MCCQE Part I Internal Medicine Questions: 10 Free Practice MCQs
Ten MCCQE Part I-style internal medicine questions with the answer and the reasoning behind it. They come from the CA.med bank, which has 145 internal medicine questions and many more across every topic.
1 / 10
A 70-year-old man with a history of atrial fibrillation on warfarin presents with hematemesis and melena. His INR is 3.5, and he is hypotensive with a hemoglobin of 80 g/L.
What is the most appropriate initial management step for this patient?
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Answer: D. Administer vitamin K and fresh frozen plasma (FFP) for reversal of anticoagulation
Why: The patient's presentation with hematemesis, melena, and an elevated INR while on warfarin necessitates urgent reversal of anticoagulation to control the bleeding. The Canadian Pharmacists Association and CPS guidelines emphasize the importance of prompt management of anticoagulant-related bleeding, including the use of vitamin K and FFP for urgent reversal.
- A. While PPIs are important in managing upper GI bleeding, the immediate priority in this case is to reverse the anticoagulation and stabilize the patient's vital signs.
- B. Although endoscopy is crucial in managing GI bleeding, the patient's initial management should focus on stabilizing his vital signs and reversing anticoagulation before proceeding with diagnostic procedures.
- C. Simply discontinuing warfarin without reversing its anticoagulant effect is insufficient in the setting of active bleeding and an elevated INR.
Sources: Canadian Pharmacists Association Guidelines
2 / 10
A 70-year-old patient with a history of dementia is admitted to the hospital with a diagnosis of pneumonia. The patient's family requests that the patient be intubated and mechanically ventilated, despite the patient's previously expressed wish to avoid life-sustaining treatments.
What is the most ethical course of action in this situation?
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Answer: A. Respecting the patient's previously expressed wish to avoid life-sustaining treatments
Why: The patient's autonomy and previously expressed wishes should be respected, even if they are no longer able to communicate their decisions. The Canadian Medical Protective Association emphasizes the importance of respecting patients' autonomy and previously expressed wishes, particularly in situations where they are no longer able to communicate their decisions.
- B. While the family's wishes should be considered, they should not override the patient's previously expressed autonomy.
- C. While a court order may be necessary in some cases, it is not the most ethical course of action in this situation.
- D. While education is important, it should not delay treatment or override the patient's previously expressed autonomy.
Sources: Canadian Medical Protective Association
3 / 10
A 52-year-old man presents in July with a 5-day history of an expanding red rash on his thigh, low-grade fever, myalgia and headache. He recalls removing a small tick after hiking in a wooded area of southeastern Ontario two weeks ago. There is no focal neurological deficit.
What is the most likely diagnosis?
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Answer: A. Early localized Lyme disease
Why: The Public Health Agency of Canada states that the incubation period for early localized Lyme disease is 3 to 30 days and that the diagnosis of early localized disease is primarily clinical, made from a history of tick exposure, the clinical signs and symptoms, in particular the presence of an erythema migrans rash, and laboratory testing when appropriate. This man has a compatible exposure in an endemic region, an expanding rash at the bite site and systemic symptoms within the correct interval. Disseminated disease occurs later, and the description does not fit erythema multiforme or a bacterial cellulitis.
- B. Disseminated disease appears later in the illness, whereas this rash began within the early localized window of three to thirty days.
- C. The rash is described as expanding at the bite site with a tick exposure history, which points to erythema migrans rather than a targetoid reaction.
- D. There is no marked warmth, purulence or rapid local spread typical of bacterial cellulitis, and the exposure history points to a tick-borne spirochete.
Sources: Public Health Agency of Canada. Lyme disease: For health professionals (2026).
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4 / 10
A 52-year-old woman with a first degree relative who has kidney disease has an initial urine albumin-to-creatinine ratio of 5.6 mg/mmol. She is well, has not exercised recently, and her urine microscopy is normal.
What is the most appropriate next step?
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Answer: B. Repeat the urine albumin-to-creatinine ratio on two further samples over the next 4 to 12 weeks
Why: The urine albumin-to-creatinine ratio is the preferred method to screen for protein in the urine. An elevated ratio is only abnormal when at least two of three results over a 4 to 12 week period are raised, so the initial value of 5.6 mg/mmol must be confirmed before the result is acted on. A threshold of 3.0 mg/mmol or more is abnormal, so reassurance is not appropriate, and a 24-hour collection is usually unnecessary. Starting treatment before confirmation is premature.
- A. In most cases a 24-hour collection is not needed to assess protein excretion, and the preferred step is to confirm the albumin-to-creatinine ratio itself.
