ls -la "/tmp/workspace/attachments/29a932e9-b2ef-4699-b7a9-c30b90b6addd/"

**/*.md in /skills

python3 -c " import pdfplumber with pdfplumber.open('/tmp/workspace/attachments/29a932e9-b2ef-4699-b7a9-c30b90b6addd/COL AVINASH VERMA.pdf') as pdf: print(f'Total pages: {len(pdf.pages)}') for i, page in enumerate(pdf.pages): text = page.extract_text() print(f'--- PAGE {i+1} ---') print(text) print() "

VNG videonystagmography interpretation abnormal gaze nystagmus positional nystagmus Dix-Hallpike smooth pursuit reduced gain

mkdir -p /tmp/workspace/col-avinash-vng && ls -la /tmp/workspace/col-avinash-vng/

python3 << 'EOF' from docx import Document from docx.shared import Pt, Inches, RGBColor from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.oxml.ns import qn from docx.oxml import OxmlElement import datetime doc = Document() # --- Page margins --- from docx.shared import Cm section = doc.sections[0] section.top_margin = Cm(2.0) section.bottom_margin = Cm(2.0) section.left_margin = Cm(2.5) section.right_margin = Cm(2.5) # --- Default style --- normal_style = doc.styles['Normal'] normal_style.font.name = 'Arial' normal_style.font.size = Pt(10.5) # Helper: add a styled heading def add_heading(doc, text, level=1, color=None): h = doc.add_heading(text, level=level) h.alignment = WD_ALIGN_PARAGRAPH.LEFT for run in h.runs: run.font.name = 'Arial' if color: run.font.color.rgb = RGBColor(*color) return h # Helper: add a colored horizontal rule via border def add_rule(doc): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(0) p.paragraph_format.space_after = Pt(0) pPr = p._p.get_or_add_pPr() pBdr = OxmlElement('w:pBdr') bottom = OxmlElement('w:bottom') bottom.set(qn('w:val'), 'single') bottom.set(qn('w:sz'), '6') bottom.set(qn('w:space'), '1') bottom.set(qn('w:color'), '2E4057') pBdr.append(bottom) pPr.append(pBdr) return p # ============================================= # HEADER BLOCK # ============================================= # Institution line inst = doc.add_paragraph() inst.alignment = WD_ALIGN_PARAGRAPH.CENTER r = inst.add_run('NEUROLOGY REFERRAL DOCUMENT') r.font.name = 'Arial' r.font.size = Pt(7) r.font.color.rgb = RGBColor(0x8B, 0x8B, 0x8B) # Title title = doc.add_paragraph() title.alignment = WD_ALIGN_PARAGRAPH.CENTER title.paragraph_format.space_before = Pt(2) title.paragraph_format.space_after = Pt(2) r = title.add_run('VNG FINDINGS & DIFFERENTIAL DIAGNOSIS SUMMARY') r.font.name = 'Arial' r.font.bold = True r.font.size = Pt(16) r.font.color.rgb = RGBColor(0x2E, 0x40, 0x57) subtitle = doc.add_paragraph() subtitle.alignment = WD_ALIGN_PARAGRAPH.CENTER subtitle.paragraph_format.space_before = Pt(0) subtitle.paragraph_format.space_after = Pt(4) r = subtitle.add_run('Prepared for Neurology Department Review') r.font.name = 'Arial' r.font.italic = True r.font.size = Pt(10) r.font.color.rgb = RGBColor(0x55, 0x55, 0x55) add_rule(doc) # ============================================= # PATIENT DEMOGRAPHICS TABLE # ============================================= doc.add_paragraph() tbl_head = doc.add_paragraph() r = tbl_head.add_run('PATIENT INFORMATION') r.font.name = 'Arial' r.font.bold = True r.font.size = Pt(10) r.font.color.rgb = RGBColor(0x2E, 0x40, 0x57) table = doc.add_table(rows=2, cols=4) table.style = 'Table Grid' table.autofit = True demo_data = [ ('Patient Name', 'Col Avinash Verma', 'Patient ID', 'CCDA00403 / EHPG.830955'), ('Age / Sex', '79 Years / Male', 'VNG Date', '15 July 2026'), ] header_color = RGBColor(0x2E, 0x40, 0x57) for row_idx, row_data