from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import PageBreak

OUTPUT = "/tmp/workspace/ophthalmology-notes/MS_Ophthalmology_Short_Notes.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=2*cm,
    leftMargin=2*cm,
    topMargin=2*cm,
    bottomMargin=2*cm,
    title="MS Ophthalmology - Short Notes",
    author="Orris Medical Education",
)

styles = getSampleStyleSheet()

# Custom styles
title_style = ParagraphStyle(
    "MainTitle",
    parent=styles["Title"],
    fontSize=18,
    textColor=colors.HexColor("#1a3a5c"),
    spaceAfter=4,
    fontName="Helvetica-Bold",
    alignment=TA_CENTER,
)
subtitle_style = ParagraphStyle(
    "SubTitle",
    parent=styles["Normal"],
    fontSize=10,
    textColor=colors.HexColor("#4a6fa5"),
    spaceAfter=2,
    alignment=TA_CENTER,
)
marks_style = ParagraphStyle(
    "Marks",
    parent=styles["Normal"],
    fontSize=10,
    textColor=colors.HexColor("#c0392b"),
    spaceAfter=12,
    alignment=TA_CENTER,
    fontName="Helvetica-Bold",
)
topic_title_style = ParagraphStyle(
    "TopicTitle",
    parent=styles["Heading1"],
    fontSize=15,
    textColor=colors.white,
    fontName="Helvetica-Bold",
    spaceAfter=0,
    spaceBefore=0,
    leading=20,
)
h2_style = ParagraphStyle(
    "H2",
    parent=styles["Heading2"],
    fontSize=12,
    textColor=colors.HexColor("#1a3a5c"),
    fontName="Helvetica-Bold",
    spaceBefore=10,
    spaceAfter=3,
    borderPadding=(0, 0, 2, 0),
)
body_style = ParagraphStyle(
    "Body",
    parent=styles["Normal"],
    fontSize=10,
    leading=15,
    textColor=colors.HexColor("#2c3e50"),
    spaceAfter=4,
    fontName="Helvetica",
    alignment=TA_JUSTIFY,
)
bullet_style = ParagraphStyle(
    "Bullet",
    parent=styles["Normal"],
    fontSize=10,
    leading=14,
    textColor=colors.HexColor("#2c3e50"),
    leftIndent=15,
    spaceAfter=3,
    fontName="Helvetica",
    bulletIndent=5,
)
sub_bullet_style = ParagraphStyle(
    "SubBullet",
    parent=styles["Normal"],
    fontSize=9.5,
    leading=13,
    textColor=colors.HexColor("#34495e"),
    leftIndent=30,
    spaceAfter=2,
    fontName="Helvetica",
    bulletIndent=20,
)
source_style = ParagraphStyle(
    "Source",
    parent=styles["Normal"],
    fontSize=8.5,
    textColor=colors.HexColor("#7f8c8d"),
    spaceAfter=2,
    fontName="Helvetica-Oblique",
    alignment=TA_RIGHT,
)
footer_note_style = ParagraphStyle(
    "FooterNote",
    parent=styles["Normal"],
    fontSize=8,
    textColor=colors.HexColor("#95a5a6"),
    spaceAfter=0,
    alignment=TA_CENTER,
)

def topic_header(title, topic_num, color_hex):
    """Create a colored header band for each topic."""
    header_table = Table(
        [[Paragraph(f"Topic {topic_num}: {title}", topic_title_style)]],
        colWidths=[17*cm],
    )
    header_table.setStyle(TableStyle([
        ("BACKGROUND", (0, 0), (-1, -1), colors.HexColor(color_hex)),
        ("TOPPADDING", (0, 0), (-1, -1), 8),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 8),
        ("LEFTPADDING", (0, 0), (-1, -1), 12),
        ("RIGHTPADDING", (0, 0), (-1, -1), 12),
        ("ROUNDEDCORNERS", [5, 5, 5, 5]),
    ]))
    return header_table

def section_heading(text):
    return Paragraph(text, h2_style)

def body(text):
    return Paragraph(text, body_style)

def bullet(text):
    return Paragraph(f"\u2022  {text}", bullet_style)

def sub_bullet(text):
    return Paragraph(f"    \u25e6  {text}", sub_bullet_style)

def source(text):
    return Paragraph(f"Source: {text}", source_style)

story = []

