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MCQ exam 2014/2015 Rotation 4

Author: Roger Ho

Vetted by Iris Rawtaer and A/Prof John Wong

History, mental state exam, psychopathology,diagnosis

1. You are a resident doctor working at the Instituteof Mental Health (IMH). The police officersbought a 39-year-old man charged withpossessing a scheduled weapon and was sent tothe IMH for a psychiatric evaluation. Although hespeaks English, you cannot make out what he issaying because his speech becomes diffuse andunfocused. Which of the following best describeshis psychopathology?

A. CircumstantialityB. Loosening of associationC. Thought insertionD. Thought withdrawalE. Tangentiality.

The answer is B.

Explanation: Loosening ofassociation is defined as aspeech where topics seem to bedisconnected and it is hard forothers to establish a logical linkbetween topics. The speechbecomes diffuse and unfocused.

Author: Roger HoYear: 2014.

2. You are a resident working at the Accident andEmergency Department (AED). A 35-year-oldman was sent to the AED for psychiatricassessment by an ambulance. He was involvedin a road traffic accident. He was a passenger in

a taxi. He told the taxi driver that he was God andthreatened the driver to believe that he was thesaviour of the world. The driver found him veryirritable and he kept hitting the head of the driver.The driver stopped the taxi and tried to call thepolice. The patient drove the taxi at high speedand crashed the taxi into a lamp post. He was notunder influence of alcohol at the time of accident.You are required to enter a diagnosis into the AED computerised system. Based on theinformation provided, which of the followingpsychiatric diagnosis is most relevant?

A. Antisocial personality disorderB. Bipolar disorderC. Conversion disorderD. Dissociative disorderE. Schizophrenia.

The answer is B

Explanation: This man suffersfrom bipolar disorder, manicepisode as evidence based by

grandiose delusion, irritability,reckless and dangerousbehaviour.


Cognitive assessment

3. A 30-year-old woman has received 6 sessions ofelectroconvulsive therapy (ECT). After the ECT,she complains of cognitive impairment andattributes the following symptoms as side effectsof ECT. Which of the following is most likelycaused by ECT?

The answer is B.

Explanation: Young patientsusually develop retrogradeamnesia of recent events but notanterograde amnesia (option A)

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A. Cannot follow the instructions given by hersupervisor after she returns to work

B. Cannot recall the password of her email accountC. Cannot remember details of her ex-marriageD. Difficulty to perform two tasks at one timeE. Unable to calculate.

or life events (option C). ECTdoes not affect multi-tasking andcalculation.


4. You are administering the “Serial 7” test to a patient.His answers are listed as follows: 100 – 7 = 90; 90 – 7= 77; 77 – 7 = 70; 70 – 7 = 63; 63 – 7 = 50. What is hisscore?

A. 0 out of 5B. 1 out of 5C. 2 out of 5D. 3 out of 5E. 4 out of 5.

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Psychiatric epidemiology

5. Which of the following is the most commonpsychiatric co-morbidity of panic disorder?

A. Alcohol misuseB. AgoraphobiaC. Avoidant personality disorderD. Benzodiazapine misuseE. Generalised anxiety disorder.

The answer is B.

Explanation: Agoraphobia (40%)> alcohol dependence (30%).The other options are less likelyto be associated with panicdisorder.


Psychiatric aetiology, diagnosis and classification

6. The prevalence of borderline personalitydisorder in Singapore and worldwide hasincreased in the past three decades. The mostlikely explanation for this observation is:

A. Changes in diagnostic criteriaB. Increase in competition in schools

C. Increase in divorce rateD. Increase in immigration and migrationE. Increasing urbanization of the population.

The answer is C.

Explanation: increase in divorcerate is associated with trauma,neglect and splitting in family.These are importantpredisposing factors forborderline personality disorder.

There is no major change indiagnostic criteria. Some of thefactors may occur too late toaffect personality development(e.g. migration). As Singapore isa city state, the effect ofurbanization is minimal.

Author: Roger HoYear: 2014

7. Which of the following is least likely to be a riskfactor for delusional disorder?

A. Having a religion

The answer is A.