in enumerate(demo_data): row = table.rows[row_idx] for col_idx, text in enumerate(row_data): cell = row.cells[col_idx] cell.text = '' p = cell.paragraphs[0] r = p.add_run(text) r.font.name = 'Arial' r.font.size = Pt(10) if col_idx % 2 == 0: r.font.bold = True r.font.color.rgb = header_color else: r.font.bold = False info_data = [ ('Referring Physician', 'Dr. K.M. Hassan, Senior Director Neurology, Max Noida 128', 'VNG Performed at', 'Priority Hearing Care'), ('Chief Complaint', 'Dizziness & blackouts on neck extension x 3 yrs; daytime sleepiness', 'Referred to', 'Neurology Department'), ] for row_data in info_data: row = table.add_row() for col_idx, text in enumerate(row_data): cell = row.cells[col_idx] cell.text = '' p = cell.paragraphs[0] r = p.add_run(text) r.font.name = 'Arial' r.font.size = Pt(10) if col_idx % 2 == 0: r.font.bold = True r.font.color.rgb = header_color doc.add_paragraph() # ============================================= # CLINICAL BACKGROUND # ============================================= add_heading(doc, '1. CLINICAL BACKGROUND', level=2, color=(0x2E, 0x40, 0x57)) add_rule(doc) bg_items = [ ('Chief Complaints:', 'Transient dizziness and occasional blackouts specifically on neck extension for 3 years. Dizziness while looking upward for 2-3 years. Excessive daytime sleepiness and snoring for several years.'), ('Past Medical History:', 'Hypertension (HTN), Diabetes Mellitus (DM), Benign Prostatic Hyperplasia (BPH), Cervical Spondylosis.'), ('No prior MRI:', 'Confirmed by patient.'), ('Relevant Labs:', 'BSF 147 mg/dL | HbA1c 6.8% | Vit B12 208 pg/mL (low-normal) | Vit D 67.8 | Creatinine 1.5 mg/dL'), ('Vitals at Neurology Visit:', 'BP 145/67 mmHg | Pulse 77/min | SpO2 98% | Weight 77.8 kg'), ('Neurological Examination:', 'No focal neurological deficit (NFD) recorded.'), ] for label, value in bg_items: p = doc.add_paragraph() p.paragraph_format.space_before = Pt(1) p.paragraph_format.space_after = Pt(1) r = p.add_run(label + ' ') r.font.bold = True r.font.name = 'Arial' r.font.size = Pt(10.5) r2 = p.add_run(value) r2.font.name = 'Arial' r2.font.size = Pt(10.5) doc.add_paragraph() # ============================================= # VNG FINDINGS TABLE # ============================================= add_heading(doc, '2. VNG TEST RESULTS', level=2, color=(0x2E, 0x40, 0x57)) add_rule(doc) note_p = doc.add_paragraph() r = note_p.add_run('Test performed on 15 July 2026 at Priority Hearing Care (Patient ID: CCDA00403). The VNG report impression field was left blank by the performing clinician; this document provides clinical interpretation of the recorded data.') r.font.name = 'Arial' r.font.size = Pt(10) r.font.italic = True r.font.color.rgb = RGBColor(0x55, 0x55, 0x55) doc.add_paragraph() # Main VNG findings table vng_table = doc.add_table(rows=1, cols=4) vng_table.style = 'Table Grid' vng_table.autofit = False # Column widths col_widths = [Inches(1.6), Inches(2.4), Inches(1.2), Inches(2.2)] for i, w in enumerate(col_widths): for cell in vng_table.columns[i].cells: cell.width = w # Header row hdr = vng_table.rows[0] hdr_labels = ['Test', 'Key Parameters', 'Result', 'Clinical Significance'] hdr_fill_color = '2E4057' for i, label in enumerate(hdr_labels): cell = hdr.cells[i] # fill header tc = cell._tc tcPr = tc.get_or_add_tcPr() shd = OxmlElement('w:shd') shd.set(qn('w:val'), 'clear') shd.set(qn('w:color'), 'auto') shd.set(qn('w:fill'), hdr_fill_color) tcPr.append(shd) cell.text = '' p = cell.paragraphs[0] r = p.add_run(label) r.font.bold = True r.font.name = 'Arial' r.font.size = Pt(10) r.