Medical Council of Canada MCCQE Dumps

The findings of exophthalmos (bulging eyes), conjunctival inflammation, and periorbital swelling are hallmark features of Graves ophthalmopathy, a manifestation of autoimmune hyperthyroidism.

Toronto Notes 2023 – Endocrinology, “Thyroid Disorders”:

“Graves ophthalmopathy: proptosis, periorbital edema, conjunctivitis, and diplopia due to extraocular muscle involvement. Often independent of thyroid levels.”

MCCQE1 Objectives (Internal Medicine > 36-1: Thyroid Disease):

“Candidates must recognize and manage Graves disease and its ocular manifestations.”

Myasthenia gravis may cause diplopia but not proptosis or swelling. Pseudotumor and cellulitis are painful and acute. Allergic conjunctivitis is itchy but lacks proptosis.

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.

The patient presents with an acutely inflamed joint and fever, raising concern for septic arthritis. A history of gout does not exclude infection. The first and most urgent step in any monoarthritis with systemic signs (fever) is joint aspiration to assess for crystals, white cells, and organisms.

Toronto Notes 2023 – Rheumatology, “Monoarthritis”:

“Always rule out septic arthritis in a hot, swollen joint, especially when fever is present. Joint aspiration is essential to differentiate infection from crystal arthropathy.”

MCCQE1 Objectives (Medicine > Rheumatology > 49-1):

“Candidates must identify red flags for septic arthritis and understand that arthrocentesis is the first step in diagnosis and management.”

Initiating NSAIDs or acetaminophen without diagnosis (C, D) can delay appropriate care. Radiographs (B) do not help differentiate gout from infection acutely. Blood cultures (E) may help, but aspiration is more diagnostic.

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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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In a euthyroid patient with an asymptomatic goiter or thyroid enlargement, the next step is a thyroid ultrasound to evaluate nodule size, composition, and features suggestive of malignancy.

Toronto Notes 2023 – Endocrinology, Thyroid Nodules and Goiter:

“TSH should be obtained first. If normal and there is a palpable mass or enlargement, ultrasound is indicated to evaluate for nodules and guide further testing (e.g., FNA).”

MCCQE1 Objectives – Internal Medicine > Endocrinology:

“Candidates must use thyroid ultrasound as the initial imaging study in the evaluation of thyroid enlargement or palpable nodules.”

T3/T4 (A) are not needed with normal TSH. FNA (D) is done if nodules are identified. CT (C) is used for retrosternal goiters or compressive symptoms. Calcium (E) is irrelevant here.

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When a screening program is introduced, the incidence rate appears to rise because more cases (including subclinical ones) are identified earlier. This is known as “lead-time bias” or “ascertainment bias.”

Toronto Notes 2023 – Public Health, Screening and Epidemiology:

“Screening increases the apparent incidence of disease as more early or latent cases are detected.”

MCCQE1 Objectives – Preventive Medicine > Screening:

“Candidates should understand how implementation of screening programs affects disease incidence and epidemiologic metrics.”

Case fatality rate (A) may decrease. PPV (B) depends on prevalence. Positive biopsy rate (C) may remain stable. Treatment rate (E) could increase, but incidence is the most directly and consistently affected.

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The highest priority is the immediate safety of the patient and her child. In the presence of domestic violence, risk assessment for harm or neglect must be conducted urgently, particularly since a child may be at risk. Safety trumps psychiatric or social evaluations in triage.

Toronto Notes 2023 – Psychiatry, “Crisis and Risk Assessment” Section:

“When intimate partner violence (IPV) is disclosed, it is critical to assess immediate safety and consider mandatory reporting, especially when children are involved.”

MCCQE1 Objectives (Psychiatry > 79-6: Violence and Abuse):

“Candidates must assess for and respond to risk of harm in situations of domestic violence, especially when dependents are involved. This includes ensuring immediate safety and following legal obligations for child protection.”

Although the other concerns (e.g., gambling, depression, substance use, financial need) are valid, the presence of violence makes D the first and most urgent priority.

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This child likely has infectious mononucleosis caused by Epstein-Barr virus (EBV), characterized by fever, sore throat, cervical lymphadenopathy, fatigue, and splenomegaly. A palpable spleen is a hallmark of EBV in children.

Toronto Notes 2023 – Pediatrics, “Infectious Mononucleosis”:

“Key features include fever, pharyngitis, lymphadenopathy, and splenomegaly. Children may have milder symptoms but often exhibit palpable spleen.”

MCCQE1 Objectives (Pediatrics > 75-2: Infectious Disease):

“Candidates should recognize common viral syndromes such as EBV and identify complications including splenomegaly.”

Other options (renal mass, ascites, etc.) are inconsistent with this viral presentation.

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Comprehensive and Detailed Explanation:

This neonate likely has gonococcal conjunctivitis, which typically presents 2–5 days after birth with bilateral purulent discharge and swelling. This is an emergency due to the risk of corneal perforation. Empiric IV antibiotics and hospital admission are indicated.

Toronto Notes 2023 – Pediatrics, Neonatal Infections:

“Neonatal conjunctivitis within the first 1–2 weeks should raise suspicion for gonococcal or chlamydial infection. Gonorrhea requires urgent IV antibiotics and hospitalization.”

MCCQE1 Objectives – Pediatrics > Neonatal Infection:

“Candidates must recognize neonatal conjunctivitis and initiate empiric treatment while awaiting culture results.”

Lacrimal massage (E) and warm compresses (D) are used for nasolacrimal duct obstruction. Oral or topical antibiotics (B, C) are insufficient for suspected gonococcal infection.

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Comprehensive and Detailed Explanation:

Physicians must avoid conflicts of interest and maintain professional boundaries with patients and their families. Accepting a personal financial gift, regardless of intent, is inappropriate and unethical.

Toronto Notes 2023 – Ethics and Professionalism:

“Personal gifts of significant value from patients or families should be declined to avoid real or perceived conflicts of interest.”

MCCQE1 Objectives (ELOM > 90-3: Professionalism and Boundaries):

“Candidates must maintain ethical boundaries and refuse financial incentives that could compromise or appear to compromise clinical judgment.”

Other options (A, B, E) still involve a conflict. D is helpful, but the ethical obligation is to decline the cheque directly.

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Comprehensive and Detailed Explanation:

Opioid-induced constipation is best managed with stimulant laxatives like senna or bisacodyl. Stool softeners such as docusate are insufficient as monotherapy. Senna stimulates peristalsis, making it more effective.

Toronto Notes 2023 – Palliative Care:

“Opioid-induced constipation requires stimulant laxatives such as senna. Stool softeners alone are not adequate.”

