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 copy

doc = Document()

# ── Page margins ────────────────────────────────────────────────────────────
from docx.shared import Inches
section = doc.sections[0]
section.top_margin    = Inches(1.0)
section.bottom_margin = Inches(1.0)
section.left_margin   = Inches(1.2)
section.right_margin  = Inches(1.0)

# ── Default styles ───────────────────────────────────────────────────────────
normal_style = doc.styles['Normal']
normal_style.font.name = 'Times New Roman'
normal_style.font.size = Pt(12)

def set_heading_style(para, level, color_hex='1F4E79', size=14, bold=True):
    para.style = doc.styles[f'Heading {level}']
    run = para.runs[0] if para.runs else para.add_run('')
    run.font.name = 'Times New Roman'
    run.font.size = Pt(size)
    run.font.bold = bold
    run.font.color.rgb = RGBColor(
        int(color_hex[0:2], 16),
        int(color_hex[2:4], 16),
        int(color_hex[4:6], 16)
    )

def add_title(text, size=20, color_hex='1F3864'):
    p = doc.add_paragraph()
    p.alignment = WD_ALIGN_PARAGRAPH.CENTER
    run = p.add_run(text)
    run.font.name = 'Times New Roman'
    run.font.size = Pt(size)
    run.font.bold = True
    run.font.color.rgb = RGBColor(
        int(color_hex[0:2], 16),
        int(color_hex[2:4], 16),
        int(color_hex[4:6], 16)
    )
    return p

def add_h1(text):
    p = doc.add_heading(text, level=1)
    for run in p.runs:
        run.font.name = 'Times New Roman'
        run.font.size = Pt(15)
        run.font.color.rgb = RGBColor(0x1F, 0x4E, 0x79)
    return p

def add_h2(text):
    p = doc.add_heading(text, level=2)
    for run in p.runs:
        run.font.name = 'Times New Roman'
        run.font.size = Pt(13)
        run.font.color.rgb = RGBColor(0x17, 0x50, 0x2B)
    return p

def add_h3(text):
    p = doc.add_heading(text, level=3)
    for run in p.runs:
        run.font.name = 'Times New Roman'
        run.font.size = Pt(12)
        run.font.color.rgb = RGBColor(0x7B, 0x27, 0x00)
    return p

def add_para(text, bold=False, italic=False):
    p = doc.add_paragraph()
    run = p.add_run(text)
    run.font.name = 'Times New Roman'
    run.font.size = Pt(12)
    run.font.bold = bold
    run.font.italic = italic
    return p

def add_bullet(text, level=0):
    p = doc.add_paragraph(style='List Bullet')
    run = p.add_run(text)
    run.font.name = 'Times New Roman'
    run.font.size = Pt(12)
    return p

def add_table_2col(rows_data, header=None):
    n = len(rows_data) + (1 if header else 0)
    table = doc.add_table(rows=n, cols=2)
    table.style = 'Table Grid'
    idx = 0
    if header:
        row = table.rows[0]
        for i, h in enumerate(header):
            cell = row.cells[i]
            cell.text = h
            for run in cell.paragraphs[0].runs:
                run.font.bold = True
                run.font.name = 'Times New Roman'
                run.font.size = Pt(11)
                run.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
            # shade header
            tc = cell._tc
            tcPr = tc.get_or_add_tcPr()
            shd = OxmlElement('w:shd')
            shd.set(qn('w:val'), 'clear')
            shd.set(qn('w:color'), 'auto')
            shd.set(qn('w:fill'), '1F4E79')
            tcPr.append(shd)
        idx = 1
    for r, (k, v) in enumerate(rows_data):
        row = table.rows[r + idx]
        row.cells[0].text = k
        row.cells[1].text = v
        for cell in row.cells:
            for para in cell.paragraphs:
                for run in para.runs:
                    run.font.name = 'Times New Roman'
                    run.font.size = Pt(11)
    return table

def add_table_multi(rows_data, headers):
    n_rows = len(rows_data) + 1
    n_cols = len(headers)
    table = doc.add_table(rows=n_rows, cols=n_cols)
    table.style = 'Table Grid'
    # header row
    for i, h in enumerate(headers):
        cell = table.rows[0].cells[i]
        cell.text = h
        for run in cell.paragraphs[0].runs:
            run.font.bold = True
            run.font.name = 'Times New Roman'
            run.font.size = Pt(11)
            run.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
        tc = cell._tc
        tcPr = tc.get_or_add_tcPr()
        shd = OxmlElement('w:shd')
        shd.set(qn('w:val'), 'clear')
        shd.set(qn('w:color'), 'auto')
        shd.set(qn('w:fill'), '1F4E79')
        tcPr.append(shd)
    for r, row_data in enumerate(rows_data):
        for c, val in enumerate(row_data):
            cell = table.rows[r + 1].cells[c]
            cell.text = val
            for para in cell.paragraphs:
                for run in para.runs:
                    run.font.name = 'Times New Roman'
                    run.font.size = Pt(10)
    return table

def add_page_break():
    doc.add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  COVER / TITLE PAGE
# ═══════════════════════════════════════════════════════════════════════════
add_title("CASE PRESENTATION", size=22, color_hex='1F3864')
add_title("RADIUS AND ULNA FRACTURE", size=20, color_hex='C00000')
doc.add_paragraph()
add_title("Department of Medical-Surgical Nursing", size=13, color_hex='2E4057')
add_title("B.Sc. Nursing — 2nd Year", size=12, color_hex='2E4057')
doc.add_paragraph()

p = doc.add_paragraph()
p.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = p.add_run("Submitted by: Student Nurse\nGuided by: Clinical Instructor\nDate of Submission: August 2026")
run.font.name = 'Times New Roman'
run.font.size = Pt(12)

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 1: PATIENT DETAILS
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 1: PATIENT DETAILS")
add_table_2col([
    ("Patient Name", "Mr. Ramesh Kumar"),
    ("Age", "32 years"),
    ("Gender", "Male"),
    ("Religion", "Hindu"),
    ("Marital Status", "Married"),
    ("Education", "Higher Secondary (12th)"),
    ("Occupation", "Construction Labourer"),
    ("Address", "Village Nandpur, District Satna, Madhya Pradesh"),
    ("Ward / Bed No.", "Orthopaedic Ward, Bed No. 12"),
    ("IP No.", "OPD/IP-2026-0804"),
    ("Date of Admission", "02 August 2026"),
    ("Date of Assessment", "04 August 2026"),
    ("Diagnosis", "Fracture of Radius and Ulna (Both-bone Forearm Fracture) — Right"),
    ("Informant", "Patient and Wife (reliable)"),
    ("Language", "Hindi"),
])

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 2: CHIEF COMPLAINT
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 2: CHIEF COMPLAINT")
add_para("The patient presented with the following complaints:")
add_bullet("Pain in the right forearm — severe, since 2 days")
add_bullet("Swelling and deformity of the right forearm — since 2 days")
add_bullet("Inability to move the right wrist and fingers — since 2 days")
add_bullet("Tenderness on touch over the mid-forearm region")
add_bullet("Visible angulation / deformity of the forearm")

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 3: HISTORY OF PRESENT ILLNESS
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 3: HISTORY OF PRESENT ILLNESS")
add_para(
    "Mr. Ramesh Kumar, a 32-year-old male construction labourer, sustained injury to his right forearm on 02 August 2026 when he accidentally fell from scaffolding at a height of approximately 6 feet. He landed on his outstretched right hand. Immediately after the fall, he developed severe pain in the right forearm, swelling, and a visible deformity. He was unable to use his right hand and was brought to the casualty department of District Hospital, Satna, within 2 hours of the injury."
)
add_para(
    "At the time of admission, he was conscious and alert, complaining of 8/10 pain (NRS scale) in the right forearm. An X-ray was taken which revealed fracture of both the radius and ulna at the mid-shaft level of the right forearm. He was given analgesics and the forearm was immobilised with a POP (Plaster of Paris) back-slab. He was admitted for further management including surgical fixation."
)

add_h2("History of Presenting Illness — OLDCARTS Format")
add_table_2col([
    ("Onset", "Sudden; following fall from height on 02 August 2026"),
    ("Location", "Mid-shaft of right forearm (radius and ulna)"),
    ("Duration", "2 days at time of assessment"),
    ("Character", "Constant, throbbing, aching pain with sharp exacerbations on movement"),
    ("Alleviating Factors", "Rest, immobilisation, analgesics (Inj. Ketorolac 30 mg IV)"),
    ("Radiating", "Pain radiates to right wrist and elbow"),
    ("Timing", "Continuous; worst on attempted movement"),
    ("Severity", "8/10 on Numeric Rating Scale (NRS) at admission; 5/10 at assessment"),
], header=["Parameter", "Description"])

