MCCQE Part I Mock Exam: 20 Timed Questions

Answer: D. One dose of 0.5 mL intramuscularly

Why: The BC guideline reports that in July 2025 the recommended HPV9 dose schedule changed to include a single-dose schedule for many patients, a shift in practice for providers. Immunocompetent individuals aged 9 to 20 receive one dose of 0.5 mL intramuscularly, immunocompetent individuals aged 21 to 45 receive two doses at 0 and 6 months, and immunocompromised individuals and those living with HIV receive three doses. HPV9 is routinely offered in grade 6.

• A. The two-dose schedule applies to immunocompetent individuals aged 21 to 45, not to a 14-year-old.
• B. Three doses are recommended for immunocompromised individuals, for those living with HIV and after post-colposcopy treatment, not for a healthy teenager.
• C. HPV9 is routinely offered to grade 6 students in BC through school based clinics, so this statement is not correct.

Sources: BC Ministry of Health (BC Guidelines and Protocols Advisory Committee). Cervical cancer prevention and screening (HPV primary screening, ages 25-69).

Answer: D. A single dose of intravenous immunoglobulin 2 g/kg

Why: One dose of intravenous immunoglobulin at 2 g/kg reduces the risk of coronary artery aneurysms to under 5% when provided within the first 10 days of fever, and treatment is still given after day 10 when fever and inflammation persist. Acetylsalicylic acid is added for its antiplatelet effect, and serial echocardiography is needed because aneurysms may develop up to 4 to 6 weeks after onset.

• A. Antibiotics are not the treatment for this systemic vasculitis, although a coexisting infection should still be treated.
• B. Acetylsalicylic acid is used for its antiplatelet effect, but it does not reduce aneurysm formation on its own.
• C. Evidence for corticosteroids and coronary outcomes is conflicting, and steroids are used with rheumatology input for intensification or after resistance to immunoglobulin.

Sources: Canadian Paediatric Society. Kawasaki disease: Practical guidance on diagnosis and management. Practice point, 2026.

Answer: C. Screening average-risk individuals under age 50 is not recommended

Why: The BC Guidelines state that screening average-risk individuals under age 50 is not recommended, and the American recommendation to start at 45 has not been adopted here. Starting stool testing now, beginning screening colonoscopy, or annual stool testing below age 50 all contradict the Canadian position.

• A. The American recommendation to start at 45 has not been adopted here, and screening average-risk individuals under 50 is not recommended.
• B. Colonoscopy is not used as a primary screening test, and there is no indication to start it in this age group.
• D. An annual stool test schedule is not recommended, and starting any screening below age 50 is not supported.

Sources: Government of British Columbia. BC Guidelines: Colorectal Cancer Part 1, Screening (2022).

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

Answer: B. 2-4 weeks

Why: According to CANMAT guidelines, patients initiating SSRI antidepressant therapy like sertraline must be educated that clinical onset of antidepressant response requires 2 to 4 weeks, with full trial assessment at 6 to 8 weeks. Option A (2-4 days) and Option D (immediately) are pharmacologically impossible due to neuroreceptor adaptation lag; Option C (3 months) represents an inappropriately long wait before assessing response.

• A. Too soon.
• C. Too long.
• D. Placebo effect maybe, but not pharmacological.

Sources: CANMAT Clinical Guidelines for the Management of Major Depressive Disorder

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

Answer: C. It is positive: age 71 gives a cutoff of 710 mcg/L, and 900 mcg/L warrants imaging.

Why: Age adjustment raises the cutoff to age multiplied by 10 mcg/L for patients at least 50 years old. D-dimer is not diagnostic by itself, so a positive result leads to imaging rather than automatic treatment. The tempting alternative, Apply the standard 500 mcg/L cutoff and classify 900 as negative because the patient is elderly, does not change the next step: the age-adjusted FEU threshold is 710 mcg/L at age 71; 900 is above it and calls for imaging.

• A. Choosing “Apply the standard 500 mcg/L cutoff and classify 900 as negative because the patient is elderly.” would lead to the wrong next step here because the age-adjusted FEU threshold is 710 mcg/L at age 71; 900 is above it and calls for imaging.
• B. Choosing “Use an age-adjusted threshold of 1000 mcg/L for anyone over 70, so no imaging is needed.” would lead to the wrong next step here because the age-adjusted FEU threshold is 710 mcg/L at age 71; 900 is above it and calls for imaging.
• D. Choosing “Diagnose PE from the elevated D-dimer and start treatment without imaging.” would lead to the wrong next step here because the age-adjusted FEU threshold is 710 mcg/L at age 71; 900 is above it and calls for imaging.