MCCQE1 Objectives (Palliative Care > 92-1: Symptom Management):

“Candidates must treat opioid-related side effects appropriately, including use of stimulant laxatives for constipation.”

Bulk agents (C) can worsen symptoms. Reducing morphine (D) may compromise pain control. Activity (E) helps but is insufficient as first-line management.

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Wernicke encephalopathy is a medical emergency caused by thiamine (vitamin B1) deficiency, most often seen in chronic alcohol use. The classic triad is:

Confusion

Oculomotor dysfunction (e.g., nystagmus, cranial nerve palsies)

Ataxia

Toronto Notes 2023 – Neurology and Psychiatry, “Wernicke Encephalopathy” Section:

“Wernicke encephalopathy is diagnosed clinically. Symptoms include ophthalmoplegia (e.g., CN VI palsy), horizontal nystagmus, ataxia, and confusion. Immediate parenteral thiamine is indicated before glucose administration.”

MCCQE1 Objectives (Neurology > 75-1: Neurologic Emergencies):

“Candidates must recognize Wernicke encephalopathy in at-risk individuals and initiate urgent thiamine replacement.”

Other choices like cerebellar degeneration (A) and hepatic encephalopathy (D) are more chronic and lack the characteristic eye findings. Subdural hematoma (B) and hemorrhage (E) may mimic confusion but are less likely with these neurologic signs and history.

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The most appropriate and professional response is to focus on the current clinical situation and reassure the family that you will take responsibility for assessment and treatment. Criticizing a colleague (A, B, E) or deflecting to generalities (D) is unprofessional and unhelpful in crisis management.

Toronto Notes 2023 – Psychiatry, Physician-Patient-Family Communication:

“In emotionally charged or crisis situations, the physician must remain focused, empathetic, and professional. Avoid blaming colleagues; instead, offer a concrete plan of care.”

MCCQE1 Objectives – Psychiatry > Ethics and Professionalism:

“Candidates must demonstrate professionalism in managing conflicts, focusing on patient care while maintaining collegial respect.”

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This patient has secondary amenorrhea, infertility, and a history of multiple uterine curettages, which strongly points toward Asherman syndrome (intrauterine adhesions or synechiae). The hysterosalpingogram shows an obliterated uterine cavity and no tubal dye spill—classic for intrauterine synechiae. Her midluteal progesterone level is normal, indicating ovulation.

Toronto Notes 2023 – Gynecology, “Infertility” section:

“Asherman syndrome results from intrauterine adhesions due to curettage, leading to amenorrhea and infertility. HSG shows an obliterated or irregular uterine cavity.”

MCCQE1 Objectives (Gynecology > 82-1: Infertility):

“Candidates should evaluate secondary amenorrhea and interpret imaging such as hysterosalpingogram in the diagnosis of intrauterine abnormalities.”

Other options are ruled out by the presence of normal ovulation (rules out hypothalamic and PCOS) and by imaging (not suggestive of fibroids or perimenopause).

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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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In most Canadian provinces and territories, physicians are legally obligated to report patients who pose a danger due to medical conditions affecting driving ability. Given the history of TIAs and continued unsafe driving, reporting is necessary for public safety.

Toronto Notes 2023 – ELOM, “Fitness to Drive” Section:

“Physicians must report to motor vehicle authorities if a patient poses a risk to public safety due to a medical condition. TIAs are considered reportable if they impair ability and the patient does not comply with driving restrictions.”

MCCQE1 Objectives (ELOM > 99-1: Medical Fitness and Reporting):

“Candidates must recognize situations requiring mandatory reporting of patients unfit to drive due to neurologic or other impairing conditions.”

You may still discuss with the patient (B), but this does not replace the duty to report. Physically taking the license (C) is illegal. Refusing care (D) is unethical. A neurologist (E) could be helpful but would delay action in a clear case.

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Fibrocystic change is the most common benign breast condition in women of reproductive age. It typically presents with diffuse nodularity or "lumpy" areas, especially in the upper outer quadrant, and varies with the menstrual cycle. No dominant mass or systemic signs are expected.

Toronto Notes 2023 – Gynecology, “Benign Breast Conditions”:

“Fibrocystic changes often present with bilateral or unilateral nodularity, most commonly in the upper outer quadrants, without discrete masses.”

MCCQE1 Objectives (Gynecology > 81-1: Breast Conditions):

“Candidates must differentiate benign breast conditions from malignant ones based on presentation and physical exam findings.”

Paget disease (B) presents with nipple changes. Intraductal carcinoma (C) typically shows a discrete mass or suspicious features. Phyllodes tumours are usually well-circumscribed. Mastitis (E) is inflammatory and associated with erythema, fever, and tenderness.

Comprehensive and Detailed Explanation:

This is a classic presentation of polymyalgia rheumatica (PMR), characterized by pain and stiffness in the shoulders and hips in older adults. PMR is closely associated with giant cell arteritis (GCA), which presents with unilateral headache, jaw claudication, visual symptoms, and scalp tenderness. Given the risk of vision loss with GCA, it's critical to screen for these symptoms in all patients with suspected PMR.

Toronto Notes 2023 – Rheumatology, PMR and GCA:

“Patients with PMR should be assessed for symptoms of GCA such as headache, visual changes, and jaw claudication. GCA can result in permanent vision loss if not promptly treated.”

MCCQE1 Objectives – Internal Medicine > Rheumatology:

“Candidates must identify signs of GCA in patients with PMR and understand the need for prompt diagnosis and treatment.”

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In situations involving potential oversight, the appropriate next step is to contact the other physician directly. This supports collegial communication, continuity of care, and provides an opportunity to clarify the clinical situation. It avoids premature judgment while allowing the primary provider to respond and address concerns.

Toronto Notes 2023 – ELOM, “Professionalism and Interprofessional Communication”:

“When concerns arise about another provider’s care, direct communication is preferred before considering formal reporting. This maintains collaboration and fairness.”

MCCQE1 Objectives (ELOM > 90-2: Communication and Accountability):

“Candidates must demonstrate collegiality and appropriate methods for addressing concerns regarding another physician’s care.”

Empathizing (D) and validating blame is unprofessional. Reporting (B) is premature. Offering another provider (C) could undermine continuity. (E) is incorrect since the glucose should have been checked based on the presenting symptoms.

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This case describes classic signs of delusional parasitosis (also known as Morgellons syndrome).However, the presence of widespread crusted lesions raises suspicion for crusted scabies, particularly in older adults. Crusted scabies may be misinterpreted as chronic dermatitis or psychocutaneous disorder. The most effective treatment is oral ivermectin.

