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Medical Council of Canada MCCQE Part 1 Exam Sample Questions (Q74-Q79):

NEW QUESTION # 74
A 47-year-old man has been training for a marathon. After a long run, he develops mild pain and swelling in his left knee. Examination shows a mild joint effusion and a soft tissue mass in the popliteal fossa. The knee radiograph is normal. Which one of the following is the best method of confirming the diagnosis?

A. Arthrocentesis.
B. Computed tomography.
C. Ultrasound.
D. Arthroscopy.
E. Aspiration of the popliteal mass.

Answer: C

Explanation:
This patient's presentation-knee effusion with a soft tissue mass in the popliteal fossa following exertion-is classic for a Baker (popliteal) cyst , which represents distention of the gastrocnemius-semimembranosus bursa, often associated with intra-articular pathology (e.g., meniscal injury or osteoarthritis). MCCQE objectives emphasize selecting the least invasive, most appropriate imaging modality to confirm suspected cystic lesions.
Ultrasound is the best initial diagnostic test because it is noninvasive, readily available, and highly sensitive for distinguishing a cystic structure from a solid mass or vascular pathology (e.g., popliteal artery aneurysm or deep vein thrombosis). It can also assess for complications such as cyst rupture.
Arthroscopy is invasive and not required for diagnosis. Arthrocentesis evaluates joint effusion but does not confirm a popliteal cyst. Aspiration of the mass without imaging is inappropriate due to risk of vascular injury. CT is unnecessary and exposes the patient to radiation.
Therefore, ultrasound is the preferred method to confirm a Baker cyst.

NEW QUESTION # 75
A 94-year-old woman with severe dementia is referred for vaginal bleeding and a persistent foul odour from the vagina. She lives in a long-term care facility. She has been using a ring pessary for the past 15 years. Her current pessary has not been replaced in 2 years. On examination, there is moderate vaginal atrophy. After removing the pessary, which one of the following is the best next step?

A. Perform a vaginal biopsy.
B. Arrange for a hysteroscopy and endometrial biopsy.
C. Start vaginal estrogen.
D. Prescribe vaginal metronidazole gel.
E. Wash the pessary and recommend a daily saline douche.

Answer: C

Explanation:
In elderly women with long-term pessary use and signs of vaginal atrophy (thin epithelium, bleeding, odor), local estrogen is the most appropriate initial treatment to restore the vaginal epithelium and reduce inflammation and discharge. Vaginal estrogen improves mucosal integrity and reduces complications like ulceration, infection, and bleeding.
Toronto Notes 2023 - Gynecology, "Pelvic Organ Prolapse and Pessary Care" Section:
"Local vaginal estrogen therapy is recommended for postmenopausal women with vaginal atrophy who are using pessaries. It reduces the risk of erosions, bleeding, and infection, especially when pessary follow-up has been suboptimal." MCCQE1 Objectives (Obstetrics and Gynecology > 82-9: Vaginal Bleeding in Postmenopausal Women):
"Candidates should recognize vaginal atrophy as a common and treatable cause of bleeding in elderly women using pessaries." A biopsy (E) may be needed if symptoms persist after atrophy is treated. Hysteroscopy (A) is invasive and not first-line in this setting. Metronidazole (B) is not indicated without evidence of bacterial vaginosis. Daily saline douching (D) is not recommended and may irritate atrophic mucosa.

NEW QUESTION # 76
A 70-year-old woman presents to the Emergency Department with a 2-day history of dysuria and right flank pain. Upon arrival, she is quite unwell. Her vital signs are as follows: blood pressure 70/38 mm Hg, heart rate
130/min, respiratory rate 24/min, temperature 39.4 °C.
Due to difficulty obtaining peripheral access, a central line is inserted. There is a lot of ongoing bleeding around the line insertion site. Her blood work shows:
White blood cell count: 19.8 × 10#/L (4-10)
Hemoglobin: 101 g/L (123-157)
Platelets: 85 × 10#/L (130-400)
Blood film: schistocytes
INR: 1.9 (0.9-1.2)
Fibrinogen: < 1 g/L (2-4)
Which one of the following is the most likely cause of her ongoing bleeding?

A. Vitamin K deficiency.
B. Heparin-induced thrombocytopenia.
C. Thrombotic thrombocytopenic purpura.
D. Idiopathic thrombocytopenic purpura.
E. Disseminated intravascular coagulation.

Answer: E

Explanation:
This patient is in septic shock, likely from pyelonephritis, with hypotension, tachycardia, and fever. Her laboratory findings demonstrate thrombocytopenia (platelets 85 × 10#/L), elevated INR, very low fibrinogen (
< 1 g/L), and schistocytes on blood film, along with active bleeding from the central line site. These findings are classic for disseminated intravascular coagulation (DIC).
MCCQE objectives emphasize recognizing DIC as a complication of severe sepsis. In DIC, systemic activation of coagulation leads to widespread microthrombi formation and consumption of platelets and clotting factors (consumptive coagulopathy), resulting in both thrombosis and bleeding. Low fibrinogen and prolonged INR are key distinguishing features.
ITP causes isolated thrombocytopenia without coagulation abnormalities. TTP presents with thrombocytopenia and schistocytes but typically has normal coagulation studies. Heparin-induced thrombocytopenia requires prior heparin exposure and does not cause elevated INR or low fibrinogen.
Vitamin K deficiency causes prolonged INR but does not produce thrombocytopenia or schistocytes.
Thus, DIC secondary to sepsis is the most likely cause of her bleeding.

NEW QUESTION # 77
A 3-year-old boy is brought to the office because he is not using his right arm after a fall from a swing.
Radiographs reveal a new fracture and old healing fractures. The parents deny any previous injuries. In addition to providing care for the fracture, which one of the following is the best next step?

A. Notify child protection services.
B. Advise the parents to better supervise the patient.
C. Investigate the patient to rule out metabolic or endocrine disorders.
D. Refer the family to the social work department.
E. Monitor the patient for future injuries.

Answer: A

Explanation:
The clinical presentation ofmultiple fractures at different stages of healingin a young child raisesstrong suspicion of physical abuse(non-accidental trauma). In such situations,mandatory reporting to child protection services is legally and ethically required, even in the absence of parental admission or clear history.
Toronto Notes 2023 - Pediatrics, Child Maltreatment Section:
"Red flags include inconsistent history, delay in seeking care, multiple injuries in various stages of healing, and injuries not consistent with developmental level. Health care professionals arelegally obligatedto report suspected child abuse or neglect to child protection authorities without delay." MCCQE1 Objectives (Medical Expert > Pediatrics > 77-2):
"The candidate must be able to recognize when the findings are consistent with child abuse... When child abuse is suspected,the physician has a legal obligation to report to the appropriate child protection agency immediately." Options B, C, D, and E do not address the immediate child safety risk and legal duty. Social work involvement (E) is supportive but must follow or accompany notification to child protection, not replace it.

NEW QUESTION # 78
A 10-year-old girl is brought to the Emergency Department by her mother because her daughter is crying and says she "can't pee." Her daughter fell on the monkey bars at school earlier that day. On examination, there is a large vulvar bruise anteriorly. Which one of the following is the best next step?

A. Consult gynecology if bladder catheterization is difficult.
B. Discharge the patient home to do sitz baths.
C. Order complete blood count and coagulation studies.
D. Ask the mother to leave the room and ask the patient if someone abused her.
E. Arrange a retrograde outpatient arthrography.

Answer: A

Explanation:
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.

NEW QUESTION # 79
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