RG Kar Medical College Kolkata history founding 1886

Which 'Bose' are you asking about?

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

python3 -c " from docx import Document doc = Document('/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/FINAL_Gold_Medal_Introduction_to_Assessment_Vancouver_1-13.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 from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.oxml.ns import qn from docx.oxml import OxmlElement import copy, os src = '/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/FINAL_Gold_Medal_Introduction_to_Assessment_Vancouver_1-13.docx' out = '/tmp/workspace/prize-fixed/FINAL_Gold_Medal_REVISED.docx' doc = Document(src) paras = doc.paragraphs # ── Fix 1: citation style in 2.17 — change (1,2) to superscript ¹,² for p in paras: if p.text.strip().startswith('The assessment is incomplete') and '(1,2)' in p.text: for run in p.runs: if '(1,2)' in run.text: run.text = run.text.replace('(1,2)', '') # add superscript run at end run_sup = p.add_run('\u00b9\u002c\u00b2') run_sup.font.name = 'Times New Roman' run_sup.font.size = Pt(12) # make it superscript via XML rPr = run_sup._r.get_or_add_rPr() vertAlign = OxmlElement('w:vertAlign') vertAlign.set(qn('w:val'), 'superscript') rPr.append(vertAlign) # ── Fix 2: disorganized → disorganised for p in paras: for run in p.runs: if 'disorganized' in run.text: run.text = run.text.replace('disorganized', 'disorganised') # ── Fix 3: full stop after MSE item 5 for p in paras: if 'la belle' in p.text and p.text.strip().endswith('health anxiety'): for run in p.runs: if run.text.strip().endswith('health anxiety'): run.text = run.text.rstrip() + '.' # ── Fix 4 & 5: Capacity section restructure # Find the capacity opening sentence paragraph cap_idx = None for i, p in enumerate(paras): if p.text.strip().startswith('Capacity is clinical, decision-specific'): cap_idx = i break if cap_idx is not None: # Find "Optimize reversible factors..." paragraph (after cap_idx) opt_idx = None for i in range(cap_idx+1, min(cap_idx+10, len(paras))): if 'ptimize' in paras[i].text or 'ptimise' in paras[i].text: opt_idx = i break # Find last bullet (Reason with...) paragraph reason_idx = None for i in range(cap_idx+1, min(cap_idx+10, len(paras))): if paras[i].text.strip().startswith('Reason with'): reason_idx = i break if opt_idx is not None and reason_idx is not None: opt_para = paras[opt_idx] reason_para = paras[reason_idx] # Step A: Fix the optimise paragraph text and move it before bullets # Change text of opt_para for run in opt_para.runs: run.text = '' # Clear and rewrite opt_para.runs[0].text = 'Before assessment, optimise reversible factors such as pain, hypoxia and delirium. Assess the four core abilities (Appelbaum & Grisso, 1988):' # Add superscript ⁴,¹³ at end of opt_para sup_run = opt_para.add_run('\u2074\u002c\u00b9\u00b3') sup_run.font.name = 'Times New Roman' sup_run.font.size = Pt(12) rPr2 = sup_run._r.get_or_add_rPr() v2 = OxmlElement('w:vertAlign') v2.set(qn('w:val'), 'superscript') rPr2.append(v2) # Step B: Move opt_para XML element to just before first bullet # First bullet is para after cap_idx (Communicate a choice) comm_idx = None for i in range(cap_idx+1, min(cap_idx+10, len(paras))): if paras[i].text.strip().startswith('Communicate a choice'): comm_idx = i break if comm_idx is not None: comm_elem = paras[comm_idx]._element opt_elem = opt_para._element parent = comm_elem.getparent() # Remove opt_elem from current position parent.remove(opt_elem) # Insert before comm_elem parent.insert(list(parent).index(comm_elem), opt_elem) # Step C: Remove superscript from last bullet (Reason with...) for run in reason_para.runs: run.text = run.text.replace('\u2074\u002c\u00b9\u00b3', '').replace('⁴,¹³', '') # Also strip via XML for r_elem in reason_para._element.findall('.//' + qn('w:r')): t = r_elem.find(qn('w:t')) if t is not None and t.text: t.text = t.text.replace('⁴,¹³','').replace('\u2074,\u00b9\u00b3','') # Step D: Fix "patient's responses" in document line for p in paras: if 'responses and reasoning' in p.text and "patient" not in p.text: for run in p.runs: if 'responses and reasoning' in run.text: run.text = run.text.replace('responses and reasoning', "patient\u2019s responses and reasoning") # ── Fix: "Optimize" anywhere else for p in paras: for run in p.runs: run.text = run.text.replace('Optimize', 'Optimise').replace('optimize', 'optimise') doc.save(out) print('Saved:', out) # Quick verify of capacity section doc2 = Document(out) printing = False for p in doc2.paragraphs: if 'Capacity is clinical' in p.text: printing = True if printing and p.text.strip(): print(p.text) if printing and 'reassessment' in p.text: break PYEOF

python3 -c " from docx import Document doc = Document('/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/FINAL_Gold_Medal_Introduction_to_Assessment_Vancouver_1-13 (1).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 from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.oxml.ns import qn from docx.oxml import OxmlElement import os src = '/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/FINAL_Gold_Medal_Introduction_to_Assessment_Vancouver_1-13 (1).docx' out = '/tmp/workspace/prize-fixed/FINAL_Gold_Medal_PROOFED.docx' doc = Document(src) paras = doc.paragraphs def make_superscript(para, text): """Add a superscript run to a paragraph.""" run = para.add_run(text) run.font.name = 'Times New Roman' run.font.size = Pt(12) rPr = run._r.get_or_add_rPr() v = OxmlElement('w:vertAlign') v.set(qn('w:val'), 'superscript') rPr.append(v) return run def strip_parenthetical(text): """Remove (1), (2), (1,2), (6), (1,2) etc from text.""" import re return re.sub(r'\s*\(\d+(?:,\d+)*\)', '', text) # ── Fix 1: disorganized → disorganised ────────────────────────── for p in paras: for run in p.runs: run.text = run.text.replace('disorganized', 'disorganised') # ── Fix 2: NICE guidelines recommends → recommend ─────────────── for p in paras: for run in p.runs: run.text = run.text.replace('guidelines recommends', 'guidelines recommend') # ── Fix 3: MSE item 5 - add full stop ─────────────────────────── for p in paras: if 'la belle' in p.text and p.text.strip().endswith('health anxiety'): for run in p.runs: if run.text.strip().endswith('health anxiety'): run.text = run.text.rstrip() + '.' # ── Fix 4: Optimize → Optimise ────────────────────────────────── for p in paras: for run in p.runs: run.text = run.text.replace('Optimize', 'Optimise').replace('optimize', 'optimise') # ── Fix 5: Capacity section restructure ───────────────────────── # Find capacity opening para cap_idx = None for i, p in enumerate(paras): if p.text.strip().startswith('Capacity is clinical, decision-specific'): cap_idx = i break if cap_idx is not None: # Find "Optimize/Optimise reversible factors..." para opt_idx = None for i in range(cap_idx+1, min(cap_idx+12, len(paras))): if 'ptimise reversible' in paras[i].text or 'ptimize reversible' in paras[i].text: opt_idx = i break # Find "Communicate a choice" para (first bullet) comm_idx = None for i in range(cap_idx+1, min(cap_idx+12, len(paras))): if paras[i].text.strip().startswith('Communicate a choice'): comm_idx = i break # Find "Reason with..." para (last bullet) - remove its superscript citation reason_idx = None for i in range(cap_idx+1, min(cap_idx+12, len(paras))): if paras[i].text.strip().startswith('Reason with'): reason_idx = i break if opt_idx and comm_idx and opt_idx != comm_idx: opt_elem = paras[opt_idx]._element comm_elem = paras[comm_idx]._element parent = opt_elem.getparent() # Remove opt from current position parent.remove(opt_elem) # Re-insert before Communicate a choice idx = list(parent).index(comm_elem) parent.insert(idx, opt_elem) # Remove superscript from "Reason with..." bullet if reason_idx: for r_elem in paras[reason_idx]._element.findall('.//' + qn('w:r')): t = r_elem.find(qn('w:t')) if t is not None and t.text: import re t.text = re.sub(r'[\u2074\u00b9\u00b3,\u00b2\xb9]+$', '', t.text).rstrip(',') # ── Fix 6: Convert parenthetical citations in 2.16 and 2.17 to superscripts ── import re # Map of parenthetical to superscript unicode sup_map = { '(1,2)': '\u00b9\u002c\u00b2', '(1)' : '\u00b9', '(2)' : '\u00b2', '(6)' : '\u2076', } in_target = False for p in paras: txt = p.text.strip() # Start converting from 2.16 onwards if txt.startswith('2.16') or txt.startswith('2.17') or txt.startswith('A.') or \ txt.startswith('B.') or txt.startswith('C.') or \ 'HOME trial' in txt or 'Avery et al' in txt or \ 'Postpartum psychosis' in txt or \ 'assessment is incomplete without communication' in txt or \ any(bullet_start in txt for bullet_start in ['Gestational', 'Previous psychiatric illness', 'Current mood', 'Medication and substance', 'Validated screening', 'Time since delivery', 'Depressive/anxiety', 'Past bipolar', 'Mania, disorgan', 'Suicidal thoughts', 'Breastfeeding', 'Establish premorbid', 'Actively screen', 'Review anticholinergic', 'Assess hearing', 'Screen depression', 'PHQ-2', 'MMSE/MoCA', 'Interview child', 'Assess developmental', 'Explore the child', 'Assess mood', 'Assess cognition', 'Assess self-harm', 'Consider assent', 'Delirium, dementia', 'Requires simultaneous', 'To the treating team', 'To the patient and family', 'Confirmed psychiatric', 'Inconclusive diagnosis', 'Suicidal ideation: serial']): in_target = True if in_target: for run in p.runs: for old, new in sup_map.items(): if old in run.text: # Split run text, replace parenthetical with superscript parts = run.text.split(old) if len(parts) > 1: run.text = parts[0] # Add superscript runs for each replacement for j, part in enumerate(parts[1:]): sup_r = OxmlElement('w:r') # Copy rPr from original run orig_rPr = run._r.find(qn('w:rPr')) if orig_rPr is not None: import copy sup_r.append(copy.deepcopy(orig_rPr)) # Add vertAlign superscript sup_rPr = sup_r.find(qn('w:rPr')) if sup_rPr is None: sup_rPr = OxmlElement('w:rPr') sup_r.insert(0, sup_rPr) vA = OxmlElement('w:vertAlign') vA.set(qn('w:val'), 'superscript') sup_rPr.append(vA) sup_t = OxmlElement('w:t') sup_t.text = new sup_t.set('{http://www.w3.org/XML/1998/namespace}space', 'preserve') sup_r.append(sup_t) run._r.addnext(sup_r) # Add the rest of the text if part: rest_r = OxmlElement('w:r') orig_rPr2 = run._r.find(qn('w:rPr')) if orig_rPr2 is not None: import copy rest_r.append(copy.deepcopy(orig_rPr2)) rest_t = OxmlElement('w:t') rest_t.text = part rest_t.set('{http://www.w3.org/XML/1998/namespace}space', 'preserve') rest_r.append(rest_t) sup_r.addnext(rest_r) break doc.save(out) print('Saved:', out) PYEOF

python3 << 'PYEOF' from docx import Document from docx.shared import Pt from docx.oxml.ns import qn from docx.oxml import OxmlElement import copy, re, os src = '/tmp/workspace/prize-fixed/FINAL_Gold_Medal_PROOFED.docx' out = '/tmp/workspace/prize-fixed/FINAL_Gold_Medal_SUBMIT.docx' doc = Document(src) for p in doc.paragraphs: if 'HOME trial' in p.text or '2024 HOME' in p.text: for run in p.runs: if 'HOME trial' in run.text or '2024 HOME' in run.text: run.text = run.text.replace( '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)', 'Recent evidence supports proactive, integrated C-L psychiatric assessment in older medical in-patients, with studies demonstrating improved recognition of psychiatric morbidity and better overall medical care outcomes.\u00b9' ).replace( '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.', 'Recent evidence supports proactive, integrated C-L psychiatric assessment in older medical in-patients, with studies demonstrating improved recognition of psychiatric morbidity and better overall medical care outcomes.\u00b9' ) # Also fix via XML text elements for r_elem in p._element.findall('.//' + qn('w:r')): t = r_elem.find(qn('w:t')) if t is not None and t.text and ('HOME trial' in t.text or '2024 HOME' in t.text): t.text = 'Recent evidence supports proactive, integrated C-L psychiatric assessment in older medical in-patients, with studies demonstrating improved recognition of psychiatric morbidity and better overall medical care outcomes.\u00b9' doc.save(out) print('Saved:', out) # Verify the change doc2 = Document(out) for p in doc2.paragraphs: if 'HOME' in p.text or 'Recent evidence supports proactive' in p.text: print('CHANGED:', p.text) PYEOF

python3 -c " from docx import Document doc = Document('/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/FINAL_Gold_Medal_PROOFREAD.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 from docx.oxml.ns import qn from docx.oxml import OxmlElement import copy, os src = '/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/FINAL_Gold_Medal_PROOFREAD.docx' out = '/tmp/workspace/prize-fixed/FINAL_Gold_Medal_FINAL.docx' doc = Document(src) paras = doc.paragraphs def add_superscript_run(para, sup_text): run = para.add_run(sup_text) run.font.name = 'Times New Roman' run.font.size = Pt(12) rPr = run._r.get_or_add_rPr() v = OxmlElement('w:vertAlign') v.set(qn('w:val'), 'superscript') rPr.append(v) return run # ── FIX 1: Add ABC bullet back to section 2.4 ─────────────────── # Find "2.4 Initial Triage" section heading para triage_heading_idx = None for i, p in enumerate(paras): if '2.4 Initial Triage' in p.text: triage_heading_idx = i break # Find "Before detailed psychiatric assessment" para (next after heading) before_idx = None if triage_heading_idx: for i in range(triage_heading_idx, triage_heading_idx+5): if 'Before detailed psychiatric assessment' in paras[i].text: before_idx = i break # Find first bullet "Vital signs..." vital_idx = None if triage_heading_idx: for i in range(triage_heading_idx, triage_heading_idx+8): if paras[i].text.strip().startswith('Vital signs'): vital_idx = i break if vital_idx is not None: vital_elem = paras[vital_idx]._element parent = vital_elem.getparent() idx = list(parent).index(vital_elem) # Create new paragraph for ABC bullet new_p = OxmlElement('w:p') # Copy paragraph properties from vital_signs para orig_pPr = vital_elem.find(qn('w:pPr')) if orig_pPr is not None: new_p.append(copy.deepcopy(orig_pPr)) new_r = OxmlElement('w:r') # Copy run properties orig_r = vital_elem.find('.//' + qn('w:r')) if orig_r is not None: orig_rPr = orig_r.find(qn('w:rPr')) if orig_rPr is not None: new_r.append(copy.deepcopy(orig_rPr)) new_t = OxmlElement('w:t') new_t.text = 'Airway, breathing and circulation where relevant.' 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, new_p) print('Fix 1: ABC bullet added') # ── FIX 2a: Delete duplicate NICE sentence (line 118 - "guidelines recommends") # Find and delete the duplicate NICE line with "guidelines recommends" to_remove = [] for i, p in enumerate(paras): if 'guidelines recommends' in p.text and 'NICE' in p.text: to_remove.append(p._element) for elem in to_remove: elem.getparent().remove(elem) print(f'Fix 2a: Removed {len(to_remove)} duplicate NICE line(s) with grammar error') # ── FIX 2b: Fix "guidelines recommend" in remaining NICE line ──── for p in doc.paragraphs: for run in p.runs: run.text = run.text.replace('guidelines recommends', 'guidelines recommend') # ── FIX 3: Remove duplicate "Screening instruments aid detection" ─ # Keep only the LAST occurrence (end of 2.11), delete earlier ones screening_paras = [] for i, p in enumerate(doc.paragraphs): if p.text.strip().startswith('Screening instruments aid detection'): screening_paras.append(p._element) # Remove all but last if len(screening_paras) > 1: for elem in screening_paras[:-1]: elem.getparent().remove(elem) print(f'Fix 3: Removed {len(screening_paras)-1} duplicate screening sentence(s)') # ── FIX 4: Add ⁶ citation to Children section opening ─────────── for p in doc.paragraphs: if p.text.strip().startswith('Assessment must be developmentally sensitive') and '\u2076' not in p.text: # Find last run and check it doesn't end with citation last_run = None for run in p.runs: if run.text.strip(): last_run = run if last_run and '\u2076' not in last_run.text: # Add superscript ⁶ sup = p.add_run('\u2076') sup.font.name = 'Times New Roman' sup.font.size = Pt(12) rPr = sup._r.get_or_add_rPr() v = OxmlElement('w:vertAlign') v.set(qn('w:val'), 'superscript') rPr.append(v) print('Fix 4: Added ⁶ to children section') # ── FIX 5: Fix ¹ ² → ¹,² (remove space between superscripts) ───── for p in doc.paragraphs: if 'Recent evidence supports proactive' in p.text: for r_elem in p._element.findall('.//' + qn('w:r')): t = r_elem.find(qn('w:t')) if t is not None and t.text: # Fix space in regular text between sup markers t.text = t.text.replace('\u00b9 \u00b2', '\u00b9\u002c\u00b2') # Also fix by looking at all runs text combined full = ''.join(r.text for r in p.runs if r.text) print(f'Fix 5 check - para text: {p.text[:80]}') # ── FIX 6: Add ¹ citation to last follow-up bullet ─────────────── for p in doc.paragraphs: if 'serial risk reassessment' in p.text and '\u00b9' not in p.text: sup = p.add_run('\u00b9') sup.font.name = 'Times New Roman' sup.font.size = Pt(12) rPr = sup._r.get_or_add_rPr() v = OxmlElement('w:vertAlign') v.set(qn('w:val'), 'superscript') rPr.append(v) print('Fix 6: Added ¹ to last follow-up bullet') # ── FIX: Move NICE guideline sentence to after validated tools list ─ # Find the NICE para and the "After identifying delirium" para nice_idx = None after_delirium_idx = None for i, p in enumerate(doc.paragraphs): if 'NICE guidance recommends the 4AT' in p.text and nice_idx is None: nice_idx = i if 'After identifying delirium' in p.text: after_delirium_idx = i if nice_idx and after_delirium_idx: nice_p = doc.paragraphs[nice_idx] after_p = doc.paragraphs[after_delirium_idx] nice_elem = nice_p._element after_elem = after_p._element parent = nice_elem.getparent() # Remove from current position parent.remove(nice_elem) # Insert just before "After identifying delirium" after_elem_idx = list(parent).index(after_elem) parent.insert(after_elem_idx, nice_elem) print('Fix: NICE sentence moved after tools list') doc.save(out) print('Saved:', out) # Quick verify key sections print('\n--- Verify 2.4 triage start ---') doc2 = Document(out) printing = False for p in doc2.paragraphs: if '2.4 Initial Triage' in p.text: printing = True if printing and p.text.strip(): print(p.text) if printing and 'Do not diagnose' in p.text: break print('\n--- Verify 2.11 delirium (check duplicates gone) ---') printing = False for p in doc2.paragraphs: if '2.11 Delirium' in p.text: printing = True if printing and p.text.strip(): print(p.text) if printing and '2.12' in p.text: break PYEOF

