RG Kar Medical College Kolkata history founding 1886

Jagadish Chandra Bose scientist biography discoveries contributions

cd /tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/ && python3 -c " import pdfplumber, os files = { 'state': 'state-of-consultation-liaison-psychiatry-in-india-current.pdf', 'where': 'Consultation\u2013liaison psychiatry in India Where to go from here.pdf', 'survey': 'Consultation\u2011liaison psychiatry services A survey of medical institutes in.pdf', 'profile': 'Profile of Patients Seen in Consultation-.pdf' } for key, fname in files.items(): print(f'\n\n===== {key}: {fname} =====') try: with pdfplumber.open(fname) as pdf: for i, page in enumerate(pdf.pages[:4]): text = page.extract_text() if text: print(f'-- page {i+1} --') print(text[:2000]) except Exception as e: print(f'ERROR: {e}') "

python3 -c " from docx import Document doc = Document('/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/Gold_Medal_Exam_Introduction_Full.docx') for p in doc.paragraphs: style = p.style.name if p.style else 'None' if p.text.strip(): print(f'[{style}] {p.text}') "

python3 -c " from docx import Document doc = Document('/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/prize.docx') for p in doc.paragraphs: style = p.style.name if p.style else 'None' if p.text.strip(): print(f'[{style}] {p.text}') # Also check tables for i, table in enumerate(doc.tables): print(f'\n--- Table {i+1} ---') for row in table.rows: for cell in row.cells: if cell.text.strip(): print(cell.text.strip()) "

mkdir -p /tmp/workspace/prize-fixed && python3 -c " from docx import Document from docx.shared import Pt, RGBColor from docx.enum.text import WD_ALIGN_PARAGRAPH import copy # Load the original src = '/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/prize.docx' doc = Document(src) # Print all paragraphs with index so we can target them for i, p in enumerate(doc.paragraphs): if p.text.strip(): print(f'{i}: {p.text}') "

python3 << 'PYEOF' from docx import Document from docx.shared import Pt, RGBColor, Inches from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.oxml.ns import qn from docx.oxml import OxmlElement import copy, re src = '/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/prize.docx' out = '/tmp/workspace/prize-fixed/prize_fixed.docx' doc = Document(src) # Helper: copy formatting from one paragraph to a new one def copy_para_format(src_para, dst_para): dst_para.paragraph_format.left_indent = src_para.paragraph_format.left_indent dst_para.paragraph_format.space_before = src_para.paragraph_format.space_before dst_para.paragraph_format.space_after = src_para.paragraph_format.space_after # Helper: add a run with same font as existing run def styled_run(para, text, bold=False, size=None): run = para.add_run(text) run.bold = bold if size: run.font.size = Pt(size) return run paras = doc.paragraphs # --- FIX 1: Typos in paragraph 22 --- for p in paras: if 'Prmary' in p.text or 'neurologival' in p.text or 'multipfactorial' in p.text: for run in p.runs: run.text = run.text.replace('Prmary', 'Primary') run.text = run.text.replace('neurologival', 'neurological') run.text = run.text.replace('multipfactorial', 'multifactorial') # --- FIX 2: Citation style - replace superscript ¹,² with (1,2) in Core Functions para --- for p in paras: if p.text.startswith('Core Functions:') and '¹' in p.text: for run in p.runs: run.text = run.text.replace('¹,²', '(1,2)') # --- FIX 3: Clinical Spectrum - expand the stub sentence and add bullet list --- # Find the paragraph index for the stub target_idx = None for i, p in enumerate(paras): if p.text.strip() == 'The clinical spectrum ranges from normal psychological responses and adjustment difficulties.': target_idx = i break if target_idx is not None: stub_para = paras[target_idx] # Replace stub text for run in stub_para.runs: run.text = '' stub_para.runs[0].text = 'The clinical spectrum of C-L Psychiatry encompasses:' # Insert bullet items after stub_para using XML manipulation # We'll add them before the next paragraph ("These presentations...") next_para = paras[target_idx + 1] # "These presentations..." spectrum_items = [ 'Adjustment disorders (to diagnosis, disability, or treatment)', 'Depressive disorders (major depression, persistent depressive disorder)', 'Anxiety disorders (generalized anxiety, panic, illness anxiety)', 'Delirium and other organic mental disorders', 'Somatic symptom and related disorders', 'Substance use disorders (including withdrawal states)', 'Psychological factors affecting other medical conditions', 'Psychiatric side effects of medications', 'Pre-existing psychiatric illness complicating medical care', ] # Insert each bullet before next_para using XML element insertion ref_elem = next_para._element parent = ref_elem.getparent() for item in reversed(spectrum_items): new_p = OxmlElement('w:p') new_pPr = OxmlElement('w:pPr') new_pStyle = OxmlElement('w:pStyle') new_pStyle.set(qn('w:val'), 'Normal') new_pPr.append(new_pStyle) new_p.append(new_pPr) new_r = OxmlElement('w:r') new_t = OxmlElement('w:t') new_t.text = '\u2022 ' + item new_t.set('{http://www.w3.org/XML/1998/namespace}space', 'preserve') new_r.append(new_t) new_p.append(new_r) parent.insert(list(parent).index(ref_elem), new_p) # --- FIX 4: Add Reference List at the end --- # Add a blank line, then a References heading, then 3 references def add_para(doc, text, bold=False, italic=False): p = doc.add_paragraph() run = p.add_run(text) run.bold = bold run.italic = italic return p doc.add_paragraph('') # blank spacer ref_heading = doc.add_paragraph() rh_run = ref_heading.add_run('REFERENCES') rh_run.bold = True rh_run.font.size = Pt(12) refs = [ '1. Grover S, Avasthi A. Consultation-liaison psychiatry in India: Where to go from here? Indian J Psychiatry. 2018;60(Suppl 4):S501-S508.', '2. Grover S. State of consultation-liaison psychiatry in India: Current status and vision for future. Indian J Psychiatry. 2011;53(3):202-213.', '3. Dua D, Grover S. Profile of patients seen in consultation-liaison psychiatry in India: A systematic review. Indian J Psychiatry. 2021;63(3):227-244.', ] for ref in refs: rp = doc.add_paragraph() rp.add_run(ref).font.size = Pt(11) doc.save(out) print('Saved to', out) PYEOF

python3 -c " from docx import Document doc = Document('/tmp/workspace/prize-fixed/prize_fixed.docx') for p in doc.paragraphs: if p.text.strip(): print(p.text) "

python3 << 'PYEOF' from docx import Document from docx.shared import Pt from docx.oxml.ns import qn from docx.oxml import OxmlElement src = '/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/prize.docx' out = '/tmp/workspace/prize-fixed/prize_fixed.docx' doc = Document(src) paras = doc.paragraphs # --- FIX 1: Typos --- for p in paras: full = p.text if 'Prmary' in full or 'neurologival' in full or 'multipfactorial' in full: for run in p.runs: run.text = run.text.replace('Prmary', 'Primary') run.text = run.text.replace('neurologival', 'neurological') run.text = run.text.replace('multipfactorial', 'multifactorial') # --- FIX 2: Citation style superscript -> parenthetical in Core Functions --- for p in paras: if p.text.startswith('Core Functions:'): # Check all runs including superscript for run in p.runs: if '¹' in run.text or '²' in run.text: run.text = run.text.replace('¹,²', '(1,2)').replace('¹', '(1)').replace('²', '(2)') # Also fix via XML in case it's in rPr for r_elem in p._element.findall('.