Psychiatry Viva Exam question bank 2023
Q1
You are an intern working in accident and emergency at 8pm. A 35-year-old man is brought in by friends. The friends state that
he had been increasingly anxious, ringing them late at night and talking about having to “take measures to escape the plot”. One
friend was so concerned he spent last night with the patient to make sure he was OK. The patient is agitated, fearful, hypervigilant
and insists on speaking with you privately without his friends present. He tells you that his life is in danger and he has to leave
the emergency department immediately. He states that over the last month he has noticed increasing evidence of a plot against
him e.g., cars following him on the street, passers-by giving him meaningful glances.
Your tasks are to discuss with the examiner:
•
What further relevant information you would seek about the patient in order to make an assessment of the problem.
•
An initial management plan including recommendations to the nursing staff about managing the behaviour.
Q2
You are an intern working for a rehabilitation team in a public hospital. The ward nurses ask you to review a 75-year-old
married man with a 4-year history of Alzheimer-type dementia who is 14 days post op and rehabilitating from surgery for a
hip fracture. He is reported to be verbally abusive towards female staff when they assist him with his shower in the mornings
and resists their efforts to help him get changed when he is in the bathroom. He has been harassing other ward patients in
the 4-bedded room in the evening especially by swearing at one-non-English-speaking woman who got upset when he went
into her wardrobe. The behaviour has been present since his admission but has become worse in recent days. He has not hit
anyone. He is not on any regular medication for his behaviour or dementia but the night intern prescribed haloperidol 5mg
prn the previous night although it was not used.
Your tasks are to discuss with the examiner:
•
What further relevant information about the patient you would seek in order to make an assessment of the problem.
•
An initial management plan including recommendations to the nursing staff about managing the behaviour.
Q3.
A 17 year old student is excessively worried about her performance in the HSC exams. Even though she reads regularly and
completes all the academic assignments on time, she is constantly preoccupied with the thought that she won’t do well in
exams and might even fail.
She is very apprehensive and fearful all the time and these feelings increase prior to her exams. She feels very tired and is
worried that her concentration is not as good as it was before. These symptoms have been present from childhood but have
become worse in the past 2-3 years. Her mother has noted that she is irritable and tearful. She describes herself as a worrier
and needs a lot of reassurance. Sometimes she gets dizzy and has palpitations and diarrhoea.
Last week she cut her wrist following an argument with her mother.
Your tasks are to discuss with the examiner:
1. The most likely diagnosis and at list 2 possible differential diagnoses and describe reasons for it.
2. How you will further assess and manage this patient?
Q4
You are a GP. One of your patients, a 40-year-old woman with a previous diagnosis of Bipolar I Disorder, reluctantly comes to
see you with her partner. As far as you are aware, her mood state has been under good control with Lithium for a decade –
although she has not seen you as often as recommended. She is displaying features of mania and her partner is concerned
that she is spending at a rate that will rapidly get them into major debts.
Your tasks are to discuss with the examiner:
1. What factors might have contributed to his recent manic episode?
2. How would you investigate and manage this patient?
Q5
The Community Mental Health team has been alerted by the Department of Housing to assess a 41-year-old, single
unemployed gentleman by the name of Colin living by himself in a Department of Housing unit after neighbours complained
of having to block their air vents because of cockroaches coming out of his unit. He has also been abusive and threatening to
them on confrontation.
Colin is known to the local Community Mental Health team and has been treated for a chronic psychotic illness for the last 15
years. Although he is prescribed Clozapine and is on a Community Treatment Order, his compliance with medication is
unknown. His home is in disarray and there are cockroaches everywhere. His family has not been in contact for months. He has
not withdrawn money from his bank account for a while and there is no food in the house. He has no history of use of illicit
drugs. He does smoke 1-2 packets of cigarettes a day.
On assessment Colin appeared obese, dishevelled and irritable. Although alert and orientated, he seemed somewhat
preoccupied. He talked of being the dragon from the book of “Revelations” in the Bible, although these ideas seemed vague and
jumbled. His case manager has suggested a referral to the local inpatient mental health rehabilitation unit.
Your tasks are to discuss with the examiner:
A. What factors would help to determine his suitability for a mental health rehabilitation programme.
B. further management options including suggestions for rehabilitation interventions for this patient.
Q6
You are an intern working in the accident and emergency department. A 31-year-old female, Miranda, has been brought in
by her husband. Miranda suffered a sudden onset of anxiety, breathlessness, light-headedness, palpitations, tingling in her
fingers, sweating and an associated overwhelming belief that she was about to have a heart attack. The attack lasted fifteen
minutes and has now subsided.