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

python3 -c " from docx import Document doc = Document('/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/FINAL_Gold_Medal_MANAGEMENT_40min.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 from docx.oxml.ns import qn from docx.oxml import OxmlElement import copy, os, re src = '/tmp/workspace/attachments/51e0210b-2a6f-4ee8-8ef3-481b0e45ad0e/FINAL_Gold_Medal_MANAGEMENT_40min.docx' out = '/tmp/workspace/prize-fixed/MANAGEMENT_FINAL.docx' doc = Document(src) def add_superscript(para, text): run = para.add_run(text) run.font.name = 'Times New Roman' run.font.size = Pt(12) rPr = run._r.get_or_add_rPr() v = OxmlElement('w:vertAlign') v.set(qn('w:val'), 'superscript') rPr.append(v) return run # ── FIX 1: Convert **text** markdown to actual bold in Word ────── bold_pattern = re.compile(r'\*\*(.+?)\*\*') for p in doc.paragraphs: if '**' not in p.text: continue # Rebuild the paragraph runs with bold applied full_text = p.text if not bold_pattern.search(full_text): continue # Clear all existing runs for run in p.runs: run.text = '' # Split and rebuild parts = bold_pattern.split(full_text) # parts alternates: normal, bold, normal, bold, ... # index 0,2,4... = normal; 1,3,5... = bold # Get font info from first run if available first_run = p.runs[0] if p.runs else None for i, part in enumerate(parts): if not part: continue if first_run: r = p.add_run(part) r.font.name = first_run.font.name or 'Times New Roman' r.font.size = first_run.font.size or Pt(12) r.bold = (i % 2 == 1) # odd indices are bold content else: r = p.add_run(part) r.font.name = 'Times New Roman' r.font.size = Pt(12) r.bold = (i % 2 == 1) # Clear the original first run text (already emptied above) if first_run: first_run.text = '' # ── FIX 2: Add ¹ citation to Section 3.9 special settings ──────── settings_items = ['ICU', 'Neurological illness', 'Oncology and palliative', 'Transplantation', 'Chronic medical illness'] in_settings = False last_settings_para = None for p in doc.paragraphs: if '3.9 Special Clinical Settings' in p.text: in_settings = True continue if in_settings: if p.text.strip().startswith('3.10'): break # Last bullet in settings section if p.text.strip() and any(s in p.text for s in settings_items): last_settings_para = p # Add citation to last settings bullet if last_settings_para: if '\u00b9' not in last_settings_para.text: add_superscript(last_settings_para, '\u00b9\u2074') # ¹⁴ print('Fix 2: Added ¹⁴ to last special settings bullet') # ── FIX 3: etiology → aetiology consistency ────────────────────── for p in doc.paragraphs: for run in p.runs: run.text = run.text.replace('etiology', 'aetiology').replace('etiolog', 'aetiolog') # ── FIX 4: Add delirium prevention note to 3.4 non-pharm section ─ # Find the last bullet of 3.4 (Avoid unnecessary catheters...) avoid_idx = None for i, p in enumerate(doc.paragraphs): if 'Avoid unnecessary urinary catheters' in p.text: avoid_idx = i break # Find "In delirium, correction..." sentence after it in_delirium_idx = None if avoid_idx: for i in range(avoid_idx, avoid_idx+5): if 'In delirium, correction of reversible' in doc.paragraphs[i].text: in_delirium_idx = i break if in_delirium_idx: ref_elem = doc.paragraphs[in_delirium_idx]._element parent = ref_elem.getparent() idx = list(parent).index(ref_elem) # Insert prevention note before "In delirium, correction..." new_p = OxmlElement('w:p') orig_pPr = ref_elem.find(qn('w:pPr')) if orig_pPr is not None: new_p.append(copy.deepcopy(orig_pPr)) new_r = OxmlElement('w:r') orig_r = ref_elem.find('.//' + qn('w:r')) if orig_r: orig_rPr = orig_r.find(qn('w:rPr')) if orig_rPr is not None: new_r.append(copy.deepcopy(orig_rPr)) new_t = OxmlElement('w:t') new_t.text = ('Multicomponent prevention programmes (such as the Hospital Elder Life Programme, HELP) ' 'have demonstrated reduction in delirium incidence in high-risk hospitalised patients ' 'through targeted non-pharmacological interventions.') 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, new_p) print('Fix 4: HELP programme prevention note added') doc.save(out) print('Saved:', out) # Verify bold rendering doc2 = Document(out) for p in doc2.paragraphs: if 'Treat the cause' in p.text or 'Identify cause' in p.text or 'Treat the patient' in p.text: for run in p.runs: if run.text.strip(): print(f'Bold={run.bold}: "{run.text[:60]}"') PYEOF

Kuruvilla Jacob consultation liaison psychiatry India CMC

Anju Kuruvilla Jacob consultation liaison psychiatry CMC Vellore India paper findings

python3 << 'PYEOF' from docx import Document from docx.shared import Pt, 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/CLOSING_SECTIONS_FINAL.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(14) 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) 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) def para(text, sb=3, sa=4, italic=False, center=False): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(sb) p.paragraph_format.space_after = Pt(sa) if center: p.alignment = WD_ALIGN_PARAGRAPH.CENTER r = p.add_run(text) r.italic = italic r.font.name = 'Times New Roman'; r.font.size = Pt(12) return p def bullet(text): p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.3) 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) def sup_run(para_obj, text): run = para_obj.add_run(text) run.font.name = 'Times New Roman'; run.font.size = Pt(12) rPr = run._r.get_or_add_rPr() v = OxmlElement('w:vertAlign') v.set(qn('w:val'), 'superscript') rPr.append(v) def bold_intro(label, rest, sb=3, sa=3): p = doc.add_paragraph() 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) 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) # ══════════════════════════════════════════════════════════════════ # SECTION 4: PREVENTION AND DISCHARGE PLANNING # ══════════════════════════════════════════════════════════════════ h1('4. PREVENTION, DISCHARGE PLANNING AND FOLLOW-UP') h2('4.1 Prevention and Early Intervention') p = para( 'Prevention of psychiatric morbidity in medically ill patients begins with early identification ' 'of high-risk individuals and proactive implementation of non-pharmacological strategies. ' 'The most evidence-based multicomponent prevention programme is the ', sb=2, sa=0 ) # inline bold r_bold = p.add_run('Hospital Elder Life Programme (HELP)') r_bold.bold = True; r_bold.font.name = 'Times New Roman'; r_bold.font.size = Pt(12) r_rest = p.add_run( ', which has demonstrated significant reduction in delirium incidence in high-risk ' 'hospitalised patients through targeted non-pharmacological interventions including ' 'reorientation, sleep promotion, early mobilization, sensory correction and hydration.' ) r_rest.font.name = 'Times New Roman'; r_rest.font.size = Pt(12) sup_run(p, '\u00b9\u2074') # ¹⁴ for b in [ 'Identify high-risk patients early: older adults, cognitive impairment, severe medical illness, polypharmacy, prior psychiatric history, substance use and poor social support.', 'Prevent delirium through multicomponent non-pharmacological interventions; review and rationalize medications.', 'Ensure adequate pain control, sleep, hydration and nutrition from admission.', 'Encourage early mobilization, sensory aids and family involvement.', 'Ensure timely C-L referral, psychiatric assessment and risk evaluation.', 'Treat reversible medical and medication-related causes promptly.', 'Provide psychoeducation and supportive interventions to patient and family.', ]: bullet(b) h2('4.2 Discharge Planning and Follow-up') para( 'Discharge planning should begin at the time of admission and be integrated with the overall ' 'medical treatment plan. A psychiatric syndrome identified during hospitalisation should not ' 'be left unaddressed at discharge.', sb=2, sa=3 ) for b in [ 'Confirm whether the psychiatric syndrome has resolved or requires continued treatment.', 'Review the ongoing indication for psychotropic medication; do not allow a medication started for an acute problem to become an indefinite prescription without reassessment.', 'Reassess suicide risk where relevant and ensure a documented safety plan.', 'Perform medication reconciliation and provide clear written instructions.', 'Provide patient and family education regarding the psychiatric diagnosis, its relationship to the medical illness and the treatment plan.', 'Arrange appropriate psychiatric and medical follow-up with clear communication between services.', 'Plan relapse prevention and substance-use interventions when appropriate.', 'Link the patient with community psychiatric and rehabilitation services when required.', ]: bullet(b) # ══════════════════════════════════════════════════════════════════ # SECTION 5: INDIAN CONTEXT # ══════════════════════════════════════════════════════════════════ h1('5. CONSULTATION-LIAISON PSYCHIATRY IN THE INDIAN CONTEXT') para( 'In India, C-L Psychiatry began in 1933 when Dr. Girindra Shekhar Bose established the ' 'first General Hospital Psychiatric Unit (GHPU) at R.G. Kar Medical College and Hospital, ' 'Calcutta — a landmark that placed India among the early pioneers of general hospital ' 'psychiatry globally.', sb=2, sa=4 ) p2 = para( 'Despite this early start, C-L Psychiatry has lagged behind developed countries. An Indian ' 'systematic review of 33 studies found inpatient psychiatric referral rates of only 0.01%–3.6%, ' 'with depression, delirium, substance-use disorders, intentional self-harm and anxiety among ' 'the most commonly identified diagnoses.', sb=2, sa=0 ) sup_run(p2, '\u00b3') # ³ p3 = para( ' The large discrepancy between the burden of psychiatric morbidity in medically ill patients ' 'and the low rate of referral highlights a persistent recognition\u2013referral gap in Indian ' 'general hospitals.', sb=0, sa=4 ) sup_run(p3, '\u00b3') h2('5.1 Training Gap and the Need for Curriculum Reform') p4 = para( 'A fundamental barrier to improving C-L Psychiatry in India is the inadequate training of ' 'non-psychiatric physicians in recognizing and managing psychological distress in medical ' 'settings. Jacob, Kuruvilla and Zachariah from the Christian Medical College, Vellore, have ' 'argued that psychiatric training in India remains confined to specialist and tertiary care ' 'settings, employing biomedical frameworks and detailed diagnostic protocols that do not ' 'reflect the reality of common presentations in primary and secondary care. They propose that ' 'this specialist approach generates a \u201ccategory fallacy\u201d \u2014 the unwarranted assumption that ' 'psychiatric categories carry the same meaning when imposed on different clinical contexts ' '\u2014 and that current training deskills and disempowers physicians, who would rather refer ' 'than manage common mental distress.', sb=2, sa=0 ) sup_run(p4, '\u00b2\u00b9') # ²¹ p5 = para( ' Their proposed curriculum, situated in primary and secondary care, uses broad clinical ' 'presentations, general management guidelines and a liaison approach that understands local ' 'context. This has direct implications for C-L Psychiatry: a physician unable to recognise ' 'psychological distress in a medical ward will not refer, and the recognition\u2013referral ' 'gap will persist.', sb=0, sa=4 ) sup_run(p5, '\u00b2\u00b9') note( 'Key point: The integration of C-L Psychiatry principles into the undergraduate and ' 'postgraduate curricula of medicine, surgery, nursing and allied health disciplines is an ' 'urgent and unmet priority in India.' ) # ══════════════════════════════════════════════════════════════════ # SECTION 6: CHALLENGES AND FUTURE DIRECTIONS # ══════════════════════════════════════════════════════════════════ h1('6. CHALLENGES AND FUTURE DIRECTIONS') h2('6.1 Current Challenges') for b in [ 'Low psychiatric referral rates from non-psychiatric wards, reflecting a persistent recognition\u2013referral gap.', 'Stigma towards mental illness among medical professionals, reducing willingness to refer and collaborate.', 'Inadequate staffing: most C-L services in India operate on an on-call model with junior residents as the first-line respondent, without structured multidisciplinary teams.', 'Absence of structured, accredited C-L Psychiatry training programmes; no subspecialty recognition in India.', 'Psychiatric training confined to tertiary specialist settings, producing physicians ill-equipped to recognize mental distress in general hospital wards.', 'Limited research output in Indian C-L Psychiatry; heterogeneity in service models across institutions.', ]: bullet(b) h2('6.2 Future Directions') for b in [ 'Establish structured, accredited fellowship training programmes in C-L Psychiatry at national centres.', 'Integrate C-L Psychiatry principles \u2014 recognition of common presentations, biopsychosocial assessment and basic psychological interventions \u2014 into the undergraduate and postgraduate curricula of all medical and nursing disciplines.', 'Shift from reactive (on-call referral) to proactive C-L models, with regular ward rounds and multidisciplinary team integration.', 'Expand telepsychiatry-based C-L services to increase reach in under-resourced hospitals and district-level care.', 'Develop Indian-specific research and clinical guidelines for C-L Psychiatry, grounded in local epidemiology, culture and health system context.', 'Strengthen the liaison component: educate medical and surgical teams, reduce stigma and build collaborative care pathways.', ]: bullet(b) # ══════════════════════════════════════════════════════════════════ # SECTION 7: CONCLUSION # ══════════════════════════════════════════════════════════════════ h1('7. CONCLUSION') para( 'Psychiatric disorders in medically ill patients are common, clinically significant, ' 'frequently under-recognised and eminently treatable. Their presentation may reflect a ' 'primary psychiatric disorder, a direct manifestation of the medical illness, the effect ' 'of medications or substances, or a psychological response to illness and hospitalisation. ' 'Effective care requires a systematic, patient-centred and multidisciplinary approach: ' 'early recognition, medical stabilisation, identification and treatment of reversible causes, ' 'careful medication review, appropriate psychological intervention and judicious psychopharmacology.', sb=2, sa=4 ) para( 'Consultation-Liaison Psychiatry bridges the divide between physical and mental healthcare, ' 'helping to reduce suffering, improve treatment outcomes, restore functioning and ensure ' 'continuity of care. In India, realising this potential demands expansion of CL services, ' 'reform of psychiatric training across all medical disciplines, and investment in collaborative ' 'models of care that are grounded in local context and evidence.', sb=2, sa=6 ) # Engel quote q = doc.add_paragraph() q.alignment = WD_ALIGN_PARAGRAPH.CENTER q.paragraph_format.space_before = Pt(8) q.paragraph_format.space_after = Pt(4) qr = q.add_run( '\u201cThe dominant model of disease today is biomedical... it leaves no room within its ' 'framework for the social, psychological and behavioural dimensions of illness.\u201d' ) qr.italic = True; qr.font.name = 'Times New Roman'; qr.font.size = Pt(11) attr = doc.add_paragraph() attr.alignment = WD_ALIGN_PARAGRAPH.CENTER attr.paragraph_format.space_before = Pt(2) attr.paragraph_format.space_after = Pt(6) ar = attr.add_run('\u2014 George Engel, 1977') ar.italic = True; ar.font.name = 'Times New Roman'; ar.font.size = Pt(11) para( 'Consultation-Liaison Psychiatry exists precisely to correct this \u2014 bridging the gap ' 'between mind and body, between psychiatry and medicine, and between the diagnosis and ' 'the whole person.', sb=4, sa=10, italic=True, center=True ) # ══════════════════════════════════════════════════════════════════ # REFERENCES # ══════════════════════════════════════════════════════════════════ h2('REFERENCES \u2014 Continuing from Management Section') refs = [ '21. Jacob KS, Kuruvilla A, Zachariah A. Psychiatric curriculum for training physicians. Natl Med J India. 2019;32(1):32\u201337.', ] 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) note( 'Note: References 1\u201313 are in the Introduction + Assessment section. ' 'References 14\u201320 are in the Management section. ' 'Reference 21 is new to this closing section. ' 'When combining all sections, renumber sequentially throughout.' ) 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 from docx.oxml.ns import qn from docx.oxml import OxmlElement import os out = '/tmp/workspace/prize-fixed/CLOSING_LEAN.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(14) 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) def h2(text): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(8) 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) def sup_run(para_obj, text): run = para_obj.add_run(text) run.font.name = 'Times New Roman'; run.font.size = Pt(12) rPr = run._r.get_or_add_rPr() v = OxmlElement('w:vertAlign') v.set(qn('w:val'), 'superscript') rPr.append(v) def mixed_para(parts, sb=3, sa=4): """parts = list of (text, bold, italic, superscript)""" p = doc.add_paragraph() p.paragraph_format.space_before = Pt(sb) p.paragraph_format.space_after = Pt(sa) for text, bold, italic, superscript in parts: r = p.add_run(text) r.bold = bold; r.italic = italic r.font.name = 'Times New Roman'; r.font.size = Pt(12) if superscript: rPr = r._r.get_or_add_rPr() v = OxmlElement('w:vertAlign') v.set(qn('w:val'), 'superscript') rPr.append(v) return p def bullet(text): p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.3) 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) # ── SECTION 4 ────────────────────────────────────────────────── h1('4. PREVENTION, DISCHARGE PLANNING AND FOLLOW-UP') mixed_para([ ('Prevention begins at admission. High-risk patients (elderly, cognitive impairment, polypharmacy, prior psychiatric history) should be identified early and receive multicomponent non-pharmacological interventions. The ', False, False, False), ('Hospital Elder Life Programme (HELP)', True, False, False), (' has the strongest evidence for delirium prevention.', False, False, False), ('14', False, False, True), ], sb=2, sa=4) mixed_para([ ('Discharge planning should begin at admission and include: confirmation of psychiatric diagnosis and treatment plan, medication reconciliation, patient and family psychoeducation, and clear follow-up arrangements between psychiatric and medical services.', False, False, False), ], sb=2, sa=6) # ── SECTION 5 ────────────────────────────────────────────────── h1('5. CONSULTATION-LIAISON PSYCHIATRY IN THE INDIAN CONTEXT') mixed_para([ ('C-L Psychiatry in India began in 1933, with referral rates still as low as 0.01\u20133.6% of inpatients in many centres, highlighting a persistent recognition\u2013referral gap.', False, False, False), ('3', False, False, True), ], sb=2, sa=4) mixed_para([ ('Jacob, Kuruvilla and Zachariah (Christian Medical College, Vellore) have argued that psychiatric training confined to tertiary settings generates a ', False, False, False), ('\u201ccategory fallacy\u201d', False, True, False), (' \u2014 the unwarranted assumption that specialist psychiatric categories carry the same meaning across different clinical contexts \u2014 and that current training deskills physicians in recognising common presentations in general hospital settings. They advocate for a liaison approach grounded in local context, with training situated in primary and secondary care settings.', False, False, False), ('21', False, False, True), ], sb=2, sa=6) # ── SECTION 6 ────────────────────────────────────────────────── h1('6. CHALLENGES AND FUTURE DIRECTIONS') h2('Challenges') for b in [ 'Low referral rates and under-recognition of psychiatric morbidity in general wards.', 'Professional stigma towards mental illness reducing willingness to refer.', 'Inadequate staffing and no formal C-L subspecialty recognition in India.', 'Psychiatric training confined to specialist tertiary settings, disempowering general physicians.', ]: bullet(b) h2('Future Directions') for b in [ 'Structured, accredited C-L Psychiatry fellowship programmes at national centres.', 'Integration of C-L Psychiatry into undergraduate and postgraduate curricula of all medical and nursing disciplines.', 'Shift from reactive (on-call referral) to proactive C-L models with regular ward rounds.', 'Telepsychiatry-based C-L services to expand reach to district and under-resourced hospitals.', ]: bullet(b) # ── SECTION 7: CONCLUSION ───────────────────────────────────── h1('7. CONCLUSION') mixed_para([ ('Psychiatric disorders in medically ill patients are common, under-recognised and treatable. Effective C-L Psychiatry demands a systematic, biopsychosocial and patient-centred approach encompassing early recognition, medical stabilisation, psychological intervention and multidisciplinary collaboration. In India, realising this potential requires expansion of CL services, reform of psychiatric training across all medical disciplines and investment in collaborative models of care grounded in local context and evidence.', False, False, False), ], sb=2, sa=8) # Engel quote q = doc.add_paragraph() q.alignment = WD_ALIGN_PARAGRAPH.CENTER q.paragraph_format.space_before = Pt(6) q.paragraph_format.space_after = Pt(2) qr = q.add_run( '\u201cThe dominant model of disease today is biomedical... it leaves no room within its ' 'framework for the social, psychological and behavioural dimensions of illness.\u201d' ) qr.italic = True; qr.font.name = 'Times New Roman'; qr.font.size = Pt(11) attr = doc.add_paragraph() attr.alignment = WD_ALIGN_PARAGRAPH.CENTER attr.paragraph_format.space_before = Pt(2) attr.paragraph_format.space_after = Pt(8) ar = attr.add_run('\u2014 George Engel, 1977') ar.italic = True; ar.font.name = 'Times New Roman'; ar.font.size = Pt(11) closing = doc.add_paragraph() closing.alignment = WD_ALIGN_PARAGRAPH.CENTER closing.paragraph_format.space_before = Pt(4) closing.paragraph_format.space_after = Pt(12) cr = closing.add_run( 'Consultation-Liaison Psychiatry exists precisely to correct this \u2014 bridging the gap ' 'between mind and body, between psychiatry and medicine, and between the diagnosis and ' 'the whole person.' ) cr.italic = True; cr.font.name = 'Times New Roman'; cr.font.size = Pt(12) # ── REFERENCES ──────────────────────────────────────────────── h2('NEW REFERENCE') 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( '21. Jacob KS, Kuruvilla A, Zachariah A. Psychiatric curriculum for training physicians. ' 'Natl Med J India. 2019;32(1):32\u201337.' ) rr.font.name = 'Times New Roman'; rr.font.size = Pt(10) doc.save(out) print('Saved:', out) PYEOF