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF) # Data rows: (Test, Parameters, Result [NORMAL/ABNORMAL/BORDERLINE], Significance) findings = [ ( 'Spontaneous Nystagmus\n(Light & Dark)', 'SPV: Absent\nAmplitude: Absent\nFrequency: Absent', 'NORMAL', 'No resting nystagmus. Argues against active uncompensated peripheral vestibular lesion.' ), ( 'Saccades\n(Horizontal)', 'Velocity: R 528°/s / L 687°/s\nPrecision: R 78% / L 79%\nLatency: R 237ms / L 258ms', 'BORDERLINE', 'Precision mildly reduced (normal >80%). Velocity adequate. Slight left latency prolongation.' ), ( 'Saccades\n(Vertical)', 'Velocity: R 221°/s / L 298°/s\nPrecision: R 37.7% / L 40.5%\nLatency: R 217ms / L 240ms', 'ABNORMAL', 'Vertical precision markedly reduced (<50%, normal >70%). Indicates cerebellar/central saccadic dysmetria.' ), ( 'Smooth Pursuit\n(Horizontal)', 'Rightward Gain: R 0.53 / L 0.61\nLeftward Gain: R 0.76 / L 0.73', 'ABNORMAL', 'Rightward pursuit gain significantly reduced bilaterally (normal ≥0.7). Asymmetric deficit suggests central (cerebellar hemisphere) lesion.' ), ( 'Smooth Pursuit\n(Vertical)', 'Upward Gain: R 0.54 / L 0.44\nDownward Gain: R 0.41 / L 0.42', 'ABNORMAL', 'Markedly reduced vertical pursuit bilaterally (normal ≥0.6). Reduced vertical smooth pursuit is a reliable central vestibular sign.' ), ( 'Optokinetic\nTest (OKN)', 'Horizontal: Gains 0.92–1.17\nVertical: Gains 0.74–1.13', 'NORMAL', 'Horizontal OKN within normal limits. Mild reduction in downward OKN consistent with smooth pursuit findings.' ), ( 'Head Shake\nNystagmus', 'SPV: Absent\nAll parameters negative', 'NORMAL', 'No post-head-shake nystagmus. No significant unilateral peripheral vestibular hypofunction at rest.' ), ( 'Hyperventilation\nNystagmus', 'SPV: Absent', 'NORMAL', 'Negative. No perilymphatic fistula or demyelinating lesion pattern.' ), ( 'Gaze Nystagmus\n(with fixation)', 'Left gaze – Right eye:\nSPV 5.33°/s | Amp 2.64° | Freq 1.08 Hz\nAll other gaze directions: Absent', 'ABNORMAL', 'LEFT GAZE-EVOKED NYSTAGMUS (GEN) with fixation. GEN with fixation = central sign (cerebellum/brainstem). Endpoint nystagmus excluded as it is unilateral (left only).' ), ( 'Gaze Nystagmus\n(without fixation)\nDown gaze', 'Both eyes:\nSPV: R -6.10°/s / L -5.09°/s\nAmp: R -4.40° / L -4.57°\nFreq: R 0.88 Hz / L 0.60 Hz', 'ABNORMAL', 'DOWN-GAZE NYSTAGMUS (without fixation) bilateral. Combined with reduced vertical smooth pursuit = strong central (brainstem/cerebellar) indicator.' ), ( 'Positional Test\nPitch Backward\n(Head Extension)', 'Right eye:\nHorizontal SPV 7.28°/s | Amp 1.60°\nVertical SPV -8.85°/s | Amp -2.78°\nFreq 2.64 Hz | FPD 60°', 'ABNORMAL\n★ KEY FINDING', 'NYSTAGMUS TRIGGERED BY HEAD EXTENSION. Directly correlates with chief complaint of dizziness on neck extension. Strongly supports vertebrobasilar/cervicogenic mechanism.' ), ( 'Dix-Hallpike\n(Right side)', 'All positions: Absent nystagmus', 'NORMAL', 'No BPPV on right side. Right posterior canal intact.' ), ( 'Dix-Hallpike\n(Left side – supine,\nhead ext + left)', 'Right eye: Vertical SPV 12.57°/s | Amp 3.58° | Freq 1.09 Hz\nLeft eye: Horizontal SPV -16.96°/s | Amp -2.08° | Freq 1.18 Hz', 'ABNORMAL', 'Mixed horizontal + vertical nystagmus. Atypical for posterior canal BPPV (which produces torsional-vertical). Suggests horizontal canal BPPV or central positional nystagmus.' ), ( 'Dix-Hallpike\n(Return to sit,\nLeft side)', 'Left eye: Vertical SPV 3.51°/s | Amp 3.46° | Freq 1.05 Hz', 'ABNORMAL', 