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 4: PAST MEDICAL HISTORY
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 4: PAST MEDICAL HISTORY")
add_table_2col([
    ("Previous Fractures", "No history of previous fractures or bone disease"),
    ("Hospitalisation", "No previous hospitalisation"),
    ("Chronic Diseases", "No known hypertension, diabetes mellitus, or heart disease"),
    ("Surgeries", "No previous surgeries"),
    ("Allergies", "No known drug / food allergy"),
    ("Medications", "Not on any regular medications"),
    ("Blood Transfusions", "Nil"),
    ("Immunisation History", "Completed as per national schedule; Tetanus toxoid given at casualty"),
], header=["Item", "Details"])

doc.add_paragraph()
add_h2("Family History")
add_bullet("No family history of osteoporosis, bone tumours, or metabolic bone disease")
add_bullet("Father: alive, healthy; Mother: alive, healthy")
add_bullet("No consanguineous marriage")

doc.add_paragraph()
add_h2("Personal History")
add_table_2col([
    ("Diet", "Mixed (vegetarian + non-vegetarian); adequate caloric intake"),
    ("Sleep", "6-7 hours/night; disturbed since injury"),
    ("Bowel and Bladder", "Regular; no complaints"),
    ("Appetite", "Decreased since injury"),
    ("Tobacco Use", "Occasional bidi smoking — 2-3/day"),
    ("Alcohol", "Occasional; once a week"),
    ("Exercise", "Occupational physical activity — construction work"),
])

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 5: FINDINGS OF HISTORY TAKING
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 5: FINDINGS OF HISTORY TAKING")
add_para("The following significant findings were elicited during history taking:")
add_bullet("High-energy trauma: fall from scaffolding (~6 feet), direct axial loading on outstretched right hand")
add_bullet("Acute onset of severe pain, swelling, and deformity of right forearm immediately after trauma")
add_bullet("Inability to pronate, supinate, flex, or extend the right wrist and fingers")
add_bullet("No history of paresthesia or loss of sensation (rules out nerve injury at presentation)")
add_bullet("No history of vascular compromise — fingers warm and pink at admission")
add_bullet("No previous bone disease or predisposing fracture risk factors identified")
add_bullet("Occupation involves heavy manual work with repetitive lifting — relevant to injury risk")
add_bullet("No family history of metabolic bone disease or osteoporosis")
add_bullet("Adequate nutritional history — no evidence of calcium/vitamin D deficiency")

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 6: FINDINGS OF PHYSICAL EXAMINATION
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 6: FINDINGS OF PHYSICAL EXAMINATION")

add_h2("A. General Examination")
add_table_2col([
    ("General Appearance", "Conscious, alert, moderately built, in pain"),
    ("Temperature", "37.2°C (afebrile)"),
    ("Pulse", "92 beats/min — regular, good volume"),
    ("Blood Pressure", "118/76 mmHg — right arm (measured on left); normal"),
    ("Respiratory Rate", "18 breaths/min"),
    ("SpO2", "99% on room air"),
    ("Weight", "68 kg"),
    ("Height", "5 feet 8 inches"),
    ("BMI", "22.8 kg/m² (normal)"),
    ("Pallor", "Mild pallor (post-traumatic anaemia)"),
    ("Icterus / Cyanosis", "Absent"),
    ("Lymphadenopathy", "Not detected"),
    ("Oedema", "Present — right forearm (traumatic)"),
])

add_h2("B. Local Examination — Right Forearm")
add_h3("Inspection")
add_bullet("Visible deformity — angulation of right forearm at mid-shaft level")
add_bullet("Diffuse swelling extending from distal third of right forearm to wrist")
add_bullet("Skin intact over the fracture site (closed fracture)")
add_bullet("Mild ecchymosis over the mid-forearm, dorsal aspect")
add_bullet("Shortening apparent on comparison with left forearm")

add_h3("Palpation")
add_bullet("Tenderness present at mid-shaft of radius and ulna — point tenderness")
add_bullet("Crepitus felt on gentle palpation at fracture sites")
add_bullet("Pitting oedema — 2+ over forearm and dorsum of hand")
add_bullet("Skin warm (inflammatory response)")
add_bullet("Capillary refill time: < 2 seconds (vascular integrity preserved)")

add_h3("Movement")
add_bullet("Wrist flexion/extension — markedly restricted due to pain and immobilisation")
add_bullet("Forearm pronation/supination — completely restricted")
add_bullet("Finger movements — slightly restricted due to oedema; grip strength markedly reduced")
add_bullet("Elbow flexion/extension — present but painful")

add_h3("Neurovascular Assessment")
add_table_2col([
    ("Radial Pulse (right)", "Present; 2+ strength"),
    ("Capillary Refill Time", "< 2 seconds in fingers"),
    ("Sensation", "Intact in median, ulnar, and radial nerve distribution"),
    ("Motor Function (intrinsics)", "Grip and pinch mildly reduced due to pain; no motor deficit"),
    ("Compartment Syndrome Signs", "No tense compartment; pain with passive stretch — being monitored"),
])

add_h2("C. Systemic Examination")
add_bullet("Cardiovascular System: S1 S2 heard; no murmur")
add_bullet("Respiratory System: Air entry equal bilaterally; no added sounds")
add_bullet("Abdomen: Soft, non-tender; no organomegaly")
add_bullet("CNS: GCS 15/15; no focal neurological deficit")

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 7: ANATOMY AND PHYSIOLOGY OF RADIUS AND ULNA
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 7: ANATOMY AND PHYSIOLOGY OF RADIUS AND ULNA")

add_h2("A. Anatomy of the Radius")
add_para(
    "The radius is the lateral bone of the forearm. It is shorter proximally and wider distally. It extends from the lateral aspect of the elbow to the lateral aspect of the wrist. The radius consists of a head, neck, tuberosity, shaft, and distal extremity. The radial head is disc-shaped and articulates with the capitellum of the humerus (humeroradial joint) and with the radial notch of the ulna (proximal radioulnar joint). The bicipital tuberosity (radial tuberosity) is the point of insertion for the biceps brachii muscle."
)
add_para(
    "The shaft of the radius has three surfaces (anterior, posterior, lateral) and three borders (anterior, posterior, interosseous). The interosseous border is sharp and gives attachment to the interosseous membrane. The distal radius is wide and has a concave articular surface for articulation with the proximal row of carpal bones (scaphoid and lunate). It also has the sigmoid notch for articulation with the ulna (distal radioulnar joint — DRUJ)."
)

add_h2("B. Anatomy of the Ulna")
add_para(
    "The ulna is the medial bone of the forearm. It is wider proximally and narrow distally. Proximally, the ulna has the olecranon (posterior bony prominence of the elbow), the coronoid process, and the trochlear notch (semilunar notch) which articulates with the trochlea of the humerus (humeroulnar joint). The radial notch on the lateral surface of the ulna articulates with the radial head (proximal radioulnar joint). The tuberosity of the ulna is the insertion site for the brachialis muscle."
)
add_para(
    "The shaft of the ulna has three surfaces (anterior, posterior, medial) and three borders (anterior, posterior, interosseous). The distal end tapers to the ulnar head, which articulates with the sigmoid notch of the radius at the DRUJ. The ulnar styloid process projects distally and is an attachment point for the triangular fibrocartilage complex (TFCC)."
)

add_h2("C. Interosseous Membrane")
add_para(
    "The interosseous membrane (IOM) is a fibrous structure connecting the interosseous borders of the radius and ulna. Its fibres run obliquely downward and medially from the radius to the ulna. The IOM serves as an important force-transmitting structure: it transfers approximately 60% of axial load from the radius to the ulna. It also provides attachment for several forearm flexor and extensor muscles and is frequently disrupted in both-bone forearm fractures and Galeazzi/Monteggia fracture-dislocations."
)

add_h2("D. Proximal and Distal Radioulnar Joints")
add_bullet("Proximal Radioulnar Joint (PRUJ): pivot joint between radial head and radial notch of ulna; stabilised by the annular ligament")
add_bullet("Distal Radioulnar Joint (DRUJ): pivot joint between ulnar head and sigmoid notch of radius; stabilised by the TFCC")
add_bullet("These two joints together allow forearm pronation (0-80°) and supination (0-80°)")

add_h2("E. Muscles of the Forearm")
add_h3("Anterior Compartment (Flexors — supplied by median and ulnar nerves)")
add_table_2col([
    ("Superficial Layer", "Pronator teres, Flexor carpi radialis, Palmaris longus, Flexor carpi ulnaris"),
    ("Intermediate Layer", "Flexor digitorum superficialis"),
    ("Deep Layer", "Flexor digitorum profundus, Flexor pollicis longus, Pronator quadratus"),
])