Explanation: Having a religion isnot a risk factor for developing

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B. Increased ageC. ImmigrationD. Sensory impairmentE. Social isolation.

delusional disorder. The risk ofdelusional disorder increaseswith age. Hearing loss is a riskfactor. Low socioeconomic statusand severe stress are also riskfactors.


8. The genetic polymorphisms of which of thefollowing neurotransmitter transporter genesaffect the risk of developing depressive disorder?

A. DopamineB. γ-Aminobutyric acid (GABA)C. Glutamate

D. NorephinephrineE. Serotonin.

The answer is E.

Explanation: Individuals withhomozygous short alleles at theserotonin transporter gene aremore likely to developdepression.


9. A 40-year-old patient with schizophrenia presentsto the emergency department with confusion andagitation following an overdose of haloperidol.The patient has a temperature of 41 degreeCelsius, blood pressure of 160/100 mm Hg, andpulse of 120 beats per minute. Physicalexamination reveals rigidity, hot, wet skin, anddecreased bowel sounds. This patient’s

symptoms, are most likely caused by blocking ofwhich of the following receptors?

A. Alpha1-adrenergicB. DopaminergicC. HistaminergicD. Muscurinic cholinergicE. Nicotinic cholinergic.

The answer is B.

Explanation: This patientdevelops neuroleptic malignantsyndrome due to blockage ofdopamine receptors byhaloperidol.


General adult psychiatry

10. A 30-year-old man suffers from schizophrenia.He first exhibited first rank symptoms at the ageof 16 and the onset was insidious. He exhibitsanhedonia although his hallucinations are undercontrol by antipsychotic drug. His uncle suffersfrom depressive disorder. All of the following arepoor prognostic factors except?

A. AnhedoniaB. Exhibition of first rank symptoms at the age of 16C. Family history of depressive disorderD. Male genderE. Insidious onset.

The answer is C.

Explanation: Poor prognosticfactors include young onset, noprecipitating factors, insidiousonset, poor premorbidfunctioning, family history ofschizophrenia, negativesymptoms, poor support,neurological symptoms and poorcompliance.


11. You are the resident working in the Accident andEmergency Department. A schizophrenia patient The answer is B.

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informs you that he has homicidal thought. Whichof the following sign or symptom is leastimportant in predicting homicide?

A. Command hallucinationsB. Delusion of referenceC. History of previous violenceD. Irresistible urge to attackE. Need to defend oneself as are result of

persecutory delusion.

Explanation: Delusion ofreference is not directly relatedto violence and carries lower riskof homicide as compared toother signs and symptoms.


12. All of the following are poor prognostic signs forobsessive compulsive disorder except:

A. Bizarre compulsionsB. Childhood onset

C. Episodic courseD. Comorbid major depressionE. Succumbing to obsessions and compulsions.

The answer is C.

Explanation:Poor prognosis:

1. yielding to compulsions(not resisting)

2. childhood onset3. bizarre compulsions4. need for hospitalization5. presence of overvalued

ideas (i.e. acceptance)6. personality disorders

(especially schizotypal)7. co-existing delusional

beliefs8. co-existent major

depressive disorder


13. You are a general practitioner. A 35-year-oldhotel butler came to see you because his lawyerwants him to be seen by a psychiatrist. He wasrecently arrested for installing pinhole camera inthe hotel guestrooms. He secretly filmed coupleshaving sex in the hotel guestrooms. He hasfilmed more than 100 videos and enjoyedwatching them over and over again. He claimsthat he has the compulsion to collect thosevideos and he feels relieved after the arrest.Which of the following is the most likelydiagnosis?

A. ErotomaniaB. KleptomaniaC. Obsessive compulsive disorderD. SadomasochismE. Voyeurism.

The answer is E.

Explanation: Voyeurism isdefined as recurrent and intensesexual arousal from observingother people being naked orengaging sexual activity.


14. A 30-year-old woman always believes that she issocially inept and fears of negative evaluation by

other people. Her sisters describe her as timidand insecure. She is single and stays with two

The answer is A.

Explanation: She suffers fromavoidance personality disorder

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elder sisters. She was admitted to the psychiatricward due to ‘nervous breakdown’ after meetingnew colleagues in her workplace. She refuses toattend family meeting with her sisters becauseshe feels that her sisters do not like her althoughthey appear to be very concerned about hercondition. She is isolated and has one best friendin her work place. Which of the followingpersonality best describes this patient?