'Residual nystagmus on return to upright. Persistence weakens classic peripheral BPPV pattern. Supports central or horizontal canal BPPV.' ), ( 'Positional Test\nRoll Right', 'Right eye: Horizontal SPV -2.68°/s\nFreq 1.14 Hz', 'BORDERLINE', 'Mild horizontal nystagmus on rightward roll. SPV <3°/s; borderline significance. May reflect early horizontal canal BPPV or central positional change.' ), ( 'Subjective Visual\nVertical (SVV)', 'Trial 1 CW: -88° (outlier/artifact)\nTrial 2 CW: 0°\nACW: -4°\nBlank: -2°', 'NORMAL\n(excl. outlier)', 'SVV essentially normal when outlier first trial excluded (likely patient error). Normal SVV argues against significant utricular dysfunction or major brainstem tilt lesion.' ), ] result_colors = { 'NORMAL': RGBColor(0x00, 0x70, 0x2F), 'BORDERLINE': RGBColor(0xB8, 0x86, 0x00), 'ABNORMAL': RGBColor(0xC0, 0x00, 0x00), 'ABNORMAL\n★ KEY FINDING': RGBColor(0xC0, 0x00, 0x00), 'NORMAL\n(excl. outlier)': RGBColor(0x00, 0x70, 0x2F), } for row_data in findings: row = vng_table.add_row() for i, text in enumerate(row_data): cell = row.cells[i] cell.text = '' p = cell.paragraphs[0] r = p.add_run(text) r.font.name = 'Arial' r.font.size = Pt(9.5) if i == 2: # Result column r.font.bold = True r.font.color.rgb = result_colors.get(text, RGBColor(0, 0, 0)) if i == 0: r.font.bold = True doc.add_paragraph() # ============================================= # OVERALL SUMMARY BOX # ============================================= add_heading(doc, '3. OVERALL VNG INTERPRETATION', level=2, color=(0x2E, 0x40, 0x57)) add_rule(doc) summary_table = doc.add_table(rows=1, cols=2) summary_table.style = 'Table Grid' summary_table.autofit = False summary_table.columns[0].width = Inches(2.5) summary_table.columns[1].width = Inches(5.0) sum_hdr = summary_table.rows[0] for lbl, cell in zip(['Domain', 'Interpretation'], sum_hdr.cells): cell.text = '' tc = cell._tc tcPr = tc.get_or_add_tcPr() shd = OxmlElement('w:shd') shd.set(qn('w:val'), 'clear') shd.set(qn('w:color'), 'auto') shd.set(qn('w:fill'), '2E4057') tcPr.append(shd) p = cell.paragraphs[0] r = p.add_run(lbl) r.font.bold = True r.font.name = 'Arial' r.font.size = Pt(10) r.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF) summary_rows = [ ('Peripheral vestibular function', 'No spontaneous nystagmus; no head-shake nystagmus → No active peripheral lesion at rest'), ('Oculomotor (central)', 'Bilateral reduced vertical smooth pursuit + gaze-evoked nystagmus (left) + down-gaze nystagmus without fixation → CENTRAL VESTIBULAR INVOLVEMENT'), ('Positional (dynamic)', 'Pitch-backward nystagmus correlating with head extension complaints → Vertebrobasilar/cervicogenic mechanism likely'), ('BPPV assessment', 'Atypical left Dix-Hallpike (mixed H+V, persistent) → Central positional nystagmus preferred over classic BPPV'), ('Overall pattern', 'CENTRAL VESTIBULAR SYNDROME superimposed on possible cervicogenic contribution'), ] for d, interp in summary_rows: row = summary_table.add_row() c0, c1 = row.cells[0], row.cells[1] c0.text = '' p = c0.paragraphs[0] r = p.add_run(d) r.font.bold = True; r.font.name = 'Arial'; r.font.size = Pt(10) c1.text = '' p2 = c1.paragraphs[0] r2 = p2.add_run(interp) r2.font.name = 'Arial'; r2.font.size = Pt(10) doc.add_paragraph() # ============================================= # PRIMARY DIAGNOSIS # ============================================= add_heading(doc, '4. PRIMARY DIAGNOSIS', level=2, color=(0x2E, 0x40, 0x57)) add_rule(doc) prim_box = doc.add_table(rows=1, cols=1) prim_box.style = 