MCCQE MCCQE Part 1 Exam Questions and Answers

In adolescents presenting with vague or potentially sensitive symptoms, it is critical to speak with them alone to obtain a complete and honest history, including mental health, sexual activity, substance use, and abuse screening.

Toronto Notes 2023 – Pediatrics, Adolescent Medicine:

“Private interviews are essential to obtain accurate histories in adolescents, especially when symptoms may have underlying psychosocial or reproductive causes.”

MCCQE1 Objectives – Pediatrics > Adolescent Health:

“Candidates must demonstrate adolescent-appropriate interviewing techniques, including private questioning to identify sensitive or risk-related concerns.”

Physical examination and pregnancy testing (A, B, D) may follow based on the private history. Vital signs (E) are standard but do not replace psychosocial assessment.

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Comprehensive and Detailed Explanation:

Postpartum psychosis is strongly associated with bipolar disorder and other mood disorders. A personal or family history of bipolar disorder significantly increases the risk. It typically presents within the first 2 weeks postpartum and is a psychiatric emergency.

Toronto Notes 2023 – Psychiatry, “Postpartum Psychiatric Disorders”:

“Risk factors for postpartum psychosis include personal or family history of bipolar disorder or postpartum psychosis.”

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

“Candidates must recognize risk factors for postpartum psychiatric illness, particularly the association with bipolar spectrum disorders.”

Advanced maternal age (A), multiparity (B), and panic disorder (D) do not significantly increase the risk of postpartum psychosis.

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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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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.

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 is experiencing social instability (homelessness, job loss) likely contributing to poorly controlled diabetes. Before investigating or prescribing further, it is essential to address his ability to afford and manage self-monitoring and insulin.

Toronto Notes 2023 – Endocrinology, Diabetes:

“Social determinants such as housing insecurity and financial barriers significantly affect diabetes self-management. Addressing access to glucose monitoring and insulin is critical.”

MCCQE1 Objectives – Internal Medicine > Chronic Disease Management:

“Candidates must assess barriers to effective disease control, including financial and psychosocial limitations.”

Antidepressants (B) may be helpful later if depression is suspected. Thyroid testing (C) is not the priority. A dietitian (D) may help long-term, but immediate access and adherence are more urgent.

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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.

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In cross-cultural care, especially for recent immigrants, it is essential to build rapport and respect patient preferences regarding family involvement. Involving family in the interview respects cultural norms and improves trust. A trained interpreter should be used to maintain confidentiality and accuracy, but collaboration with the family initially may encourage later private disclosure.

Toronto Notes 2023 – Ethics and Communication, “Cultural Competence”:

“When encountering language or cultural barriers, patient comfort and cultural context must be respected. Interviewing the patient and family together may facilitate trust, after which individual conversations may be possible.”

MCCQE1 Objectives (ELOM > 90-1: Communication and Patient-Centered Care):

“Candidates must approach patients in a culturally sensitive manner, particularly recent immigrants or those with language barriers, and foster trust.”

Insisting on a private interview (A) may alienate the patient. Family members should not act as interpreters (C). Written accounts (D) are inefficient and impersonal in acute mental health settings.

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Comprehensive and Detailed Explanation:

Rapid progression of pain out of proportion to exam, systemic symptoms (anxiety), and skinchanges without major swelling are classic for necrotizing fasciitis—a surgical emergency. Discoloration and extreme tenderness should raise immediate concern.

Toronto Notes 2023 – Emergency Medicine / Surgery:

“Necrotizing fasciitis presents with severe pain, systemic toxicity, rapid progression, and early skin changes (discoloration). Pain out of proportion is a key clue.”

MCCQE1 Objectives (Emergency Medicine > 51-1: Soft Tissue Infections):

“Candidates must recognize necrotizing fasciitis and initiate urgent surgical consultation.”

Plantaris rupture (A) is benign and localized. DVT (B) is more gradual and often with swelling. Cellulitis (C) progresses more slowly and is less painful. Baker’s cyst (D) causes posterior knee pain, not severe systemic illness.

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

Toronto Notes 2023 – Pain Management and Addiction Medicine:

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

MCCQE1 Objectives – Internal Medicine > Chronic Pain:

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

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

Calculating food-specific attack rates (i.e., number of people who became ill after eating aparticular food divided by the total number who ate that food) is the most effective method to identify the probable source of infection in a known cohort outbreak.

