Free Medical Council of Canada MCCQE Practice Exam with Questions & Answers | Set: 3

One of the strongest modifiable risk factors for postoperative delirium in older adults is exposure to anticholinergic medications (e.g., diphenhydramine, certain antidepressants). Avoiding these can reduce delirium risk.

Toronto Notes 2023 – Geriatrics, “Delirium Prevention”:

“Avoid high-risk medications including anticholinergics, benzodiazepines, and narcotics if possible. Maintain orientation cues and adequate pain control.”

MCCQE1 Objectives (Medicine > Geriatrics > 41-1: Cognitive Impairment):

“Candidates must recognize predisposing factors for delirium and apply prevention strategies, including medication review.”

Opiates (B) should be used judiciously; untreated pain can also cause delirium. Cognitive screening (C) is helpful for baseline but does not prevent delirium. Benzodiazepines (D) increase delirium risk. Family involvement is actually helpful (E).

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Comprehensive and Detailed Explanation:

During mass casualty incidents, effective triage is essential to optimize care delivery. A trained physician is best used in triage or direct care. Triage is the foundation of disaster management.

Toronto Notes 2023 – Public Health / Disaster Medicine:

“In disaster response, trained healthcare providers should be deployed to triage and stabilize patients in emergency departments.”

MCCQE1 Objectives (Public Health > 65-1: Disaster Response):

“Candidates must understand principles of mass casualty management and assign appropriate roles during triage and care delivery.”

Media (D) and logistics (A, C) are secondary roles. Triage and direct care take priority.

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Valproic acid is well known to cause thrombocytopenia, especially at higher serum concentrations or in patients over 60. Bruising with platelet count < 100 × 10⁹/L is a classic manifestation.

Toronto Notes 2023 – Psychiatry, Mood Disorders & Pharmacology Section:

“Valproic acid is associated with hematologic side effects including thrombocytopenia. Platelet counts should be monitored regularly.”

MCCQE1 Objectives – Psychiatry > Pharmacotherapy:

“The candidate must recognize adverse effects of mood stabilizers including hematologic complications of valproic acid.”

Other listed medications (A–D) have no common or direct link with thrombocytopenia in this context.

This patient with known metastatic prostate cancer presents with acute back pain, bilateral lower limb weakness, decreased reflexes, and new fecal incontinence—classic red flags for malignant spinal cord compression . MCCQE objectives emphasize that this is an oncologic emergency requiring immediate intervention to prevent irreversible neurologic damage.

The first step is prompt administration of high-dose parenteral corticosteroids (e.g., dexamethasone) to reduce vasogenic edema around the spinal cord and preserve neurologic function. Steroids should be given immediately upon suspicion, even before confirmatory imaging. Urgent MRI of the spine and consultation with oncology, radiation oncology, and/or neurosurgery follow for definitive management (radiotherapy or surgical decompression depending on stability and prognosis).

Bed rest and analgesia alone are inadequate. A stellate ganglion block is unrelated. Although radiotherapy or surgery will likely be required, steroids must be administered first without delay. Early treatment significantly improves the likelihood of maintaining ambulation and continence.

This elderly man has classic lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) : hesitancy, straining, and incomplete emptying (obstructive symptoms). MCCQE objectives emphasize recognizing obstructive voiding symptoms in older men as most commonly due to prostatic enlargement causing bladder outlet obstruction.

First-line pharmacologic therapy for symptomatic BPH is an alpha-1 adrenergic receptor blocker (e.g., tamsulosin), which relaxes smooth muscle in the prostate and bladder neck, thereby improving urinary flow and reducing obstruction. Tamsulosin works relatively quickly and is appropriate for symptomatic relief.

Nitrofurantoin treats urinary tract infections, which are not suggested here. Fesoterodine is an antimuscarinic used for overactive bladder and could worsen urinary retention in obstructive BPH. Empagliflozin (an SGLT2 inhibitor) increases urinary glucose excretion and may worsen urinary frequency. Hydrochlorothiazide increases urine output and would not relieve obstructive symptoms.

Therefore, tamsulosin is the most appropriate medication to improve this patient’s symptoms.

