Free Medical Council of Canada MCCQE Practice Exam with Questions & Answers | Set: 2

The patient is obese (BMI 35), has type 2 diabetes, and shows a hepatocellular pattern of transaminitis (elevated ALT > AST). These are typical features of nonalcoholic steatohepatitis (NASH), the inflammatory subtype of nonalcoholic fatty liver disease (NAFLD).

Toronto Notes 2023 – Gastroenterology, NAFLD and NASH:

“NASH should be suspected in patients with metabolic syndrome, obesity, and type 2 diabetes, especially with elevated transaminases and normal bilirubin or INR.”

MCCQE1 Objectives – Internal Medicine > Hepatology:

“Candidates should recognize the clinical profile of NAFLD/NASH, particularly in asymptomatic patients with metabolic risk factors and isolated liver enzyme elevations.”

Acute hepatitis B (A) typically has higher ALT and symptoms. Pancreatic carcinoma (B) affects biliary enzymes or bilirubin. Metformin (D) does not elevate liver enzymes. HCC (E) would often present with systemic or localized symptoms and abnormal imaging.

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Multiple sclerosis (MS) is most likely because the patient has vertigo-like symptoms plus objective central neurologic signs : optic disc pallor (suggesting prior optic neuritis with optic atrophy), generalized hyperreflexia (upper motor neuron involvement), and nystagmus (can be central when accompanied by other CNS findings). MCCQE objectives emphasize differentiating peripheral from central causes of vertigo. Peripheral disorders (labyrinthitis, Ménière disease) typically present with vertigo and nausea but do not cause optic nerve abnormalities or diffuse hyperreflexia . Acoustic neuroma can cause vestibular symptoms but usually features progressive unilateral hearing loss/tinnitus and does not explain optic disc pallor and generalized UMN signs. Prolactinoma causes endocrine symptoms (galactorrhea, amenorrhea, infertility) and may cause bitemporal hemianopia from chiasmal compression, not intermittent vertigo with UMN findings. MS commonly affects young women and can produce brainstem/cerebellar involvement (vertigo, nystagmus) and optic nerve involvement, with symptoms separated in time, matching a 6-month intermittent course.

MCCQE objectives emphasize the distinction between ethical obligations and legal duties in emergency “Good Samaritan” situations. Physicians generally do not have a legal obligation to provide care outside of a formal physician–patient relationship, nor are they legally required to accompany a patient to hospital. Good Samaritan laws are designed primarily to protect healthcare providers from liability when they voluntarily provide emergency assistance in good faith and within the scope of their competence; they do not compel physicians to act.

Professional ethical standards, however, state that physicians should render reasonable assistance in emergencies , considering their own safety, competence, and available resources. This reflects the profession’s commitment to beneficence and social responsibility. In this case, the physician appropriately provided emergency resuscitation. Subsequent poor outcome (irreversible brain injury due to hypoglycemia) does not imply negligence if care was reasonable and provided in good faith. Therefore, the most accurate statement is that professional ethics require physicians to render reasonable

A febrile neonate (≤28 days old) requires a full sepsis evaluation (e.g., blood cultures, urine testing, lumbar puncture) because of the high risk of serious bacterial infection despite a well appearance. MCCQE objectives emphasize both appropriate medical management and effective communication with parents. When caregivers are distressed about painful procedures, the best approach is empathetic communication and reassurance that adequate analgesia and comfort measures (e.g., topical anesthetic, oral sucrose, swaddling) will be provided.

Threatening child protection involvement is inappropriate unless there is clear refusal of life-saving care after thorough discussion. Saying the infant “will not remember” dismisses parental concerns and undermines trust. Proceeding without addressing concerns violates principles of shared decision-making. Excluding parents from procedures may increase anxiety and is not routinely recommended.

The physician should acknowledge concerns, explain the rationale for testing (risk of occult sepsis), outline pain-control strategies, and invite questions. This maintains trust while ensuring timely, evidence-based care.

Given the request for opioids and history of non-prescribed opioid use (oxycodone obtained from a friend), the next appropriate step is to conduct a urine drug screen. This helps assess current substance use and guides safe prescribing decisions.

Toronto Notes 2023 – Pain Management and Addiction Medicine:

“Urine drug screening is recommended before initiating opioid therapy or when there is suspicion of substance misuse. A history of using non-prescribed opioids mandates assessment for opioid use disorder and further risk stratification.”

MCCQE1 Objectives – Internal Medicine > Chronic Pain:

“Candidates must assess for opioid misuse and dependence before initiating opioid therapy. Urine drug testing is a standard tool in this assessment.”