A. Avoidant personality disorderB. Borderline personality disorderC. Histrionic personality disorderD. Paranoid personality disorderE. Schizoid personality disorder

as evidenced by pervasivetension (e.g. nervousbreakdown), unwilling to beinvolved unless being liked (e.g.family meeting with her sister),fear of criticism, showingrestraint in intimate relationship(e.g. being single) and inhibitionof new interpersonal situations(e.g. meeting new colleagues)and belief of socially inept.


15. Which of the following is not a common feature ofserotonin syndrome?

A. AcidosisB. DiaphoresisC. HyperreflexiaD. HypothermiaE. Myoclonus.

Answer: D

Explanation: Serotonin syndromeactually causes fever. Metabolicacidosis in seen in 9% ofpatients.


16. You are a resident working in the accidentand emergency department (AED). A singlemother was sent to the AED with her 2-year-old daughter. She was arrested by policebecause she tried to assault her daughterand stopped by passer-by. According to theinformant, her partner refuses to marry herdue to her drug habit. She does not havepast forensic history. She appears to beagitated and restless. At one moment, shewants to stay in the AED. At anothermoment, she wants to walk out of the AED.Physical examination reveals nystagmus.Which of the following diagnosis is mostrelevant?

A. Antisocial personality disorderB. Cannabis intoxicationC. Delusion of jealousyD. Paranoid schizophreniaE. Phencyclidine intoxication

The answer is E.

Explanation: The immediatediagnosis is PCP intoxication

as evidenced byunpredictability (staying in AED versus walking out of AED), assaultativeness on herdaughter, agitation andnystagmus. Antisocialpersonality disorder requiresfurther evidence as forensichistory is negative and cannotexplain nystagmus.


Old age psychiatry

17. You are about to start a selective serotoninreuptake inhibitor (SSRI) for an 80-year-old manwho suffers from depression. Which of thefollowing pharmacokinetic changes has the leasteffect on drug therapy in the elderly?

A. AbsorptionB. Distribution

The answer is A.

Explanation: There is noconsistent age effect onabsorption of antidepressant inelderly. For distribution, theelderly have more fat stores;therefore they will have lower

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C. ExcretionD. MetabolismE. Protein binding.

plasma concentrations of lipidsoluble drugs, but will havelarger distribution volumes ofthese drugs and therefore longerhalf-lives. This may causeproblems for elderly takingfluoxetine.

For metabolism, all psychotropicmedications metabolized in theliver have their elimination half-life increased two or three-fold inthe elderly.

For excretion, decreased GFRand renal blood flow lead todecreased clearance of lithium

and antidepressant metabolites.

For protein binding, the elderlyhave lower levels of plasmaalbumin due to malnutrition, andtherefore have an increased freefraction of protein bound drugs.


This is an advanced level

question.

18. A 79-year-old man complains of extremedrowsiness when he goes to toilet at midnightand he almost fell down on several occasions. Hewants to avoid fall at night. The following is thelist of his medications. Which of the followingmedications should be stopped?

A. MelatoninB. MirtazapineC. Risperidone

D. RivastigmineE. Sodium valproate.

The answer is B.

Explanation: Mirtazapine is themost sedative medication amongall the options.


19. A 70-year-old woman suffering from bipolardisorder and her daughter came to see youtoday. Her daughter read about the symptoms ofbipolar disorder and found her mother differentfrom younger adults suffering from the samecondition. Which of the following clinical featuresis more likely to be found in this 70-year-oldwoman?

A. Demonstrates less paranoid ideas as comparedto adult patients

The answer is D.

Explanation: Elderly with bipolardisorder are more likely to beparanoid and present with mixedclinical presentations. Elderly areless likely to develop flight ofideas, hyperactivity andoverspending.


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B. Demonstrates more flight of ideas as comparedto adult patients

C. More likely to be hyperactive as compared toadult patients

D. More likely to demonstrate mixed(depressive/manic) clinical presentations ascompared to adult patients

E. More spending as compared to adult patients.

20. Which of the following is most important riskfactor for vascular dementia?

A. History of depressionB. History of poor academic performanceC. History of hypertensionD. High level of physical activityE. High level of high density lipoproteins.