'Table Grid' prim_cell = prim_box.rows[0].cells[0] prim_cell.text = '' tc = prim_cell._tc tcPr = tc.get_or_add_tcPr() shd = OxmlElement('w:shd') shd.set(qn('w:val'), 'clear') shd.set(qn('w:color'), 'auto') shd.set(qn('w:fill'), 'FFF3CD') tcPr.append(shd) p = prim_cell.paragraphs[0] r = p.add_run('Central Vestibular Syndrome - Vertebrobasilar Insufficiency (VBI) / Cervicogenic Vestibular Disturbance') r.font.bold = True; r.font.name = 'Arial'; r.font.size = Pt(11) r.font.color.rgb = RGBColor(0x85, 0x45, 0x00) doc.add_paragraph() rationale_items = [ 'Dizziness and blackouts specifically triggered by neck extension - hallmark of vertebrobasilar insufficiency with vertebral artery compromise at the level of cervical spondylosis.', 'VNG demonstrates gaze-evoked nystagmus (left, with fixation) and down-gaze nystagmus (without fixation) - both are central signs implicating brainstem or cerebellar pathway involvement.', 'Bilaterally reduced vertical smooth pursuit gain - not explained by age alone; a reliable indicator of central vestibular/cerebellar pathology.', 'Pitch-backward positional nystagmus on VNG directly mirrors the patient\'s positional complaint.', 'Multiple vascular risk factors: age 79, HTN (BP 145/67), DM (HbA1c 6.8, BSF 147), cervical spondylosis.', 'No spontaneous or head-shake nystagmus argues against active peripheral labyrinthine pathology as the primary cause.', ] p_rat = doc.add_paragraph() r = p_rat.add_run('Rationale:') r.font.bold = True; r.font.name = 'Arial'; r.font.size = Pt(10.5) for item in rationale_items: p = doc.add_paragraph(style='List Bullet') p.paragraph_format.left_indent = Inches(0.3) p.paragraph_format.space_before = Pt(1) p.paragraph_format.space_after = Pt(1) r = p.add_run(item) r.font.name = 'Arial'; r.font.size = Pt(10.5) doc.add_paragraph() # ============================================= # DIFFERENTIAL DIAGNOSES # ============================================= add_heading(doc, '5. DIFFERENTIAL DIAGNOSES', level=2, color=(0x2E, 0x40, 0x57)) add_rule(doc) ddx_table = doc.add_table(rows=1, cols=4) ddx_table.style = 'Table Grid' ddx_table.autofit = False ddx_table.columns[0].width = Inches(0.4) ddx_table.columns[1].width = Inches(2.2) ddx_table.columns[2].width = Inches(2.3) ddx_table.columns[3].width = Inches(2.6) hdr_ddx = ddx_table.rows[0] for lbl, cell in zip(['#', 'Diagnosis', 'Supporting Evidence', 'Against / Notes'], hdr_ddx.cells): cell.text = '' tc = cell._tc tcPr = tc.get_or_add_tcPr() shd = OxmlElement('w:shd') shd.set(qn('w:val'), 'clear') shd.set(qn('w:color'), 'auto') shd.set(qn('w:fill'), '2E4057') tcPr.append(shd) p = cell.paragraphs[0] r = p.add_run(lbl) r.font.bold = True; r.font.name = 'Arial'; r.font.size = Pt(10) r.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF) ddx_data = [ ('1', 'Vertebrobasilar Insufficiency (VBI)\n[Most Likely - PRIMARY]', 'Extension-triggered symptoms; central VNG (GEN, reduced vertical SP); pitch-backward nystagmus; HTN, DM, age 79; cervical spondylosis', 'No caloric test data; MRI/MRA not yet done to confirm ischemia or vessel stenosis'), ('2', 'Central Positional Nystagmus\n(Cerebellar / Brainstem lesion)', 'Atypical Dix-Hallpike (mixed H+V, no torsion, persistent); central oculomotor signs on VNG; reduced vertical smooth pursuit', 'No structural MRI yet; SVV normal argues against large brainstem lesion. MRI brain mandatory'), ('3', 'Horizontal Canal BPPV\n(Left side)', 'Left Dix-Hallpike shows horizontal nystagmus component; roll-right borderline positive', 'Roll maneuver (supine roll) did not clearly elicit diagnostic geotropic/apogeotropic pattern; nystagmus persists on return to sit (atypical for peripheral BPPV)'), ('4', 'Cervicogenic Dizziness\n(Cervical proprioceptive dysfunction)', 'Confirmed cervical spondylosis; dizziness on neck extension/rotation; pitch-backward nystagmus on VNG', 'True nystagmus recorded (not purely proprioceptive). Cannot be sole explanation. Likely a contributing factor'), ('5', 'Age-related Multisensory Dizziness\n(Presbyvestibulopathy)', 'Age 79; bilateral reduced smooth pursuit (partially age-expected); multiple sensory deficits', 'GEN and positional nystagmus exceed normal aging pattern. Contributing factor, not primary diagnosis'), ('6', 'Obstructive Sleep Apnea (OSA)\nwith cerebrovascular consequences', 'Excessive daytime sleepiness, snoring for years; OSA accelerates vascular disease and hypertension', 'Indirect contributor. Requires formal sleep study (polysomnography) for confirmation'), ] for num, dx, for_, against in ddx_data: row = ddx_table.add_row() cells = row.cells # Num cells[0].text = '' r = cells[0].paragraphs[0].add_run(num) r.font.bold = True; r.font.name = 'Arial'; r.font.size = Pt(10) # Dx cells[1].text = '' r = cells[1].paragraphs[0].add_run(dx) r.font.bold = True; r.font.name = 'Arial'; r.font.size = Pt(9.5) if '1' in num and 'PRIMARY' in dx: r.font.color.rgb = RGBColor(0xC0, 0x00, 0x00) # For cells[2].text = '' r = cells[2].paragraphs[0].add_run(for_) r.font.name = 'Arial'; r.font.size = Pt(9.5) # Against cells[3].text = '' r = cells[3].paragraphs[0].add_run(against) r.font.name = 'Arial'; r.font.size = Pt(9.5) doc.add_paragraph() # ============================================= # RECOMMENDED INVESTIGATIONS # ============================================= add_heading(doc, '6. RECOMMENDED INVESTIGATIONS (URGENT)', level=2, color=(0x2E, 0x40, 0x57)) add_rule(doc) inv_table = doc.add_table(rows=1, cols=3) inv_table.style = 'Table Grid' inv_table.autofit = False inv_table.columns[0].width = Inches(0.5) inv_table.columns[1].width = Inches(3.0) inv_table.columns[2].width = Inches(4.0) for lbl, cell in zip(['#', 'Investigation', 'Rationale'], inv_table.rows[0].cells): cell.text = '' tc = cell._tc tcPr = tc.get_or_add_tcPr() shd = OxmlElement('w:shd') shd.set(qn('w:val'), 'clear') shd.set(qn('w:color'), 'auto') shd.set(qn('w:fill'), '2E4057') tcPr.append(shd) p = cell.paragraphs[0] r = p.add_run(lbl) r.font.bold = True; r.font.name = 'Arial'; r.font.size = Pt(10) r.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF) investigations = [ ('1', 'MRI Brain + MRA Posterior Circulation\n[PRIORITY - not yet done]', 'Rule out cerebellar/brainstem infarct, demyelination, or mass. Assess vertebrobasilar artery stenosis. Most critical pending investigation.'), ('2', 'USG Doppler Neck Vessels\n[Already ordered]', 'Assess vertebral artery flow, especially during head extension/rotation. Look for dynamic compression by cervical spondylosis.'), ('3', 'Video Head Impulse Test (vHIT)', 'Quantify VOR gain per semicircular canal. Useful to detect canal-specific hypofunction not shown on VNG alone.'), ('4', 'Caloric Test\n(if available with VNG system)', 'Not recorded in this VNG study. Caloric testing quantifies unilateral canal paresis (UCP%) and directional preponderance.'), ('5', 'Polysomnography (Sleep Study)', 'Evaluate for OSA - high clinical suspicion given daytime sleepiness and snoring. OSA is a modifiable cerebrovascular risk factor.'), ('6', 'Cardiovascular workup\n(ECG, Holter, Echo)', 