Free Medical Council of Canada MCCQE Practice Exam with Questions & Answers | Set: 7

This patient has gross painless hematuria (reddish-brown urine) and is over age 50 with a smoking history—major risk factors for urothelial carcinoma (bladder cancer) . MCCQE objectives emphasize that any episode of gross painless hematuria in adults warrants urgent evaluation for malignancy , regardless of the number of red blood cells seen on urinalysis. Even microscopic hematuria in higher-risk individuals requires thorough workup.

The most important next step is cystoscopy , which directly visualizes the bladder and lower urinary tract to identify tumors, the most common cause of painless hematuria in this demographic. Imaging (e.g., CT urography) is also part of a complete evaluation, but cystoscopy is essential for diagnosing bladder lesions. Intravenous pyelography is outdated and less sensitive. Ultrasonography may detect masses but does not replace cystoscopy. Reassurance or delayed repeat urinalysis would risk missing a malignancy.

Therefore, immediate urologic referral for cystoscopic evaluation is the appropriate next step.

The patient’s pain is no longer medically justified for opioids, but there is no evidence of misuse. The most appropriate and supportive action is to explain concerns, provide education about opioid tapering or dependency, and transition care to her family physician for ongoing management.

Toronto Notes 2023 – ELOM, “Safe Prescribing and Opioid Stewardship” Section:

“When opioids are no longer indicated, engage the patient in a conversation about tapering and arrange appropriate follow-up. Coordinate care with primary providers when long-term management is needed.”

MCCQE1 Objectives (ELOM > 99-1: Professionalism and Substance Use):

“Candidates must address the risk of dependency, counsel the patient, and ensure a safe transition to appropriate care without abrupt termination.”

Methadone (E) and fentanyl (A) are for opioid use disorder or chronic pain, not for tapering in low-risk patients. Discharging the patient (B) or reporting (C) is punitive and unnecessary.

In a case-control study, participants are selected based on outcome (e.g., presence or absence of neonatal jaundice), and then past exposures are evaluated. This is consistent with the described methodology.

Toronto Notes 2023 – Epidemiology, “Study Designs”:

“Case-control studies start with the outcome and look backward to assess exposures. They are efficient for studying rare conditions or those with long latency.”

MCCQE1 Objectives (Population Health > 65-2: Epidemiology and Study Design):

“Candidates must distinguish between common study designs and recognize the correct classification based on study structure.”

Cross-sectional studies (A) assess exposure and outcome at the same time. Cohort studies (C) begin with exposure and follow forward. Clinical trials (D) are interventional. Ecological studies (E) analyze population-level data.

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Patients with borderline personality disorder commonly engage in non-suicidal self-injury (NSSI) such as superficial cutting. According to MCCQE objectives in psychiatry, this behavior is typically a maladaptive coping mechanism used to regulate intense emotional distress, feelings of emptiness, anger, or dissociation. The act of cutting often produces a transient sense of relief due to reduction of psychological tension and may be reinforced by endogenous opioid release. Therefore, patients frequently report that they “feel better afterward.”

It is important to distinguish NSSI from suicidal intent. Although individuals with borderline personality disorder are at increased risk of suicide, superficial cutting behavior is most often performed to relieve affective dysregulation rather than to die. It is not primarily attention-seeking, obsession with blood, or body modification. Management priorities include thorough suicide risk assessment, validation of emotional distress, establishing safety, and referral for evidence-based psychotherapy such as dialectical behavior therapy (DBT), which specifically targets emotional regulation and self-harm behaviors.

This patient has classic features of exertional heat stroke—hyperthermia, hypotension, CNS symptoms (collapse), and hot, dry skin. A key complication of heat stroke is rhabdomyolysis, which can cause renal failure. Serum creatine kinase (CK) is the best next diagnostic step to confirm muscle breakdown.

Toronto Notes 2023 – Emergency Medicine, “Environmental Exposures”:

“In heat stroke, check for rhabdomyolysis (↑CK), renal impairment, and coagulopathy. Prompt cooling and hydration are critical.”

MCCQE1 Objectives (Internal Medicine > 59-3: Environmental and Toxic Exposures):

“Candidates must recognize heat-related illnesses and investigate for complications such as rhabdomyolysis and acute kidney injury.”