The answer is C.

Explanation: Among all theoptions, hypertension is the mostsignificant risk factor for vasculardementia.

Author: Roger Ho

Year: 2014

21. You are the visiting physician of a nursing home.The nursing home staffs feel very helpless whenhandling aggression in dementia patients andthey need to seek your advice. Which of thefollowing psychotropic medication have the mostevidence in managing aggression in patientssuffering from dementia?

A. Antipsychotic drug

B. Beta-blockerC. BenzodiazapineD. LithiumE. Stimulant.

The answer is A.

Explanation: Antipsychotic drug(e.g. risperidone) has the mostevidence in improvingaggression in dementia patientsamong all options.

Author: Roger Ho

Year: 2014

Child and adolescent psychiatry

22. In children and adolescents, high stimulation-seeking behaviour is associated with which of thefollowing conditions?

A. Adolescent-onset schizophreniaB. AutismC. Conduct disorderD. Obsessive-compulsive disorderE. School refusal.

The answer is C.

Explanation: Young people withconduct disorder have to beinvolved in delinquent behaviourto get high stimulus.


23. Children with autism are most comfortable inwhich of the following situations?

A. Attending a party where there are a lot ofsurprises and have a chance to meet differentpeople.

B. Attending drama classes and imagines oneself

playing different roles in the drama.C. Looking for toys in a multi-storey department

The answer is D.

Explanation: Travelling in a busbecause it has a predictableroute (i.e. the bus stops at everybus stop and there isuncertainty).

Author: Roger Ho

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store from one level to another level.D. Travelling in a bus when it stops at every bus

stop until it reaches the bus terminal.E. Going to school where there are multiple classes

to attend in a day and teaching content variesfrom subject to subject.

Year: 2014

24. Which of the following statements is most correctregarding the impact of divorce on children?

A. Boys aged two to four are not significantlyaffected.

B. Children do best if they have no contact with thefather for two years.

C. Most children have no significant problems afterthree to six months.

D. Socio-economic status is not associated with thedegree of impairment.

E. To evaluate the impact, one must take intoconsideration the age and the developmentallevel of the child.

The answer is E.

Explanation: Options A and Bhave no evidence base. Foroption C, most children take 3-5years to recover. Socio-economic status affects theoutcome.


25. A 15-year-old obese female is brought by herparents for an evaluation as part of the admissionprocess for a weight management program. Theadolescent agrees with the fact that she isoverweight and she is keen to lose weight.Which of the following is most indicative that shewill be successful in the program?

A. Her current BMI is between 26 and 30.B. Mother suffered from obesity and successfully

lost weightC. No family history of eating disordersD. Motivation to take antidepressantE. Willingness to change her eating habits.

The answer is E.

Explanation: The patient mustagree to use conservativemethods including changing diethabits, seeing a dietician andgoing for exercise to lose weight.


Substance abuse

26. Methylene dimethylamphteamine (street name:ecstasy) usually cause people with which of thefollowing symptom?a. Amotivationb. Closeness to othersc. Depressiond. Introversione. Phobia.

The answer is B.

Explanation: Ecstasy is alsoknown as an empathogen andmakes the patient to feel close toothers.


27. A 30-year-old adult claims to suffer from adultonset attention deficit and hyperactivity disorder(ADHD). He has been seeing different doctors toobtain methylphenidate. He claims that he lost allmethylphenidate in the bus few days ago and hiswife has noticed that he looks very tired. Which

of the following is most appropriate explanationfor his tiredness?

The answer is D.

Explanation: This patient isdoctor shopping and tries toobtain methylphenidate becausehe is dependent on this

medication. He lost themedication few days ago and

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A. He develops depression and psychomotorretardation

B. He exhibits secondary gain and seekingattention from his wife

C. He suffers from comorbid somatisationdisorder in addition to ADHD

D. He suffers from psychological withdrawalsymptoms from stimulant misuse

E. He suffers from stimulant intoxication.

developed psychologicalwithdrawal symptoms includingdepression, tiredness,oversleeping and overeating.