Sources: Thrombosis Canada Clinical Guide, Pulmonary Embolism Diagnosis, version 30 April 2025

Answer: C. Antidepressants are more effective than placebo across a range of medical comorbidities

Why: The guideline notes that rates of comorbid major depressive disorder are high in patients with nonpsychiatric medical conditions and that the relationship is bidirectional. Patients with psychiatric and medical comorbidities have a worse treatment response to antidepressants than those without, but antidepressants remain indicated, and an umbrella meta-analysis of randomized trials in depression comorbid with many other medical conditions reported that antidepressants were more efficacious than placebo. Clinicians should minimize polypharmacy, check for drug interactions, and choose side effect profiles that do not worsen comorbid conditions. Psychological treatments such as cognitive behavioural therapy and behavioural activation also benefit patients with medical comorbidity.

• A. The guideline reports the opposite, that antidepressants remain more effective than placebo across a range of medical comorbidities.
• B. Antidepressants remain indicated for treating major depressive disorder when comorbid medical conditions are present.
• D. Electroconvulsive therapy is reserved for severe or treatment-resistant illness rather than first treatment in a medically ill patient.

Sources: CANMAT 2023 update on clinical guidelines for management of major depressive disorder (MDD) in adults

Answer: D. Advise a shower, bath or bed bath on the day before or the day of surgery

Why: The Ontario Health surgical site infection quality standard advises that people having surgery are advised to have, or are helped to have, a shower, bath or bed bath on the day before or the day of surgery, and that hair removal, if required, is performed immediately before surgery. Nasal decolonization may be performed if indicated, and antibiotic prophylaxis is given at the appropriate time, dose and postoperative duration rather than as a prolonged course.

• A. The standard says nasal decolonization may be performed if indicated, rather than routinely for people having surgery.
• B. Antibiotic prophylaxis is given at the appropriate time, dose and postoperative duration, with repeat intraoperative doses when indicated, and a 7 day course is not part of that advice.
• C. If hair removal is required it is performed immediately before surgery, and the previous evening is not the recommended timing.

Sources: Surgical Site Infections Quality Standard, Ontario Health

Answer: D. From 28 to 36 weeks of gestation

Why: The RSVpreF vaccine is given during pregnancy so that protective maternal antibody crosses the placenta and protects the infant in the early postnatal period. The National Advisory Committee on Immunization recommends administration from 28 to 36 weeks of gestation, an off-label recommendation relative to the Canadian authorisation at 32 to 36 weeks that is supported by safety and efficacy data, broader access and alignment with international guidance. Infants born to mothers who did not receive the vaccine are offered monoclonal antibody instead.

• A. Vaccination in the first trimester is not the recommended timing for this product, whose purpose is to generate maternal antibody that is transferred later in pregnancy.
• B. The recommended window sits later in pregnancy so that antibodies are transferred to the baby before birth.
• C. The maternal vaccine is specifically designed to protect the infant before birth, and infant monoclonal antibody products are used when the mother did not receive it.

Sources: Public Health Agency of Canada / National Advisory Committee on Immunization. Updated guidance to protect infants and children from respiratory syncytial virus (RSV) disease (2026)

Answer: B. Weak D types 1, 2 and 3 carry no risk of alloimmunization, so prophylaxis is not recommended

Why: Guideline 448 states that weak D types 1, 2 and 3 carry no risk of alloimmunization and that prophylaxis is not recommended for these individuals, so this patient does not need antenatal immune globulin on account of her genotype. Not every D variant behaves in the same way: other weak D variants and partial D do carry a risk, which is why genotyping is performed when routine typing is inconclusive. Repeating the genotype or waiting for the blood type of the baby would not change the management.

• A. Only some D variants carry risk; types 1, 2 and 3 are in the group that does not, so prophylaxis is not indicated.
• C. Genotyping has already answered the question, so repeating it later does not change management.
• D. Prophylaxis is withheld on the basis of her genotype rather than the blood type of the baby.

