This document provides an overview of competency assessment for mental health patients. It discusses key concepts like mental health, mental disorders, mental illness, and the impacts of mental disorders. It also covers competence vs capacity, fluctuating capacity, and the components of capacity evaluation. The document outlines standards for assessing decision making capacity, including a 2 stage functional test. It discusses who should perform competency assessments, when they should be done, why, and how using tools like MacCAT-T and MacCAT-CR. It notes limitations of competency assessment tools and the legal variations in competency definitions.
Vitamin B12 deficiency is a common cause of nutritional myelopathy. It presents as slowly progressive myelopathy involving the posterior and lateral spinal cord. Peripheral neuropathy and neuropsychiatric manifestations may also occur. Diagnosis is based on low vitamin B12 levels and elevated methylmalonic acid and homocysteine levels. Treatment involves lifelong parenteral vitamin B12 replacement therapy. Neurological symptoms may improve over months following treatment. Nitrous oxide exposure can also cause vitamin B12 deficient myelopathy, especially in individuals with underlying B12 deficiency.
This case report describes an adult female patient presenting with fever, cough, joint pain, and skin rash. Laboratory tests revealed elevated white blood cell count with neutrophilia. Imaging showed pulmonary nodules. She fulfilled criteria for adult onset Still's disease (AOSD), which can involve the lungs in 50% of cases. AOSD is diagnosed based on Yamaguchi or Fautrel criteria, which this patient met. Treatment involves corticosteroids and immunosuppressants to control the abnormal cytokine levels caused by AOSD. Pulmonary involvement requires close monitoring for serious complications like acute respiratory distress syndrome.
Brain tumors are a diverse group of neoplasms that arise from different cells within the central nervous system. They are named based on their location and cell of origin. Common types include gliomas, meningiomas, and ependymomas. Tumors are classified based on location, morphology, and biological behavior. Symptoms depend on the location of the tumor and can include increased intracranial pressure, focal neurological deficits, and seizures. Diagnosis involves imaging and biopsy. Treatment options are surgery, radiation, chemotherapy, and targeted therapies depending on tumor type and grade.
This document discusses various central nervous system infections that can be seen on CT and MRI imaging. It covers different types of infections including bacterial, viral, fungal and parasitic. It describes the routes of spread and typical presentations of these infections. Specific pathogens are discussed along with the imaging appearance of associated conditions like meningitis, encephalitis, brain abscesses and more. Common findings on CT and MRI are presented with examples of imaging findings for infections caused by organisms like herpes simplex virus, tuberculosis, HIV and fungi such as Cryptococcus.
This document provides information about brain abscesses:
1. Brain abscesses usually begin as a focal intracranial infection that evolves into a collection of pus surrounded by a capsule. Common causative agents are streptococci, staphylococci, and various gram-negative bacteria.
2. Brain abscesses most often occur in the first four decades of life and are more common in males. Location is commonly the corticomedullary junction. Presentation includes headache, fever, seizures, and altered mental status.
3. Treatment involves surgical drainage, excision, and long-term antibiotics. Differential diagnosis includes tuberculomas, which appear as round or lobulated masses
Rheumatic fever is an inflammatory disease that can affect the heart, joints, nervous system and skin following a streptococcus infection such as strep throat. It primarily affects children aged 5 to 15 years old. Rheumatoid arthritis is an autoimmune disease where the immune system attacks the body's own tissues, causing chronic inflammation of the joints and surrounding tissues. It can also affect other organs and is considered a systemic illness. Both conditions involve inflammation and can damage tissues over time.
This presentation briefly summarizes pathophysiology, clinical features, diagnosis and treatment of different types of tuberculosis of brain and spinal cord.
VIRAL PNEUMONIA BY DR BASHIR AHMED DAR ASSOCIATE PROFESSOR MEDICINE SOPORE KA...Prof Dr Bashir Ahmed Dar
DR BASHIR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIR PRESENTLY WORKING IN MALAYSIA TEACHING MEDICAL STUDENTS THE ART OF TREATING PATIENTS SPEAKS ABOUT THE IMPORTANCE OF HISTORY TAKING.MEDICAL STUDENTS AND DOCTORS should probe more deeply WHILE TAKING HISTORY OF A PATIENT as it gives the useful information in formulating a diagnosis and providing medical care to the patient.
Vitamin B12 deficiency is a common cause of nutritional myelopathy. It presents as slowly progressive myelopathy involving the posterior and lateral spinal cord. Peripheral neuropathy and neuropsychiatric manifestations may also occur. Diagnosis is based on low vitamin B12 levels and elevated methylmalonic acid and homocysteine levels. Treatment involves lifelong parenteral vitamin B12 replacement therapy. Neurological symptoms may improve over months following treatment. Nitrous oxide exposure can also cause vitamin B12 deficient myelopathy, especially in individuals with underlying B12 deficiency.
This case report describes an adult female patient presenting with fever, cough, joint pain, and skin rash. Laboratory tests revealed elevated white blood cell count with neutrophilia. Imaging showed pulmonary nodules. She fulfilled criteria for adult onset Still's disease (AOSD), which can involve the lungs in 50% of cases. AOSD is diagnosed based on Yamaguchi or Fautrel criteria, which this patient met. Treatment involves corticosteroids and immunosuppressants to control the abnormal cytokine levels caused by AOSD. Pulmonary involvement requires close monitoring for serious complications like acute respiratory distress syndrome.
Brain tumors are a diverse group of neoplasms that arise from different cells within the central nervous system. They are named based on their location and cell of origin. Common types include gliomas, meningiomas, and ependymomas. Tumors are classified based on location, morphology, and biological behavior. Symptoms depend on the location of the tumor and can include increased intracranial pressure, focal neurological deficits, and seizures. Diagnosis involves imaging and biopsy. Treatment options are surgery, radiation, chemotherapy, and targeted therapies depending on tumor type and grade.
This document discusses various central nervous system infections that can be seen on CT and MRI imaging. It covers different types of infections including bacterial, viral, fungal and parasitic. It describes the routes of spread and typical presentations of these infections. Specific pathogens are discussed along with the imaging appearance of associated conditions like meningitis, encephalitis, brain abscesses and more. Common findings on CT and MRI are presented with examples of imaging findings for infections caused by organisms like herpes simplex virus, tuberculosis, HIV and fungi such as Cryptococcus.
This document provides information about brain abscesses:
1. Brain abscesses usually begin as a focal intracranial infection that evolves into a collection of pus surrounded by a capsule. Common causative agents are streptococci, staphylococci, and various gram-negative bacteria.
2. Brain abscesses most often occur in the first four decades of life and are more common in males. Location is commonly the corticomedullary junction. Presentation includes headache, fever, seizures, and altered mental status.