python3 << 'PYEOF' from docx import Document for fname in [ '/tmp/workspace/prize-fixed/FINAL_Gold_Medal_FINAL.docx', '/tmp/workspace/prize-fixed/MANAGEMENT_FINAL.docx', '/tmp/workspace/prize-fixed/CLOSING_LEAN.docx', ]: doc = Document(fname) print(f'\n{"="*60}') print(f'FILE: {fname}') print('="*60') for i, p in enumerate(doc.paragraphs): t = p.text.strip() if t: print(f' [{i:3d}] {t[:120]}') PYEOF

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 from copy import deepcopy import re, os out = '/tmp/workspace/prize-fixed/GOLD_MEDAL_COMPLETE_FINAL.docx' doc = Document() sec = doc.sections[0] sec.top_margin = Inches(1) sec.bottom_margin = Inches(1) sec.left_margin = Inches(1.2) sec.right_margin = Inches(1.2) normal = doc.styles['Normal'] normal.font.name = 'Times New Roman' normal.font.size = Pt(12) # ── helpers ────────────────────────────────────────────────────────────────── def add_sup(para_obj, text): r = para_obj.add_run(text) r.font.name = 'Times New Roman'; r.font.size = Pt(12) rPr = r._r.get_or_add_rPr() v = OxmlElement('w:vertAlign'); v.set(qn('w:val'), 'superscript') rPr.append(v) def h_title(text): p = doc.add_paragraph() p.alignment = WD_ALIGN_PARAGRAPH.CENTER p.paragraph_format.space_before = Pt(0); p.paragraph_format.space_after = Pt(6) r = p.add_run(text); r.bold = True r.font.name = 'Times New Roman'; r.font.size = Pt(14) def h1(text): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(16); 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) 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) def h3(text): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(7); 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) def para(text, sb=3, sa=4, italic=False, center=False, bold=False): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(sb); p.paragraph_format.space_after = Pt(sa) if center: p.alignment = WD_ALIGN_PARAGRAPH.CENTER r = p.add_run(text); r.italic = italic; r.bold = bold 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) def sub_bullet(text): p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.55) p.paragraph_format.first_line_indent = Inches(-0.2) p.paragraph_format.space_before = Pt(1); p.paragraph_format.space_after = Pt(1) r = p.add_run('\u25e6 ' + text) r.font.name = 'Times New Roman'; r.font.size = Pt(11) def kp(label, rest, sb=3, sa=3): p = doc.add_paragraph() 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) def ref_line(text): p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.35) p.paragraph_format.first_line_indent = Inches(-0.35) p.paragraph_format.space_before = Pt(3); p.paragraph_format.space_after = Pt(3) r = p.add_run(text); r.font.name = 'Times New Roman'; r.font.size = Pt(10) def divider(): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(6); p.paragraph_format.space_after = Pt(6) p.alignment = WD_ALIGN_PARAGRAPH.CENTER r = p.add_run('\u2500'*55) r.font.name = 'Times New Roman'; r.font.size = Pt(10) # ══════════════════════════════════════════════════════════════════════════════ # TITLE # ══════════════════════════════════════════════════════════════════════════════ h_title('Assessment and Management of Psychiatric Disorders\nin Medically Ill In-patients') p = doc.add_paragraph() p.alignment = WD_ALIGN_PARAGRAPH.CENTER p.paragraph_format.space_before = Pt(4); p.paragraph_format.space_after = Pt(12) r = p.add_run( '\u201cThe good physician treats the disease; the great physician treats the patient who has the disease.\u201d' '\n\u2014 Sir William Osler' ); r.italic = True; r.font.name = 'Times New Roman'; r.font.size = Pt(11) # ══════════════════════════════════════════════════════════════════════════════ # 1. INTRODUCTION # ══════════════════════════════════════════════════════════════════════════════ h1('1. INTRODUCTION') p = para( 'A medically ill patient is an individual with an acute or chronic physical illness requiring medical or surgical ' 'care, in whom a psychiatric disorder may coexist, complicate or arise as a direct consequence of the illness or ' 'its treatment. Consultation-Liaison (C-L) Psychiatry is the branch of psychiatry concerned with the assessment ' 'and management of psychological, psychiatric and behavioural problems in medically ill patients, providing expert ' 'psychiatric input at the interface of psychiatry and medicine.', sb=2, sa=4) add_sup(p, '\u00b9') h2('Historical Perspective') p = para( 'The roots of C-L Psychiatry lie in psychosomatic medicine and general-hospital psychiatry units. The development ' 'of George Engel\u2019s biopsychosocial model in 1977 provided a theoretical framework that remains the foundation of ' 'C-L practice. In India, a major milestone occurred in 1933 when Dr. Girindra Shekhar Bose established the first ' 'General Hospital Psychiatric Unit (GHPU) at R.G. Kar Medical College and Hospital, Calcutta, preceding many ' 'Western countries in integrating psychiatry within general hospital care.', sb=2, sa=4) add_sup(p, '\u00b2') h2('Epidemiology') p = para( 'Psychiatric morbidity among medically ill in-patients is common but substantially underrecognized, undertreated ' 'and undocumented. Prevalence rates of psychiatric disorders vary by setting and methodology. In India, a ' 'systematic review of 33 studies reported a wide range of referral rates (0.01\u20133.6% of inpatients), with ' 'depression, delirium, substance-use disorders, intentional self-harm and anxiety the most commonly identified ' 'diagnoses.', sb=2, sa=4) add_sup(p, '\u00b3') h2('Scope and Clinical Spectrum') p = para( 'C-L Psychiatry functions across emergency departments, intensive care units, perioperative care, ' 'medical/surgical wards and outpatient settings. The clinical spectrum includes adjustment disorders, depressive ' 'and anxiety disorders, delirium and other neurocognitive disorders, substance-use disorders, somatic symptom and ' 'related disorders, psychological responses to medical illness, medically unexplained symptoms, and psychiatric ' 'emergencies including suicidality, agitation and catatonia.', sb=2, sa=6) add_sup(p, '\u00b9\u00b2') # ══════════════════════════════════════════════════════════════════════════════ # 2. ASSESSMENT # ══════════════════════════════════════════════════════════════════════════════ h1('2. ASSESSMENT OF PSYCHIATRIC DISORDERS IN MEDICALLY ILL IN-PATIENTS') h2('2.1 Why Psychiatric Assessment is Important') p = para( 'Psychiatric assessment is the cornerstone of C-L Psychiatry. Its goal is not merely to establish a diagnosis ' 'but to determine the aetiology, formulate an integrated biopsychosocial understanding, guide management and ' 'facilitate communication with the treating team.', sb=2, sa=3) add_sup(p, '\u00b9') para('A C-L assessment addresses five core questions: What syndrome is present? Why now? Is it primary or secondary? ' 'What risk does it carry? What does the patient need?', sb=2, sa=3) p = para( 'Assessment is dynamic rather than static. Serial evaluations are essential, especially in delirium, critical ' 'illness, fluctuating presentations and where capacity is in question. An underlying medical cause should be ' 'actively investigated when psychiatric symptoms are new, atypical, acute, fluctuating or associated with ' 'physical signs.', sb=2, sa=3) add_sup(p, '\u00b9') p = para( 'Unaddressed psychiatric morbidity may adversely affect treatment adherence, recovery and rehabilitation, length ' 'of hospital stay and overall medical outcomes. Proactive integrated C-L assessment has been associated with ' 'improved clinical outcomes in medically ill patients.', sb=2, sa=4) add_sup(p, '\u00b9') h2('2.2 Principles and Objectives') kp('Principles: ', 'Think organic first \u2022 Stabilize first \u2022 Biopsychosocial approach \u2022 Build chronology \u2022 Review medications and substances \u2022 Obtain collateral \u2022 Watch serially \u2022 Collaborate with MDT', sb=2, sa=3) h3('Objectives:') for b in [ 'Establish nature, severity, chronology and functional impact.', 'Differentiate primary psychiatric from medical, neurological, medication- or substance-related causes.', 'Detect delirium and neurocognitive disorders early.', 'Assess capacity, suicide risk, violence risk and vulnerability.', 'Identify psychosocial stressors, coping, caregiver burden and supports.', 'Assess treatment-adherence factors.', 'Formulate an integrated biopsychosocial diagnosis.', ]: bullet(b) p = doc.add_paragraph(); p.paragraph_format.space_before = Pt(2); p.paragraph_format.space_after = Pt(4) r = p.add_run('\u2022 Communicate the management plan and arrange reassessment.') r.font.name = 'Times New Roman'; r.font.size = Pt(12) add_sup(p, '\u00b9') h2('2.3 Preparatory Phase \u2013 Before Seeing the Patient') p = para('One of the distinctive features of C-L Psychiatry is that assessment begins before bedside contact.', sb=2, sa=3) add_sup(p, '\u00b9') for b in [ 'Review current medical diagnosis, severity, complications and trajectory.', 'Review medical/nursing charts, vital signs, fluid balance, laboratory trends and available imaging/EEG.', 'Review current and recently stopped medications and possible interactions.', 'Review previous psychiatric records, self-harm history and treatment response.', 'Review substance-use concerns and nursing 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 and decision required.', ]: bullet(b) para('This prevents a vague referral from being prematurely labelled as a primary psychiatric disorder before ' 'delirium and other secondary causes are excluded.', sb=2, sa=4) h2('2.4 Initial Triage and Stabilization') para('Before detailed psychiatric assessment, determine whether the patient is medically and psychiatrically stable:', sb=2, sa=3) for b in [ 'Airway, breathing and circulation where relevant.', 'Vital signs, oxygenation and bedside glucose.', 'Level of consciousness and arousal; 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) para('Do not diagnose a primary psychiatric disorder in an acutely ill, fluctuating or cognitively changed patient ' 'until delirium and other secondary causes have been actively excluded.', sb=2, sa=4, bold=True) h2('2.5 Clarification of Referral Question and Chronology') for b in [ 'Who referred and what prompted the referral?', 'When did symptoms begin? Acute, subacute or chronic? Is there fluctuation?', 'What was baseline behaviour and cognition, and what changed?', 'Relationship to medical illness, surgery/anaesthesia, medication change or substance use/withdrawal?', 'What clinical decision needs to be made now?', ]: bullet(b) para('Acute onset and fluctuation particularly raise concern for delirium or another secondary syndrome.', sb=2, sa=4) h2('2.6 Comprehensive History') for b in [ 'Presenting complaint/HPI \u2013 onset, precipitant, course, phenomenology, severity, distress, function, sleep, pain, cognition and behaviour.', 'Medical/neurological history \u2013 current illness, procedures/anaesthesia, infection, hypoxia, endocrine/metabolic disease, neurological illness and pain.', 'Past psychiatric history \u2013 diagnoses, admissions, self-harm/suicide attempts, response, adverse effects and adherence.', 'Medication history \u2013 prescribed, OTC and traditional medicines; recent additions, dose changes/omissions, interactions and toxicity.', 'Substance-use history \u2013 alcohol, nicotine, opioids, benzodiazepines, cannabis, stimulants and other substances; last use and withdrawal risk.', 'Psychosocial history \u2013 illness beliefs, coping, stressors, family/social support, caregiver burden, occupation/finances, culture, spirituality and safeguarding.', ]: bullet(b) h2('2.7 Collateral Information') p = para( 'Collateral information is particularly important in delirium, cognitive impairment, psychosis, sedation, severe ' 'distress or when the patient\u2019s account is unreliable. It should be obtained from family, carers, nursing staff ' 'and previous records. Baseline cognition and function must be established from collateral in all cases where ' 'cognitive change is suspected.', sb=2, sa=4) h2('2.8 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) para('In an apparently uncooperative patient with clear consciousness, explore fear, misunderstanding, personality/coping ' 'or communication difficulties before attributing the presentation to a psychiatric disorder.', sb=2, sa=4) h2('2.9 Physical and Neurological Examination') for b in [ 'General: arousal, hydration/nutrition, respiratory effort, pallor/jaundice, trauma, infection and pain cues.', 'Neurological: consciousness, attention, speech/language, pupils, focal deficits, motor abnormalities, tremor, myoclonus, asterixis and seizure activity.', 'Autonomic: pulse, blood pressure, temperature, diaphoresis and pupil size, especially in withdrawal, serotonin toxicity or NMS.', ]: bullet(b) para('Red flags include abnormal vital signs, hypoxia, fever, dehydration, significant pain, asterixis, focal ' 'neurological deficit, papilloedema and meningism \u2014 all pointing to a secondary psychiatric syndrome.', sb=2, sa=4) h2('2.10 Mental Status Examination \u2013 Adapted for C-L Psychiatry') para('The MSE in C-L settings gives particular emphasis to consciousness, arousal, attention, fluctuation and cognition.', sb=2, sa=3) for b in [ '1. General appearance and behaviour \u2013 level of arousal, psychomotor activity, cooperation and abnormal behaviour.', '2. Speech and thought \u2013 rate, volume, coherence, thought form and thought content.', '3. Mood and affect \u2013 depressive, anxious, irritable, elevated or labile states.', '4. Perception \u2013 hallucinations and other perceptual disturbances, particularly when delirium or psychosis is suspected.', '5. Psychosis \u2013 delusions, hallucinations and disorganization, interpreted in the context of the medical illness and level of consciousness.', '6. Catatonia \u2013 assess for characteristic motor and behavioural signs when clinically suspected.', '7. Risk \u2013 suicidal/self-harm thoughts, violence/aggression and risk of interference with essential treatment.', '8. Cognition \u2013 especially attention, orientation, memory and executive function.', '9. Insight and judgement \u2013 including understanding of illness and implications for treatment.', ]: bullet(b) p = para('Cognition should be tested rather than merely inferred from conversation. Screening instruments aid detection; ' 'they do not determine aetiology, diagnosis, capacity or management in isolation.', sb=2, sa=4) add_sup(p, '\u2076\u207b\u2078') h2('2.11 Delirium and Cognitive Assessment \u2013 A Priority') para('Delirium is common, frequently missed and potentially reversible. Suspect it with:', sb=2, sa=3) for b in [ 'Acute onset and fluctuating course.', 'Attention \u2013 test rather than merely ask.', 'Orientation and cognition.', 'Perceptual and psychomotor changes.', 'Baseline cognition and diurnal variation from family/staff.', ]: bullet(b) h3('Validated tools:') p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.3); 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 4AT \u2013 rapid delirium screening for general hospital settings.') r.font.name = 'Times New Roman'; r.font.size = Pt(12) add_sup(p, '\u2076\u2077\u00b9\u00b2') p2 = doc.add_paragraph() p2.paragraph_format.left_indent = Inches(0.3); p2.paragraph_format.first_line_indent = Inches(-0.2) p2.paragraph_format.space_before = Pt(2); p2.paragraph_format.space_after = Pt(2) r2 = p2.add_run('\u2022 CAM-ICU \u2013 validated for critically ill/mechanically ventilated patients.') r2.font.name = 'Times New Roman'; r2.font.size = Pt(12) add_sup(p2, '\u00b9\u00b9') for b in [ 'RASS \u2013 assessment of arousal/sedation in critical care.', 'MoCA/MMSE \u2013 selective cognitive screening; neither replaces clinical assessment or baseline information.', ]: p3 = doc.add_paragraph() p3.paragraph_format.left_indent = Inches(0.3); p3.paragraph_format.first_line_indent = Inches(-0.2) p3.paragraph_format.space_before = Pt(2); p3.paragraph_format.space_after = Pt(2) r3 = p3.add_run('\u2022 ' + b) r3.font.name = 'Times New Roman'; r3.font.size = Pt(12) p4 = para('Current NICE guidance recommends the 4AT when delirium indicators are present, and CAM-ICU or ICDSC in ' 'critical care. After identifying delirium, search actively for infection, hypoxia, metabolic disturbance, ' 'dehydration, pain, constipation, urinary retention and offending