Toronto Notes 2023 – Public Health, Outbreak Investigations:

“Foodborne outbreaks are best analyzed using food-specific attack rates to determine associations between individual foods and illness.”

MCCQE1 Objectives – Preventive Medicine > Epidemiologic Principles:

“Candidates must use epidemiologic tools, such as attack rates, to identify probable sources during outbreak investigations.”

Cohort study (C) is also acceptable but more time-intensive. Stool and food cultures (B, D) confirm the pathogen but not the source. HACCP (E) is a preventive method, not a tool for outbreak investigation.

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Comprehensive and Detailed Explanation:

Middle-aged to older men with social isolation and substance use disorders (especially alcohol) are among the highest-risk groups for completed suicide. They are less likely to seek help and often use more lethal methods.

Toronto Notes 2023 – Psychiatry, “Suicide Risk Assessment”:

“High-risk demographics include older men, social isolation, comorbid alcohol use, and chronic illness. These patients have the highest rates of completed suicide.”

MCCQE1 Objectives (Psychiatry > 71-1: Suicide Risk):

“Candidates must recognize epidemiologic risk factors for completed suicide, including demographics and comorbidities.”

Although women and youth have higher rates of suicidal ideation and attempts, men over 50 have the highest completion rates.

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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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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During an outbreak in a long-term care facility, prompt control measures include keeping symptomatic staff at home to prevent spread. Staff are often vectors of infection, and exclusion is a key public health intervention.

Toronto Notes 2023 – Infectious Diseases, “Infection Control and Prevention”:

“During influenza outbreaks in institutional settings, exclusion of symptomatic staff is critical to controlling spread.”

MCCQE1 Objectives (Population Health > 63-2: Outbreak Management):

“Candidates must understand outbreak control, including staff exclusion, cohorting, and surveillance in congregate settings.”

Vaccination (B) is preventive but not immediately effective during an outbreak. Masking and visitor vaccination are supportive but secondary measures.

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.

This clinical presentation is highly suggestive of chronic pelvic inflammatory disease (PID), especially given the left lower quadrant pain and dyspareunia with a normal pelvic ultrasound. PID is often caused by sexually transmitted infections (STIs), such as Chlamydia trachomatis or Neisseria gonorrhoeae, which may not be evident on imaging.

Toronto Notes 2023 – Gynecology:

“Cervical swabs for N. gonorrhoeae and C. trachomatis are essential in the workup of suspected PID or cervicitis, even when imaging is normal. Dyspareunia and chronic pelvic pain with normal imaging should prompt testing for STIs.”

MCCQE1 Objectives (Obstetrics & Gynecology > 82-6: Pelvic Pain):

“Candidates must consider and investigate for infectious causes of pelvic pain, including PID, which requires cervical swab testing as an essential first-line investigation.”

Laparoscopy (A) is invasive and reserved for uncertain or refractory cases. Hysterosalpingography (C) is used in infertility workups, not acute pain. Endometrial biopsy (D) and MRI (E) are not first-line.

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Accurate dating is critical in pregnancies at high risk for preeclampsia and intrauterine growthrestriction. First-trimester ultrasound is used to establish gestational age, which guides monitoring and interventions.

Toronto Notes 2023 – Obstetrics, High-Risk Pregnancy:

“In women with a history of preeclampsia, early and accurate dating allows for appropriate fetal surveillance and timely delivery.”

MCCQE1 Objectives – Obstetrics > Prenatal Care:

“Candidates should recognize the importance of accurate pregnancy dating in high-risk pregnancies.”

Prophylactic labetalol (E) is not indicated in normotensive patients. Genetic testing (A, B) is not appropriate unless additional risk factors are present. Bed rest (D) is not evidence-based for preeclampsia prevention.

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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:

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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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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A mood journal is a structured tool that allows the patient to record mood fluctuations, triggers, and timing. It is particularly helpful in identifying mood disorders such as premenstrual dysphoric disorder, bipolar disorder, or cyclothymia.

Toronto Notes 2023 – Psychiatry, Mood Disorders:

“Mood diaries are useful in identifying temporal patterns, such as menstrual cycle–linked mood changes, and in distinguishing between affective disorders.”

MCCQE1 Objectives – Psychiatry > Diagnostic Evaluation:

“Candidates should use clinical tools such as symptom diaries to assist in establishing the pattern and nature of psychiatric symptoms.”

