#!/usr/bin/env python3
"""
MBBS Phase 3 Part 2 - General Surgery & Allied
Long Answer Questions - Comprehensive Study PDF
"""

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm, mm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.platypus.flowables import Flowable
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.graphics.shapes import Drawing, Rect, String, Line, Arrow, Polygon, Circle
from reportlab.graphics.charts.flowcharts import *
from reportlab.graphics import renderPDF
import io

# ─── Colour palette ───────────────────────────────────────────────────────────
DARK_BLUE   = colors.HexColor('#1a2a5e')
MED_BLUE    = colors.HexColor('#2563eb')
LIGHT_BLUE  = colors.HexColor('#dbeafe')
ACCENT_TEAL = colors.HexColor('#0e7490')
ACCENT_GREEN= colors.HexColor('#15803d')
GOLD        = colors.HexColor('#b45309')
LIGHT_GOLD  = colors.HexColor('#fef9c3')
LIGHT_GREEN = colors.HexColor('#dcfce7')
LIGHT_TEAL  = colors.HexColor('#ccfbf1')
RED         = colors.HexColor('#dc2626')
LIGHT_RED   = colors.HexColor('#fee2e2')
PURPLE      = colors.HexColor('#7c3aed')
LIGHT_PURPLE= colors.HexColor('#ede9fe')
GREY_BG     = colors.HexColor('#f8fafc')
GREY_BORDER = colors.HexColor('#e2e8f0')
WHITE       = colors.white
BLACK       = colors.black

# ─── Custom Flowables ─────────────────────────────────────────────────────────

class ColoredBox(Flowable):
    """A rounded colored info box."""
    def __init__(self, content_paragraphs, bg_color=LIGHT_BLUE, border_color=MED_BLUE,
                 left_accent=True, width=None):
        self.content = content_paragraphs
        self.bg = bg_color
        self.border = border_color
        self.left_accent = left_accent
        self._width = width or (A4[0] - 4*cm)
        super().__init__()

    def wrap(self, availWidth, availHeight):
        self._width = availWidth
        return self._width, 0  # height computed in draw

    def draw(self):
        pass  # rendered via Table


def make_box(paragraphs, bg=LIGHT_BLUE, border=MED_BLUE, width=None):
    """Return a Table acting as a styled box."""
    w = width or (A4[0] - 4*cm)
    data = [[paragraphs]]
    t = Table(data, colWidths=[w])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), bg),
        ('BOX', (0,0), (-1,-1), 1.5, border),
        ('LEFTPADDING', (0,0), (-1,-1), 10),
        ('RIGHTPADDING', (0,0), (-1,-1), 10),
        ('TOPPADDING', (0,0), (-1,-1), 8),
        ('BOTTOMPADDING', (0,0), (-1,-1), 8),
        ('ROWBACKGROUNDS', (0,0), (-1,-1), [bg]),
    ]))
    return t


def make_two_col_table(left_items, right_items, headers=("",""), bg=LIGHT_BLUE, border=MED_BLUE):
    """Two-column comparison table."""
    data = [list(headers)]
    max_rows = max(len(left_items), len(right_items))
    for i in range(max_rows):
        l = left_items[i] if i < len(left_items) else ""
        r = right_items[i] if i < len(right_items) else ""
        data.append([l, r])
    col_w = (A4[0] - 4*cm) / 2
    t = Table(data, colWidths=[col_w, col_w])
    style = [
        ('BACKGROUND', (0,0), (-1,0), border),
        ('TEXTCOLOR', (0,0), (-1,0), WHITE),
        ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
        ('FONTSIZE', (0,0), (-1,0), 10),
        ('ALIGN', (0,0), (-1,-1), 'LEFT'),
        ('VALIGN', (0,0), (-1,-1), 'TOP'),
        ('BACKGROUND', (0,1), (-1,-1), bg),
        ('ROWBACKGROUNDS', (0,1), (-1,-1), [bg, WHITE]),
        ('GRID', (0,0), (-1,-1), 0.5, border),
        ('LEFTPADDING', (0,0), (-1,-1), 6),
        ('RIGHTPADDING', (0,0), (-1,-1), 6),
        ('TOPPADDING', (0,0), (-1,-1), 4),
        ('BOTTOMPADDING', (0,0), (-1,-1), 4),
        ('FONTSIZE', (0,1), (-1,-1), 9),
    ]
    t.setStyle(TableStyle(style))
    return t


def make_table(headers, rows, bg=LIGHT_BLUE, border=MED_BLUE):
    data = [headers] + rows
    n_cols = len(headers)
    col_w = (A4[0] - 4*cm) / n_cols
    t = Table(data, colWidths=[col_w]*n_cols)
    style = [
        ('BACKGROUND', (0,0), (-1,0), border),
        ('TEXTCOLOR', (0,0), (-1,0), WHITE),
        ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
        ('FONTSIZE', (0,0), (-1,0), 10),
        ('ALIGN', (0,0), (-1,-1), 'LEFT'),
        ('VALIGN', (0,0), (-1,-1), 'TOP'),
        ('BACKGROUND', (0,1), (-1,-1), bg),
        ('ROWBACKGROUNDS', (0,1), (-1,-1), [bg, WHITE]),
        ('GRID', (0,0), (-1,-1), 0.5, border),
        ('LEFTPADDING', (0,0), (-1,-1), 6),
        ('RIGHTPADDING', (0,0), (-1,-1), 6),
        ('TOPPADDING', (0,0), (-1,-1), 4),
        ('BOTTOMPADDING', (0,0), (-1,-1), 4),
        ('FONTSIZE', (0,1), (-1,-1), 9),
    ]
    t.setStyle(TableStyle(style))
    return t


# ─── Flowchart using Drawing ──────────────────────────────────────────────────

def make_flowchart(steps, colors_list=None, width=None, title=""):
    """Create a simple vertical flowchart."""
    w = width or (A4[0] - 4*cm)
    box_h = 30
    box_w = w - 20
    arrow_h = 20
    total_h = len(steps) * (box_h + arrow_h) + 20 + (30 if title else 0)
    d = Drawing(w, total_h)
    y = total_h - 10

    if title:
        d.add(String(w/2, y-15, title, fontSize=11, fontName='Helvetica-Bold',
                     textAnchor='middle', fillColor=DARK_BLUE))
        y -= 30

    default_colors = [MED_BLUE, ACCENT_TEAL, ACCENT_GREEN, GOLD, PURPLE, RED]
    for i, step in enumerate(steps):
        col = (colors_list[i] if colors_list and i < len(colors_list)
               else default_colors[i % len(default_colors)])
        box_y = y - box_h - i * (box_h + arrow_h)
        # Box
        d.add(Rect(10, box_y, box_w, box_h, rx=5, ry=5,
                   fillColor=col, strokeColor=WHITE, strokeWidth=1))
        # Text
        d.add(String(w/2, box_y + box_h/2 - 5, step, fontSize=9,
                     fontName='Helvetica-Bold', textAnchor='middle',
                     fillColor=WHITE))
        # Arrow (not after last)
        if i < len(steps) - 1:
            arrow_y_top = box_y
            arrow_y_bot = arrow_y_top - arrow_h
            d.add(Line(w/2, arrow_y_top, w/2, arrow_y_bot + 6,
                       strokeColor=DARK_BLUE, strokeWidth=2))
            # Arrowhead triangle
            d.add(Polygon([w/2 - 6, arrow_y_bot + 8, w/2 + 6, arrow_y_bot + 8,
                           w/2, arrow_y_bot], fillColor=DARK_BLUE, strokeColor=DARK_BLUE))
    return d


def make_horizontal_flowchart(steps, col_list=None, width=None):
    """Horizontal flowchart for shorter step chains."""
    w = width or (A4[0] - 4*cm)
    n = len(steps)
    arrow_w = 15
    box_w = (w - arrow_w * (n-1)) / n
    box_h = 50
    pad = 10
    total_h = box_h + 20
    d = Drawing(w, total_h)
    default_colors = [MED_BLUE, ACCENT_TEAL, ACCENT_GREEN, GOLD, PURPLE, RED]
    for i, step in enumerate(steps):
        col = (col_list[i] if col_list and i < len(col_list)
               else default_colors[i % len(default_colors)])
        x = i * (box_w + arrow_w)
        d.add(Rect(x, pad, box_w, box_h, rx=4, ry=4,
                   fillColor=col, strokeColor=WHITE, strokeWidth=1))
        # Wrap text
        words = step.split()
        line1 = ' '.join(words[:3])
        line2 = ' '.join(words[3:]) if len(words) > 3 else ''
        d.add(String(x + box_w/2, pad + box_h/2 + (4 if line2 else 0), line1,
                     fontSize=8, fontName='Helvetica-Bold', textAnchor='middle',
                     fillColor=WHITE))
        if line2:
            d.add(String(x + box_w/2, pad + box_h/2 - 8, line2,
                         fontSize=8, fontName='Helvetica-Bold', textAnchor='middle',
                         fillColor=WHITE))
        if i < n-1:
            ax = x + box_w
            ay = pad + box_h / 2
            d.add(Line(ax, ay, ax + arrow_w - 5, ay,
                       strokeColor=DARK_BLUE, strokeWidth=2))
            d.add(Polygon([ax + arrow_w - 7, ay - 5, ax + arrow_w - 7, ay + 5,
                           ax + arrow_w, ay], fillColor=DARK_BLUE, strokeColor=DARK_BLUE))
    return d