add_h3("Posterior Compartment (Extensors — supplied by radial nerve)")
add_table_2col([
    ("Superficial Layer", "Brachioradialis, Extensor carpi radialis longus and brevis, Extensor digitorum, Extensor digiti minimi, Extensor carpi ulnaris"),
    ("Deep Layer", "Supinator, Abductor pollicis longus, Extensor pollicis longus and brevis, Extensor indicis"),
])

add_h2("F. Neurovascular Supply")
add_table_2col([
    ("Radial Nerve", "Supplies posterior compartment (extensors and supinator); sensory to lateral dorsum of hand"),
    ("Median Nerve", "Supplies anterior compartment (most flexors, pronators); passes through carpal tunnel"),
    ("Ulnar Nerve", "Supplies flexor carpi ulnaris, medial half of flexor digitorum profundus; sensory to medial hand"),
    ("Anterior Interosseous Nerve (AIN)", "Branch of median nerve; supplies deep anterior muscles — FPL, FDP (radial half), pronator quadratus"),
    ("Posterior Interosseous Nerve (PIN)", "Deep branch of radial nerve; at risk in proximal radius fractures"),
    ("Radial Artery", "Lateral forearm; palpable at wrist; anastomoses with ulnar artery in palmar arch"),
    ("Ulnar Artery", "Medial forearm; palpable medial to flexor carpi ulnaris tendon at wrist"),
])

add_h2("G. Physiology of the Forearm")
add_para(
    "The forearm functions as the main positioning mechanism for the hand. Through coordinated activity of the proximal and distal radioulnar joints, the forearm provides two critical motions:"
)
add_bullet("Pronation (0-80°): forearm rotates medially; radius crosses over the ulna; accomplished primarily by pronator teres and pronator quadratus")
add_bullet("Supination (0-85°): forearm rotates laterally; radius and ulna run parallel; accomplished primarily by supinator and biceps brachii")
add_para(
    "These motions are essential for activities of daily living such as eating, writing, turning door handles, and personal hygiene. Fractures of the radius and/or ulna, if not properly reduced and fixed, result in malunion, rotational deformity, and significant loss of pronation and supination — leading to marked functional disability."
)

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 8: DISEASE PROFILE
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 8: DISEASE PROFILE — FRACTURE OF RADIUS AND ULNA")

add_h2("A. Definition")
add_para(
    "A fracture of the radius and ulna refers to a break in continuity of one or both bones of the forearm. A both-bone forearm fracture (BBFF) involves simultaneous fracture of the radial shaft and ulnar shaft. These fractures are of particular significance because the forearm is a paired-bone system — a fracture of one bone mandates assessment of the other bone and the radioulnar joints. Diaphyseal (shaft) fractures are defined as occurring between the radial neck proximally and the metaphysis-diaphysis junction distally for the radius, and between the distal coronoid and the ulnar neck for the ulna. (Rockwood and Green's Fractures in Adults, 10th ed., 2025)"
)

add_h2("B. Classification")
add_h3("AO/OTA Classification (Diaphyseal Forearm Fractures — Segment 22)")
add_table_2col([
    ("Type A — Simple", "A1: Isolated ulna; A2: Isolated radius; A3: Both bones — simple fractures"),
    ("Type B — Wedge", "B1: Ulna wedge; B2: Radius wedge; B3: Ulna wedge + simple radius (or vice versa)"),
    ("Type C — Complex / Comminuted", "C1: Complex ulna + simple radius; C2: Simple ulna + complex radius; C3: Complex both bones"),
])

add_h3("Special Fracture-Dislocation Patterns")
add_table_2col([
    ("Monteggia Fracture-Dislocation", "Fracture of proximal ulna + dislocation of radial head at PRUJ"),
    ("Galeazzi Fracture-Dislocation", "Fracture of distal third of radius shaft + DRUJ disruption / dislocation"),
    ("Essex-Lopresti Injury", "Radial head fracture + IOM disruption + DRUJ disruption (rare, high energy)"),
    ("Nightstick Fracture", "Isolated ulnar shaft fracture from direct blow (e.g. defensive injury)"),
])

add_h3("Classification by Open/Closed Status (Gustilo-Anderson for open fractures)")
add_table_2col([
    ("Type I", "Wound < 1 cm; minimal contamination; simple fracture pattern"),
    ("Type II", "Wound 1-10 cm; moderate contamination"),
    ("Type IIIA", "Wound > 10 cm; adequate soft tissue coverage"),
    ("Type IIIB", "Extensive periosteal stripping; requires flap coverage"),
    ("Type IIIC", "Associated arterial injury requiring repair"),
])

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 9: EPIDEMIOLOGY
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 9: EPIDEMIOLOGY")
add_para(
    "Radius and ulna fractures are among the most common orthopaedic injuries. According to data from the National Hospital Ambulatory Medical Care Survey (USA, 1998), forearm/hand fractures account for 1.5% of all emergency department visits. Radius and ulna fractures constitute approximately 44% of all forearm fractures. The average annual incidence of diaphyseal forearm shaft fractures in adults is 1.35 per 10,000 population, ranging 0-4 per 10,000 depending on age and gender. Four-fifths of forearm shaft fractures occur in children. In adults above 20 years, the incidence remains below 2 per 10,000 and predominates in males throughout all age groups. (Rockwood and Green's, 2025)"
)
add_bullet("Male predominance across all age groups")
add_bullet("In children: peak incidence 10-14 years")
add_bullet("In adults: bimodal distribution — young males (trauma) and elderly females (osteoporotic falls)")
add_bullet("1 diaphyseal forearm fracture occurs for every 10 distal radius fractures")
add_bullet("Distal radius fractures are the most common upper extremity fractures overall")
add_bullet("Approximately one-third of surgically treated forearm shaft fractures occur as isolated injuries; remaining two-thirds have at least one associated injury")
add_bullet("Open fractures range from < 10% in isolated radial shaft fractures to 43% in both-bone forearm fractures")
add_bullet("Compartment syndrome occurs in approximately 3% of forearm fractures — most commonly in males under 35 years")

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 10: CAUSES
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 10: CAUSES OF RADIUS AND ULNA FRACTURE")

add_h2("A. Traumatic Causes (Most Common)")
add_table_2col([
    ("Fall on Outstretched Hand (FOOSH)", "Most common mechanism; creates axial compressive load transferred through radius to ulna"),
    ("Fall from Height", "High-energy injury; often causes both-bone fractures with displacement and comminution"),
    ("Road Traffic Accidents (RTAs)", "Direct impact or crush injury; often open fractures"),
    ("Direct Blow", "Nightstick fracture (isolated ulna) from defensive blow; direct forearm impact"),
    ("Sports Injuries", "Contact sports — rugby, football, martial arts; gymnastics"),
    ("Crush Injuries", "Industrial machinery, heavy objects"),
    ("Gunshot Wounds", "High-velocity gunshot wounds cause Type III open fractures with severe comminution"),
], header=["Mechanism", "Description"])

add_h2("B. Pathological Causes (Less Common)")
add_bullet("Osteoporosis — reduced bone mineral density; fracture with minimal trauma")
add_bullet("Bone metastases — pathological fracture at tumour sites")
add_bullet("Primary bone tumours (e.g. giant cell tumour, osteosarcoma)")
add_bullet("Paget's disease of bone")
add_bullet("Osteogenesis imperfecta")
add_bullet("Osteomyelitis — cortical thinning leading to pathological fracture")

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 11: RISK FACTORS
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 11: RISK FACTORS")
add_table_2col([
    ("Age", "Children (peak 10-14 y; growth plate vulnerability); Elderly (osteoporosis, falls)"),
    ("Gender", "Males: higher incidence (trauma, physical work); Females in elderly: osteoporosis"),
    ("Occupation", "Construction, mining, heavy industries, agriculture — occupational trauma"),
    ("Osteoporosis", "Reduced bone density — fracture with trivial trauma; post-menopausal women, elderly"),
    ("Vitamin D / Calcium Deficiency", "Poor bone mineralisation; rickets in children"),
    ("Sports Activities", "Contact sports, extreme sports"),
    ("Alcohol Use", "Impaired coordination; osteopenia; increased fall risk"),
    ("Tobacco Smoking", "Impairs fracture healing; reduces bone mineral density"),
    ("Corticosteroid Use", "Chronic use causes osteoporosis"),
    ("Previous Fractures", "History of fracture indicates fragile bone"),
    ("Neurological Conditions", "Epilepsy (fall risk), cerebral palsy, stroke — increased fall and fracture risk"),
    ("Low Socioeconomic Status", "Unsafe living/working conditions; inadequate nutrition"),
    ("High BMI / Obesity", "Increased fall risk; altered load on bones"),
], header=["Risk Factor", "Description"])