Sources: SOGC Clinical Practice Guideline No. 448: Prevention of Rh D Alloimmunization, 2024

Answer: C. Progestin-only pills are oestrogen-free and are particularly useful for recently postpartum or breastfeeding women

Why: The SOGC position statement notes that progestin-only pills are oestrogen-free and are therefore particularly useful when oestrogen is contraindicated or less appropriate, including in recently postpartum, breastfeeding or perimenopausal women. The statement also notes that the older advice to take the pill at exactly the same time each day is not supported by the evidence. Reported typical-use failure rates are lower for these pills than for depot medroxyprogesterone acetate, so a progestin-only pill is a suitable option for this breastfeeding patient.

• A. The statement identifies recently postpartum and breastfeeding women as a group for whom these pills are particularly useful rather than contraindicated.
• B. Perimenopausal women are one group mentioned, but the statement also names recently postpartum and breastfeeding women among those who benefit.
• D. Reported typical-use failure rates are lower for progestin-only pills than for depot medroxyprogesterone acetate, so this comparison is reversed.

Sources: SOGC Position Statement: Managing Bleeding Patterns Associated with Progestin-Only Contraceptives (2025)

Answer: C. HLA-DQ2 and HLA-DQ8

Why: Coeliac disease is strongly associated with HLA-DQ2 (95% of cases) and HLA-DQ8 (remaining 5%). Absence of these alleles makes the diagnosis extremely unlikely. Testing is recommended according to gastroenterology guidelines.

• A. Associated with Ankylosing Spondylitis.
• B. Associated with Rheumatoid Arthritis and Type 1 Diabetes.
• D. Associated with SLE and Type 1 Diabetes, though DQ2 is in linkage disequilibrium with DR3.

Sources: Canadian Association of Gastroenterology Clinical Practice Guidelines

Answer: D. Start renal replacement therapy without delay

Why: KDIGO advises that renal replacement therapy be initiated emergently when life-threatening changes in fluid, electrolyte, and acid-base balance exist. Severe hyperkalaemia, severe acidosis, pulmonary oedema, and uraemic complications are recognised emergent indications, and this patient has at least three of them. Watchful waiting for repeat blood work, further diuresis, or an arbitrary creatinine threshold all delay treatment that is needed at once.

• A. Deferring treatment to repeat blood work leaves severe hyperkalaemia and acidaemia untreated, and timing follows the clinical picture and trends rather than laboratory values alone.
• B. Diuretics have already failed to control the pulmonary oedema, so continuing medical therapy delays the treatment this presentation requires.
• C. There is no creatinine threshold that must be reached before dialysis, and volume overload, solute imbalance, and acidaemia drive the decision.

Sources: KDIGO 2012 Clinical Practice Guideline for Acute Kidney Injury

Answer: C. Needle decompression in the second intercostal space, midclavicular line

Why: Tension pneumothorax is a clinical diagnosis and a medical emergency. Immediate needle decompression (or finger thoracostomy) must be performed prior to obtaining a chest X-ray to relieve pressure, restore venous return, and correct obstructive shock. A chest tube is inserted subsequently.

• A. Intubation and positive-pressure ventilation will worsen tension pneumothorax by increasing air accumulation in the pleural space.
• B. Tension pneumothorax is a clinical diagnosis; delaying treatment to obtain imaging can lead to cardiovascular collapse.
• D. Definitive treatment, but needle decompression is faster and must be performed immediately in an unstable patient.

Sources: Trauma Association of Canada Guidelines / ATLS Guidelines

Answer: B. Continue lithium at a therapeutic level, because withdrawal can precipitate recurrence

Why: Maintenance treatment aims to consolidate remission, restore functioning and prevent recurrence. The medication that was effective in the acute phase is generally continued into the maintenance phase, and the guidelines note that treatment withdrawal may precipitate recurrence, with 50% to 90% of patients who discontinue lithium experiencing a recurrence within 3 to 5 months. Lithium, quetiapine, divalproex, lamotrigine, asenapine and aripiprazole, as monotherapy or in combination, should be considered first-line for those initiating or switching treatment during maintenance. Antidepressant monotherapy is not recommended in bipolar I disorder, and benzodiazepines do not prevent mood episodes.