- C. The threshold for an abnormal ratio is 3.0 mg/mmol rather than 30 mg/mmol, so this result does require confirmation.
- D. One value is not enough to establish persistent albuminuria, and treatment decisions follow confirmation of an abnormal ratio on serial testing.
Sources: BC Guidelines (BC Ministry of Health), Chronic Kidney Disease: Diagnosis and Management (2025)
5 / 10
A 55-year-old male patient with a history of coronary artery disease presents to your clinic for follow-up. His current medications include atorvastatin 80mg daily, aspirin 81mg daily, and metoprolol 50mg twice daily. His lipid profile shows a total cholesterol of 4.2mmol/L, LDL-C of 2.1mmol/L, HDL-C of 1.2mmol/L, and triglycerides of 1.8mmol/L. He has no new symptoms and his blood pressure is well-controlled at 120/80mmHg.
What would be the next step in managing this patient's lipid profile?
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Answer: B. Add ezetimibe 10mg daily to further reduce LDL-C
Why: The Canadian Cardiovascular Society (CCS) guidelines recommend targeting an LDL-C level of less than 2.0mmol/L for patients with high cardiovascular risk. In this case, the patient's LDL-C is 2.1mmol/L, and adding ezetimibe to his current atorvastatin regimen would be a reasonable next step to further reduce his LDL-C and cardiovascular risk. Ezetimibe works by inhibiting the intestinal absorption of cholesterol, and its addition to statin therapy has been shown to provide additional LDL-C reduction.
- A. While rosuvastatin is a potent statin, switching from atorvastatin to rosuvastatin may not be necessary in this case, and ezetimibe would be a more appropriate addition to his current regimen.
- C. Fenofibrate may be considered for patients with high triglycerides, but in this case, the patient's triglycerides are not significantly elevated, and reducing LDL-C remains the priority.
- D. Discontinuing atorvastatin would not be appropriate, as the patient has a history of coronary artery disease and requires ongoing statin therapy to reduce his cardiovascular risk.
Sources: CCS Guidelines for the Diagnosis and Treatment of Dyslipidemia
6 / 10
A 52-year-old woman is admitted to hospital with community-acquired pneumonia. She has no symptoms or signs of thyroid disease and no personal or family history of thyroid problems. The admitting team considers adding thyroid function tests to her admission bloodwork.
Which approach to thyroid testing is most appropriate?
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Answer: B. Do not screen for thyroid dysfunction during her acute illness
Why: Measurement of thyroid stimulating hormone is the principal test for evaluating thyroid function provided there is no clinical or historical evidence of hypothalamic or pituitary disease, in which case central hypothyroidism is possible and a free T4 should be requested. Free T3 is rarely indicated, and free thyroid hormones ordered without thyroid stimulating hormone require a clinical indication. Ideally thyroid function tests are not performed in hospitalized patients unless thyroid disease is the suspected cause of the presentation or a significant comorbidity, because sick euthyroid syndrome is the likely explanation for an abnormal result obtained in hospital.
- A. Free T3 is rarely indicated in suspected thyroid disease and is reserved for situations where thyroid disease is suspected, the thyroid stimulating hormone is abnormal, and the free T4 is inappropriately normal.
- C. If free thyroid hormones are ordered without thyroid stimulating hormone, a clinical indication is required, and measurement of thyroid stimulating hormone is the principal test for evaluating thyroid function in the vast majority of circumstances.
- D. An abnormal result obtained during hospitalization is more likely to reflect the sick euthyroid state than true thyroid disease, and the guideline advises that thyroid function tests should not be performed in this setting.
Sources: Government of British Columbia, BC Guidelines - Thyroid Function Testing in the Diagnosis and Monitoring of Thyroid Function Disorder (2018)
7 / 10
A 60-year-old patient with chronic obstructive pulmonary disease (COPD) presents to the emergency department with a 2-day history of increasing shortness of breath and wheezing. The patient has a history of smoking and has been experiencing frequent exacerbations of COPD.
What is the next step in the management of this patient?
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Answer: B. Order a chest X-ray and arterial blood gas
Why: The patient presents with symptoms of a severe exacerbation of COPD, including increasing shortness of breath and wheezing. The next step in management would be to order a chest X-ray and arterial blood gas to evaluate the severity of the exacerbation and guide further management. According to the Canadian Thoracic Society, a chest X-ray and arterial blood gas are recommended for patients with severe COPD exacerbations.
- A. While bronchodilators are an important part of COPD management, the patient's symptoms suggest a more severe exacerbation that requires further evaluation and treatment.