Personality testing (A) is not first-line. Urine drug screen (B) is only indicated with suspicion of substance use. Lorazepam (D) treats symptoms, not diagnosis. Interviewing the boyfriend (E) may help, but only as a supplement to direct observation and self-report.

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Anaphylaxis requires immediate administration of epinephrine via the intramuscular (IM) route, typically in the lateral thigh. This route provides the fastest and most reliable absorption for emergency treatment.

Toronto Notes 2023 – Pediatrics, Anaphylaxis:

“Epinephrine 0.01 mg/kg IM is the first-line treatment for anaphylaxis. The intramuscular route provides the most rapid and safe absorption in emergencies.”

MCCQE1 Objectives – Pediatrics > Allergy and Immunology:

“Candidates must know the emergency management of anaphylaxis, including proper dosage and intramuscular administration of epinephrine.”

IV administration (A) is reserved for critical care settings. Subcutaneous (C) and intranasal/inhaled routes (D, E) are ineffective in anaphylaxis.

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Comprehensive and Detailed Explanation:

The image and clinical history are consistent with physiologic pubertal gynecomastia, which is common in adolescent boys. It usually resolves spontaneously within 6 months to 2 years and does not require investigation unless other signs of endocrine pathology are present.

Toronto Notes 2023 – Pediatrics / Endocrinology:

“Pubertal gynecomastia is benign, self-limited, and common in adolescent males. No further investigation is needed in the absence of systemic signs.”

MCCQE1 Objectives (Pediatrics > 77-2: Endocrine Disorders):

“Candidates must differentiate physiologic gynecomastia from pathologic causes based on history and physical exam.”

Other tests (A–C, E) are unnecessary unless there are red flags (e.g., testicular mass, rapid progression, neurological symptoms).

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It is essential to balance medical guidelines with trauma-informed, patient-centered care. This includes offering future discussion while respecting boundaries. Acknowledging distress and offering to explore more in the future (B) preserves trust and autonomy.

Toronto Notes 2023 – ELOM and LGBTQ2S+ Health Section:

“For transgender individuals, screening decisions should be personalized. Trauma-informed care includes validating distress and deferring invasive exams when not urgent.”

MCCQE1 Objectives (ELOM > 99-2: Cultural Safety):

“Candidates must prioritize patient-centered communication and consent, particularly when distress or marginalization may influence healthcare interactions.”

Option A is coercive. Option C is documentation only and lacks engagement or exploration.

This patient presents with signs of acute compartment syndrome (pain out of proportion, paresthesia, pallor, swelling, decreased pulses, and dark urine indicating rhabdomyolysis). Measuring compartment pressures is the diagnostic test of choice to confirm the diagnosis and guide urgent surgical fasciotomy.

Toronto Notes 2023 – Orthopedics:

“Acute compartment syndrome should be suspected in any patient with severe extremity pain, swelling, sensory deficits, and tense compartments. Confirm with compartment pressure measurements. Fasciotomy is indicated if pressure is >30 mmHg or within 30 mmHg of diastolic pressure.”

MCCQE1 Objectives (Surgery > 51-2: Limb Trauma):

“Candidates must diagnose acute compartment syndrome and initiate appropriate surgical referral after confirming with pressure measurements.”

Angiography and Doppler studies assess vascular compromise but are not the first step in suspected compartment syndrome. Fixing the hip (C) and testing myoglobin (E) are not diagnostic steps.

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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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Comprehensive and Detailed Explanation:

Sexual dysfunction, including anorgasmia, is a common side effect of SSRIs like escitalopram. Bupropion, a norepinephrine-dopamine reuptake inhibitor, has minimal sexual side effects and can be safely added to mitigate this issue while preserving the antidepressant effect.

Toronto Notes 2023 – Psychiatry / Pharmacology:

“SSRI-induced sexual dysfunction can be managed by dose reduction, switching agents, or adding bupropion.”

MCCQE1 Objectives (Psychiatry > 71-1: Depressive Disorders):

“Candidates should be able to address side effects of antidepressants, including sexual dysfunction, and adjust therapy appropriately.”

Increasing the dose (A) may worsen sexual dysfunction. Venlafaxine (B), an SNRI, also has sexual side effects. D (no change) does not address the patient's concern.

