MedicalCouncilofCanada

GUIDELINESFORTHEDEVELOPMENT

OFMULTIPLECHOICEQUESTIONS

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TABLEOFCONTENTS Page1. Introduction 32. BasicItemWritingTechniques 43. OtherDirectivesPertainingtoWritingQuestionsfortheMedicalCouncilofCanada 74. ExamplesofWellandPoorlyConstructedMultipleChoiceQuestions(MCQ) 85. ChecklistfortheDevelopmentofTestItems 116. ItemClassificationSpecifications 137. SampleLeadInQuestionswithExamples 14 7.1 History 14 7.2 PhysicalExamination 16 7.3 Investigation 19 7.4 Diagnosis 228. Appendices 26 8.1 ClinicalLaboratoryTestsNormalValues 26 8.2 References 27 8.3 SampleItemDevelopmentForm 29 8.4 SampleItemDevelopmentTemplateMCCQEPARTI 30 8.5 SampleItemDevelopmentTemplateMCCEE 31 8.6 FeedbackForm 32

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PREFACEAsamemberofoneoftheMedicalCouncilofCanada(MCC)TestCommitteesorasaparticipantofaworkshop,oneofthetasksassignedtoyouwillbethedevelopmentofmultiplechoicequestions(MCQ)inyourgeneralareaofexpertise.Althoughthismayappearasarelativelyeasytaskatfirstglance,itisaskillforwhichweprovidegeneralguidelinestocreatewellconstructed,reliableandvaliditems.This booklet will help guide you towards good MCQ development by reviewing basic rules pertaining to itemdevelopment, provide itemwriting techniques, provide examples of good and bad questions and explain ourclassificationsystem.Itismyhopethatyouwillfindthisguideuseful.ClaireTouchie,MD,FRCPCViceChairoftheMCCCentralExaminationCommittee

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INTRODUCTIONMultiplechoicequestions(MCQ)havelongbeenusedintheassessmentofmedicalknowledgeastheyhavebeenshowntobevalidandreliableaswellastimeandcosteffective.Since2000,theMedicalCouncilofCanada(MCC)QualifyingExamination (QE) Part I has been administered in a computeradaptivemodewhich allows candidates to be testedreliablyusingfewerquestionsthanwouldbeused inatraditionalwrittenexam. Thecomputerwilltestthecandidateaccordingtohis/herabilitybyadaptingtoahigherorlowerlevelofdifficultybasedonthecandidatesperformanceonabaselinesetofquestions.Thesegroupsofquestions,knownastestlets,includequestionsfromdifferentdisciplineswithdifferentlevelsofdifficulty.Therefore,noteverycandidatehasthesamesetofquestionsduringhis/herexamination.Inturn,thismeansthebankofquestionsavailablemustbelargerthanaclassicalexaminationwhereeachcandidatereceivesthesamesetofpredeterminedquestions.Both theMCCQEPart Iand theEvaluatingExamination (MCCEE)useMCQsaspartof their testing. AllMCQsaresinglebestanswer(Atype.)Thesearemadeupofastem(usuallyaclinicalscenario)withaleadinquestion,followedbyfiveresponseoptions(onecorrectorbestanswerandfourdistractors.)ItemstobedevelopedshouldbebasedontheObjectivesfortheQualifyingExaminationwhichhasbeenprovidedtoyou.EachitemthatyoumustdesignshouldbeclassifiedaccordingtotheclassificationschemeoftheMCCwhichisalsoprovidedasaseparatedocument.Your taskasaquestionwriter is toconstructaquestion thatwillallow thecandidate todemonstrateaccuratelywhathe/sheknowsordoesnotknowabouttheobjectivethatisbeingtested.IndevelopingMCQsfortheQualifyingExaminationortheEvaluatingExamination,thefollowingworkingguidelinefordevelopingtestitemsmustbeused:TheMedicalCouncilofCanadaQualifyingExaminationPartIassessesthecompetencyofcandidatesafterobtainingtheMDdegree for entry into supervised clinicalpractice inpostgraduate trainingprogramswith respect to theirknowledge,clinicalskillsandattitudesasdefinedbytheMCCObjectives.

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BASICITEMWRITINGTECHNIQUESMultiplechoicequestions(MCQ)aremadeupof:1. The stem is usually a clinical scenario of a common or lifethreatening patient presentation. It should be clear,

unambiguousand includeallpertinent information. This informationshould include thepatientsageandgender,clinical setting (ED, office), present complaint and duration, and depending on the nature of the item, otherinformationsuchaspertinentpatienthistory,physicalexaminationandresultsofdiagnostictesting.Thisistypicallyfollowedbyaleadinusuallyintheformofaquestion(e.g.:Whichoneofthefollowingisthemostlikelydiagnosis?)Thestemoftheitemcanbeofanylength.

2. Theanswerconsistsoffiveresponseoptionsincludingthecorrectanswerandfourdistractors.Theoptionsshouldbe

short.Hereisanexampleofhowtogoaboutdevelopinganitem:1. Choose an objective from which the item will be developed. The objectives are usually based on patient

presentationsofclinicalproblemswhichshouldhavebeenencounteredinthecandidatestraining.Presentation: Chestdiscomfort/pain/anginapectorisObjective: Differentiatecardiacpainfromothertypesofvisceralpain2. The item should assess theapplicationofknowledge,not recallofan isolated fact. The candidatewillhave to

establishadifferentialdiagnosisoftheproblemtobesolved. Askingaquestioninthecontextofaclinicalsituationwillmaketheitemappearrelevanttothecandidate.

3. Thecontentshouldbeappropriateforthelevelofdifficulty.ForthecandidateoftheMCCQEPartIortheMCCEE,

thisisexplicitlystatedonp.3.Ifyouarewritingitemsforotherpurposes(clerkship,residencytraining),thelevelofdifficultyoftheitemshouldreflectthelevelofclinicalknowledgeexpectedofthecandidate.

4. Thestemoftheitemmustposeaclearquestionanditshouldbepossibletoarriveatananswerwiththeoptionscovered. Todetermine if thequestion is focused, coverup theoptions and see if thequestion is clear and if theexamineecananswerbasedonlyonthestem.