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 12: PATHOPHYSIOLOGY
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 12: PATHOPHYSIOLOGY")

add_h2("A. Mechanism of Fracture")
add_para(
    "In a fall on an outstretched hand, the axial load is transmitted from the wrist proximally through the radius and ulna. When the force exceeds the tensile and compressive strength of the bone, fracture occurs. High-energy mechanisms (falls from height, RTAs) cause greater energy transfer, resulting in more comminution, displacement, and soft tissue injury."
)

add_h2("B. Stages of Normal Bone Fracture Healing")
add_table_2col([
    ("Stage 1: Haematoma Formation\n(0-48 hrs)", "Blood fills the fracture gap; clot forms; platelets release growth factors (PDGF, TGF-beta); vasodilation and inflammation begin"),
    ("Stage 2: Inflammatory Phase\n(Days 1-7)", "Inflammatory cells (neutrophils, macrophages) debride necrotic tissue; cytokines recruit osteoprogenitor cells; pain, swelling, heat present"),
    ("Stage 3: Soft Callus\n(Days 7-21)", "Fibroblasts and chondroblasts form fibrocartilaginous soft callus bridging fracture gap; woven bone begins forming; fracture becomes sticky but not solid"),
    ("Stage 4: Hard Callus\n(Weeks 3-12)", "Endochondral ossification converts soft callus to woven bone (hard callus); fracture becomes firm on X-ray"),
    ("Stage 5: Remodelling\n(Months to 2 years)", "Woven bone converted to lamellar bone along lines of stress (Wolff's Law); callus gradually resorbed; cortical continuity restored"),
], header=["Stage", "Description"])

add_h2("C. Pathophysiology of Both-Bone Forearm Fracture")
add_para(
    "When both the radius and ulna fracture simultaneously, the following pathological events occur:"
)
add_bullet("Disruption of the paired-bone forearm unit — loss of normal radius-ulna relationship")
add_bullet("Tearing of the interosseous membrane along the path connecting both fractures — destabilises the entire forearm unit")
add_bullet("Muscle pull causes fracture displacement: supinator and biceps supinate the proximal radial fragment; pronator teres pronates the middle fragment; pronator quadratus pronates the distal radial fragment")
add_bullet("Shortening occurs due to muscle spasm pulling fracture ends together")
add_bullet("Angulation deformity — apex of deformity usually directed toward the direction of muscle pull")
add_bullet("Loss of radial bow — radius has a physiological lateral bow; if lost during fracture or malunion, pronation/supination is lost")
add_bullet("Oedema formation — inflammatory mediators increase vascular permeability; tissue oedema may elevate compartment pressure (compartment syndrome risk)")
add_bullet("Neurovascular compromise risk — nerves and vessels can be injured by bone fragments or by elevated compartment pressure")

add_h2("D. Complications Arising from Pathophysiology")
add_table_2col([
    ("Compartment Syndrome", "Elevated pressure (>30 mmHg) in fascial compartment; ischaemia to muscles and nerves; requires emergency fasciotomy"),
    ("Neurovascular Injury", "PIN injury at radial neck; AIN injury; radial artery laceration"),
    ("Malunion", "Fracture heals in poor alignment; loss of radial bow; restricted pro-supination"),
    ("Nonunion", "Failure of fracture to heal by 6-9 months; requires bone grafting and fixation"),
    ("Radioulnar Synostosis", "Ossification of IOM creates bony bridge between radius and ulna — total loss of pro-supination"),
    ("Post-Traumatic Arthritis", "DRUJ or PRUJ injury leads to long-term arthritic changes"),
    ("Infection / Osteomyelitis", "Open fractures at risk; deep plate infection after ORIF"),
    ("Refracture after plate removal", "Especially if cortical porosity present under plate"),
])

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 13: CLINICAL MANIFESTATIONS
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 13: CLINICAL MANIFESTATIONS")

add_h2("A. Subjective Symptoms")
add_table_2col([
    ("Pain", "Severe, immediate-onset pain at fracture site; 8-10/10 NRS; worsened by movement"),
    ("Swelling", "Localised then diffuse forearm swelling due to haematoma and oedema"),
    ("Loss of Function", "Unable to pronate/supinate or use wrist and hand"),
    ("Weakness", "Decreased grip strength; difficulty holding objects"),
    ("Paresthesia", "Numbness or tingling if nerve injury present (PIN, AIN, or from compartment pressure)"),
], header=["Symptom", "Description"])

add_h2("B. Objective Signs")
add_table_2col([
    ("Deformity", "Visible angulation or shortening of forearm"),
    ("Swelling and Ecchymosis", "Diffuse forearm swelling; bruising over fracture site"),
    ("Point Tenderness", "Maximum tenderness directly over fracture site"),
    ("Crepitus", "Grating sensation on palpation or passive movement"),
    ("Loss of Movement", "Severely restricted pronation, supination, wrist movement"),
    ("Abnormal Mobility", "Movement detected at fracture site in unstable fractures"),
    ("Skin Injury", "Open wound in open fractures"),
    ("Tight Compartment", "Tense, woody feeling forearm in compartment syndrome"),
    ("Pulse Changes", "Absent/weak radial pulse if vascular injury"),
    ("5 P's of Compartment Syndrome", "Pain (severe, passive stretch), Pallor, Pulselessness, Paraesthesia, Paralysis"),
], header=["Sign", "Description"])

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 14: DIAGNOSTIC INVESTIGATIONS
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 14: DIAGNOSTIC INVESTIGATIONS")

add_h2("A. Radiological Investigations")
add_table_2col([
    ("X-Ray Forearm AP and Lateral\n(FIRST LINE — MANDATORY)", "Shows fracture site, type, displacement, angulation, and comminution. MUST include elbow and wrist to detect associated joint injuries (Monteggia, Galeazzi)."),
    ("X-Ray Wrist PA and Lateral", "Rules out DRUJ injury; assesses ulnar variance"),
    ("X-Ray Elbow AP and Lateral", "Rules out PRUJ dislocation; radial head fractures"),
    ("CT Scan (3D reconstruction)", "Useful for complex comminuted fractures, malunion assessment, rotational deformity evaluation, pre-operative planning"),
    ("MRI", "Rarely needed acutely; useful for IOM and TFCC injury assessment; diagnosing nonunion"),
], header=["Investigation", "Purpose / Findings"])

add_h2("B. Laboratory Investigations")
add_table_2col([
    ("Complete Blood Count (CBC)", "Haemoglobin to assess post-traumatic anaemia; WBC for infection screening"),
    ("Blood Group and Cross-matching", "Pre-operative preparation for potential blood transfusion"),
    ("Blood Glucose (RBS/FBS)", "Pre-operative screening; rules out undiagnosed diabetes"),
    ("Serum Electrolytes", "Na+, K+, Cl- — pre-operative assessment"),
    ("Renal Function Tests (BUN, Creatinine)", "Pre-anaesthetic evaluation"),
    ("Coagulation Profile (PT, aPTT, INR)", "Pre-operative bleeding risk assessment"),
    ("Serum Calcium, Phosphorus", "If pathological fracture suspected; baseline bone metabolism"),
    ("Vitamin D Level", "If osteoporosis/malnutrition suspected"),
    ("Bone Mineral Density (DEXA Scan)", "In elderly patients to assess osteoporosis"),
])

add_h2("C. Patient's Diagnostic Findings (Mr. Ramesh Kumar)")
add_table_2col([
    ("X-Ray Right Forearm (AP + Lateral)", "Both-bone fracture at mid-shaft of radius and ulna; transverse fracture pattern; moderate displacement; no open injury; DRUJ and PRUJ intact"),
    ("Haemoglobin", "10.8 g/dL (mild anaemia)"),
    ("WBC Count", "10,200/mm³ (normal)"),
    ("Blood Group", "B positive"),
    ("Blood Glucose (RBS)", "98 mg/dL (normal)"),
    ("Serum Electrolytes", "Within normal limits"),
    ("Creatinine", "0.9 mg/dL (normal)"),
    ("PT / INR", "13 sec / 1.1 (normal)"),
])