3. Treatment involves surgical drainage, excision, and long-term antibiotics. Differential diagnosis includes tuberculomas, which appear as round or lobulated masses
Rheumatic fever is an inflammatory disease that can affect the heart, joints, nervous system and skin following a streptococcus infection such as strep throat. It primarily affects children aged 5 to 15 years old. Rheumatoid arthritis is an autoimmune disease where the immune system attacks the body's own tissues, causing chronic inflammation of the joints and surrounding tissues. It can also affect other organs and is considered a systemic illness. Both conditions involve inflammation and can damage tissues over time.
This presentation briefly summarizes pathophysiology, clinical features, diagnosis and treatment of different types of tuberculosis of brain and spinal cord.
VIRAL PNEUMONIA BY DR BASHIR AHMED DAR ASSOCIATE PROFESSOR MEDICINE SOPORE KA...Prof Dr Bashir Ahmed Dar
DR BASHIR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIR PRESENTLY WORKING IN MALAYSIA TEACHING MEDICAL STUDENTS THE ART OF TREATING PATIENTS SPEAKS ABOUT THE IMPORTANCE OF HISTORY TAKING.MEDICAL STUDENTS AND DOCTORS should probe more deeply WHILE TAKING HISTORY OF A PATIENT as it gives the useful information in formulating a diagnosis and providing medical care to the patient.
This document discusses various tumors and lesions of the skull. It describes benign tumors such as osteoma, hemangioma, dermoid tumors, chondromas, meningiomas, and aneurysmal bone cysts. It also discusses malignant tumors including bone metastases, chondrosarcoma, osteogenic sarcoma, and fibrosarcoma. Additionally, it covers some non-neoplastic lesions such as Paget's disease, Langerhans cell histiocytosis, fibrous dysplasia, and sinus pericranii. For each condition, it provides details on presentation, imaging appearance, pathology, and treatment options.
Cystic fibrosis is an inherited disorder that affects the lungs and digestive system. It is caused by mutations in the CFTR gene that result in thick, sticky mucus buildup in organs. Symptoms include persistent lung infections, problems digesting food, and other issues. Treatment focuses on loosening mucus, treating infections, improving nutrition, and managing symptoms, though there is no cure currently. Screening at birth and ongoing testing monitors disease progression and treatment effectiveness.
Lyme neuroborreliosis (LNB) is an infectious disorder of the nervous system caused by the Borrelia burgdorferi bacterium transmitted through tick bites. Common symptoms include headache, fatigue, neck and back pain, joint pain and swelling, and an EM rash. Diagnosis involves detecting B. burgdorferi antibodies in serum and cerebrospinal fluid. Differential diagnoses include viral meningitis and multiple sclerosis. Treatment options include oral doxycycline or intravenous ceftriaxone or cefotaxime antibiotics. LNB has also been connected to neurological conditions like anxiety, depression and schizophrenia.
The lower respiratory system, or lower respiratory tract, consists of the trachea, the bronchi and bronchioles, and the alveoli, which make up the lungs. These structures pull in air from the upper respiratory system, absorb the oxygen, and release carbon dioxide in exchange.
this is detailed study on lower respiratory diseases
please comment
thank you
Primary CNS Vasculitis - diagnostic and therapeutic challengesDiana Girnita
1. This 38-year-old male presented with severe frontal headache, speech difficulties, weakness, and confusion. Imaging showed multiple small white matter lesions that progressed significantly over 4 days.
2. Cerebrospinal fluid analysis showed elevated white blood cells and protein with positive oligoclonal bands. Infectious and autoimmune workups were negative.
3. Brain biopsy showed early acute ischemic changes and a microscopic focus of acute infarction without evidence of vasculitis, inflammation, or other pathologies. This is consistent with a diagnosis of primary central nervous system vasculitis.
This document summarizes the epidemiology, mechanisms, and myths surrounding firearm injuries. It discusses that while high velocity was once thought to cause more damage, studies show bullet fragmentation and type of tissue are more important factors. It also debunks myths such as the "sterility" of bullets and that temporary cavities determine tissue disruption. The role of emergency physicians is to carefully document wounds before intervention to aid legal proceedings.
This document discusses central nervous system vasculitis, including its classification, diagnosis, and treatment. It covers primary angiitis of the CNS and secondary causes. Diagnosis is challenging due to non-specific symptoms and lack of sensitive tests. Evaluation involves clinical assessment, CSF analysis, neuroimaging, and cerebral angiography. Treatment depends on the specific type but often involves immunosuppressants like cyclophosphamide with glucocorticoids. Pathology evaluation can help in difficult cases but has low sensitivity.
A POWER POINT PRESENTATION BY DR.SANGEETA CHOWDHRY & DR.SUNIL SHARMA, DEPARTMENT OF FORENSIC MEDICINE & TOXICOLOGY, GOVT. MEDICAL COLLEGE, JAMMU (JAMMU AND KASHMIR)
The document discusses smoking-related interstitial lung diseases. Cigarette smoke can injure lung cells through oxidative stress and inflammation, potentially leading to fibrosis in some smokers. Respiratory bronchiolitis-associated interstitial lung disease (RB-ILD) is a rare smoking-related lung condition seen in heavy smokers, with symptoms of cough and wheezing. Physiologic testing may show obstruction, restriction, or normal results. Radiographs often appear normal or show subtle reticulation, especially in lung bases.
This document provides an overview of pulmonary renal syndromes (PRS), which refers to the combination of diffuse alveolar hemorrhage and rapidly progressive glomerulonephritis. PRS can be caused by a variety of conditions and represents a major diagnostic and treatment challenge with mortality rates reaching 25-50% if not addressed early. The document discusses the classification, presentation, diagnostic workup, and management of PRS, and provides three case examples to illustrate the approach to diagnosis and treatment.
ACUTE FLACCID PARALYSIS
Kanishk Deep Sharma
definition
Sudden onset of weakness or paralysis over a period of 15 days in a patient aged less than 15 years age
Ddx
poliomyelitis
Non enveloped, positive stranded RNA virus
Genus ENTEROVIRUS
family PICORNAVIRIDAE
3 antigenically distinct serotypes:-1,2,3
pathogenesis
•Entry into mouth.
•Replication in pharynx, GI tract, Local Lymphatic.
•Hematologic spread to lymphatic and central nervous system.
•Viral spread along nerve fibers.