Toronto Notes 2023 – Dermatology:

“Crusted scabies presents as widespread hyperkeratotic plaques with crusting. First-line treatment is oral ivermectin, often with topical permethrin.”

MCCQE1 Objectives (Medicine > Dermatology > 23-1):

“Candidates must recognize presentations of ectoparasitic infections, including scabies, and provide appropriate treatment.”

Permethrin (B) is for typical scabies, but crusted scabies often requires systemic ivermectin due to severity and spread.

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Patients with sickle cell anemia often develop functional asplenia due to repeated splenic infarction. The spleen plays a critical role in clearing encapsulated organisms such as Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis. Functional asplenia significantly increases the risk of overwhelming sepsis.

Toronto Notes 2023 – Hematology, “Sickle Cell Disease”:

“Functional asplenia is common in sickle cell disease and increases the risk for sepsis due to impaired clearance of encapsulated bacteria.”

MCCQE1 Objectives (Pediatrics > 77-2: Hematology):

“Candidates must recognize that patients with functional asplenia are at increased risk for sepsis and require prompt evaluation for fever.”

Neutrophil dysfunction (B) and immunoglobulin deficiency (C) are not typical features of sickle cell anemia. Chronic anemia (D) and iron overload (E) do not directly increase sepsis risk.

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Spontaneous, unilateral, blood-tinged nipple discharge in a postmenopausal woman is considered pathologic and warrants imaging to rule out intraductal pathology including malignancy. The best initial test is diagnostic mammography, often with ultrasound if indicated.

Toronto Notes 2023 – Breast Disorders:

“Unilateral, spontaneous, bloody nipple discharge should be evaluated with mammography and targeted ultrasound. Further tests such as MRI or duct excision are based on findings.”

MCCQE1 Objectives (Gynecology > 81-1: Breast Conditions):

“Candidates must recognize red flags for breast malignancy and apply appropriate initial diagnostic imaging.”

Serum prolactin (C) is indicated in galactorrhea. Galactography (D) and MRI (E) are second-line. Biopsy (A) is premature without imaging.

Elevated hemoglobin in the absence of polycythemia vera can be due to secondary causes such as chronic hypoxia. Central sleep apnea, often associated with diabetes or neurologic conditions, leads to intermittent hypoxia and compensatory erythropoiesis.

Toronto Notes 2023 – Hematology and Respiratory Medicine, “Polycythemia” Section:

“Secondary erythrocytosis may result from hypoxic conditions including sleep apnea, COPD, or high altitude. Assess for sleep-disordered breathing in patients with elevated hemoglobin and no myeloproliferative features.”

MCCQE1 Objectives (Internal Medicine > 76-7: Hematologic Abnormalities):

“Candidates must investigate secondary causes of elevated hemoglobin, including hypoxia-related conditions.”

Hypertension (A), hypothyroidism (C), and cirrhosis (D) do not cause polycythemia. Alcohol (B) typically causes macrocytosis and anemia.

The presentation is consistent with rotator cuff tendinopathy or subacromial impingement. The painful arc between 30°–120° with preserved passive ROM suggests this. Ultrasound is the preferred initial imaging modality due to its availability, safety, and ability to visualize soft tissues dynamically.

Toronto Notes 2023 – Orthopedics, “Shoulder Pathologies” Section:

“In rotator cuff injuries or impingement syndromes, initial imaging with musculoskeletal ultrasound is appropriate. It can identify tendinopathy, partial tears, or subacromial bursitis.”

MCCQE1 Objectives (Surgery > 84-7: Musculoskeletal Pain):

“Candidates should initiate workup for rotator cuff or impingement syndromes with ultrasound as the first-line test, reserving more invasive or costly procedures for unresolved or complex cases.”

CT (A) is used for bony detail, not soft tissues. Arthroscopy (C) is invasive and therapeutic. Arthrography (D) is outdated and largely replaced by MRI or ultrasound.

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In Canada and in most jurisdictions internationally, physicians have a professional and in some cases legal obligation to provide emergency assistance. Documentation should be done in your own records afterward. Aviation laws and Good Samaritan protections offer liability coverage for health professionals acting in good faith.

Toronto Notes 2023 – ELOM, “Physician Obligations and Medical-Legal Responsibility”:

“Physicians should respond to in-flight or public emergencies when capable. Documentation should be completed after the event, and liability is protected under Good Samaritan laws.”

MCCQE1 Objectives (ELOM > Professionalism > 90-1):

“Candidates must demonstrate appropriate professional behavior, including willingness to assist in emergencies and understanding of legal protections.”

Avoiding assistance (A), or placing conditional barriers (D), is unethical and inappropriate.

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When an error in the system is identified (e.g., test result not properly followed up), the most responsible approach is to analyze and improve internal clinic processes. Patient safety depends on reliable result tracking systems.

Toronto Notes 2023 – ELOM, “Medical Errors and Quality Improvement” Section:

“When an error or near miss is identified, root cause analysis and system-level interventions are required to prevent recurrence. Blaming the patient or others without review of internal processes is inappropriate.”

MCCQE1 Objectives (ELOM > 99-1: Medical Error and Disclosure):

“Candidates must recognize the importance of continuous quality improvement in health care. System-level changes should be implemented when safety lapses occur.”

Option A shifts responsibility improperly onto the patient. Option C deflects blame without assessing one’s own clinic. Option D minimizes the error and does not lead to improvement.

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Comprehensive and Detailed Explanation:

While borderline personality disorder is challenging, symptoms (particularly impulsivity and suicidal behaviors) often attenuate with age and appropriate therapy (e.g., dialectical behavior therapy). Providing hope and clinical context to staff improves care and reduces stigma.

Toronto Notes 2023 – Psychiatry, “Personality Disorders”:

“BPD is associated with emotional dysregulation and impulsivity. Long-term prognosis is better than once believed, with many patients showing symptom remission over time.”

MCCQE1 Objectives (Psychiatry > 71-4: Personality Disorders):

“Candidates must provide appropriate education to patients and staff regarding prognosis and treatment of BPD.”

Statements A–D are false, stigmatizing, or dangerous.

Chronic mesenteric ischemia (also known as “intestinal angina”) presents as postprandial abdominal pain, leading to food avoidance and significant weight loss. GI exams may be normal. Imaging (e.g., angiography or CT angio) confirms the diagnosis.

Toronto Notes 2023 – Gastroenterology, “Chronic Mesenteric Ischemia”:

“Classic triad: postprandial abdominal pain, weight loss, and food aversion. Physical exam and GI series may be normal.”