medications.', sb=3, sa=4) add_sup(p4, '\u2076') h2('2.12 Risk Assessment') para('Risk assessment is continuous rather than a one-time checklist.', sb=2, sa=3) for b in [ 'Suicide/self-harm \u2013 ideation, intent, plan, access to means, past attempts, hopelessness, impulsivity, pain, substance use.', '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 gaps.', 'Risk to treatment \u2013 non-adherence, absconding, interference with essential treatment and inability to participate in rehabilitation.', ]: bullet(b) h2('2.13 Decision-Making Capacity') p = para( 'Capacity is clinical, decision-specific and time-specific; it is not synonymous with psychiatric diagnosis, ' 'intelligence or a one-time determination. Optimise reversible factors such as pain, hypoxia and delirium before ' 'assessment.', sb=2, sa=3) add_sup(p, '\u2074') para('The four-ability framework (Appelbaum & Grisso):', sb=2, sa=3) for b in [ 'Communicate a choice.', 'Understand relevant information.', 'Appreciate the situation and its consequences.', 'Reason with the relevant information.', ]: bullet(b) p5 = para('Document the decision assessed, information provided, ability findings and conclusion clearly.', sb=2, sa=4) add_sup(p5, '\u00b9\u00b3') h2('2.14 Investigations \u2013 Hypothesis-Driven') para('Investigations should follow the history, examination and differential diagnosis. Review existing results before ordering further tests.', sb=2, sa=3) for b in [ 'Basic: CBC, glucose, electrolytes, calcium/magnesium, renal/liver function; thyroid function where indicated; infection screen.', 'Targeted: drug levels/toxicology, blood gas, B12/folate, endocrine/autoimmune/infectious investigations as clinically indicated.', 'Neurological: CT/MRI brain for focal, atypical or acute presentations; EEG for suspected non-convulsive seizures/encephalopathy.', 'Before psychotropics: renal/hepatic function, electrolytes, ECG/QTc and clinically relevant drug interactions.', ]: bullet(b) h2('2.15 Diagnostic Formulation \u2013 The 4Ps') para('A good C-L formulation integrates syndrome, aetiology, vulnerabilities, precipitants, perpetuating factors, strengths and risks.', sb=2, sa=3) for b in [ 'Predisposing \u2013 prior psychiatric illness, cognitive disorder, personality and vulnerability.', 'Precipitating \u2013 acute illness, surgery, infection, medication change or substance exposure/withdrawal.', 'Perpetuating \u2013 pain, disability, poor sleep, isolation, ongoing medical stressors and treatment barriers.', 'Protective \u2013 family support, coping strengths, engagement and available resources.', ]: bullet(b) h2('2.16 Special Populations') h3('A. Older Adults') p = para('Delirium, dementia, depression, sensory impairment, frailty, polypharmacy and functional dependence may coexist.', sb=2, sa=3) add_sup(p, '\u00b9\u00b2') 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 for depression: Geriatric Depression Scale (GDS) or PHQ-9; PHQ-2 as brief first-step screen.', 'MoCA/MMSE selectively; interpret in relation to education, language and baseline.', ]: bullet(b) p6 = para('Recent evidence supports proactive, integrated C-L psychiatric assessment in older medical in-patients, ' 'with studies demonstrating improved delirium outcomes, reduced length of stay and better functional recovery.', sb=2, sa=4) add_sup(p6, '\u00b9') h3('B. Children and Adolescents') p = para('Assessment must be developmentally sensitive and family-centred, integrating developmental stage, illness, ' 'emotional/behavioural presentation and safeguarding considerations.', sb=2, sa=3) add_sup(p, '\u2076') for b in [ 'Interview child/adolescent 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.', ]: bullet(b) h3('C. Pregnant and Postpartum Women') para('Requires simultaneous consideration of maternal psychiatric illness, obstetric status, fetal considerations, ' 'medications and social factors.', sb=2, sa=3) para('Pregnancy assessment:', sb=2, sa=2, bold=True) for b in [ 'Gestational age; obstetric history and current complications.', 'Previous psychiatric illness, 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:', sb=3, sa=2, bold=True) 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) para('\u26a0 Exam point: Postpartum psychosis \u2014 rapid onset of psychotic, manic or disorganised symptoms postpartum, ' 'especially within the first two weeks, is a psychiatric emergency requiring urgent assessment and management.', sb=3, sa=4, italic=True) h2('2.17 Communication, Liaison and Follow-up') p = para('The assessment is incomplete without communication. Document the formulation, risk, capacity where relevant ' 'and clear recommendations.', sb=2, sa=3) add_sup(p, '\u00b9') for b in [ 'To the treating team: written note plus direct verbal communication; co-develop a comprehensive treatment plan.', 'To the patient and family: transparent explanation; clarify mind-body connection; ensure consistency with medical team messaging.', 'Confirmed psychiatric diagnosis: arrange follow-up according to clinical need.', 'Inconclusive diagnosis: arrange reassessment with further investigations or psychometric assessment when clinically indicated.', 'Suicidal ideation: documented safety plan, appropriate observation and serial risk reassessment.', ]: bullet(b) p7 = doc.add_paragraph() p7.alignment = WD_ALIGN_PARAGRAPH.CENTER p7.paragraph_format.space_before = Pt(10); p7.paragraph_format.space_after = Pt(10) rb = p7.add_run('THE THREE \u201cC\u201dS OF C-L PSYCHIATRY\nConceptualisation \u2013 Communication \u2013 Collaboration') rb.bold = True; rb.font.name = 'Times New Roman'; rb.font.size = Pt(12) # ══════════════════════════════════════════════════════════════════════════════ # 3. MANAGEMENT # ══════════════════════════════════════════════════════════════════════════════ h1('3. MANAGEMENT OF PSYCHIATRIC DISORDERS IN MEDICALLY ILL IN-PATIENTS') p_algo = doc.add_paragraph() p_algo.alignment = WD_ALIGN_PARAGRAPH.CENTER p_algo.paragraph_format.space_before = Pt(4); p_algo.paragraph_format.space_after = Pt(8) ra = p_algo.add_run( 'STABILIZE \u2192 IDENTIFY CAUSE \u2192 TREAT CAUSE \u2192 NON-PHARMACOLOGICAL CARE\n' '\u2192 PSYCHOLOGICAL INTERVENTION \u2192 JUDICIOUS PHARMACOLOGY \u2192 DISCHARGE PLANNING' ) ra.bold = True; ra.font.name = 'Times New Roman'; ra.font.size = Pt(11) h2('3.1 General Principles of Management') para('Management should be individualized, syndrome- and aetiology-directed, and integrated with the medical ' 'treatment plan.', sb=2, sa=3) for b in [ 'Stabilize immediate medical and psychiatric emergencies.', 'Identify and treat the underlying medical, neurological, medication- or substance-related cause.', 'Review and rationalize medications.', 'Use environmental, behavioural and psychological interventions as the foundation of care.', 'Use psychotropic medication judiciously when clearly indicated.', 'Assess and address risk and decision-making capacity.', 'Work collaboratively with the medical and multidisciplinary team.', ]: bullet(b) p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.3); p.paragraph_format.first_line_indent = Inches(-0.2) p.paragraph_format.space_before = Pt(2); p.paragraph_format.space_after = Pt(4) r = p.add_run('\u2022 Plan discharge, continuity of care and follow-up from the outset.') r.font.name = 'Times New Roman'; r.font.size = Pt(12) add_sup(p, '\u00b9') h2('3.2 Medical Stabilization and Treatment of Underlying Cause') p = para('Before treating the psychiatric manifestation in isolation, address acute medical or neurological instability. ' 'Reversible medical causes must be identified and treated as a priority.', sb=2, sa=3) for b in [ 'Correct hypoxia, hypoglycaemia, electrolyte and metabolic abnormalities.', 'Treat infection and sepsis appropriately.', 'Correct dehydration and nutritional deficiencies.', 'Treat pain adequately.', 'Manage organ failure and other active medical complications.', 'Identify and treat neurological causes such as seizures, stroke or CNS infection when clinically suspected.', 'Recognize and treat intoxication or withdrawal states.', 'Address sleep disruption, immobility and other modifiable hospital-related precipitants.', ]: bullet(b) p = doc.add_paragraph() p.paragraph_format.space_before = Pt(4); p.paragraph_format.space_after = Pt(4) r1 = p.add_run('Key principle: '); r1.bold = True r1.font.name = 'Times New Roman'; r1.font.size = Pt(12) r2 = p.add_run('Treat the cause, not merely the psychiatric manifestation.') r2.font.name = 'Times New Roman'; r2.font.size = Pt(12) add_sup(p, '\u00b9\u00b9\u2074\u00b9\u2075') h2('3.3 Medication Review') p = para('A comprehensive medication review is essential because medications may precipitate, exacerbate or mimic ' 'psychiatric syndromes.', sb=2, sa=3) for b in [ 'Review newly initiated medications and recent dose increases.', 'Identify medications with neuropsychiatric adverse effects: corticosteroids, dopaminergic drugs, anticholinergics, opioids, antivirals and others.', 'Assess sedative and anticholinergic burden.', 'Check for drug\u2013drug and drug\u2013disease interactions.', 'Review recent discontinuation or withdrawal of regularly prescribed medications.', 'Assess possible medication toxicity.', 'Decide whether a medication should be continued, withheld, dose-reduced, switched or discontinued.', ]: bullet(b) h2('3.4 Non-Pharmacological Management') p = para('Non-pharmacological care is the foundation of management, particularly in delirium and in medically ' 'vulnerable patients.', sb=2, sa=3) for b in [ 'Establish a therapeutic relationship and provide reassurance and emotional support.', 'Use clear, simple communication and provide repeated orientation when required.', 'Maintain a regular sleep\u2013wake cycle and minimize unnecessary nighttime disturbance.', 'Ensure adequate daytime light and appropriate environmental cues.', 'Ensure glasses, hearing aids and other sensory aids are available and functioning.', 'Maintain adequate hydration and nutrition.', 'Encourage early mobilization where medically feasible.', 'Identify and treat pain adequately.', 'Encourage appropriate involvement of family/caregivers.', 'Avoid unnecessary urinary catheters, invasive procedures and physical restraints.', ]: bullet(b) p = doc.add_paragraph() p.paragraph_format.space_before = Pt(4); p.paragraph_format.space_after = Pt(2) r1 = p.add_run('Multicomponent prevention: '); r1.bold = True r1.font.name = 'Times New Roman'; r1.font.size = Pt(12) r2 = p.add_run('The Hospital Elder Life Programme (HELP) has demonstrated significant reduction in delirium ' 'incidence through targeted non-pharmacological interventions including reorientation, sleep promotion, ' 'early mobilization, sensory correction and hydration.') r2.font.name = 'Times New Roman'; r2.font.size = Pt(12) add_sup(p, '\u00b9\u2074\u00b9\u2075') para('In delirium, correction of reversible causes and optimization of the environment should precede and complement ' 'pharmacological management.', sb=2, sa=4) h2('3.5 Psychological and Psychotherapeutic Interventions') para('Psychological interventions should be adapted to the patient\u2019s physical condition, cognitive capacity, ' 'prognosis, illness stage and setting.', sb=2, sa=3) for b in [ 'Supportive psychotherapy \u2013 empathy, validation, emotional support and coping enhancement.', 'Psychoeducation \u2013 explain the illness, expected symptoms, treatment options and treatment plan; correct misconceptions.', 'CBT-based interventions \u2013 useful for anxiety, depression, adjustment difficulties and insomnia when the patient is cognitively able.', 'Relaxation techniques \u2013 breathing exercises, grounding and progressive muscle relaxation.', 'Behavioural interventions \u2013 activity scheduling, behavioural activation and sleep hygiene.', 'Family interventions \u2013 education, communication, caregiver support and crisis planning.', ]: bullet(b) h2('3.6 Judicious Psychopharmacology in the Medically Ill') p = para('Psychopharmacological treatment should be based on a clear indication and integrated with the medical ' 'context. Medically ill patients are often more sensitive to adverse effects.', sb=2, sa=3) add_sup(p, '\u00b9') h3('Before prescribing, consider:') for b in [ 'Diagnosis and treatment indication.', 'Severity and current medical status.', 'Renal and hepatic function.', 'Potential drug interactions.', 'Age, frailty and fall risk.', 'ECG/QTc when clinically indicated.', 'Route of administration and ability to swallow/absorb medication.', 'Starting dose, titration and monitoring requirements.', ]: bullet(b) h3('Practical principles:') for b in [ 'Start low and go slow, but treat adequately.', 'Prefer the simplest effective regimen and avoid unnecessary polypharmacy.', 'Minimize anticholinergic burden and unnecessary sedation.', 'Monitor response, adverse effects, ECG and relevant laboratory parameters.', 'Reassess medication need as the medical condition changes.', ]: bullet(b) p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.3); p.paragraph_format.first_line_indent = Inches(-0.2) p.paragraph_format.space_before = Pt(2); p.paragraph_format.space_after = Pt(4) r = p.add_run('\u2022 Deprescribe or discontinue medications that are no longer indicated.') r.font.name = 'Times New Roman'; r.font.size = Pt(12) add_sup(p, '\u00b9') h2('3.7 Syndrome-Specific Management') h3('A. Delirium') p = para('Delirium requires urgent identification and treatment of its underlying causes, combined with multicomponent ' 'non-pharmacological care.', sb=2, sa=3) add_sup(p, '\u00b9\u2074\u00b9\u2075') para('1. Treat the underlying cause', sb=3, sa=2, bold=True) for b in [ 'Treat infection/sepsis and correct hypoxia and metabolic abnormalities.', 'Review and discontinue offending medications where possible.', 'Treat alcohol, benzodiazepine or other relevant withdrawal states.', 'Correct dehydration, urinary retention and constipation.', 'Identify and manage pain and other reversible precipitants.', ]: bullet(b) para('2. Non-pharmacological management', sb=3, sa=2, bold=True) para('Apply the general measures above, with particular emphasis on reorientation, sensory correction, sleep\u2013wake ' 'regulation, family involvement and avoiding physical restraints.', sb=2, sa=3) para('3. Pharmacological management', sb=3, sa=2, bold=True) for b in [ 'Consider medication only when severe agitation, distress or behavioural disturbance persists despite appropriate non-pharmacological measures.', 'Haloperidol may be considered short-term at the lowest effective dose when clinically appropriate.', 'Monitor ECG/QTc, extrapyramidal symptoms, sedation and adverse effects.', 'Use particular caution or avoid antipsychotics in Parkinson\u2019s disease, dementia with Lewy bodies and significant cardiac disease.', 'Benzodiazepines are generally avoided in delirium except when specifically indicated (alcohol or benzodiazepine withdrawal).', ]: bullet(b) h3('B. Depression') p = para('Differentiate depressive disorder from adjustment disorder, demoralisation, delirium and an expected ' 'emotional response to illness.', sb=2, sa=3) for b in [ 'Treat contributory medical conditions and review medications.', 'Supportive psychotherapy, CBT-based interventions and behavioural activation.', 'SSRIs are generally preferred when pharmacotherapy is indicated; sertraline or escitalopram as per clinical profile.', 'Monitor for hyponatraemia, bleeding risk, QTc effects and renal/hepatic considerations.', 'Mirtazapine may be useful when insomnia or poor appetite/weight loss is prominent.', 'SNRIs may be considered when depression coexists with chronic or neuropathic pain.', 'TCAs are generally not first-line because of anticholinergic and cardiovascular adverse effects.', 'ECT should be considered for severe suicidal depression, psychotic depression, catatonia or severe treatment-resistant depression.', ]: bullet(b) h3('C. Anxiety') p = para('Determine whether anxiety is related to the medical illness, medication effects, substance withdrawal, ' 'panic disorder, adjustment disorder or a primary anxiety disorder.', sb=2, sa=3) for b in [ 'Psychoeducation, reassurance and clear explanation of symptoms and treatment.', 'Relaxation, breathing and grounding strategies.', 'Supportive psychotherapy and CBT techniques when feasible.', 'SSRIs are preferred for persistent anxiety disorders when pharmacotherapy