NOTE: Questions where the stem comprises of Which one of the following is

CORRECT/INCORRECT? or Each of the following statements are correct EXCEPT? arestronglydiscouragedastheyareunfocusedandoftenhaveheterogeneousoptions.

Thefollowingisanexampleofanappropriatestemandleadin:

A58yearoldmanpresentstotheemergencydepartmentwithsuddenonsetofleftsidedchestpainassociatedwithshortnessofbreath,palpitationsanddizziness.Hispasthistoryisrelevantforarecentdiagnosisofalungcarcinoma.Whichoneofthefollowinghistoricalfactsismostusefulinestablishingtheetiologyofhisdiagnosis?5. All incorrectdistractorsshouldbehomogeneouswith thecorrectorbestanswer. Distractorsshould fall into the

same category as the correct answer (e.g.: all diagnoses, tests, treatment, prognoses, and disposition alternatives.)Avoidusingdoubleoptions(e.g.:doWandX;doYbecauseofZ)unlessthecorrectanswerandalldistractorsaredoubleoptions. Alldistractorsshouldbeplausible,grammaticallyconsistent, logicallycompatibleandofrelativelythesamelengthasthecorrectanswer.

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Eachdistractor shouldbe sufficientlyapplicable so as tobe selectedby some examinees; therefore, eachdistractorshouldbeplausibleandnone should standoutasbeingobviously incorrect. Commonmisconceptionsand faultyreasoningprovideagood sourceofplausibledistractors,asdo themistakes thatareoftenmadeby theminimallycompetentcandidate.Youshouldbeabletoprovidethelineofreasoningthatacandidatewouldusetoselectanyoneofthedistractorsasananswer.Ifyouareunabletoprovidethelineofreasoningthenmorethanlikely,thedistractorisnotplausible.

NEVERuseAlloftheaboveorNoneoftheaboveasdistractors.In the following example, all of thedistractors areplausibly associatedwith leftsided chestpain. The candidateshouldbeabletodetermine,withtheinformationprovided,thatthemostlikelydiagnosisisapulmonaryembolism.Ifthecandidatethinksthisismostlikelyadiagnosisofpneumoniaormyocardialinfarction,theotherdistractorsmayseemplausibleandthuschosenastheirmostusefulhistoricalfact.

A58yearoldmanpresentstotheemergencydepartmentwithsuddenonsetofleftsidedchestpainassociatedwithshortnessofbreath,palpitationsanddizziness.Hispasthistoryisrelevantforarecentdiagnosisofalungcarcinoma.Whichoneofthefollowinghistoricalfactsismostusefulinestablishingtheetiologyofhisdiagnosis?1. Dailyrecurrentfevers.2. Purulentsputum.3. Historyofhypercholesterolemia.*4. Swollentenderlowerextremity.5. Radiationofpaintoleftarm.6. Usethesameobjectivetocreateotheritems.Youcanusetheobjectivetocreatemorequestionsconcerningthesame

clinicalstembut targetingdifferentaspectssuchasphysicalexamination,diagnostic tests,establishingadiagnosis,treatmentandriskfactors. Byvaryingthepatientsageorgender,settingandprovidedinformation,youcantestanewtopicrelatedtothesameobjective.Producingtestquestionsinthisfashionisoftenreferredtoasitemcloning.

A58yearoldmanpresentstotheemergencydepartmentwithsuddenonsetofleftsidedchestpainassociatedwithshortnessofbreath,palpitationsanddizziness.Hispasthistoryisrelevantforarecentdiagnosisofalungcarcinoma.Whichoneofthefollowingtestsismostlikelytoconfirmhisdiagnosis?1. Electrocardiogram.2. Chestradiograph.*3. Ventilationperfusion(V/Q)scan.4. Echocardiogram.5. Holtermonitoring.A78yearoldmanpresentstotheemergencydepartmentwithsuddenonsetofleftsidedchestpainradiatingtohisback.Hehasapasthistoryofstableanginaandperipheralvasculardisease.Hisbloodpressureis80/50withaheartrateof120/min.Whichoneofthefollowingtestsismostlikelytoconfirmhisdiagnosis?1. Electrocardiogram.2. Chestradiograph.*3. Computerizedtomography(CT)ofthechest.4. Echocardiogram.5. Ventilationperfusion(V/Q)ofthelung.

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7. Technicalitemflawsthatprovidespecialbenefittotestwiseexamineesorthatposeirrelevantdifficultymustbeavoided.Examplesoftheseare:

Grammaticalcues:oneormoredistractorsdonotfollowgrammaticallyfromthestem Logicalcues:asubsetoftheoptionsiscollectivelyexhaustive Absoluteterms:termssuchasalwaysorneverareinsomeoptions Longcorrectanswer:correctanswerislonger,morespecificormorecompletethanotheroptions Wordrepeats:awordorphraseisincludedinthestemandinthecorrectanswer Convergencestrategy:thecorrectanswerincludesthemostelementsincommonwiththeotheroptions

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OTHERDIRECTIVESPERTAININGTOWRITINGITEMSFORTHEMEDICALCOUNCILOFCANADA TheMCCsCentralExaminationCommittee(CEC)hasrequestedtheexaminationalwayslistdrugsbytheirgeneric

namebutthat,intheeventthetestcommitteemembersfeelthatcandidateswillbeunfamiliarwiththegenericdrugname,thetradenamebeinsertedinparentheses.

Theuseofacronymsshouldfollowthefullspellingofterms;e.g.,magneticresonanceimaging(MRI.) TheClinicalLaboratoryTests NormalValues(appended)areavailableasareferencetothecandidateseitherby

clickingontheappropriateicononthecomputerbasedexaminationoronthecoverofallMCCexaminationbooklets.Whencomposingquestions,pleaseensurethatany laboratoryreferencevalueswhicharenot listedontheClinicalLaboratoryTestsNormalValuespageareinsertedinparenthesesfollowingtheresultrecordedinthequestion.Aswell,allnormalvaluesforpediatricquestionsmustbeprovidedinthequestion(inparentheses)iftheydifferfromtheadultvalues.