# ─── COVER HEADER ───────────────────────────────────────────────────────────
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph("MS Ophthalmology Theory Examination", title_style))
story.append(Paragraph("Short Answer Notes — 15 Marks Each", subtitle_style))
story.append(Paragraph("[15 Marks Each Topic]", marks_style))
story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor("#1a3a5c")))
story.append(Spacer(1, 0.5*cm))

# ═══════════════════════════════════════════════════════════════════════════
# TOPIC 1: TOXOCARIASIS
# ═══════════════════════════════════════════════════════════════════════════
story.append(topic_header("OCULAR TOXOCARIASIS", 1, "#1a3a5c"))
story.append(Spacer(1, 0.25*cm))

story.append(section_heading("1. Introduction / Aetiology"))
story.append(body(
    "Toxocariasis is caused by infestation with <b>Toxocara canis</b>, the common intestinal "
    "roundworm (ascarid) of dogs. The feline variant <i>Toxocara cati</i> may also be causative. "
    "Human infestation occurs by <b>ingestion of soil or food contaminated with ova</b> shed in "
    "canine faeces. Puppies are more commonly infected and are the primary source of spread. "
    "Young children are at particular risk from soil in parks and playgrounds. Once ingested, "
    "ova develop into larvae, which penetrate the intestinal wall and travel haematogenously to "
    "the liver, lungs, skin, brain, and eyes, eliciting an intense inflammatory reaction."
))
story.append(source("Kanski's Clinical Ophthalmology: A Systematic Approach, 10th ed."))

story.append(section_heading("2. Clinical Presentations"))
story.append(body(
    "<b>Three main systemic forms</b> are recognised, with ocular disease typically occurring "
    "independently of visceral disease:"
))
story.append(bullet("<b>Visceral larva migrans (VLM):</b> Systemic infection in children aged 2-7 years; "
                   "fever, abdominal pain, pneumonitis, lymphadenopathy, hepatomegaly, myocarditis. "
                   "Spontaneous recovery is usual."))
story.append(bullet("<b>Covert toxocariasis:</b> Mild systemic symptoms."))
story.append(bullet("<b>Ocular larva migrans (OLM):</b> Typically unilateral; occurs in older children "
                   "and adults, independently of VLM. Associated with a <i>lower</i> parasitic load. "
                   "Causes permanent visual impairment in ~two-thirds of cases."))

story.append(Spacer(1, 0.15*cm))
story.append(body("<b>Ocular presentations:</b>"))
story.append(bullet("<b>Chronic endophthalmitis:</b> Presents with leukocoria, strabismus, floaters, or "
                   "unilateral visual loss. Features include anterior uveitis, vitritis, chorioretinitis, "
                   "papillitis, and fundus granuloma. Dense grey-white peripheral exudate (resembles "
                   "snowbanking of pars planitis). Complications: tractional retinal detachment, "
                   "hypotony, phthisis bulbi."))
story.append(bullet("<b>Posterior pole / peripheral granuloma (without active inflammation):</b> "
                   "Classic in older child or adult. A 1-2 disc diameter round yellow-white granuloma "
                   "in the posterior fundus or periphery. Vitreoretinal traction may cause macular "
                   "distortion or retinal detachment."))
story.append(bullet("<b>Chorioretinal scar.</b>"))
story.append(bullet("<b>Diffuse unilateral subacute neuroretinitis (DUSN).</b>"))

story.append(section_heading("3. Investigations"))
story.append(bullet("<b>Full blood count:</b> Eosinophilia (more common in VLM than OLM)."))
story.append(bullet("<b>Immunoglobulins:</b> Raised IgE (hypergammaglobulinaemia)."))
story.append(bullet("<b>Serology (ELISA):</b> Antibodies to <i>T. canis</i> detectable in only ~50% of "
                   "ocular cases; seropositivity is also common in the general population (~14% in USA) "
                   "- therefore interpret with caution."))
story.append(bullet("<b>Ultrasonography:</b> Useful when vitreous haze limits fundal examination."))
story.append(bullet("<b>Aqueous/vitreous sampling:</b> Eosinophilia, antibody detection, PCR."))
story.append(bullet("<b>Biopsy:</b> Of a skin or other accessible granuloma for larvae, occasionally possible."))
story.append(bullet("<b>Important differential:</b> Retinoblastoma must be excluded, especially in children "
                   "presenting with leukocoria."))