•Destruction of motor neurons
Immunity
Initially protected by maternal antibodies for first few weeks of life
Types
Asymptomatic
Abortive Polio
Non-paralytic
Paralytic
Spinal
Bulbar
Bulbospinal
Cf- asymptomatic
• Accounts for approximately 95% of cases
• Virus stays in intestinal tract and does not attack the nerves
• Virus is shed in the stool so infected individual is still able to infect others
Cf-abortive
•Does not lead to paralysis
•Mild symptoms seen such as sore throat, fever, n/v, diarrhea, constipation ( Minor illness)
•Most recover in <1><5><4days />95% immune after 3 doses
Immunity probably lifelong
Inactivated polio vaccine
Humoral immunity and to some extend pharyngeal immunity
Duration of immunity not known with certainty
Strategies for polio eradication
Global Polio Eradication Initiative launched in 1988
Polio cases have decreased by over 99%
1988 - >125 countries
In 2010 - 4 countries
The remaining countries are Afghanistan, India, Nigeria and Pakistan
Core strategies
High infant immunization coverage with four doses of oral poliovirus vaccine (OPV) in the first year of life
Supplementary doses of OPV to all children under five years of age during national immunization days
AFP surveillance among children under fifteen years of age
Targeted “mop-up” campaigns once wild poliovirus transmission is limited to a specific focal area.
Immunisation in india
Polio Vaccination under UIP
OPVº birth
OPV1 6 wks
OPV2 10 wks
OPV3 14 wks
OPV4 16-24 Months
Pulse Polio Immunization (PPI)
The supplementary immunization activities (SIAs) in India launched in 1995
Irrespective of the immunisation status
Usually Dec & Jan – Peak transmission
aim
Providing additional OPV doses to every child aged <5><15 years who have had the onset of flaccid paralysis within the preceding 60 days
All cases that are found are investigated immediately, with collection of two stool specimens before administration of OPV.
This document provides information on different types of headaches, including their causes, symptoms, and characteristics. It discusses primary headaches like tension headaches, which most commonly affect women, and migraines, which often affect younger females. It also covers secondary headaches that can result from issues like infections, head injuries, or vascular disorders. Specific headache types like clusters headaches that predominantly impact adolescent males are also outlined. The document details factors like headache location, duration, frequency, and associated symptoms that can provide clues to determining the underlying headache type and cause.
HIV can infect the nervous system at any stage, potentially involving the brain, spinal cord, nerves or muscles. Common neurological syndromes include meningitis, dementia, peripheral neuropathies and myelopathies. Evaluation involves consideration of HIV stage and status, labs including spinal fluid analysis, imaging and testing for secondary infections. Treatment depends on identified primary or opportunistic causes but may include antiretrovirals, immune therapies or symptom management. Prognosis depends on specific syndrome and ability to treat any identified underlying cause.
Radiation injury and countermeasures: ALOK SONIAlok kumar Soni
Radiation can be ionizing or non-ionizing, with ionizing radiation including alpha, beta, gamma, and neutron radiation capable of damaging cells. Radiation exposure is measured in units like the gray (Gy) and sievert (Sv) which account for both energy absorbed and biological effects. Radiation can directly damage DNA and indirectly generate reactive oxygen species, leading to acute effects above 1 Gy or chronic effects like cancer. Potential countermeasures include radioprotectors administered before exposure, mitigators after exposure, and therapeutics for symptoms. Promising agents include amifostine, 5-AED, G-CSF and HDAC inhibitors, but developing safe and effective countermeasures remains an ongoing challenge.
This document presents a case of a 46-year-old male patient with complaints of exertional breathlessness, cough and fatigue for 3 months. He has a history of working in a poultry farm for 20 years. Differential diagnoses include hypersensitivity pneumonitis, chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis and community-acquired pneumonia. The document then discusses hypersensitivity pneumonitis in detail, covering epidemiology, pathogenesis, clinical presentations, diagnostic approach and treatment, which is primarily antigen avoidance and corticosteroids.
Hypersensitivity pneumonitis (HP) is an interstitial lung disease caused by repeated inhalation and sensitization to various antigens. It affects the lung interstitium and has variable clinical presentations. Common causative agents include avian and microbial antigens. The immunopathogenesis involves both humoral and cellular immune responses. HP is classified as acute, subacute, or chronic based on clinical manifestations. Diagnosis relies on a history of antigen exposure, precipitating antibodies, clinical features, imaging, and pathology. Chest radiography and HRCT are important diagnostic tools, with HRCT showing findings like nodules, ground glass opacity, and fibrosis that vary depending on the disease stage.
Meningitis is an inflammation of the meninges that can cause significant morbidity and mortality, especially in children. The most common causes are bacterial and include Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis. Symptoms vary by age but may include fever, headache, nausea, and neck stiffness. Lumbar puncture and CSF analysis are important for diagnosis. Empiric antibiotic therapy should cover the most common pathogens. Complications can include neurological deficits, hearing loss, seizures, and hydrocephalus. Prevention through immunization against preventable causes such as Hib, meningococcus, and pneumococcus can reduce the burden of disease.
Progressive Multifocal Leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by the JC polyomavirus that occurs almost exclusively in immunosuppressed individuals. It presents with focal neurological deficits and MRI shows multifocal white matter lesions. There is no effective treatment, but starting antiretroviral therapy for HIV-infected patients can improve outcomes.
Tb meningitis presentation david & marshaDavid Paraide
Tuberculosis meningitis is an inflammatory disease of the membranes surrounding the brain and spinal cord caused by the Mycobacterium tuberculosis bacteria. The bacteria typically enter the body through inhalation and can spread from the lungs to the central nervous system. Symptoms include headache, vomiting, and neck stiffness. Diagnosis involves lumbar puncture, MRI or CT scan. Treatment requires a prolonged multi-drug antibiotic regimen along with physiotherapy. Outcomes depend on early diagnosis and treatment, with complications including seizures, brain damage and death if left untreated. Prevention involves BCG vaccination of high-risk groups like children and healthcare workers.
Tuberculous infection of the central nervous system (CNS) can occur via hematogenous spread or direct extension from a local infection. It most commonly manifests as tuberculous meningitis or tuberculomas. Tuberculous meningitis involves thick exudate in the subarachnoid space and can lead to hydrocephalus or ischemic infarcts. Tuberculomas appear as ring-enhancing lesions on imaging. Pott's disease is spinal tuberculosis that causes vertebral body collapse and kyphosis. Management involves antituberculous medications for at least 6-9 months.
This document discusses assessment of psychological problems in patients with neurological disorders. It notes that assessment may help with differential diagnosis or identifying treatable psychiatric conditions. Assessing psychological symptoms can be complicated by overlap with neurological symptoms. Clinical interviews and observations can be aided by checklists of psychological symptoms. Self-report instruments and reports from family members can also provide information, especially for patients with cognitive impairments. The document discusses several methods and instruments used to assess conditions like depression, anxiety, apathy, psychosis, and more.
1) Capacity refers to one's ability to understand treatment information and foreseeable consequences of decisions. Capacity is decision-specific and can change over time.