Youare requested to indicate the correct response toyourquestions. Please indicate the correct responsewithan

asterisk. Distractorsshouldbelistedinanumericalfashion(e.g.15andnotAE.) Youmustprovideareferenceforeachtestitemthatyouwrite.Thereferenceshouldincludetheauthorsname,title

oftext,edition,publisherandpagenumber. Imagestohelpcomplementanitemarewelcomed.Theymustbedigitalized.TheymustNOTbecopyrightedand/or

mustbeaccompaniedbyapatientconsentifprovidedfromyourpersonalcollection.

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EXAMPLESOFWELLANDPOORLYCONSTRUCTEDMULTIPLECHOICEQUESTIONS(MCQS)Thefollowingexampleswillillustratebothwellandpoorlyconstructedquestions. Potentialproblemswiththequestionswillbepointedouttoyou.Example1A76yearoldmanisbroughttotheEmergencyDepartmentbyrelativeswhostatethathehadcollapsedsuddenlybutregainedconsciousnesswithinminutes. Therewasnoseizureactivity. Hiselectrocardiogramshowedasinusrhythm(76/minute), a right bundle branch block and left anterior fascicular block (left axis deviation.) Which one of thefollowingmostlikelyaccountsforthismanslossofconsciousness?1. Ventriculartachycardia.2. TypeIseconddegreeatrioventricularblock(Wenckebach.)3. Paroxysmalsupraventriculartachycardia.*4. Intermittentheartblock.5. Atrialflutterwith2:1atrioventricularblock.Comments: Wellconstructeditem. Allnecessaryinformationprovided. Correctansweranddistractorarehomogeneousandplausible.Example2AllofthefollowingstatementsregardingobstructivejaundicearecorrectEXCEPT?1. Itisassociatedwithanelevatedconjugatedbilirubin.2. Itisoftenassociatedwithimpactedgallstones.*3. Itisnotcausedbyexternalcompression.4. DiagnosismayrequireanERCP.5. Laboratoryabnormalitiesusuallyincludeanelevatedalkalinephosphatase.Comments: Noclinicalstem. UseoftheEXCEPTformat. Cannothidetheoptionstoanswerquestion. Useofanegativeinanexceptquestionisgrammaticallydifficult. Useofacronym(ERCP)withoutwritingitoutinfull. Heterogeneityofdistractorswithetiology,laboratoryanddiagnostic/therapeutictests. NOTE:thesamecanbesaidofquestionssuchasWhichoneofthefollowingisTRUE?orWhichoneofthefollowing

isFALSE?Example3An86yearoldwoman fellat the localnursinghomeandsustainedan intertrochanteric fractureofher lefthip. Onclinicalexamination,youwouldexpecttofindherleftleg1. Shortened,abductedandinternallyrotated.2. Lengthened,abductedandinternallyrotated.3. Shortened,adductedandexternallyrotated.*4. Shortened,abductedandexternallyrotated.5. Lengthened,abductedandexternallyrotated.

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Comments: Youwouldnotbeabletoanswerthisitemcorrectlyiftheoptionswerecovered. Althoughdistractorsarehomogeneous,candidatescanusetheconvergencestrategy. Thatisshortened,abductedand

externally rotatedare themost commonlyusedvariablesofall thedistractorsand thereforemaybe themost logicalanswertosomeonewhohaslittlecontentknowledge.

Abetterwaytoconstructthisitemwouldbetoputtheclinicalfindingsinthestemandtoaskwhattypeoffracturethepatientpresentswith.

Example4A24yearoldfemalepresentstoawalkinclinicwithfever,flankpain,frequencyanddysuria. Theurinalysis(urinemicroscopy)shows1+proteinuria,25whitebloodcellsperhighpowerfieldandafewgranularcasts.Whichoneofthefollowinginvestigationsisthenextbeststep?1. Intravenouspyelography.2. Intravenousantibiotics.3. Creatinineclearance.*4. Midstreamurineculture.5. Oralanalgesia.Comments: Wellconstructedstem. Leadinquestionasksforinvestigationsthereforedistractors2and5canbeeliminatedastheyaretreatments;thisisan

exampleofalogicalcue. Could change the leadinquestion toWhichoneof the following is thenextbest step?whereeither treatmentsor

investigationsmaybecorrect.Example5A45yearoldwomanpresentswithsuddenlossofconsciousness.Onexam,hervitalsarenormal,sheisnotpaleandshe isnotdiaphoretic. Whichoneof the following ismore typicaloffaintingasaconversionsymptom thanofasyncopalattackduetoorthostatichypotension?1. Bradycardia.2. Muscletwitching.*3. Absenceofpallorandsweating.4. Urinaryincontinence.5. Rapidrecovery.Comments: Stemcontainselementsthataredirectlyrelatedtothecorrectanswer.Bothlackofpallorandsweating(diaphoresis)are

mentionedinthestemwhichleadstothecorrectanswer.Thisisanexampleofwordrepeats. Theclinicalinformationisactuallynotnecessaryastheleadinquestioncontainsalltheinformationnecessary.

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Thefollowingexamplesdemonstratehowtomakeanitemeasierorharder:Example6A62yearoldmanpresentswithafewdayshistoryofperipheraledemaanddecreasedurineoutput.Onexamination,hisbloodpressureis195/90with3+pittingedemaofhislowerextremities.Hiscreatinineis230mmol/Landurinalysisshows2+leukocyteesterasewith3+proteinuria.Whichoneofthefollowingisthemostlikelydiagnosis?1. Urinarytractinfection.2. Urolithiasis.*3. Nephroticsyndrome.4. Hepatorenalsyndrome.5. Congestiveheartfailure.Example7A62yearoldmanpresentswithafewdayshistoryofperipheraledemaanddecreasedurineoutput.Onexamination,hisbloodpressureis195/90with3+pittingedemaofhislowerextremities.Hiscreatinineis230mmol/Landurinalysisshows2+leukocyteesterasewith3+proteinuria.Whichoneofthefollowingisthemostlikelydiagnosis?1. Hypertensivenephropathy.2. Chronicpyelonephritis.*3. Nephroticsyndrome.4. IgAnephropathy.5. Allergicinterstitialnephritis.Comments: Byusingthesamestemyoucanmakeanitemeasierormoredifficultbyvaryingthedistractors.Becarefulto

rememberwhoyouraudienceis(inthecaseoftheMCCexam,candidatesobtainingtheirMDandenteringsupervisedpractice.)