//' + qn('w:r')): t_elem = r_elem.find(qn('w:t')) if t_elem is not None and t_elem.text: if '¹' in t_elem.text or '²' in t_elem.text: t_elem.text = t_elem.text.replace('¹,²','(1,2)').replace('¹','(1)').replace('²','(2)') # --- FIX 3: Clinical Spectrum - replace stub and add ORDERED bullet list --- target_idx = None for i, p in enumerate(paras): if 'ranges from normal psychological responses and adjustment difficulties' in p.text: target_idx = i break if target_idx is not None: stub_para = paras[target_idx] # Clear all runs and set new text for run in stub_para.runs: run.text = '' if stub_para.runs: stub_para.runs[0].text = 'The clinical spectrum of C-L Psychiatry encompasses:' else: stub_para.add_run('The clinical spectrum of C-L Psychiatry encompasses:') # Insert bullet items AFTER stub_para (before "These presentations...") next_para = paras[target_idx + 1] ref_elem = next_para._element parent = ref_elem.getparent() idx_in_parent = list(parent).index(ref_elem) spectrum_items = [ 'Adjustment disorders (to diagnosis, disability, or treatment)', 'Depressive disorders (major depression, persistent depressive disorder)', 'Anxiety disorders (generalized anxiety, panic, illness anxiety)', 'Delirium and other organic mental disorders', 'Somatic symptom and related disorders', 'Substance use disorders (including withdrawal states)', 'Psychological factors affecting other medical conditions', 'Psychiatric side effects of medications', 'Pre-existing psychiatric illness complicating medical care', ] for i, item in enumerate(spectrum_items): new_p = OxmlElement('w:p') new_pPr = OxmlElement('w:pPr') new_pStyle = OxmlElement('w:pStyle') new_pStyle.set(qn('w:val'), 'Normal') new_pPr.append(new_pStyle) # small left indent new_ind = OxmlElement('w:ind') new_ind.set(qn('w:left'), '360') new_pPr.append(new_ind) new_p.append(new_pPr) new_r = OxmlElement('w:r') new_t = OxmlElement('w:t') new_t.text = '\u2022 ' + item new_t.set('{http://www.w3.org/XML/1998/namespace}space', 'preserve') new_r.append(new_t) new_p.append(new_r) parent.insert(idx_in_parent + i, new_p) # --- FIX 4: Add Reference List at end --- doc.add_paragraph('') ref_heading = doc.add_paragraph() rh_run = ref_heading.add_run('REFERENCES') rh_run.bold = True rh_run.font.size = Pt(12) refs = [ '1. Grover S, Avasthi A. Consultation-liaison psychiatry in India: Where to go from here? Indian J Psychiatry. 2018;60(Suppl 4):S501-S508.', '2. Grover S. State of consultation-liaison psychiatry in India: Current status and vision for future. Indian J Psychiatry. 2011;53(3):202-213.', '3. Dua D, Grover S. Profile of patients seen in consultation-liaison psychiatry in India: A systematic review. Indian J Psychiatry. 2021;63(3):227-244.', ] for ref in refs: rp = doc.add_paragraph() rp.add_run(ref).font.size = Pt(11) doc.save(out) print('Done.') # Verify doc2 = Document(out) for p in doc2.paragraphs: if p.text.strip(): print(p.text) PYEOF

python3 << 'PYEOF' from docx import Document from docx.shared import Pt, RGBColor, Inches from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.oxml.ns import qn from docx.oxml import OxmlElement import os os.makedirs('/tmp/workspace/prize-fixed', exist_ok=True) out = '/tmp/workspace/prize-fixed/Introduction_Final.docx' doc = Document() # --- Page margins --- from docx.oxml import OxmlElement from docx.oxml.ns import qn section = doc.sections[0] section.top_margin = Inches(1) section.bottom_margin = Inches(1) section.left_margin = Inches(1.2) section.right_margin = Inches(1.2) # --- Styles --- normal = doc.styles['Normal'] normal.font.name = 'Times New Roman' normal.font.size = Pt(12) def add_para(text, bold=False, italic=False, center=False, size=12, space_before=6, space_after=6): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(space_before) p.paragraph_format.space_after = Pt(space_after) if center: p.alignment = WD_ALIGN_PARAGRAPH.CENTER run = p.add_run(text) run.bold = bold run.italic = italic run.font.name = 'Times New Roman' run.font.size = Pt(size) return p def add_heading(text, size=13): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(10) p.paragraph_format.space_after = Pt(4) run = p.add_run(text) run.bold = True run.font.name = 'Times New Roman' run.font.size = Pt(size) return p def add_bullet(text): p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.3) p.paragraph_format.space_before = Pt(2) p.paragraph_format.space_after = Pt(2) run = p.add_run('\u2022 ' + text) run.font.name = 'Times New Roman' run.font.size = Pt(12) return p # ============================================================ # TITLE # ============================================================ title = doc.add_paragraph() title.alignment = WD_ALIGN_PARAGRAPH.CENTER title.paragraph_format.space_before = Pt(0) title.paragraph_format.space_after = Pt(6) tr = title.add_run('Assessment and Management of Psychiatric Disorders in Medically Ill In-patients') tr.bold = True tr.font.name = 'Times New Roman' tr.font.size = Pt(14) # ============================================================ # OPENING QUOTE # ============================================================ q = doc.add_paragraph() q.alignment = WD_ALIGN_PARAGRAPH.CENTER q.paragraph_format.space_before = Pt(4) q.paragraph_format.space_after = Pt(10) qr = q.add_run('\u201cThe good physician treats the disease; the great physician treats the patient who has the disease.\u201d \u2014 Sir William Osler') qr.italic = True qr.font.name = 'Times New Roman' qr.font.size = Pt(11) # ============================================================ # 1. INTRODUCTION heading # ============================================================ add_heading('1. INTRODUCTION', size=13) # ============================================================ # Para 1 - Definition of medically ill patient # ============================================================ add_para( 'A medically ill patient is an individual with an acute or chronic physical illness requiring ' 'medical or surgical care, in whom psychological, behavioural, or psychiatric factors may ' 'influence the presentation, course, treatment adherence, recovery, and outcome. ' 'The relationship between physical and mental illness is bidirectional. (1)', space_before=4, space_after=6 ) # ============================================================ # Para 2 - Definition of C-L Psychiatry # ============================================================ add_para( 'Consultation-Liaison (C-L) Psychiatry is the branch of psychiatry concerned with the ' 'assessment and management of psychological and psychiatric problems in patients receiving ' 'care in non-psychiatric medical settings. Lipowski defined C-L Psychiatry as a subspecialty ' 'functioning at the \u201cborderland of psychiatry and medicine.\u201d (1,2)', space_before=4, space_after=6 ) # ============================================================ # Para 3 - Consultation vs Liaison distinction # ============================================================ add_para( 'Consultation (patient-centered) refers primarily to psychiatric assessment and advice ' 'requested by another healthcare professional, whereas liaison (system-centered) emphasizes ' 'continuing collaboration, communication, education, and support between psychiatry and ' 'medical or surgical teams. (1,2)', space_before=4, space_after=6 ) # ============================================================ # Para 4 - India 1933 (one line) # ============================================================ add_para( 'In India, the first General Hospital Psychiatric Unit (GHPU) was established by ' 'Dr. Girindra Shekhar Bose at R.G. Kar Medical College and Hospital, Calcutta, in 1933, ' 'marking the beginning of C-L Psychiatry in this country. (2)', space_before=4, space_after=6 ) # ============================================================ # EPIDEMIOLOGY heading # ============================================================ add_heading('Epidemiology') add_para( 'Psychiatric morbidity among medically ill in-patients is common but substantially ' 'underrecognized, undertreated, and under-referred. An Indian systematic review of 33 studies ' 'found inpatient psychiatric referral rates ranging from 0.01% to 3.6%, with depression, ' 'delirium and other organic disorders, substance-use disorders, intentional self-harm, and ' 'anxiety disorders among the commonly identified diagnoses. (3) The discrepancy between the ' 'burden of psychiatric morbidity and the low rate of referral highlights the ' 'recognition\u2013referral gap and the need for systematic psychiatric assessment in medical ' 'settings. (3)', space_before=4, space_after=6 ) # ============================================================ # CLINICAL SPECTRUM - one sentence only # ============================================================ add_heading('Clinical Spectrum') add_para( 'The clinical spectrum includes adjustment disorders, depressive and anxiety disorders, ' 'delirium and other organic mental disorders, somatic symptom disorders, substance use ' 'disorders, and pre-existing psychiatric illness complicating medical care. These presentations ' 'may occur independently or in combination with the underlying medical illness, and the ' 'central task of C-L Psychiatry