2) Health professionals determine a patient's capacity. Everyone is presumed capable unless determined otherwise. Tests of capacity evaluate understanding of why treatment is proposed, what the treatment is, and consequences of decisions.
3) When a patient lacks capacity, a substitute decision maker may be an appointed representative or family. Prior capable wishes must be followed if relevant to the circumstances. Without prior wishes, the substitute considers the patient's values and whether treatment benefits outweigh risks.
This document discusses various tumors and lesions of the skull. It describes benign tumors such as osteoma, hemangioma, dermoid tumors, chondromas, meningiomas, and aneurysmal bone cysts. It also discusses malignant tumors including bone metastases, chondrosarcoma, osteogenic sarcoma, and fibrosarcoma. Additionally, it covers some non-neoplastic lesions such as Paget's disease, Langerhans cell histiocytosis, fibrous dysplasia, and sinus pericranii. For each condition, it provides details on presentation, imaging appearance, pathology, and treatment options.
Cystic fibrosis is an inherited disorder that affects the lungs and digestive system. It is caused by mutations in the CFTR gene that result in thick, sticky mucus buildup in organs. Symptoms include persistent lung infections, problems digesting food, and other issues. Treatment focuses on loosening mucus, treating infections, improving nutrition, and managing symptoms, though there is no cure currently. Screening at birth and ongoing testing monitors disease progression and treatment effectiveness.
Lyme neuroborreliosis (LNB) is an infectious disorder of the nervous system caused by the Borrelia burgdorferi bacterium transmitted through tick bites. Common symptoms include headache, fatigue, neck and back pain, joint pain and swelling, and an EM rash. Diagnosis involves detecting B. burgdorferi antibodies in serum and cerebrospinal fluid. Differential diagnoses include viral meningitis and multiple sclerosis. Treatment options include oral doxycycline or intravenous ceftriaxone or cefotaxime antibiotics. LNB has also been connected to neurological conditions like anxiety, depression and schizophrenia.
The lower respiratory system, or lower respiratory tract, consists of the trachea, the bronchi and bronchioles, and the alveoli, which make up the lungs. These structures pull in air from the upper respiratory system, absorb the oxygen, and release carbon dioxide in exchange.
this is detailed study on lower respiratory diseases
please comment
thank you
Primary CNS Vasculitis - diagnostic and therapeutic challengesDiana Girnita
1. This 38-year-old male presented with severe frontal headache, speech difficulties, weakness, and confusion. Imaging showed multiple small white matter lesions that progressed significantly over 4 days.
2. Cerebrospinal fluid analysis showed elevated white blood cells and protein with positive oligoclonal bands. Infectious and autoimmune workups were negative.
3. Brain biopsy showed early acute ischemic changes and a microscopic focus of acute infarction without evidence of vasculitis, inflammation, or other pathologies. This is consistent with a diagnosis of primary central nervous system vasculitis.
This document summarizes the epidemiology, mechanisms, and myths surrounding firearm injuries. It discusses that while high velocity was once thought to cause more damage, studies show bullet fragmentation and type of tissue are more important factors. It also debunks myths such as the "sterility" of bullets and that temporary cavities determine tissue disruption. The role of emergency physicians is to carefully document wounds before intervention to aid legal proceedings.
This document discusses central nervous system vasculitis, including its classification, diagnosis, and treatment. It covers primary angiitis of the CNS and secondary causes. Diagnosis is challenging due to non-specific symptoms and lack of sensitive tests. Evaluation involves clinical assessment, CSF analysis, neuroimaging, and cerebral angiography. Treatment depends on the specific type but often involves immunosuppressants like cyclophosphamide with glucocorticoids. Pathology evaluation can help in difficult cases but has low sensitivity.
A POWER POINT PRESENTATION BY DR.SANGEETA CHOWDHRY & DR.SUNIL SHARMA, DEPARTMENT OF FORENSIC MEDICINE & TOXICOLOGY, GOVT. MEDICAL COLLEGE, JAMMU (JAMMU AND KASHMIR)
The document discusses smoking-related interstitial lung diseases. Cigarette smoke can injure lung cells through oxidative stress and inflammation, potentially leading to fibrosis in some smokers. Respiratory bronchiolitis-associated interstitial lung disease (RB-ILD) is a rare smoking-related lung condition seen in heavy smokers, with symptoms of cough and wheezing. Physiologic testing may show obstruction, restriction, or normal results. Radiographs often appear normal or show subtle reticulation, especially in lung bases.
This document provides an overview of pulmonary renal syndromes (PRS), which refers to the combination of diffuse alveolar hemorrhage and rapidly progressive glomerulonephritis. PRS can be caused by a variety of conditions and represents a major diagnostic and treatment challenge with mortality rates reaching 25-50% if not addressed early. The document discusses the classification, presentation, diagnostic workup, and management of PRS, and provides three case examples to illustrate the approach to diagnosis and treatment.
ACUTE FLACCID PARALYSIS
Kanishk Deep Sharma
definition
Sudden onset of weakness or paralysis over a period of 15 days in a patient aged less than 15 years age
Ddx
poliomyelitis
Non enveloped, positive stranded RNA virus
Genus ENTEROVIRUS
family PICORNAVIRIDAE
3 antigenically distinct serotypes:-1,2,3
pathogenesis
•Entry into mouth.
•Replication in pharynx, GI tract, Local Lymphatic.
•Hematologic spread to lymphatic and central nervous system.
•Viral spread along nerve fibers.
•Destruction of motor neurons
Immunity
Initially protected by maternal antibodies for first few weeks of life
Types
Asymptomatic
Abortive Polio
Non-paralytic
Paralytic
Spinal
Bulbar
Bulbospinal
Cf- asymptomatic
• Accounts for approximately 95% of cases
• Virus stays in intestinal tract and does not attack the nerves
• Virus is shed in the stool so infected individual is still able to infect others
Cf-abortive
•Does not lead to paralysis
•Mild symptoms seen such as sore throat, fever, n/v, diarrhea, constipation ( Minor illness)
•Most recover in <1><5><4days />95% immune after 3 doses
Immunity probably lifelong
Inactivated polio vaccine
Humoral immunity and to some extend pharyngeal immunity
Duration of immunity not known with certainty
Strategies for polio eradication
Global Polio Eradication Initiative launched in 1988
Polio cases have decreased by over 99%
1988 - >125 countries
In 2010 - 4 countries
The remaining countries are Afghanistan, India, Nigeria and Pakistan
Core strategies
High infant immunization coverage with four doses of oral poliovirus vaccine (OPV) in the first year of life
Supplementary doses of OPV to all children under five years of age during national immunization days
AFP surveillance among children under fifteen years of age
Targeted “mop-up” campaigns once wild poliovirus transmission is limited to a specific focal area.