# ─── Styles ───────────────────────────────────────────────────────────────────

styles = getSampleStyleSheet()

cover_title_style = ParagraphStyle('CoverTitle', fontSize=26, leading=32,
    textColor=WHITE, fontName='Helvetica-Bold', alignment=TA_CENTER, spaceAfter=8)
cover_sub_style = ParagraphStyle('CoverSub', fontSize=14, leading=18,
    textColor=colors.HexColor('#bfdbfe'), fontName='Helvetica', alignment=TA_CENTER)
cover_info_style = ParagraphStyle('CoverInfo', fontSize=11, leading=15,
    textColor=WHITE, fontName='Helvetica', alignment=TA_CENTER)

section_header_style = ParagraphStyle('SectionHeader', fontSize=16, leading=20,
    textColor=WHITE, fontName='Helvetica-Bold', alignment=TA_LEFT,
    spaceBefore=16, spaceAfter=4, leftIndent=0)
question_title_style = ParagraphStyle('QuestionTitle', fontSize=13, leading=18,
    textColor=DARK_BLUE, fontName='Helvetica-Bold', alignment=TA_LEFT,
    spaceBefore=10, spaceAfter=6)
sub_heading_style = ParagraphStyle('SubHeading', fontSize=11, leading=15,
    textColor=ACCENT_TEAL, fontName='Helvetica-Bold', alignment=TA_LEFT,
    spaceBefore=8, spaceAfter=4)
body_style = ParagraphStyle('Body', fontSize=10, leading=15,
    textColor=BLACK, fontName='Helvetica', alignment=TA_JUSTIFY,
    spaceBefore=4, spaceAfter=4)
bullet_style = ParagraphStyle('Bullet', fontSize=10, leading=14,
    textColor=BLACK, fontName='Helvetica', leftIndent=16, bulletIndent=4,
    spaceBefore=2, spaceAfter=2)
bold_body_style = ParagraphStyle('BoldBody', fontSize=10, leading=14,
    textColor=DARK_BLUE, fontName='Helvetica-Bold', spaceBefore=4, spaceAfter=2)
italic_style = ParagraphStyle('Italic', fontSize=9.5, leading=13,
    textColor=colors.HexColor('#374151'), fontName='Helvetica-Oblique',
    spaceBefore=2, spaceAfter=2)
ref_style = ParagraphStyle('Ref', fontSize=8, leading=11,
    textColor=colors.HexColor('#6b7280'), fontName='Helvetica-Oblique',
    alignment=TA_RIGHT)
small_bold = ParagraphStyle('SmallBold', fontSize=9, leading=13,
    textColor=DARK_BLUE, fontName='Helvetica-Bold')
note_style = ParagraphStyle('Note', fontSize=9, leading=13,
    textColor=GOLD, fontName='Helvetica-BoldOblique', spaceBefore=2, spaceAfter=2)

def b(text): return f'<b>{text}</b>'
def i(text): return f'<i>{text}</i>'
def bi(text): return f'<b><i>{text}</i></b>'
def col(text, c): return f'<font color="{c}">{text}</font>'

def section_banner(title, bg=DARK_BLUE):
    data = [[Paragraph(title, section_header_style)]]
    t = Table(data, colWidths=[A4[0] - 4*cm])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), bg),
        ('LEFTPADDING', (0,0), (-1,-1), 12),
        ('RIGHTPADDING', (0,0), (-1,-1), 12),
        ('TOPPADDING', (0,0), (-1,-1), 8),
        ('BOTTOMPADDING', (0,0), (-1,-1), 8),
    ]))
    return t


def question_banner(qnum, title, marks, bg=MED_BLUE):
    txt = f'Q{qnum}. {title}  [{marks}]'
    data = [[Paragraph(txt, ParagraphStyle('QBanner', fontSize=12, leading=16,
                                           textColor=WHITE, fontName='Helvetica-Bold'))]]
    t = Table(data, colWidths=[A4[0] - 4*cm])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), bg),
        ('LEFTPADDING', (0,0), (-1,-1), 10),
        ('RIGHTPADDING', (0,0), (-1,-1), 10),
        ('TOPPADDING', (0,0), (-1,-1), 7),
        ('BOTTOMPADDING', (0,0), (-1,-1), 7),
    ]))
    return t

# ─── Document setup ───────────────────────────────────────────────────────────

OUTPUT = '/tmp/workspace/surgery-exam/Surgery_Exam_Answers.pdf'
doc = SimpleDocTemplate(OUTPUT, pagesize=A4,
                        leftMargin=2*cm, rightMargin=2*cm,
                        topMargin=2.2*cm, bottomMargin=2.2*cm,
                        title="MBBS Surgery Long Answer Exam")

story = []
W = A4[0] - 4*cm  # usable width

# ═══════════════════════════════════════════════════════════════════════════════
# COVER PAGE
# ═══════════════════════════════════════════════════════════════════════════════

cover_bg_data = [[
    Paragraph("MBBS Phase 3 Part 2", cover_sub_style),
    Spacer(1, 0.3*cm),
    Paragraph("GENERAL SURGERY &amp; ALLIED", cover_title_style),
    Spacer(1, 0.2*cm),
    Paragraph("Term 2 Examination", cover_sub_style),
    Spacer(1, 0.8*cm),
    Paragraph("Long Answer Model Responses", ParagraphStyle('X', fontSize=15,
        textColor=colors.HexColor('#a5f3fc'), fontName='Helvetica-Bold', alignment=TA_CENTER)),
    Spacer(1, 1.5*cm),
    Paragraph("Questions Covered", ParagraphStyle('Y', fontSize=12,
        textColor=WHITE, fontName='Helvetica-Bold', alignment=TA_CENTER)),
    Spacer(1, 0.3*cm),
    Paragraph("Q3 | Q4 | Q5 | Q6 | Q7 | Q8 | Q21", ParagraphStyle('Z', fontSize=13,
        textColor=colors.HexColor('#fde68a'), fontName='Helvetica-Bold', alignment=TA_CENTER)),
    Spacer(1, 1.8*cm),
    HRFlowable(width=W, thickness=1, color=colors.HexColor('#93c5fd')),
    Spacer(1, 0.4*cm),
    Paragraph("References: Bailey &amp; Love's Surgery 28e | Robbins Pathology | Current Surgical Therapy 14e | Bailey &amp; Love | Scott-Brown's Otolaryngology",
              ParagraphStyle('Refs', fontSize=9, textColor=colors.HexColor('#93c5fd'),
                             fontName='Helvetica-Oblique', alignment=TA_CENTER)),
]]
cover_table = Table([[cover_bg_data[0][i] for i in range(len(cover_bg_data[0]))]], colWidths=[W])
# Actually let's do it as a single cell block
cover_content = [
    Spacer(1, 1*cm),
]
cover_items = [
    Paragraph("MBBS Phase 3 Part 2", cover_sub_style),
    Spacer(1, 0.3*cm),
    Paragraph("GENERAL SURGERY &amp; ALLIED", cover_title_style),
    Spacer(1, 0.2*cm),
    Paragraph("Term 2 Examination", cover_sub_style),
    Spacer(1, 0.8*cm),
    Paragraph("Long Answer Model Responses", ParagraphStyle('X', fontSize=15,
        textColor=colors.HexColor('#a5f3fc'), fontName='Helvetica-Bold', alignment=TA_CENTER)),
    Spacer(1, 1.5*cm),
    Paragraph("Questions Covered", ParagraphStyle('Y', fontSize=12,
        textColor=WHITE, fontName='Helvetica-Bold', alignment=TA_CENTER)),
    Spacer(1, 0.3*cm),
    Paragraph("Q3 | Q4 | Q5 | Q6 | Q7 | Q8 | Q21", ParagraphStyle('Z', fontSize=13,
        textColor=colors.HexColor('#fde68a'), fontName='Helvetica-Bold', alignment=TA_CENTER)),
    Spacer(1, 2*cm),
    HRFlowable(width=W, thickness=1, color=colors.HexColor('#93c5fd')),
    Spacer(1, 0.4*cm),
    Paragraph("References: Bailey &amp; Love's Surgery 28e | Robbins Pathology | Current Surgical Therapy 14e | Scott-Brown's Otolaryngology | Murray &amp; Nadel Respiratory Medicine",
              ParagraphStyle('Refs', fontSize=9, textColor=colors.HexColor('#93c5fd'),
                             fontName='Helvetica-Oblique', alignment=TA_CENTER)),
]

cover_cell = Table([[item] for item in cover_items], colWidths=[W])
cover_cell.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,-1), DARK_BLUE),
    ('LEFTPADDING', (0,0), (-1,-1), 20),
    ('RIGHTPADDING', (0,0), (-1,-1), 20),
    ('TOPPADDING', (0,0), (-1,-1), 2),
    ('BOTTOMPADDING', (0,0), (-1,-1), 2),
]))
story.append(cover_cell)
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# Q3 SHORT NOTES (4 marks each = 20 marks)
# ═══════════════════════════════════════════════════════════════════════════════

story.append(section_banner("Q3. SHORT NOTES (4 Marks Each = 20 Marks)"))
story.append(Spacer(1, 0.3*cm))

# ── 3a. Pleomorphic Adenoma ───────────────────────────────────────────────────
story.append(question_banner("3a", "Pleomorphic Adenoma", "4 Marks"))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(b("Definition"), sub_heading_style))
story.append(Paragraph(
    "Pleomorphic adenoma (PA) is the most common benign salivary gland tumour, accounting for "
    "60–70% of all salivary gland neoplasms. The term 'pleomorphic' reflects the histological "
    "diversity of epithelial, myoepithelial, and stromal components.",
    body_style))

story.append(Paragraph(b("Epidemiology"), sub_heading_style))
story.append(make_table(
    ["Parameter", "Details"],
    [["Age", "Any age; peak 3rd–6th decade (avg. 45 years)"],
     ["Sex", "More common in women"],
     ["Site", "Parotid gland >80%; also submandibular, hard palate"],
     ["Malignant transformation", "~5%; carcinoma ex pleomorphic adenoma"]],
    bg=LIGHT_BLUE, border=MED_BLUE))

story.append(Paragraph(b("Clinical Features"), sub_heading_style))
story.append(Paragraph(
    "Presents as a <b>painless, well-defined, solitary, mobile mass</b> with slow progressive "
    "growth over years. Deep lobe parotid tumours may cause a paratonsillar bulge. Warning signs "
    "of malignant transformation include sudden increase in size and facial nerve palsy.",
    body_style))

story.append(Paragraph(b("Histopathology"), sub_heading_style))
story.append(Paragraph(
    "Gross: well-circumscribed, firm, white-to-tan nodular mass with possible cartilaginous areas. "
    "Microscopy reveals a mixture of epithelial cells (ductal), myoepithelial cells, and variable "
    "stroma (myxoid, chondroid, hyalinised). Immunohistochemistry: luminal cells express CK7; "
    "myoepithelial cells express p63, S-100, SOX10, SMA.",
    body_style))

story.append(Paragraph(b("Treatment"), sub_heading_style))
story.append(Paragraph(
    "Superficial parotidectomy with preservation of facial nerve, ensuring excision with a cuff "
    "of normal tissue around the pseudopods. <b>Enucleation alone is avoided</b> due to capsular "
    "breach and high local recurrence rate (20–45%).",
    body_style))
story.append(make_box(
    [Paragraph("<b>Key Point:</b> Do NOT enucleate - high recurrence. Superficial parotidectomy is standard. "
               "Recurrent PA may undergo malignant transformation (carcinoma ex PA).", note_style)],
    bg=LIGHT_GOLD, border=GOLD))
story.append(Paragraph(i("Reference: Bailey and Love's Short Practice of Surgery, 28th Ed., Ch. 54"), ref_style))
story.append(Spacer(1, 0.4*cm))