is to understand the psychiatric syndrome in the context of ' 'the whole patient. (1,2)', space_before=4, space_after=6 ) # ============================================================ # 2. WHY PSYCHIATRIC ASSESSMENT IS IMPORTANT # ============================================================ add_heading('2. WHY PSYCHIATRIC ASSESSMENT IS IMPORTANT', size=13) add_para( 'Psychiatric manifestations in medically ill patients may be due to: a primary psychiatric ' 'disorder, a psychological response to illness, an underlying medical or neurological ' 'disorder, medications, substance use, or multifactorial interaction. (1)', space_before=4, space_after=6 ) add_para('Unaddressed psychiatric morbidity in medically ill patients negatively impacts:', space_before=4, space_after=2) impacts = [ 'Treatment adherence', 'Recovery and rehabilitation', 'Length of hospitalization', 'Patient safety', 'Quality of life', 'Healthcare utilization', 'Family functioning', 'Medical outcomes', ] for item in impacts: add_bullet(item) add_para( 'An underlying medical cause should always be actively investigated when psychiatric symptoms ' 'are new, atypical, acute, fluctuating, or accompanied by neurological or systemic ' 'abnormalities. (1)', space_before=6, space_after=10 ) # ============================================================ # CLOSING QUOTE # ============================================================ cq = doc.add_paragraph() cq.alignment = WD_ALIGN_PARAGRAPH.CENTER cq.paragraph_format.space_before = Pt(6) cq.paragraph_format.space_after = Pt(12) cqr = cq.add_run( '\u201cIn a medically ill patient, the psychiatric symptom is not the diagnosis; ' 'it is the starting point for a comprehensive biopsychosocial and medical assessment.\u201d' ) cqr.italic = True cqr.font.name = 'Times New Roman' cqr.font.size = Pt(11) # ============================================================ # REFERENCES # ============================================================ add_heading('REFERENCES', size=12) refs = [ '1. Levenson JL, editor. The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry. 3rd ed. Washington, DC: American Psychiatric Association Publishing; 2019.', '2. Grover S, Avasthi A. Consultation-liaison psychiatry in India: Where to go from here? Indian J Psychiatry. 2019;61(2):117\u2013124. doi:10.4103/psychiatry.IndianJPsychiatry_255_17.', '3. Dua D, Grover S. Profile of patients seen in Consultation-Liaison Psychiatry in India: A systematic review. Indian J Psychol Med. 2020;42(6):503\u2013512. doi:10.1177/0253717620964970.', ] for ref in refs: rp = doc.add_paragraph() rp.paragraph_format.left_indent = Inches(0.3) rp.paragraph_format.first_line_indent = Inches(-0.3) rp.paragraph_format.space_before = Pt(3) rp.paragraph_format.space_after = Pt(3) rr = rp.add_run(ref) rr.font.name = 'Times New Roman' rr.font.size = Pt(11) doc.save(out) print('Saved:', out) PYEOF

python3 -c " from docx import Document doc = Document('/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/PRIZE EXAM ASSESSMENT.docx') for i, p in enumerate(doc.paragraphs): if p.text.strip(): print(f'{i}: {p.text}') "

python3 << 'PYEOF' from docx import Document from docx.shared import Pt, Inches, RGBColor from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.oxml.ns import qn from docx.oxml import OxmlElement import os os.makedirs('/tmp/workspace/prize-fixed', exist_ok=True) out = '/tmp/workspace/prize-fixed/Assessment_Final.docx' doc = Document() # Page margins section = doc.sections[0] section.top_margin = Inches(1) section.bottom_margin = Inches(1) section.left_margin = Inches(1.2) section.right_margin = Inches(1.2) # Normal style normal = doc.styles['Normal'] normal.font.name = 'Times New Roman' normal.font.size = Pt(12) # ── helpers ────────────────────────────────────────────────────────────────── def para(text, bold=False, italic=False, center=False, size=12, sb=4, sa=4, indent=0): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(sb) p.paragraph_format.space_after = Pt(sa) if indent: p.paragraph_format.left_indent = Inches(indent) if center: p.alignment = WD_ALIGN_PARAGRAPH.CENTER r = p.add_run(text) r.bold = bold r.italic = italic r.font.name = 'Times New Roman' r.font.size = Pt(size) return p def heading(text, size=12, sb=10, sa=3): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(sb) p.paragraph_format.space_after = Pt(sa) r = p.add_run(text) r.bold = True r.font.name = 'Times New Roman' r.font.size = Pt(size) return p def bullet(text, indent=0.3): p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(indent) p.paragraph_format.first_line_indent = Inches(-0.2) p.paragraph_format.space_before = Pt(2) p.paragraph_format.space_after = Pt(2) r = p.add_run('\u2022 ' + text) r.font.name = 'Times New Roman' r.font.size = Pt(12) return p def sub_bullet(text): return bullet(text, indent=0.55) def box_note(text): """Italicised indented note / exam-edge box.""" p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.3) p.paragraph_format.space_before = Pt(4) p.paragraph_format.space_after = Pt(4) r = p.add_run(text) r.italic = True r.font.name = 'Times New Roman' r.font.size = Pt(11) return p # ══════════════════════════════════════════════════════════════════════════════ # TITLE # ══════════════════════════════════════════════════════════════════════════════ t = doc.add_paragraph() t.alignment = WD_ALIGN_PARAGRAPH.CENTER t.paragraph_format.space_before = Pt(0) t.paragraph_format.space_after = Pt(6) tr = t.add_run('ASSESSMENT OF PSYCHIATRIC DISORDERS IN MEDICALLY ILL IN-PATIENTS') tr.bold = True; tr.font.name = 'Times New Roman'; tr.font.size = Pt(14) # Flowchart mnemonic box_note('PREPARE \u2192 STABILIZE \u2192 REFERRAL QUESTION \u2192 HISTORY/COLLATERAL \u2192 MSE/COGNITION \u2192 DELIRIUM \u2192 PHYSICAL/NEUROLOGICAL \u2192 INVESTIGATIONS \u2192 RISK/CAPACITY \u2192 FORMULATION \u2192 LIAISON/FOLLOW-UP') # ══════════════════════════════════════════════════════════════════════════════ # OPENING STATEMENT # ══════════════════════════════════════════════════════════════════════════════ para( 'Psychiatric assessment is the cornerstone of C-L Psychiatry. Its goal is not merely to ' 'establish a diagnosis but to determine the aetiology of psychiatric symptoms, identify ' 'reversible causes, assess impact on medical care, and formulate an integrated management ' 'plan. (1)', sb=6, sa=4 ) para( 'Psychiatric assessment in a medically ill in-patient addresses five core questions: ' 'What syndrome is present? Why now? Is it primary or secondary? What risks exist? ' 'What guides management? (1,2)', sb=2, sa=4 ) box_note( 'Assessment is dynamic, not static \u2014 serial evaluations are essential, especially in ' 'delirium, critical illness or fluctuating cognition. New, late-onset, atypical or ' 'neurologically accompanied symptoms demand reassessment whenever physiology or treatment ' 'changes. (1,2)' ) # ══════════════════════════════════════════════════════════════════════════════ # 2.1 PRINCIPLES & OBJECTIVES # ══════════════════════════════════════════════════════════════════════════════ heading('2.1 Principles and Objectives of C-L Psychiatric Assessment', size=12) para('Principles \u2014 \u201cTO ABC SWC\u201d', bold=True, sb=2, sa=2) para( 'Objectives:', bold=False, sb=4, sa=2 ) for obj in [ 'Establish nature, severity, chronology and functional impact of symptoms.', 'Differentiate primary psychiatric vs. medical/drug/substance-related aetiology.', 'Detect delirium and neurocognitive disorders early.', 'Assess capacity, suicide risk, violence risk and vulnerability.', 'Identify psychosocial stressors, coping mechanisms, caregiver burden and support.', 'Assess treatment adherence factors.', 'Formulate an integrated biopsychosocial diagnosis.', 'Communicate management plan and arrange reassessment. (1,2)', ]: bullet(obj) # ══════════════════════════════════════════════════════════════════════════════ # 2.2 PREPARATORY PHASE # ══════════════════════════════════════════════════════════════════════════════ heading('2.2 Preparatory Phase (Before Seeing the Patient)', size=12) para( 'One of the distinctive features of C-L Psychiatry is that assessment begins before ' 'bedside contact. (1)', sb=2, sa=2 ) for b in [ 'Review current medical diagnosis, severity, complications and trajectory.', 'Review medical/nursing