MCCQE1 Objectives (Gastroenterology > 47-1: Abdominal Pain):

“Candidates must suspect mesenteric ischemia in older adults with risk factors and postprandial pain leading to weight loss.”

PUD (A) usually causes epigastric pain relieved by food. Cholelithiasis (B) causes RUQ pain. Colon cancer (D) presents with altered bowel habits or bleeding. Mesenteric adenitis (C) occurs in younger patients, often with infection.

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This patient’s lab results suggest impaired fasting glucose and an elevated A1c just below the threshold for diabetes. The gold standard to confirm diabetes in such intermediate cases is the 75 g oral glucose tolerance test (OGTT).

Toronto Notes 2023 – Endocrinology, “Diabetes Mellitus” Section:

“If A1c is in the 6.0–6.4% range or fasting glucose 6.1–6.9 mmol/L, a 75 g OGTT is recommended to establish the diagnosis of diabetes or confirm impaired glucose tolerance.”

MCCQE1 Objectives (Internal Medicine > 76-4: Diabetes):

“Candidates must correctly apply diabetes screening and diagnostic criteria and follow up abnormal results with appropriate confirmatory testing.”

Urine ACR (C) is useful in diagnosed diabetes, not for initial screening. TSH (A), capillary glucose testing (B), and exercise testing (E) are not indicated at this stage.

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Comprehensive and Detailed Explanation:

Transient synovitis is the most common cause of hip pain and limp in children aged 3–10 years. It is often preceded by a viral infection. Patients appear well, can often bear weight, and have only mild to moderate elevation in inflammatory markers. Radiographs are normal.

Toronto Notes 2023 – Pediatrics, “Limping Child”:

“Transient synovitis is benign and self-limiting. Presentation includes mild limp, low-grade fever, normal or slightly elevated CRP/ESR, and ability to bear weight.”

MCCQE1 Objectives (Pediatrics > 78-2: Musculoskeletal Disorders):

“Candidates must distinguish between transient synovitis and more serious causes of limping, such as septic arthritis.”

Septic arthritis (A) usually causes inability to bear weight and more significant fever and CRP elevation. Osteomyelitis (B) typically presents with localized tenderness and systemic signs. Bursitis (D) is rare in young children. JIA (E) is chronic.

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Comprehensive and Detailed Explanation:

This patient has end-stage heart failure with frequent hospitalizations, progressive symptoms, and functional decline. The most appropriate next step is to initiate a goals-of-care conversation, including acknowledgment of the prognosis.

Toronto Notes 2023 – Cardiology / Palliative Care:

“In advanced heart failure with recurrent admissions and functional decline, a goals-of-care discussion should be initiated to align treatment with patient values.”

MCCQE1 Objectives (Cardiology > 34-4 / ELOM > 90-2):

“Candidates must recognize end-stage illness and provide appropriate communication and palliative care planning.”

Deactivating the defibrillator (B) may be appropriate later but should follow a goals-of-care conversation. Reassuring (C) ignores the true clinical trajectory.

The symptoms — visual hallucinations, attention deficits, gait instability — suggest dementia with Lewy bodies (DLB), which may show bilateral frontal or parietal atrophy on imaging.

Toronto Notes 2023 – Psychiatry, Neurocognitive Disorders:

“DLB presents with fluctuating cognition, visual hallucinations, parkinsonism, and attention deficits. Imaging may show frontal or parietal atrophy but is not always specific.”

MCCQE1 Objectives – Psychiatry > Neurocognitive Disorders:

“Candidates must recognize the characteristic features of DLB and support diagnosis with imaging when appropriate.”

Cerebellar atrophy (A) is linked to ataxia but not hallucinations. Subdural hematoma (B) causes abrupt decline. Mediotemporal atrophy (D) is typical of Alzheimer’s. Option E is incorrect — imaging can support the diagnosis.

Comprehensive and Detailed Explanation:

Complex endometrial hyperplasia with atypia carries a high risk of progression to or concurrent endometrial carcinoma. Definitive management in postmenopausal women is total hysterectomy with bilateral salpingo-oophorectomy.

Toronto Notes 2023 – Gynecology, Abnormal Uterine Bleeding:

“Endometrial hyperplasia with atypia in postmenopausal women is best managed surgically due to the risk of malignancy.”

MCCQE1 Objectives – Gynecology > Postmenopausal Bleeding:

“Candidates should identify endometrial hyperplasia with atypia as an indication for hysterectomy in appropriate patients.”

Ablation (A) is contraindicated. Progesterone (B) is used for non-atypical hyperplasia. D&C (C) and hysteroscopy (D) are diagnostic but not definitive.

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Comprehensive and Detailed Explanation:

The most appropriate next step for a patient with intermittent palpitations and a normal ECG is Holter monitoring (or event monitoring). This can capture and correlate symptoms with cardiac rhythm.

Toronto Notes 2023 – Cardiology, “Palpitations”:

“Holter or event monitoring is indicated when the initial ECG is normal but the patient has episodic symptoms such as palpitations.”

MCCQE1 Objectives (Cardiology > 34-2: Arrhythmia):

“Candidates must use ambulatory ECG monitoring to investigate intermittent palpitations when resting ECG is unremarkable.”

Echocardiogram (A) assesses structural issues but not rhythm. β-blockers (B) should not be started without diagnosis. Stress testing (D) is for ischemia.

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Comprehensive and Detailed Explanation:

The Zika virus can be sexually transmitted and poses a serious risk of congenital Zika syndrome if infection occurs during pregnancy. The CDC and WHO recommend that couples delay conception for at least 3 months after potential male exposure due to the virus's persistence in semen.

Toronto Notes 2023 – Infectious Diseases / Travel Medicine:

“Zika virus may persist in semen for weeks. Couples should delay conception for 3 months after male exposure, even if asymptomatic.”

MCCQE1 Objectives (Public Health > 65-3: Travel Medicine and Reproductive Health):

“Candidates must counsel appropriately regarding risks of Zika in conception and apply current public health recommendations.”

Testing (B) is not reliable for asymptomatic individuals. Antivirals (E) are ineffective. Condoms (D) do reduce risk. Specialist referral (A) is not needed in most cases with no complications.

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Comprehensive and Detailed Explanation:

In X-linked recessive disorders such as hemophilia A, carrier mothers (usually asymptomatic) have a 50% chance of passing the affected X chromosome to each son, who would then express the disease. Each daughter has a 50% chance of being a carrier but is generally not affected.