Physical examination is normal.
Miranda has had many of these attacks over the last two months. She has presented to the emergency department on several
occasions. On previous presentations to the emergency department Miranda has had routine investigations including a full
blood count, electrolytes, urea and creatinine, thyroid function tests and an ECG and these were all normal.
Last time Miranda was in the emergency department the doctor mentioned something called “CBT.” Miranda does not know
what this means or how it can help her.
Your tasks are to discuss with the examiner:
1. the most likely diagnosis and the most appropriate management options.
2. How you would explain the basic principles of Cognitive Behavioural Therapy and its relevance to this patient.
Q7
You are a general practitioner consulted by a young male, age 22 and well known to you, for removal of stitches from a
lacerated arm sustained on an iron fence while trying to evade apprehension by police who had observed him behaving
‘strangely’ near a suburban bus stop 2 weeks previously.
You have a copy of a discharge summary from a psychiatric inpatient facility, dated 5 days ago, in which it is stated that he has
been diagnosed with paranoid schizophrenia and treatment involves oral Risperidone 6 mg daily.
This has been his sixth admission for psychosis in 12 months and you happen to know that he “hates” taking medication but
consumes tobacco, alcohol and marijuana.
He has been discharged into your care and that of the local community mental health team.
Your tasks are to discuss with the examiner
1. What further information you would seek in order to confirm the main issues in this case.
2. Outline the principles of your management plan based including:
3. The measures you could take to address the problem of his non-adherence to medication.
Q8.
You are an intern working in a medical ward. A 60-year-old man has been in intensive care for three weeks following resection
of large bowel for cancer. He is now refusing to have an abdominal MRI as he has “had enough”. You are asked to make an
assessment of his ability to give consent. Relevant information includes:
•
Normally works as an accountant in a small firm, said to do a good job.
•
Friends say he is always quiet, “likes to do his own thing”.
•
He has a 40-year history of smoking a pack a day and “a few beers” every night.
•
He has a history of hypertension, myocardial ischemia, COPD, GORD
•
Nurses say he is generally awake from 3 am, uncooperative in mornings, at times has woken up in the night shouting.
Your tasks are to discuss with the examiner
1. What information you would seek in order to assess this gentleman and determine a differential diagnosis.
2. how you would assess his capacity to give informed consent.
Q9 Mrs Taylor is an 80-year-old woman who lives alone.
a. She has been an active woman with a wide range of activities and social contacts.
b. Over the last two or three months she has stopped going to bridge and to the local club to see her friends.
c. She is tired, has lost weight and her daughter is worried that there is something seriously wrong with her.
d. She has neglected the housework and grocery shopping.
e. She hardly speaks when her daughter comes to visit her.
f. She has no past psychiatric history
g. She has a history of diabetes, hypertension, hyperlipidemia and a DVT.
h. She usually has frequent contact with her elder daughter (with whom she has a good relationship), although has a
difficult relationship with her youngest daughter.
Your tasks are to discuss with the examiner:
•
what else you would like to find about Mrs Taylor and how,
•
your provisional diagnosis and differential diagnoses and management plan.
Q10
You are an intern working in the emergency department and you are asked to see Mr. Allen, a forty-five-year-old, single
accountant living with his mother, who has presented three times in the last week with chest discomfort, light-headedness,
breathlessness and an overwhelming fear that he would die. He has been thoroughly assessed with numerous investigations
and medical specialist consultations and all major medical disorders have been definitely excluded. This is the first time you
have seen this patient. It appears previous medical staff have placed little emphasis on possible psychological issues.
Your first impression is that he looks shaky and anxious. He is drinking a large double espresso and there is an empty coffee
cup next to it on the table. His briefcase is on the bed and is bulging with end of financial year tax returns. He is worried
about his health and fears having another episode like the ones he has had lately.
Discuss with the Examiner:
•
Your approach to assessing for a possible psychological basis for Mr Allen’s presentation.
•
Your feedback to Mr Allen about his symptoms and treatment recommendations
Q11.