charts, vital signs, fluid balance, laboratory trends and imaging/EEG.', 'Review all current and recently stopped medications and possible drug interactions.', 'Review past psychiatric records, previous self-harm and previous treatment response.', 'Read nursing/duty-doctor observations of behaviour, sleep, orientation and fluctuation.', 'Arrange collateral from family/caregivers when required.', 'Speak directly with the referring consultant to clarify the exact clinical question.', ]: bullet(b) box_note( 'This prevents a vague referral such as \u201cbehaviour problem\u201d from being prematurely ' 'labelled as a primary psychiatric disorder. (1)' ) # ══════════════════════════════════════════════════════════════════════════════ # 2.3 TRIAGE & STABILIZATION # ══════════════════════════════════════════════════════════════════════════════ heading('2.3 Initial Triage and Stabilization', size=12) para('Before detailed psychiatric assessment, determine whether the patient is medically and psychiatrically stable:', sb=2, sa=2) for b in [ 'Airway, breathing and circulation where relevant.', 'Vital signs, oxygenation and bedside glucose.', 'Level of consciousness, arousal and acute neurological change.', 'Evidence of infection, hypoxia, metabolic disturbance or organ failure.', 'Drug intoxication, toxicity or withdrawal.', 'Severe agitation, violence or inability to cooperate safely.', 'Suicidal/self-harm risk or risk to others.', 'Risk of interference with essential treatment, lines/tubes or monitoring.', ]: bullet(b) box_note( '\u26a0 Do NOT diagnose a primary psychiatric disorder in an acutely ill, fluctuating or ' 'cognitively changed patient until delirium and other medical causes have been actively ' 'excluded. (1,2)' ) # ══════════════════════════════════════════════════════════════════════════════ # 2.4 REFERRAL QUESTION & CHRONOLOGY # ══════════════════════════════════════════════════════════════════════════════ heading('2.4 Clarification of Referral Question and Chronology', size=12) for b in [ 'Who referred the patient and what exactly prompted the referral?', 'When did symptoms begin? Was onset acute, subacute or chronic? Is there fluctuation?', 'What was the patient\u2019s baseline behaviour and cognition? What changed from baseline?', 'Is there a temporal relationship with medical illness, surgery, anaesthesia, medication change or substance use/withdrawal?', 'What clinical decision needs to be made now?', ]: bullet(b) box_note( 'Acute onset and fluctuation particularly raise concern for delirium or another secondary ' 'syndrome. Baseline cognition is often the most diagnostically valuable information in ' 'medically ill patients. (1,3)' ) # ══════════════════════════════════════════════════════════════════════════════ # 2.5 COLLATERAL HISTORY (condensed, merged) # ══════════════════════════════════════════════════════════════════════════════ heading('2.5 Collateral History', size=12) para( 'Collateral is essential when the patient has delirium, cognitive impairment, psychosis, ' 'sedation or communication difficulties. Sources include family/caregivers, nursing staff, ' 'treating physicians, previous records and medication charts. Establish the patient\u2019s ' 'baseline cognition, personality and behaviour, and the exact time and nature of any change. (1,3)', sb=2, sa=4 ) # ══════════════════════════════════════════════════════════════════════════════ # 2.6 PSYCHOSOCIAL & ENVIRONMENT # ══════════════════════════════════════════════════════════════════════════════ heading('2.6 Psychosocial and Hospital-Environment Assessment', size=12) for b in [ 'Understanding of illness, prognosis and treatment; fear, uncertainty and stigma.', 'Coping style and previous responses to illness.', 'Family relationships, caregiver burden and social support.', 'Financial, occupational, housing and access-to-care issues.', 'Cultural, religious and spiritual factors.', 'Communication difficulties, mistrust or conflict with treating team.', 'Safeguarding and vulnerability.', ]: bullet(b) box_note( 'In an apparently uncooperative patient with clear consciousness, explore whether behaviour ' 'reflects fear, misunderstanding, personality/coping, or communication failure \u2014 ' 'rather than assuming psychosis. (1)' ) # ══════════════════════════════════════════════════════════════════════════════ # 2.7 PHYSICAL & NEUROLOGICAL EXAM # ══════════════════════════════════════════════════════════════════════════════ heading('2.7 Physical and Neurological Examination', size=12) para( 'The psychiatrist must personally observe relevant physical signs. Look for features ' 'suggesting a secondary psychiatric syndrome: (1,2)', sb=2, sa=2 ) for b in [ 'General: level of arousal, hydration/nutrition, respiratory effort, pallor/jaundice, ' 'evidence of trauma, lines/catheters, infection or pain cues.', 'Neurological: consciousness, attention, speech/language, pupils, cranial nerves, focal ' 'signs, motor tone/power, reflexes, tremor, myoclonus, gait and extrapyramidal signs.', 'Autonomic: pulse, blood pressure, temperature, diaphoresis and pupil size \u2014 especially ' 'in withdrawal, serotonin toxicity, NMS or malignant catatonia.', 'Red flags: abnormal vitals, hypoxia, fever, dehydration, pain, asterixis, focal deficits, ' 'altered consciousness, seizures or rigidity.', ]: bullet(b) # ══════════════════════════════════════════════════════════════════════════════ # 2.8 MSE # ══════════════════════════════════════════════════════════════════════════════ heading('2.8 Mental Status Examination \u2014 Adapted for C-L Psychiatry', size=12) para( 'The MSE is systematic but C-L assessment gives particular emphasis to consciousness, ' 'arousal, attention, fluctuation and cognition. (1)', sb=2, sa=2 ) for b in [ '1. General inspection: evidence of delirium (floccillation, hallucinatory behaviour, ' 'agitation, pulling at lines/ports).', '2. Catatonia: rule out from motor and speech behaviour.', '3. Speech and thought organisation.', '4. Affect: depression, anxiety and adjustment difficulties are very common.', '5. Somatic distress/medically unexplained symptoms: la belle indiff\u00e9rence, secondary gain, ' 'health anxiety.', '6. Elevated/irritable mood: followed by mania screen.', '7. Delusions and hallucinations: if guarded or hostile behaviour.', '8. Suicidal and homicidal ideation: assessed in every patient.', '9. Brief cognitive assessment: especially in the elderly \u2014 mnemonic Memory-LAPSE ' '(Memory, Language, Attention, Perceptuomotor, Socialisation, Executive function).', ]: bullet(b) # ══════════════════════════════════════════════════════════════════════════════ # 2.9 DELIRIUM # ══════════════════════════════════════════════════════════════════════════════ heading('2.9 Delirium and Cognitive Assessment \u2014 A Priority', size=12) para( 'Delirium is common, frequently missed, potentially reversible, and frequently mistaken ' 'for psychosis, depression or behavioural disturbance. (2,3) ' 'Suspect it with: acute onset, fluctuation, inattention, altered arousal or disorganised thinking.', sb=2, sa=2 ) heading('Validated Assessment Tools:', size=11) for b in [ '4AT \u2014 rapid delirium screen; validated in 234 hospitalised older patients (MacLullich et al., 2014). (4)', 'CAM (Confusion Assessment Method) \u2014 gold standard for general wards/acute settings. (3)', 'CAM-ICU \u2014 for non-verbal ICU patients; use with RASS for arousal/sedation.', 'NEECHAM \u2014 nursing-led screening in medical/surgical wards.', 'MMSE / MoCA \u2014 quantify global cognitive impairment when patient can participate; ' 'neither replaces clinical assessment or baseline information.', ]: bullet(b) box_note( 'Delirium = acute + fluctuating + inattention/altered arousal.\n' 'Dementia = insidious + progressive, attention/arousal relatively preserved early.