# ── 3b. Thoracic Outlet Syndrome ─────────────────────────────────────────────
story.append(question_banner("3b", "Thoracic Outlet Syndrome (TOS)", "4 Marks"))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(b("Definition"), sub_heading_style))
story.append(Paragraph(
    "Thoracic Outlet Syndrome (TOS) is a group of disorders caused by compression of the "
    "neurovascular structures (brachial plexus, subclavian artery/vein) as they pass through "
    "the thoracic outlet - the space between the clavicle, first rib, and scalene muscles.",
    body_style))

story.append(Paragraph(b("Types"), sub_heading_style))
story.append(make_table(
    ["Type", "Compressed Structure", "Frequency", "Features"],
    [["Neurogenic TOS", "Brachial plexus (C8/T1)", "~95%", "Pain, paraesthesia, weakness in arm/hand"],
     ["Venous TOS (Paget-Schroetter)", "Subclavian vein", "~4%", "Arm swelling, cyanosis, effort thrombosis"],
     ["Arterial TOS", "Subclavian artery", "~1%", "Ischaemia, Raynaud's, emboli to hand"]],
    bg=LIGHT_TEAL, border=ACCENT_TEAL))

story.append(Paragraph(b("Causes / Anatomy"), sub_heading_style))
story.append(Paragraph(
    "Bony anomalies: cervical rib (most common), elongated C7 transverse process, abnormal "
    "first rib, post-clavicular fracture callus. Soft tissue: tight scalene muscles, anomalous "
    "fibromuscular bands. Predisposing postures: overhead repetitive activities.",
    body_style))

story.append(Paragraph(b("Clinical Features"), sub_heading_style))
for pt in [
    "Neck and shoulder pain radiating to arm (C8/T1 distribution)",
    "Paraesthesia and numbness in ring and little fingers (ulnar pattern)",
    "Weakness of intrinsic hand muscles - Gilliatt-Sumner hand (wasting of thenar, hypothenar)",
    "Positive provocation tests: Adson's test, Wright's test, Roos test (EAST test)",
    "In venous TOS: arm oedema, cyanosis, dilated collateral veins over shoulder"
]:
    story.append(Paragraph(f"• {pt}", bullet_style))

story.append(Paragraph(b("Investigations"), sub_heading_style))
for inv in ["X-ray: cervical rib, first rib anomaly",
            "MRI/CT angiography: vascular compression",
            "Nerve conduction studies: ulnar nerve slowing",
            "Duplex ultrasound / venography for venous TOS"]:
    story.append(Paragraph(f"• {inv}", bullet_style))

story.append(Paragraph(b("Treatment"), sub_heading_style))
story.append(make_two_col_table(
    ["Physiotherapy and postural correction", "Scalene muscle stretching", "NSAIDs for pain"],
    ["First rib resection (transaxillary/supraclavicular approach)", "Cervical rib excision",
     "Thrombolysis + vein decompression (Paget-Schroetter)"],
    headers=["Conservative", "Surgical"],
    bg=LIGHT_TEAL, border=ACCENT_TEAL))
story.append(Paragraph(i("Reference: Rosen's Emergency Medicine 10e; Sabiston Textbook of Surgery"), ref_style))
story.append(Spacer(1, 0.4*cm))

# ── 3c. Stages of Tubercular Lymphadenitis ────────────────────────────────────
story.append(question_banner("3c", "Stages of Tubercular Lymphadenitis", "4 Marks"))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(b("Introduction"), sub_heading_style))
story.append(Paragraph(
    "Tubercular lymphadenitis is the most common form of extra-pulmonary tuberculosis, "
    "accounting for 30–40% of peripheral lymphadenopathy. The cervical group is most often "
    "affected (scrofula). Caused by Mycobacterium tuberculosis.",
    body_style))

stages_flow = make_flowchart([
    "Stage I: Reactive Lymphadenitis",
    "Stage II: Periadenitis",
    "Stage III: Caseation / Caseous Necrosis",
    "Stage IV: Collar-Stud Abscess",
    "Stage V: Sinus Formation"
], colors_list=[MED_BLUE, ACCENT_TEAL, ACCENT_GREEN, GOLD, RED], title="Stages of Tubercular Lymphadenitis")
story.append(stages_flow)
story.append(Spacer(1, 0.3*cm))

story.append(make_table(
    ["Stage", "Pathology", "Clinical Features"],
    [["I - Reactive lymphadenitis",
      "Lymphocytic proliferation, no caseation. Node soft, tender.",
      "Single or multiple enlarged, tender, soft, discrete nodes"],
     ["II - Periadenitis",
      "Pericapsular inflammation; nodes become matted together.",
      "Matted nodes; adherent to overlying skin and deep structures"],
     ["III - Caseation",
      "Central caseous necrosis within node. Typical TB granuloma: Langhans giant cells.",
      "Firm, non-tender node; skin may become indurated"],
     ["IV - Collar-stud / Cold abscess",
      "Caseous material liquefies, pus tracks through deep fascia; bilocular collection.",
      "Fluctuant swelling above and below deep fascia connected through a defect - 'collar-stud'"],
     ["V - Sinus",
      "Collar-stud abscess ruptures through skin; chronic discharging sinus.",
      "Discharging sinus with bluish-undermined edges; secondary infection possible"]],
    bg=LIGHT_BLUE, border=MED_BLUE))

story.append(Paragraph(b("Treatment"), sub_heading_style))
story.append(Paragraph(
    "<b>Anti-tubercular therapy (ATT):</b> HRZE for 2 months (intensive phase) then HR for "
    "4 months (continuation phase). Surgery indicated for: diagnostic biopsy, aspiration of "
    "fluctuant nodes, excision of persistently enlarged nodes, sinus tract excision.",
    body_style))
story.append(Paragraph(i("Reference: Bailey and Love's Surgery 28e; Das's Clinical Surgery"), ref_style))
story.append(Spacer(1, 0.4*cm))

# ── 3d. Solitary Thyroid Nodule ───────────────────────────────────────────────
story.append(question_banner("3d", "Solitary Thyroid Nodule", "4 Marks"))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(b("Definition"), sub_heading_style))
story.append(Paragraph(
    "A solitary thyroid nodule (STN) is a discrete swelling within an otherwise normal thyroid "
    "gland, palpable or detected on imaging. Prevalence: palpable ~5%; ultrasound detectable ~19–67%. "
    "About 5–10% of STNs are malignant.",
    body_style))

story.append(Paragraph(b("Causes (Differential Diagnosis)"), sub_heading_style))
story.append(make_table(
    ["Benign (90–95%)", "Malignant (5–10%)"],
    [["Colloid cyst / adenomatous nodule", "Papillary carcinoma (most common, 80%)"],
     ["Follicular adenoma", "Follicular carcinoma"],
     ["Thyroid cyst (simple/haemorrhagic)", "Medullary carcinoma"],
     ["Hashimoto's thyroiditis (focal)", "Anaplastic carcinoma"],
     ["Hürthle cell adenoma", "Lymphoma (rare)"]],
    bg=LIGHT_GREEN, border=ACCENT_GREEN))

story.append(Paragraph(b("Evaluation - FNAC is gold standard"), sub_heading_style))

stn_eval = make_horizontal_flowchart(
    ["History & Examination", "TFTs + USS", "FNAC (Bethesda)", "Thyroid Scan if needed", "Surgery Decision"],
    col_list=[MED_BLUE, ACCENT_TEAL, ACCENT_GREEN, GOLD, RED])
story.append(stn_eval)
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(b("Bethesda Classification (FNAC)"), sub_heading_style))
story.append(make_table(
    ["Category", "Diagnosis", "Malignancy Risk", "Action"],
    [["I", "Non-diagnostic", "1–4%", "Repeat FNAC"],
     ["II", "Benign", "0–3%", "Clinical follow-up"],
     ["III", "AUS/FLUS", "~10–15%", "Repeat FNAC or molecular testing"],
     ["IV", "Follicular neoplasm", "25–40%", "Lobectomy"],
     ["V", "Suspicious for malignancy", "50–75%", "Near-total thyroidectomy"],
     ["VI", "Malignant", "97–99%", "Total thyroidectomy"]],
    bg=LIGHT_BLUE, border=MED_BLUE))

story.append(Paragraph(b("Features Favouring Malignancy"), sub_heading_style))
for feat in ["Age <20 or >60 years", "Male sex", "Rapidly growing solid nodule",
             "Hard, irregular, fixed", "Cervical lymphadenopathy",
             "Hoarseness (RLN involvement)", "History of radiation to neck",
             "Family history of MEN2 or medullary carcinoma"]:
    story.append(Paragraph(f"• {feat}", bullet_style))
story.append(Paragraph(i("Reference: Bailey and Love's Surgery 28e; Das's Clinical Surgery"), ref_style))
story.append(Spacer(1, 0.4*cm))