28. The most important objective ofpsychological intervention in treating peoplesuffering from alcohol misuse is:

A. To conduct in a group therapy formatB. To apply cognitive behaviour therapy (CBT) as

the first approach

C. To combine psychological intervention andpharmacotherapy (e.g. disulfiram)

D. To focus on achieving and maintainingabstinence or reducing alcohol use

E. Explore unresolved psychodynamic conflicts.

The answer is D.

Explanation: Achievingabstinence or reduction ofalcohol use is most importantpsychotherapeutic objective.


Psychopharmacology

29. Which of the following medications is notassociated with weight gain?

A. ClozapineB. Mirtazapine

C. OlanzapineD. Sodium valproateE. Topiramate.

The answer is E.

Explanation: Topiramate isassociated with weight loss andnot weight gain.


30. A 60-year-old man is started on anantidepressant for treatment of major depressivedisorder. Three weeks later, he complains ofblurred vision, dry mouth, constipation, urinaryretention and tachycardia. Which of the followingmedications is most likely to have caused thispresentation?

A. AgomelatineB. DuloxetineC. FluoxetineD. ImipramineE. Mirtazapine

The answer is D.

Explanation: Imipramine is atricyclic antidepressant andassociated with anticholinergicside effect.


31. Which of the following medications is most likelyto be associated with polycystic ovariansyndrome in female patients?

A. Carbamazapine

B. LamotrigineC. Lithium

The answer is D.

Explanation: Sodium valproate isassociated with polycystic ovarysyndrome in female patients.

Author: Roger Ho

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D. Sodium valproateE. Topiramate.

Year: 2014

32. Regarding an antidepressant called bupropion,which of the following statements is false?

A. It causes insomnia.B. It has a half-life of approximately 12 hours.C. It is safe for patients suffering from bulimia

nervosa.D. It is an antidepressant used for depressed

patients with cardiovascular disease and habit ofsmoking.

E. It does not cause weight gain.

The answer is C.

Explanation: bupoprion works onnoradrenaline and dopamine butnot serotonin. It is notrecommended for eating disorderbecause of the risk of seizure.


33. Mirtazapine is associated with lesser sexual sideeffects. Which of the following

pharmacodynamics actions explains thisphenomenon?

A. Serotonin receptor 5HT1A agonismB. Serotonin receptor 5HT2A antagonismC. Serotonin receptor 5HT2C antagonismD. Serotonin receptor 5HT3 antagonismE. Histamine receptor antagonism.

The answer is B.

Explanation: Mirtazapineantagonises 5HT2A receptors andleads to anxiolytic effects,restores sleep and less sexualside effects.


34. Which of the following side effects is least likelyto occur in patients taking quetiapine?

A. Antihistamine effectsB. Orthostatic hypotensionC. Increase in liver transaminaseD. Increase in prolactinE. Weight gain.

The answer is D.

Explanation: Quetiapine is

associated with antihistamineeffects, orthostatic hypotension,increase in liver transaminaseand weight gain.


35. Which of the following is the best treatmentoption for severe depressive episode withpsychotic features?

A. AmitriptylineB. Cognitive behaviour therapyC. LamotrigineD. MethylphenidateE. Electroconvulsive therapy.

Answer is E.

Explanation: ECT has the mostevidence in treating psychoticdepression as compared to othertreatment options.


36. A 35-year-old man suffers from schizophrenia

symptoms and his GP has started him a

medication to treat his symptoms. He develops

jaundices after taking the medication. Which of

the following medications is most likely to cause

The answer is B.

Explanation: Chlorpromazine isassociated with cholestatic jaundice and is most likely to

cause jaundice among alloptions.

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jaundice?

A. ClozapineB. ChlorpromazineC. Haloperidol

D. RisperidoneE. Sulpiride.


37. A 60-year-old man suffers from depressivedisorder and you have increased the dose ofantidepressant. He is seeing you today. His bloodpressure is 180/90. Which of the followingmedications should be stopped?

A. DiazepamB. QuetiapineC. Fluvoxamine

D. HydroxyzineE. Venlafaxine.

The answer is E.

Explanation: Venlafaxine isassociated with dose-dependenthypertension.


38. A 25-year-old woman with bipolar disorder ispregnant for the first time. Throughout thepregnancy, she has been maintained on a moodstabilizer. At the time of birth, the baby is notedto have Ebstein’s anamoly. Which of thefollowing medications is most responsible for thisteratogenic effect?