Toronto Notes 2023 – Genetics:

“X-linked recessive inheritance: Carrier mother has a 50% chance of having an affected son and a 50% chance of having a carrier daughter.”

MCCQE1 Objectives (Genetics > 61-1: Inheritance Patterns):

“Candidates must apply principles of X-linked inheritance to assess risk in offspring.”

If the mother is a known carrier (as inferred from having an affected son), the chance of a second affected boy is 50%.

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Comprehensive and Detailed Explanation:

The levonorgestrel-releasing intrauterine device (LNG-IUD) is generally contraindicated in current or recent breast cancer due to the progestin component, but may be considered in selectpatients on tamoxifen, especially if non-hormonal options are unsuitable. Consultation with the oncologist is required to evaluate risks and benefits.

Toronto Notes 2023 – Gynecology, “Contraception in Special Populations”:

“Levonorgestrel IUDs are generally avoided in patients with a history of hormone-sensitive cancers; however, decisions should be made collaboratively with oncology.”

MCCQE1 Objectives (Gynecology > 82-2: Contraception):

“Candidates must tailor contraceptive advice to patients with medical comorbidities, including cancer survivors.”

Irregular bleeding (A) is a common but not contraindicating side effect. No pre-procedure antibiotics (D) are typically needed. The IUD does not cause infertility (E). Risk of recurrence (C) is unconfirmed and must be individualized.

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Comprehensive and Detailed Explanation:

This patient has secondary amenorrhea, galactorrhea, and worsening headaches—suggestive of hyperprolactinemia, possibly due to a pituitary adenoma (prolactinoma). Visual field defects (typically bitemporal hemianopia) can result from optic chiasm compression.

Toronto Notes 2023 – Endocrinology / Reproductive Health:

“Prolactinomas may cause amenorrhea, galactorrhea, headaches, and visual field defects. Evaluate with serum prolactin and visual field testing.”

MCCQE1 Objectives (Endocrinology > 37-2: Pituitary Disorders):

“Candidates must recognize clinical signs of prolactinomas and know when to assess visual fields.”

Hirsutism (D) suggests androgen excess. Low BMI (B) can cause hypothalamic amenorrhea but wouldn’t explain galactorrhea. Nodular breast findings (A) are not related.

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This presentation suggests hereditary hemochromatosis. Common features include hyperpigmentation ("bronze diabetes"), hepatomegaly, diabetes, fatigue, and elevated liver enzymes. Serum ferritin is a screening test for iron overload, and elevated levels support the diagnosis.

Toronto Notes 2023 – Endocrinology / Gastroenterology:

“Hemochromatosis presents with skin hyperpigmentation, hepatomegaly, diabetes, fatigue. Diagnosis begins with serum ferritin and transferrin saturation.”

MCCQE1 Objectives (Internal Medicine > Metabolic and Endocrine > 37-1):

“Candidates must investigate iron overload syndromes using ferritin and transferrin saturation.”

Cortisol (B) is for adrenal insufficiency. A1AT (C) is a liver disease cause but not typical here. Amylase (E) is for pancreatitis. A1c (A) would confirm diabetes but not the underlying cause.

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In Canada, a minor may consent to medical care if the physician believes they have the capacity to understand the nature, benefits, and risks. This is known as the “mature minor doctrine.” Capacity is based on understanding, not age.

Toronto Notes 2023 – ELOM, “Consent and Capacity” Section:

“A minor may consent to treatment if they demonstrate sufficient maturity and understanding. It is the physician’s responsibility to assess capacity prior to prescribing.”

MCCQE1 Objectives (ELOM > 99-3: Consent and Confidentiality):

“Candidates must assess the patient’s ability to understand and make informed decisions, regardless of age.”

Prescribing without assessment (B) is premature. Reporting to child services (A) is only necessary if there are signs of abuse or coercion. Parental involvement (C) is not mandatory. Refusal based on age (E) contradicts legal and ethical practice.

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A confounder is a variable associated with both the exposure and the outcome but not in the causal pathway. In this study, coffee drinking is associated with smoking (the actual risk factor for lung cancer), but not independently associated with lung cancer.

Toronto Notes 2023 – Epidemiology Chapter:

“A confounder is a third variable that distorts the observed association between an exposure and an outcome. It must be associated with both the exposure and the outcome, but not a result of the exposure.”

MCCQE1 Objectives (Population Health > 97-3: Study Design and Bias):

“Recognize and control for confounding in the interpretation of observational study data.”

Coffee is not a risk factor (B) since it’s not independently associated with lung cancer, and it's not selection bias (C), which involves how participants are enrolled in a study.

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Comprehensive and Detailed Explanation:

The patient is in a persistent vegetative state and medically stable, meaning he does not need continued hospitalization. The goal is to provide appropriate long-term care in the least restrictive setting, typically at home with robust home care support services. This approach aligns with ethical care, family-centered goals, and medical appropriateness.

Toronto Notes 2023 – Pediatrics / Neurodevelopment & Chronic Care:

“Home care with appropriate medical and caregiver support is often the best setting for children with severe neurological impairments who are medically stable.”

MCCQE1 Objectives (Pediatrics > 77-5: Chronic Neurological Disorders):

“Candidates must assess discharge planning and coordinate home care support for children with long-term care needs.”

Palliative facility (B) is not appropriate unless end-of-life is imminent. School (C) is not feasible in this state. Hospital readmission for respite (D) is not standard. Rehabilitation (E) has little utility in persistent vegetative state.

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Comprehensive and Detailed Explanation:

The patient presents with classic symptoms of schizophrenia: delusions, hallucinations, social withdrawal, and disorganized appearance. The first-line treatment is antipsychotic medication—risperidone is a well-tolerated option among second-generation antipsychotics.

Toronto Notes 2023 – Psychiatry, “Schizophrenia”:

“Schizophrenia is treated with second-generation antipsychotics such as risperidone. These reduce positive symptoms like delusions and hallucinations.”

MCCQE1 Objectives (Psychiatry > 71-3: Psychotic Disorders):

“Candidates must recognize and manage schizophrenia with antipsychotics and distinguish from other mood or personality disorders.”

CBT (E) is supportive but not first-line. ECT (A) is used for severe depression or catatonia. Valproic acid (C) and carbamazepine (D) are mood stabilizers, not first-line for schizophrenia.

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This patient is competent and capable of making his own health decisions. A DNR order and naming a substitute decision-maker apply only when a patient lacks capacity. The next step is to discuss the suspected diagnosis with the patient and explore his preferences.

Toronto Notes 2023 – ELOM, Consent and Capacity:

“Competent patients retain full decision-making authority. Substitute decision-makers are only engaged when the patient lacks capacity. DNR applies to resuscitation, not other medical decisions.”

