MCCQE1 Sample Questions With Answers (2026): 10 Realistic Vignettes
MDReview Editorial — written with input from Canadian residents and medical students.
The single fastest way to know whether you're ready for the MCCQE Part I is to sit down with real, exam-style vignettes and time yourself. Reading review notes is comfortable. Answering stems under time pressure is not — and that gap is where most first-attempt failures come from.
This page collects ten MCCQE1-style sample questions across the body systems you'll actually see on exam day, each with a fully worked answer and the reasoning the examiners are testing. They're written to Canadian practice patterns (CTFPHC screening, CHEP hypertension targets, C-Section indications from SOGC) — not USMLE reflexes.
If you want an unlimited supply of these with AI-graded feedback and spaced repetition, start a free MDReview account. Otherwise, work through the ten below with a laminated sheet and a timer set to 75 seconds per MCQ.
How to use these questions
- Read the stem once. Don't peek at options.
- On scrap paper, write your one-line differential and the single next best step.
- Then look at the options and pick the closest match.
- Read the explanation only after committing.
That sequence — commit, then verify — is what trains the reasoning MCCQE1 actually scores.
1. Cardiovascular — chest pain in a 58-year-old
A 58-year-old man presents to the ED with 45 minutes of substernal chest pressure radiating to the left jaw. BP 148/92, HR 96, SpO2 97% on room air. ECG shows 2 mm ST depression in leads V4–V6. Troponin I is pending. He has taken 325 mg ASA en route.
What is the single most appropriate next step?
A. Immediate coronary angiography B. Ticagrelor 180 mg PO + IV nitroglycerin + subcutaneous fondaparinux C. Full-dose tenecteplase D. Repeat ECG in 6 hours E. Discharge home with outpatient stress test
Answer: B. This is a non-ST-elevation acute coronary syndrome (NSTE-ACS). Canadian and CCS guidance is dual antiplatelet therapy (ASA already given, add a P2Y12 inhibitor) plus anticoagulation plus anti-ischemic therapy. Fibrinolytics (C) are contraindicated in NSTEMI. Angiography (A) is indicated within 24 hours for high-risk NSTE-ACS but medical stabilization comes first. Waiting 6 hours (D) or discharging (E) is unsafe.
2. Respiratory — a returning traveller with cough
A 34-year-old previously healthy woman returns from a two-week trip to rural Ontario. Ten days later she develops a productive cough, fevers to 39.2°C, and pleuritic right-sided chest pain. CXR shows a right lower lobe consolidation. She has no comorbidities and is hemodynamically stable.
What is the most appropriate outpatient management?
A. Amoxicillin 1 g PO TID for 5 days B. Azithromycin 500 mg PO once, then 250 mg daily for 4 days C. Levofloxacin 750 mg PO daily for 5 days D. Admission for IV ceftriaxone + azithromycin E. Oseltamivir 75 mg PO BID for 5 days
Answer: A. She has low-severity community-acquired pneumonia (CAP), no comorbidities, and no recent antibiotic exposure. Canadian AMMI/CTS guidelines recommend high-dose amoxicillin as first-line monotherapy. Azithromycin monotherapy (B) is no longer recommended in most of Canada because of macrolide resistance in S. pneumoniae. Fluoroquinolones (C) are reserved for patients with comorbidities or recent antibiotic exposure. IV therapy (D) is not needed. This is not influenza (E).
3. Gastroenterology — new-onset dysphagia
A 62-year-old man reports six weeks of progressive dysphagia — solids first, now liquids — and 4 kg unintentional weight loss. He drinks two beers a day and has smoked for 40 pack-years. Exam is unremarkable.
What is the single most appropriate next investigation?
A. Trial of PPI for 8 weeks B. Barium swallow C. Upper GI endoscopy (EGD) D. CT chest and abdomen E. High-resolution esophageal manometry
Answer: C. Progressive dysphagia with weight loss in a smoker/drinker is esophageal cancer until proven otherwise. EGD gives you visualization plus biopsy in one procedure. Barium swallow (B) is useful for motility disorders and rings, but delays tissue diagnosis. CT (D) is for staging after diagnosis. Manometry (E) is for suspected achalasia after malignancy is excluded. Empiric PPI (A) is a common trap and would delay diagnosis.
4. Renal — a low sodium
An 82-year-old woman on hydrochlorothiazide and sertraline is brought in confused. Na 118 mmol/L, K 3.6, urea 4.2, glucose 5.5. She is euvolemic clinically. Urine Na 62 mmol/L, urine osmolality 480 mOsm/kg.
What is the most likely diagnosis?
A. SIADH B. Cerebral salt wasting C. Beer potomania D. Pseudohyponatremia E. Primary polydipsia
Answer: A. SIADH: euvolemic, urine Na > 40, urine osm > 100 with plasma hypoosmolality, on a known culprit (SSRIs, thiazides). Cerebral salt wasting (B) requires overt volume depletion. Beer potomania (C) and primary polydipsia (E) both show dilute urine (osm < 100). Pseudohyponatremia (D) requires hyperlipidemia or hyperproteinemia.
5. Neurology — a young woman with visual loss
A 28-year-old woman reports one week of blurred vision and pain with left eye movement. Visual acuity is 20/80 OS, colour desaturation on Ishihara, and a left relative afferent pupillary defect. Fundoscopy is normal.
What is the single most likely diagnosis, and what is the most appropriate next step?