A. CarbamazepineB. LamotrigineC. LithiumD. Sodium valproateE. Topiramate

The answer is C

Explanation: Ebstein’s anomalyis associated with lithium.


Psychotherapy and defence mechanisms

39. A 28-year-old woman comes to consult youbecause she is very upset after being scolded byher manager. The chief executive officer (CEO)of her company has raised the standard forannual performance. Her manager is very upsetthis arrangement and scolds her for no reason.

Which of the following is the defence mechanismexhibits by the manager?

A. AltruismB. DenialC. DisplacementD. RepressionE. Reaction formation.

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40. You are a doctor working in polyclinic. A 25-year-old man bought his 55-year-old mother to seeyou. He is concerned that his mother suffers from

depression but she refuses to takeantidepressant. You realise that the mother and

The answer is E.

Explanation: Family therapy such

as structural family therapyfocusing on boundary is helpful

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son are enmeshed as the son is unmarried andnot able to work. He claims that he needs to lookafter his mother although she has good pasthealth. The mother and son hold very negativeview against the father who is the solebreadwinner of family. There is a psychologistworking in your polyclinic. Which of the followingforms of psychological treatment is mostappropriate?

A. Couple therapyB. Dialectical behaviour therapyC. Problem solving psychotherapyD. Supportive psychotherapyE. Family therapy.

in this situation.


41. A national serviceman is seeing a male

psychologist because he suffers from adjustmentdisorder and he finds his army supervisoruncaring. Furthermore, he is very angry with hisown father. He recalls an incident in camp aboutgetting angry with his male supervisor. Thepsychologist asks a factual question about thecircumstance and rage in the patient. Then thepatient complains that the psychologist isuncaring and trying to find fault in him. Thepsychologist says, ‘I wonder if what you’vefeeling right now is just like the feeling you havein camp, when you attributed the same uncaring

attitude toward your father and supervisor incamp. These repetitive patterns ofmisunderstanding seem to make you very upsetin different situations and affect your life.’ Whichof the following most accurately describes thepsychotherapeutic technique?

A. AffirmationB. ClarificationC. Empathic validationD. ObservationE. Interpretation.

The answer is E.

Explanation: Interpretation is astatement made by thepsychologist to enhance patient’sunderstanding of his or her ownthoughts or behaviours. Affirmation refers to confirmationof validity of previous judgementor behaviour in a patient.Empathetic validation refers tothe situation when the therapisttries to put himself into the

patients’ shoes and tries tounderstand patient’s inner state.


42. A medical student used to be very keen tobecome an orthopaedic surgeon. He hasassisted an orthopaedic surgeon to conductresearch since the second year of medicalschool. During the residency application, he tellsother classmates that he does not bother whetherhe is accepted by the orthopaedic residency. Healso encourages other classmates not to applyfor orthopaedic surgery as this specialty is not agood career choice. On the other hand, he is

secretly asking his orthopaedic mentor to preparehim for the orthopaedic residency intakeinterview. What is his defence mechanism?

The answer is E.

Explanation: His external attitudeand behaviours (not caring aboutorthopaedic surgery) is theopposite of the internal intention(wanted to join orthopaedicsurgery).

Author: Roger Ho

Year: 2014

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A. AltruismB. DenialC. DisplacementD. RepressionE. Reaction formation.

43. Which of the following is the most effectiveapproach for a 30-year-old woman withobsession about contamination and washes herhands every time she touches something whichshe considers dirty?

A. Having the patient place her hands in a containerof worms to create extreme phobia and ability toovercome obsession

B. Having the patient snap her wrist with a rubberband when she thinks about contamination and

about to wash her handsC. Having the patient touch a dirty object, then not

allowing her to wash her hands for several hoursD. Highlighting to the patient that her obsession is a

cognitive error.E. Providing the patient with message cards to

remind herself that the hand washing isunnecessary.

The answer is C.

Explanation: Option C is knownas exposure and responseprevention (ERP) and is the mosteffective approach among alloptions. Option D is not goodenough because thepsychologist should guide thepatient to further challenge theobsessions rather than just

highlighting the obsessions.Option B is thought stopped andis not as effective as ERP.