story.append(section_heading("4. Management"))
story.append(bullet("<b>Prevention:</b> Good hygiene practices; regular deworming of household pets."))
story.append(bullet("<b>Corticosteroids:</b> Topical, periocular (sub-Tenon's), or systemic to reduce inflammation."))
story.append(bullet("<b>Anthelmintic agents:</b> Mebendazole or thiabendazole may be used; note that "
                   "worm death can precipitate further inflammation, so steroids must be co-prescribed."))
story.append(bullet("<b>Laser photocoagulation:</b> Directed at the larva when visible, to destroy it."))
story.append(bullet("<b>Vitrectomy:</b> For sight-threatening tractional complications (retinal detachment, "
                   "vitreoretinal traction)."))
story.append(source("Kanski's Clinical Ophthalmology, 10th ed., p. 482-484"))

story.append(Spacer(1, 0.4*cm))
story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor("#bdc3c7")))
story.append(Spacer(1, 0.4*cm))

# ═══════════════════════════════════════════════════════════════════════════
# TOPIC 2: AMAUROSIS FUGAX
# ═══════════════════════════════════════════════════════════════════════════
story.append(topic_header("AMAUROSIS FUGAX", 2, "#154360"))
story.append(Spacer(1, 0.25*cm))

story.append(section_heading("1. Definition"))
story.append(body(
    "<b>Amaurosis fugax</b> is defined as <b>transient, painless, monocular loss of vision</b>, "
    "classically described by the patient as a \"curtain coming down over the eye.\" Vision "
    "typically returns to normal within seconds to minutes (rarely up to 1-2 hours). "
    "It is considered by the <b>American Heart Association as a form of Transient Ischaemic "
    "Attack (TIA)</b> and carries a high risk of subsequent stroke; urgent investigation "
    "and management are therefore mandatory."
))
story.append(body(
    "The <i>Amaurosis Fugax Study Group</i> classifies causes into five categories: "
    "<b>embolic, haemodynamic, ocular, neurological, and idiopathic</b>. In clinical "
    "practice, the term most often refers to transient visual loss of <i>embolic origin</i>."
))
story.append(source("Kanski's Clinical Ophthalmology, 10th ed. | Wills Eye Manual, 8th ed."))

story.append(section_heading("2. Aetiology"))
story.append(bullet("<b>Embolism</b> (most common): From carotid artery atherosclerosis (cholesterol / "
                   "Hollenhorst plaques), cardiac valvular disease (mitral valve prolapse, rheumatic), "
                   "mural thrombus (post-MI), or arrhythmia (atrial fibrillation)."))
story.append(bullet("<b>Haemodynamic:</b> Arteriosclerotic disease causing hypoperfusion, often "
                   "precipitated by postural change or cardiac arrhythmia."))
story.append(bullet("<b>Hypercoagulable / hyperviscosity states:</b> Polycythaemia, thrombocytosis, "
                   "antiphospholipid syndrome."))
story.append(bullet("<b>Giant Cell Arteritis (GCA):</b> Particularly in patients >50 years; "
                   "transient visual loss may be a harbinger of permanent ischaemic optic neuropathy."))
story.append(bullet("<b>Vasospasm:</b> Especially in younger patients."))
story.append(bullet("<b>Ocular causes:</b> Impending CRVO, elevated IOP (intermittent angle-closure), "
                   "optic disc drusen."))
story.append(bullet("<b>Rare:</b> Intraorbital mass compressing the optic nerve in certain gaze positions "
                   "(gaze-evoked transient visual loss)."))