# ── 3e. MEN Syndrome ──────────────────────────────────────────────────────────
story.append(question_banner("3e", "Multiple Endocrine Neoplasia (MEN) Syndrome", "4 Marks"))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(b("Definition"), sub_heading_style))
story.append(Paragraph(
    "Multiple Endocrine Neoplasia (MEN) syndromes are a group of autosomal dominant inherited "
    "disorders characterised by the development of tumours in two or more endocrine glands.",
    body_style))

story.append(make_table(
    ["Feature", "MEN 1 (Wermer's)", "MEN 2A (Sipple's)", "MEN 2B"],
    [["Gene mutation", "MEN1 (menin, Ch. 11q13)", "RET proto-oncogene", "RET proto-oncogene"],
     ["Parathyroid", "Hyperplasia/adenoma (95%)", "Hyperplasia (20–30%)", "Usually absent"],
     ["Pancreas", "Gastrinoma, insulinoma, VIPoma (30–75%)", "Absent", "Absent"],
     ["Thyroid", "Absent", "Medullary carcinoma (100%)", "Medullary carcinoma (100%)"],
     ["Adrenal", "Absent", "Phaeochromocytoma (50%)", "Phaeochromocytoma (50%)"],
     ["Other", "Pituitary adenoma (prolactinoma 60%)", "Nil specific", "Marfanoid, mucosal neuromas, ganglioneuromas"],
     ["Mnemonic", "3 Ps: Pituitary, Parathyroid, Pancreas", "2 Ps: Parathyroid + Phaeochromocytoma + Medullary Ca", "Marfanoid body"]],
    bg=LIGHT_PURPLE, border=PURPLE))

story.append(Paragraph(b("Clinical Significance"), sub_heading_style))
story.append(Paragraph(
    "MEN syndromes require genetic screening of family members. In MEN2, prophylactic "
    "thyroidectomy is recommended in RET mutation carriers before age 5 (MEN2A) or in infancy "
    "(MEN2B). Phaeochromocytoma must be treated before thyroid surgery.",
    body_style))
story.append(Paragraph(i("Reference: Bailey and Love's Surgery 28e; Sabiston Textbook of Surgery"), ref_style))
story.append(Spacer(1, 0.4*cm))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# Q4 EXPLAIN WHY (4 marks each = 12 marks)
# ═══════════════════════════════════════════════════════════════════════════════

story.append(section_banner("Q4. EXPLAIN WHY (4 Marks Each = 12 Marks)", bg=ACCENT_TEAL))
story.append(Spacer(1, 0.3*cm))

# ── 4a. Abdominal TB at IC junction ───────────────────────────────────────────
story.append(question_banner("4a", "Abdominal Tuberculosis is More Common at the Ileocaecal Junction", "4 Marks", bg=ACCENT_TEAL))
story.append(Spacer(1, 0.2*cm))

story.append(make_box([
    Paragraph("<b>Short Answer:</b> The ileocaecal (IC) region accounts for 80–90% of all "
              "gastrointestinal tuberculosis cases because of a unique combination of anatomical, "
              "physiological, and immunological factors.", body_style)], bg=LIGHT_TEAL, border=ACCENT_TEAL))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(b("Reasons"), sub_heading_style))
reasons_4a = [
    ("<b>1. Abundant lymphoid tissue (Peyer's patches):</b>",
     "The terminal ileum and ileocaecal region contain the highest concentration of Peyer's patches "
     "in the gut. M. tuberculosis, after being swallowed, is taken up by M cells overlying Peyer's patches, "
     "establishing primary infection."),
    ("<b>2. Physiological stasis:</b>",
     "The ileocaecal valve slows intestinal transit. Prolonged contact time between ingested "
     "mycobacteria and intestinal mucosa greatly increases the chance of mucosal penetration."),
    ("<b>3. Relative alkaline pH:</b>",
     "The caecum and terminal ileum have a relatively alkaline environment, which is favourable "
     "for mycobacterial survival and growth."),
    ("<b>4. Extensive lymphatic drainage:</b>",
     "Rich mesenteric lymphatic supply around the ileocaecal region facilitates retrograde "
     "spread from mesenteric nodes back to bowel wall."),
    ("<b>5. High absorptive activity:</b>",
     "The terminal ileum is the primary site of absorption - increased absorptive surface contact "
     "promotes mycobacterial uptake."),
    ("<b>6. Retrograde spread from appendix:</b>",
     "The lymphatic drainage of the appendix drains directly into the ileocaecal lymph nodes, "
     "facilitating direct spread to the IC junction."),
]
for title, desc in reasons_4a:
    story.append(Paragraph(title, bold_body_style))
    story.append(Paragraph(desc, body_style))

story.append(Paragraph(b("Pathological Forms at IC junction"), sub_heading_style))
story.append(make_table(
    ["Form", "Frequency", "Key Features"],
    [["Ulcerative", "~60%", "Transverse ulcers along lymphoid follicles; bleeding, malabsorption"],
     ["Hypertrophic", "~10%", "Fibrosis, thickening; RIF mass mimicking carcinoma caecum"],
     ["Ulcero-hypertrophic", "~30%", "Mixed features; stricture, obstruction"]],
    bg=LIGHT_TEAL, border=ACCENT_TEAL))
story.append(Paragraph(i("Reference: Bailey and Love's Surgery 28e; Das's Clinical Surgery"), ref_style))
story.append(Spacer(1, 0.4*cm))

# ── 4b. Beta Blocker before Thyroid Surgery ───────────────────────────────────
story.append(question_banner("4b", "Beta Blocker is Needed Before Thyroid Surgery", "4 Marks", bg=ACCENT_TEAL))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(b("Context"), sub_heading_style))
story.append(Paragraph(
    "Beta blockers are administered preoperatively in patients with <b>hyperthyroidism</b> "
    "(Graves' disease, toxic adenoma, toxic MNG) who are undergoing thyroid surgery. They are "
    "not routinely required for euthyroid patients.",
    body_style))

story.append(Paragraph(b("Reasons Beta Blockers are Needed"), sub_heading_style))
beta_reasons = [
    ("1. Control of sympathetic hyperactivity:",
     "Hyperthyroidism causes excess thyroid hormone which sensitises the myocardium to "
     "catecholamines via upregulation of beta-adrenergic receptors. This causes tachycardia, "
     "hypertension, AF, and tremor. Beta blockers (propranolol) block these effects."),
    ("2. Prevention of thyroid storm:",
     "Surgical manipulation of a toxic gland can release large amounts of preformed T3/T4 into "
     "circulation, triggering thyroid storm (hyperpyrexia, tachycardia, hypotension, coma). "
     "Beta blockade prevents the cardiovascular manifestations and is life-saving."),
    ("3. Reduce vascularity of gland:",
     "Propranolol decreases thyroid blood flow by blocking beta-2 adrenergic vasodilation, "
     "reducing intraoperative bleeding."),
    ("4. Inhibit peripheral T4 to T3 conversion:",
     "Propranolol inhibits 5'-deiodinase, reducing conversion of T4 to the more active T3, "
     "thus reducing the metabolic effects."),
    ("5. Anxiolysis and stabilisation:",
     "Helps control tremor, anxiety, and tachycardia preoperatively, improving patient fitness for anaesthesia."),
]
for title, desc in beta_reasons:
    story.append(Paragraph(f"<b>{title}</b>", bold_body_style))
    story.append(Paragraph(desc, body_style))

story.append(make_box([
    Paragraph("<b>Standard Protocol:</b> Propranolol 40–80 mg TDS for 7–10 days preoperatively, "
              "maintained until heart rate &lt;80 bpm. Combined with antithyroid drugs (Carbimazole) "
              "and Lugol's iodine (reduces vascularity by Wolf-Chaikoff effect).", body_style)],
    bg=LIGHT_GOLD, border=GOLD))
story.append(Paragraph(i("Reference: Bailey and Love's Surgery 28e; Das's Clinical Surgery"), ref_style))
story.append(Spacer(1, 0.4*cm))

# ── 4c. Appendicitis managed earlier in children & elderly ────────────────────
story.append(question_banner("4c", "Appendicitis is Managed Earlier in Children and Elderly", "4 Marks", bg=ACCENT_TEAL))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(b("General Principle"), sub_heading_style))
story.append(Paragraph(
    "Acute appendicitis progresses to perforation faster and with less obvious signs in both "
    "extremes of age (children and elderly) compared with young adults. Early operative "
    "intervention is therefore mandatory to prevent perforation and peritonitis.",
    body_style))

story.append(make_two_col_table(
    [
        b("In Children:"),
        "Appendix wall is thin - rapid perforation (within 24-36 hrs)",
        "Omentum is underdeveloped - cannot wall off perforation",
        "High prevalence of lymphoid hyperplasia as cause",
        "Inability to localise pain - diagnosis is delayed",
        "Vomiting and diarrhoea common - mistaken for gastroenteritis",
        "Free perforation leads to generalised peritonitis rapidly",
        "High mortality if generalised peritonitis develops",
    ],
    [
        b("In Elderly:"),
        "Atherosclerosis reduces mesenteric blood flow - rapid ischaemia",
        "Blunted immune response - less inflammatory reaction",
        "Atypical presentation - little guarding or rebound",
        "Delayed presentation to hospital (>48 hrs usually)",
        "Higher incidence of appendiceal malignancy (underlying cause)",
        "Omentum less mobile - poor localisation",
        "High co-morbidities increase perioperative risk",
    ],
    headers=["Children", "Elderly"],
    bg=LIGHT_RED, border=RED
))
story.append(Paragraph(b("Consequence"), sub_heading_style))
story.append(Paragraph(
    "Perforation rates: up to 80–100% in children under 2 years vs. 70% in elderly vs. "
    "20–30% in young adults. Hence the Alvarado score is used to guide early surgery, "
    "and threshold for appendicectomy is lower at these age extremes.",
    body_style))
story.append(Paragraph(i("Reference: Bailey and Love's Surgery 28e; Current Surgical Therapy 14e"), ref_style))
story.append(Spacer(1, 0.4*cm))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# Q5 SHORT NOTES (3 marks each = 15 marks)
# ═══════════════════════════════════════════════════════════════════════════════

story.append(section_banner("Q5. SHORT NOTES (3 Marks Each = 15 Marks)", bg=ACCENT_GREEN))
story.append(Spacer(1, 0.3*cm))