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 15: AIM OF MANAGEMENT
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 15: AIM OF MANAGEMENT")
add_para("The goals of management for radius and ulna fracture are:")

aims = [
    ("Restore Bone Anatomy", "Achieve anatomical reduction of fracture fragments with preservation of the radial bow"),
    ("Achieve Stable Fixation", "Provide rigid fixation to allow early mobilisation and prevent loss of reduction"),
    ("Restore Forearm Function", "Regain full pronation and supination; prevent malunion and rotational deformity"),
    ("Relieve Pain", "Adequate analgesia throughout treatment"),
    ("Prevent Complications", "Monitor and prevent compartment syndrome, neurovascular injury, infection, nonunion, malunion"),
    ("Promote Healing", "Optimise nutrition, blood supply, and mechanical environment for fracture healing"),
    ("Rehabilitate the Patient", "Restore full upper extremity function through physiotherapy and occupational therapy"),
    ("Prevent Disability", "Return patient to pre-injury occupational and daily activities"),
]
for aim, desc in aims:
    p = doc.add_paragraph()
    run_bold = p.add_run(f"{aim}: ")
    run_bold.font.bold = True
    run_bold.font.name = 'Times New Roman'
    run_bold.font.size = Pt(12)
    run_norm = p.add_run(desc)
    run_norm.font.name = 'Times New Roman'
    run_norm.font.size = Pt(12)

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 16: MANAGEMENT
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 16: MANAGEMENT")

add_h2("A. MEDICAL MANAGEMENT")

add_h3("1. Immobilisation (Non-Operative)")
add_para(
    "Non-operative treatment is reserved for minimally displaced fractures (< 10° angulation, < 1 cm shortening) and undisplaced nightstick fractures. It includes:"
)
add_bullet("Above-elbow POP cast (long arm cast) for 6-8 weeks: forearm in neutral or slight supination, elbow at 90°")
add_bullet("Short arm brace for undisplaced isolated ulnar shaft fractures for 4-6 weeks")
add_bullet("Serial X-rays at 1, 2, 4, 6 weeks to monitor reduction")
add_bullet("Displaced both-bone forearm fractures in adults do NOT heal well with conservative management alone — operative fixation is the standard of care")

add_h3("2. Pharmacological Management")
add_table_2col([
    ("Analgesics", "Inj. Ketorolac 30 mg IV 8-hourly (for 3-5 days); Tab. Paracetamol 500 mg TDS; Inj. Diclofenac 75 mg IM 12-hourly"),
    ("Opioid Analgesics", "Inj. Tramadol 50 mg IV in severe pain; Inj. Morphine 2-4 mg IV if needed (with monitoring)"),
    ("Antibiotics (prophylactic)", "Inj. Cefuroxime 1.5 g IV pre-op; Inj. Cefazolin 1 g IV 8-hourly for 24-48 hrs post-op"),
    ("Antibiotics (open fracture)", "Broad-spectrum coverage: Cefazolin + Gentamicin; add Metronidazole for contaminated wounds"),
    ("Tetanus Prophylaxis", "Inj. Tetanus Toxoid 0.5 mL IM if not immunised within 5 years"),
    ("Anti-oedema / Anti-inflammatory", "Inj. Dexamethasone 4-8 mg IV for severe swelling (selected cases); Limb elevation"),
    ("DVT Prophylaxis", "Low Molecular Weight Heparin (Enoxaparin 40 mg SC daily) post-operative"),
    ("Calcium + Vitamin D", "Tab. Calcium 500 mg + Vitamin D3 400 IU BD — support fracture healing"),
    ("Haematinics", "Tab. Ferrous sulphate + Folic acid for post-traumatic anaemia"),
    ("Antacid / PPI", "Tab. Pantoprazole 40 mg OD to prevent NSAID-induced gastritis"),
], header=["Drug Category", "Drug / Dose / Route"])

add_h3("3. Local Measures")
add_bullet("Immobilisation: POP back-slab initially; full cast after swelling subsides")
add_bullet("Limb elevation: 30-45° above heart level to reduce oedema")
add_bullet("Ice pack application (20 min QID for first 48 hours) over bandage — reduces swelling")
add_bullet("Wound care for open fractures: irrigation with normal saline; debridement; sterile dressing")
add_bullet("Monitoring: hourly pulse oximetry, neurovascular check — especially for compartment syndrome")

add_h2("B. SURGICAL MANAGEMENT")

add_h3("Indications for Surgery in Both-Bone Forearm Fractures")
add_bullet("All displaced diaphyseal both-bone forearm fractures in adults — standard indication for ORIF")
add_bullet("Failed conservative management")
add_bullet("Monteggia and Galeazzi fracture-dislocations")
add_bullet("Open fractures (debridement + fixation)")
add_bullet("Compartment syndrome (fasciotomy ± fixation)")
add_bullet("Vascular injury requiring repair")
add_bullet("Multiple trauma patients")

add_h3("1. Open Reduction and Internal Fixation (ORIF) with Dynamic Compression Plate (DCP)")
add_para(
    "ORIF with 3.5 mm DCP (dynamic compression plate) is the gold standard for adult both-bone forearm fractures. The procedure is performed under general or regional anaesthesia."
)
add_bullet("Approach: Henry's (anterior/volar) approach for radius; dorsal (Thompson) approach for radius diaphysis; direct approach for ulna (subcutaneous border)")
add_bullet("Fixation: 3.5 mm DCP or Limited Contact DCP (LC-DCP) with 6-8 cortices on each side of fracture")
add_bullet("Compression plating — inter-fragmentary compression for simple fractures; bridging plate for comminuted fractures")
add_bullet("Radial bow must be restored during fixation — critical for pronation/supination")
add_bullet("Lag screws used for oblique fractures to achieve inter-fragmentary compression")
add_bullet("Post-operative: POP splint for 2-4 weeks; then mobilisation")

add_h3("2. Intramedullary Nailing (IMN)")
add_bullet("Less commonly used for forearm diaphyseal fractures compared to plate fixation")
add_bullet("Used in children (elastic nailing / titanium elastic nails — TENS), comminuted fractures in adults, segmental fractures")
add_bullet("Advantage: biological fixation; less periosteal stripping")
add_bullet("Disadvantage: rotational instability; difficulty restoring radial bow")

add_h3("3. External Fixation")
add_bullet("Used as temporising measure in open fractures with severe contamination")
add_bullet("Damage-control orthopaedics in polytrauma patients")
add_bullet("Definitive fixation planned after wound healing")

add_h3("4. Fasciotomy")
add_bullet("Emergency procedure for acute compartment syndrome")
add_bullet("Volar forearm fasciotomy (releases volar compartment) ± dorsal fasciotomy")
add_bullet("Skin left open; wound closed by delayed primary closure or skin graft at 48-72 hrs")
add_bullet("Indication: compartment pressure > 30 mmHg or within 20-30 mmHg of diastolic BP")

add_h3("Post-Operative Care")
add_bullet("Monitor neurovascular status every 1-2 hours for first 24 hours")
add_bullet("Elevate limb post-operatively to reduce oedema")
add_bullet("Wound inspection at 48-72 hours; suture removal at 10-14 days")
add_bullet("Physiotherapy: finger and wrist movements immediately; elbow and forearm at 2-4 weeks")
add_bullet("Serial X-rays at 2, 6, 12 weeks post-operatively")
add_bullet("Full weight-bearing avoided until radiological healing")
add_bullet("Plate removal: considered 18-24 months post-operatively if symptomatic or in young patients")

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# ═══════════════════════════════════════════════════════════════════════════
#  SECTION 17: NURSING MANAGEMENT
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 17: NURSING MANAGEMENT")

add_h2("A. NURSING ASSESSMENT")
add_h3("1. Subjective Data")
add_bullet('Patient states: "My right hand is very painful, I cannot move it at all"')
add_bullet("Reports pain 8/10 on NRS; constant; worsened by touch or movement")
add_bullet("Reports swelling and visible deformity since injury 2 days ago")
add_bullet("Reports inability to use right hand for any activity — dependent for ADLs")
add_bullet("Expresses anxiety: 'How long will it take? Can I go back to work?'")
add_bullet("Reports disturbed sleep due to pain")
add_bullet("Decreased appetite since injury")

add_h3("2. Objective Data")
add_bullet("Alert and oriented; GCS 15/15")
add_bullet("Right forearm: deformity, swelling, ecchymosis; POP back-slab in situ")
add_bullet("Pain assessment: NRS 5/10 at rest; 8/10 on movement")
add_bullet("Vital signs: Temp 37.2°C; PR 92/min; BP 118/76 mmHg; RR 18/min; SpO2 99%")
add_bullet("Capillary refill < 2 seconds; fingers warm and pink")
add_bullet("Sensation intact in all nerve distributions")
add_bullet("Mild pallor on conjunctival examination (Hb 10.8 g/dL)")
add_bullet("Patient is dependent for bathing, dressing, eating with right hand")