story.append(section_heading("3. Clinical Features"))
story.append(bullet("Monocular visual loss lasting seconds to minutes (embolic); recovery generally "
                   "in the same pattern as the loss, though usually more gradual."))
story.append(bullet("Frequency varies from several times a day to once every few months."))
story.append(bullet("May be accompanied by ipsilateral cerebral TIA (contralateral arm/leg weakness, "
                   "dysphasia - indicating middle cerebral artery territory ischaemia)."))
story.append(bullet("Fundal exam: May be normal; an embolus (Hollenhorst plaque) may be visible at "
                   "an arteriolar bifurcation; signs of ocular ischaemic syndrome may be present."))
story.append(body("<i>Important:</i> Patients may be unaware whether visual loss is monocular or a "
                 "homonymous hemianopia - covering each eye separately during the episode, or "
                 "a careful history clarifying laterality, is essential."))

story.append(section_heading("4. Differential Diagnosis"))
data = [
    ["Condition", "Key Distinguishing Features"],
    ["Migraine with aura", "Visual disturbance 10-50 min; positive phenomena (scintillating scotoma); bilateral"],
    ["GCA", "Age >50, elevated ESR/CRP/platelets, scalp tenderness, jaw claudication"],
    ["Papilloedema", "Bilateral; seconds duration; postural or Valsalva-triggered; disc swelling present"],
    ["Vertebrobasilar insufficiency", "Bilateral blurred vision; associated vertigo, dysarthria, hemisensory loss"],
    ["Impending CRVO", "Dilated tortuous veins on fundoscopy"],
    ["Ocular ischaemic syndrome", "Unilateral; disc and retinal signs of chronic hypoperfusion"],
]
t = Table(data, colWidths=[5.5*cm, 11.5*cm])
t.setStyle(TableStyle([
    ("BACKGROUND", (0, 0), (-1, 0), colors.HexColor("#1a3a5c")),
    ("TEXTCOLOR", (0, 0), (-1, 0), colors.white),
    ("FONTNAME", (0, 0), (-1, 0), "Helvetica-Bold"),
    ("FONTSIZE", (0, 0), (-1, -1), 9),
    ("GRID", (0, 0), (-1, -1), 0.5, colors.HexColor("#bdc3c7")),
    ("ROWBACKGROUNDS", (0, 1), (-1, -1), [colors.white, colors.HexColor("#eaf2fb")]),
    ("TOPPADDING", (0, 0), (-1, -1), 5),
    ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
    ("LEFTPADDING", (0, 0), (-1, -1), 6),
    ("VALIGN", (0, 0), (-1, -1), "TOP"),
]))
story.append(t)

story.append(section_heading("5. Investigations (Workup)"))
story.append(bullet("<b>MRI brain with DWI:</b> To detect silent infarcts; current AHA guidelines recommend "
                   "urgent MRI and neurology referral."))
story.append(bullet("<b>Carotid duplex Doppler US:</b> First-line non-invasive study for carotid stenosis. "
                   "Consider orbital colour Doppler US for retrolaminar CRA stenosis."))
story.append(bullet("<b>ESR, CRP, platelet count:</b> Urgently if GCA is suspected."))
story.append(bullet("<b>Cardiac evaluation:</b> ECG, echocardiogram (to detect valvular disease, thrombus, PFO)."))
story.append(bullet("<b>Blood tests:</b> CBC (polycythaemia), fasting glucose, HbA1c, lipid profile."))
story.append(bullet("<b>Ophthalmic exam:</b> Dilated fundoscopy, confrontation fields, IOP, slit lamp."))

story.append(section_heading("6. Management"))
story.append(body("<b>A. Carotid disease:</b>"))
story.append(sub_bullet("Aspirin 81-325 mg/day (antiplatelet therapy)."))
story.append(sub_bullet("Carotid endarterectomy (CEA) or endovascular stenting in high-grade (>70%) "
                        "surgically accessible carotid stenosis (refer to vascular surgery)."))
story.append(sub_bullet("Control of modifiable risk factors: hypertension, diabetes, dyslipidaemia."))
story.append(sub_bullet("Lifestyle modification: smoking cessation, diet, exercise."))
story.append(body("<b>B. Cardiac disease:</b>"))
story.append(sub_bullet("Aspirin 325 mg/day for non-embolic cardiac disease."))
story.append(sub_bullet("Anticoagulation (heparin, then warfarin/NOAC) if intracardiac thrombus or AF."))
story.append(body("<b>C. GCA:</b> Urgent high-dose systemic corticosteroids (IV methylprednisolone "
                 "if vision threatened, then oral prednisolone), temporal artery biopsy."))
story.append(source("Wills Eye Manual, 8th ed., pp. 733-735 | Kanski's Clinical Ophthalmology, 10th ed."))

