Free Practice Questions for Medical Council of Canada MCCQE Exam

This child experienced a first unprovoked generalized tonic-clonic seizure that resolved spontaneously and now has a normal neurologic examination and stable vital signs. MCCQE objectives emphasize that the immediate priority after a first seizure is to identify reversible metabolic causes , particularly hypoglycemia and electrolyte abnormalities (e.g., hyponatremia, hypocalcemia). Therefore, urgent serum electrolytes (and glucose) are indicated.

Neuroimaging (CT or MRI) is not urgently required in a neurologically normal child without focal deficits, trauma, persistent altered consciousness, or signs of increased intracranial pressure. MRI may be arranged later for further evaluation if clinically indicated. Electroencephalography is useful in outpatient follow-up to assess seizure type and recurrence risk but is not an emergency test. Lumbar puncture is reserved for suspected central nervous system infection (e.g., fever, meningeal signs, altered mental status), which are absent here.

Thus, immediate laboratory evaluation for metabolic derangements is the appropriate urgent investigation.

Laryngomalacia is the most common cause of chronic stridor in infants. It presents with inspiratory stridor that worsens with feeding, supine positioning, or agitation. The child remains otherwise well and meets developmental milestones.

Toronto Notes 2023 – Pediatrics, Airway Disorders:

“Laryngomalacia presents with intermittent inspiratory stridor, typically beginning in the first few months of life. Diagnosis is clinical and prognosis is usually good.”

MCCQE1 Objectives – Pediatrics > Respiratory Disorders:

“Candidates must recognize the typical presentation of laryngomalacia and differentiate it from other causes of pediatric stridor.”

Vascular ring (A) or subglottic hemangioma (C) often present with more severe or progressive symptoms. Foreign body aspiration (D) presents acutely. TE fistula (E) usually causes feeding difficulties from birth.

This case represents a failure of follow-up of a critical test result , a common systems error in ambulatory care. MCCQE ELOM objectives emphasize physician responsibility for ensuring that ordered investigations are reviewed, communicated, and acted upon appropriately. The most effective prevention strategy is implementing a system-level tracking process for all investigative reports, ensuring that results are received, reviewed, documented, and followed up—especially abnormal findings requiring urgent action.

Relying on ad hoc communication (e.g., radiologists phoning every result) is impractical and not sustainable. Booking routine return appointments does not guarantee abnormal results are addressed in a timely manner. Informing patients only if abnormal findings exist is insufficient, as missed reports may still go unnoticed. Asking patients to retrieve their own results shifts professional responsibility inappropriately.

A structured tracking system (e.g., electronic alerts, mandatory acknowledgment of results, reconciliation logs) reduces missed diagnoses and enhances patient safety. This systems-based approach aligns with quality improvement principles and shared accountability in healthcare delivery.

This presentation is classic for neuroleptic malignant syndrome (NMS), a rare but life- threatening reaction to antipsychotic drugs (particularly dopamine antagonists like risperidone). Features include hyperthermia, rigidity, altered mental status, and autonomic instability.

Toronto Notes 2023 – Psychiatry, “Neuroleptic Malignant Syndrome”:

“NMS is associated with antipsychotic use. Key features: hyperthermia, lead-pipe rigidity, altered consciousness, autonomic dysfunction. Elevated CK, leukocytosis often present.”

MCCQE1 Objectives (Psychiatry > 71-5: Adverse Effects of Psychotropics):

“Candidates must recognize and manage neuroleptic malignant syndrome and differentiate it from other drug toxicities.”

Amitriptyline (B) overdose causes anticholinergic symptoms. Lamotrigine (A) causes rash or seizures in toxicity. Lithium (D) leads to tremor, ataxia, and GI upset. Lorazepam (E) causes CNS depression, not rigidity or fever.

Persistent bloody diarrhea with negative stool cultures and ova/parasite testing in an older adult suggests inflammatory bowel disease (IBD) or another colitis such as ischemic or microscopic colitis. Colonoscopy is the best next diagnostic step to evaluate for ulcerative colitis, Crohn disease, ischemic colitis, or malignancy.

Toronto Notes 2023 – Gastroenterology, " Inflammatory Bowel Disease " :

“Persistent bloody diarrhea with negative infectious work-up should prompt colonoscopic evaluation to rule out IBD or other forms of colitis.”

MCCQE1 Objectives (Internal Medicine > Gastrointestinal > 47-1):

“Candidates must assess and investigate chronic or persistent diarrhea. In the presence of red flag features such as bleeding, weight loss, or anemia, colonoscopy is indicated.”