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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 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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Palliative radiotherapy is the treatment of choice for painful bone metastases, including those from prostate cancer. It provides localized pain relief and functional improvement.

Toronto Notes 2023 – Oncology, “Metastatic Bone Pain”:

“External beam radiotherapy is first-line treatment for localized bone pain from metastases. Relief occurs within days to weeks.”

MCCQE1 Objectives (Internal Medicine > Oncology > 52-1):

“Candidates must identify treatment options for symptom control in metastatic cancer, including palliative radiotherapy for painful bone lesions.”

Androgen deprivation therapy (B, C) treats systemic disease but doesn’t address acute pain. Opioids (D) may be used, but radiotherapy provides disease-targeted relief. Intrathecal steroids (A) are not standard for prostate metastases.

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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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Comprehensive and Detailed Explanation:

Postmenopausal women with abdominal distension, bloating, a complex pelvic mass, and elevated CA-125 are highly suggestive of epithelial ovarian cancer, especially serous cystadenocarcinoma—the most common type.

Toronto Notes 2023 – Gynecology / Oncology:

“Serous epithelial ovarian carcinoma presents with vague abdominal symptoms, ascites, complex pelvic mass, and elevated CA-125.”

MCCQE1 Objectives (Gynecology > 82-5: Ovarian Masses):

“Candidates must recognize signs and investigations of ovarian cancer, including elevated tumor markers and imaging findings.”

Ovarian hyperstimulation (A) occurs in fertility treatments. Colorectal cancer (C) may mimic these symptoms but typically causes rectal bleeding and has lower CA-125 levels. Uterine adenocarcinoma (D) usually causes bleeding. Hematosalpinx (E) presents with pelvic pain, not ascites.

Comprehensive and Detailed Explanation:

Pulsatile tinnitus synchronous with the pulse may be vascular in origin. The association with headaches and elevated BMI (a risk factor for idiopathic intracranial hypertension, IIH) warrants neuroimaging to assess for cerebral venous sinus thrombosis, vascular malformations, or raised intracranial pressure.

Toronto Notes 2023 – Neurology / ENT:

“Pulsatile tinnitus requires investigation for vascular causes including idiopathic intracranial hypertension. MRI or MRV is the next step.”

MCCQE1 Objectives (Neurology > 35-1: Headache and Tinnitus):

“Candidates must investigate pulsatile tinnitus with neuroimaging when vascular causes are suspected.”

Audiogram (A) is for hearing loss. EEG (C) is not useful for tinnitus. CRP (D) is irrelevant.

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Chlamydia trachomatis is the most common cause of cervicitis in young sexually active women and frequently presents with dysuria, dyspareunia, intermenstrual bleeding, and a normal vulvovaginal exam. It may be asymptomatic or have subtle signs and often affects the endocervix.

Toronto Notes 2023 – Gynecology, “Sexually Transmitted Infections” Section:

“Chlamydia is the most common bacterial STI. Symptoms may include intermenstrual bleeding, postcoital bleeding, dyspareunia, mucopurulent cervical discharge, and dysuria. The vulva and vagina may appear normal.”

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

“Candidates should evaluate STI-related cervicitis as a common cause of postcoital and intermenstrual bleeding in young women.”

Other options:

A. Actinomyces israelii is associated with IUD use, not relevant here.

B. Herpes simplex virus usually presents with painful ulcerations, not abnormal bleeding.

C. Treponema pallidum (syphilis) causes painless ulcers or systemic symptoms in later stages.

D. HPV causes warts or asymptomatic cervical dysplasia, not acute symptoms.

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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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Comprehensive and Detailed Explanation:

For small renal masses (<4 cm), partial nephrectomy (nephron-sparing surgery) is the standard of care in patients who are surgical candidates. It preserves renal function and provides oncologic control.

Toronto Notes 2023 – Urology / Oncology:

“Small renal tumors <4 cm should be treated with partial nephrectomy. Active surveillance or ablation may be alternatives in poor surgical candidates.”

MCCQE1 Objectives (Urology > 59-2: Renal Masses):

“Candidates must manage small renal tumors with nephron-sparing surgery when feasible.”

MRI (A) is unnecessary after CT confirmation. Radiation (B) is not first-line. Surveillance (D) may be appropriate for elderly or frail patients, not this one. Ablation (E) is for high-risk surgical patients.