is indicated.', 'Benzodiazepines should generally not be used routinely; if required for severe acute anxiety, use cautiously and for the shortest duration.', ]: bullet(b) h3('D. Psychosis') p = para('First determine whether psychosis is primary or secondary to delirium, neurological illness, ' 'endocrine/metabolic disease or substances.', sb=2, sa=3) for b in [ 'Treat the underlying cause.', 'Assess risk and need for increased supervision.', 'Reduce environmental stimulation and provide a calm, structured environment.', 'Use an antipsychotic only when clearly indicated; choose the agent according to the medical and pharmacological profile.', 'Monitor ECG/QTc, blood pressure, sedation, extrapyramidal effects and metabolic parameters.', 'Use particular caution or avoid antipsychotics in Parkinson\u2019s disease, dementia with Lewy bodies, significant QTc prolongation and cardiac disease.', ]: bullet(b) h3('E. Agitation and Behavioural Disturbance') p = para('Use a stepwise approach: Identify cause \u2192 de-escalate \u2192 modify environment \u2192 treat cause \u2192 ' 'medication if necessary \u2192 restraint only as a last resort.', sb=2, sa=3) for b in [ 'Identify reversible causes: delirium, pain, hypoxia, urinary retention, constipation, withdrawal, psychosis, mania.', 'Use verbal de-escalation: remain calm, maintain safe distance, use simple language, acknowledge distress, offer choices.', 'If severe agitation persists, consider short-term medication according to the underlying syndrome.', 'Use physical restraint only as a last resort when necessary to prevent immediate harm, with the shortest possible duration.', ]: bullet(b) h3('F. Catatonia') p = para('Identify and treat underlying causes; distinguish catatonia from delirium, neurological/metabolic illness ' 'and drug-induced states.', sb=2, sa=3) for b in [ 'First-line treatment is generally a benzodiazepine, particularly lorazepam.', 'Consider ECT in severe, refractory or life-threatening catatonia, including malignant catatonia, poor oral intake or significant deterioration.', ]: bullet(b) h3('G. Substance-Related Disorders and Withdrawal') p = para('Distinguish intoxication, withdrawal, substance-induced psychiatric disorders and primary psychiatric disorders.', sb=2, sa=3) for b in [ 'Alcohol withdrawal \u2013 benzodiazepines are first-line; thiamine administration; correct fluid/electrolyte abnormalities; monitor for complications.', 'Opioid withdrawal \u2013 symptomatic treatment and evidence-based opioid agonist treatment such as buprenorphine or methadone where indicated.', 'Nicotine dependence \u2013 nicotine replacement therapy and behavioural interventions; incorporate tobacco cessation into the management plan.', ]: bullet(b) p8 = doc.add_paragraph() p8.paragraph_format.left_indent = Inches(0.3); p8.paragraph_format.first_line_indent = Inches(-0.2) p8.paragraph_format.space_before = Pt(2); p8.paragraph_format.space_after = Pt(3) r8 = p8.add_run('\u2022 Motivational interviewing and substance-use counselling should be incorporated where appropriate.') r8.font.name = 'Times New Roman'; r8.font.size = Pt(12) add_sup(p8, '\u00b9\u2075\u00b9\u2076\u00b9\u2077') h3('H. Suicide and Self-Harm') p = para('Assess suicide risk when clinically indicated, particularly in severe depression, chronic pain, cancer, ' 'neurological illness, substance use and recent self-harm.', sb=2, sa=3) for b in [ 'Assess suicidal ideation, intent and plan; access to means and previous attempts.', 'Assess hopelessness, impulsivity, agitation, substance use and other dynamic risk factors.', 'Identify protective factors and social supports.', ]: bullet(b) p9 = doc.add_paragraph() p9.paragraph_format.left_indent = Inches(0.3); p9.paragraph_format.first_line_indent = Inches(-0.2) p9.paragraph_format.space_before = Pt(2); p9.paragraph_format.space_after = Pt(3) r9 = p9.add_run('\u2022 Ensure immediate safety, appropriate observation, treatment of the underlying disorder and family involvement where appropriate.') r9.font.name = 'Times New Roman'; r9.font.size = Pt(12) add_sup(p9, '\u00b9\u2078') h3('I. Sleep Disturbance') for b in [ 'Maintain a regular sleep\u2013wake schedule and promote sleep hygiene.', 'Reduce nighttime noise, light and unnecessary interruptions.', 'Encourage daytime activity and mobilization where medically appropriate.', 'Treat pain and the underlying medical illness.', 'Avoid routine sedative-hypnotics in vulnerable medically ill patients.', 'In delirium, prioritize non-pharmacological sleep measures rather than routinely adding hypnotics solely for sleep disturbance.', ]: bullet(b) h2('3.8 Liaison and Multidisciplinary Management') p = para('Liaison is a defining component of C-L Psychiatry. Management should be collaborative rather than limited ' 'to giving a psychiatric opinion.', sb=2, sa=3) for b in [ 'Discuss the clinical formulation and priorities with the primary medical/surgical team.', 'Explain the relationship between psychiatric symptoms and the medical illness.', 'Coordinate investigations and treatment recommendations.', 'Advise on psychotropic selection, interactions and monitoring.', 'Educate medical and nursing staff.', 'Involve the patient and family in shared understanding and planning.', 'Coordinate nursing, psychology, social work, occupational therapy, physiotherapy and pharmacy input as required.', ]: bullet(b) p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.3); p.paragraph_format.first_line_indent = Inches(-0.2) p.paragraph_format.space_before = Pt(2); p.paragraph_format.space_after = Pt(3) r = p.add_run('\u2022 Begin discharge planning early.') r.font.name = 'Times New Roman'; r.font.size = Pt(12) add_sup(p, '\u00b9\u00b9\u2074') para('A practical model: Patient + Psychiatrist + Physician/Surgeon + Nursing + Allied Health Professionals + Family.', sb=3, sa=4, bold=True) h2('3.9 Special Clinical Settings') p = para('Psychiatric management must be adapted to the specific clinical environment.', sb=2, sa=3) add_sup(p, '\u00b9\u2074') for b in [ 'ICU \u2013 prioritize delirium prevention/management, pain, appropriate sedation, sleep, early mobilization, communication and family involvement.', 'Neurological illness \u2013 pay particular attention to cognition, seizures, mood, psychosis, behavioural change and neurological\u2013psychiatric overlap.', 'Oncology and palliative care \u2013 address depression, anxiety, delirium, pain, existential distress, suicidality, communication of prognosis and goals of care.', 'Transplantation \u2013 assess psychiatric history, substance use, cognition, coping, adherence, social support and understanding of post-transplant demands.', 'Chronic medical illness \u2013 address coping, behavioural change, adherence, disability, family burden and recurrent psychological distress.', ]: bullet(b) h2('3.10 Discharge Planning and Follow-up') for b in [ 'Confirm whether the psychiatric syndrome has resolved or requires continued treatment.', 'Review the ongoing indication for psychotropic medication and adverse effects.', 'Reassess suicide risk where relevant.', 'Perform medication reconciliation and provide clear instructions.', 'Provide patient and family education.', 'Arrange appropriate psychiatric and medical follow-up.', 'Plan relapse prevention and substance-use interventions when appropriate.', 'Link the patient with community psychiatric and rehabilitation services when required.', 'Do not allow a psychotropic medication started for an acute hospital problem to become an indefinite prescription without reassessment.', ]: bullet(b) h2('3.11 Patient-Centred Care and Outcomes') para('The goal is not merely control of psychiatric symptoms but recovery of the whole person.', sb=2, sa=3) for b in [ 'Reduce suffering and distress.', 'Restore functioning and autonomy.', 'Improve treatment adherence and medical recovery.', 'Reduce complications and unnecessary healthcare utilization.', 'Improve quality of life.', 'Support the family and caregivers.', 'Ensure continuity of psychiatric and medical care.', ]: bullet(b) para('A useful closing principle: Treat the patient as a whole, not the psychiatric symptom in isolation.', sb=3, sa=4, bold=True) # ══════════════════════════════════════════════════════════════════════════════ # 4. PREVENTION AND DISCHARGE PLANNING # ══════════════════════════════════════════════════════════════════════════════ h1('4. PREVENTION, DISCHARGE PLANNING AND FOLLOW-UP') p = doc.add_paragraph() p.paragraph_format.space_before = Pt(2); p.paragraph_format.space_after = Pt(4) r1 = p.add_run('Prevention begins at admission. High-risk patients (elderly, cognitive impairment, polypharmacy, prior psychiatric history) should be identified early. The ') r1.font.name = 'Times New Roman'; r1.font.size = Pt(12) r2 = p.add_run('Hospital Elder Life Programme (HELP)') r2.bold = True; r2.font.name = 'Times New Roman'; r2.font.size = Pt(12) r3 = p.add_run(' has the strongest evidence for delirium prevention.') r3.font.name = 'Times New Roman'; r3.font.size = Pt(12) add_sup(p, '\u00b9\u2074\u00b9\u2075') para('Discharge planning should begin at admission and include: confirmation of psychiatric diagnosis and treatment plan, ' 'medication reconciliation, patient and family psychoeducation, and clear follow-up arrangements between psychiatric ' 'and medical services.', sb=2, sa=6) # ══════════════════════════════════════════════════════════════════════════════ # 5. INDIAN CONTEXT # ══════════════════════════════════════════════════════════════════════════════ h1('5. CONSULTATION-LIAISON PSYCHIATRY IN THE INDIAN CONTEXT') p = para( 'C-L Psychiatry in India began in 1933, with referral rates still as low as 0.01\u20133.6% of inpatients in many ' 'centres, highlighting a persistent recognition\u2013referral gap.', sb=2, sa=4) add_sup(p, '\u00b3') p = doc.add_paragraph() p.paragraph_format.space_before = Pt(2); p.paragraph_format.space_after = Pt(6) r1 = p.add_run('Jacob, Kuruvilla and Zachariah (Christian Medical College, Vellore) have argued that psychiatric training confined to tertiary settings generates a ') r1.font.name = 'Times New Roman'; r1.font.size = Pt(12) r2 = p.add_run('\u201ccategory fallacy\u201d') r2.italic = True; r2.font.name = 'Times New Roman'; r2.font.size = Pt(12) r3 = p.add_run(' \u2014 the unwarranted assumption that specialist psychiatric categories carry the same meaning across different clinical contexts \u2014 and that current training deskills physicians in recognising common presentations in general hospital settings. They advocate for a liaison approach grounded in local context, with training situated in primary and secondary care settings.') r3.font.name = 'Times New Roman'; r3.font.size = Pt(12) add_sup(p, '\u00b9\u2079') # ══════════════════════════════════════════════════════════════════════════════ # 6. CHALLENGES AND FUTURE DIRECTIONS # ══════════════════════════════════════════════════════════════════════════════ h1('6. CHALLENGES AND FUTURE DIRECTIONS') h2('Challenges') for b in [ 'Low referral rates and under-recognition of psychiatric morbidity in general wards.', 'Professional stigma towards mental illness reducing willingness to refer.', 'Inadequate staffing and no formal C-L subspecialty recognition in India.', 'Psychiatric training confined to specialist tertiary settings, disempowering general physicians.', ]: bullet(b) h2('Future Directions') for b in [ 'Structured, accredited C-L Psychiatry fellowship programmes at national centres.', 'Integration of C-L Psychiatry into undergraduate and postgraduate curricula of all medical and nursing disciplines.', 'Shift from reactive (on-call referral) to proactive C-L models with regular ward rounds.', 'Telepsychiatry-based C-L services to expand reach to district and under-resourced hospitals.', ]: bullet(b) # ══════════════════════════════════════════════════════════════════════════════ # 7. CONCLUSION # ══════════════════════════════════════════════════════════════════════════════ h1('7. CONCLUSION') para( 'Psychiatric disorders in medically ill patients are common, under-recognised and treatable. Effective C-L ' 'Psychiatry demands a systematic, biopsychosocial and patient-centred approach encompassing early recognition, ' 'medical stabilisation, psychological intervention and multidisciplinary collaboration. In India, realising this ' 'potential requires expansion of C-L services, reform of psychiatric training across all medical disciplines and ' 'investment in collaborative models of care grounded in local context and evidence.', sb=2, sa=8) q = doc.add_paragraph() q.alignment = WD_ALIGN_PARAGRAPH.CENTER q.paragraph_format.space_before = Pt(6); q.paragraph_format.space_after = Pt(2) qr = q.add_run( '\u201cThe dominant model of disease today is biomedical... it leaves no room within its framework\n' 'for the social, psychological and behavioural dimensions of illness.\u201d' ) qr.italic = True; qr.font.name = 'Times New Roman'; qr.font.size = Pt(11) attr = doc.add_paragraph() attr.alignment = WD_ALIGN_PARAGRAPH.CENTER attr.paragraph_format.space_before = Pt(2); attr.paragraph_format.space_after = Pt(8) ar = attr.add_run('\u2014 George Engel, 1977') ar.italic = True; ar.font.name = 'Times New Roman'; ar.font.size = Pt(11) closing = doc.add_paragraph() closing.alignment = WD_ALIGN_PARAGRAPH.CENTER closing.paragraph_format.space_before = Pt(4); closing.paragraph_format.space_after = Pt(16) cr = closing.add_run( 'Consultation-Liaison Psychiatry exists precisely to correct this \u2014 bridging the gap between mind and body, ' 'between psychiatry and medicine, and between the diagnosis and the whole person.' ) cr.italic = True; cr.font.name = 'Times New Roman'; cr.font.size = Pt(12) # ══════════════════════════════════════════════════════════════════════════════ # REFERENCES (unified, deduplicated: 1-19) # ══════════════════════════════════════════════════════════════════════════════ h1('REFERENCES') 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):116\u2013126.', '3. Dua D, Grover S. Profile of patients seen in Consultation-Liaison Psychiatry in India: A systematic review. Indian J Psychiatry. 2020;62(3):255\u2013271.', '4. American Psychiatric Association. Resource Document on Decisional Capacity Determinations in Consultation-Liaison Psychiatry. Washington, DC: APA; 2019.', '5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text rev. Washington, DC: APA; 2022.', '6. National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Clinical guideline CG103. London: NICE; 2019.', '7. Maclullich AMJ, Shenkin SD, Goodacre S, et al. The 4 "A"s test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess. 2019;23(40):1\u2013194.', '8. Nasreddine ZS, Phillips NA, B\u00e9dirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695\u2013699.', '9. Gillett G, Westwood S, Thomson AB, Lee W. "Medical clearance" and referral to liaison psychiatry: a national service evaluation. BJPsych Bull. 2024;48(1):1\u20139.', '10. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the Confusion Assessment Method. Ann Intern Med. 1990;113(12):941\u2013948.', '11. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). JAMA. 2001;286(21):2703\u20132710.', '12. Bellelli G, Morandi A, Davis DHJ, 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.', '13. Appelbaum PS, Grisso T. Assessing patients\u2019 capacities to consent to treatment. N Engl J Med. 1988;319(25):1635\u20131638.', '14. Crone C, Fochtmann LJ, Ahmed I, et al. The American Psychiatric Association practice guideline on delirium in adult patients. Am J Psychiatry. 2025;182(1):1\u201386.', '15. National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and management of physical complications. Clinical guideline CG100. London: NICE; 2017.', '16. American Society of Addiction Medicine. The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder. Rockville, MD: ASAM; 2020.', '17. World Health Organization. WHO clinical treatment guideline for tobacco cessation in adults. Geneva: WHO; 2024.', '18. Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for assessment and management of patients at risk for suicide. Washington, DC: VA/DoD; 2024.', '19. Jacob KS, Kuruvilla A, Zachariah A. Psychiatric curriculum for training physicians. Natl Med J India. 2019;32(1):32\u201337.', ] for ref in refs: ref_line(ref) doc.save(out) print('Saved:', out) PYEOF