Immunisation in india
Polio Vaccination under UIP
OPVº birth
OPV1 6 wks
OPV2 10 wks
OPV3 14 wks
OPV4 16-24 Months
Pulse Polio Immunization (PPI)
The supplementary immunization activities (SIAs) in India launched in 1995
Irrespective of the immunisation status
Usually Dec & Jan – Peak transmission
aim
Providing additional OPV doses to every child aged <5><15 years who have had the onset of flaccid paralysis within the preceding 60 days
All cases that are found are investigated immediately, with collection of two stool specimens before administration of OPV.
This document provides information on different types of headaches, including their causes, symptoms, and characteristics. It discusses primary headaches like tension headaches, which most commonly affect women, and migraines, which often affect younger females. It also covers secondary headaches that can result from issues like infections, head injuries, or vascular disorders. Specific headache types like clusters headaches that predominantly impact adolescent males are also outlined. The document details factors like headache location, duration, frequency, and associated symptoms that can provide clues to determining the underlying headache type and cause.
HIV can infect the nervous system at any stage, potentially involving the brain, spinal cord, nerves or muscles. Common neurological syndromes include meningitis, dementia, peripheral neuropathies and myelopathies. Evaluation involves consideration of HIV stage and status, labs including spinal fluid analysis, imaging and testing for secondary infections. Treatment depends on identified primary or opportunistic causes but may include antiretrovirals, immune therapies or symptom management. Prognosis depends on specific syndrome and ability to treat any identified underlying cause.
Radiation injury and countermeasures: ALOK SONIAlok kumar Soni
Radiation can be ionizing or non-ionizing, with ionizing radiation including alpha, beta, gamma, and neutron radiation capable of damaging cells. Radiation exposure is measured in units like the gray (Gy) and sievert (Sv) which account for both energy absorbed and biological effects. Radiation can directly damage DNA and indirectly generate reactive oxygen species, leading to acute effects above 1 Gy or chronic effects like cancer. Potential countermeasures include radioprotectors administered before exposure, mitigators after exposure, and therapeutics for symptoms. Promising agents include amifostine, 5-AED, G-CSF and HDAC inhibitors, but developing safe and effective countermeasures remains an ongoing challenge.
This document presents a case of a 46-year-old male patient with complaints of exertional breathlessness, cough and fatigue for 3 months. He has a history of working in a poultry farm for 20 years. Differential diagnoses include hypersensitivity pneumonitis, chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis and community-acquired pneumonia. The document then discusses hypersensitivity pneumonitis in detail, covering epidemiology, pathogenesis, clinical presentations, diagnostic approach and treatment, which is primarily antigen avoidance and corticosteroids.
Hypersensitivity pneumonitis (HP) is an interstitial lung disease caused by repeated inhalation and sensitization to various antigens. It affects the lung interstitium and has variable clinical presentations. Common causative agents include avian and microbial antigens. The immunopathogenesis involves both humoral and cellular immune responses. HP is classified as acute, subacute, or chronic based on clinical manifestations. Diagnosis relies on a history of antigen exposure, precipitating antibodies, clinical features, imaging, and pathology. Chest radiography and HRCT are important diagnostic tools, with HRCT showing findings like nodules, ground glass opacity, and fibrosis that vary depending on the disease stage.
Meningitis is an inflammation of the meninges that can cause significant morbidity and mortality, especially in children. The most common causes are bacterial and include Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis. Symptoms vary by age but may include fever, headache, nausea, and neck stiffness. Lumbar puncture and CSF analysis are important for diagnosis. Empiric antibiotic therapy should cover the most common pathogens. Complications can include neurological deficits, hearing loss, seizures, and hydrocephalus. Prevention through immunization against preventable causes such as Hib, meningococcus, and pneumococcus can reduce the burden of disease.
Progressive Multifocal Leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by the JC polyomavirus that occurs almost exclusively in immunosuppressed individuals. It presents with focal neurological deficits and MRI shows multifocal white matter lesions. There is no effective treatment, but starting antiretroviral therapy for HIV-infected patients can improve outcomes.
Tb meningitis presentation david & marshaDavid Paraide
Tuberculosis meningitis is an inflammatory disease of the membranes surrounding the brain and spinal cord caused by the Mycobacterium tuberculosis bacteria. The bacteria typically enter the body through inhalation and can spread from the lungs to the central nervous system. Symptoms include headache, vomiting, and neck stiffness. Diagnosis involves lumbar puncture, MRI or CT scan. Treatment requires a prolonged multi-drug antibiotic regimen along with physiotherapy. Outcomes depend on early diagnosis and treatment, with complications including seizures, brain damage and death if left untreated. Prevention involves BCG vaccination of high-risk groups like children and healthcare workers.
Tuberculous infection of the central nervous system (CNS) can occur via hematogenous spread or direct extension from a local infection. It most commonly manifests as tuberculous meningitis or tuberculomas. Tuberculous meningitis involves thick exudate in the subarachnoid space and can lead to hydrocephalus or ischemic infarcts. Tuberculomas appear as ring-enhancing lesions on imaging. Pott's disease is spinal tuberculosis that causes vertebral body collapse and kyphosis. Management involves antituberculous medications for at least 6-9 months.
This document discusses assessment of psychological problems in patients with neurological disorders. It notes that assessment may help with differential diagnosis or identifying treatable psychiatric conditions. Assessing psychological symptoms can be complicated by overlap with neurological symptoms. Clinical interviews and observations can be aided by checklists of psychological symptoms. Self-report instruments and reports from family members can also provide information, especially for patients with cognitive impairments. The document discusses several methods and instruments used to assess conditions like depression, anxiety, apathy, psychosis, and more.
1) Capacity refers to one's ability to understand treatment information and foreseeable consequences of decisions. Capacity is decision-specific and can change over time.
2) Health professionals determine a patient's capacity. Everyone is presumed capable unless determined otherwise. Tests of capacity evaluate understanding of why treatment is proposed, what the treatment is, and consequences of decisions.
3) When a patient lacks capacity, a substitute decision maker may be an appointed representative or family. Prior capable wishes must be followed if relevant to the circumstances. Without prior wishes, the substitute considers the patient's values and whether treatment benefits outweigh risks.
The document discusses the assessment of a patient named Daniel who presented to the emergency department exhibiting signs of agitation and psychosis. Some key points:
- Daniel is highly agitated, kicking out at staff and saying he wants to die. His BAL is 0.12 and he has dilated pupils and tachycardia.
- The psychiatrist must consider Daniel's decision making capacity, duty of care, potential for harm, and criteria for involuntary treatment under the MHA 2014.
- Assessing capacity involves evaluating for psychiatric illness, its influence on judgment, and determining if treatment is refused. Capacity can be affected by factors like intoxication, mental illness, or stress.