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# ═══════════════════════════════════════════════════════════════════════════
#  NURSING DIAGNOSES TABLE
# ═══════════════════════════════════════════════════════════════════════════
add_h2("B. NURSING DIAGNOSES (NANDA)")
add_table_multi(
    [
        ["1", "Acute Pain", "Related to fracture, muscle spasm, tissue injury", "Patient reports pain; guarding behaviour; NRS 5-8/10", "Patient will report pain ≤ 3/10 within 24 hours with analgesic intervention"],
        ["2", "Impaired Physical Mobility", "Related to fractured radius/ulna; pain; immobilisation in POP cast", "Restricted movement; unable to pronate/supinate; dependent for ADLs", "Patient will perform ADLs with minimal assistance; maintain position of comfort"],
        ["3", "Risk for Peripheral Neurovascular Dysfunction", "Related to fracture; oedema; pressure from cast", "Oedema present; cast in situ; potential for compartment syndrome", "No signs of neurovascular compromise; CRT < 2s; sensation intact throughout"],
        ["4", "Risk for Infection", "Related to disruption of skin integrity (open wound in post-op); surgical incision", "Post-operative wound; IV lines; altered WBC", "Wound clean; no signs of infection; afebrile"],
        ["5", "Self-Care Deficit (Bathing, Dressing, Eating)", "Related to immobilised dominant hand (right); pain", "Unable to use right hand; states needs help with eating, bathing, dressing", "Patient performs ADLs with adaptations; accepts appropriate assistance"],
        ["6", "Anxiety", "Related to hospitalisation; uncertainty about recovery and return to work", "Patient expresses fear about recovery; concern about income loss", "Patient verbalises understanding of treatment; reduced anxiety score"],
        ["7", "Deficient Knowledge", "Related to unfamiliarity with fracture management, rehabilitation process", "Asks questions about surgery, healing time, physiotherapy", "Patient demonstrates understanding of treatment plan and self-care"],
        ["8", "Disturbed Sleep Pattern", "Related to pain; unfamiliar hospital environment", "Reports poor sleep since injury; wakes with pain at night", "Patient reports 6+ hours uninterrupted sleep with pain management"],
        ["9", "Imbalanced Nutrition: Less Than Body Requirements", "Related to decreased appetite; increased metabolic needs for fracture healing", "Hb 10.8 g/dL; patient reports poor appetite", "Patient consumes ≥ 80% of prescribed diet; Hb improves toward normal"],
    ],
    headers=["No.", "Nursing Diagnosis", "Related To (Etiology)", "As Evidenced By", "Expected Outcome"]
)

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  NURSING INTERVENTIONS
# ═══════════════════════════════════════════════════════════════════════════
add_h2("C. NURSING INTERVENTIONS AND RATIONALE")

add_h3("ND 1: Acute Pain")
add_table_multi(
    [
        ["Assess pain using NRS every 2-4 hours and before/after analgesic administration", "Provides baseline and evaluates effectiveness of pain management"],
        ["Administer prescribed analgesics (Ketorolac, Tramadol) as ordered; evaluate response within 30 mins", "Pharmacological management reduces pain signals; monitoring ensures adequacy"],
        ["Maintain POP cast/splint in position of comfort; support with pillows", "Immobilisation reduces muscle spasm and movement at fracture site"],
        ["Elevate right forearm above heart level (30-45°) using foam pillow", "Reduces oedema and thereby reduces pressure causing pain"],
        ["Apply ice pack (wrapped in cloth) for 20 minutes QID for first 48 hours", "Cryotherapy reduces inflammation and oedema; decreases pain"],
        ["Teach patient non-pharmacological pain management: deep breathing, distraction, relaxation techniques", "Non-pharmacological methods reduce pain perception and analgesic needs"],
        ["Maintain quiet environment; reduce unnecessary disturbance at night", "Environmental factors influence pain perception and rest"],
        ["Document pain score, location, character in nursing notes", "Ensures accurate documentation and communication with healthcare team"],
    ],
    headers=["Intervention", "Rationale"]
)

doc.add_paragraph()
add_h3("ND 2: Impaired Physical Mobility")
add_table_multi(
    [
        ["Assess range of motion, grip strength, and functional capacity daily", "Establishes baseline and monitors progress"],
        ["Assist patient with positioning; use triangular sling for arm support during ambulation", "Maintains limb in functional position and prevents dependent oedema"],
        ["Teach and encourage active exercises of unaffected joints: shoulder and elbow movements, finger exercises (as tolerated)", "Prevents joint stiffness and muscle atrophy; maintains circulation"],
        ["Collaborate with physiotherapist for exercise programme post-operatively", "Structured rehabilitation restores function safely"],
        ["Ensure call bell is within reach; assist with all ADLs (eating, personal hygiene) using left hand", "Maintains patient safety and comfort; promotes independence"],
        ["Educate patient on cast care: keep dry, do not insert objects under cast, report tightness or increasing pain immediately", "Prevents complications of cast; empowers patient in self-care"],
        ["Ambulate patient to bathroom with assistance; encourage left-hand ADLs", "Promotes early mobilisation; reduces complications of bed rest"],
    ],
    headers=["Intervention", "Rationale"]
)

doc.add_paragraph()
add_h3("ND 3: Risk for Peripheral Neurovascular Dysfunction")
add_table_multi(
    [
        ["Perform neurovascular checks every 1-2 hours for first 24 hours post-operative; then every 4 hours: assess 5 P's (Pain, Pallor, Pulselessness, Paraesthesia, Paralysis)", "Early detection of compartment syndrome or vascular compromise; potentially limb-saving intervention"],
        ["Assess capillary refill time in all fingers; compare bilaterally", "CRT > 2 seconds suggests vascular compromise"],
        ["Monitor cast tightness; inspect skin at cast edges for pressure sores", "Tight cast can compress vessels and nerves; pressure areas cause skin breakdown"],
        ["Elevate limb above heart level continuously post-operatively", "Reduces oedema; decreases risk of elevated compartment pressure"],
        ["Assess sensory function (light touch, 2-point discrimination) in median, ulnar, and radial nerve distributions", "Sensory deficit is an early sign of nerve compression"],
        ["Instruct patient to immediately report numbness, tingling, increased pain, or skin colour changes", "Empowers patient to participate in early detection of complications"],
        ["If compartment syndrome suspected: remove cast/constrictive dressings immediately; notify surgeon; prepare for emergency fasciotomy", "Time-critical intervention; delay leads to irreversible muscle necrosis (Volkmann's contracture)"],
    ],
    headers=["Intervention", "Rationale"]
)

doc.add_paragraph()
add_h3("ND 4: Risk for Infection")
add_table_multi(
    [
        ["Monitor wound/incision site for signs of infection: redness, warmth, swelling, purulent discharge, fever", "Early detection allows prompt treatment"],
        ["Perform sterile wound dressing changes as per protocol (every 24-48 hours)", "Maintains sterile wound environment; prevents bacterial colonisation"],
        ["Administer prescribed prophylactic antibiotics as ordered; monitor for adverse reactions", "Prevents surgical site infection; antibiotic prophylaxis reduces SSI risk by 60-70%"],
        ["Monitor temperature, WBC count, CRP — record and report abnormal values", "Systemic signs of infection warrant immediate intervention"],
        ["Maintain IV cannula site care; change every 72-96 hours or if site inflamed", "Reduces risk of IV-site thrombophlebitis and line infection"],
        ["Maintain hand hygiene before and after all patient contact", "Primary measure to prevent healthcare-associated infection"],
        ["Ensure adequate nutritional intake; encourage protein-rich foods (eggs, dals, chicken, milk)", "Adequate nutrition supports immune function and wound healing"],
    ],
    headers=["Intervention", "Rationale"]
)

add_page_break()

add_h3("ND 5: Self-Care Deficit")
add_table_multi(
    [
        ["Assess patient's current functional abilities and ADL limitations daily", "Identifies areas of dependence and guides care planning"],
        ["Provide complete assistance with bathing, oral hygiene, and dressing for first 2-3 days; progress to supervised self-care", "Maintains hygiene and dignity; promotes gradual independence"],
        ["Set up meal tray within reach; cut food as needed; encourage use of left hand for eating", "Facilitates independent feeding; maintains nutrition"],
        ["Provide adaptive equipment (wide-grip spoon, straw, non-slip mat for plate)", "Promotes independence in feeding with one functional hand"],
        ["Collaborate with occupational therapist for ADL training and adaptive strategies", "Specialised training accelerates independence with disability"],
        ["Explain rationale for each care activity to patient; involve patient in care decisions", "Preserves patient autonomy and dignity; improves compliance"],
    ],
    headers=["Intervention", "Rationale"]
)

doc.add_paragraph()
add_h3("ND 6: Anxiety")
add_table_multi(
    [
        ["Establish therapeutic relationship; spend time listening to patient concerns without judgement", "Trust reduces anxiety; patient feels heard and supported"],
        ["Provide clear, simple explanations of the diagnosis, surgical plan, expected outcomes, and recovery timeline", "Knowledge reduces fear of the unknown — a primary driver of anxiety"],
        ["Involve patient in care planning and goal-setting; answer all questions honestly", "Sense of control reduces anxiety"],
        ["Arrange for social worker consultation if patient expresses financial concerns (income during sick leave)", "Addresses real-world anxiety triggers beyond clinical scope"],
        ["Encourage family involvement; brief family members on treatment plan", "Family support is a protective factor against anxiety"],
        ["Teach relaxation techniques: deep breathing, guided imagery, progressive muscle relaxation", "Non-pharmacological anxiety reduction; evidence-based effectiveness"],
    ],
    headers=["Intervention", "Rationale"]
)