story.append(Spacer(1, 0.4*cm))
story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor("#bdc3c7")))
story.append(Spacer(1, 0.4*cm))

# ═══════════════════════════════════════════════════════════════════════════
# TOPIC 3: CHLOROQUINE / HYDROXYCHLOROQUINE RETINOPATHY
# ═══════════════════════════════════════════════════════════════════════════
story.append(topic_header("CHLOROQUINE / HYDROXYCHLOROQUINE RETINOPATHY", 3, "#0e4d6e"))
story.append(Spacer(1, 0.25*cm))

story.append(section_heading("1. Introduction"))
story.append(body(
    "Chloroquine (CQ) and hydroxychloroquine (HCQ) are 4-aminoquinoline antimalarials. "
    "CQ was historically used for malaria prophylaxis/treatment; HCQ is widely used for "
    "<b>long-term inflammatory disorders</b> (rheumatoid arthritis, SLE, other connective tissue "
    "diseases). Both drugs are concentrated in <b>melanin-containing structures</b> of the eye "
    "(retinal pigment epithelium [RPE] and choroid) and can cause <b>irreversible retinal toxicity</b>. "
    "Retinal adverse effects may be more common than previously believed; progression can occur "
    "even after discontinuation."
))
story.append(source("Kanski's Clinical Ophthalmology, 10th ed., pp. 914-916"))

story.append(section_heading("2. Risk Factors for Toxicity"))
story.append(bullet("<b>Dose:</b> HCQ: risk rises sharply when dose exceeds <b>5 mg/kg real body weight/day</b>. "
                   "CQ: cumulative dose >300 g."))
story.append(bullet("<b>Duration:</b> HCQ risk ~7.5% after >5 years; 20-50% after >20 years. "
                   "Cumulative HCQ dose >1000 g (standard 400 mg/day for ~7 years)."))
story.append(bullet("<b>Renal impairment:</b> Reduces drug clearance, raising plasma levels."))
story.append(bullet("<b>Tamoxifen co-use:</b> Markedly increases retinal toxicity risk."))
story.append(bullet("<b>Pre-existing maculopathy.</b>"))
story.append(bullet("<b>Obesity:</b> Drug is not stored in fat; dosing by total body weight overestimates "
                   "safe dose."))
story.append(body(
    "<b>Note:</b> Chloroquine is more toxic than hydroxychloroquine at equivalent doses. "
    "HCQ is much safer when the recommended dosing is strictly followed."
))

story.append(section_heading("3. Pathogenesis"))
story.append(body(
    "The drugs bind to melanin in the RPE and cause progressive <b>photoreceptor and RPE damage</b>, "
    "predominantly in the parafoveal region. The central fovea is initially spared, giving rise to "
    "the characteristic 'bull's eye' pattern on examination. The mechanism involves disruption of "
    "lysosomal function within RPE cells, impairing photoreceptor outer-segment renewal."
))