The symptoms described — haloes at night, monocular diplopia, and improved near vision (second sight) — are classic signs of nuclear sclerosis-type cataracts. On exam, the most consistent finding would be an altered red reflex due to lens opacification.

Toronto Notes 2023 – Ophthalmology, Cataracts:

“Cataracts can cause glare, monocular diplopia, and improved near vision. A diminished or irregular red reflex is commonly seen on direct ophthalmoscopy.”

MCCQE1 Objectives – Internal Medicine > Ophthalmologic Disorders:

“The candidate must recognize symptoms and physical findings of cataracts, including changes in red reflex and visual acuity.”

Options A and B are associated with lipid deposition and Wilson’s disease, respectively. Retinal exudates (D) suggest diabetic or hypertensive retinopathy. Increased intraocular pressure (E) suggests glaucoma but is not supported by this clinical picture.

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When encountering vaccine hesitancy, the first and most effective step is to open a non-judgmental conversation and explore the patient’s reasons. This helps build trust and tailor subsequent education and counseling.

Toronto Notes 2023 – Public Health and Preventive Medicine, Immunization:

“Addressing vaccine hesitancy requires understanding parental concerns. Begin with open-ended questions to identify underlying beliefs and information gaps.”

MCCQE1 Objectives – Preventive Medicine > Immunization:

“Candidates must demonstrate effective communication with vaccine-hesitant parents, beginning with eliciting their rationale before providing evidence-based recommendations.”

Jumping to education (B) or punitive measures (C, D) may close communication. The patient is an adult; speaking with her parents (E) violates her autonomy.

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This case addresses informed consent and professional integrity. MCCQE ELOM objectives emphasize that competent patients have the right to refuse recommended treatment, but they cannot demand a treatment that is medically inappropriate or contrary to the standard of care. If a proposed intervention (e.g., bypass of a strictured Crohn segment expected not to heal) is not clinically indicated and may cause harm, the physician is not ethically obligated to provide it.

The appropriate response is to decline to perform the inappropriate procedure while clearly explaining the rationale, including risks, benefits, alternatives, and likely outcomes. Shared decision-making and addressing the patient’s fears (e.g., risk of short bowel syndrome) are essential. If disagreement persists, offering a second opinion is reasonable—but transferring care solely to find someone willing to perform an inappropriate surgery is unethical.

A formal competency assessment is unnecessary unless there is evidence of impaired decision-making capacity. Performing a different surgery than agreed upon would violate consent. The physician must balance respect for autonomy with nonmaleficence and adherence to evidence-based practice.

In any suspected occupational exposure, the first step is a detailed occupational history to assess the nature, intensity, and duration of the exposure. This determines whether surveillance or further testing is appropriate.

Toronto Notes 2023 – Respiratory Medicine, “Occupational Lung Diseases” Section:

“When a patient presents with concerns about exposure to occupational hazards such as asbestos, detailed history is essential. Ask about job tasks, duration of exposure, use of personal protective equipment, and prior workplace assessments.”

MCCQE1 Objectives (Population Health > 97-2: Environmental and Occupational Health):

“Candidates must be able to obtain a detailed environmental and occupational history and determine the risk of exposure before ordering investigations.”

Ordering a chest radiograph (B) or PFTs (E) without confirming meaningful exposure is premature. Referral to a specialist (D) and reassurance (A) come only after the exposure risk is assessed.

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Comprehensive and Detailed Explanation:

This patient demonstrates excellent exercise tolerance (17 METs) and no ischemic changes or exertional symptoms, which makes cardiac ischemia unlikely. However, the hypertensive response to exercise (BP > 190 systolic) indicates masked or latent hypertension. This should be managed proactively, typically starting with a thiazide.

Toronto Notes 2023 – Cardiology:

“An exaggerated hypertensive response during exercise is predictive of future hypertension. Treatment with antihypertensive agents such as thiazides may be warranted.”

MCCQE1 Objectives (Internal Medicine > 31-1: Hypertension and Risk Management):

“Candidates must identify abnormal BP responses to exercise and initiate appropriate treatment.”

Reassurance alone (A) ignores the hypertensive response. Catheterization (C) and beta-blockers (D) are unnecessary without ischemia. Advising against exercise (B) is counterproductive in a young, otherwise healthy patient.

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