Exam MCCQE Topic 1 Question 5 Discussion

Actual exam question for Medical Council of Canada's MCCQE exam
Question #: 5
Topic #: 1

A 16-year-old girl presents to the clinic with concerns about her toenails. The lesions, as shown in the attached image, have been present for 2 to 3 months. She is otherwise healthy and is in training for a triathlon.
Which one of the following is the best next step?

A. Recommend that the patient's running shoes provide adequate toe space. B. Advise the patient to carefully wash and dry feet after all activity. C. Arrange for biopsy of the lesions. D. Suggest that the patient avoid swimming pools and hot tubs. E. Prescribe daily antifungal cream application.

Suggested Answer: A Vote an answer

In a healthy adolescent training for a triathlon, the most likely cause of subacute toenail changes is repetitive microtrauma from running-often due to shoes with inadequate toe box space or downhill running-leading to nail plate injury (e.g., subungual hemorrhage/onycholysis and dystrophic discoloration). MCCQE objectives emphasize choosing the most probable diagnosis based on context and initiating the least invasive, most appropriate first-line management. The key intervention is correcting the mechanical cause: ensuring adequate toe space, proper shoe fit, and appropriate nail trimming, which typically prevents progression and allows gradual regrowth over months.
Topical antifungal creams are unlikely to help if the primary issue is trauma and, even in onychomycosis, topical creams generally do not penetrate the nail plate effectively. Hygiene advice and avoiding pools/hot tubs may reduce superficial fungal exposure but does not address the principal driver in this scenario. Biopsy is unnecessary for typical trauma-related nail changes in a low-risk patient without concerning features (rapid growth, pigment extending onto adjacent skin, or mass).

by Matt at Mar 06, 2026, 07:36 PM

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