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  NURSING THEORY — HENDERSON'S
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 18: APPLICATION OF NURSING THEORY — VIRGINIA HENDERSON'S THEORY")

add_h2("Overview of Henderson's Theory")
add_para(
    "Virginia Henderson (1897-1996) defined nursing as: 'The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible.' Henderson identified 14 Fundamental Needs of an individual that nurses must address."
)

add_h2("Application of 14 Fundamental Needs to Mr. Ramesh Kumar")
add_table_multi(
    [
        ["1. Breathe Normally", "No respiratory compromise", "Maintain SpO2 ≥ 95%; deep breathing exercises post-anaesthesia; position for adequate ventilation"],
        ["2. Eat and Drink Adequately", "Decreased appetite; mild anaemia (Hb 10.8); increased nutritional demands for healing", "High-protein, calcium-rich diet; encourage 2500-3000 mL fluids/day; involve dietitian; monitor oral intake"],
        ["3. Eliminate Body Wastes", "Constipation risk (analgesic opioids, reduced mobility, pain)", "Monitor bowel movements; adequate hydration; early ambulation; laxatives if needed"],
        ["4. Move and Maintain Desirable Posture", "Impaired mobility due to fractured right forearm and POP cast", "Assist with safe positioning; sling support; early shoulder and finger exercises; physiotherapy referral"],
        ["5. Sleep and Rest", "Disturbed sleep from pain and hospital environment", "Scheduled analgesics before sleep; quiet environment; comfort positioning; sleep hygiene education"],
        ["6. Select Suitable Clothing", "Unable to dress self due to right arm immobilisation", "Assist with loose-fitting clothing; front-open garments; teach one-hand dressing techniques"],
        ["7. Maintain Body Temperature", "Post-operative risk of hypothermia (anaesthesia); infection risk (fever)", "Monitor temperature QID; warm blankets post-op; report fever > 38°C to physician"],
        ["8. Keep Body Clean and Well-Groomed", "Self-care deficit — cannot bathe/groom with right arm in cast", "Assist with bed bath; oral hygiene; teach left-hand techniques; maintain cast dryness"],
        ["9. Avoid Dangers in the Environment", "Fall risk (one-arm balance); cast-related complications; infection", "Side rails up; call bell within reach; anti-slip footwear; neurovascular checks; wound care"],
        ["10. Communicate Feelings and Emotions", "Anxiety about recovery; fear about return to work and financial impact", "Therapeutic communication; regular reassurance; clear information; family involvement; social worker referral"],
        ["11. Worship According to Beliefs", "Patient is Hindu; may desire prayer", "Respect religious practices; allow family to bring religious items; facilitate prayer time if desired"],
        ["12. Work in a Way That Provides Accomplishment", "Unable to work; fear about job security", "Counselling about expected return to work (4-6 months after ORIF); occupation-specific rehabilitation"],
        ["13. Play or Participate in Recreation", "Limited recreation due to immobilisation and hospitalisation", "Provide TV, radio, reading material; encourage left-hand activities; occupational therapy for adaptation"],
        ["14. Learn, Discover, or Satisfy Curiosity", "Patient needs education about fracture, surgery, recovery, and home care", "Structured patient education: fracture care, cast care, exercises, signs of complications, follow-up schedule"],
    ],
    headers=["Henderson's Need", "Patient's Problem (Mr. Ramesh)", "Nursing Intervention"]
)

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  NURSING EVALUATION
# ═══════════════════════════════════════════════════════════════════════════
add_h2("D. NURSING EVALUATION")
add_para("Evaluation of nursing outcomes for Mr. Ramesh Kumar:")
add_table_multi(
    [
        ["Acute Pain", "Patient reports pain 3/10 at rest; 5/10 on movement; states analgesics are helping", "Partially met — pain reduced but goal of ≤ 3/10 at all times ongoing"],
        ["Impaired Physical Mobility", "Patient performs shoulder range of motion; finger exercises 4 times daily; mobilises to bathroom with supervision", "Partially met — progressing; full rehabilitation post-discharge"],
        ["Risk for Neurovascular Dysfunction", "Capillary refill < 2s; sensation intact; no signs of compartment syndrome; radial pulse 2+", "Goal met — neurovascular status intact"],
        ["Risk for Infection", "Wound clean, no erythema or discharge; temperature 37.0°C; no signs of SSI", "Goal met — no infection to date"],
        ["Self-Care Deficit", "Patient feeds self with left hand; family assists with bathing; reduced dependence", "Partially met — continuing adaptive strategies"],
        ["Anxiety", "Patient expresses understanding of surgical plan; less verbal distress; resting quietly", "Goal met — anxiety reduced"],
        ["Deficient Knowledge", "Patient correctly identifies cast care, signs of complications, and follow-up date", "Goal met — demonstrated understanding"],
    ],
    headers=["Nursing Diagnosis", "Evaluation Findings", "Goal Status"]
)

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  3-DAY PROGRESS REPORT
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 19: 3-DAY PROGRESS REPORT")

add_h2("Day 1 — 02 August 2026 (Admission Day)")
add_table_2col([
    ("Chief Complaints at Admission", "Severe pain (8/10), swelling, deformity of right forearm; inability to use hand"),
    ("Vital Signs", "T: 37.2°C; PR: 92/min; BP: 118/76; RR: 18; SpO2: 99%"),
    ("Investigations Done", "X-ray forearm (both-bone fracture confirmed); CBC; BG; electrolytes; INR"),
    ("Medical Management", "IV access established; Inj. Ketorolac 30 mg IV; Inj. TT 0.5 mL IM; POP back-slab applied"),
    ("Surgical Plan", "Patient and family counselled for ORIF under regional anaesthesia; consent obtained"),
    ("Nursing Care", "Pain assessment, neurovascular monitoring every 2 hours; limb elevation; psychological support"),
    ("Patient Response", "Cooperative; pain partially controlled (6/10 after medication); anxious but reassured"),
    ("Problems Identified", "Acute pain; impaired mobility; anxiety; risk for neurovascular dysfunction"),
])

doc.add_paragraph()
add_h2("Day 2 — 03 August 2026 (Operative Day)")
add_table_2col([
    ("Procedure", "ORIF right radius and ulna with 3.5 mm DCP under regional anaesthesia (brachial plexus block)"),
    ("Intra-operative Findings", "Both-bone mid-shaft fracture; comminution at radius; radial bow restored; anatomical reduction achieved"),
    ("Post-operative Vital Signs", "T: 36.9°C; PR: 84/min; BP: 112/70; RR: 16; SpO2: 98%"),
    ("Post-op Medications", "Inj. Cefuroxime 750 mg IV TDS; Inj. Ketorolac 30 mg IV 8-hourly; Inj. Tramadol 50 mg IV PRN; Enoxaparin 40 mg SC; IV fluids RL @ 80 mL/hr"),
    ("Post-op Nursing Care", "Limb elevated on 2 pillows; neurovascular check every 1 hour for first 6 hours, then 2 hourly; ice pack; wound inspection; wound drain output recorded"),
    ("Pain Score", "5/10 at 4 hours post-op; 4/10 by evening"),
    ("Intake / Output", "IV fluids 2000 mL; urine output 1200 mL; drain output 60 mL (haemoserous)"),
    ("Complications", "None detected — no compartment syndrome; wound clean; neurovascular intact"),
    ("Family Education", "Surgeon briefed family; nurse explained post-op care, monitoring, and expected recovery"),
])

doc.add_paragraph()
add_h2("Day 3 — 04 August 2026 (Post-Operative Day 1 — Day of Assessment)")
add_table_2col([
    ("General Condition", "Stable; alert; comfortable; pain 4/10 at rest; 6/10 on movement"),
    ("Vital Signs", "T: 37.0°C; PR: 80/min; BP: 116/74; RR: 16; SpO2: 99%"),
    ("Wound Status", "Clean; no erythema or discharge; dressing intact; 1 suction drain removed"),
    ("Neurovascular Status", "Radial pulse 2+; CRT < 2s; sensation intact; fingers warm and pink"),
    ("Limb", "Swelling decreased compared to Day 1; POP back-slab maintained; arm elevated in triangular sling"),
    ("Physiotherapy", "Physiotherapist reviewed; shoulder pendulum exercises and finger movements initiated"),
    ("Oral Intake", "Patient consumed 70% of breakfast and lunch; tolerating oral medications"),
    ("Medications Continued", "Oral Amoxicillin-Clavulanate 625 mg TDS (stepped down); Tab. Ketorolac 10 mg TDS; Tab. Pantoprazole 40 mg OD; Tab. Calcium + Vit D3 BD"),
    ("Patient Education", "Cast care, signs of complications, exercises, and follow-up education provided"),
    ("Discharge Planning Started", "Target discharge Day 4-5; discharge teaching in progress"),
    ("Nursing Problems Today", "Mild pain; self-care deficit; anxiety about return to work addressed; knowledge deficit being resolved"),
])