• A. Stopping the mood stabiliser once symptoms remit leaves him at high risk of recurrence, since most patients who discontinue lithium relapse within 3 to 5 months.
• C. An antidepressant alone does not protect against manic relapse and is not recommended as monotherapy in bipolar I disorder, so it cannot replace mood stabilisation.
• D. Benzodiazepines do not prevent mood episodes, carry risks of dependence and sedation, and have no role as maintenance treatment for bipolar disorder.

Sources: CANMAT/ISBD 2018 guidelines for the management of patients with bipolar disorder

Answer: C. Refer for colonoscopy

Why: A positive fecal immunochemical test is specific for human blood and must be followed by colonoscopy; the test is not repeated. Repeating the stool test, reassurance with return to routine screening and substitution with barium enema all delay or fail to provide the diagnostic endoscopy that a positive result requires.

• A. Because the test detects human blood, repeating it rather than proceeding to endoscopy delays diagnosis and is explicitly discouraged.
• B. A positive result reflects an abnormal finding that requires evaluation, so simple reassurance is inappropriate.
• D. Barium enema is listed among the tests that are not recommended, and it does not replace colonoscopy here.

Sources: Government of British Columbia. BC Guidelines: Colorectal Cancer Part 1, Screening (2022).

Answer: C. Paroxetine

Why: Where medication is used for post-traumatic stress disorder, the agents with good evidence for core symptoms are the SSRIs fluoxetine, paroxetine and sertraline, and the SNRI venlafaxine XR. Benzodiazepines are not effective for core symptoms, and early benzodiazepine use after trauma has not been beneficial and may increase the risk of developing the disorder. Divalproex has negative evidence. Combination treatment with an SSRI plus psychotherapy has not consistently proved superior to psychotherapy alone in small trials, so the role of combining treatment requires further study.

• A. Benzodiazepines such as clonazepam have not shown benefit for core symptoms, and early benzodiazepine use after trauma may increase the risk of developing the disorder.
• B. Beta-blocker treatment has not been established for core post-traumatic stress symptoms, and its use to prevent the disorder has shown conflicting results.
• D. This anticonvulsant has not demonstrated efficacy for the core symptoms of post-traumatic stress disorder.

Sources: Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders

Answer: B. Ursodeoxycholic acid 10 to 15 mg/kg per day in 2 to 3 divided doses

Why: Ursodeoxycholic acid 10 to 15 mg/kg per day, given in 2 to 3 divided doses, is the mainstay of symptomatic treatment for the itching of intrahepatic cholestasis of pregnancy and may also reduce the risk of preterm birth, although not stillbirth. Dexamethasone, cholestyramine and several other agents have been shown to be ineffective for this condition.

• A. Dexamethasone has been shown to be ineffective for this condition and should not be prescribed.
• C. Cholestyramine is among the therapies shown to be ineffective for intrahepatic cholestasis and should not be used.
• D. Dietary fat restriction alone does not treat the itching, and ursodeoxycholic acid is the recommended therapy.

Sources: SOGC CPG No. 452 - Diagnosis and management of intrahepatic cholestasis of pregnancy (medical disorder in pregnancy)

Answer: B. Atrioventricular septal defect (AVSD)

Why: Down syndrome (trisomy 21) is the most common chromosomal disorder (1:700 live births, rising with advanced maternal age). Features: upslanting palpebral fissures, epicanthal folds, flat nasal bridge, protruding tongue, single palmar crease, fifth finger clinodactyly, sandal gap, Brushfield spots. Congenital heart disease in 40-50%: AVSD most common, followed by VSD, ASD, PDA, TOF. Mandatory workup: echocardiogram, hearing assessment, thyroid function, ophthalmology. Chromosomal analysis confirms diagnosis. Complications: Hirschsprung disease, leukaemia (AML/ALL), Alzheimer disease (early onset), atlantoaxial instability, obstructive sleep apnoea.

• A. Tetralogy of Fallot occurs in ~10% of Down syndrome patients with CHD but is not the most common lesion. AVSD is the classic association.
• C. TGA is not a characteristic lesion of Down syndrome. It is associated with diabetic embryopathy and laterality defects but not trisomy 21.
• D. HLHS is not specifically associated with Down syndrome. It is associated with Turner syndrome and various genetic conditions, but AVSD is the classic cardiac defect of trisomy 21.

Sources: CPS Position Statement: Health Supervision for Children with Down Syndrome (2018); American Academy of Pediatrics Down Syndrome Guidelines