- If capacity is
n your reply posts, discuss challenges in knowing when to evalua.docxhallettfaustina
n your reply posts, discuss challenges in knowing when to evaluate a person's capacity in decision making. Are there instances, such as refusing to care for a chronic illness or choosing to drink alcohol while on complex medications, that may trigger action, and if so, what challenges might you encounter? posts should be 100 to 150 words, with a minimum of one supporting reference included.
Response 1
Evaluating capacity for older adults poses a challenge as there is a high prevalence of cognitive impairment, such as dementia, as well as medical and neurological comorbidities for this patient population. According to Moye and Marson (2007), these cognitive and physical changes are linked with declines in everyday functioning that includes loss of decision-making skills. This raises legal and ethical concerns in healthcare as some older adult patients may lack the capacity to make decisions regarding their own care. When a patient is deemed incapable of making decisions for themselves, decision making falls to the patient's guardian or health care proxy (Moye et al., 2005).
From the assigned readings, I was pleasantly surprised to understand the legal implications in place for protection when an individual is deemed incapable of making decisions for themselves. As capacity evaluations strive to protect the dignity and autonomy of all persons (Moye et al., 2005), the legal healthcare proxy or guardian is also in place to represent the individuals’ perceived intentions and desires. It is also reassuring that evaluation of capacity is thorough as to not to inaccurately deem an individual incapable of making their own decisions. Moye et al. (2005) explains that capacity assessment involves causal, functional, interactive, and judgmental abilities.
As a healthcare provider working with elderly patients, it is necessary to utilize all resources when determining an individual’s legal capacity. Moye et al. (2005) states that psychologists working in rehabilitation settings are called on to use their expertise in psychological assessment to help address complex presentations and related capacity questions. Utilizing the expertise of clinical psychologists assists in making the more efficient and concise decisions regarding an elderly individuals' capacity. Challenges of capacity arise inpatient as well, with the concern if elderly individuals have the capacity to consent for various acute procedures. From my experience, when the nurse practitioners I work with have concerns regarding their patient's legal capacity, they will consult psych and sometimes social work for guidance. It is important to have a capacity assessment guide in place when working with an older patient population. Tools such as the virtual reality functional capacity assessment tool assist healthcare providers in assessing a patient’s ability to complete instrumental activities such as searching a pantry at home, making a shopping list, or paying for groceries (Atkins et al..
The document provides an overview of the Mental Capacity Act 2005 in the UK. It explains that the Act provides a framework for making decisions for those lacking mental capacity and defines key terms like mental capacity, competence, and best interests. It states that capacity is decision-specific and cannot be assumed based on appearance alone. For those deemed to lack capacity, decisions must consider past wishes, values, and be in their best interests. Advanced directives and lasting powers of attorney are also discussed.
This document discusses key concepts for patient assessment and communication in medical imaging. It emphasizes the importance of critical thinking, problem solving, cultural awareness and establishing effective communication. The radiographer must collect subjective and objective data on the patient, analyze the data to develop a customized care plan, implement the plan and evaluate the results. Nonverbal communication, gender factors and other variables that could impact the patient experience are also addressed.
This document discusses key concepts for patient assessment and communication in medical imaging. It emphasizes the importance of critical thinking, problem solving, cultural awareness and establishing rapport when interacting with patients. Effective communication involves both verbal and nonverbal elements, with factors like gender, disabilities and grief needing consideration. The goals are to obtain necessary medical histories, explain procedures, ensure patient comfort and provide education to support patient rights and self determination.
This document discusses key concepts for patient assessment and communication in medical imaging. It emphasizes the importance of critical thinking, problem solving, cultural awareness and establishing rapport when interacting with patients. The radiographer must collect both subjective and objective data about the patient, analyze the information to develop an individualized care plan, implement the plan and evaluate the results. Nonverbal communication, gender factors and other variables that could impact the patient experience are also addressed.
This document discusses key concepts for patient assessment and communication in medical imaging. It emphasizes the importance of critical thinking, problem solving, cultural awareness and establishing rapport when interacting with patients. The radiographer must collect both subjective and objective data about the patient, analyze the information to develop an individualized care plan, implement the plan and evaluate the results. Non-verbal communication, gender factors and other variables that could impact the patient experience are also addressed.
Clinical decision making is the thinking processes & strategy we use to understand data with regard to identifying patient problems in preparation for diagnosis & selecting outcome & intervention
Ethical issues of Care of elderly patients:-
Decision making capacity.
Informed consent.
Refusal of treatment.
Advance directive.
Major ethical principles.
Psycho-social aspects of aging.
The document discusses diagnostic error in emergency departments and how emergency physicians think. It outlines that the ED is prone to error due to factors like uncertainty, time pressure, and high cognitive load. It describes a dual-process theory of thinking, with intuitive and analytical approaches, and how understanding this can help mitigate errors. It provides suggestions for EPs to improve their thinking, such as using aids to reduce reliance on memory and practicing metacognition to take a reflective problem-solving approach.
- The document discusses a training course on the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
- It provides an overview of the topics to be covered including the five key principles of the MCA, assessing capacity, best interests decisions, DoLS, and the role of IMCAs.
- The aims are to explore the MCA and its principles, enable staff to apply it properly, and understand the safeguards it introduces.
This document provides an overview of a training course on the Mental Capacity Act 2005. It discusses key topics that will be covered in the training including the five principles of the Act, assessing capacity, best interests decisions, deprivation of liberty safeguards, lasting powers of attorney, advanced decisions, the role of the Court of Protection and Public Guardian, and independent mental capacity advocates. The training aims to enable staff to apply the Mental Capacity Act in their work and understand the legal framework and safeguards in place for supporting those lacking capacity.
The document summarizes psychological disorders and their treatment according to the biopsychosocial model. It discusses the criteria for abnormality (deviance, distress, dysfunction) and approaches that view disorders as arising from interactions among biological, psychological, and sociocultural factors. It also outlines classification systems (DSM, ICD); behavioral therapies like systematic desensitization and exposure therapy; cognitive behavioral therapy for OCD; and factors considered in evaluating diagnostic systems.
Chapter 14
Mental Health
Chapter Objectives
Outline issues inherent in the provision of mental health care in the correctional setting.
Understand when inmate participation in mental health care and treatment can be required.
Explore the right to privacy with regard to mental health records.
Introduction
Provision of mental health services is a necessary and complex part of any correctional operation.
Attention to planning and implementation of services to meet the mental health needs of population greatly contribute to a smooth running facility; inattention can lead to problems, negative publicity and litigation.
Correctional administrators must know the standards for care of mentally ill offenders.
