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The Resident's Guide to LMCC II (And MCC Qualifying Exam II)

The Resident's Guide to LMCC II (And MCC Qualifying Exam II)



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Published by bobsherif
This is the formidable source for any one willing to take the Medical Council Of Canada Qualifying Exam Two. Good luck..
This is the formidable source for any one willing to take the Medical Council Of Canada Qualifying Exam Two. Good luck..

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Published by: bobsherif on Oct 10, 2010
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The Resident’s Guide to the LMCC II
3rd Edition
Revised by AMB.
The Licentiate of the Medical Council of Canada Exam, part II, also known as the MCCQE II, was the traditional means of
qualifying for a general license to practice medicine in Canada. Now that both the internship year and the general license are
no longer available, many residents view the exam as a stressful and expensive exercise in futility. While the process is
stressful and expensive, it need not be futile. Preparation for the exam can be an enlightening review. Scenarios tend to repeat
over the years, the pass rate is greater than 95% on the first attempt, and there is an option to rewrite, so don’t panic.
The exam is an OSCE (Observed Scenario Clinical Exam) in which the candidate progresses through a series of stations. Your
starting point is determined alphabetically. At each station there is a physician examiner and either a real person posing as a
patient or a telephone over which you must speak to a patient or another physician requesting assistance.
The most recent sessions (since 1997) contain six short cases known as 5-minute couplets, in which the candidate is allotted 5
minutes to assess a patient and 5 minutes to write short answers to questions related to the case. There was also a series of six
longer cases in which the candidates were presented with a more involved clinical problem, such as a resuscitation or
psychosocial counseling session, lasting 10 minutes each. The physician examiner may ask one or two questions in the last
minute of a 10-minute station. There is one minute between stations during which you can look at a brief description of the
patient and consider your approach. Occasionally “pilot” questions will be included in the exam, which will not count towards
the final mark but are used to test new questions. You will not know which questions are “pilot” questions.
The content of the exam is general medicine. This means family practice & emergency medicine. The following topics appear
Pediatrics – diarrhea, development, neonatal jaundice, asthma
Obs/Gyn – amenorrhea, vaginal blood, abdominal pain, PIH, OCP, elective abortion counseling
Suturing – choice of suture, tetanus vaccine
Chest Pain – read CXR, ECG
Resuscitation – fluid resuscitation after blood loss, ABCDs
Overdose – ASA, TCA
Needle stick – AIDS, hepatitis, vaccinations
Psychiatry – depression, mania, schizophrenia
Neurosurgery – back and neck radiculopathies, carpal tunnel
(Note that every history should include name, age, occupation, past medical history, family history, medications, drugs/alcohol,
review of systems)
1. First year university student, 9 weeks pregnant, considering abortion. Take a history and counsel. Findings: tearful,
guilty, sleep disturbance, has not engaged social supports.
History: combine a pregnancy history with a social history and a screen for depression.
Pregnancy: Patient ID (name, age, occupation). GTPAL (number of gestations, term pregnancies, premature births, abortions,
live children), history of problems, if any, with previous pregnancies. Current pregnancy, establish gestational age (GA) by
last menstrual period (LMP) if regular periods and sure dates (if unsure a dating ultrasound would be needed). The GA is the
number of weeks from the first day of the LMP. The EDC is first day of LMP + 7 days – 3 months. Ask about use of alcohol,
smoking, drugs, domestic violence (50% begins in pregnancy), maternal illnesses during the pregnancy (particularly diabetes,
rubella, toxoplasmosis, herpes, CMV, thyroid dysfunction, HTN, hypercoagulation). Use of birth control, if any. Past medical
history, family history of pregnancy related problems, medications.
Social: Status of any relationships at present including relationship with the child’s father. Social supports (family, friends,
boyfriend), do they know? Are they helping? Employment/financial/educational status of the patient, does the patient feel
prepared to raise a child?
Psychiatric: How does the patient feel about this decision? How is she coping? Cover mnemonic for major depression.