A. Central retinal artery occlusion — urgent CRAO protocol B. Optic neuritis — MRI brain and orbits with gadolinium C. Migraine with aura — reassure and abortive therapy D. Idiopathic intracranial hypertension — lumbar puncture with opening pressure E. Anterior ischemic optic neuropathy — temporal artery biopsy
Answer: B. Painful monocular vision loss + RAPD + normal fundus in a young woman is optic neuritis until proven otherwise; MRI brain/orbits assesses demyelination risk (multiple sclerosis) and is standard of care before considering IV methylprednisolone.
6. Endocrine — an adrenal incidentaloma
A 55-year-old woman has a 2.4 cm right adrenal mass found on CT for renal colic. She is normotensive and asymptomatic.
What is the most appropriate initial workup?
A. Adrenalectomy B. Repeat CT in 6 months only C. 1 mg overnight dexamethasone suppression test + plasma metanephrines + (if hypertensive) aldosterone:renin ratio D. FDG-PET E. Fine-needle aspiration biopsy
Answer: C. Every adrenal incidentaloma needs biochemical workup for functional tumours (cortisol, catecholamines, and aldosterone if hypertensive) and imaging characterization. Biopsy (E) is contraindicated before excluding pheochromocytoma.
7. Infectious disease — suspected meningitis
A 21-year-old university student presents febrile, confused, with neck stiffness and a petechial rash on the trunk.
What is the correct sequence of the next steps?
A. LP → blood cultures → antibiotics B. CT head → LP → blood cultures → antibiotics C. Blood cultures → empiric ceftriaxone + vancomycin ± dexamethasone → CT if focal signs, then LP D. Empiric acyclovir first, then investigate E. Isolate and await culture results
Answer: C. In suspected bacterial meningitis, do not delay antibiotics for imaging or LP. Draw cultures, give empiric ceftriaxone + vancomycin (add ampicillin if > 50 or immunocompromised) plus dexamethasone if pneumococcal is possible, then image if focal deficits/altered LOC/immunocompromised, then LP.
8. Obstetrics — a headache at 32 weeks
A 27-year-old G2P1 at 32 weeks presents with a new headache, BP 156/104 on two readings 15 minutes apart, 2+ proteinuria, platelets 92 × 10⁹/L, AST 76.
What is the most appropriate management?
A. Outpatient monitoring with weekly BP checks B. Admission, labetalol, magnesium sulfate, corticosteroids, and delivery planning C. Immediate C-section D. Nifedipine PRN, discharge home E. Induction of labour without magnesium
Answer: B. Preeclampsia with severe features (BP ≥ 160/110 on repeat, thrombocytopenia < 100, elevated transaminases, and CNS symptoms). Admit, control BP (labetalol/hydralazine/nifedipine), give MgSO₄ for seizure prophylaxis, betamethasone for fetal lung maturity, and plan delivery — usually within 24–48 hours of stabilization at ≥ 34 weeks, sooner if maternal/fetal status worsens.
9. Pediatrics — a limping child
A 5-year-old boy has three days of a right-sided limp and a low-grade fever. He is otherwise well, weight-bearing but reluctant. Hip exam shows guarding on internal rotation. WBC 11, ESR 22, CRP 18, temperature 37.9°C.
What is the most likely diagnosis?
A. Septic arthritis B. Transient synovitis C. Legg-Calvé-Perthes disease D. Slipped capital femoral epiphysis E. Juvenile idiopathic arthritis
Answer: B. Kocher criteria (fever > 38.5, non-weight-bearing, ESR > 40, WBC > 12) — he meets 0–1 → transient synovitis is likely. SCFE (D) is typically 10–16 years old; Perthes (C) is 4–8 but usually painless limp with hip stiffness over weeks. Still image the hip and reassess in 48 hours; if fever climbs, revisit septic arthritis.
10. Psychiatry — the CDM-style stem
A 34-year-old man is brought to the ED by police after threatening his neighbour with a knife. He believes his neighbour is a government agent monitoring him through the electrical outlets. He has not slept in four days, is malodorous, and refuses food. There is no prior psychiatric history. Toxicology screen is pending.
List (in the free-text answer box) the three most important immediate management steps.
Model answer.
- Ensure safety of patient, staff, and public — private room, security nearby, remove ligature risks; consider a Form 1 (Ontario) or equivalent involuntary hold under provincial mental-health legislation to permit assessment.
- Complete urgent medical workup to exclude organic causes of first-episode psychosis — vitals, glucose, electrolytes, CBC, TSH, liver enzymes, urine toxicology, CT head if focal signs or atypical features.
- Initiate short-acting oral antipsychotic (e.g., olanzapine 5–10 mg PO or risperidone 2 mg PO) with benzodiazepine adjunct for agitation; arrange inpatient psychiatric admission.
That CDM answer style — enumerated, action-oriented, safe-first — is exactly what the graders reward.
What your accuracy means
- ≥ 75% on timed mixed blocks: you're on track for a comfortable pass.
- 65–74%: you'll likely pass but should target your two weakest systems for two more weeks.
- < 65% with two weeks to go: shift from reading to volume — 40–50 questions/day, mixed random, timed.
For a deeper look at how the scaled score works, see MCCQE1 passing score explained. If you want a full timeline, how long to study for the MCCQE1 breaks it down by starting accuracy.
Practice more, graded automatically
Ten questions is enough to calibrate. It isn't enough to pass. MDReview has a full MCCQE1 question bank with AI-graded CDM cases, spaced-repetition review, and per-system analytics that tell you exactly which chapters to revisit.