\n' 'Delirium and dementia can coexist \u2014 acute deterioration in known dementia should prompt ' 'assessment for superimposed delirium. (2,3)' ) para('After identifying delirium, search for precipitants:', sb=4, sa=2) for b in [ 'Infection, hypoxia, metabolic disturbance, dehydration, pain.', 'Constipation/urinary retention, sleep disruption, sensory impairment.', 'Polypharmacy, anticholinergics, sedatives, withdrawal.', 'Neurological causes including non-convulsive seizures when clinically suspected. (2)', ]: bullet(b) # ══════════════════════════════════════════════════════════════════════════════ # 2.10 RISK ASSESSMENT # ══════════════════════════════════════════════════════════════════════════════ heading('2.10 Risk Assessment', size=12) para( 'Risk assessment is continuous, not a one-time checklist. It must specify the nature, ' 'immediacy, modifiable drivers, protective factors, and the level of observation or support ' 'required. Document the risk formulation and communicate it to the team. (1,2)', sb=2, sa=2 ) para('Monitoring tools:', bold=True, sb=4, sa=2) for b in [ 'Columbia Suicide Severity Rating Scale (C-SSRS) \u2014 for serial suicidality monitoring.', 'Scale for Suicidal Ideation (SSI) \u2014 for confirmed suicidal ideation.', ]: bullet(b) # ══════════════════════════════════════════════════════════════════════════════ # 2.11 CAPACITY # ══════════════════════════════════════════════════════════════════════════════ heading('2.11 Decision-Making Capacity', size=12) para( 'Capacity is clinical, decision-specific and time-specific; it is not synonymous with ' 'psychiatric diagnosis, intelligence or disagreement with the clinician. (5)', sb=2, sa=2 ) for b in [ 'Define the exact decision, alternatives, benefits/risks and consequences of refusal.', 'Optimise conditions: treat pain, hypoxia and delirium; use interpreters and sensory aids; ' 'simplify information and allow time.', 'Assess four abilities (Appelbaum & Grisso, 1988): communicate a choice; understand relevant ' 'information; appreciate its personal implications; reason with the information. (5)', 'Identify causes of impaired decision-making: delirium, dementia, intoxication/withdrawal, ' 'psychosis, severe mood disorder or communication difficulty.', 'Document supports provided, patient\u2019s responses and reasoning, conclusion and need for ' 'reassessment.', ]: bullet(b) # ══════════════════════════════════════════════════════════════════════════════ # 2.12 INVESTIGATIONS # ══════════════════════════════════════════════════════════════════════════════ heading('2.12 Investigations \u2014 Hypothesis-Driven, Not Routine Panels', size=12) para( 'Investigations should follow the history, examination and differential diagnosis. ' 'Review existing results before ordering tests; avoid the false dichotomy of ' '\u201cmedical clearance\u201d before psychiatric assessment. (1,2)', sb=2, sa=2 ) for cat, items in [ ('Basic/medical', 'CBC, glucose, electrolytes, calcium/magnesium, renal/liver function, thyroid function where indicated, urinalysis/infection work-up, ECG.'), ('Targeted', 'Drug levels/toxicology, blood cultures, blood gas, B12/folate, endocrine/autoimmune/infectious investigations as clinically indicated.'), ('Neurological', 'CT/MRI brain for focal/atypical presentations; EEG for suspected non-convulsive seizures/encephalopathy; CSF when CNS infection/inflammation suspected.'), ('Before psychotropics', 'Review renal/hepatic function, electrolytes, ECG/QTc and drug interactions according to proposed medication and medical risk.'), ]: p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.3) p.paragraph_format.space_before = Pt(3) p.paragraph_format.space_after = Pt(2) r1 = p.add_run(cat + ': ') r1.bold = True; r1.font.name = 'Times New Roman'; r1.font.size = Pt(12) r2 = p.add_run(items) r2.font.name = 'Times New Roman'; r2.font.size = Pt(12) # ══════════════════════════════════════════════════════════════════════════════ # 2.13 DIAGNOSTIC FORMULATION # ══════════════════════════════════════════════════════════════════════════════ heading('2.13 Diagnostic Formulation and Differential Diagnosis', size=12) para( 'A good C-L formulation integrates syndrome, aetiology, vulnerabilities, precipitants, ' 'perpetuating factors, strengths, risks, capacity and a practical plan. ' 'Organise using the 4Ps: (1,2)', sb=2, sa=2 ) for b in [ 'Predisposing \u2014 prior psychiatric illness, cognitive disorder, personality.', 'Precipitating \u2014 acute illness, surgery, infection, new medication.', 'Perpetuating \u2014 pain, disability, poor sleep, isolation.', 'Protective \u2014 family support, coping strengths, engagement.', ]: bullet(b) para('Explicitly state whether symptoms are best understood as:', sb=4, sa=2) for b in [ '(a) A primary psychiatric disorder.', '(b) A mental disorder due to another medical condition.', '(c) A substance/medication-induced disorder.', '(d) Delirium or another neurocognitive disorder.', '(e) An adjustment response/demoralisation.', '(f) A multifactorial interaction. (1,2)', ]: bullet(b) para( 'The C-L note should include: provisional/differential diagnoses (DSM/ICD); probable ' 'aetiology; treatment interactions; biopsychosocial background; risk assessment; and ' 'recommendations for management including uncooperative behaviour. (1)', sb=4, sa=4 ) # ══════════════════════════════════════════════════════════════════════════════ # 2.14 COMMUNICATION & FOLLOW-UP # ══════════════════════════════════════════════════════════════════════════════ heading('2.14 Communication, Liaison and Follow-Up', size=12) para( 'The assessment is incomplete without communication. Document the formulation, risk, ' 'capacity where relevant and clear recommendations. Discuss directly with the treating ' 'team; explain the role of psychiatric care to the patient/family; specify what requires ' 'urgent action. C-L Psychiatry is collaborative, not merely referral-based. (1,2)', sb=2, sa=2 ) for b in [ 'To the treating team: written note plus direct verbal communication; clarify doubts and ' 'co-develop a comprehensive treatment plan.', 'To the patient and family: transparent explanation; clarify mind-body connection; ensure ' 'no discrepancy between the primary team\u2019s and psychiatrist\u2019s messages.', 'Confirmed psychiatric diagnosis requiring pharmacotherapy: follow-up within 1 week, then ' 'outpatient follow-up after discharge.', 'Inconclusive diagnosis: regular follow-up with psychometric evaluation and symptomatic ' 'management.', 'Suicidal ideation: serial monitoring with SSI or C-SSRS.', ]: bullet(b) # ══════════════════════════════════════════════════════════════════════════════ # 2.15 SPECIAL POPULATIONS # ══════════════════════════════════════════════════════════════════════════════ heading('2.15 Special Populations', size=12) # Older adults heading('A. Older Adults', size=11) para( 'Delirium, dementia, depression, sensory impairment, frailty, polypharmacy and functional ' 'dependence may coexist. (1,2)', sb=2, sa=2 ) for b in [ 'Establish premorbid cognition and function from family; do not rely on the current interview alone.', 'Actively screen for delirium; assess for superimposed delirium in known dementia.', 'Review anticholinergic burden, sedatives, analgesics, polypharmacy and renal/hepatic impairment.', 'Assess hearing/vision; use glasses/hearing aids; adapt communication and allow more time.', 'Screen depression: Geriatric Depression Scale (GDS) when dementia is not prominent.', 'Use PHQ-2 as a brief first-step screen on busy medical wards; follow with PHQ-9 if positive.', 'MMSE/MoCA selectively; interpret in relation to education, language and baseline.', ]: bullet(b) box_note( 'The 2024 HOME trial evaluated proactive integrated C-L psychiatry in older medical ' 'in-patients and found supportive evidence for its role in improving medical care, although ' 'it did not demonstrate a significant reduction in hospital length of stay. (2)' ) # Paediatric heading('B. Children and Adolescents', size=11) para( 'Assessment must be developmentally sensitive and family-centred, integrating developmental ' 'stage, illness, emotional/behavioural symptoms, family context and safeguarding. (6)', sb=2, sa=2 ) for b in [ 'Interview child/adolescent directly at a developmentally appropriate level; obtain collateral from parents and paediatric team.', 'Assess developmental and premorbid functioning.', 'Explore the child\u2019s understanding and experience of illness and hospitalisation.', 'Assess mood, anxiety, behavioural, trauma-related and somatic symptoms.', 'Assess cognition and delirium when there is acute change.', 'Assess self-harm/suicide risk; assess family functioning and safeguarding.', 'Consider assent/capacity and parental/guardian involvement.', ]: bullet(b) box_note( 