44. A 30-year-old army officer presents for treatmentof post-traumatic stress disorder after survivingan accident which his tank fell into the river froma bridge. He was driving a tank on a bridge when

it suddenly collapsed. Several army officers wereseriously injured in this accident. As part of thetreatment, the psychologist asks the patient toimagine that he is safely driving his tank over abridge. Which of the following best describes thistherapeutic intervention?

A. Aversion therapyB. Cognitive therapyC. Exposure therapyD. Interpersonal therapyE. Supportive therapy.

The answer is C.

Explanation: The psychologist isproviding in-vivo exposure by

imaging the accident scene toovercome fear and anxietyassociated with flashback.


Ethics, management dilemma and laws

45. You are a paediatric resident. A 14-year-old girlhas stayed in the paediatric ward for 1 week aftera suicide attempt by drug overdose. She is duefor discharge tomorrow. At 6 pm, she suddenlyclaims that her elder sister had physically abusedher prior to admission. Her medical recordreveals that she suffers from conduct disorder.She also made similar reports of physical abusein the past. The police officer and social worker

found her claims inconclusive and did notinvestigate further. She is ambivalent to make a

The answer is E.

Explanation: As this femaleadolescent suffers from conductdisorder, she has the tendencyto tell lies to avoid discharge. Asthe patient is currently in theward and she is safe, there is noneed to inform the police

immediately without furtherclarification from the treatment

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report about the alleged abuse and she is notkeen for discharge. You try to contact theconsultant in charge of this case but theconsultant is not contactable. Which of thefollowing is most appropriate action?

A. Banning her parents from visiting her.B. Call 995 to inform the police immediatelyC. Inform the on-call team and request the on-call

doctors to inform the police before midnightD. Refer the patient to gynaecologist for further

assessmentE. Discuss with the consultant-in-charge and the

social worker on the next day.

team. Furthermore, the patient isambivalent to make a report. Thebest approach is to discuss withthe treatment team and they canclarify with her parents whetherthe elder sister did physicallyabuse her.


46. A 35-year-old man was hospitalised for treatmentof severe depressive episode in September. The

inpatient team prescribed two antidepressants forthe patient and then referred the patient topolyclinic. The patient came to the polyclinic forreview in October and November respectively.The patient had a relapse of depression andcommitted suicide in December. Thecomputerised record shows that the polyclinicdoctors had forgotten to prescribeantidepressants since the first visit. Which of thefollowing best describes the above situationbased on the Common Law?

A. BatteryB. Diminished responsibilityC. Intentional tortsD. NegligenceE. Tarasoff’s rule

The answer is D.

Explanation: The polyclinicdoctors forgot to prescribeantidepressants and resulted inrelapse and suicide. Their act isconsidered to be negligence /unintentional torts. Option A isintentional torts and not relevantfor this case. Diminishedresponsibility only applies inmurder cases. Tarasoff’s ruleinvolves duty to warn when apatient expresses his/her wish to

harm another person.


Liaison psychiatry and neuropsychiatry

47. You are a resident in obstetrics. Which of thefollowing is the safest medication to be given to apregnant woman who develops psychosis duringpregnancy?

A. AripiprazoleB. HaloperidolC. OlanzapineD. QuetiapineE. Risperidone

The answer is B.

Explanation: Haloperidol is theoldest medication and is thesafest among all options.


48. A 25-year-old man expresses concerns that hegot infected with HIV after visiting commercial sexworkers last week. According to him, he onlyreceived hand-genital stimulation and there wasno vaginal intercourse. He also mentions that thecommercial sex worker kissed his body. He has

sought his girl-friend’s forgiveness. Today, herequests HIV test urgently. He consulted you one

The answer is B.

Explanation: It is common inclinical practice for patientsasking for urgent HIV test afterthey engaged in activities which

did not transmit HIV. Thepatients request for such test as

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year ago for similar concern after he kissedanother lady without informing his girl-friend.What is the most likely explanation of hisbehaviour?

A. Underlying depressionB. Underlying guiltC. Underlying obsessionD. Underlying psychosisE. Underlying somatic concern

a result of guilt. It is unlikely to becaused by obsession as thepatient requests for the HIV testafter sexual activity but not athought. The patient does nothave any somatic concern.