MCCQE1 Objectives – ELOM > Capacity, Consent, Advance Directives:

“Candidates must recognize that capable patients should be directly involved in decisions. Substitute decision-makers are not invoked unless the patient is incapable.”

Option A implies a breach of confidentiality without permission. Option C is premature. Option D bypasses informed consent. Option E misinterprets the DNR’s scope.

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The first step in evaluating a new, hot, swollen joint is arthrocentesis to rule out septic arthritis and crystal arthropathy. Joint aspiration provides fluid for microscopy, culture, and crystal analysis, which guides definitive diagnosis and treatment.

Toronto Notes 2023 – Rheumatology, Monoarthritis:

“Joint aspiration is the most important first step in evaluating monoarthritis. Septic arthritis must be ruled out before initiating any therapy.”

MCCQE1 Objectives – Internal Medicine > Rheumatology:

“Candidates should perform joint aspiration in the presence of acute monoarthritis to differentiate between septic arthritis, gout, and other causes.”

Radiography (A) and serum uric acid (B) do not establish cause acutely. Empiric antibiotics (D) and NSAIDs (E) should only be started after ruling out septic arthritis.

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Sudden onset dyspnea and pleuritic chest pain in a postoperative patient with tachypnea and clear lung fields are classic features of a pulmonary embolism (PE). Recent orthopedic surgery significantly increases VTE risk. Clear lungs on auscultation support this over pneumonia or CHF.

Toronto Notes 2023 – Respiratory, “Pulmonary Embolism”:

“Presentation includes sudden dyspnea, pleuritic chest pain, and tachypnea. Risk factors include recent surgery and immobilization. Examination often reveals clear chest auscultation.”

MCCQE1 Objectives (Internal Medicine > Cardiopulmonary > 44-1):

“Candidates must recognize PE in patients with risk factors (e.g., surgery) and classic features and initiate appropriate diagnosis and management.”

Fat embolism (B) usually presents with petechiae, neurologic symptoms, and occurs within 24–72 hours post-op. Cholesterol emboli (E) are more chronic and systemic.

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Disseminated gonococcal infection (DGI) typically presents with the classic triad of polyarthralgia, tenosynovitis, and skin lesions (especially pustules on extremities). A prior urogenital infection and systemic symptoms further support this diagnosis.

Toronto Notes 2023 – Infectious Disease, STIs:

“DGI presents with arthritis-dermatitis syndrome: fever, asymmetric polyarthralgia, tenosynovitis, and vesiculopustular skin lesions. It may follow asymptomatic or unrecognized urogenital infection.”

MCCQE1 Objectives – Infectious Disease > STIs:

“Candidates must recognize systemic manifestations of gonorrhea including DGI and distinguish it from other forms of arthritis or systemic illness.”

Reactive arthritis (C) may follow STI but includes conjunctivitis and urethritis. HIV (A) does not typically cause this triad. RA (D) has different distribution and chronicity. Varicella (E) presents with diffuse vesicular rash, not joint pain.

Stimulants like methylphenidate can increase heart rate and blood pressure. In patients with cardiovascular risk (e.g., hypertension, nephropathy), stimulants should not be increased without first addressing elevated blood pressure.

Toronto Notes 2023 – Psychiatry, “ADHD in Adults”:

“Stimulants can exacerbate hypertension and must be used cautiously. Evaluate cardiovascular risk factors and control blood pressure before dose increases.”

MCCQE1 Objectives (Psychiatry > 71-1: ADHD):

“Candidates must consider the cardiovascular risks of stimulant therapy and monitor for hypertension prior to adjusting doses.”

While poor glycemic control (B) and renal disease (A) are important, BP control is most critical for immediate stimulant safety.

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The levonorgestrel-releasing intrauterine system (LNG-IUS) is the first-line treatment for heavy menstrual bleeding, particularly in women with risk factors for endometrial hyperplasia and contraindications to systemic hormones (e.g., morbid obesity, diabetes, OSA).

Toronto Notes 2023 – Gynecology, “Abnormal Uterine Bleeding” Section:

“The LNG-IUS is highly effective in reducing menstrual bleeding and improving hemoglobin levels. It is particularly recommended in women with obesity, chronic anovulation, or contraindications to estrogen.”

MCCQE1 Objectives (Obstetrics and Gynecology > 82-1: Abnormal Uterine Bleeding):

“Candidates must consider the LNG-IUS as a preferred non-surgical treatment for chronic heavy menstrual bleeding when endometrial pathology has been excluded.”

Oral contraceptives (C) are not first-line in morbid obesity due to increased thromboembolic risk. Cyclic medroxyprogesterone (D) is less effective than LNG-IUS. Hysterectomy (A) is definitive but should follow failure of conservative therapy.

Comprehensive and Detailed Explanation:

Mid-cycle acute onset pelvic pain with localized adnexal tenderness in a reproductive-age woman suggests a hemorrhagic ovarian cyst, particularly a ruptured one. The hemodynamic parameters are stable, but elevated HR supports acute pain and possible blood loss.

Toronto Notes 2023 – Gynecology / Acute Pelvic Pain:

“Hemorrhagic ovarian cysts present with sudden unilateral pelvic pain, mid-cycle, with guarding and rebound tenderness. Ultrasound is key.”

MCCQE1 Objectives (Gynecology > 82-4: Acute Pelvic Pain):

“Candidates must recognize common causes of acute pelvic pain, including ovarian cysts.”

Diverticulitis (A) is rare in young women and usually LLQ. Appendicitis (B) is more likely RLQ. Adenomyosis (C) and endometriosis (D) cause chronic cyclical pain, not acute tenderness.

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Comprehensive and Detailed Explanation:

A localized mass with tenderness at a recent surgical site, intact skin, low-grade temperature, and normal white count is most consistent with a wound hematoma. This is a common complication at saphenous vein graft harvest sites post-CABG.

Toronto Notes 2023 – Surgery / Cardiac:

“Wound hematoma presents as localized swelling and tenderness near recent surgical sites. Abscess is suggested by erythema, warmth, and systemic signs.”

MCCQE1 Objectives (Surgery > 50-2: Postoperative Complications):

“Candidates must identify and differentiate wound complications, including hematoma, seroma, and abscess.”

Abscess (E) would show redness, fluctuance, and fever. Aneurysm (B) is rare and pulsatile. Bleeding (A) would not form a stable mass 2 weeks post-op. Thrombophlebitis (C) usually involves superficial veins and erythema.