# ── 5a. Zuska's (Atkin's) Disease ─────────────────────────────────────────────
story.append(question_banner("5a", "Zuska's Disease (Atkin's Disease / Periductal Mastitis)", "3 Marks", bg=ACCENT_GREEN))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "Zuska's disease (also called periductal mastitis or mammary duct fistula) is a benign "
    "inflammatory condition of the breast characterised by <b>non-lactational breast abscesses</b> "
    "recurring at the areolar margin with eventual <b>mammary duct fistula</b> formation.",
    body_style))
story.append(Paragraph(b("Pathogenesis"), sub_heading_style))
story.append(Paragraph(
    "Squamous metaplasia of lactiferous duct epithelium near the nipple causes ductal "
    "obstruction. Keratin plugs accumulate, causing ductal dilatation and rupture. "
    "Spillage of keratin into periductal tissue triggers intense inflammatory reaction. "
    "Strong association with <b>smoking</b> (anaerobic organisms like Bacteroides).",
    body_style))
story.append(Paragraph(b("Clinical Features"), sub_heading_style))
for pt in [
    "Young women, often smokers",
    "Recurrent periareolar abscess (often off-centre)",
    "Nipple retraction (central/slit-like) due to periductal fibrosis",
    "Mammary duct fistula: sinus opening at areolar margin discharging caseous material",
    "Not associated with pregnancy or lactation",
]:
    story.append(Paragraph(f"• {pt}", bullet_style))
story.append(Paragraph(b("Treatment"), sub_heading_style))
story.append(Paragraph(
    "Acute: incision and drainage. Definitive: total duct excision (Hadfield's operation) "
    "with fistulectomy. Antibiotics covering anaerobes (metronidazole + co-amoxiclav). "
    "Cessation of smoking is essential.",
    body_style))
story.append(Spacer(1, 0.3*cm))

# ── 5b. Traumatic Fat Necrosis of Breast ─────────────────────────────────────
story.append(question_banner("5b", "Traumatic Fat Necrosis of the Breast", "3 Marks", bg=ACCENT_GREEN))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "A benign condition caused by saponification of fat in breast tissue following trauma. "
    "Clinically and radiologically it can mimic carcinoma - making it a <b>great simulator of cancer</b>.",
    body_style))
story.append(Paragraph(b("Pathogenesis"), sub_heading_style))
story.append(Paragraph(
    "Blunt trauma (seat belt, sports, biopsy, surgery, radiation) disrupts adipocytes. "
    "Lipase released causes saponification. Initially haemorrhage and necrosis, then "
    "macrophage infiltration (foam cells/lipophages), giant cell reaction, fibrosis, "
    "and ultimately calcification.",
    body_style))
story.append(Paragraph(b("Clinical Features"), sub_heading_style))
for pt in [
    "History of trauma (sometimes forgotten)",
    "Hard, irregular, painless lump - closely mimics carcinoma",
    "Skin tethering or dimpling (due to fibrosis)",
    "Eggshell calcification on mammography (pathognomonic when present)",
    "No axillary lymphadenopathy",
]:
    story.append(Paragraph(f"• {pt}", bullet_style))
story.append(Paragraph(b("Diagnosis & Treatment"), sub_heading_style))
story.append(Paragraph(
    "Triple assessment (clinical + imaging + FNAC/core biopsy). On core biopsy: lipophages, "
    "foreign body giant cells, haemosiderin deposits. If benign: reassurance and observation. "
    "Excision if diagnosis is uncertain or lump is large.",
    body_style))
story.append(Spacer(1, 0.3*cm))

# ── 5c. Omental Torsion ───────────────────────────────────────────────────────
story.append(question_banner("5c", "Omental Torsion", "3 Marks", bg=ACCENT_GREEN))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "Omental torsion is a rare cause of acute abdomen caused by twisting of the omentum "
    "around its vascular pedicle, leading to venous obstruction, oedema, and eventually "
    "haemorrhagic infarction of the affected omental segment.",
    body_style))
story.append(Paragraph(b("Types"), sub_heading_style))
story.append(make_two_col_table(
    ["Primary (idiopathic): no predisposing lesion; rotation of free omental segment",
     "More common on right side (redundant omentum near caecum)"],
    ["Secondary: associated with hernia sac, adhesions, cysts, or tumour",
     "Precipitated by sudden exertion, coughing, or change in posture"],
    headers=["Primary Torsion", "Secondary Torsion"],
    bg=LIGHT_GREEN, border=ACCENT_GREEN
))
story.append(Paragraph(b("Clinical Features"), sub_heading_style))
for pt in [
    "Acute right-sided abdominal pain (mimics acute appendicitis or cholecystitis)",
    "Nausea, vomiting present",
    "Low-grade fever; leucocytosis",
    "Tender mass palpable in RIF/RUQ",
    "Normal WBC appendicitis labs - important differentiator",
]:
    story.append(Paragraph(f"• {pt}", bullet_style))
story.append(Paragraph(b("Diagnosis & Treatment"), sub_heading_style))
story.append(Paragraph(
    "Diagnosed at laparoscopy/laparotomy (CT scan may show omental lesion with whirl sign). "
    "Treatment: resection of necrotic omentum (laparoscopic preferred).",
    body_style))
story.append(Spacer(1, 0.3*cm))

# ── 5d. Stages of Wound Healing ──────────────────────────────────────────────
story.append(question_banner("5d", "Stages of Wound Healing", "3 Marks", bg=ACCENT_GREEN))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "Wound healing is a precisely orchestrated biological process involving four overlapping phases. "
    "The phases are: Haemostasis, Inflammation, Proliferation, and Remodelling.",
    body_style))

wh_flow = make_flowchart([
    "Phase 1: HAEMOSTASIS (Seconds to hours)",
    "Phase 2: INFLAMMATION (Days 1-4)",
    "Phase 3: PROLIFERATION / REPAIR (Days 4-21)",
    "Phase 4: REMODELLING / MATURATION (Weeks to years)"
], colors_list=[RED, MED_BLUE, ACCENT_GREEN, PURPLE], title="Phases of Wound Healing")
story.append(wh_flow)
story.append(Spacer(1, 0.2*cm))

story.append(make_table(
    ["Phase", "Duration", "Key Events", "Key Cells/Molecules"],
    [["Haemostasis",
      "Seconds - hours",
      "Vasoconstriction; platelet plug; coagulation cascade; fibrin clot formation",
      "Platelets; thrombin; fibrin; PDGF, TGF-β released"],
     ["Inflammation",
      "Hours - day 4",
      "Vasodilation and vascular permeability (rubor, calor, dolor, tumor); phagocytosis of bacteria and debris",
      "Neutrophils (day 1-2); Macrophages (day 2-4); IL-1, TNF-α, IL-6"],
     ["Proliferation",
      "Day 4 - 3 weeks",
      "Fibroblast migration; collagen synthesis (type III initially); angiogenesis; epithelialisation; wound contraction",
      "Fibroblasts; Myofibroblasts (contraction); EGF, FGF, VEGF; Type III collagen"],
     ["Remodelling",
      "Weeks - 2 years",
      "Type III collagen replaced by Type I; cross-linking; scar maturation; tensile strength increases to 80% of normal",
      "Collagenase (MMPs); collagen type I; scar tissue pale, flat, avascular"]],
    bg=LIGHT_GREEN, border=ACCENT_GREEN))

story.append(make_box([
    Paragraph("<b>Important:</b> Maximum tensile strength of healed wound is only 80% of original "
              "tissue. Myofibroblasts are responsible for wound contraction (important in hypertrophic "
              "scars and contractures). Vitamin C deficiency impairs collagen synthesis.", note_style)],
    bg=LIGHT_GOLD, border=GOLD))
story.append(Paragraph(i("Reference: Scott-Brown's Otorhinolaryngology; Robbins Pathology"), ref_style))
story.append(Spacer(1, 0.3*cm))

# ── 5e. Martorell's Ulcer ─────────────────────────────────────────────────────
story.append(question_banner("5e", "Martorell's Ulcer", "3 Marks", bg=ACCENT_GREEN))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "Martorell's ulcer (hypertensive ischaemic leg ulcer / HYTILU) is a type of skin ulcer "
    "occurring in the context of poorly controlled <b>hypertension</b>, resulting from "
    "arteriolar occlusion in the skin and subcutaneous tissue.",
    body_style))
story.append(Paragraph(b("Pathogenesis"), sub_heading_style))
story.append(Paragraph(
    "Chronic hypertension causes arteriolar medial calcification and hyalinosis (particularly "
    "in the leg). This leads to progressive subcutaneous arteriolar occlusion, ischaemia of "
    "the dermis and subcutaneous fat, causing ulceration without large vessel disease.",
    body_style))
story.append(Paragraph(b("Clinical Features"), sub_heading_style))
for pt in [
    "Typical patient: older female, obese, poorly controlled hypertension",
    "Location: postero-lateral aspect of lower leg (unlike venous ulcers which are medial)",
    "Extremely painful (unlike venous ulcers which are mildly painful)",
    "Regular, well-defined margins with necrotic base",
    "No varicosities; no oedema initially",
    "Normal peripheral pulses (unlike ischaemic ulcers)",
    "Biopsy: arteriolar hyalinosis, medial calcification",
]:
    story.append(Paragraph(f"• {pt}", bullet_style))
story.append(Paragraph(b("Treatment"), sub_heading_style))
story.append(Paragraph(
    "Strict blood pressure control (the primary treatment). Analgesia (opioids may be needed). "
    "Wound care. Skin grafting once blood pressure controlled.",
    body_style))
story.append(Spacer(1, 0.4*cm))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# Q6 PRE-OPERATIVE EVALUATION
# ═══════════════════════════════════════════════════════════════════════════════

story.append(section_banner("Q6. PRE-OPERATIVE EVALUATION (4+3+3 = 10 Marks)", bg=GOLD))
story.append(Spacer(1, 0.3*cm))