49. You are orthopaedic resident. A 25-year-oldconstruction worker had a fall, fractured his spineand injured the brain. He develops pain inmultiple sites. He has one episode of epilepsyafter the injury. He is depressed but does nothave suicidal thought. Electrocardiogram isnormal. Which of the following medication is most

helpful in this situation?

A. AmitriptylineB. BupropionC. ChlorpromazineD. DuloxetineD. Moclobemide

The answer is D.

Explanation: Duloxetine is anantidepressant indicated for bothdepression and pain. Bupropion,amitriptyline and chlorpromazineincreases the risk of seizure.

There is no indication toprescribe moclobemide in thiscase.


50. You are a medical resident and rotated torheumatology. A 24-year-old woman suffersfrom systemic lupus erythematosus (SLE).She suffers from lupus nephritis and requiresdialysis three times a week. She was veryconcerned about her illness and felthopeless. She took an overdose of her lupusmedications and admitted to the medicalward. You need to take a history from her.Which of the following is not part of theneuropsychiatric symptoms of SLEexperienced by this patient?

A. AnxietyB. Binge eating

C. Cognitive impairmentD. EpilepsyE. Headache.

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EMI

Author: Cyrus Ho

Modified by Roger Ho

Vetted by Iris Rawtaer, A/Prof John Wong

Question 51 – 53

Options:

A. Abstinent

B. Action

C. Contemplation

D. Pre-contemplation

E. Preparation

Lead-in: Choose the most appropriate stage based on Prochaska and DiClemente’s stages of change

model.

51. A 35-year-old man with cannabis misuse ignores the advice of family and friends, and

continues using the drug and causing amotivational syndrome.

Answer: D

52. A 40-year-old woman has been attending Narcotics Anonymous meetings and cessation to

use pain killer has been integrated into her life.

Answer: B

53. A 40-year-old man recognises the problem of alcohol misuse and is considering the pros and

cons of treatment.

Answer: C

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Question 54 – 57

Options:

A. Deficiency of thiamine

B. Deficiency of vitamin B12

C. Presence of amyloid plaques and neurofibrillary tangles

D. Presence of eosinophilic intracytoplamic neuronal inclusions with abnormal phorphorylation

E. Raised growth hormone level with dysregulation of hypothalamic-pituitary-adrenal axis

Lead-in: Select the most appropriate item from the above that is most likely seen in the following

clinical scenario.

54. An 80-year-old man presents with increased forgetfulness and memory problems over the last 2years. He often misplaces his things and unable to find his own way home when he goes out of thehouse.

Answer: C

55. A 50-year-old man with long standing alcohol dependence presents with acute onset of confusion

and unsteady gait. On physical examination, he has opthalmoplegia and nystagmus.

Answer: A

56: A 22-year-old female presents with syncope and dizziness. She believes that she is overweight

and has been restricting her diet. Her BMI is17 and she has not had her menstruation for the past 3

months.

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Answer: E

Question 58 – 59

Options:

A. Alcohol intoxication

B. Cannabis intoxication

C. Frontal lobe dementia

D. Manic episode

E. Pseudobulbar palsy

Lead-in: Select the most appropriate diagnosis from the above for the following clinical scenario.

57. A 54-year-old man is admitted following a stroke. He is noted to be crying and laughing in the

ward at time. His speech has become nasal “like a duck” and his tongue is spastic and stiff.

His score for Mini Mental State Examination is 28/30.

Answer: E

58. A 45-year-old man presents to the Emergency Department in a disinhibited manner. He tries to

hit the nurses when they attempt to draw blood from him and he shouts loudly on how badly

treated he is by his wife. However he soon becomes apologetic and tearful. He is unsteady in

his gait and speech is slurred. He subsequently falls asleep soundly in the cubicle while

waiting for the doctor.

Answer: A

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Question 59 - 60

Options:

A. Acetaldehyde dehydrogenase inhibitor

B. Acetylcholine dehydrogenase inhibitor

C. Dopamine D2 receptor antagonist

D. NMDA receptor antagonist

E. Partial dopamine D2 agonist

Lead-in Select the most likely mechanism of drug action from above.

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MCQ and EMI 2014 R4

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