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CHECKLISTFORTHEDEVELOPMENTOFTESTITEMSGuidelinesforItemStructure5Followfourbasicstepsforthedevelopmentoftestitems:

1. Startwiththeclinicalpresentationandtheobjective/keyfeature.2. Writethestemoftheitem.3. Formulatethecorrectorbestanswer.4. Developfourdistractors(foratotaloffivepossibleanswers.)

5Theproblemtobesolvedshouldbeclearlydefinedinthestem.Candidatesshouldnothavetolookattheoptionstodeterminewhattheitemisrequesting.

5Iftheincompletesentenceformatisusedforthestem,theoptionsshouldflowdirectlyandgrammaticallyfromthestem.

GuidelinesforItemStems5Thestemshouldbewritteninaclearandconcisemanner.Ifaclinicalvignetteisused,includeinformationwhichis

relevanttothecaseathand.Thestemmustincludealeadinthatstatesthetaskrequiredofthecandidate(e.g.:makeadiagnosis,orderatest.)

5Thequestionformatfortheleadinshouldbethepreferredformat.Iftheincompletesentenceformatistobeusedatall,useitforveryshortstems.

5Awellconstructedstemshouldcontainallthenecessarycontentforacompetentstudenttoanswertheitemwithouthavingtoreadanyoftheoptions.Agoodtestofthisruleistohidealltheoptionsandtryingtoanswertheitemquestionposedinthestem.

4Avoidusingthenegativeformunlessthereissomemeritfromaclinicalperspectivetobemeasuringsomenegativeaspects.

5Givecleardirectionsastowhatthecandidateshouldbedoinginordertoidentifythecorrectanswer.Thestemshouldclearlyintroducewhatisexpectedofthecandidate.

4Avoidtrickyandoverlycomplexitems.GuidelinesforCorrectorBestAnswers5Thecorrectanswershouldbeclearlytheonlycorrectoneorbetterthanthedistractors.Ifthebestanswerissought,

thisshouldbeclearlystatedinthestem.4Avoidmakingthecorrectanswerclearlylongerthantheotheroptions.Ifitislongerthantheotheroptions,try

varyingthelengthacrossalloptions.4Avoidcluestothecorrectanswer:

usingtextbookwordinginthecorrectanswerandnotinthedistractors usingspecificdeterminerssuchasalways,never,etc. thecorrectanswercontainstheexactwordingofanimportantconceptmentionedinthestem thereisnolinkbetweenthestemandsomeoftheoptions thereislackofparallelismamongtheoptions(grammatical,structural,vocabulary,technicaljargon)

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GuidelinesforDistractors5Distractorsshouldbeconsistentwiththestem.5Distractorsshouldbeplausible;distractorsshouldbedevelopedwiththeacceptablycompetentstudent/clinicianin

mind.Thedistractorsshouldincludecontentwhichisreflectiveofcommonmisconceptionsorerrorswhicharenotacceptable.Ifthecorrectanswerisofthebesttype,cancompetentstudentsmakeacaseforoneorseveraldistractors?Ifso,reformulatethosedistractors.Canthequestionbeansweredbysomeonewhodoesnotknowthecorrectanswer?

5Acceptabledistractors: arehomogeneousincontent(e.g.,allarediagnosesorallaretherapies) areincorrectordefinitelyinferiortothecorrectanswer donotcontainanyhintstothecorrectanswer wouldseemplausibleandattractivetotheuninformed aresimilartothecorrectanswerinconstructionandlength arenotmutuallyexclusivetoeachotherortoinformationinthestem

5Examplesofirrelevantdifficultywouldinclude: optionsarelong,complicatedordouble numericaldataisnotstatedconsistently termsintheoptionsarevague(e.g.,rarely,usually) languageintheoptionsisnotparallel optionsareinanonlogicalorder Noneoftheaboveisusedasanoption

GeneralGuidelines5Keepoptionshomogeneousincontentandstructure.5Useasmanyfunctionaldistractorsaspossible.4Avoidtheuseofhumorasthiscanpotentiallydistractstudents.4AvoidtheuseofAlloftheaboveandNoneoftheaboveasoptions.4Avoidoverlappingcontentinthecorrectansweranddistractors.

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ITEMCLASSIFICATIONSPECIFICATIONSItem classification specifications are broken down into 9 parts. In turn, each part of the specifications is assigned anumber which identifies a specific area of interest. This provides information to help in the construction of theexaminationandhelpstodeterminewhatitemsmaybelackinginthequestionbank.The following listprovides thekey to the itemspecificationdesignations. Pleaserefer to thedocumentClassificationReferenceformoredetailsabouttheclassificationsystem.Constructyourquestionssotheyadheretothespecificationsthathavebeenprovidedtoyouinyourassignment.A. PRESENTINGSIGNSANDSYMPTOMSB. DIAGNOSISD. DISCIPLINE(MCCEEonly)E. LIFESPANPERIODF. CONTEXTA(MCCQEPartIonly)G. CONTEXTB(MCCQEPartIonly)*I. TASKK. KEYWORDSANDPHRASES(MCCQEPartIonly)L. MASTERY(MCCEEonly)*NOTE: ThemethodofclassifyingthetaskisdifferentforbothMCCQEPartIandMCCEEMCQsrespectively.For

furtherinformation,pleaserefertotheabovementionedClassificationReferencedocument.

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SAMPLELEADINQUESTIONSWITHEXAMPLESExamplesofthetypeofstemformatsthataretypicalofquestionsineacharea,followedbyanexamplequestionthatwasconstructedfromagivenitemspecification,areprovidedbelow.HistoryMostRelevantSymptomsStemformatsuggestions:

1. Whichoneofthefollowingadditionalsymptomswouldyouconsidermostcontributorytothediagnosis?2. Apatientpresentswith...Whichoneofthefollowingsymptomswouldsupportthediagnosis?3. Whichoneofthefollowingsymptomswouldbemosthelpfulinestablishingadiagnosis?4. Whichoneofthefollowingwouldbethemostappropriateinitialquestiontoaskthepatient?