story.append(section_heading("4. Clinical Stages / Fundal Appearance"))
story.append(bullet("<b>Premaculopathy (subclinical):</b> No visible fundal changes; functional and "
                   "structural changes detectable only on sensitive tests. Goal of screening is to "
                   "detect toxicity at this stage before irreversible damage."))
story.append(bullet("<b>Early maculopathy:</b> Subtle macular disturbance; mild VA reduction (6/9-6/12). "
                   "FAF shows oval areas of hyperautofluorescence. OCT reveals loss of cone outer-segment "
                   "tip-line and disruption of IS/OS junction at the parafovea - 'flying saucer' sign."))
story.append(bullet("<b>Established maculopathy - Bull's Eye lesion:</b> Moderate-severe VA reduction "
                   "(6/36-6/60). Classic <b>bull's eye</b> pattern: central foveolar island of pigment "
                   "surrounded by a depigmented ring of RPE atrophy, encircled by a hyperpigmented ring. "
                   "FA shows corresponding hyperfluorescence in a bull's eye distribution."))
story.append(bullet("<b>Advanced retinopathy:</b> Widespread RPE atrophy surrounding the fovea; "
                   "retinal arteriolar attenuation; peripheral pigment clumping (resembles RP). "
                   "Severe permanent visual impairment."))
story.append(body(
    "<b>Vortex keratopathy</b> (corneal whorl-like epithelial deposits) may also occur with both drugs."
))

story.append(section_heading("5. Screening / Investigations"))
story.append(body(
    "The objective of screening is to detect <b>premaculopathy</b> - reversible functional changes "
    "before irreversible structural damage occurs."
))
story.append(bullet("<b>Baseline assessment:</b> Before or soon after commencing therapy: VA, colour "
                   "vision, Amsler grid, fundoscopy, and SD-OCT of the macula. Establishes a "
                   "baseline and excludes pre-existing maculopathy."))
story.append(bullet("<b>Annual review:</b> In the absence of risk factors, routine annual review "
                   "(central visual fields [Humphrey 10-2], FAF, SD-OCT) should begin 5 years after "
                   "starting treatment."))
story.append(bullet("<b>Early annual review (from year 1):</b> Children; patients on chloroquine "
                   "(more toxic); supplementary risk factors (renal impairment, tamoxifen, "
                   "pre-existing maculopathy)."))
story.append(body("<b>Key investigations:</b>"))
story.append(sub_bullet("<b>SD-OCT (Spectral Domain OCT):</b> Most sensitive for early structural change; "
                        "shows parafoveal outer retinal thinning, loss of IS/OS junction, 'flying saucer' sign."))
story.append(sub_bullet("<b>Multifocal ERG (mfERG):</b> Functional test; demonstrates early parafoveal "
                        "dysfunction. Recommended when available."))
story.append(sub_bullet("<b>Humphrey 10-2 visual fields:</b> Central field defects detectable; less "
                        "sensitive than imaging modalities."))
story.append(sub_bullet("<b>Fundus Autofluorescence (FAF):</b> Useful for detecting early RPE dysfunction."))
story.append(sub_bullet("<b>Colour vision testing (Ishihara):</b> Low sensitivity; mild defects may be present."))
story.append(sub_bullet("<b>Fluorescein Angiography (FA):</b> Shows bull's eye hyperfluorescence in "
                        "established disease; largely superseded by OCT for early detection."))

story.append(section_heading("6. Management"))
story.append(bullet("<b>Prevention (primary):</b> Prescribe at the lowest effective dose; calculate dose "
                   "on real (not ideal or total) body weight; avoid dose >5 mg/kg/day for HCQ."))
story.append(bullet("<b>Discontinuation:</b> If toxicity is suspected, discuss cessation with the "
                   "patient's rheumatologist. <i>Note:</i> progression can continue after stopping "
                   "the drug due to drug stored in melanin."))
story.append(bullet("<b>No specific treatment</b> exists to reverse established retinal damage; "
                   "management is therefore primarily preventive."))
story.append(bullet("Regular monitoring enables early discontinuation before irreversible visual "
                   "impairment occurs."))
story.append(source("Kanski's Clinical Ophthalmology, 10th ed., pp. 914-916"))

# ─── FOOTER ─────────────────────────────────────────────────────────────────
story.append(Spacer(1, 0.8*cm))
story.append(HRFlowable(width="100%", thickness=1.5, color=colors.HexColor("#1a3a5c")))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "Prepared for MS Ophthalmology Theory Examination  |  "
    "Sources: Kanski's Clinical Ophthalmology (10th ed.), Wills Eye Manual (8th ed.)  |  "
    "August 2026",
    footer_note_style,
))

# Build PDF
doc.build(story)
print(f"PDF generated: {OUTPUT}")

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/ophthalmology-notes/generate_notes.py'