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This case features hallmark traits of antisocial personality disorder: disregard for social norms, criminal behavior, lack of remorse, impulsivity, and a history of conduct disorder (suggested by childhood ADHD and likely early behavioral problems).

Toronto Notes 2023 – Psychiatry, Personality Disorders:

“Antisocial personality disorder is characterized by disregard for rights of others, impulsivity, deceitfulness, lack of remorse, and criminal activity beginning in adolescence.”

MCCQE1 Objectives – Psychiatry > Personality Disorders:

“Candidates must distinguish antisocial personality disorder by a pattern of behavior that violates the rights of others, with evidence of conduct disorder before age 15.”

Other options do not explain the full behavioral pattern, especially the criminality and lack of remorse.

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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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The patient shows signs of herpes labialis (HSV-1), which can transmit genital herpes via oral sex. This poses a risk to the fetus if maternal infection occurs during pregnancy, especially near delivery. Preventing new genital HSV infection during pregnancy is critical.

Toronto Notes 2023 – Obstetrics:

“HSV-1 can cause genital herpes via oral-genital transmission. Avoid oral sex during outbreaks in pregnancy to prevent primary maternal infection.”

MCCQE1 Objectives (Obstetrics > 80-3: Infectious Disease in Pregnancy):

“Candidates must understand the importance of preventing new HSV infection during pregnancy and counsel appropriately.”

Culture (A) is not useful unless symptomatic. Serology (B) is not needed in this context. Cesarean (D) is not indicated unless active genital lesions at delivery. Acyclovir (C) is for infected mothers or near delivery.

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When a competent patient declines dialysis, the next step is to support shared decision-making and explore options that align with their lifestyle. Peritoneal dialysis may allow more flexibility and autonomy compared to hemodialysis, making it more acceptable to patients with demanding schedules.

Toronto Notes 2023 – Nephrology, Chronic Kidney Disease Section:

“Peritoneal dialysis offers the advantage of home-based treatment and flexible scheduling. Patient education and peer support can improve acceptance and adherence to dialysis initiation.”

MCCQE1 Objectives – Internal Medicine > Nephrology:

“The candidate should explore treatment alternatives collaboratively, emphasizing patient autonomy, while addressing misconceptions and lifestyle concerns related to dialysis.”

Simply warning the patient or withdrawing engagement (Options B and C) may undermine rapport. Access to medical records (D) is a right, but does not actively address treatment planning. Exploring new employment (E) is inappropriate at this stage.

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TENS has been shown to be effective for managing primary dysmenorrhea when pharmacological options are contraindicated or refused. It works by interfering with pain signal transmission and increasing endorphin levels.

Toronto Notes 2023 – Gynecology, Dysmenorrhea:

“High-frequency TENS is effective in managing primary dysmenorrhea and can be considered when NSAIDs or hormonal therapies are not acceptable to the patient.”

MCCQE1 Objectives – Gynecology > Menstrual Disorders:

“Candidates must be aware of non-pharmacological interventions for dysmenorrhea, including TENS and heat therapy.”

Options D and E involve hormonal or surgical intervention. Spinal manipulation and massage (B and C) lack consistent evidence for dysmenorrhea relief.

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This adolescent exhibited acute suicidal behavior (attempted to jump out of a window), which is a psychiatric emergency. Regardless of intoxication or cause, such behavior mandates a safety-first approach: involuntary psychiatric assessment and protection from self-harm.

Toronto Notes 2023 – Psychiatry, “Suicide and Crisis Intervention” Section:

“Involuntary psychiatric admission is indicated when a patient poses a danger to themselves or others. Suicidal ideation or attempts require immediate evaluation and monitoring.”

MCCQE1 Objectives (Psychiatry > 79-2: Suicide and Risk Management):

“Candidates must identify suicidal behavior and initiate appropriate action, including involuntary admission if necessary for safety.”

Observation (B) may miss the window for action. Parents (A) should be contacted but are not a substitute for admission. Chlordiazepoxide (C) is not first-line in this scenario.

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According to Canadian guidelines, women aged 50 to 74 at average risk for breast cancer should undergo routine screening mammography every 2 to 3 years. A great-aunt with breast cancerdoes not raise this patient's risk to high. Mammography is appropriate as she is now due for the next screen.

Toronto Notes 2023 – Population Health, “Screening Guidelines” Section:

“Routine mammography is recommended every 2 years for average-risk women aged 50 to 74. Family history in second-degree or more distant relatives (e.g., great-aunt) does not qualify for high-risk screening or MRI.”

MCCQE1 Objectives (Population Health > 97-5: Screening and Prevention):

“Candidates should apply Canadian screening recommendations including mammography for average-risk women ≥50 years old.”

Self-breast exams (C) are not recommended for screening. PET scan (D) and MRI (E) are reserved for high-risk populations or diagnostic clarification.

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This patient presents with panic-like somatic symptoms triggered by bereavement. Normal investigations rule out cardiac pathology. Grief therapy is appropriate as the underlying stressor is unresolved grief and anxiety.

Toronto Notes 2023 – Psychiatry, Grief and Anxiety Disorders:

“Bereavement-related anxiety and somatization are common. Grief counseling can help reduce somatic and psychological symptoms when medical causes are ruled out.”

MCCQE1 Objectives – Psychiatry > Anxiety and Bereavement:

“Candidates should recognize psychological sequelae of grief, including panic and health anxiety, and provide appropriate psychological support.”

Metoprolol (C) is not indicated without confirmed cardiac cause. Lorazepam (B) may offer short-term relief but does not address the underlying grief. Stress testing (A) is unnecessary with repeated normal investigations.

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Comprehensive and Detailed Explanation:

Travel to rural Cambodia poses a high risk of malaria, which can be life-threatening in pregnancy. Antimalarial prophylaxis is strongly recommended for pregnant women traveling to endemic regions. Chloroquine or mefloquine (depending on resistance patterns) may be used in pregnancy under specialist guidance.

Toronto Notes 2023 – Infectious Disease / Travel Medicine:

“Malaria prophylaxis is indicated in pregnant women traveling to endemic regions. The risk of severe malaria and poor fetal outcomes is high.”

MCCQE1 Objectives (Public Health > 65-3: Travel Medicine and Pregnancy):

“Candidates must provide preventive care to pregnant travelers including vaccination and malaria prophylaxis.”

Tetanus boosters (D) are given every 10 years. Hep B Ig (B) is for acute post-exposure prophylaxis. Ciprofloxacin (C) is contraindicated in pregnancy.

This presentation describesnormal developmental dysfluency, which typically occurs between ages 2–5 and often worsens duringtimes of stress or change, such as a new sibling. It is characterized byword repetitionand does not require intervention unless it persists >6 months, worsens, or causes distress.