Antibiotics (A) are not indicated with negative stool cultures. Observation (C) and loperamide (D) risk delaying diagnosis. Steroids (E) may be required later but only after confirmation of diagnosis.

Comprehensive and Detailed Explanation:

Pulsatile tinnitus synchronous with the pulse may be vascular in origin. The association with headaches and elevated BMI (a risk factor for idiopathic intracranial hypertension, IIH) warrants neuroimaging to assess for cerebral venous sinus thrombosis, vascular malformations, or raised intracranial pressure.

Toronto Notes 2023 – Neurology / ENT:

“Pulsatile tinnitus requires investigation for vascular causes including idiopathic intracranial hypertension. MRI or MRV is the next step.”

MCCQE1 Objectives (Neurology > 35-1: Headache and Tinnitus):

“Candidates must investigate pulsatile tinnitus with neuroimaging when vascular causes are suspected.”

Audiogram (A) is for hearing loss. EEG (C) is not useful for tinnitus. CRP (D) is irrelevant.

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This patient presents with signs of acute compartment syndrome (pain out of proportion, paresthesia, pallor, swelling, decreased pulses, and dark urine indicating rhabdomyolysis). Measuring compartment pressures is the diagnostic test of choice to confirm the diagnosis and guide urgent surgical fasciotomy.

Toronto Notes 2023 – Orthopedics:

“Acute compartment syndrome should be suspected in any patient with severe extremity pain, swelling, sensory deficits, and tense compartments. Confirm with compartment pressure measurements. Fasciotomy is indicated if pressure is > 30 mmHg or within 30 mmHg of diastolic pressure.”

MCCQE1 Objectives (Surgery > 51-2: Limb Trauma):

“Candidates must diagnose acute compartment syndrome and initiate appropriate surgical referral after confirming with pressure measurements.”

Angiography and Doppler studies assess vascular compromise but are not the first step in suspected compartment syndrome. Fixing the hip (C) and testing myoglobin (E) are not diagnostic steps.

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This patient exhibits perfectionism, preoccupation with order and control, and reluctance to delegate — classic features of obsessive-compulsive personality disorder (OCPD). Unlike OCD, there are no intrusive thoughts or compulsions; rather, behaviors are ego-syntonic.

Toronto Notes 2023 – Psychiatry, Personality Disorders:

“OCPD is marked by perfectionism, rigidity, and preoccupation with productivity. It differs from OCD in lacking obsessions or compulsions.”

MCCQE1 Objectives – Psychiatry > Personality Disorders:

“Candidates must distinguish OCPD by traits of excessive perfectionism, control, and inflexibility, particularly when these interfere with functioning.”

Major depression (A) is marked by pervasive low mood, which is not reported. OCD (B) involves distressing obsessions and compulsions. GAD (C) is more generalized worry without the perfectionism and rigidity.

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A history of previous alcohol withdrawal seizures is the single greatest predictor of future withdrawal seizures. This establishes a sensitization response within the central nervous system.

Toronto Notes 2023 – Addiction Medicine:

“A prior history of alcohol withdrawal seizures is the most important risk factor for recurrent seizures during future withdrawal episodes.”

MCCQE1 Objectives (Internal Medicine > Substance Use > 58-3):

“Candidates must identify individuals at high risk for severe alcohol withdrawal based on past withdrawal history, including seizures and delirium tremens.”

Although quantity, duration, and comorbidities contribute to risk, a prior withdrawal seizure most strongly predicts recurrence.

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A molar pregnancy (gestational trophoblastic disease) is the most likely diagnosis because the β-hCG level is markedly elevated (300,000 IU/L) for an 8-week gestation, far exceeding typical levels for a normal intrauterine pregnancy. MCCQE objectives highlight that unusually high β-hCG—often accompanied by first-trimester bleeding—should raise strong suspicion for a hydatidiform mole. Bleeding is common due to abnormal trophoblastic proliferation and placental separation. A closed cervix does not exclude a molar pregnancy; it simply indicates that products of conception are not being expelled at the time of exam.

Ectopic (tubal) pregnancy more often presents with abdominal/pelvic pain and typically has lower or inappropriately rising β-hCG. Incomplete abortion usually features heavier bleeding, cramping, and an open cervix. Threatened abortion involves bleeding with a closed cervix but does not explain an extremely high β-hCG. Implantation bleeding occurs earlier (around the time of missed menses), not at 8 weeks, and would not be associated with very high β-hCG.