MSIGECAPS: mood (depressed), sleep (increased or decreased…if decreased, often early morning awakening), interest
(decreased), guilt/worthlessness, energy (decreased or fatigued), concentration/difficulty making decisions, appetite and/or
weight increase or decrease, psychomotor activity (increased or decreased), suicidal ideation – positive diagnosis of major
depression requires five of these over a 2 week period, one of the five must be loss of interest or depressed mood. Symptoms
do not meet criteria for mixed episode, significant social/occupational impairment, exclude substance or GMC, not
Counseling: Make empathetic statements, e.g. “This must be very hard for you.”
Health while pregnant: recommend abstinence from harmful agents (alcohol, smoking, drugs) while pregnant and use of
medications only after consulting with a physician, treatment for pregnancy-related illnesses as above, and healthy eating
Social supports: Discuss the importance of engaging social supports, and consider a visit with both the patient and her partner
or other supporting person.
Abortion: Provide information on local abortion services. Make the patient aware that the gestational age limit after which
many practitioners will not perform an elective abortion in Canada is 20 weeks, but that this is a late limit and her decision
should be made sooner, before 16 weeks would be best. Inform the patient that further advice is available from private
gynecologists who perform abortions and counselors at elective abortion centers. Offer to refer the patient if she wishes.
Depression management: Normalize the patient’s depressed mood in view of her circumstances. If there is evidence of major
clinical depression, arrange close follow up to monitor for suicidal ideation, refer to psychiatry. Do not prescribe medications
at this time (because of the pregnancy).
2. 20 year old female wants an oral contraceptive. Take a history and counsel.
History: Name, age occupation/school level. Why does patient want an OCP? Has she been on it before or other forms of
contraception? If so, why was it stopped? How long has the patient been sexually active? How many partners? Current
contraception used. Is there a possibility that the patient could be pregnant? Obtain the date of last menstrual period.
Pregnancy history: GTPAL (number of gestations, term pregnancies, premature births, abortions, live children), history of
problems, if any, with previous pregnancies.
Gynecological history: Ask about sexually transmitted disease (STDs), PID, migraine, fibroids, diabetes, thromboembolic
disease, heart problems, cancer, liver disease. Date of last Pap smear, history of abnormal Pap smear and follow-up/treatment?
When did the patient start menstruating? Menstrual history: regularity and length of cycle and duration of periods, heaviness of
flow (number of pads required), cramping, associated discomfort/pain, bloating, mood swings (PMS). Medications, drugs,
alcohol, smoking, past medical history (especially breast cancer), family history, review of systems.
Contraindications to OCP: current pregnancy, undiagnosed vaginal bleeding, active cardiovascular/thromboembolic diseases
(includes coronary and carotid disease, symptomatic mitral valve prolapse, cerebrovascular disease, moderate-severe HTN,
active DVT), proliferative retinopathy, history of breast cancer or other estrogen dependent tumors (liver, breast, uterus),
impaired liver function (obstructive jaundice in pregnancy), congenital hyperlipidemia, age > 35 and smoking, Wilson’s
disease. Relative contraindications to OCP: smoker > 35 years old, diabetes, migraines, fibroids.
Mechanism of action of OCP: standard preparations contains estrogen and progesterone or just progesterone, prevents
ovulation by interfering with feedback of hormone signaling, atrophic endometrium, change in cervical mucous (mucous
plug…thought to be due to progesterone component).
Available preparations: 21 day vs. 28 day tablets (7 placebo days). Other preparations: Depo injections q3m (Depo-Provera –
medroxyprogesterone, restoration of fertility may take up to 1-2 years, irregular menstrual bleeding), implants q5y (Norplant –
levonorgestrel, six capsules inserted subdermally in arm, irregular menstrual bleeding). Longer term preparations offer lower
cost over the duration of action (but greater one-time cost) and greater convenience.
Benefits of all the hormonal contraceptives: ABCDEs: Anemia reduced, often clears Acne; Benign breast disease and cysts
decreased;C ancer (ovarian decreased),C ycles regulated, IncreasedCervical mucous which reduces STDs;Dysmenorrhea
decreased, decreasesEctopic pregnancy rates and of course: virtually no chance of pregnancy when taken as directed (98-
Risks of hormonal contraceptives: slight weight gain is usual (5 lbs), increases risk of DVT especially in combination with
smoking, may stimulate estrogen-receptor positive breast cancers, but does not appear to cause them, may have to try two or
three different preparations to arrive at the one for the patient. Also note that hormonal contraceptives do not provide as much
protection against sexually transmitted diseases, compared to barrier methods.