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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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The image shows classic features of “early childhood caries” (ECC), often called "baby bottle tooth decay.” This typically affects upper incisors first due to prolonged exposure to milk/formula or sugary drinks during sleep.

Toronto Notes 2023 – Pediatrics, “Dental Health” Section:

“ECC is most commonly caused by prolonged nighttime bottle feeding with milk or juice. It affects upper anterior teeth due to pooling and lack of protective salivary flow.”

MCCQE1 Objectives (Pediatrics > 78-2: Preventive Care):

“Candidates must recognize risk factors for dental caries in young children, including nighttime bottle use and sugary liquid exposure.”

Antibiotics (C) or iron (D) can stain but do not cause this pattern of decay. Vitamin D (A) causes enamel hypoplasia or delayed eruption. Fluoride deficiency (B) causes diffuse decay, not selective anterior tooth loss.

This child presents with “red flag” features for malignancy: a firm, fixed, nontender supraclavicular lymph node >2 cm in size, with associated hepatosplenomegaly and night sweats. These features are most concerning for lymphoma.

Toronto Notes 2023 – Pediatrics, “Lymphadenopathy in Children”:

“Malignant lymphadenopathy tends to be firm, fixed, painless, and located in supraclavicular areas. Systemic signs (fever, weight loss, hepatosplenomegaly, night sweats) are concerning for lymphoma.”

MCCQE1 Objectives (Pediatrics > 78-3: Hematology/Oncology):

“Candidates should differentiate between benign and malignant lymphadenopathy and recognize features suggestive of lymphoma.”

Cat-scratch disease (B) is usually tender and associated with cat exposure. Kawasaki disease (C) presents with fever and mucocutaneous findings. Acute bacterial lymphadenitis (D) is painful, warm, and rapid in onset. Viral lymphadenopathy (E) is often bilateral, small, and tender.

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In a patient with known diverticular bleeding and no red flags (e.g., weight loss, anemia, family history), repeating colonoscopy is not required. Diverticular bleeding is typically self-limited. Colonoscopy within the past few years with clear findings suffices.

Toronto Notes 2023 – Gastroenterology, Lower GI Bleed:

“Patients with known diverticulosis and self-limited bleeding who have had prior complete colonoscopy do not require repeat endoscopy unless symptoms recur or persist.”

MCCQE1 Objectives – Internal Medicine > Gastroenterology:

“Candidates must recognize when no further invasive investigation is necessary in elderly patients with known benign findings and resolved symptoms.”

Option E is considerate but not clinically necessary for independent patients. Options A, B, and D are not indicated in resolved, low-risk cases.

In a non-lactating woman with a partially responsive breast mass after antibiotics, inflammatory breast cancer must be ruled out. A breast biopsy (core or excisional) is indicated to assess for malignancy. Inflammatory breast cancer may mimic mastitis but does not improve with antibiotics.

Toronto Notes 2023 – Breast Disorders:

“In non-lactating women, persistent breast inflammation should raise suspicion for inflammatory breast cancer. If symptoms persist after antibiotic therapy, proceed with imaging and biopsy.”

MCCQE1 Objectives – Gynecology > Breast Disease:

“Candidates must differentiate between mastitis and inflammatory breast cancer and initiate appropriate investigations such as biopsy when response to antibiotics is incomplete.”

Options A, D, and E may be appropriate for a confirmed abscess or infectious cause, but further investigation is mandatory in this scenario. NSAIDs (C) are symptomatic but do not address the diagnostic concern.

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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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Radiation proctitis is a well-known complication of pelvic radiation therapy (e.g., for prostate cancer). It presents months to years after treatment with rectal bleeding, tenesmus, and mucosal ulceration on colonoscopy.

Toronto Notes 2023 – Gastroenterology, “Radiation-Induced GI Injury”:

“Radiation proctitis presents with rectal bleeding, tenesmus, urgency. Colonoscopy shows pale, friable mucosa, ulcerations, and telangiectasia.”

MCCQE1 Objectives (Gastroenterology > 47-2: GI Bleeding and Complications):

“Candidates must recognize radiation proctitis based on history of radiation and characteristic endoscopic findings.”

Ulcerative colitis (B) usually starts younger and is more diffuse. Diverticulosis (C) affects the left colon and causes painless bleeding. Recurrent prostate cancer (D) and rectal cancer (E) would show mass or infiltration.