Providing naloxone (A) may be appropriate later if opioids are prescribed, but the priority is evaluation. Cannabis (B) is not first-line and lacks controlled evidence in chronic pain. Tramadol (D) is an opioid-like agent and not appropriate until misuse risk is evaluated.

Clozapine and quetiapine are associated with significant weight gain and increased risk of type 2 diabetes. With a BMI of 32 and weight gain over the past year, screening for diabetes is appropriate and evidence-based.

Toronto Notes 2023 – Endocrinology, Diabetes & Psychiatry Sections:

“Second-generation antipsychotics such as clozapine increase the risk of metabolic syndrome and type 2 diabetes. Regular screening is recommended for patients with these risk factors.”

MCCQE1 Objectives – Internal Medicine > Endocrinology:

“Candidates should screen high-risk individuals, especially those on antipsychotics with weight gain, for diabetes using fasting glucose or HbA1c.”

While sleep apnea (C) is also possible, diabetes screening is the most appropriate and urgent next step in this patient. COPD (A) would present with respiratory symptoms. Cushing’s (B) and acromegaly (E) are less common and have other distinct features.

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This patient presents with symptoms and signs of ulnar neuropathy—most likely at the elbow (cubital tunnel). Weakness in the intrinsic hand muscles and positive Tinel sign at the ulnar nerve are suggestive. Nerve conduction studies are the gold standard to confirm and localize the lesion.

Toronto Notes 2023 – Neurology, “Peripheral Nerve Disorders”:

“In cases of suspected mononeuropathy such as ulnar nerve compression, nerve conduction studies confirm the diagnosis and localize the lesion.”

MCCQE1 Objectives (Medicine > Neurology > 35-2):

“Candidates should identify and investigate focal mononeuropathies using nerve conduction studies to confirm the diagnosis and location.”

Splinting (A, C) may help after diagnosis. Physiotherapy (B) is adjunctive. MRI (D) is not the first-line investigation.

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This patient’s obstetric history suggests recurrent fetal macrosomia (birthweight > 4000–4500 g) and rapid (precipitous) labours. MCCQE objectives emphasize identifying maternal risk factors for postpartum hemorrhage (PPH) , particularly those associated with uterine atony , the most common cause of PPH. Delivery of a macrosomic infant increases uterine overdistension, which reduces effective postpartum uterine contraction and predisposes to atony and hemorrhage. In addition, precipitous labour can be associated with genital tract trauma, which can also contribute to postpartum bleeding, but the strongest and most consistent risk factor in the options provided is PPH from atony related to prior large infants.

The other choices are less supported by the stem: prior macrosomic term deliveries do not inherently increase risk of preterm delivery, gestational hypertension, or DVT. Therefore, the most likely risk to anticipate and plan for is postpartum hemorrhage, prompting proactive intrapartum planning (active management of the third stage, readiness with uterotonics, and risk-based monitoring).

Physicians in Canada may charge patients for uninsured services (e.g., completion of forms, cosmetic procedures, some travel-related vaccines), but they may not charge extra for insured services or preferential access. Doing so violates the Canada Health Act, which mandates accessibility and universality of insured services.

Toronto Notes 2023 – ELOM, Health Care System:

“Physicians may charge for uninsured services but may not charge block fees for insured services, nor can they charge for expedited access to insured services.”

MCCQE1 Objectives – ELOM > Health Policy and System:

“Candidates must recognize practices that violate the principles of publicly funded health care, including charging for insured services or access premiums.”

Option A is not permitted under law. Options B, D, and E involve insured services (e.g., home visits, after-hours care) and cannot be billed directly to patients.

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The patient has clinical evidence of genital warts (condyloma acuminata), which are caused by low-risk HPV types. Even though she is not currently sexually active and has visible warts, HPV vaccination is still beneficial for protection against other oncogenic strains (especially types 16 and 18). Vaccination is safe and recommended up to age 45.

Toronto Notes 2023 – Gynecology, " STIs and HPV " :

“Vaccination is recommended up to age 45, regardless of prior exposure or visible warts. It may prevent reinfection with or acquisition of high-risk HPV strains.”

MCCQE1 Objectives (Gynecology > 83-3: STIs and HPV):

“Candidates must counsel patients appropriately on prevention, including the role of HPV vaccination, even after exposure or infection.”

Pap testing (B) is routine screening, not management of visible warts. Cryotherapy (D) is optional if the patient desires removal, but she declined treatment. Biopsy (A) is reserved for atypical lesions. Contact tracing (E) is not typically required for HPV warts.

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