An 80-year-old widower is brought to the ED by ambulance after was found unconscious at home by his daughter who had
been unable to reach him all day. A note in his pocket said that he no longer wanted to live. Empty packets of paracetamol
and temazepam packets were found close by. His daughter explains that his beloved wife of 55 years died of cancer a year
ago and last week his closest friend and golf partner died suddenly. She has been concerned for a while that he has not been
looking after himself well and has been irritable and out of sorts. He doesn’t seem to be enjoying himself as he previously
did. He had a fall a few months ago and she has suggested to him that he move into a home. He has now regained
consciousness and you have been asked to see him.
Discuss with the examiner:
•
What further information you would seek and from whom in order to develop a provisional diagnosis and differential diagnosis.
•
Your management plan whilst he is in the emergency department
Q12.
You are the intern on the psychiatry ward. Ben, a 45-year-old man with a history of severe melancholic depression is
admitted to the ward. He has had similar episodes before and has made 2 previous serious suicide attempts. He is
psychomotor retarded, anhedonic, has lost weight and wakes up at 4am unable to get back to sleep. He feels responsible for
his wife’s death in an accident 3 year earlier although there is no basis for this. His previous episodes responded to
antidepressant treatment but this time he is not improving. His treatment team have suggested that he have ECT. Your
consultant asks you to sit down with Ben after the ward round to discuss his treatment with him because he expects that he
has not fully understood what was said.
Your consultant asks you to:
1 determine whether Ben has capacity to consent to ECT
2. explain the process of ECT to Ben and why it is indicated.
Please discuss with the examiner how you would proceed to manage this request.
Q13
You are asked to see Kylie, a 29-year-old woman who presents to the emergency department after self-harming. She lives with
and is the primary carer of her mother who is disabled after a head injury incurred whilst inebriated. Kylie has a troubled
relationship with her mother who has a history of alcohol dependency. Kylie was sexually abused by her mother’s partner when
she was 13 and was taken into foster care. Kylie has been diagnosed with fetal alcohol syndrome and is on a carer’s pension.
Her mother had a fall last night and Kylie felt overwhelmed and superficially cut her wrists. She rang a friend who brought both
her and her mother to the ED for an assessment.
You are to discuss with the examiner:
•
How you would proceed to assess Kylie.
•
What historical factors may underly her presentation and influence the future course of management.
•
Your management plan, with reference to the principles of trauma informed care.
Q14
As night intern, you are asked to urgently review Mr Cohen is a 74 year old, widowed, retired accountant who had an
elective hip replacement operation the day before and is now in a shared room on the fifth floor of the hospital. You are
informed that Mr Cohen has been very agitated for the last few hours and tried to leave the hospital as he believes that the
nursing staff are trying to poison him.
You briefly review Mr Cohen’s medical file as he is not one of your regular patients. Mr Cohen lives alone and was
hospitalised 2 days back. Apart from osteoarthritis, he also suffers from impaired hearing, essential hypertension, Type 2
Diabetes Mellitus, and hypercholesterolemia. Mr Cohen’s only other hospitalization was last year for a Cerebrovascular
accident. He was reviewed by his treating team in the morning and they found him to be a ‘bit flat’ but otherwise stable and
oriented.
Discuss with the examiner:
1. What further information you would seek and from whom and what investigations you would undertake in order to reach a
differential diagnosis.
2. Your management plan including:
•
your approach to pharmacological and non-pharmacological management.
•
your communication about the situation with the patient, the nursing and medical team.
Q15
A 34-year-old employed lady presents to your general practice. She reports that she is finding life very stressful at the
moment and wonders if you might be able to help her. She lives with her husband and two children and works full time. She
says that she is unable to get anything done around the house and that she is spending a lot of time checking that things are
safe in the house especially checking locks, stoves and taps many times before going to bed or out. She struggles to get to
sleep because she worries that she hasn’t checked everything properly. It can take an hour to get out of the house in the
morning and she is often late for work because of her need to check.
“I am at my wits end with anxiety. I cannot go to sleep at night until I have checked my house many times to be sure the
house is locked, the gas is off and the taps are turned off. I think I am going mad”.
Discuss with the examiner:
1. What further information you would seek to clarify the presenting problem and reach a provisional diagnosis and differential
diagnosis.
2. What other problems you would like to rule out.
3. What advice you would give the woman in terms of
a) the likely nature of her problem
b) her treatment options
c) her prognosis
Q16
You are working in a general practice. Adam, a 50-year-old patient known to you attends for a follow up appointment.