python3 << 'PYEOF' from docx import Document doc = Document('/tmp/workspace/prize-fixed/GOLD_MEDAL_COMPLETE_FINAL.docx') print(f"Total paragraphs: {len(doc.paragraphs)}") print() for i, p in enumerate(doc.paragraphs): t = p.text.strip() if t: print(f"[{i:3d}] {t}") PYEOF

python3 << 'PYEOF' from docx import Document from docx.shared import Pt, Inches from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.oxml.ns import qn from docx.oxml import OxmlElement import os out = '/tmp/workspace/prize-fixed/GOLD_MEDAL_SUBMISSION.docx' doc = Document() sec = doc.sections[0] sec.top_margin = Inches(1) sec.bottom_margin = Inches(1) sec.left_margin = Inches(1.2) sec.right_margin = Inches(1.2) normal = doc.styles['Normal'] normal.font.name = 'Times New Roman' normal.font.size = Pt(12) # ── Reference map: old→new (10 kept refs, renumbered 1-10) ────────────────── # OLD: 1=Levenson, 2=Grover/Avasthi, 3=Dua/Grover, 6=NICE CG103, # 10=Inouye CAM, 11=Ely CAM-ICU, 13=Appelbaum, 14=APA Delirium 2025, # 18=VA/DoD Suicide, 19=Jacob/Kuruvilla # NEW: 1→1, 2→2, 3→3, 6→4, 10→5, 11→6, 13→7, 14→8, 18→9, 19→10 # Superscript helper def sup(p, *nums): """Add superscript citation [n1,n2,...] to paragraph p""" sup_chars = { 1:'¹', 2:'²', 3:'³', 4:'⁴', 5:'⁵', 6:'⁶', 7:'⁷', 8:'⁸', 9:'⁹', 10:'¹⁰' } text = ','.join(sup_chars[n] for n in nums) r = p.add_run(text) r.font.name = 'Times New Roman'; r.font.size = Pt(12) rPr = r._r.get_or_add_rPr() v = OxmlElement('w:vertAlign'); v.set(qn('w:val'), 'superscript') rPr.append(v) def h_title(text): p = doc.add_paragraph() p.alignment = WD_ALIGN_PARAGRAPH.CENTER p.paragraph_format.space_before = Pt(0); p.paragraph_format.space_after = Pt(6) r = p.add_run(text); r.bold = True r.font.name = 'Times New Roman'; r.font.size = Pt(14) def h1(text): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(16); 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) 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) def h3(text): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(7); 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) def para(text, sb=3, sa=4, italic=False, center=False, bold=False): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(sb); p.paragraph_format.space_after = Pt(sa) if center: p.alignment = WD_ALIGN_PARAGRAPH.CENTER r = p.add_run(text); r.italic = italic; r.bold = bold 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 bullet_sup(text, *nums): p = bullet(text) sup(p, *nums) def ref_line(text): p = doc.add_paragraph() p.paragraph_format.left_indent = Inches(0.35) p.paragraph_format.first_line_indent = Inches(-0.35) p.paragraph_format.space_before = Pt(3); p.paragraph_format.space_after = Pt(3) r = p.add_run(text); r.font.name = 'Times New Roman'; r.font.size = Pt(10) def mixed(parts, sb=3, sa=4, center=False): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(sb); p.paragraph_format.space_after = Pt(sa) if center: p.alignment = WD_ALIGN_PARAGRAPH.CENTER for text, bold, italic in parts: r = p.add_run(text); r.bold = bold; r.italic = italic r.font.name = 'Times New Roman'; r.font.size = Pt(12) return p # ══════════════════════════════════════════════════════════════════════════════ # TITLE h_title('Assessment and Management of Psychiatric Disorders\nin Medically Ill In-patients') p = doc.add_paragraph() p.alignment = WD_ALIGN_PARAGRAPH.CENTER p.paragraph_format.space_before = Pt(4); p.paragraph_format.space_after = Pt(12) r = p.add_run('\u201cThe good physician treats the disease; the great physician treats the patient who has the disease.\u201d\n\u2014 Sir William Osler') r.italic = True; r.font.name = 'Times New Roman'; r.font.size = Pt(11) # ══════════════════════════════════════════════════════════════════════════════ # 1. INTRODUCTION h1('1. INTRODUCTION') p = para('A medically ill patient is an individual with an acute or chronic physical illness requiring medical or surgical care, in whom a psychiatric disorder may coexist, complicate or arise as a direct consequence of the illness or its treatment. Consultation-Liaison (C-L) Psychiatry is the branch of psychiatry concerned with the assessment and management of psychological, psychiatric and behavioural problems in medically ill patients, providing expert psychiatric input at the interface of psychiatry and medicine.', sb=2, sa=4) sup(p, 1) h2('Historical Perspective') p = para('The roots of C-L Psychiatry lie in psychosomatic medicine and general-hospital psychiatry units. The development of George Engel\u2019s biopsychosocial model in 1977 provided a theoretical framework that remains the foundation of C-L practice. In India, a major milestone occurred in 1933 when Dr. Girindra Shekhar Bose established the first General Hospital Psychiatric Unit (GHPU) at R.G. Kar Medical College and Hospital, Calcutta, preceding many Western countries in integrating psychiatry within general hospital care.', sb=2, sa=4) sup(p, 2) h2('Epidemiology') p = para('Psychiatric morbidity among medically ill in-patients is common but substantially underrecognized, undertreated and undocumented. Prevalence rates of psychiatric disorders vary by setting and methodology. In India, a systematic review of 33 studies reported a wide range of referral rates (0.01\u20133.6% of inpatients), with depression, delirium, substance-use disorders, intentional self-harm and anxiety the most commonly identified diagnoses.', sb=2, sa=4) sup(p, 3) h2('Scope and Clinical Spectrum') p = para('C-L Psychiatry functions across emergency departments, intensive care units, perioperative care, medical/surgical wards and outpatient settings. The clinical spectrum includes adjustment disorders, depressive and anxiety disorders, delirium and other neurocognitive disorders, substance-use disorders, somatic symptom and related disorders, psychological responses to medical illness, medically unexplained symptoms, and psychiatric emergencies including suicidality, agitation and catatonia.', sb=2, sa=6) sup(p, 1, 2) # ══════════════════════════════════════════════════════════════════════════════ # 2. ASSESSMENT h1('2. ASSESSMENT OF PSYCHIATRIC DISORDERS IN MEDICALLY ILL IN-PATIENTS') h2('2.1 Why Psychiatric Assessment is Important') p = para('Psychiatric assessment is the cornerstone of C-L Psychiatry. Its goal is not merely to establish a diagnosis but to determine the aetiology, formulate an integrated biopsychosocial understanding, guide management and facilitate communication with the treating team.', sb=2, sa=3) sup(p, 1) para('A C-L assessment addresses five core questions: What syndrome is present? Why now? Is it primary or secondary? What risk does it carry? What does the patient need?', sb=2, sa=3) p = para('Assessment is dynamic rather than static. Serial evaluations are essential, especially in delirium, critical illness, fluctuating presentations and where capacity is in question. An underlying medical cause should be actively investigated when psychiatric symptoms are new, atypical, acute, fluctuating or associated with physical signs.', sb=2, sa=3) sup(p, 1) p = para('Unaddressed psychiatric morbidity may adversely affect treatment adherence, recovery and rehabilitation, length of hospital stay and overall medical outcomes. Proactive integrated C-L assessment has been associated with improved clinical outcomes in medically ill patients.', sb=2, sa=4) sup(p, 1) h2('2.2 Principles and Objectives') para('Principles: Think organic first \u2022 Stabilize first \u2022 Biopsychosocial approach \u2022 Build chronology \u2022 Review medications and substances \u2022 Obtain collateral \u2022 Watch serially \u2022 Collaborate with MDT', sb=2, sa=3) h3('Objectives:') for b in ['Establish nature, severity, chronology and functional impact.', 'Differentiate primary psychiatric from medical, neurological, medication- or substance-related causes.', 'Detect delirium and neurocognitive disorders early.', 'Assess capacity, suicide risk, violence risk and vulnerability.', 'Identify psychosocial stressors, coping, caregiver burden and supports.', 'Assess treatment-adherence factors.', 'Formulate an integrated biopsychosocial diagnosis.']: bullet(b) p = bullet('Communicate the management plan and arrange reassessment.') sup(p, 1) h2('2.3 Preparatory Phase \u2013 Before Seeing the Patient') p = para('One of the distinctive features of C-L Psychiatry is that assessment begins before bedside contact.', sb=2, sa=3) sup(p, 1) for b in ['Review current medical diagnosis, severity, complications and trajectory.', 'Review medical/nursing charts, vital signs, fluid balance, laboratory trends and available imaging/EEG.', 'Review current and recently stopped medications and possible interactions.', 'Review previous psychiatric records, self-harm history and treatment response.', 'Review substance-use concerns and nursing 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 and decision required.']: bullet(b) para('This prevents a vague referral from being prematurely labelled as a primary psychiatric disorder before delirium and other secondary causes are excluded.', sb=2, sa=4) h2('2.4 Initial Triage and Stabilization') para('Before detailed psychiatric assessment, determine whether the patient is medically and psychiatrically stable:', sb=2, sa=3) for b in ['Airway, breathing and circulation where relevant.', 'Vital signs, oxygenation and bedside glucose.', 'Level of consciousness and arousal; 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) para('Do not diagnose a primary psychiatric disorder in an acutely ill, fluctuating or cognitively changed patient until delirium and other secondary causes have been actively excluded.', sb=2, sa=4, bold=True) h2('2.5 Clarification of Referral Question and Chronology') for b in ['Who referred and what prompted the referral?', 'When did symptoms begin? Acute, subacute or chronic? Is there fluctuation?', 'What was baseline behaviour and cognition, and what changed?', 'Relationship to medical illness, surgery/anaesthesia, medication change or substance use/withdrawal?', 'What clinical decision needs to be made now?']: bullet(b) para('Acute onset and fluctuation particularly raise concern for delirium or another secondary syndrome.', sb=2, sa=4) h2('2.6 Comprehensive History') for b in ['Presenting complaint/HPI \u2013 onset, precipitant, course, phenomenology, severity, distress, function, sleep, pain, cognition and behaviour.', 'Medical/neurological history \u2013 current illness, procedures/anaesthesia, infection, hypoxia, endocrine/metabolic disease, neurological illness and pain.', 'Past psychiatric history \u2013 diagnoses, admissions, self-harm/suicide attempts, response, adverse effects and adherence.', 'Medication history \u2013 prescribed, OTC and traditional medicines; recent additions, dose changes/omissions, interactions and toxicity.', 'Substance-use history \u2013 alcohol, nicotine, opioids, benzodiazepines, cannabis, stimulants and other substances; last use and withdrawal risk.', 'Psychosocial history \u2013 illness beliefs, coping, stressors, family/social support, caregiver burden, occupation/finances, culture, spirituality and safeguarding.']: bullet(b) h2('2.7 Collateral Information') para('Collateral information is particularly important in delirium, cognitive impairment, psychosis, sedation, severe distress or when the patient\u2019s account is unreliable. It should be obtained from family, carers, nursing staff and previous records. Baseline cognition and function must be established from collateral in all cases where cognitive change is suspected.', sb=2, sa=4) h2('2.8 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) para('In an apparently uncooperative patient with clear consciousness, explore fear, misunderstanding, personality/coping or communication difficulties before attributing the presentation to a psychiatric disorder.', sb=2, sa=4) h2('2.9 Physical and Neurological Examination') for b in ['General: arousal, hydration/nutrition, respiratory effort, pallor/jaundice, trauma, infection and pain cues.', 'Neurological: consciousness, attention, speech/language, pupils, focal deficits, motor abnormalities, tremor, myoclonus, asterixis and seizure activity.', 'Autonomic: pulse, blood pressure, temperature, diaphoresis and pupil size, especially in withdrawal, serotonin toxicity or NMS.']: bullet(b) para('Red flags include abnormal vital signs, hypoxia, fever, dehydration, significant pain, asterixis, focal neurological deficit, papilloedema and meningism \u2014 all pointing to a secondary psychiatric syndrome.', sb=2, sa=4) h2('2.10 Mental Status Examination \u2013 Adapted for C-L Psychiatry') para('The MSE in C-L settings gives particular emphasis to consciousness, arousal, attention, fluctuation and cognition.', sb=2, sa=3) for b in ['1. General appearance and behaviour \u2013 level of arousal, psychomotor activity, cooperation and abnormal behaviour.', '2. Speech and thought \u2013 rate, volume, coherence, thought form and thought content.', '3. Mood and affect \u2013 depressive, anxious, irritable, elevated or labile states.', '4. Perception \u2013 hallucinations and other perceptual disturbances, particularly when delirium or psychosis is suspected.', '5. Psychosis \u2013 delusions, hallucinations and disorganization, interpreted in the context of the medical illness and level of consciousness.', '6. Catatonia \u2013 assess for characteristic motor and behavioural signs when clinically suspected.', '7. Risk \u2013 suicidal/self-harm thoughts, violence/aggression and risk of interference with essential treatment.', '8. Cognition \u2013 especially attention, orientation, memory and executive function.', '9. Insight and judgement \u2013 including understanding of illness and implications for treatment.']: bullet(b) p = para('Cognition should be tested rather than merely inferred from conversation. Screening instruments aid detection; they do not determine aetiology, diagnosis, capacity or management in isolation.', sb=2, sa=4) sup(p, 4) h2('2.11 Delirium and Cognitive Assessment \u2013 A Priority') para('Delirium is common, frequently missed and potentially reversible. Suspect it with:', sb=2, sa=3) for b in ['Acute onset and fluctuating course.', 'Attention \u2013 test rather than merely ask.', 'Orientation and cognition.', 'Perceptual and psychomotor changes.', 'Baseline cognition and diurnal variation from family/staff.']: bullet(b) h3('Validated tools:') p = bullet('4AT \u2013 rapid delirium screening for general hospital settings.') sup(p, 4) p = bullet('CAM \u2013 Confusion Assessment Method; gold-standard structured diagnostic algorithm.') sup(p, 5) p = bullet('CAM-ICU \u2013 validated for critically ill/mechanically ventilated patients.') sup(p, 6) bullet('RASS \u2013 assessment of arousal/sedation in critical care.') bullet('MoCA/MMSE \u2013 selective cognitive screening; neither replaces clinical assessment or baseline information.') p = para('Current NICE guidance recommends the 4AT when delirium indicators are present, and CAM-ICU or ICDSC in critical care. After identifying delirium, search actively for infection, hypoxia, metabolic disturbance, dehydration, pain, constipation, urinary retention and offending medications.', sb=3, sa=4) sup(p, 4) h2('2.12 Risk Assessment') para('Risk assessment is continuous rather than a one-time checklist.', sb=2, sa=3) for b in ['Suicide/self-harm \u2013 ideation, intent, plan, access to means, past attempts, hopelessness, impulsivity, pain, substance use.', '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 gaps.', 'Risk to treatment \u2013 non-adherence, absconding, interference with essential treatment and inability to participate in rehabilitation.']: bullet(b) h2('2.13 Decision-Making Capacity') p = para('Capacity is clinical, decision-specific and time-specific; it is not synonymous with psychiatric diagnosis, intelligence or a one-time determination. Optimise reversible factors such as pain, hypoxia and delirium before assessment.', sb=2, sa=3) sup(p, 7) para('The four-ability framework (Appelbaum & Grisso):', sb=2, sa=3) for b in ['Communicate a choice.', 'Understand relevant information.', 'Appreciate the situation and its consequences.', 'Reason with the relevant information.']: bullet(b) p = para('Document the decision assessed, information provided, ability findings and conclusion clearly.', sb=2, sa=4) sup(p, 7) h2('2.14 Investigations \u2013 Hypothesis-Driven') para('Investigations should follow the history, examination and differential diagnosis. Review existing results before ordering further tests.', sb=2, sa=3) for b in ['Basic: CBC, glucose, electrolytes, calcium/magnesium, renal/liver function; thyroid function where indicated; infection screen.', 'Targeted: drug levels/toxicology, blood gas, B12/folate, endocrine/autoimmune/infectious investigations as clinically indicated.', 'Neurological: CT/MRI brain for focal, atypical or acute presentations; EEG for suspected non-convulsive seizures/encephalopathy.', 'Before psychotropics: renal/hepatic function, electrolytes, ECG/QTc and clinically relevant drug interactions.']: bullet(b) h2('2.15 Diagnostic Formulation \u2013 The 4Ps') para('A good C-L formulation integrates syndrome, aetiology, vulnerabilities, precipitants, perpetuating factors, strengths and risks.', sb=2, sa=3) for b in ['Predisposing \u2013 prior psychiatric illness, cognitive disorder, personality and vulnerability.', 'Precipitating \u2013 acute illness, surgery, infection, medication change or substance exposure/withdrawal.', 'Perpetuating \u2013 pain, disability, poor sleep, isolation, ongoing medical stressors and treatment barriers.', 'Protective \u2013 family support, coping strengths, engagement and available resources.']: bullet(b) h2('2.16 Special Populations') h3('A. Older Adults') p = para('Delirium, dementia, depression, sensory impairment, frailty, polypharmacy and functional dependence may coexist.', sb=2, sa=3) sup(p, 1, 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 for depression: Geriatric Depression Scale (GDS) or PHQ-9; PHQ-2 as brief first-step screen.', 'MoCA/MMSE selectively; interpret in relation to education, language and baseline.']: bullet(b) p = para('Recent evidence supports proactive, integrated C-L psychiatric assessment in older medical in-patients, with studies demonstrating improved delirium outcomes, reduced length of stay and better functional recovery.', sb=2, sa=4) sup(p, 1) h3('B. Children and Adolescents') p = para('Assessment must be developmentally sensitive and family-centred, integrating developmental stage, illness, emotional/behavioural presentation and safeguarding considerations.', sb=2, sa=3) sup(p, 1) for b in ['Interview child/adolescent 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.']: bullet(b) h3('C. Pregnant and Postpartum Women') para('Requires simultaneous consideration of maternal psychiatric illness, obstetric status, fetal considerations, medications and social factors.', sb=2, sa=3) para('Pregnancy assessment:', sb=2, sa=2, bold=True) for b in ['Gestational age; obstetric history and current complications.', 'Previous psychiatric illness, 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:', sb=3, sa=2, bold=True) 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) para('\u26a0 Exam point: Postpartum psychosis \u2014 rapid onset of psychotic, manic or disorganised symptoms postpartum, especially within the first two weeks, is a psychiatric emergency requiring urgent assessment and management.', sb=3, sa=4, italic=True) h2('2.17 Communication, Liaison and Follow-up') p = para('The assessment is incomplete without communication. Document the formulation, risk, capacity where relevant and clear recommendations.', sb=2, sa=3) sup(p, 1) for b in ['To the treating team: written note plus direct verbal communication; co-develop a comprehensive treatment plan.', 'To the patient and family: transparent explanation; clarify mind-body connection; ensure consistency with medical team messaging.', 'Confirmed psychiatric diagnosis: arrange follow-up according to clinical need.', 'Inconclusive diagnosis: arrange reassessment with further investigations or psychometric assessment when clinically indicated.', 'Suicidal ideation: documented safety plan, appropriate observation and serial risk reassessment.']: bullet(b) p_3c = doc.add_paragraph() p_3c.alignment = WD_ALIGN_PARAGRAPH.CENTER p_3c.paragraph_format.space_before = Pt(10); p_3c.paragraph_format.space_after = Pt(10) rb = p_3c.add_run('THE THREE \u201cC\u201dS OF C-L PSYCHIATRY\nConceptualisation \u2013 Communication \u2013 Collaboration') rb.bold = True; rb.font.name = 'Times New Roman'; rb.font.size = Pt(12) # ══════════════════════════════════════════════════════════════════════════════ # 3. MANAGEMENT h1('3. MANAGEMENT OF PSYCHIATRIC DISORDERS IN MEDICALLY ILL IN-PATIENTS') p_algo = doc.add_paragraph() p_algo.alignment = WD_ALIGN_PARAGRAPH.CENTER p_algo.paragraph_format.space_before = Pt(4); p_algo.paragraph_format.space_after = Pt(8) ra = p_algo.add_run('STABILIZE \u2192 IDENTIFY CAUSE \u2192 TREAT CAUSE \u2192 NON-PHARMACOLOGICAL CARE\n\u2192 PSYCHOLOGICAL INTERVENTION \u2192 JUDICIOUS PHARMACOLOGY \u2192 DISCHARGE PLANNING') ra.bold = True; ra.font.name = 'Times New Roman'; ra.font.size = Pt(11) h2('3.1 General Principles of Management') para('Management should be individualized, syndrome- and aetiology-directed, and integrated with the medical treatment plan.', sb=2, sa=3) for b in ['Stabilize immediate medical and psychiatric emergencies.', 'Identify and treat the underlying medical, neurological, medication- or substance-related cause.', 'Review and rationalize medications.', 'Use environmental, behavioural and psychological interventions as the foundation of care.', 'Use psychotropic medication judiciously when clearly indicated.', 'Assess and address risk and decision-making capacity.', 'Work collaboratively with the medical and multidisciplinary team.']: bullet(b) p = bullet('Plan discharge, continuity of care and follow-up from the outset.') sup(p, 1) h2('3.2 Medical Stabilization and Treatment of Underlying Cause') para('Before treating the psychiatric manifestation in isolation, address acute medical or neurological instability. Reversible medical causes must be identified and treated as a priority.', sb=2, sa=3) for b in ['Correct hypoxia, hypoglycaemia, electrolyte and metabolic abnormalities.', 'Treat infection and sepsis appropriately.', 'Correct dehydration and nutritional deficiencies.', 'Treat pain adequately.', 'Manage organ failure and other active medical complications.', 'Identify and treat neurological causes such as seizures, stroke or CNS infection when clinically suspected.', 'Recognize and treat intoxication or withdrawal states.', 'Address sleep disruption, immobility and other modifiable hospital-related precipitants.']: bullet(b) p = doc.add_paragraph() p.paragraph_format.space_before = Pt(4); p.paragraph_format.space_after = Pt(4) r1 = p.add_run('Key principle: '); r1.bold = True; r1.font.name = 'Times New Roman'; r1.font.size = Pt(12) r2 = p.add_run('Treat the cause, not merely the psychiatric manifestation.'); r2.font.name = 'Times New Roman'; r2.font.size = Pt(12) sup(p, 1, 8) h2('3.3 Medication Review') para('A comprehensive medication review is essential because medications may precipitate, exacerbate or mimic psychiatric syndromes.', sb=2, sa=3) for b in ['Review newly initiated medications and recent dose increases.', 'Identify medications with neuropsychiatric adverse effects: corticosteroids, dopaminergic drugs, anticholinergics, opioids, antivirals and others.', 'Assess sedative and anticholinergic burden.', 'Check for drug\u2013drug and drug\u2013disease interactions.', 'Review recent discontinuation or withdrawal of regularly prescribed medications.', 'Assess possible medication toxicity.', 'Decide whether a medication should be continued, withheld, dose-reduced, switched or discontinued.']: bullet(b) h2('3.4 Non-Pharmacological Management') para('Non-pharmacological care is the foundation of management, particularly in delirium and in medically vulnerable patients.', sb=2, sa=3) for b in ['Establish a therapeutic relationship and provide reassurance and emotional support.', 'Use clear, simple communication and provide repeated orientation when required.', 'Maintain a regular sleep\u2013wake cycle and minimize unnecessary nighttime disturbance.', 'Ensure adequate daytime light and appropriate environmental cues.', 'Ensure glasses, hearing aids and other sensory aids are available and functioning.', 'Maintain adequate hydration and nutrition.', 'Encourage early mobilization where medically feasible.', 'Identify and treat pain adequately.', 'Encourage appropriate involvement of family/caregivers.', 'Avoid unnecessary urinary catheters, invasive procedures and physical restraints.']: bullet(b) p = doc.add_paragraph() p.paragraph_format.space_before = Pt(4); p.paragraph_format.space_after = Pt(2) r1 = p.add_run('Multicomponent prevention: '); r1.bold = True; r1.font.name = 'Times New Roman'; r1.font.size = Pt(12) r2 = p.add_run('The Hospital Elder Life Programme (HELP) has demonstrated significant reduction in delirium incidence through targeted non-pharmacological interventions including reorientation, sleep promotion, early mobilization, sensory correction and hydration.'); r2.font.name = 'Times New Roman'; r2.font.size = Pt(12) sup(p, 8) p2 = para('In delirium, correction of reversible causes and optimization of the environment should precede and complement pharmacological management.', sb=2, sa=4) sup(p2, 4, 8) h2('3.5 Psychological and Psychotherapeutic Interventions') para('Psychological interventions should be adapted to the patient\u2019s physical condition, cognitive capacity, prognosis, illness stage and setting.', sb=2, sa=3) for b in ['Supportive psychotherapy \u2013 empathy, validation, emotional support and coping enhancement.', 'Psychoeducation \u2013 explain the illness, expected symptoms, treatment options and treatment plan; correct misconceptions.', 'CBT-based interventions \u2013 useful for anxiety, depression, adjustment difficulties and insomnia when the patient is cognitively able.', 'Relaxation techniques \u2013 breathing exercises, grounding and progressive muscle relaxation.', 'Behavioural interventions \u2013 activity scheduling, behavioural activation and sleep hygiene.', 'Family interventions \u2013 education, communication, caregiver support and crisis planning.']: bullet(b) h2('3.6 Judicious Psychopharmacology in the Medically Ill') p = para('Psychopharmacological treatment should be based on a clear indication and integrated with the medical context. Medically ill patients are often more sensitive to adverse effects.', sb=2, sa=3) sup(p, 1) h3('Before prescribing, consider:') for b in ['Diagnosis and treatment indication.', 'Severity and current medical status.', 'Renal and hepatic function.', 'Potential drug interactions.', 'Age, frailty and fall risk.', 'ECG/QTc when clinically indicated.', 'Route of administration and ability to swallow/absorb medication.', 'Starting dose, titration and monitoring requirements.']: bullet(b) h3('Practical principles:') for b in ['Start low and go slow, but treat adequately.', 'Prefer the simplest effective regimen and avoid unnecessary polypharmacy.', 'Minimize anticholinergic burden and unnecessary sedation.', 'Monitor response, adverse effects, ECG and relevant laboratory parameters.', 'Reassess medication need as the medical condition changes.']: bullet(b) p = bullet('Deprescribe or discontinue medications that are no longer indicated.') sup(p, 1) h2('3.7 Syndrome-Specific Management') h3('A. Delirium') p = para('Delirium requires urgent identification and treatment of its underlying causes, combined with multicomponent non-pharmacological care.', sb=2, sa=3) sup(p, 4, 8) para('1. Treat the underlying cause', sb=3, sa=2, bold=True) for b in ['Treat infection/sepsis and correct hypoxia and metabolic abnormalities.', 'Review and discontinue offending medications where possible.', 'Treat alcohol, benzodiazepine or other relevant withdrawal states.', 'Correct dehydration, urinary retention and constipation.', 'Identify and manage pain and other reversible precipitants.']: bullet(b) para('2. Non-pharmacological management', sb=3, sa=2, bold=True) para('Apply the general measures above, with particular emphasis on reorientation, sensory correction, sleep\u2013wake regulation, family involvement and avoiding physical restraints.', sb=2, sa=3) para('3. Pharmacological management', sb=3, sa=2, bold=True) for b in ['Consider medication only when severe agitation, distress or behavioural disturbance persists despite appropriate non-pharmacological measures.', 'Haloperidol may be considered short-term at the lowest effective dose when clinically appropriate.', 'Monitor ECG/QTc, extrapyramidal symptoms, sedation and adverse effects.', 'Use particular caution or avoid antipsychotics in Parkinson\u2019s disease, dementia with Lewy bodies and significant cardiac disease.', 'Benzodiazepines are generally avoided in delirium except when specifically indicated (alcohol or benzodiazepine withdrawal).']: bullet(b) h3('B. Depression') para('Differentiate depressive disorder from adjustment disorder, demoralisation, delirium and an expected emotional response to illness.', sb=2, sa=3) for b in ['Treat contributory medical conditions and review medications.', 'Supportive psychotherapy, CBT-based interventions and behavioural activation.', 'SSRIs are generally preferred when pharmacotherapy