Psychiatry
Psychiatry is tested through risk assessment, the boundary between psychiatric and organic illness, psychotropic safety, and Israeli mental health law. Vignettes often end with "what is the next step?"
Core rules
- First-episode psychosis: exclude organic causes - glucose, thyroid function, toxicology, infection, and neuroimaging if focal signs or sudden onset.
- Delirium: fluctuating attention and consciousness; it is a medical emergency, not a psychiatric referral.
- Suicide risk: ask directly about thoughts, plans, means, intent, previous attempts and protective factors; document the assessment.
- Serotonin syndrome: clonus, hyperreflexia, agitation, fever after serotonergic drugs. Neuroleptic malignant syndrome: rigidity, high fever, autonomic instability, raised creatine kinase - stop the antipsychotic, cool, give dantrolene or bromocriptine.
- Treatment of the Mentally Ill Law, 1991: involuntary admission is decided by a district psychiatrist when a person is dangerous to self or others, or unable to care for themselves with grave risk. A court can review detention.
- Capacity requires understanding, appreciation, reasoning and communication.
Worked example
A 23-year-old man is brought in after three weeks of paranoia, auditory hallucinations and agitation. Vitals are normal, glucose normal, urine toxicology negative. Reasoning: first-episode psychosis. Exclude organic causes, start a low-dose antipsychotic with a benzodiazepine for agitation, assess suicide and violence risk, and admit if risk is high or insight is absent. Do not start an antidepressant alone, and do not routinely combine two antipsychotics.
Traps that cost marks
- Labeling delirium in an older patient as "psychosis".
- Missing catatonia, which needs benzodiazepines or electroconvulsive therapy.
- Discharging without a documented risk assessment.
- Forgetting metabolic monitoring on antipsychotics.