'A 2025 mixed-methods systematic review (Avery et al.) of 53 studies on paediatric mental ' 'health liaison services found supportive, though methodologically limited, evidence for ' 'integrated multidisciplinary, child- and family-centred paediatric liaison care. (6)' ) # Perinatal heading('C. Pregnant and Postpartum Women', size=11) para( 'Requires simultaneous consideration of maternal psychiatric illness, obstetric status, ' 'fetal considerations, medications and psychosocial factors. (1)', sb=2, sa=2 ) para('Pregnancy assessment:', bold=True, sb=3, sa=1) for b in [ 'Gestational age; obstetric history and current complications.', 'Previous psychiatric illness \u2014 especially bipolar disorder and psychosis; previous perinatal episodes.', 'Current mood, anxiety, panic, trauma, psychosis and mania; suicidality.', 'Medication and substance exposure; sleep, pain and nutrition.', 'Validated screening: EPDS or PHQ-9 for depression; GAD-7 for anxiety.', ]: bullet(b) para('Postpartum assessment:', bold=True, sb=3, sa=1) for b in [ 'Time since delivery; sleep deprivation.', 'Depressive/anxiety symptoms; intrusive/obsessive thoughts; birth-related trauma.', 'Past bipolar disorder or psychosis and previous postpartum episodes.', 'Mania, disorganisation, delusions, hallucinations, rapidly changing mental state.', 'Suicidal thoughts and thoughts of harming the infant; bonding and infant-care capacity.', 'Breastfeeding and current medications: consider maternal and infant safety.', ]: bullet(b) box_note( '\u26a0 Postpartum psychosis \u2014 Exam point: Rapid onset of psychotic/manic/disorganised symptoms ' 'postpartum, especially with confusion or marked behavioural change, requires urgent ' 'assessment, medical exclusion of secondary causes, immediate risk assessment and close ' 'collaboration with obstetric, paediatric and psychiatric teams. (1)' ) # ══════════════════════════════════════════════════════════════════════════════ # CLOSING BOX # ══════════════════════════════════════════════════════════════════════════════ para('', sb=6, sa=2) box_note( 'THE THREE \u201cC\u201dS OF C-L PSYCHIATRY\n' 'Conceptualisation \u2013 Communication \u2013 Collaboration\n' 'These define what is unique about C-L practice. A sound parallel knowledge of medicine ' 'is equally essential alongside psychiatric expertise.' ) para( '\u201cIn a medically ill patient, the psychiatric symptom is not the diagnosis; it is the ' 'starting point for a comprehensive biopsychosocial and medical assessment.\u201d', italic=True, center=True, size=11, sb=6, sa=8 ) # ══════════════════════════════════════════════════════════════════════════════ # WHAT WAS REMOVED # ══════════════════════════════════════════════════════════════════════════════ heading('NOTE: Sections removed from original draft', size=11) for b in [ 'Paras 7-8: Introductory filler repeating objectives \u2014 removed.', 'Section 3.3 \u201cComprehensive history\u201d \u2014 merged into 2.4 and 2.5.', 'Section 2.6 collateral \u2014 condensed from 8 lines to 2 lines; merged into 2.5.', 'INTRODUCTION/RAPPORT/INTERVIEW section \u2014 removed (implied in MSE section).', 'Section 3.9 duplicate investigations \u2014 removed; 2.12 retained.', 'Section 2.15 clinical settings (ED/ICU/Ward brief bullets) \u2014 removed.', 'Section 3.11 \u201cPractical principles\u201d \u2014 removed (covered in objectives and formulation).', 'PHQ-2 added as brief ward screening scale (was missing).', 'Section numbering corrected and made sequential throughout.', ]: bullet(b) # ══════════════════════════════════════════════════════════════════════════════ # REFERENCES # ══════════════════════════════════════════════════════════════════════════════ heading('REFERENCES', size=12) refs = [ '1. Ghosal MK, Ray AK. Assessment of psychiatric disorders in consultation-liaison setting. Indian J Psychiatry. 2022;64(Suppl 2):S211\u2013S227. doi:10.4103/indianjpsychiatry.indianjpsychiatry_20_22.', '2. American Psychiatric Association. The American Psychiatric Association Practice Guideline for the Prevention and Treatment of Delirium. Am J Psychiatry. 2025;182(9):880\u2013884. doi:10.1176/appi.ajp.25182013.', '3. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the Confusion Assessment Method. Ann Intern Med. 1990;113(12):941\u2013948. doi:10.7326/0003-4819-113-12-941.', '4. MacLullich AMJ, Ryan T, Cash H, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014;43(4):496\u2013502. doi:10.1093/ageing/afu021.', '5. Appelbaum PS, Grisso T. Assessing patients\u2019 capacities to consent to treatment. N Engl J Med. 1988;319(25):1635\u20131638. doi:10.1056/NEJM198812223192504.', '6. Avery M, Kirk S, Pryjmachuk S. A mixed methods systematic review of the impact of paediatric mental health liaison services. Eur Child Adolesc Psychiatry. 2025;34(12):3749\u20133767. doi:10.1007/s00787-025-02815-5.', ] for ref in refs: rp = doc.add_paragraph() rp.paragraph_format.left_indent = Inches(0.3) rp.paragraph_format.first_line_indent = Inches(-0.3) rp.paragraph_format.space_before = Pt(3) rp.paragraph_format.space_after = Pt(3) rr = rp.add_run(ref) rr.font.name = 'Times New Roman' rr.font.size = Pt(10) doc.save(out) print('Saved:', out) PYEOF

python3 << 'PYEOF' from docx import Document from docx.shared import Pt, Inches from docx.enum.text import WD_ALIGN_PARAGRAPH import os os.makedirs('/tmp/workspace/prize-fixed', exist_ok=True) out = '/tmp/workspace/prize-fixed/Assessment_Section_Fixed.docx' doc = Document() section = doc.sections[0] section.top_margin = Inches(1) section.bottom_margin = Inches(1) section.left_margin = Inches(1.2) section.right_margin = Inches(1.2) normal = doc.styles['Normal'] normal.font.name = 'Times New Roman' normal.font.size = Pt(12) def h1(text): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(12) p.paragraph_format.space_after = Pt(4) r = p.add_run(text) r.bold = True; r.font.name = 'Times New Roman'; r.font.size = Pt(13) return p def h2(text): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(10) p.paragraph_format.space_after = Pt(3) r = p.add_run(text) r.bold = True; r.font.name = 'Times New Roman'; r.font.size = Pt(12) return p def h3(text): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(6) p.paragraph_format.space_after = Pt(2) r = p.add_run(text) r.bold = True; r.italic = True; r.font.name = 'Times New Roman'; r.font.size = Pt(12) return p def para(text, bold=False, italic=False, sb=3, sa=3): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(sb) p.paragraph_format.space_after = Pt(sa) r = p.add_run(text) r.bold = bold; r.italic = italic r.font.name = 'Times New Roman'; r.font.size = Pt(12) return p def bullet(text, indent=0.3): p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(indent) p.paragraph_format.first_line_indent = Inches(-0.2) p.paragraph_format.space_before = Pt(2) p.paragraph_format.space_after = Pt(2) r = p.add_run('\u2022 ' + text) r.font.name = 'Times New Roman'; r.font.size = Pt(12) return p def note(text): p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.3) p.paragraph_format.space_before = Pt(4) p.paragraph_format.space_after = Pt(4) r = p.add_run(text) r.italic = True; r.font.name = 'Times New Roman'; r.font.size = Pt(11) return p def bold_intro(label, rest, sb=3, sa=3): p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.3) p.paragraph_format.space_before = Pt(sb) p.paragraph_format.space_after = Pt(sa) r1 = p.add_run(label) r1.bold = True; r1.font.name = 'Times New Roman'; r1.font.size = Pt(12) r2 = p.add_run(rest) r2.font.name = 'Times New Roman'; r2.font.size = Pt(12) return p # ══════════════════════════════════════════════════════════════════ # MAIN HEADING — fix #1: use "2." to match 2.x subsections # ══════════════════════════════════════════════════════════════════ h1('2. ASSESSMENT OF PSYCHIATRIC DISORDERS IN MEDICALLY ILL IN-PATIENTS') # ── 2.1 ────────────────────────────────────────────────────────── h2('2.1 Principles and Objectives of C-L Psychiatric Assessment') h3('Principles:') for b in [ 'Think organic first: new behavioural or cognitive symptoms in medically ill patients.', 'Stabilize the patient first.', 'Adopt a biopsychosocial approach.', 'Build chronology \u2014 the temporal relationship between symptoms, illness, procedures, medications and substances is diagnostically crucial.', 'Review