Process for care of the mentally ill has changed significantly over the past fifty years. With the advent of psychopharmacology and focused therapies most people suffering from mental illness may be managed in outpatient settings.
Introduction
The management of most mentally ill patients as outpatients has resulted in the deinstitutionalization of people needing care.
However, the lack of community resources and existing support systems has led to the inadequate treatment of some mentally ill persons and has resulted in their placement in the criminal justice system.
Current data reflect more mentally ill persons in jails and prisons than in community mental institutions.
About half of the inmate population has been diagnosed with a mental health problem with approximately 16% diagnosed with serious mental illness.
The Diagnostic and Statistical Manual of Mental Disorders
Most commonly used classification system of mental illness and defects.
A mental disorder is a: “clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability.”
Major mental disorders include diagnosis of: schizophrenia, major depression, or bipolar disorder.
Many inmates demonstrate personality dysfunction and meet criteria for Antisocial Personality Disorder and other personality disorders, which remain difficult to treat.
Guidelines and Standards
The responsibility for provision of care to those who are denied the ability to choose their own care because of confinement has been defined in the Courts and standards of several organizations published to review.
The current standard of care requires basic and clinically relevant care. Problems arise when care falls below accepted standards and may result in deliberate indifference.
Deliberate indifference can be evidenced by: lack of access, failure to follow through with care, insufficient provision of staff resources, and poor outcomes due to negligent care.
Guidelines and Standards
Several organizations have established minimum guidelines for the treatment of mentally ill in correctional environments:
a. American Correctional Association (ACA)
b. American Medical Association (AMA)
c. American Public He.
The Life Science Addiction Treatment Center is a private residential facility that offers short, moderate, and long-term inpatient treatment for adults struggling with alcohol and/or drug addiction. Its mission is to provide evidence-based treatment in a professional and affordable manner using a personalized approach. The treatment program utilizes principles from cognitive behavioral therapy and other therapeutic models. It offers a variety of group and individual therapy sessions, educational workshops, recreational activities, and medical and psychiatric support to help clients develop coping skills and achieve rehabilitation and wellness goals. The facility is located in a serene natural setting near Montreal, Quebec and employs a multidisciplinary clinical team.
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Establishing competency in mentally ill
1. Dr Akhila K Chandran
Research Ethics Scholar
Centre for Ethics
Yenepoya Deemed to be University
1
2. ROAD MAP
Mental health, mental disorder
Mental illness(MCA)
Impacts of mental disorders
Competence
Competency vs capacity
Fluctuating capacity
Lack of capacity
Components of capacity evaluation
Standards for assessing decision making capacity
2 stage functional test for capacity
Competency assessment- who?, when?, why?, how?
Competency assessment tools- MacCAT-T, MacCAT-CR
Limitation of competency assessment tools
2
3. MENTAL
HEALTH
A state of well-being in which an
individual realizes his or her own
abilities, can cope with the
normal stresses of life, can work
productively and fruitfully, and
is able to make a contribution to
his or her community
3
4. MENTAL
DISORDERS
As per WHO-
“Mental disorders comprise a broad range of problems, with
different symptoms. However, they are generally characterized
by some combination of abnormal thoughts, emotions,
behavior and relationships with others.”
4
5. Mental illness
A substantial disorder
of
thinking
mood
perception
orientation or
memory
It does not include mental retardation
that grossly impairs
judgment,
behavior,
capacity to recognize reality or
ability to meet the ordinary demands
of life,
mental conditions associated with the
abuse of alcohol and drugs.
5
6. Individual-
poor quality of life, stigma
and discrimination, stress
restriction of social activities
,suffering from physical
illnesses ,are unable to
participate in work and
leisure
Family-
stigma and
discrimination, stress
,economic loss,
restriction of social
activities
Society-
Economic loss, violence,
crimes
Impact of
mental
disorders
7. Competence
As per MerriamWebster- “the quality or state of having
sufficient knowledge, judgment, skill, or strength (as for
a particular duty or in a particular respect)”
In law- legal authority, ability, or admissibility.
In mental health-
7
8. Competency vs.
Capacity
Capacity- A person’s ability to make an informed decision;
a physician can determine capacity.
Competency-The degree of
mental soundness necessary to
1. make decision about specific issues or
2. carry out a specific act;
Competency- A judicial finding made by the court, not by
a physician.
8
9. FLUCTUATING
CAPACITY
Fluctuating capacity means that a P at some
times has the mental capacity pursuant to the
MCA to make decisions and sometimes does
not.
The main MCA 2005 Code of Practice notes
that some people have fluctuating capacity
as a result of “a problem or condition that
gets worse occasionally and affects their
ability to make decisions” (the examples
being given are manic depression (or, as it is
now termed, bipolar disorder) or a
psychotic illness).
9
10. 3 broad groups:
Those with mental
illness who have a
temporary episode of
crisis or those who
experience a change in
their physical health
which impacts on their
mental functioning
Those whose capacity
fluctuates on a
predictable basis and in
circumstances which
are easily identifiable.
Those whose
fluctuations in their
capacity are
unpredictable.
10
11. Temporary
factors that
may also affect
someone’s
ability to
make
decisions-
Distress
after a
death or
shock.
The effect
of
medication,
or
Severe
pain,
Acute
illness,
11
12. The
consequences
of fluctuating
capacity will
depend upon
the context.
a)There may be situations in which a person’s
fluctuating capacity will solely impact upon the
extent to which they can be held to the legal
consequences of their actions (for instance in
relation to property and affairs);
b) there may also be situations in which their
fluctuating capacity will impact upon the ability of
others to rely upon their consent (most obviously in
relation to capacity to consent to sexual relations
but also when consenting to medical treatment).
12
13. Lack of capacity
a) to understand the information relevant to the
decision,
b) to retain that information,
c) to use or weigh that information as part of
the process of making the decision, or
d) to communicate his decision (whether by
talking, using sign language or any other
means) (2)
“A person lacks capacity in
relation to a matter if at the
material time he is unable
to make a decision for
himself in relation to the
matter because of an
impairment of, or a
disturbance in the
functioning of, the mind or
brain.”(1)
A person is unable to make a decision for himself if he is
unable
13
14. A lack of
mental
capacity could
be due to:
a stroke or brain injury
a mental health problem
dementia
a learning disability
confusion, drowsiness or unconsciousness because of an illness of the
treatment for it
substance misuse
14
15. Components of a
capacity evaluation
Comprehension
It refers to a patient’s factual understanding of his /her medical
condition—for example, including the risks and benefits of treatment
and reasonable alternatives. The patient should show an understanding
of 1) the situation as it relates to his condition, and 2) the consequences
of his decisions. He also should demonstrate a rational manipulation of
the information presented, applying a coherent and logical thought
process to analyze possible courses of action.