A58yearoldmanpresentstotheemergencydepartmentwithsuddenonsetofleftsidedchestpainassociatedwithshortnessofbreath,palpitationsanddizziness.Hispasthistoryisrelevantforarecentdiagnosisofalungcarcinoma.Whichoneofthefollowinghistoricalfactsismostusefulinestablishingtheetiologyofhisdiagnosis?1. Dailyrecurrentfevers.2. Purulentsputum.3. Historyofhypercholesterolemia.*4. Swollentenderlowerextremity.5. Radiationofpaintoleftarm.A. PresentingSignsandSymptoms: A14 ChestDiscomfort/Pain/AnginaPectorisB. Diagnosis: BI82 OthervenousembolismandthrombosisD. Discipline: D028 Medicine(MCCEE)E. LifeSpanPeriod: E06 Adult:1869yearsF. ContextA: F02 OngoingproblemsG. ContextB: G02 TypicalproblemI. Task: I01 Obtainhistory(MCCQEPartI) CT001 Datagathering(MCCEE)K. KeyWordsandPhrases: ChestpainL. Mastery: Yes(MCCEE)

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CauseandRiskFactorsStemformatsuggestions:

1. Whichoneofthefollowingfactorsismostlikelyresponsiblefor/topredisposeto(causes?)2. Theriskfor...isincreasedinpatientswith/who...?3. Whichoneofthefollowingdiseasesisassociatedwithexposureto...?4. Inthispatient/diseasewhichoneofthefollowingrisketiologicalfactorsshouldbeinquiredabout?5. Thedevelopmentof...isprimarilytheresultof...?

A63yearoldpreviouslyhealthyfemalepresentstoyourofficewitha1cmlesioninherrightbreast.Nolymphadenopathyispalpable.Whichoneofthefollowingismostlikelytopredisposehertoamalignantlesion?1. 40packperyearsmokinghistory.*2. Useofhormonereplacementtherapy.3. Lateonsetofmenarche.4. Caucasianrace.5. 2ouncesofalcoholdaily.A. PresentingSignsandSymptoms: A101 Breastlump/screeningB. Diagnosis: BC50 MalignantneoplasmsofthebreastD. Discipline: D028 Medicine(MCCEE)E. LifeSpanPeriod: E06 Adult:1869yearsF. ContextA: F02 OngoingproblemsG. ContextB: G02 TypicalproblemI. Task: I01 Obtainhistory(MCCQEPartI) CT001 Datagathering(MCCEE)K. KeyWordsandPhrases: BreastcancerL. Mastery: No(MCCEE)

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PhysicalExaminationMostRelevantSignsStemformatsuggestions:

1. Whichoneofthefollowingsignsismostindicative/infavorof...?2. Onphysicalexamination,specialattentionshouldbedirectedtowardwhichoneofthefollowing?3. ...isthemostcharacteristicclassicfindingofwhichoneofthefollowing?4. Whichoneofthefollowingsignsismosthelpfulinestablishingadiagnosisinthispatient?

An18yearoldwomanpresentswithprimaryamenorrhea. Onexamination,whichoneofthefollowingfindingsbestsupportsthediagnosisofTurnersyndrome?1. Hypertension.2. Hirsutism.*3. Shortstature.4. Epicanthalfolds.5. Normalexternalgenitalia.A. PresentingSignsandSymptoms: A561 Amenorrhea/OligomenorrheaB. Diagnosis: Q96 TurnersyndromeD. Discipline: D028 Medicine(MCCEE)E. LifeSpanPeriod: E06 Adult:1869yearsF. ContextA: F02 OngoingproblemsG. ContextB: G02 TypicalproblemI. Task: I02 Obtainphysicalsigns(MCCQEPartI) CT001 Datagathering(MCCEE)K. KeyWordsandPhrases: TurnersyndromeL. Mastery: No(MCCEE)

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ExpectedSignsOrAppropriateExaminationStemformatsuggestions:

1. Whichoneofthefollowingsignsismostlikelytobefoundonphysicalexamination?2. Whichoneofthefollowingshouldbemostparticularlylookedfor?3. Physicalexaminationof...wouldmostlikelydisclosewhichoneofthefollowing?

A72yearoldbachelorpresentstotheofficecomplainingoffacialpain,swelling,nauseaandshakingchillsfor24hours.Helooksunwellandhasared,raised,confluenteruptionoveronecheekandthebridgeofthenose.Whichoneofthefollowingareyoumostlikelytofindonphysicalexamination?*1. Sharpdemarcationofthemargins.2. Pustulesatthebaseofhairfollicles.3. Mucosallesionsinthemouth.4. Vesiclesintheipsilateralear.5. Bilateraltonsillarexudates.A. PresentingSignsandSymptoms: A1072 Feverofunknownorigin A922 Urticaria/Angiodema/AnaphylaxisB. Diagnosis: L03 CellulitisD. Discipline: D028 Medicine(MCCEE)E. LifeSpanPeriod: E07 Olderadult70+yearsF. ContextA: F01 AcuteproblemsG. ContextB: G02 TypicalproblemI. Task: I05 Interpretdata/makeadiagnosis(MCCQEPartI) CT001 Datagathering(MCCEE)K. KeyWordsandPhrases: Erysipelas,cellulitisL. Mastery: No(MCCEE)

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InterpretationofClinicalSignsStemformatsuggestions:

1. Whichoneofthefollowingstatementsbestexplainsthissign?2. Thesesignsaremostsuggestiveof...?3. Onemustexpecttofindthissignin...?4. Whichoneofthefollowing(disease)ismostlikelyresponsibleforthesefindings?