'Blackouts require exclusion of cardiogenic syncope (arrhythmia, aortic stenosis). ECG already ordered. Consider Holter if ECG unremarkable.'), ] for num, inv, rat in investigations: row = inv_table.add_row() cells = row.cells cells[0].text = '' r = cells[0].paragraphs[0].add_run(num) r.font.bold = True; r.font.name = 'Arial'; r.font.size = Pt(10) cells[1].text = '' r = cells[1].paragraphs[0].add_run(inv) r.font.bold = True; r.font.name = 'Arial'; r.font.size = Pt(9.5) cells[2].text = '' r = cells[2].paragraphs[0].add_run(rat) r.font.name = 'Arial'; r.font.size = Pt(9.5) doc.add_paragraph() # ============================================= # CLINICAL NOTES / CAUTION BOX # ============================================= add_heading(doc, '7. MANAGEMENT NOTES FOR NEUROLOGY', level=2, color=(0x2E, 0x40, 0x57)) add_rule(doc) mgmt_items = [ ('DO NOT perform Epley maneuver at this stage:', 'The Dix-Hallpike nystagmus is atypical (mixed H+V, no torsion, persistent on return). Central positional nystagmus must be excluded before canalith repositioning is attempted.'), ('Vascular risk factor optimization:', 'BP target <130/80 mmHg (patient has DM + HTN). HbA1c target <7%. Evaluate statin therapy. Consider antiplatelet therapy once structural lesion is excluded.'), ('Fall risk:', 'Patient has Fall Risk Assessment score of 1. Extension-triggered blackouts pose a significant fall risk. Activity restrictions and fall prevention advice required.'), ('Vitamin B12:', 'Level 208 pg/mL is low-normal. Given ongoing neurological symptoms, supplementation (Rejunex CD3 NF already started) is appropriate. Repeat in 3 months.'), ('OSA management:', 'High clinical suspicion. Untreated OSA worsens BP control, promotes cerebrovascular disease, and may contribute to dizziness via nocturnal hypoxia. Refer to sleep medicine.'), ] for label, value in mgmt_items: p = doc.add_paragraph() p.paragraph_format.space_before = Pt(2) p.paragraph_format.space_after = Pt(2) r = p.add_run(label + ' ') r.font.bold = True; r.font.name = 'Arial'; r.font.size = Pt(10.5) r2 = p.add_run(value) r2.font.name = 'Arial'; r2.font.size = Pt(10.5) doc.add_paragraph() # ============================================= # FOOTER DISCLAIMER # ============================================= add_rule(doc) disc_p = doc.add_paragraph() disc_p.alignment = WD_ALIGN_PARAGRAPH.CENTER r = disc_p.add_run( 'This document is a clinical interpretation of VNG data prepared for neurology review. ' 'The VNG report impression field was not completed by the performing clinician. ' 'All clinical decisions should be made by the treating neurologist after direct review of the original VNG tracings and examination findings. ' 'Prepared: 16 July 2026.' ) r.font.name = 'Arial'; r.font.size = Pt(8.5) r.font.italic = True; r.font.color.rgb = RGBColor(0x77, 0x77, 0x77) # Save out_path = '/tmp/workspace/col-avinash-vng/VNG_Summary_Col_Avinash_Verma_Neurology.docx' doc.save(out_path) print(f'Saved: {out_path}') EOF

python3 -c " from docx import Document doc = Document('/tmp/workspace/col-avinash-vng/VNG_Summary_Col_Avinash_Verma_Neurology.docx') print('Pages/sections:', len(doc.sections)) print('Paragraphs:', len(doc.paragraphs)) print('Tables:', len(doc.tables)) print('File size:', __import__('os').path.getsize('/tmp/workspace/col-avinash-vng/VNG_Summary_Col_Avinash_Verma_Neurology.docx'), 'bytes') print() print('--- First 20 paragraphs ---') for i, p in enumerate(doc.paragraphs[:20]): if p.text.strip(): print(f' [{p.style.name}] {p.text[:80]}') "