Directions: Start OCP on the first day of the next menstrual period. Place package in an obvious location to help you to
remember. Take at the same approximate time each day. Use additional contraception for the first two months, as OCP
contraception is not reliable until then. If you miss a day, take two pills the next. If you miss two days, take two pills for the
next two days and use an alternative method until the next period. Give prescription for OCP of choice…any family members
(sisters/mother) on OCP? What works for them? Arrange follow up.
3. 16 year old boy with epilepsy documented by neurologist, comes to you because he does not want to see his parent’s
family doctor. Wants a driver’s license. Take a history and counsel.
History of seizure disorder: Patient ID. Age of onset (primary generalized rarely begin < 3 or > 20 years old). Precipitants:
Sleep deprivation, drugs, EtOH, TV screen, strobe, emotional upset. Describe seizures (Jacksonian march? Salivation,
cyanosis, tongue biting, incontinence, automatisms, motor vs. visual/gustatory/olfactory), frequency, duration, what body parts
affected and in what order (motor – frontal lobe, visual/olfactory/gustatory hallucinations = temporal lobe), promontory signs
(presence of aura: implies focal attack), post-ictal state (decrease in level of consciousness, headache, sensory phenomena,
tongue soreness, limb pains, Todd’s paralysis - hemiplegia), degree of control achieved with medications, at what dose and for
how long, corroboration from family if possible. Was a CT scan done when seizures were first diagnosed? Number and
description of recent seizures, are they different from previous seizures? Is the patient having any new symptoms such as
headache, morning vomiting, new neurological deficits. If the drug worked in the past why does the patient believe it isn’t
working now? Side effects of antiepileptics: drowsiness, poor concentration, poor performance in school, ataxias, peripheral
neuropathy, acne, nystagmus, dysarthria, hypertrichosis (excessive hairiness), gingival hypertrophy (phenytoin). Medications,
drugs and alcohol, smoking, allergies, past medical history, family history, review of systems.
Compliance: Is the patient taking meds? Why not? Problems at school or home? Ask about relationship problems.
Depression screen as in #19 above. Social supports.
Physical exam: neurologic exam including mini mental, cranial nerves, bulk, tone, power, sensation, cerebellar exam, deep
tendon reflexes.
Treatment: Discuss importance of compliance with medication and avoiding dangerous activities such as driving until good
control is achieved. Ministry of Transportation regulations require 1 year seizure free before they will grant a driver’s license
in Canada. Inform the MOT of the patient’s seizure disorder if you have not already done so and inform the patient that this is
required by law. If alcohol is an issue, inform the patient that chronic alcohol intake may decrease blood levels of antiepileptics
(via increased liver metabolism), and excess alcohol intake can precipitate seizures by lowering the seizure threshold thereby
precipitating a seizure. It is generally recommended that the patient not drink at all. Fatigue and concomitant illness can also
lower seizure threshold. The patient should consult a physician before taking other medications, as they may also lower the
seizure threshold. The same is also true of sedatives, cocaine, amphetamines and insulin. Fatigue and other illnesses can also
lower seizure threshold, in addition to various other medications. If patient is having stress management, anxiety issues, he
may require further counseling. Outline a treatment plan consisting of: EEG, CT head, metabolic screen, medications (if not
done already), and follow up appointments. Get the parents involved if possible.
Send blood for serum Dilantin (phenytoin) levels if patient is on this already. If Dilantin levels are therapeutic, but the patient
is having severe side effects or poor seizure control, a second drug may be added (usually carbamazepine or valproic acid).
Discuss what to do in the event of seizure, counsel parents if possible. Bystanders are not to insert objects into the patient’s
mouth. Turn patient on his side while seizing. Call ambulance or take to Emergency if seizure doesn’t stop in 5 minutes.

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