A74yearoldmancomplainsofprogressiveonsetofmuscleweakness,especiallyinthethighmuscles,andstiffnessinhisshoulders.Hecomplainsofdifficultyrisingfromachairandcombinghishair.Whichoneofthefollowingfindingswillmostlikelyhelpinestablishingadiagnosis?1. Elevatedserumcreatinekinase.*2. Elevatederythrocytesedimentationrate.3. Elevatedserumcalcium.4. Positiveacetylcholinereceptorantibody.5. Evidenceofmuscledamageonelectromyogram.A. PresentingSignsandSymptoms: A117 Weakness/Paralysis/Paresis/LossofMotionB. Diagnosis: M35 OthersystemicinvolvementofconnectivetissueD. Discipline: D028 Medicine(MCCEE)E. LifeSpanPeriod: E07 Olderadult70+yearsF. ContextA: F02 OngoingproblemsG. ContextB: G02 TypicalproblemI. Task: I03 Obtainlaboratorydata(MCCQEPartI) CT001 Datagathering(MCCEE)K. KeyWordsandPhrases: PolymyalgiarheumaticaL. Mastery: No(MCCEE)

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InvestigationAppropriateInvestigationStemformatsuggestions:

1. Whichoneofthefollowingdiagnosticstudies/examinationsismostindicatedatthistime?2. Thebestinitialdiagnosticstepistoorder...?3. Whichoneofthefollowingtestsismostlikelytoconfirmthediagnosisof...?4. Thediagnosisof...isbestsupportedbywhichoneofthefollowing?5. Whichoneofthefollowingfindingsismostcharacteristicof...?

A 32yearoldunemployedmanwho abuses alcoholwhounderwent amastoidectomy as a youngsterpresentswithheadaches, nausea, vomiting, drowsiness and confusion. He does not have a fever but his right eardrum is notvisualized and there appears tobe somedischarge there. There is slightneck stiffness aswell. Which one of thefollowinginvestigationsisthemostappropriateatthistime?1. Lumbarpuncture.2. Electroencephalogram.3. Skullxray.*4. Computedtomographyscanofhead.5. Bloodculture.A. PresentingSignsandSymptoms: A581 ComaB. Diagnosis: G06 IntracranialandintraspinalabscessandgranulomaD. Discipline: D028 Medicine(MCCEE)E. LifeSpanPeriod: E06 Adult:1869yearsF. ContextA: F01 AcuteproblemsG. ContextB: G02 TypicalproblemI. Task: I03 Obtainlaboratorydata(MCCQEPartI) CT001 Datagathering(MCCEE)K. KeyWordsandPhrases: Cerebralabscess,diagnosisL. Mastery: Yes(MCCEE)

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InterpretationOfResultsStemformatsuggestions:

1. Thesefindingsaremostconsistentwiththediagnosisof...?2. Whichoneofthefollowingresults/findingsismostconsistentwiththediagnosisof?3. Whichoneofthefollowingresultsismostlikelytobefoundinthiscase?

An84yearoldwomanpresentswithahistoryofconfusionandconstipation.Laboratoryinvestigationsrevealaserumcalciumof2.9mmol/L,acreatinineof146mmol/Landahemoglobinof108. Thesefindingsaremostsuggestiveofadiagnosisof:1. Hyperparathyroidism.2. Chronicrenalfailure.*3. Multiplemyeloma.4. VitaminDintoxication.5. Renalcellcarcinoma.A. PresentingSignsandSymptoms: A582 Delirium/ConfusionB. Diagnosis: BC90 MultiplemyelomaD. Discipline: D028 Medicine(MCCEE)E. LifeSpanPeriod: E07 Olderadult70+yearsF. ContextA: F02 OngoingproblemsG. ContextB: G02 TypicalproblemI. Task: I05 Interpretdata/makeadiagnosis(MCCQEPartI) CT002 Datainterpretation(MCCEE)K. KeyWordsandPhrases: Hypercalcemia,renalfailureL. Mastery: Yes(MCCEE)

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CommonScreeningTestsStemformatsuggestions:

1. Whichoneofthefollowingtestsismostusefulforthescreeningof...?2. Themostcosteffectivescreeningtestinthiscaseiswhichoneofthefollowing?3. Whichoneofthefollowingtestsismostlikelytoleadtoadiagnosis?4. Whichoneofthefollowingtestswillhelptoestablishtheetiologyof?

A 32yearoldwoman presentswith a twoweek history of diarrhea associatedwith heat intolerance, sweating andrestlessness.Physicalexaminationrevealsabloodpressureof150/60mmHgandapulseof106/minute.Shehasafinetremorofheroutstretchedarms. Herthyroidisdiffuselyenlarged,firmandtender.Whichoneofthefollowingtestswillhelptoestablishtheetiologyofherthyrotoxicosis?1. Antithyroidantibodies.2. Sensitivethyroidstimulatinghormoneassay.3. Freetriiodothyronine(T3.)*4. Radioactiveiodineuptake.5. Erythrocytesedimentationrate.A. PresentingSignsandSymptoms: A63 Neckmass/Goiter/ThyroidDiseaseB. Diagnosis: E05 AcutepericarditisD. Discipline: D028 Medicine(MCCEE)E. LifeSpanPeriod: E06 Adult:1869yearsF. ContextA: F01 AcuteproblemsG. ContextB: G02 TypicalproblemsI. Task: I05 Obtainlaboratorydata(MCCQEPartI) CT001 Datagathering(MCCEE)K. KeyWordsandPhrases: Thyrotoxicosis,etiologyL. Mastery: No(MCCEE)

22

DiagnosisMostLikelyDiagnosisStemformatsuggestions:

1. Whichoneofthefollowingdiagnosesisthemostlikely?2. Themostlikelyunderlyingcauseis...?3. Thedifferentialdiagnosisshouldconsiderwhichoneofthefollowing?

A65yearoldmanwhohadbeenmakinganapparentlysatisfactoryrecoveryfromamyocardialinfarctionsixdayspreviouslysuddenlydevelopspulmonaryedema.Thereisaregulartachycardiaof120/minute,aparasternalheave,apansystolicmurmurovertheprecordiumandaS3gallop.Bloodpressureis100/60mmHg.Whichoneofthefollowingisthemostlikelydiagnosis?1. Postinfarctpericarditis.2. Anothermyocardialinfarction.*3. Rupturedpapillarymuscle.4. Cardiactamponade.5. Ventricularaneurysm.A. PresentingSignsandSymptoms: A27 DyspneaB. Diagnosis: I23 Certaincurrentcomplicationsfollowingacutemyocardial infarctionD. Discipline: D028 Medicine(MCCEE)E. LifeSpanPeriod: E06 Adult:1869yearsF. ContextA: F01 AcuteproblemsG. ContextB: G02 TypicalproblemI. Task: I05 Interpretdata/makeadiagnosis(MCCQEPartI) CT002 Datainterpretation(MCCEE)K. KeyWordsandPhrases: Myocardialinfarction,complicationsL. Mastery: No(MCCEE)

23

Severity,Prognosis,LocationOfDiseaseStemformatsuggestions:

1. Whichoneofthefollowingismostlikelytheprimarysiteof...?2. Thestageofthe...inthiscaseis...?3. Whichoneofthefollowingfindings/testsismostusefulinestablishingthestage/severity/prognosisof...?4. Whichoneofthefollowingfindings/signs/testresultssuggestsafavorable/unfavorableprognosis?