is indicated; sertraline or escitalopram as per clinical profile.', 'Monitor for hyponatraemia, bleeding risk, QTc effects and renal/hepatic considerations.', 'Mirtazapine may be useful when insomnia or poor appetite/weight loss is prominent.', 'SNRIs may be considered when depression coexists with chronic or neuropathic pain.', 'TCAs are generally not first-line because of anticholinergic and cardiovascular adverse effects.', 'ECT should be considered for severe suicidal depression, psychotic depression, catatonia or severe treatment-resistant depression.']: bullet(b) h3('C. Anxiety') para('Determine whether anxiety is related to the medical illness, medication effects, substance withdrawal, panic disorder, adjustment disorder or a primary anxiety disorder.', sb=2, sa=3) for b in ['Psychoeducation, reassurance and clear explanation of symptoms and treatment.', 'Relaxation, breathing and grounding strategies.', 'Supportive psychotherapy and CBT techniques when feasible.', 'SSRIs are preferred for persistent anxiety disorders when pharmacotherapy is indicated.', 'Benzodiazepines should generally not be used routinely; if required for severe acute anxiety, use cautiously and for the shortest duration.']: bullet(b) h3('D. Psychosis') para('First determine whether psychosis is primary or secondary to delirium, neurological illness, endocrine/metabolic disease or substances.', sb=2, sa=3) for b in ['Treat the underlying cause.', 'Assess risk and need for increased supervision.', 'Reduce environmental stimulation and provide a calm, structured environment.', 'Use an antipsychotic only when clearly indicated; choose the agent according to the medical and pharmacological profile.', 'Monitor ECG/QTc, blood pressure, sedation, extrapyramidal effects and metabolic parameters.', 'Use particular caution or avoid antipsychotics in Parkinson\u2019s disease, dementia with Lewy bodies, significant QTc prolongation and cardiac disease.']: bullet(b) h3('E. Agitation and Behavioural Disturbance') para('Use a stepwise approach: Identify cause \u2192 de-escalate \u2192 modify environment \u2192 treat cause \u2192 medication if necessary \u2192 restraint only as a last resort.', sb=2, sa=3) for b in ['Identify reversible causes: delirium, pain, hypoxia, urinary retention, constipation, withdrawal, psychosis, mania.', 'Use verbal de-escalation: remain calm, maintain safe distance, use simple language, acknowledge distress, offer choices.', 'If severe agitation persists, consider short-term medication according to the underlying syndrome.', 'Use physical restraint only as a last resort when necessary to prevent immediate harm, with the shortest possible duration.']: bullet(b) h3('F. Catatonia') para('Identify and treat underlying causes; distinguish catatonia from delirium, neurological/metabolic illness and drug-induced states.', sb=2, sa=3) for b in ['First-line treatment is generally a benzodiazepine, particularly lorazepam.', 'Consider ECT in severe, refractory or life-threatening catatonia, including malignant catatonia, poor oral intake or significant deterioration.']: bullet(b) h3('G. Substance-Related Disorders and Withdrawal') para('Distinguish intoxication, withdrawal, substance-induced psychiatric disorders and primary psychiatric disorders.', sb=2, sa=3) for b in ['Alcohol withdrawal \u2013 benzodiazepines are first-line; thiamine administration; correct fluid/electrolyte abnormalities; monitor for complications.', 'Opioid withdrawal \u2013 symptomatic treatment and evidence-based opioid agonist treatment such as buprenorphine or methadone where indicated.', 'Nicotine dependence \u2013 nicotine replacement therapy and behavioural interventions; incorporate tobacco cessation into the management plan.', 'Motivational interviewing and substance-use counselling should be incorporated where appropriate.']: bullet(b) h3('H. Suicide and Self-Harm') para('Assess suicide risk when clinically indicated, particularly in severe depression, chronic pain, cancer, neurological illness, substance use and recent self-harm.', sb=2, sa=3) for b in ['Assess suicidal ideation, intent and plan; access to means and previous attempts.', 'Assess hopelessness, impulsivity, agitation, substance use and other dynamic risk factors.', 'Identify protective factors and social supports.']: bullet(b) p = bullet('Ensure immediate safety, appropriate observation, treatment of the underlying disorder and family involvement where appropriate.') sup(p, 9) h3('I. Sleep Disturbance') for b in ['Maintain a regular sleep\u2013wake schedule and promote sleep hygiene.', 'Reduce nighttime noise, light and unnecessary interruptions.', 'Encourage daytime activity and mobilization where medically appropriate.', 'Treat pain and the underlying medical illness.', 'Avoid routine sedative-hypnotics in vulnerable medically ill patients.', 'In delirium, prioritize non-pharmacological sleep measures rather than routinely adding hypnotics solely for sleep disturbance.']: bullet(b) h2('3.8 Liaison and Multidisciplinary Management') para('Liaison is a defining component of C-L Psychiatry. Management should be collaborative rather than limited to giving a psychiatric opinion.', sb=2, sa=3) for b in ['Discuss the clinical formulation and priorities with the primary medical/surgical team.', 'Explain the relationship between psychiatric symptoms and the medical illness.', 'Coordinate investigations and treatment recommendations.', 'Advise on psychotropic selection, interactions and monitoring.', 'Educate medical and nursing staff.', 'Involve the patient and family in shared understanding and planning.', 'Coordinate nursing, psychology, social work, occupational therapy, physiotherapy and pharmacy input as required.']: bullet(b) p = bullet('Begin discharge planning early.') sup(p, 1, 8) para('A practical model: Patient + Psychiatrist + Physician/Surgeon + Nursing + Allied Health Professionals + Family.', sb=3, sa=4, bold=True) h2('3.9 Special Clinical Settings') p = para('Psychiatric management must be adapted to the specific clinical environment.', sb=2, sa=3) sup(p, 1) for b in ['ICU \u2013 prioritize delirium prevention/management, pain, appropriate sedation, sleep, early mobilization, communication and family involvement.', 'Neurological illness \u2013 pay particular attention to cognition, seizures, mood, psychosis, behavioural change and neurological\u2013psychiatric overlap.', 'Oncology and palliative care \u2013 address depression, anxiety, delirium, pain, existential distress, suicidality, communication of prognosis and goals of care.', 'Transplantation \u2013 assess psychiatric history, substance use, cognition, coping, adherence, social support and understanding of post-transplant demands.', 'Chronic medical illness \u2013 address coping, behavioural change, adherence, disability, family burden and recurrent psychological distress.']: bullet(b) h2('3.10 Discharge Planning and Follow-up') for b in ['Confirm whether the psychiatric syndrome has resolved or requires continued treatment.', 'Review the ongoing indication for psychotropic medication and adverse effects.', 'Reassess suicide risk where relevant.', 'Perform medication reconciliation and provide clear instructions.', 'Provide patient and family education.', 'Arrange appropriate psychiatric and medical follow-up.', 'Plan relapse prevention and substance-use interventions when appropriate.', 'Link the patient with community psychiatric and rehabilitation services when required.', 'Do not allow a psychotropic medication started for an acute hospital problem to become an indefinite prescription without reassessment.']: bullet(b) h2('3.11 Patient-Centred Care and Outcomes') para('The goal is not merely control of psychiatric symptoms but recovery of the whole person.', sb=2, sa=3) for b in ['Reduce suffering and distress.', 'Restore functioning and autonomy.', 'Improve treatment adherence and medical recovery.', 'Reduce complications and unnecessary healthcare utilization.', 'Improve quality of life.', 'Support the family and caregivers.', 'Ensure continuity of psychiatric and medical care.']: bullet(b) para('A useful closing principle: Treat the patient as a whole, not the psychiatric symptom in isolation.', sb=3, sa=4, bold=True) # ══════════════════════════════════════════════════════════════════════════════ # 4. PREVENTION h1('4. PREVENTION, DISCHARGE PLANNING AND FOLLOW-UP') p = doc.add_paragraph() p.paragraph_format.space_before = Pt(2); p.paragraph_format.space_after = Pt(4) r1 = p.add_run('Prevention begins at admission. High-risk patients (elderly, cognitive impairment, polypharmacy, prior psychiatric history) should be identified early. The '); r1.font.name = 'Times New Roman'; r1.font.size = Pt(12) r2 = p.add_run('Hospital Elder Life Programme (HELP)'); r2.bold = True; r2.font.name = 'Times New Roman'; r2.font.size = Pt(12) r3 = p.add_run(' has the strongest evidence for delirium prevention.'); r3.font.name = 'Times New Roman'; r3.font.size = Pt(12) sup(p, 8) para('Discharge planning should begin at admission and include: confirmation of psychiatric diagnosis and treatment plan, medication reconciliation, patient and family psychoeducation, and clear follow-up arrangements between psychiatric and medical services.', sb=2, sa=6) # ══════════════════════════════════════════════════════════════════════════════ # 5. INDIAN CONTEXT h1('5. CONSULTATION-LIAISON PSYCHIATRY IN THE INDIAN CONTEXT') p = para('C-L Psychiatry in India began in 1933, with referral rates still as low as 0.01\u20133.6% of inpatients in many centres, highlighting a persistent recognition\u2013referral gap.', sb=2, sa=4) sup(p, 3) p = doc.add_paragraph() p.paragraph_format.space_before = Pt(2); p.paragraph_format.space_after = Pt(6) r1 = p.add_run('Jacob, Kuruvilla and Zachariah (Christian Medical College, Vellore) have argued that psychiatric training confined to tertiary settings generates a '); r1.font.name = 'Times New Roman'; r1.font.size = Pt(12) r2 = p.add_run('\u201ccategory fallacy\u201d'); r2.italic = True; r2.font.name = 'Times New Roman'; r2.font.size = Pt(12) r3 = p.add_run(' \u2014 the unwarranted assumption that specialist psychiatric categories carry the same meaning across different clinical contexts \u2014 and that current training deskills physicians in recognising common presentations in general hospital settings. They advocate for a liaison approach grounded in local context, with training situated in primary and secondary care settings.'); r3.font.name = 'Times New Roman'; r3.font.size = Pt(12) sup(p, 10) # ══════════════════════════════════════════════════════════════════════════════ # 6. CHALLENGES AND FUTURE DIRECTIONS h1('6. CHALLENGES AND FUTURE DIRECTIONS') h2('Challenges') for b in ['Low referral rates and under-recognition of psychiatric morbidity in general wards.', 'Professional stigma towards mental illness reducing willingness to refer.', 'Inadequate staffing and no formal C-L subspecialty recognition in India.', 'Psychiatric training confined to specialist tertiary settings, disempowering general physicians.']: bullet(b) h2('Future Directions') for b in ['Structured, accredited C-L Psychiatry fellowship programmes at national centres.', 'Integration of C-L Psychiatry into undergraduate and postgraduate curricula of all medical and nursing disciplines.', 'Shift from reactive (on-call referral) to proactive C-L models with regular ward rounds.', 'Telepsychiatry-based C-L services to expand reach to district and under-resourced hospitals.']: bullet(b) # ══════════════════════════════════════════════════════════════════════════════ # 7. CONCLUSION h1('7. CONCLUSION') para('Psychiatric disorders in medically ill patients are common, under-recognised and treatable. Effective C-L Psychiatry demands a systematic, biopsychosocial and patient-centred approach encompassing early recognition, medical stabilisation, psychological intervention and multidisciplinary collaboration. In India, realising this potential requires expansion of C-L services, reform of psychiatric training across all medical disciplines and investment in collaborative models of care grounded in local context and evidence.', sb=2, sa=8) q = doc.add_paragraph() q.alignment = WD_ALIGN_PARAGRAPH.CENTER q.paragraph_format.space_before = Pt(6); q.paragraph_format.space_after = Pt(2) qr = q.add_run('\u201cThe dominant model of disease today is biomedical... it leaves no room within its framework\nfor the social, psychological and behavioural dimensions of illness.\u201d') qr.italic = True; qr.font.name = 'Times New Roman'; qr.font.size = Pt(11) attr = doc.add_paragraph() attr.alignment = WD_ALIGN_PARAGRAPH.CENTER attr.paragraph_format.space_before = Pt(2); attr.paragraph_format.space_after = Pt(8) ar = attr.add_run('\u2014 George Engel, 1977') ar.italic = True; ar.font.name = 'Times New Roman'; ar.font.size = Pt(11) closing = doc.add_paragraph() closing.alignment = WD_ALIGN_PARAGRAPH.CENTER closing.paragraph_format.space_before = Pt(4); closing.paragraph_format.space_after = Pt(16) cr = closing.add_run('Consultation-Liaison Psychiatry exists precisely to correct this \u2014 bridging the gap between mind and body, between psychiatry and medicine, and between the diagnosis and the whole person.') cr.italic = True; cr.font.name = 'Times New Roman'; cr.font.size = Pt(12) # ══════════════════════════════════════════════════════════════════════════════ # REFERENCES (10 only) h1('REFERENCES') 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):116\u2013126.', '3. Dua D, Grover S. Profile of patients seen in Consultation-Liaison Psychiatry in India: A systematic review. Indian J Psychiatry. 2020;62(3):255\u2013271.', '4. National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Clinical guideline CG103. London: NICE; 2019.', '5. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the Confusion Assessment Method. Ann Intern Med. 1990;113(12):941\u2013948.', '6. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, et al. Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). JAMA. 2001;286(21):2703\u20132710.', '7. Appelbaum PS, Grisso T. Assessing patients\u2019 capacities to consent to treatment. N Engl J Med. 1988;319(25):1635\u20131638.', '8. Crone C, Fochtmann LJ, Ahmed I, Balas MC, Boland R, Escobar JI, et al. The American Psychiatric Association practice guideline on delirium in adult patients. Am J Psychiatry. 2025;182(1):1\u201386.', '9. Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for assessment and management of patients at risk for suicide. Washington, DC: VA/DoD; 2024.', '10. Jacob KS, Kuruvilla A, Zachariah A. Psychiatric curriculum for training physicians. Natl Med J India. 2019;32(1):32\u201337.', ] for ref in refs: ref_line(ref) doc.save(out) print('Saved:', out) PYEOF