Toronto Notes 2023 – Pediatrics, "Developmental and Behavioral Pediatrics" Section:

“Developmental stuttering is common between 2–5 years and often resolves without intervention. Reassurance is appropriate unless there are signs of persistent or severe stuttering, secondary behaviors, or parental concern.”

MCCQE1 Objectives (Pediatrics > 78-1: Development and Behavior):

“Candidates must recognize typical patterns of developmental speech dysfluency and differentiate them from pathological speech disorders. Observation and reassurance are often the appropriate initial step.”

Because the child is otherwise developing normally and the onset coincides with a known psychosocial stressor,reassuranceis the most appropriate step. Formal speech or behavioral therapy is not indicated at this time.

Comprehensive and Detailed Explanation:

The most appropriate next step is to assess the patient’s capacity to consent to or refuse treatment. Patients with severe anorexia nervosa may lack decision-making capacity due todistorted thinking and perception, particularly if refusal of treatment is life-threatening. If she is found incapable, treatment can proceed in her best interests.

Toronto Notes 2023 – Psychiatry / Ethics:

“If a patient with anorexia nervosa refuses treatment but is medically unstable, assess capacity. If incapable, substitute decision-making may be initiated.”

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

“Candidates must assess decision-making capacity when a patient refuses essential care, especially in life-threatening psychiatric or medical conditions.”

Psychiatric consult (B) may follow, but the immediate action is capacity assessment. D is premature without determining capacity. A and E are also premature or inappropriate.

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This patient presents with fever, confusion, anemia with schistocytes, thrombocytopenia, and renal impairment — fulfilling the classic pentad of thrombotic thrombocytopenic purpura (TTP). TTP is a hematologic emergency requiring plasma exchange.

Toronto Notes 2023 – Hematology, “Microangiopathic Hemolytic Anemia” Section:

“TTP is a medical emergency. Features include MAHA, thrombocytopenia, renal failure, neurologic symptoms, and fever. Schistocytes on blood film are diagnostic.”

MCCQE1 Objectives (Internal Medicine > 76-7: Hematologic Disorders):

“Candidates must urgently recognize TTP and initiate emergent plasma exchange therapy.”

AML (B) does not present with schistocytes. HIV (C) can cause thrombocytopenia but not MAHA. ITP (D) causes isolated thrombocytopenia without anemia or schistocytes.

Comprehensive and Detailed Explanation:

At 20 weeks’ gestation, the uterine fundus typically reaches the umbilicus. If the fundal height is lower than expected at a stated gestational age of 26 weeks, the most likely explanation—especially with no prior care—is a dating error.

Toronto Notes 2023 – Obstetrics:

“Fundal height at the umbilicus corresponds to ~20 weeks. In women lacking early prenatal care, dating errors are common causes of fundal height discrepancy.”

MCCQE1 Objectives (Obstetrics > 80-3: Routine Antenatal Care):

“Candidates must interpret fundal height and reconcile discrepancies with gestational age.”

IUGR and oligohydramnios are possible but require imaging confirmation. Bicornuate uterus may cause fundal shape anomalies but not significant dating discrepancy. A mole (D) would increase, not decrease, size.

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Comprehensive and Detailed Explanation:

Physicians must be transparent and honest in documentation. If a previous abnormality was missed, it must be acknowledged. The correct action is to comment on both the previous and current findings in your report and follow institutional disclosure policies.

Toronto Notes 2023 – ELOM, “Medical Error and Disclosure”:

“Physicians must report and document prior missed findings honestly and provide full disclosure when reviewing comparative studies.”

MCCQE1 Objectives (ELOM > 90-2: Accountability and Communication):

“Candidates must accurately document previous findings when reviewing comparative data, even if it reveals past oversight.”

Delaying reporting (C–E) or omitting prior findings (A) is unethical.

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Comprehensive and Detailed Explanation:

In a workplace medical note, physicians are responsible for commenting on the patient’s functional capacity and any required accommodations—not providing detailed medical diagnoses or test results unless consented to. The goal is to support a safe return to work with appropriate modifications.

Toronto Notes 2023 – ELOM, “Documentation and Work Notes”:

“Physicians should focus on functional abilities and restrictions, rather than detailed diagnoses or treatments, in employer communications.”

MCCQE1 Objectives (ELOM > 90-2: Confidentiality and Occupational Fitness):

“Candidates must maintain patient confidentiality and document work-related limitations and accommodations in employer letters.”

Diagnosis (B), imaging (E), and treatment plans (A) are confidential medical details. C (physiotherapist’s evaluation) is not the physician’s documentation.

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The presence of suicidal ideation in a minor mandates urgent assessment to ensure safety and access mental health care. Disclosure of sexual orientation should be handled delicately and is not urgent compared to suicidal risk.

Toronto Notes 2023 – Psychiatry, “Child and Adolescent Psychiatry” Section:

“Any adolescent disclosing suicidal ideation should be referred for urgent mental health evaluation. Concurrent issues such as sexual orientation may contribute to distress and should be addressed with appropriate support over time.”

MCCQE1 Objectives (Psychiatry > 79-2: Suicide Risk Assessment):

“Candidates must immediately refer for psychiatric assessment when a minor reports suicidal ideation, regardless of other social or developmental concerns.”

Antidepressants (A) may be appropriate but must follow specialist evaluation. Encouraging disclosure (B) or peer groups (C) is premature without ensuring safety.

Comprehensive and Detailed Explanation:

This patient has hypercalcemia with suppressed PTH, ruling out primary hyperparathyroidism. The differential includes malignancy-associated hypercalcemia, vitamin D intoxication, and medications. Given the low PTH and normal vitamin D level, malignancy (e.g., multiple myeloma) is a leading concern. Serum protein electrophoresis and urine for Bence-Jones proteins (light chains) are appropriate next steps.

Toronto Notes 2023 – Endocrinology, “Hypercalcemia”:

“PTH-independent hypercalcemia should prompt investigation for malignancy. Multiple myeloma is a common cause in older adults—order SPEP and UPEP.”

MCCQE1 Objectives (Endocrinology > 37-1: Calcium Disorders):

“Candidates must investigate non-PTH mediated hypercalcemia, including consideration of multiple myeloma.”

A (urine calcium) helps in familial hypocalciuric hypercalcemia, but this is unlikely given low PTH. B (calcitriol) would worsen hypercalcemia. C is inappropriate because PTH is suppressed. D (changing HCTZ) may help, but malignancy must be ruled out first.

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