A72yearoldmanpresentstoyourofficeforevaluationpriortocoloncarcinomaresection.Whichoneofthefollowinghistoricalfactsisassociatedwithanincreasedriskofcardiovasculardeathinthisgentleman?1. Bronchialasthma.2. Atrialfibrillation.*3. Myocardialinfarctionlessthanthreemonthsago.4. Stableangina.5. Previouscoronaryarterybypasssurgery.A. PresentingSignsandSymptoms: A743 PreoperativemedicalevaluationB. Diagnosis: BI23 Certaincurrentcomplicationsfollowingacutemyocardial infarctionD. Discipline: D028 Medicine(MCCEE)E. LifeSpanPeriod: E07 Olderadult70+yearsF. ContextA: F04 PrincipleorcircumstanceG. ContextB: G01 UndifferentiatedcomplaintI. Task: I11 Prognosis/Complications/Outcomes(MCCQEPartI) CT006 Prevention/Education(MCCEE)K. KeyWordsandPhrases: CardiovasculardeathandnoncardiacsurgeryL. Mastery: No(MCCEE)

24

Counseling,EducationStemformatsuggestions:

1. Whichoneofthefollowinginstructions/recommendationsshouldbegiventothepatient?2. Whichoneofthefollowingrecommendationsisthemostappropriate?3. Whichoneofthefollowingpiecesofinformationshouldbeprovidedto...?4. Thispatientshouldbeinstructedtoavoidwhichoneofthefollowing?

A19yearoldwomanhasbeentakinginsulinforoneyear.Sheismonitoringherbloodglucoseregularlyinanappropriatemannerandmostvaluesarewithintherecommendedrange.However,shereportstwoorthreesymptomaticepisodesofhypoglycemiawithinthepastweek.Whichoneofthefollowingisimportantforyoutoadviseherabout?*1. Nodrivinguntilshehasresolvedherepisodesofhypoglycemia.2. Glucagonshouldbegivenatthehospitalonly.3. Sheshouldstopexercising.4. Sheshouldincreasehercaloricintakeatsnacktime.5. Relativesarenotdependableintreatinghypoglycemia.A. PresentingSignsandSymptoms: A372 HypoglycemiaB. Diagnosis: E10 InsulindependentdiabetesmellitusD. Discipline: D028 Medicine(MCCEE)E. LifeSpanPeriod: E06 Adult:1869yearsF. ContextA: F02 OngoingproblemsG. ContextB: G02 TypicalproblemI. Task: I08 Managementeducation/counseling(MCCQEPartI) CT005 Counseling(MCCEE)K. KeyWordsandPhrases: Hypoglycemia,managementL. Mastery: No(MCCEE)

25

SideEffects,ContraindicationsStemformatsuggestions:

1. Whichoneofthefollowingadverseeffects/sideeffects/complicationsismostlikelytodevelopinthispatient/inapatienttreatedwith...?

2. Whichoneofthefollowingfindingscontraindicatestheuseof...?3. Whichoneofthefollowingiscontraindicatedin...?

A70yearoldmantreatedforParkinsondiseasepresentswithasixmonthhistoryofheartburnandoccasionalmorningvomiting.Yourworkuprevealsaseveregastroesophagealrefluxwithmoderateesophagitis.Whichoneofthefollowingmedicationswouldbecontraindicated?1. Ranitidine.2. Calciumcarbonate(TUMS.)*3. Metoclopramide.4. Sucralfate.5. Omeprazole.A. PresentingSignsandSymptoms: A32 Abdominalpain,acuteB. Diagnosis: K21 GastroesophagealrefluxdiseaseD. Discipline: D028 Medicine(MCCEE)E. LifeSpanPeriod: E07 Olderadult70+yearsF. ContextA: F02 OngoingproblemsG. ContextB: G02 TypicalproblemI. Task: I07 Managementdrugtherapy(MCCQEPartI) CT004 Drugtherapy(MCCEE)K. KeyWordsandPhrases: Gastroesophagealrefluxwithmoderateesophagitis,contraindicationsL. Mastery: No(MCCEE)

26

APPENDICESClinicalLaboratoryTestsNormalValuesThistablelistsreferencevaluesforthemostcommonlaboratorytestsandisintendedforinterpretationoftheresultsastheyareprovidedintheexamination.NotethatallvaluesareprovidedinSIunits.Allvaluesapplytoadults.Manyimportantlaboratoryreferencevaluesarenotlistedherebecauseofthelessfrequentuseofthesetests.Suchvaluesareinsertedinparenthesesfollowingtheresultrecordedintheexaminationquestions.BLOOD COAGULATION(HEMOSTASIS) Chloride(serum) 98106mmol/L Cholesterol(serum)

