitted to the MCC?

A certified translation into English or French (Correct answer)
An affidavit sworn before a notary
No additional documents are needed if the degree lists courses in English
A summary written by the applicant in English

Correct answer: A certified translation into English or French

All official documents not in English or French must be accompanied by a certified translation for MCC review.

Question 230: A 48-year-old marathon runner collapses during a race. He is found to be in ventricular fibrillation. After successful defibrillation, echocardiography shows asymmetric septal hypertrophy of 18 mm. What condition is most likely?

Hypertrophic cardiomyopathy (Correct answer)
Arrhythmogenic right ventricular cardiomyopathy
Dilated cardiomyopathy
Athlete's heart

Correct answer: Hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy with septal hypertrophy >15 mm and VF arrest is the most common cause of sudden cardiac death in young athletes.

Question 231: A candidate registers for MCCQE Part I and then withdraws before the examination. How does this withdrawal affect their remaining attempt count?

The attempt is counted and subtracted from their remaining lifetime attempts
The MCC grants a one-time free withdrawal regardless of timing
The attempt is counted only if the candidate no-shows on exam day
The attempt is not counted if withdrawn before the examination window opens (Correct answer)

Correct answer: The attempt is not counted if withdrawn before the examination window opens

A withdrawal completed before the examination window opens does not count as an attempt against the candidate's lifetime limit.

Medical Council of Canada Qualifying Exam

The MCCQE Part I is a computer-based examination that assesses the competence of candidates who have obtained a medical degree. It evaluates the critical medical knowledge and clinical decision-making ability required for entry into supervised clinical practice in Canada.

230

Questions

320 min

Time Limit

73%

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