He says: “Doc, I am just not getting any better. I am starting to think I will never get well again. I have tried your tablets but
they don’t work for me.”
He first presented for the first time with depressive symptoms 3 months ago and you have prescribed two different
antidepressants for him so far, without significant improvement. He now presents again asking what should happen next.
Your notes reveal that:
•
He has been depressed for six months with low mood, irritability, poor sleep, reduced interest in family and friends
and loss of satisfaction with work. He still laughs occasionally but is not feeling ‘himself’. His marriage is suffering
•
He has suicidal ideation but no plans or intentions but he has had no previous suicide attempts
•
He is moderately overweight and has mild, untreated, essential hypertension and hypercholesterolaemia.
•
He smokes 20 cigarettes daily and hee drinks “socially”
•
His work performance has suffered and he fears retrenchment from his mid-level administrative position
•
He has two teenage children currently living at home with his wife who is an accountant
Discuss with the examiner:
1. How you would evaluate Adam’s lack of improvement in mood.
3. What options exist for further treatment and how you would discuss their benefits and risks with Adam.
Q17
A mother brings her 16-year-old daughter, Naomi, to your general practice. Her mother has noticed progressive isolation
from family, irritability and weight loss.
The initial assessment from your practice nurse shows that Naomi is 165 cm tall and 47 kg. Her heart rate is 48 beats per
minute; her blood pressure is 80/40mmHg with a 10 mmHg postural drop. Her temperature is 35.5 degrees Celsius. She is
dizzy on standing. Her K+ is 3.
Discuss with the examiner:
•
What further information you would seek to assist in forming a provisional diagnosis and differential diagnosis.
•
How you would decide whether Naomi needed to be admitted to hospital and on what legal grounds.
•
Your treatment plan and how you would discuss this with Naomi and her mother.
Q18
You are working in a general practice. Nora is well known to you. He husband was diagnosed with Alzheimer’s Disease 3
years ago. She is a 72-year-old married woman who states that she is feeling exhausted and overwhelmed by the constant
interruptions to her sleep due to her husband’s wakefulness on top of his increasingly challenging behaviour during the day.
She is tense and tearful and is concerned about how she can cope with the situation. She says:
‘I am so tired; I can’t remember the last time I got an uninterrupted night’s sleep. Last night my husband got me up at
3.30am to prepare his breakfast so that he could go to work. He doesn’t seem to understand that he retired 10 years
ago – and he never had to go to work before 8am!’
Your record shows the following about this patient
•
She has no psychiatric history or history of substance abuse
•
She is in very good general health apart from mild hypertension and occasional seasonal infections
•
She has been married for nearly 50 years and has had an excellent relationship with her husband and
•
They have three married children but none live nearby
You are to discuss with the examiner:
•
How you would proceed to evaluate Nora’s concerns and
•
the reasons why Nora may be feeling tired and having difficulty coping with the situation
•
The key elements to consider in developing a management plan with Nora.
Q19
Sally, a 22-year-old science honours student attends your general practice. She has just spent the night in the emergency
department after having taken 10 temazepam tablets and making superficial cuts to both wrists in the context of breaking up
with her boyfriend. She is angry and distressed that she was not admitted or treated at the hospital and requests that you
manage her problem. She says:
“I feel terrible. I hope you are better than the hospital I just came from. They didn’t do anything to help me”
You refer to your old notes and see that she has presented in the past with periods of depressed mood and anxiety and there
have been other episodes of superficial self-harming in the context of relationship breakups and other distressing events.
From looking after other family members over the years, you also suspect that her family life has been violent and abusive.
Your tasks are to discuss with the examiner:
•
How you would proceed in assessing Sally in terms of your approach to taking the history
•
How you would discuss with Sally the nature of her presenting concern
•
What treatment options you might discuss with Sally
Q20
Cody, a 6-year-old boy is brought to your general practice by his parents who are both senior lawyers. He started school this
year, but continues to disrupt the class by leaving his desk and wandering around the class to see what other children are
doing and talking to them. When asked to complete a task, he is non-compliant and has on occasions become aggressive and
hit or kicked a teacher when gently returned to his seat. He has difficulty writing his name and uses large capital letters. His
mother is anxious and angry with the school, and says they handle him incorrectly.