- C. While oxygen therapy may be necessary, the patient's symptoms do not necessarily require intensive care unit admission at this time.
- D. While antibiotics may be necessary for some patients with COPD exacerbations, the patient's symptoms do not necessarily require antibiotics at this time.
Sources: Canadian Thoracic Society
8 / 10
A 58-year-old woman with long-standing rheumatoid arthritis has a haemoglobin of 102 g/L with a normal mean corpuscular volume. Her ferritin is 85 ug/L, which is within the laboratory reference interval, and her joints are actively inflamed. Her family physician suspects that iron deficiency may also be contributing.
Which additional test is most likely to identify coexisting iron deficiency?
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Answer: C. Fasting serum iron and transferrin saturation
Why: Anaemia of chronic disease may coexist with true iron deficiency, and ferritin is an acute phase reactant that may be falsely elevated in chronic disease, active inflammation or malignancy, so ferritin testing is not recommended during acute infection or hospitalization. In this setting the guideline suggests a fasting serum iron and transferrin saturation, because a low or low-normal transferrin with reduced saturation supports iron deficiency that ferritin alone would miss. A ferritin above 30 ug/L normally makes iron deficiency unlikely, but the threshold is higher in chronic inflammatory disease.
- A. Waiting and repeating the ferritin does not solve the problem, because ferritin is an acute phase reactant that may be falsely elevated by her active inflammation.
- B. Erythropoietin measurement is not part of the iron deficiency work-up, and the guideline discusses erythropoiesis stimulating agents only in chronic kidney disease when anaemia persists after other deficiencies are corrected.
- D. Marrow examination is invasive and unnecessary here, because the guideline offers a simple biochemical approach when ferritin is unreliable in chronic disease.
Sources: Government of British Columbia, BC Guidelines - Iron Deficiency: Diagnosis and Management (2019)
9 / 10
A 29-year-old woman has a platelet count of 62 x 10^9/L found on a routine complete blood count before a dental procedure. She feels well and has no bruising or bleeding. Her haemoglobin, white cell count and blood film are otherwise normal, and she takes no medications.
Which statement about her thrombocytopenia is most appropriate?
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Answer: A. Isolated thrombocytopenia may arise from decreased production or from increased destruction, consumption or sequestration of platelets
Why: A normal platelet count is 150 to 400 x 10^9/L. Individuals with counts below 10 x 10^9/L are at increased risk of spontaneous and serious bleeding, and the risk of bleeding from surgery or other injuries increases below 30 to 50 x 10^9/L. Thrombocytopenia is caused by decreased production or by increased destruction, consumption or sequestration of platelets. In a well patient with an otherwise normal blood count the cause still needs to be identified, and inherited or acquired platelet function disorders can also increase bleeding risk.
- B. Procedure-related bleeding risk can increase with platelet counts below 30 to 50 x 10^9/L, and a count of 62 x 10^9/L sits close to that range rather than removing all risk.
- C. The risk of spontaneous and serious bleeding rises below 10 x 10^9/L rather than 100 x 10^9/L, and she is far above that level.
- D. Prophylactic platelets are not indicated at this count, and the guide notes that the decision to transfuse depends on the underlying cause and the bleeding site.
Sources: Canadian Blood Services, Clinical Guide to Transfusion - platelet transfusion chapter
10 / 10
A 75-year-old patient with advanced dementia is admitted to the hospital with a diagnosis of pneumonia. The patient's family is unsure about the best course of action and is considering a do-not-resuscitate (DNR) order.
What is the most appropriate approach to discussing end-of-life care with the patient's family?
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Answer: C. Discuss end-of-life care with the family in a clear and compassionate manner, taking into account the patient's values and wishes
Why: Discussing end-of-life care with the patient's family requires a clear and compassionate approach that takes into account the patient's values and wishes. According to the Canadian Medical Protective Association, healthcare providers have a duty to provide patient-centered care and to respect the patient's autonomy and dignity. This includes discussing end-of-life care in a sensitive and compassionate manner and ensuring that the patient's family is informed and supported throughout the process.
- A. Discussing end-of-life care with the family is an important part of providing patient-centered care and ensuring that the patient's wishes are respected.
- B. Discussing end-of-life care requires a sensitive and compassionate approach to ensure that the family's concerns and questions are addressed.
- D. While the primary care physician may be involved in the discussion, it is the responsibility of the healthcare team to ensure that the patient's family is informed and supported throughout the process.
Sources: Canadian Medical Protective Association
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Exam-style questions written by MedHub for practice. They are not official exam questions.