# ── 6a. Components of Pre-operative Evaluation ────────────────────────────────
story.append(question_banner("6a", "Components of Pre-operative Evaluation", "4 Marks", bg=GOLD))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "Pre-operative evaluation aims to identify and optimise patient risk factors before "
    "surgery to minimise operative morbidity and mortality. It has four main components:",
    body_style))

story.append(Paragraph(b("1. History"), sub_heading_style))
story.append(make_table(
    ["Domain", "Key Points"],
    [["Chief complaint & surgical indication", "Nature, duration, urgency of surgery"],
     ["Medical co-morbidities", "IHD, HTN, DM, COPD, CKD, liver disease, coagulopathy"],
     ["Drug history", "Anticoagulants (stop), antiplatelet agents, steroids, OCP, insulin"],
     ["Allergy history", "Drugs, latex, iodine, anaesthetic agents"],
     ["Previous surgery/anaesthesia", "Complications (difficult airway, MH, bleeding)"],
     ["Family history", "Malignant hyperthermia, coagulopathies"],
     ["Social history", "Smoking (stop 8 weeks pre-op), alcohol, BMI"]],
    bg=LIGHT_GOLD, border=GOLD))

story.append(Paragraph(b("2. Physical Examination"), sub_heading_style))
for pt in [
    "General: BMI, anaemia, jaundice, cyanosis",
    "Airway assessment: Mallampati score, mouth opening, neck mobility (predict difficult intubation)",
    "CVS: BP, HR, JVP, heart sounds, peripheral pulses",
    "RS: breath sounds, wheeze, crepitations, peak flow",
    "CNS: baseline neurological status",
    "Local: examine the surgical site",
]:
    story.append(Paragraph(f"• {pt}", bullet_style))

story.append(Paragraph(b("3. Risk Assessment"), sub_heading_style))
story.append(Paragraph(
    "ASA classification (I-VI) grades patient fitness. Goldman Cardiac Risk Index used for "
    "cardiac risk. RCRI (Revised Cardiac Risk Index) for major non-cardiac surgery. "
    "CPET (cardiopulmonary exercise testing) for borderline cases.",
    body_style))

story.append(make_table(
    ["ASA Class", "Definition"],
    [["I", "Healthy patient"],
     ["II", "Mild systemic disease"],
     ["III", "Severe systemic disease"],
     ["IV", "Severe systemic disease, constant threat to life"],
     ["V", "Moribund; not expected to survive without operation"],
     ["VI", "Brain-dead (organ donation)"]],
    bg=LIGHT_GOLD, border=GOLD))

story.append(Paragraph(b("4. Consent and Documentation"), sub_heading_style))
story.append(Paragraph(
    "Informed written consent explaining: procedure, alternatives, risks (general + specific), "
    "expected outcomes. Anaesthetic review for high-risk cases. MDT discussion for complex cases.",
    body_style))
story.append(Spacer(1, 0.3*cm))

# ── 6b. Investigations before major surgery ────────────────────────────────────
story.append(question_banner("6b", "Investigations Routinely Done Before Major Surgery", "3 Marks", bg=GOLD))
story.append(Spacer(1, 0.2*cm))
story.append(make_table(
    ["Category", "Investigation", "Rationale"],
    [["Haematology", "FBC (Hb, WBC, platelets)", "Detect anaemia, infection, thrombocytopenia"],
     ["Haematology", "Blood group & crossmatch", "Blood transfusion preparation"],
     ["Haematology", "Coagulation (PT, aPTT, INR)", "Detect coagulopathy, guide anticoagulant reversal"],
     ["Biochemistry", "Urea, Creatinine, Electrolytes", "Renal function; electrolyte correction"],
     ["Biochemistry", "Liver function tests", "Hepatic reserve for drug metabolism"],
     ["Biochemistry", "Blood glucose/HbA1c", "DM optimisation"],
     ["Cardiac", "ECG", "Baseline; detect arrhythmia, ischaemia"],
     ["Cardiac", "Echo (selected patients)", "Valvular disease, LV function"],
     ["Respiratory", "CXR", "Cardiac size, pulmonary lesions, baseline"],
     ["Respiratory", "Spirometry (COPD)", "Pulmonary risk assessment"],
     ["Infection", "Urine R/E and C/S", "Exclude UTI (source of sepsis post-op)"],
     ["Special", "Sickle cell screen (relevant ethnicity)", "Prevent sickling under anaesthesia"],
     ["Special", "HIV, Hepatitis B/C", "Infection control precautions"]],
    bg=LIGHT_GOLD, border=GOLD))
story.append(Spacer(1, 0.3*cm))

# ── 6c. Premedication in Anaesthesia ──────────────────────────────────────────
story.append(question_banner("6c", "Premedication in Anaesthesia - Indications and Common Drugs", "3 Marks", bg=GOLD))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "Premedication refers to drugs administered before anaesthesia to improve patient "
    "comfort, facilitate smooth anaesthetic induction, and reduce complications.",
    body_style))

story.append(make_table(
    ["Aim", "Drug Class", "Example", "Dose/Route"],
    [["Anxiolysis/Sedation", "Benzodiazepine", "Midazolam", "0.05-0.1 mg/kg IV/IM"],
     ["Anxiolysis/Sedation", "Benzodiazepine", "Diazepam", "5-10 mg oral night before"],
     ["Analgesia", "Opioid", "Morphine / Pethidine", "0.1 mg/kg IM"],
     ["Reduce gastric acid (aspiration prophylaxis)", "H2 blocker", "Ranitidine", "150 mg oral"],
     ["Reduce gastric acid", "PPI", "Omeprazole", "20 mg oral"],
     ["Reduce gastric volume", "Prokinetic", "Metoclopramide", "10 mg IV"],
     ["Anticholinergic (reduce secretions)", "Anticholinergic", "Atropine / Glycopyrrolate", "0.6 mg IM"],
     ["Antiemetic", "5HT3 antagonist", "Ondansetron", "4-8 mg IV"],
     ["Prevent allergy/bronchospasm", "Antihistamine", "Chlorphenamine", "10 mg IV"],
     ["Reduce airway reactivity (COPD)", "Bronchodilator", "Salbutamol inhaler", "2-4 puffs"],
     ["Beta blockade (hyperthyroid)", "Beta blocker", "Propranolol", "20-40 mg oral"]],
    bg=LIGHT_GOLD, border=GOLD))

story.append(make_box([
    Paragraph("<b>Nil by Mouth (NBM) rules:</b> Solids - 6 hours; Clear fluids - 2 hours before induction. "
              "Purpose: prevent aspiration pneumonitis (Mendelson's syndrome).", body_style)],
    bg=LIGHT_TEAL, border=ACCENT_TEAL))
story.append(Spacer(1, 0.4*cm))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# Q7 FAT EMBOLISM SYNDROME
# ═══════════════════════════════════════════════════════════════════════════════

story.append(section_banner("Q7. FAT EMBOLISM SYNDROME (5 Marks)", bg=PURPLE))
story.append(Spacer(1, 0.3*cm))
story.append(question_banner("7", "Pathogenesis, Clinical Features, Management and Complications of Fat Embolism", "5 Marks", bg=PURPLE))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(b("Definition"), sub_heading_style))
story.append(Paragraph(
    "Fat embolism refers to the presence of fat globules in pulmonary or systemic circulation. "
    "Fat embolism <i>syndrome</i> (FES) is the clinical triad of respiratory distress, "
    "neurological dysfunction, and petechial rash occurring after fat embolism, usually "
    "following long bone fractures or orthopaedic surgery.",
    body_style))

story.append(Paragraph(b("Aetiology"), sub_heading_style))
story.append(make_two_col_table(
    ["Long bone fractures (femur, tibia) - most common",
     "Pelvic fractures", "Multiple fractures",
     "Intramedullary nailing", "Joint arthroplasty"],
    ["Pancreatitis", "Severe burns",
     "Liposuction", "Sickle cell disease",
     "Fatty liver with trauma", "Decompression sickness"],
    headers=["Traumatic Causes", "Non-Traumatic Causes"],
    bg=LIGHT_PURPLE, border=PURPLE))

story.append(Paragraph(b("Pathogenesis"), sub_heading_style))

path_flow = make_flowchart([
    "Long bone fracture / marrow disruption",
    "Fat globules enter torn venous sinusoids",
    "Emboli reach pulmonary capillaries",
    "MECHANICAL: occlusion of microvasculature",
    "BIOCHEMICAL: Lipase releases free fatty acids",
    "Endothelial injury + platelet aggregation + complement activation",
    "Pulmonary/cerebral oedema, petechiae, ARDS"
], colors_list=[DARK_BLUE, MED_BLUE, ACCENT_TEAL, ACCENT_GREEN, GOLD, RED, PURPLE],
   title="Pathogenesis of Fat Embolism Syndrome")
story.append(path_flow)
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(b("Clinical Features - Gurd's Criteria"), sub_heading_style))
story.append(Paragraph(
    "FES typically presents <b>24-72 hours</b> after the causative injury. Diagnosis by "
    "Gurd and Wilson criteria (1 major + 4 minor):",
    body_style))
story.append(make_two_col_table(
    ["Respiratory insufficiency (PaO2 <60 mmHg)", "Cerebral symptoms without head injury",
     "Petechial rash (pathognomonic - axilla, chest, conjunctiva)"],
    ["Tachycardia >120 bpm", "Pyrexia >38.5°C", "Thrombocytopenia",
     "Haematocrit fall >10%", "High ESR", "Fat macroglobulinaemia",
     "Urinary fat globules"],
    headers=["MAJOR Criteria", "MINOR Criteria"],
    bg=LIGHT_PURPLE, border=PURPLE))

story.append(Paragraph(b("Investigations"), sub_heading_style))
for inv in [
    "ABG: hypoxaemia (PaO2 <60 mmHg), hypocapnia",
    "CXR/HRCT: bilateral diffuse infiltrates ('snowstorm' appearance)",
    "FBC: anaemia, thrombocytopenia",
    "Serum lipase: elevated",
    "MRI brain: multiple petechial haemorrhages ('star-field' pattern)",
    "Bronchoscopy + BAL: fat-laden macrophages (oil red O stain)",
    "ECG: right heart strain, S1Q3T3",
]:
    story.append(Paragraph(f"• {inv}", bullet_style))