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  DISCHARGE TEACHING
# ═══════════════════════════════════════════════════════════════════════════
add_h1("SECTION 20: DISCHARGE TEACHING")
add_para(
    "Discharge teaching for Mr. Ramesh Kumar and his family was provided using the TEACH-BACK method, in Hindi, with written materials provided. The following key areas were covered:"
)

add_h2("1. Wound and Cast Care")
add_bullet("Keep the wound dry and clean — do not remove or wet the dressing")
add_bullet("Keep the POP cast DRY at all times — use a plastic cover when bathing; sponge bath instead of shower initially")
add_bullet("Do NOT insert any objects inside the cast to scratch — risk of wound and skin injury")
add_bullet("Report immediately to hospital if cast becomes loose, too tight, wet, cracked, or if smell develops")
add_bullet("Pad the edges of the cast with soft cotton if rubbing at skin edges")
add_bullet("Suture removal will be done at follow-up — do not attempt to remove stitches at home")

add_h2("2. Warning Signs — When to Return Immediately to Hospital")
add_table_2col([
    ("Increased or Uncontrolled Pain", "Pain that worsens despite medications — may indicate compartment syndrome or infection"),
    ("Colour Change in Fingers", "Fingers become blue, white, or dark — circulatory compromise"),
    ("Numbness / Tingling", "Increasing numbness, tingling, or inability to feel — nerve compression"),
    ("Inability to Move Fingers", "Progressive weakness or inability to move fingers"),
    ("Fever > 38.5°C", "Signs of infection — wound infection or deep plate infection"),
    ("Swelling Increasing", "Sudden increase in swelling despite elevation"),
    ("Discharge from Wound", "Any pus, blood, or foul-smelling discharge from wound"),
    ("Cast Breaks", "Broken or damaged cast must be replaced immediately"),
])

add_h2("3. Medications at Discharge")
add_table_2col([
    ("Tab. Amoxicillin-Clavulanate 625 mg", "3 times daily after food — for 5 days"),
    ("Tab. Ketorolac 10 mg", "3 times daily after food — for 5 days (take with food to prevent stomach upset)"),
    ("Tab. Pantoprazole 40 mg", "Once daily before breakfast — stomach protection"),
    ("Tab. Calcium 500 mg + Vitamin D3 400 IU", "Twice daily — for fracture healing; take with milk or food"),
    ("Tab. Ferrous Sulphate + Folic Acid", "Once daily — for anaemia; take on empty stomach if tolerated"),
    ("Tablet Paracetamol 500 mg", "SOS (as needed) for mild pain"),
], header=["Medicine", "Instructions"])

add_h2("4. Exercises and Activity")
add_bullet("Keep arm elevated in triangular sling during waking hours for first 2 weeks")
add_bullet("Perform FINGER exercises every 2 hours while awake: make a fist and open fully, 10 times each session")
add_bullet("Perform SHOULDER circles and pendulum exercises as taught by physiotherapist — prevents shoulder stiffness")
add_bullet("Do NOT lift any weight with the right arm until the surgeon advises")
add_bullet("Do NOT drive or operate machinery until cleared by surgeon")
add_bullet("Keep arm elevated while sleeping — use 2 pillows under the arm")
add_bullet("Avoid contact sports and strenuous activities for at least 4-6 months")

add_h2("5. Diet and Nutrition")
add_bullet("Eat a high-protein diet: eggs, chicken, fish, dal, milk, paneer, soya — essential for bone and wound healing")
add_bullet("Calcium-rich foods: milk (2 glasses/day), curd, cheese, ragi, sesame seeds — supports bone healing")
add_bullet("Vitamin C: amla, lemon, oranges — promotes collagen synthesis and wound healing")
add_bullet("Drink 2-3 litres of water/fluids daily (unless restricted)")
add_bullet("Avoid alcohol completely during fracture healing period — delays bone healing and interacts with medications")
add_bullet("Reduce smoking/bidi significantly — nicotine impairs bone healing and increases nonunion risk")
add_bullet("If appetite is poor, eat small frequent meals")

add_h2("6. Follow-Up Instructions")
add_table_2col([
    ("First Follow-up", "7-10 days after discharge — suture removal, wound inspection, X-ray"),
    ("Second Follow-up", "4-6 weeks — clinical and X-ray assessment; cast review"),
    ("Third Follow-up", "12 weeks — X-ray to confirm fracture union; physiotherapy progression"),
    ("Long-term Follow-up", "6 months and 1 year — full functional assessment"),
    ("Emergency", "If any warning sign develops — present to Emergency Department directly"),
    ("Contact Number", "Ward 7 (Orthopaedic): 07672-XXXXX; Emergency: 108"),
])

add_h2("7. Psychological Support and Return to Work")
add_bullet("Explain to patient that full recovery takes 4-6 months after ORIF; most patients return to light work at 3 months")
add_bullet("Heavy manual labour (construction work) can resume at 5-6 months after confirmed healing on X-ray")
add_bullet("Encourage patient to practise adaptations with left hand for daily work during recovery")
add_bullet("If financial hardship — advise to apply for Employee State Insurance (ESI) disability benefit or hospital social welfare fund")
add_bullet("Reassure family: with proper fixation and rehabilitation, full forearm function is expected to be restored")

add_h2("8. Patient Education Verification (Teach-Back)")
add_para("The following was verified with patient and wife using teach-back method before discharge:")
add_table_2col([
    ("Cast care and when to return", "Patient correctly identified 4 warning signs and demonstrated cast-drying technique"),
    ("Medication names and timing", "Wife correctly repeated medication schedule"),
    ("Exercises", "Patient demonstrated finger exercises and shoulder circles correctly"),
    ("Follow-up date", "Patient correctly stated follow-up date and hospital contact"),
    ("Diet", "Patient and wife listed protein and calcium-rich foods correctly"),
])

add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
#  REFERENCES
# ═══════════════════════════════════════════════════════════════════════════
add_h1("REFERENCES")
refs = [
    "Streubel PN, Grossman LS. Diaphyseal Fractures of the Radius and Ulna. In: Rockwood and Green's Fractures in Adults, 10th Edition. Wolters Kluwer; 2025.",
    "Henderson VA. The Nature of Nursing. Macmillan; 1966.",
    "Townsend CM. Sabiston Textbook of Surgery. 21st Edition. Elsevier; 2023.",
    "Lewis SL, Bucher L, Heitkemper MM, Harding MM. Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 10th Edition. Elsevier/Mosby; 2017.",
    "Moorhead S, Johnson M, Maas ML, Swanson E. Nursing Outcomes Classification (NOC). 6th Edition. Elsevier; 2018.",
    "Bulechek GM, Butcher HK, Dochterman JM, Wagner CM. Nursing Interventions Classification (NIC). 7th Edition. Elsevier; 2018.",
    "Herdman TH, Kamitsuru S. NANDA International Nursing Diagnoses: Definitions and Classification 2021-2023. Thieme; 2021.",
    "Indian Orthopaedic Association. Clinical Practice Guidelines for Management of Forearm Fractures. IOA; 2022.",
    "AIIMS Nursing Practice Standards. Department of Orthopaedics. AIIMS New Delhi; 2023.",
]
for i, ref in enumerate(refs, 1):
    p = doc.add_paragraph(f"{i}. {ref}")
    p.runs[0].font.name = 'Times New Roman'
    p.runs[0].font.size = Pt(11)

# ── Save ─────────────────────────────────────────────────────────────────
out_path = '/tmp/workspace/radius-ulna-case/Radius_Ulna_Fracture_Case_Presentation_BSc_Nursing.docx'
doc.save(out_path)
print(f"Saved: {out_path}")