medications and substances.', 'Obtain collateral information.', 'Watch serially \u2014 particularly when symptoms fluctuate or the medical condition changes.', 'Collaborate with the multidisciplinary team.', ]: bullet(b) h3('Objectives:') for b in [ 'Establish nature, severity, chronology and functional impact of symptoms.', 'Differentiate primary psychiatric vs. medical/drug/substance-related aetiology.', 'Detect delirium and neurocognitive disorders early.', 'Assess capacity, suicide risk, violence risk and vulnerability.', 'Identify psychosocial stressors, coping mechanisms, caregiver burden and support.', 'Assess treatment adherence factors.', 'Formulate an integrated biopsychosocial diagnosis.', 'Communicate the management plan and arrange reassessment. (1)', ]: bullet(b) # ── 2.2 ────────────────────────────────────────────────────────── h2('2.2 Preparatory Phase (Before Seeing the Patient)') para('One of the distinctive features of C-L Psychiatry is that assessment begins before bedside contact. (1)', sb=2, sa=2) for b in [ 'Review current medical diagnosis, severity, complications and trajectory.', 'Review medical/nursing charts, vital signs, fluid balance, laboratory trends and imaging/EEG.', 'Review all current and recently stopped medications and possible drug interactions.', 'Review past psychiatric records, previous self-harm and previous treatment response.', 'Read nursing/duty-doctor observations of behaviour, sleep, orientation and fluctuation.', 'Arrange collateral from family/caregivers when required.', 'Speak directly with the referring consultant to clarify the exact clinical question.', ]: bullet(b) note('This prevents a vague referral such as \u201cbehaviour problem\u201d from being prematurely labelled as a primary psychiatric disorder. (1)') # ── 2.3 ────────────────────────────────────────────────────────── h2('2.3 Initial Triage and Stabilization') para('Before detailed psychiatric assessment, determine whether the patient is medically and psychiatrically stable:', sb=2, sa=2) for b in [ 'Airway, breathing and circulation where relevant.', 'Vital signs, oxygenation and bedside glucose.', 'Level of consciousness, arousal and acute neurological change.', 'Evidence of infection, hypoxia, metabolic disturbance or organ failure.', 'Drug intoxication, toxicity or withdrawal.', 'Severe agitation, violence or inability to cooperate safely.', 'Suicidal/self-harm risk or risk to others.', 'Risk of interference with essential treatment, lines/tubes or monitoring.', ]: bullet(b) note('\u26a0 Do NOT diagnose a primary psychiatric disorder in an acutely ill, fluctuating or cognitively changed patient until delirium and other medical causes have been actively excluded. (1)') # ── 2.4 ────────────────────────────────────────────────────────── h2('2.4 Clarification of Referral Question and Chronology') for b in [ 'Who referred the patient and what exactly prompted the referral?', 'When did symptoms begin? Was the onset acute, subacute or chronic? Is there fluctuation?', 'What was the patient\u2019s baseline behaviour and cognition? What changed from baseline?', 'Is there a temporal relationship with medical illness, surgery, anaesthesia, medication change or substance use/withdrawal?', # fix #8 'What clinical decision needs to be made now?', ]: bullet(b) note('Acute onset and fluctuation particularly raise concern for delirium or another secondary syndrome. Baseline cognition is often the most diagnostically valuable information in medically ill patients. (1,3)') # ── 2.5 ────────────────────────────────────────────────────────── h2('2.5 Comprehensive History') para('The history should be organised under the following domains:', sb=2, sa=2) for b in [ 'Presenting complaint and HPI \u2013 onset, precipitant, course, phenomenology, severity, distress, functional impact, sleep, pain, cognition, mood, anxiety, psychotic and behavioural symptoms.', 'Medical and neurological history \u2013 current illness, procedures/anaesthesia, infection, hypoxia, endocrine/metabolic disease, organ failure, seizures, stroke, head injury, dementia, nutritional deficiency and pain.', 'Past psychiatric history \u2013 previous diagnoses, admissions, self-harm/suicide attempts, treatment response, adverse effects and adherence.', 'Medication history \u2013 prescribed, over-the-counter and traditional medicines; recent additions, dose changes or omissions; interactions and drugs with neuropsychiatric effects.', 'Substance-use history \u2013 alcohol, nicotine, opioids, benzodiazepines, cannabis, stimulants and other substances; last use, intoxication and withdrawal history.', 'Psychosocial history \u2013 illness beliefs, coping, stressors, family/social support, caregiver burden, occupation/finances, housing, adherence barriers, culture and spirituality. (1)', # fix #7 ]: bullet(b) # ── 2.6 Collateral ─────────────────────────────────────────────── h2('2.6 Collateral Information') para( 'Collateral information is particularly important in delirium, cognitive impairment, psychosis, ' 'sedation, severe distress or communication difficulties. Sources include family/caregivers, ' 'nursing staff, treating physicians, previous psychiatric/medical records and medication charts. ' 'Establish premorbid cognition, personality, behaviour and functioning, and the exact time and ' 'nature of the change. In medically ill patients, baseline information is often more diagnostically ' 'valuable than a single cross-sectional interview. (1)', # fix #5: superscript -> (1) sb=2, sa=4 ) # ── 2.7 Psychosocial (fix #3: was second 2.6, now 2.7) ───────── h2('2.7 Psychosocial and Hospital-Environment Assessment') for b in [ 'Understanding of illness, prognosis and treatment; fear, uncertainty and stigma.', 'Coping style and previous responses to illness.', 'Family relationships, caregiver burden and social support.', 'Financial, occupational, housing and access-to-care issues.', 'Cultural, religious and spiritual factors.', 'Communication difficulties, mistrust or conflict with the treating team.', 'Safeguarding and vulnerability.', ]: bullet(b) note('In an apparently uncooperative patient with clear consciousness, explore whether behaviour reflects fear, misunderstanding, personality/coping, or communication failure \u2014 rather than assuming psychosis. (1)') # ── 2.8 Physical exam (shifted +1) ─────────────────────────────── h2('2.8 Physical and Neurological Examination') para('The psychiatrist must personally observe relevant physical signs. Look for features suggesting a secondary psychiatric syndrome: (1,2)', sb=2, sa=2) for b in [ 'General: level of arousal, hydration/nutrition, respiratory effort, pallor/jaundice, evidence of trauma, lines/catheters, infection or pain cues.', 'Neurological: consciousness, attention, speech/language, pupils, cranial nerves, focal signs, motor tone/power, reflexes, tremor, myoclonus, gait and extrapyramidal signs.', 'Autonomic: pulse, blood pressure, temperature, diaphoresis and pupil size \u2014 especially in withdrawal, serotonin toxicity, NMS or malignant catatonia.', 'Red flags: abnormal vitals, hypoxia, fever, dehydration, pain, asterixis, focal deficits, altered consciousness, seizures or rigidity.', ]: bullet(b) # ── 2.9 MSE ────────────────────────────────────────────────────── h2('2.9 Mental Status Examination \u2014 Adapted for C-L Psychiatry') para('The MSE is systematic but C-L assessment gives particular emphasis to consciousness, arousal, attention, fluctuation and cognition. (1)', sb=2, sa=2) for b in [ '1. General inspection: evidence of delirium (floccillation, hallucinatory behaviour, agitation, pulling at lines/ports).', '2. Catatonia: rule out from motor and speech behaviour.', '3. Speech and thought organisation.', '4. Affect: depression, anxiety and adjustment difficulties are very common.', '5. Somatic distress/medically unexplained symptoms: la belle indiff\u00e9rence, secondary gain, health anxiety.', '6. Elevated/irritable mood: followed by mania screen.', '7. Delusions and hallucinations: if guarded or hostile behaviour.', '8. Suicidal and homicidal ideation: assessed in every patient.', '9. Brief cognitive assessment: especially in the elderly \u2014 mnemonic Memory-LAPSE (Memory, Language, Attention, Perceptuomotor, Socialisation, Executive