Recruiting participants from an autism seminar introduces selection bias. This non-random selection increases the likelihood of overestimating associations due to pre-existing beliefs or exposures in that subgroup.

Toronto Notes 2023 – Epidemiology:

“Selection bias occurs when participants are not representative of the general population, as in recruitment from disease-specific support groups.”

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

“Candidates must recognize sources of bias in epidemiologic studies, including selection bias due to non-representative recruitment.”

Recall bias (D) is more of a concern in retrospective studies. Sponsorship (B) may create perception bias but is not a flaw in methodology itself. Standard error reporting (A) is normal. Not accounting for confounders (E) matters but recruitment source is more directly biasing.

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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 agencyimmediately."

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.

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 patient has chronic non-cancer pain with comorbid PTSD and alcohol misuse — high-risk factors for opioid use disorder. Before any opioid prescribing, a comprehensive interdisciplinary approach including mental health and substance use support is essential.

Toronto Notes 2023 – Pain Management and Addiction Medicine:

“In chronic pain patients with substance use or mental health comorbidities, refer to addiction/mental health services before considering opioid therapy.”

MCCQE1 Objectives (ELOM > 99-4: Safe Prescribing):

“Candidates must assess for substance use risk factors and manage chronic pain using a multidisciplinary approach.”

Imaging (A) is unlikely to alter management. Opioids (B, C) should not be first-line in this context. Cannabis (E) is not first-line and lacks robust evidence in complex chronic pain.

This patient has classic signs of cardiac tamponade (Beck's triad: hypotension, muffled heartsounds, elevated JVP, plus pulsus paradoxus). However, she also has advanced metastatic cancer, functional decline, and has stopped active treatment. In this context, a goals-of-care discussion is the most appropriate next step to determine her wishes regarding interventions like pericardiocentesis.

Toronto Notes 2023 – Palliative Care:

“End-of-life care should prioritize quality of life and patient preferences. In patients with terminal illness and life-threatening conditions (e.g., tamponade), initiate a conversation about goals before aggressive intervention.”

MCCQE1 Objectives – Internal Medicine > Palliative and End-of-Life Care:

“Candidates must assess prognosis, patient values, and initiate appropriate end-of-life discussions before invasive treatment.”

Although pericardiocentesis (A) may relieve symptoms, it should follow consent based on the patient’s goals. ICU (E), fluids (B), or transfusion (D) are not appropriate without this discussion.

This scenario describes acute delirium, common in hospitalized elderly patients. Patients may say things they don’t mean. Reassuring family members not to take hurtful comments personally is an important part of family counseling.

Toronto Notes 2023 – Geriatrics, “Delirium”:

“Patients may become agitated, hallucinate, or be aggressive. Families should be counseled not to take the behavior personally and continue to support orientation.”

MCCQE1 Objectives (Geriatrics > 41-1: Cognitive Disorders):

“Candidates must support caregivers of delirious patients, providing guidance on managing emotional and behavioral symptoms.”

Avoiding visits (A), confronting the patient (C), or emotional withdrawal (E) are counterproductive. Providing gentle information is appropriate (contradicts B).

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This constellation of features—hypotonia, macroglossia, brachycephaly, single palmar crease, short broad hands with clinodactyly—is classic for Down syndrome (Trisomy 21).

Toronto Notes 2023 – Pediatrics, “Genetic Syndromes”:

“Trisomy 21 features include hypotonia, upslanting palpebral fissures, epicanthic folds, flat nasal bridge, brachycephaly, macroglossia, single palmar crease, and clinodactyly.”

MCCQE1 Objectives (Pediatrics > 78-3: Congenital and Genetic Disorders):

“Candidates must recognize key dysmorphic features associated with common genetic syndromes including Trisomy 21.”

Prader-Willi and congenital hypothyroidism may have hypotonia but lack the full phenotypic pattern. Turner syndrome is seen in females with short stature and webbed neck. Fetal alcohol syndrome presents with smooth philtrum and microcephaly.

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The classic description of brief, severe unilateral periorbital pain with autonomic symptoms (tearing), occurring in clusters (same time daily for weeks), is diagnostic of cluster headache.

Toronto Notes 2023 – Neurology, “Headaches”:

“Cluster headaches: severe unilateral periorbital pain, often with lacrimation, nasal congestion, occurring in clusters over weeks. More common in young males.”