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ReferencesAlbanese,M.A.,TypeKandothercomplexmultiplechoiceitems:AnAnalysisofresearchanditemproperties,EducationalMeasurement:IssuesandPractice,12,(1993),pp.2833Albanese,M.A.,Kent,T.H.,Whitney,D.R.,Acomparisonofdifficulty,reliability,andvalidityofcomplexmultiplechoice,multipleresponsesandmultipletruefalseitems,Report#95(IowaCity:UniversityofIowa,LearningResourcesUnit,CollegeofMedicineandEvaluationandExaminationService,1977)Albanese,M.A.,Kent,T.H.,Whitney,D.R.,Clueinginmultiplechoicetestitemswithcombinationsofcorrectresponses,JournalofMedicalEducation,1979,pp.948950Berk,R.A.,Aguidetocriterionreferencedtestconstruction(Baltimore:JohnHopkins,1984)Case,S.,Downing,S.,Performanceofvariousmultiplechoiceitemtypesonmedicalspecialtyexaminations:TypeA,B,C,K,andX,proceedingsfromtheTwentyEighthAnnualConferenceonResearchinMedicalEducation(Washington,DC:AssociationofAmericanMedicalColleges,1989)pp.167172Crocker,L.,Algina,J.,Introductiontoclassicalandmoderntesttheory(Montreal:HarcourtBraceJovanovichCollegePublishers,1986)DawsonSaunders,B.,Nungester,R.,Downing,S.,Acomparisonofsinglebestanswermultiplechoiceitems(Atype)andcomplexmultiplechoiceitems(Ktype),proceedingsfromtheTwentyEighthAnnualConferenceonResearchinMedicalEducation(Washington,DC:AssociationofAmericanMedicalColleges,1989)pp.161166Ebel,R.L.,Blindguessingonobjectiveachievementtests,JournalofEducationalMeasurement,vol.5,(1968)pp.321325Green,K.,Effectsofitemcharacteristicsonmultiplechoiceitemdifficulty,EducationalandPsychologicalMeasurement,vol.44(1984)pp.551561Gross,L.J.,Logicalversusempiricalguidelinesforwritingtestitems,EvaluationintheHealthProfessions,vol.17(1994)pp.123126Haladyna,T.M.,DevelopingandvalidatingMultipleChoiceTestItems(Hillsdale:LawrenceErlbaum,1994)Haladyna,T.M.,Downing,S.M.,Validityofataxonomyofmultiplechoiceitemwritingrules,AppliedMeasurementinEducation,vol.2,no.1(1989)pp.5178Harasym,P.H.,Price,P.G.,Brant,R.,Violato,C.,Lorscheider,F.L.,Evaluationofnegationinstemsofmultiplechoiceitems,EvaluationintheHealthProfessions,vol.15(1992)pp.198221Harasym,P.H.,Norris,D.A.,Lorscheider,F.L.,Evaluatingstudentmultiplechoiceresponses:Effectsofcodedandfreeformats,EvaluationandtheHealthProfessions,vol.3(1980)pp.6384Huntley,R.M.,Plake,B.S.,Aninvestigationofmultipleresponseoptionitems:Itemperformanceandprocessingdemands,paperpresentedatthemeetingoftheNationalCouncilonMeasurementinEducation,(NewOrleans,April1984)Kolstad,R.,Briggs,L.D.,Bryant,B.B.,Kolstad,R.A.,Complexmultiplechoiceitemsfailtomeasureachievement,JournalofResearchandDevelopmentinEducation,vol.17(1983)pp.711Kolstad,R.,Wagner,M.J.,Kolstad,R.A.,Miller,E.G.,Thefailureofdistractorsoncomplexmultiplechoiceitemstopreventguessing,EducationalResearchQuarterly,vol.8(1983)pp.4450

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Oosterhof,A.C.,Coats,P.K.,Comparisonofdifficultiesandreliabilityofquantitativewordproblemsincompletionandmultiplechoiceitemformats,AppliedPsychologicalMeasurement,vol.8(1984)pp.287294Osterlind,S.J.,Constructingtestitems(Boston:Kluwer,1998)Parker,C.S.,Somers,J.E.,AcomparisonofthedifficultyandreliabilityofTypeKandonebestresponseformats,paperpresentedatthemeetingoftheIowaEvaluationandResearchAssociation,(DesMoines,November1983)Rossi,J.S.,McCrady,B.S.,Paolino,T.J.,AandBbutnotC:Discriminatingpowerofgroupedalternatives,PsychologicalReports,vol.42(1978)p.1346Tripp,A.,Tollefson,N.,Arecomplexmultiplechoiceoptionsmoredifficultanddiscriminatingthanconventionalmultiplechoiceoptions?JournalofNursingEducation,vol.24(1985)pp.9298.Weiten,W.,Violationofselecteditemconstructionprinciplesineducationalmeasurement,JournalofExperimentalEducation,vol.52(1984)pp.174178Case,S.M.,Swanson,D.B.,ConstructingWrittenTestQuestionsfortheBasicandClinicalExaminers,NationalBoardofExaminers(Philadelphia,2002)Downing, S.M., Assessment ofKnowledgewithWritten Test Forms, InternationalHandbook of Research inMedicalEducation(2002)pp.647672

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SampleItemDevelopmentFormCLINICALPRESENTATION:Category:DysphagiaMCCOBJECTIVE: Determinewhethersymptomatologyisintermittentorprogressiveandweightloss(latesign)aproblem,any

neurologicsymptomoraspiration Determinethepresenceofcoughing,choking,droolingorregurgitationAUTHOR:Dr. A 40yearoldpatientpresents toyouroffice complainingofheartburnand somedifficulty in swallowing. Thesesymptomshavebeenpresent for several years,buthaveworsenedduring the last sixmonths. Which one of thefollowingfindingswouldyouconsiderthemostsuggestiveofrefluxesophagitis?*1. Regurgitationswhenlyingdown.2. Progressivedysphagia.3. Gastrointestinalbleeding.4. Morninghoarseness(laryngitis.)5. Recurrentpulmonaryinfections.(Pleasenotethecorrectresponseshouldbeindicatedbyanasterisk.)REFERENCE:Sabiston,TextbookofSurgery,14thEd.,Saunders,p.708MCCCLASSIFICATION:ADysphagiaBK21DD030EE08FF02GG02II05

CT002KHeartburn;dysphagia;refluxesophagitisLL02

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SampleItemDevelopmentTemplateMCCQEPartIOnlyCLINICALPRESENTATION:Category: MCCOBJECTIVE: AUTHOR:Dr. Stem:

ResponseOptions:

1.

2.

3.

4.

5.

(Pleasenotethecorrectresponseshouldbeindicatedbyanasterisk.)REFERENCE: MCCCLASSIFICATION:

A G

B I

E K

F L

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SampleItemDevelopmentTemplateMCCEEOnlyCLINICALPRESENTATION:Category: MCCOBJECTIVE: AUTHOR:Dr. Stem:

ResponseOptions:

1.

2.

3.

4.

5.

(Pleasenotethecorrectresponseshouldbeindicatedbyanasterisk.)REFERENCE: MCCCLASSIFICATION:

A

B D

E I

L

Guidelines For TheDevelopmentOf Multiple-ChoiceQuestions Table Of Contents