Free choice
The patient’s decision to accept or reject a proposed treatment should
be voluntary and free of coercion. In assessing a patient’s capacity, the
psychiatrist should determine whether choices have been rendered
impossible because of unrealistic fears or expectations about
treatment, or because of impaired mental processes.
Reliability
it refers to a patient’s ability to provide a consistent choice over time. A
patient who vacillates or is inconsistent does not have capacity to make
decisions.
15
17. 1.Ability to Evidence aChoice.
least stringent component
Individuals failing this criterion -unable to express a preference or are unable to
make their wishes known effectively.
Here we look at whether or not a decision was made.
It requires the ability to maintain and communicate stable choices long enough for
them to be implemented.
For e.g., an individual who rapidly changes his or her decision from moment to
moment -deemed unable to evidence a choice.
.
17
18. Furthermore, individuals with impairment of consciousness, with
significant thought disorders, deficits in short-term memory or
lability that impairs decision making are likely to have difficulties
with the ability to evidence a choice.
This can be tested quite simply by asking patients who have been
informed about their medical condition and proposed
interventions to respond to what they have just heard.
The stability of the choice that they express can be examined by
simply rephrasing the same question some time later
18
19. 2.Ability toUnderstand Relevant Information.
This component is adhered to by every jurisdiction.
It goes beyond evidencing a choice by assessing the individual's ability to
comprehend information disclosed in the informed consent process.
Basis-an individual who cannot understand what he or she has been told about a
proposed treatment or diagnostic intervention is not capable to decide to assent
or refuse.
The ability to understand relevant information can be best assessed by asking
patients to disclose their understanding of the proposed treatment intervention or
diagnostic procedure. It is best to ask them to paraphrase it.
19
20. 3.Ability toAppreciate theSituation and Its Likely
Consequences
This standard assesses whether the patient comprehends what the proposed
intervention means for him or her.
Here the information that is being assessed is whether the individual understands
what having the illness means, including its course and likely outcomes. In
addition, the probable consequences of treatment or its refusal and the likelihood
of each of a number of consequences, such as undergoing treatment versus
forgoing treatment versus alternative treatments, are assessed.
The concept of appreciation is a rather individualized component of the capacity
assessment.
20
21. 4.Ability to Manipulate Information Rationally.
This component refers to the patient's general ability to employ logic or rational
thought processes to manipulate information.
Basis- If patients are unable to use logic and unable to weigh information in a
rational manner to reach a decision, they will therefore be unable to compare the
benefits and risks of various treatment options or interventions proposed to them.
This component does not focus on the ultimate decision that the patient makes,
but rather the process.
Therefore, the physician examines the ability of individuals to reach a conclusion
based on the initial premises with which they start.
21
22. Two-stage
functional test
of capacity
Stage 1. Is there an impairment of
or disturbance in the functioning of
a person’s mind or brain? If so,
Stage 2. Is the impairment or
disturbance sufficient that the
person lacks the capacity to
make a particular decision?
In order to decide whether an individual has the capacity to make a
particular decision you must answer two questions:
22
23. understand information given to them
Understand
retain that information long enough to be able to make the decision
Retain
weigh up the information available to make the decision
Weigh up
communicate their decision – this could be by talking, using sign language or
even simple muscle movements such as blinking an eye or squeezing a hand.
Communicate
The MCA says that a person is unable to make their own decision if they
cannot do one or more of the following four things:
23
25. Who?
Courts determine competence by a formal judicial proceeding.(1)
A psychologist/neuropsychologist can have two roles in this regard:
(a) he/she may be the clinical care provider and assessing the patient's
capacity for the clinical procedures he/she is initiating in that role
or
(b) (b) he/she may be acting as a consultant for another clinician, that
is, asked to provide an expert opinion regarding the decisional
capacity of the patient of another healthcare provider.(2)
25
26. When?
In Healthcare-
When a patient is admitted for any treatment or emergency
procedures.
In Research-
When a participant with known h/o of any mental illness is
included in the research
When a mentally ill patient is included in the research.
26
27. Why?
Assessment of mental capacity may relate to any act
including criminal law (competency to stand trial, consent,
private defense against an insane person) to civil law
(contract, marriage, adoption, laws to prevent/ treat mental
illnesses-health and welfare decisions), choices about the
most appropriate place to live, e.g., full time residential or
nursing care and also illnesses and legal transactions.
Systematic assessment of mental capacity of individuals
undergoing studies or taking treatment will help in diffusing
the ethical controversies.
27
28. How?
By using standardized tools for the assessment of
competency.
They are
28
29. Competency
Assessment
Tools
The Mini Mental Status Examination (MMSE)
Hopkins Competency AssessmentTest (HCAT)
Capacity to Consent toTreatment Instrument (CCTI)
MacArthur CompetenceAssessmentTool –Treatment (MacCAT-T)
MacArthur CompetenceAssessmentTool – Clinical Research (MacCAT-
CR)
MaxArthur CompetenceAssessmentTool- CriminalAdjudication
(MacCaT-CA)
29
30. Competency Interview Schedule (CIS)
Structured Interview for Competency/IncompetencyAssessment
Testing and Ranking Inventory (SICIATRI)
Evaluation to Sign Consent (ESC)
Aid to Capacity Evaluation (ACE)
California Scale of Appreciation (CSA)
CapacityAssessmentTool (CAT)
30
31. MacArthur
Competence
Assessment
Tool –
Treatment
(MacCAT-T)
• Assesses choice,
understanding,
appreciation, and
rational thinking
• Adequate,
partial, or
inadequate ratings
for each item
• Score for each
ability
• Not designed
to determine
global
competence
• Intended to
identify areas of
relative capacity
• Semi-structured
interview
• 15-20 min
31
32. Pros
• High inter-rater reliability
• Correlates with MMSE
• Utilizes patient chart to make test personally
relevant
• Moderate agreement with physician ratings
• Practical for cases of ambiguous competency
Cons
• May not be valid in every population: anorexia
nervosa
• Procedure for going over the facts of disorder
and treatment “Patronizing” and “Awkward”
32
34. Pros
• Can be customized to research protocol and
diagnostic sample
• High inter-rater reliability
• Correlates with MMSE
Cons
• Possibly low test retest reliability – ceiling
effects
34
35. Limitations to
Competency
Assessment
Tools
• Legal definition varies by jurisdiction
• Every patient / clinical decision is unique
• Informed consent is required for participation in research so those
who are incompetent to consent cannot be studied
• Only authorized persons or groups (judge) can declare
incompetent – gold standard?
35
Examples are schizophrenia, depression, intellectual disabilities and disorders due to drug abuse.
Most of these disorders can be successfully treated.
These are the four legal standards, which have come to be used by the majority of researchers in the field.