MCCQE1 Objectives (Internal Medicine > 35-2: Headache Disorders):

“Candidates must distinguish among headache types based on duration, pattern, and associated symptoms.”

Migraine tends to last hours and has nausea or photophobia. Sinusitis causes dull, pressure-like pain. Tumour-related headache is progressive and worse with Valsalva. Post-concussive headache would have trauma history.

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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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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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This 6-month-old presents with signs of systemic illness, tachypnea, hypoxia, and focal lung findings. In this age group, pneumonia can rapidly progress, and given the severity of symptoms, oral treatment is insufficient. Intravenous antibiotics are urgently indicated.

Toronto Notes 2023 – Pediatrics, Respiratory Infections in Infants:

“Infants under 6 months with signs of systemic illness, hypoxia (SpO2 < 94%), and respiratory distress should receive IV antibiotics. Delayed treatment may result in rapid clinical deterioration.”

MCCQE1 Objectives – Pediatrics > Respiratory Conditions:

“Candidates must recognize signs of serious lower respiratory tract infection in infants and initiate prompt IV antibiotic therapy when criteria for hospitalization are met.”

Oral antibiotics (C) are appropriate for mild outpatient pneumonia. Reassurance (B) and oral steroids (A) are inappropriate. IV fluids (D) may be supportive but do not address the infectious cause.

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Primary herpetic gingivostomatitis caused by HSV-1 is common in toddlers. It presents with high fever, irritability, drooling, refusal to eat, and painful oral ulcers on the lips, gums, and tongue. Cervical lymphadenopathy is common.

Toronto Notes 2023 – Pediatrics, “Infectious Conditions in Children”:

“Primary HSV-1 infection in children presents with high fever, cervical lymphadenopathy, and painful oral ulcers (gingivostomatitis).”

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

“Candidates must recognize viral exanthems and enanthems, including herpetic gingivostomatitis, based on clinical findings.”

Kawasaki (A) includes conjunctivitis, strawberry tongue, and extremity changes. Epiglottitis (B) presents with drooling but without oral ulcers. Mono (C) lacks the ulcerative pattern. Hand-foot-mouth (D) affects palms and soles, not inner lips and gums predominantly.

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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.

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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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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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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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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Comprehensive and Detailed Explanation:

The ECG reveals:

Regular P waves that are not consistently followed by QRS complexes

A dissociation between the atrial (P wave) and ventricular (QRS complex) activity

A slow ventricular rate (~40 bpm) independent of atrial rate

These findings are characteristic of a third-degree (complete) atrioventricular (AV) block, where there is no conduction of atrial impulses to the ventricles. The atria and ventricles beatindependently, and the ventricular rate is maintained by an escape rhythm, often junctional or ventricular in origin.

This correlates with the patient’s symptoms (dizziness, hypotension) and bradycardia, suggesting inadequate cardiac output due to AV dissociation.

Toronto Notes 2023 – Cardiology:

“Third-degree AV block shows complete AV dissociation with independent atrial and ventricular activity. It typically presents with bradycardia and hypotension. Urgent pacing may be required.”

MCCQE1 Objectives (Cardiology > 34-2: Bradyarrhythmias and Conduction Disorders):

“Candidates must identify complete heart block and recognize its clinical urgency.”

Ruling out other options:

A. Sinus bradycardia would show regular P waves with 1:1 P-QRS conduction.

B. First-degree AV block has prolonged PR intervals (>200 ms) but all P waves are conducted.

D. Junctional escape rhythm may present with bradycardia, but P waves would be absent, inverted, or occur after QRS complexes.

E. Mobitz type I (Wenckebach) has progressively lengthening PR intervals before a dropped QRS.

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A tender, mobile lymph node following a recent localized infection (e.g., dental infection) is most likely reactive. In a young, otherwise well patient with no systemic symptoms or concerning features, observation is appropriate.

Toronto Notes 2023 – Internal Medicine, Lymphadenopathy:

“In patients with localized lymphadenopathy and a recent infection, observation for 4–8 weeks is often appropriate before further investigation.”

MCCQE1 Objectives – Internal Medicine > Hematology:

“Candidates should recognize benign features of lymphadenopathy (tender, mobile, <2 cm, localized) and manage conservatively unless red flags are present.”

Biopsy (B) and imaging (C, E) are premature. Bone marrow biopsy (D) is not relevant.

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