She reports that he has always been energetic and impulsive and has difficulty following instructions sometimes. He often
has minor accidents and rarely stays at an activity for long. He does get frustrated and lash out sometimes. He was fine at his
pre-school which allowed him to wander freely. He didn’t socialise much and didn’t make many friends, but the pre-school
didn’t express any concerns. Cody’s Dad says he was just the same and is still a bit disorganised. Both parents are a little
concerned by the school’s concerns but don’t feel that there is anything major wrong with Cody.
Your tasks are to discuss with the examiner:
•
What further information you would like and from whom in order to develop differential diagnosis for Cody.
•
What you would say to Cody and to Cody’s parents
•
the management plan you would discuss with Cody and his parents.
Q21
You are a GP. Sharif is a 45-year-old man who comes to see you for help with his sleep. He arrived in Australia a number of
years ago as an asylum seeker from Afghanistan. He works as an interpreter and is a leader in his community. He spent
several years in refugee camps in Pakistan before travelling to Australia by boat. He then spent several years in a detention
centre before being recognized as a refugee and given permission to stay in Australia. His family remains in Afghanistan.
Over recent months, he reports that his sleep has deteriorated. He finds it hard to get to sleep and often wakes with
nightmares and cannot get back to sleep as he lies awake worrying about his family and countrymen. He feels guilty that he
cannot protect them and for the good life he now has. He is more worried than ever about his family’s safety, given the
increasing power of the Taliban. He finds it hard to concentrate on his work and has been irritable and jumpy recently.
Discuss with the examiner:
•
Your approach to obtaining any extra information that would help you understand the presenting problem and to establish
a provisional diagnosis and differential diagnoses.
•
Your management plan.
Q22
You are working as a JMO in ED and have been asked to see Mr James Norman, a 32-year-old single, unemployed man who
has been living with a friend since his release from jail 4 weeks earlier. He has been ordered by the court to attend your
emergency department for a psychiatric evaluation. Mr Norman is accompanied by the police and has been charged with
armed robbery. He plans to plead not guilty. He has had multiple presentations to your hospital in similar circumstances.
He has been known to be aggressive towards hospital staff especially when his demands are not met. Since his arrest, he
has been abusive towards police, threatening to kill himself if taken to the remand centre. The court diverted him to ED for
assessment on the basis of suicide risk. Your review of the old notes reveals:
•
Previous brief psychiatric admissions but no clear diagnosis and no medications
•
At least one previous suicide attempt and threats to harm himself
•
Extensive polysubstance abuse, particularly alcohol, cannabis and speed.
•
Violent, disrupted childhood; Poor schooling with multiple suspensions due to truancy, destruction of property,
stealing, fighting. Left in year 9. Poor employment history, Multiple short-term relationships.
•
The triage nurse tells you that he is edgy but cooperative and doesn’t look depressed. She adds that he tried to flirt
with her, making her feel very uncomfortable. She says he was a smooth talker.
You are to discuss with the examiner:
•
your approach to carrying out a psychiatric assessment of this individual.
•
the specific questions that would assist you in determining the presence of psychiatric conditions that will influence your risk
assessment.
•
Suggest differential diagnoses and detail your approach to managing this individual.
Q23
You are a GP at Mrs Jones’ usual GP practice and are asked to see her because her usual GP is away. She says:
“Hello doctor, I just need some new scripts for my medications. I’ve run out early but Dr Smith is always happy to give
me a new script if need one. My pain is terrible”.
Mrs Jones is an unemployed 56-year-old divorced mother of three adult children. She has suffered chronic lower back pain
for three years after a fall. Her family are now very concerned that she continues to have the back pain and it restricts her
from leaving home most of the time necessitating frequent visits from the children to assist her at home. She describes these
visits as the only pleasure in her life. She has seen several doctors and taken many medications with inadequate effect.
She now takes three night-time sedative medications, and opiate medications three times daily and is considering surgery.
She requires increasing doses to manage her symptoms. She finds her life increasingly meaningless and feels guilt for relying
on her children so much. The mornings are the most difficult for her and she fears leaving the house in case the pain
becomes overwhelming. She spends much of the day resting in bed or on the couch.
Discuss with the examiner:
•
your approach to taking a history of her condition, its treatment and the response to treatment so far.
•
Your provisional diagnosis and differential diagnosis
•
The factors that may have contributed to her current state
•
your management plan and how you would discuss it with Mrs Jones and with her regular doctor.