Objectives: The demanding and intense environment of medical training can create excessive pressures on medical students that eventually lead to unfavorable consequences, either at a personal or professional level. These consequences can include poor academic performance and impaired cognitive ability. This study was designed to explore associations between pass-fail outcome and psychological health parameters (i.e. stress, anxiety, and depression symptoms). Methods: A cross-sectional study was conducted on a cohort of first-year medical students in a Malaysian medical school. The depression anxiety stress scale 21-item assessment (DASS-21) was administered to them right after the final paper of the first-year final examination. Their final examination outcomes (i.e. pass or fail) were traced by using their student identity code (ID) through the Universiti Sains Malaysia academic office. Results: A total of 194 (98.0%) of medical students responded to the DASS-21. An independent t-test showed that students who passed had significantly lower stress, anxiety, and depression symptoms than those who failed the first-year final examination (P <0.05). Those who experienced moderate to high stress were at 2.43 times higher risk for failing the examination than those who experienced normal to mild stress. Conclusion: Medical students who failed in the final examination had higher psychological distress than those who passed the examination. Those who experienced high stress levels were more likely to fail than those who did not. Reducing the psychological distress of medical students prior to examination may help them to perform better in the examination.