story.append(Paragraph(b("Management"), sub_heading_style))
story.append(make_table(
    ["Priority", "Intervention", "Detail"],
    [["1 - Respiratory support", "Oxygen / CPAP / Mechanical ventilation",
      "Maintain PaO2 >80 mmHg; lung-protective ventilation if ARDS (TV 6 ml/kg, PEEP 5-8)"],
     ["2 - Early fracture fixation", "IM nail / ORIF",
      "Reduces ongoing fat release; NOT contraindicated"],
     ["3 - Fluid resuscitation", "IV fluids",
      "Maintain haemodynamic stability; avoid hypovolaemia"],
     ["4 - Corticosteroids (controversial)", "Methylprednisolone 1.5 mg/kg",
      "May reduce inflammatory response; not routine"],
     ["5 - Heparin", "Low-dose heparin",
      "Activates lipase, may clear fat; also DVT prophylaxis"],
     ["6 - Supportive", "Analgesia, anti-seizure drugs",
      "Control neurological complications"]],
    bg=LIGHT_PURPLE, border=PURPLE))

story.append(Paragraph(b("Prevention"), sub_heading_style))
story.append(Paragraph(
    "Early fracture stabilisation (within 24 hours). Adequate fluid resuscitation. "
    "Corticosteroid prophylaxis (methylprednisolone) in high-risk multiple fractures. "
    "Careful intramedullary reaming technique.",
    body_style))

story.append(Paragraph(b("Complications"), sub_heading_style))
story.append(make_table(
    ["System", "Complication"],
    [["Pulmonary", "ARDS (acute respiratory distress syndrome), refractory hypoxia"],
     ["Neurological", "Coma, seizures, focal deficits, cerebral oedema"],
     ["Haematological", "DIC (disseminated intravascular coagulation)"],
     ["Renal", "Acute kidney injury (fat deposits in glomeruli)"],
     ["Ocular", "Purtscher's retinopathy (retinal fat emboli causing blindness)"],
     ["Cardiac", "Right heart failure, arrhythmias"],
     ["Mortality", "10% mortality in established FES"]],
    bg=LIGHT_PURPLE, border=PURPLE))
story.append(Paragraph(i("Reference: Robbins & Kumar Basic Pathology; Murray & Nadel Respiratory Medicine; Bailey and Love's Surgery 28e"), ref_style))
story.append(Spacer(1, 0.4*cm))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# Q8 COMPLICATIONS OF SPINAL CORD INJURY
# ═══════════════════════════════════════════════════════════════════════════════

story.append(section_banner("Q8. COMPLICATIONS OF SPINAL CORD INJURY (5 Marks)", bg=RED))
story.append(Spacer(1, 0.3*cm))
story.append(question_banner("8", "Enumerate and Discuss Various Complications of Spinal Cord Injury", "5 Marks", bg=RED))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(b("Overview"), sub_heading_style))
story.append(Paragraph(
    "Spinal cord injury (SCI) is a devastating condition with multiple systemic complications "
    "affecting virtually every organ system. Complications are the main cause of morbidity and "
    "mortality in SCI patients long after the initial injury.",
    body_style))

story.append(Paragraph(b("Classification of Complications"), sub_heading_style))

# Mindmap-style table for complications
story.append(make_table(
    ["System", "Complication", "Key Points"],
    [["Respiratory",
      "Pulmonary complications",
      "Lesions above C4: complete ventilatory failure (diaphragm denervated). "
      "C4-T6: impaired intercostal/abdominal function, atelectasis, pneumonia. "
      "Mucus plugging. Require mechanical ventilation."],
     ["Urological",
      "Neurogenic bladder",
      "Upper motor neurone: spastic, hyperreflexic bladder (reflex voiding, incomplete emptying). "
      "Lower motor neurone: flaccid bladder (overflow incontinence). "
      "Long-term: UTI, urolithiasis, chronic renal failure (major cause of late death)."],
     ["Gastrointestinal",
      "Neurogenic bowel",
      "Upper MN: hyperreflexic bowel - constipation, autonomic dysreflexia from faecal impaction. "
      "Lower MN: flaccid bowel - faecal incontinence. Requires bowel programme."],
     ["Skin",
      "Pressure ulcers",
      "Loss of sensation + immobility. Occur over bony prominences. "
      "Prevention: regular repositioning (2-hourly), pressure-relieving mattresses. "
      "Grade I-IV. Treatment: debridement, flap surgery for deep ulcers."],
     ["Cardiovascular",
      "Autonomic dysreflexia",
      "Most common in T6 and above injuries. "
      "Paroxysmal hypertension + bradycardia + flushing above injury + pallor below. "
      "Triggered by bladder/bowel distension. Emergency: sit up, remove trigger, nifedipine."],
     ["Cardiovascular",
      "Orthostatic hypotension",
      "Loss of sympathetic vasoconstriction. BP drops on sitting/standing. "
      "Managed with compression stockings, abdominal binders, fludrocortisone."],
     ["Haematological",
      "Thromboembolic disease",
      "DVT in 30% without prophylaxis within 2 weeks. PE fatal in 1-2%. "
      "Thromboprophylaxis: LMWH + compression stockings mandatory."],
     ["Musculoskeletal",
      "Spasticity",
      "Upper MN lesion: spasticity, clonus, hyperreflexia. "
      "Management: physiotherapy, baclofen (oral/intrathecal), botulinum toxin."],
     ["Musculoskeletal",
      "Heterotopic ossification",
      "Ectopic bone formation around joints (hip, knee). Occurs in ~25% of SCI. "
      "Pamidronate + NSAIDs for prevention; surgical excision if severe."],
     ["Musculoskeletal",
      "Osteoporosis",
      "Disuse osteoporosis below injury level. Pathological fractures. "
      "Bisphosphonates, weight-bearing exercises where possible."],
     ["Neurological",
      "Post-traumatic syringomyelia",
      "Fluid-filled cavity within cord. Occurs in ~28% up to 30 years post-injury. "
      "Presents with ascending pain, sensory loss, increasing weakness. MRI diagnostic. "
      "Treatment: syringopleural/syringosubarachnoid shunt."],
     ["Neurological",
      "Chronic neuropathic pain",
      "Central sensitisation. Burning, shooting pain at/below injury level. "
      "Managed with pregabalin, amitriptyline, duloxetine, spinal cord stimulation."],
     ["Reproductive",
      "Sexual dysfunction",
      "Male: erectile and ejaculatory dysfunction (majority). "
      "Female: amenorrhoea initially, then normal menstruation returns. "
      "Fertility preserved in women; male fertility impaired (sperm motility reduced)."],
     ["Psychological",
      "Depression & adjustment disorder",
      "~30% develop clinical depression. Multidisciplinary rehabilitation team essential. "
      "Cognitive behavioural therapy, antidepressants."]],
    bg=LIGHT_RED, border=RED))

story.append(Paragraph(b("Autonomic Dysreflexia - Emergency Management Flowchart"), sub_heading_style))
ad_flow = make_flowchart([
    "Identify trigger (bladder/bowel/skin)",
    "Sit patient upright (lowers BP)",
    "Loosen tight clothing/catheter",
    "Empty bladder (catheterise/irrigate)",
    "Disimpact rectum if needed",
    "If BP still >150: Nifedipine 10mg sublingual or Glyceryl trinitrate topical"
], colors_list=[RED, GOLD, MED_BLUE, ACCENT_TEAL, ACCENT_GREEN, PURPLE],
   title="Autonomic Dysreflexia - Emergency Management")
story.append(ad_flow)
story.append(Paragraph(i("Reference: Bailey and Love's Surgery 28e; Bradley & Daroff Neurology; Rosen's Emergency Medicine"), ref_style))
story.append(Spacer(1, 0.4*cm))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# Q21 APPENDIX ANATOMY + APPENDICITIS MANAGEMENT
# ═══════════════════════════════════════════════════════════════════════════════

story.append(section_banner("Q21. APPENDIX - ANATOMY, APPENDICITIS & APPENDICULAR LUMP (4+4+5 = 13 Marks)", bg=DARK_BLUE))
story.append(Spacer(1, 0.3*cm))

# ── 21a. Surgical Anatomy of Appendix ─────────────────────────────────────────
story.append(question_banner("21a", "Surgical Anatomy of the Appendix", "4 Marks"))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(b("Macroscopic Anatomy"), sub_heading_style))
story.append(make_table(
    ["Feature", "Detail"],
    [["Length", "Average 9 cm (range 2-20 cm)"],
     ["Width", "~0.6 cm"],
     ["Origin", "From the posteromedial wall of caecum, 2.5 cm below ileocaecal valve, where three taenia coli converge"],
     ["Peritoneal cover", "Completely invested by peritoneum; attached to terminal ileum by mesoappendix"],
     ["Blood supply", "Appendiceal artery (branch of ileocolic artery from SMA) - terminal artery (no collaterals)"],
     ["Venous drainage", "Appendiceal vein - ileocolic vein - SMV - portal vein (path for pylephlebitis)"],
     ["Lymphatics", "Drain to ileocolic lymph nodes in mesoappendix"],
     ["Nerve supply", "Sympathetic T10; parasympathetic vagus nerve"],
     ["Content", "All four layers: mucosa, submucosa (abundant lymphoid follicles - 'intestinal tonsil'), muscularis, serosa"]],
    bg=LIGHT_BLUE, border=MED_BLUE))

story.append(Paragraph(b("Positions of the Appendix (Surgical Importance)"), sub_heading_style))
story.append(make_table(
    ["Position", "Frequency", "Clinical Significance"],
    [["Retrocaecal / Retroperitoneal", "65%", "Most common; pain/tenderness posterior (Rovsing's +); psoas sign +"],
     ["Pelvic / Subcaecal", "31%", "Pain suprapubic/on PR; may cause urinary symptoms; Obturator sign +"],
     ["Pre-ileal", "1%", "Vomiting and periumbilical pain prominent"],
     ["Post-ileal", "0.5%", "Rare; difficult to locate at surgery"],
     ["Paracaecal (right-sided)", "2.5%", "Standard RIF tenderness at McBurney's point"]],
    bg=LIGHT_BLUE, border=MED_BLUE))

story.append(make_box([
    Paragraph("<b>McBurney's Point:</b> Junction of lateral 1/3 and medial 2/3 of line joining "
              "right ASIS to umbilicus. Point of maximum tenderness in appendicitis. "
              "Lanz's point: junction of right 1/3 and middle 1/3 of inter-ASIS line.", body_style)],
    bg=LIGHT_GOLD, border=GOLD))
story.append(Spacer(1, 0.3*cm))