CT head (C) is not indicated unless persistent neurological symptoms. TSH (B), CRP (D), and blood cultures (E) are irrelevant to acute exertional hyperthermia.

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Before proceeding with any virtual consultation, particularly by voice-only, it is essential to confirm the patient’s identity beyond name alone — for example, by verifying date of birth or health card number. This protects privacy and ensures medical confidentiality.

Toronto Notes 2023 – ELOM, Virtual Care Section:

“Virtual care must begin by verifying patient identity using at least two identifiers (e.g., full name and date of birth) to prevent disclosure of personal health information to unintended individuals.”

MCCQE1 Objectives – Ethical, Legal, and Professionalism > Virtual Care:

“The candidate must confirm patient identity and consent before initiating any virtual medical encounter, especially when video is not available.”

Option A (reason for visit) should follow identity confirmation. Option B (confirming primary care provider) is irrelevant to identity verification.

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Comprehensive and Detailed Explanation:

This patient has tardive dyskinesia, a late-onset, often irreversible movement disorder caused by chronic dopamine receptor blockade (e.g., haloperidol). It is especially common in older adults and may not resolve after stopping the drug.

Toronto Notes 2023 – Psychiatry, “Extrapyramidal Symptoms”:

“Tardive dyskinesia is often irreversible and typically occurs after prolonged antipsychotic use. Elderly patients are at greater risk.”

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

“Candidates must recognize tardive dyskinesia and understand that it can persist or worsen even after discontinuation of antipsychotics.”

Anticholinergics may worsen it (D). The condition does not reliably improve with age (C). It does not affect a majority of patients (A).

Comprehensive and Detailed Explanation:

An advance directive is a legally binding document that outlines a competent person ' s preferences regarding future medical care. If the patient clearly stated a refusal of treatment in the event of a life-threatening condition, this directive must be followed, even if the patient is currently incapacitated and family disagrees.

Toronto Notes 2023 – Ethics and Law:

“Advance directives must be respected when valid, clear, and applicable. Substitute decision-makers cannot override them.”

MCCQE1 Objectives (ELOM > 90-4: Informed Consent and Advance Directives):

“Candidates must apply valid advance directives to guide care for incapacitated patients.”

B (parents as SDMs) is incorrect if an advance directive exists. A and D are irrelevant—capacity has already been documented. C is unnecessary when an advance directive is clear.

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In pediatric trauma, inability to void with perineal bruising raises concern for urethral injury or urinary retention due to soft tissue swelling. The most immediate step is to attempt bladder catheterization. If unsuccessful, consult gynecology or urology urgently to avoid bladder overdistension.

Toronto Notes 2023 – Pediatrics, Genitourinary Trauma:

“In females, perineal trauma can lead to urinary retention due to labial hematomas or urethral injury. If catheterization is difficult, consult gynecology or urology for assistance.”

MCCQE1 Objectives – Pediatrics > Trauma and Emergency Care:

“Candidates must recognize when specialist consultation is required in pediatric genitourinary trauma, especially in cases of failed catheterization.”

Options B and D delay necessary care. Coagulation studies (C) may be considered if bleeding is unexplained. Abuse assessment (E) may be necessary later but does not address immediate retention.

For an otherwise healthy 60-year-old woman, screening mammography every 2 years provides the greatest proven population-health benefit among the listed options. MCCQE prevention objectives emphasize selecting screening that meaningfully reduces morbidity and mortality in the target age group. Breast cancer screening with mammography in women aged approximately 50–74 has evidence for earlier detection and reduction in breast-cancer mortality, and biennial screening balances benefit with harms (false positives, overdiagnosis) better than annual screening.

Annual cervical cytology is not recommended for average-risk women; screening intervals are longer (and discontinuation is generally considered after adequate prior screening at older ages). Bone densitometry is typically initiated later (commonly at 65) for average-risk women, with earlier testing reserved for additional risk factors. Routine annual fasting lipids and annual fasting glucose are not the most useful universal interventions in a healthy person; testing frequency is risk-based rather than yearly for all. Therefore, biennial mammography is the best choice for highest preventive value in this patient.