function).', ]: bullet(b) # ── 2.10 Delirium ───────────────────────────────────────────────── h2('2.10 Delirium and Cognitive Assessment \u2014 A Priority') para( 'Delirium is common, frequently missed, potentially reversible, and frequently mistaken for ' 'psychosis, depression or behavioural disturbance. (2,3) Suspect it with: acute onset, ' 'fluctuation, inattention, altered arousal or disorganised thinking.', sb=2, sa=2 ) para('Assess:', bold=True, sb=3, sa=1) for b in [ 'Acute onset and fluctuating course.', 'Attention \u2014 test rather than merely ask.', 'Level of consciousness/arousal.', 'Orientation and cognition.', 'Perceptual and psychomotor changes.', 'Baseline cognition and diurnal variation from family/staff.', ]: bullet(b) h3('Validated Assessment Tools:') for b in [ '4AT \u2014 rapid delirium screen; validated in 234 hospitalised older patients (MacLullich et al., 2014). (4)', 'CAM (Confusion Assessment Method) \u2014 gold standard for general wards/acute settings. (3)', 'CAM-ICU \u2014 for non-verbal ICU patients; use with RASS for arousal/sedation.', 'NEECHAM \u2014 nursing-led screening in medical/surgical wards.', 'MMSE / MoCA \u2014 quantify global cognitive impairment when patient can participate; neither replaces clinical assessment or baseline information.', ]: bullet(b) note( 'Delirium = acute + fluctuating + inattention/altered arousal.\n' 'Dementia = insidious + progressive, attention/arousal relatively preserved early.\n' 'Delirium and dementia can coexist \u2014 acute deterioration in known dementia should prompt assessment for superimposed delirium. (2,3)' ) para('After identifying delirium, search for precipitants:', sb=3, sa=2) for b in [ 'Infection, hypoxia, metabolic disturbance, dehydration, pain.', 'Constipation/urinary retention, sleep disruption, sensory impairment.', 'Polypharmacy, anticholinergics, sedatives, withdrawal.', 'Neurological causes including non-convulsive seizures when clinically suspected. (2)', ]: bullet(b) # ── 2.11 Risk ──────────────────────────────────────────────────── h2('2.11 Risk Assessment') para( 'Risk assessment is continuous rather than a one-time checklist. Document the risk ' 'formulation and communicate it to the team. Assess and document: (1)', sb=2, sa=2 ) for b in [ 'Suicide/self-harm \u2013 ideation, intent, plan, access to means, past attempts, hopelessness, impulsivity, pain, substance use, delirium and protective factors.', 'Violence/agitation \u2013 triggers, imminence, previous violence, delirium, psychosis, mania, withdrawal and environmental factors.', 'Vulnerability/self-neglect \u2013 nutrition, hydration, falls, wandering, treatment refusal, exploitation/abuse and caregiving capacity.', 'Risk to treatment \u2013 non-adherence, absconding, interference with essential treatment and inability to participate in rehabilitation.', ]: bullet(b) para('Monitoring tools:', bold=True, sb=4, sa=2) for b in [ 'Columbia Suicide Severity Rating Scale (C-SSRS) \u2014 for serial suicidality monitoring.', 'Scale for Suicidal Ideation (SSI) \u2014 for confirmed suicidal ideation.', ]: bullet(b) # ── 2.12 Capacity ──────────────────────────────────────────────── h2('2.12 Decision-Making Capacity') para( 'Capacity is clinical, decision-specific and time-specific; it is not synonymous with ' 'psychiatric diagnosis, intelligence or disagreement with the clinician. (5)', # fix #6: removed ref 15 sb=2, sa=2 ) para('Define the exact decision and optimise conditions for decision-making by addressing reversible factors such as pain, hypoxia and delirium. Assess the four core abilities (Appelbaum & Grisso, 1988): (5)', sb=2, sa=2) for b in [ 'Communicate a choice.', 'Understand relevant information.', 'Appreciate the situation and its consequences.', 'Reason with the relevant information.', ]: bullet(b) para('Document the decision assessed, information provided, supports used, patient\u2019s responses and reasoning, conclusion and need for reassessment. (5)', sb=3, sa=3) # ── 2.13 Investigations ────────────────────────────────────────── h2('2.13 Investigations \u2014 Hypothesis-Driven, Not Routine Panels') para( 'Investigations should follow the history, examination and differential diagnosis. ' 'Review existing results before ordering tests; avoid the false dichotomy of ' '\u201cmedical clearance\u201d before psychiatric assessment. (1,2)', sb=2, sa=2 ) for cat, items in [ ('Basic/medical: ', 'CBC, glucose, electrolytes, calcium/magnesium, renal/liver function, thyroid function where indicated, urinalysis/infection work-up, ECG.'), ('Targeted: ', 'Drug levels/toxicology, blood cultures, blood gas, B12/folate, endocrine/autoimmune/infectious investigations as clinically indicated.'), ('Neurological: ', 'CT/MRI brain for focal/atypical presentations; EEG for suspected non-convulsive seizures/encephalopathy; CSF when CNS infection/inflammation suspected.'), ('Before psychotropics: ', 'Review renal/hepatic function, electrolytes, ECG/QTc and drug interactions according to proposed medication and medical risk.'), ]: p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.3) p.paragraph_format.space_before = Pt(3) p.paragraph_format.space_after = Pt(2) r1 = p.add_run(cat); r1.bold = True; r1.font.name = 'Times New Roman'; r1.font.size = Pt(12) r2 = p.add_run(items); r2.font.name = 'Times New Roman'; r2.font.size = Pt(12) # ── 2.14 Formulation (fix #4: deleted old duplicate 2.14; merged ref ⁴,⁷ here) ── h2('2.14 Diagnostic Formulation and Differential Diagnosis') para( 'A good C-L formulation integrates syndrome, aetiology, vulnerabilities, precipitants, ' 'perpetuating factors, strengths, risks, capacity and a practical plan. ' 'Organise using the 4Ps: (1,2)', sb=2, sa=2 ) for b in [ 'Predisposing \u2014 prior psychiatric illness, cognitive disorder, personality.', 'Precipitating \u2014 acute illness, surgery, infection, new medication.', 'Perpetuating \u2014 pain, disability, poor sleep, isolation.', 'Protective \u2014 family support, coping strengths, engagement.', ]: bullet(b) para('Explicitly state whether symptoms are best understood as: (1,2)', sb=4, sa=2) for b in [ '(a) A primary psychiatric disorder.', '(b) A mental disorder due to another medical condition.', '(c) A substance/medication-induced disorder.', '(d) Delirium or another neurocognitive disorder.', '(e) An adjustment response/demoralisation.', '(f) A multifactorial interaction.', ]: bullet(b) para( 'The C-L note should include: provisional/differential diagnoses (DSM/ICD); probable ' 'aetiology; treatment interactions; biopsychosocial background; risk assessment; and ' 'recommendations for management including uncooperative behaviour. (1)', sb=4, sa=6 ) # ══════════════════════════════════════════════════════════════════ # REFERENCES # ══════════════════════════════════════════════════════════════════ h2('REFERENCES') refs = [ '1. Ghosal MK, Ray AK. Assessment of psychiatric disorders in consultation-liaison setting. Indian J Psychiatry. 2022;64(Suppl 2):S211\u2013S227. doi:10.4103/indianjpsychiatry.indianjpsychiatry_20_22.', '2. American Psychiatric Association. Practice Guideline for the Prevention and Treatment of Delirium. Am J Psychiatry. 2025;182(9):880\u2013884. doi:10.1176/appi.ajp.25182013.', '3. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the Confusion Assessment Method. Ann Intern Med. 1990;113(12):941\u2013948. doi:10.7326/0003-4819-113-12-941.', '4. MacLullich AMJ, Ryan T, Cash H, et al. Validation of the 4AT, a new instrument for rapid delirium screening. Age Ageing. 2014;43(4):496\u2013502. doi:10.1093/ageing/afu021.', '5. Appelbaum PS, Grisso T. Assessing patients\u2019 capacities to consent to treatment. N Engl J Med. 1988;319(25):1635\u20131638. doi:10.1056/NEJM198812223192504.', '6. Avery M, Kirk S, Pryjmachuk S. A mixed methods systematic review of the impact of paediatric mental health liaison services. Eur Child Adolesc Psychiatry. 2025;34(12):3749\u20133767. doi:10.1007/s00787-025-02815-5.', ] for ref in refs: rp = doc.add_paragraph() rp.paragraph_format.left_indent = Inches(0.3) rp.paragraph_format.first_line_indent = Inches(-0.3) rp.paragraph_format.space_before = Pt(3) rp.paragraph_format.space_after = Pt(3) rr = rp.add_run(ref) rr.font.name = 'Times New Roman'; rr.font.size = Pt(10) doc.save(out) print('Saved:', out) PYEOF