# ── 21b. Types of Appendicitis ─────────────────────────────────────────────────
story.append(question_banner("21b", "Types of Appendicitis", "4 Marks"))
story.append(Spacer(1, 0.2*cm))

story.append(make_table(
    ["Type", "Pathology", "Clinical Features"],
    [["Catarrhal (Simple/Mucosal)",
      "Congestion and oedema of mucosa only; neutrophil infiltration of mucosa",
      "Mild abdominal pain; may resolve spontaneously; appendix grossly normal"],
     ["Suppurative (Acute Appendicitis)",
      "Transmural inflammation; pus in lumen; surface fibrin exudate; tense, red appendix",
      "Classic presentation: periumbilical pain migrating to RIF; fever; N/V; McBurney's +"],
     ["Gangrenous",
      "Ischaemia due to arterial thrombosis; black, necrotic wall; foul-smelling pus",
      "Very ill patient; high fever >39°C; severe tenderness; rebound; toxic appearance"],
     ["Perforated",
      "Full thickness necrosis causes rupture; free pus in peritoneal cavity",
      "Sudden initial relief of pain then general peritonitis; rigid abdomen; septic shock"],
     ["Appendix Abscess",
      "Walled off perforation by omentum and loops of bowel; pericaecal abscess",
      "Localised RIF mass; tender; no generalised peritonitis - 'appendicular mass'"],
     ["Chronic / Recurrent",
      "Fibrous obliteration; recurrent episodes of subacute inflammation",
      "Recurrent dull RIF pain; resolves spontaneously"],
     ["Stump Appendicitis",
      "Inflammation of retained stump after appendicectomy (>1 cm)",
      "Post-appendicectomy RIF pain; diagnosis on CT"]],
    bg=LIGHT_BLUE, border=MED_BLUE))

story.append(Paragraph(b("Alvarado Score"), sub_heading_style))
story.append(make_table(
    ["Clinical Feature", "Score"],
    [["Migration of pain to RIF", "1"],
     ["Anorexia", "1"],
     ["Nausea/vomiting", "1"],
     ["RIF tenderness", "2"],
     ["Rebound tenderness", "1"],
     ["Elevated temperature (>37.5°C)", "1"],
     ["Leukocytosis (WBC >10,000)", "2"],
     ["Shift to left (neutrophilia)", "1"],
     ["Total", "10"],
     ["Score 1-4: Low risk, observe | 5-6: Equivocal, investigate | 7-10: High, operate", ""]],
    bg=LIGHT_BLUE, border=MED_BLUE))
story.append(Spacer(1, 0.3*cm))

# ── 21c. Management of Appendicular Lump ──────────────────────────────────────
story.append(question_banner("21c", "Management of Appendicular Lump", "5 Marks"))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(b("Definition"), sub_heading_style))
story.append(Paragraph(
    "An appendicular lump (mass) forms when a perforating appendix is walled off by the "
    "omentum, adjacent loops of bowel, and parietal peritoneum, preventing generalised "
    "peritonitis. It typically presents >72 hours after onset of symptoms.",
    body_style))

story.append(Paragraph(b("Clinical Features"), sub_heading_style))
for pt in [
    "Tender, ill-defined mass in RIF, >3 days after onset of acute appendicitis",
    "Soft, doughy consistency (resolving) vs. hard (abscess)",
    "Low-grade fever (38-38.5°C)",
    "WBC mildly elevated",
    "No generalised peritonitis",
    "USS/CT: confirms mass/collection; assesses for abscess",
]:
    story.append(Paragraph(f"• {pt}", bullet_style))

story.append(Paragraph(b("Management"), sub_heading_style))

mgmt_flow = make_flowchart([
    "Appendicular Lump Confirmed (CT/USS)",
    "OCHSNER-SHERREN CONSERVATIVE REGIMEN",
    "Monitor: Temp, Pulse, Tenderness, Mass size (draw outline daily)",
    "IV antibiotics: Ceftriaxone + Metronidazole",
    "IV fluids, NBM initially, then soft diet",
    "Resolves? YES → Interval appendicectomy at 6-8 weeks",
    "Worsens? / Abscess forms → Percutaneous CT-guided drainage / Surgery"
], colors_list=[DARK_BLUE, MED_BLUE, ACCENT_TEAL, ACCENT_GREEN, ACCENT_GREEN, GOLD, RED],
   title="Management of Appendicular Lump")
story.append(mgmt_flow)
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(b("Ochsner-Sherren Regimen (Conservative Management)"), sub_heading_style))
story.append(make_table(
    ["Parameter", "Action"],
    [["Position", "Semi-recumbent (Fowler's position) to limit spread"],
     ["Diet", "Initially NBM with IV fluids; then sips of water, gradually build up"],
     ["Antibiotics", "IV: Ceftriaxone 1g BD + Metronidazole 500mg TDS for 7-10 days"],
     ["Analgesia", "Paracetamol ± NSAIDs; avoid opioids (mask peritonism)"],
     ["Monitoring", "4-hourly temperature, pulse; daily examination; mark mass outline"],
     ["Signs of resolution", "Temperature normalises, mass decreases, tenderness resolves"],
     ["Signs of failure", "Rising temperature, increasing mass, generalised peritonitis, abscess"]],
    bg=LIGHT_BLUE, border=MED_BLUE))

story.append(Paragraph(b("Indications for Immediate Surgery Despite Appendicular Mass"), sub_heading_style))
for ind in [
    "Signs of peritonitis (mass spreading, generalised peritonitis)",
    "Appendicular abscess not amenable to percutaneous drainage",
    "Failure of conservative management (fever persisting >7 days)",
    "Intestinal obstruction",
    "Suspicion of underlying malignancy (elderly patients - always histology)",
]:
    story.append(Paragraph(f"• {ind}", bullet_style))

story.append(Paragraph(b("Interval Appendicectomy"), sub_heading_style))
story.append(Paragraph(
    "Performed <b>6-8 weeks after resolution</b> of the appendicular mass. Reasons: "
    "(1) 20% recurrence risk if not done, (2) exclude underlying malignancy (caecal carcinoma "
    "mimics appendicular mass in elderly). <b>In elderly patients, colonoscopy and barium "
    "enema must be done before interval appendicectomy.</b>",
    body_style))

story.append(make_box([
    Paragraph("<b>High Yield Points:</b> (1) Appendicular lump = conservative management first. "
              "(2) Appendicular abscess = percutaneous drainage or surgery. "
              "(3) Always do interval appendicectomy 6-8 weeks later. "
              "(4) Exclude malignancy in elderly (colonoscopy). "
              "(5) Terminal blood supply = rapid gangrene once obstructed.", note_style)],
    bg=LIGHT_GOLD, border=GOLD))
story.append(Paragraph(i("Reference: Current Surgical Therapy 14e; Bailey and Love's Surgery 28e"), ref_style))

# ═══ FINAL REF PAGE ═══
story.append(PageBreak())
story.append(section_banner("REFERENCES", bg=DARK_BLUE))
story.append(Spacer(1, 0.4*cm))
refs = [
    "1. Bailey R, Cloves H. Bailey and Love's Short Practice of Surgery, 28th Edition. CRC Press, 2023.",
    "2. Kumar V, Abbas A, Aster J. Robbins & Kumar Basic Pathology, 10th Edition. Elsevier, 2023.",
    "3. Cameron J, Cameron A. Current Surgical Therapy, 14th Edition. Elsevier, 2023.",
    "4. Murray J, Nadel J. Murray & Nadel's Textbook of Respiratory Medicine. Elsevier, 2022.",
    "5. Marx J et al. Rosen's Emergency Medicine, 10th Edition. Elsevier, 2023.",
    "6. Townsend CM. Sabiston Textbook of Surgery, 21st Edition. Elsevier, 2022.",
    "7. Cummings CW. Cummings Otolaryngology Head and Neck Surgery, 7th Edition.",
    "8. Scott-Brown's Otorhinolaryngology Head & Neck Surgery, 8th Edition.",
    "9. Das S. Das's Clinical Surgery, 16th Edition.",
    "10. Fischer JE. Fischer's Mastery of Surgery, 8th Edition.",
]
for ref in refs:
    story.append(Paragraph(ref, ParagraphStyle('RefFull', fontSize=9.5, leading=14,
                                               fontName='Helvetica', spaceBefore=4)))

# ═══════════════════════════════════════════════════════════════════════════════
# BUILD
# ═══════════════════════════════════════════════════════════════════════════════

def page_number(canvas, doc):
    canvas.saveState()
    # Header
    canvas.setFillColor(DARK_BLUE)
    canvas.setFont('Helvetica-Bold', 8)
    canvas.drawString(2*cm, A4[1] - 1.5*cm, "MBBS Phase 3 Part 2 | General Surgery & Allied")
    canvas.drawRightString(A4[0] - 2*cm, A4[1] - 1.5*cm, "Long Answer Model Responses")
    canvas.setStrokeColor(MED_BLUE)
    canvas.setLineWidth(0.5)
    canvas.line(2*cm, A4[1] - 1.7*cm, A4[0] - 2*cm, A4[1] - 1.7*cm)
    # Footer
    canvas.setFillColor(DARK_BLUE)
    canvas.setFont('Helvetica', 8)
    canvas.drawCentredString(A4[0]/2, 1.4*cm, f"Page {doc.page}")
    canvas.line(2*cm, 1.7*cm, A4[0] - 2*cm, 1.7*cm)
    canvas.restoreState()

doc.build(story, onFirstPage=page_number, onLaterPages=page_number)
print(f"PDF created: {OUTPUT}")
print("Done!")

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Successfully replaced 1 instance(s) of the string in '/tmp/workspace/surgery-exam/generate_pdf.py'

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/surgery-exam/generate_pdf.py'