back pain differential diagnosis table spinal causes

MRI lumbar spine disc herniation nerve root compression

spinal stenosis neurogenic claudication imaging

straight leg raise test sciatica examination

cauda equina syndrome saddle anaesthesia bladder

ankylosing spondylitis sacroiliitis bamboo spine xray

vertebral osteomyelitis discitis MRI spine infection

mkdir -p /home/daytona/workspace/back-pain-pptx && ls /home/daytona/workspace/ba…

node /home/daytona/skills/shared/scripts/fetch_images.js \ "https://cdn.orris.…

~/back-pain-pptx/build.js

const pptxgen = require("pptxgenjs");
const fs = require("fs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Back Pain: Differential Diagnosis, Investigations & Management";

// Load images
const img = {};
for (let i = 0; i <= 6; i++) {
  const p = `/home/daytona/workspace/back-pain-pptx/img${i}.txt`;
  if (fs.existsSync(p)) img[i] = fs.readFileSync(p, "utf8");
}

// Color palette — deep navy + white + crimson accent + teal highlights
const NAV = "0D1B2A";   // deep navy (dominant bg)
const NAV2 = "1A2E45";  // slightly lighter navy for cards
const WHT = "FFFFFF";
const CRM = "C0392B";   // crimson / red accent
const TEA = "1ABC9C";   // teal highlight
const GLD = "F1C40F";   // gold accent
const LGR = "BDC3C7";   // light grey
const DGR = "2C3E50";   // dark blue-grey

// Helper: slide background
function bg(slide) {
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: NAV }, line: { color: NAV } });
}

// Helper: header bar with title
function header(slide, title, sub) {
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 1.0, fill: { color: CRM }, line: { color: CRM } });
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 1.0, w: 10, h: 0.05, fill: { color: TEA }, line: { color: TEA } });
  slide.addText(title, { x: 0.3, y: 0.05, w: 9.4, h: 0.7, fontSize: 26, bold: true, color: WHT, fontFace: "Calibri", valign: "middle", margin: 0 });
  if (sub) slide.addText(sub, { x: 0.3, y: 0.72, w: 9.4, h: 0.32, fontSize: 12, color: "FFCCCC", fontFace: "Calibri", valign: "middle", margin: 0 });
}

// Helper: section label
function sectionBadge(slide, text, x, y, w, color) {
  slide.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w, h: 0.32, fill: { color: color || TEA }, line: { color: color || TEA }, rectRadius: 0.05 });
  slide.addText(text, { x, y, w, h: 0.32, fontSize: 9, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
}

// Helper: card
function card(slide, x, y, w, h, fillColor) {
  slide.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w, h, fill: { color: fillColor || NAV2 }, line: { color: "2980B9", width: 0.5 }, rectRadius: 0.08, shadow: { type: "outer", color: "000000", blur: 4, offset: 2, angle: 135, opacity: 0.25 } });
}

// ─────────────────────────────────────────────
// SLIDE 1 — TITLE SLIDE
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  // full-width accent bar
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.12, h: 5.625, fill: { color: CRM }, line: { color: CRM } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.12, y: 0, w: 0.06, h: 5.625, fill: { color: TEA }, line: { color: TEA } });

  s.addText("BACK PAIN", { x: 0.5, y: 0.7, w: 9, h: 1.1, fontSize: 52, bold: true, color: WHT, fontFace: "Calibri", margin: 0 });
  s.addText("Differential Diagnosis · Investigations · Management", { x: 0.5, y: 1.85, w: 9, h: 0.55, fontSize: 20, color: TEA, fontFace: "Calibri", margin: 0 });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.5, y: 2.5, w: 5, h: 0.04, fill: { color: CRM }, line: { color: CRM } });
  s.addText("Family Medicine | MBBS Year 3", { x: 0.5, y: 2.65, w: 9, h: 0.4, fontSize: 15, color: LGR, fontFace: "Calibri", margin: 0 });
  s.addText("Student Presentation — ~8 minutes", { x: 0.5, y: 3.1, w: 9, h: 0.35, fontSize: 13, color: "7F8C8D", fontFace: "Calibri", margin: 0 });

  // Spine silhouette icon using circles
  s.addShape(pres.shapes.OVAL, { x: 8.1, y: 0.8, w: 1.4, h: 1.4, fill: { color: NAV2 }, line: { color: CRM, width: 2 } });
  s.addText("⚕", { x: 8.1, y: 0.85, w: 1.4, h: 1.3, fontSize: 44, color: CRM, align: "center", valign: "middle", margin: 0 });
}

// ─────────────────────────────────────────────
// SLIDE 2 — FRAMEWORK (3 BUCKETS)
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "THE CLINICAL FRAMEWORK", "Start every back pain consultation with this");

  // 3 bucket cards
  const buckets = [
    { label: "~85%", title: "NONSPECIFIC\nMECHANICAL", sub: "Muscle strain, disc, posture\nNo red flags\nSelf-limiting", color: "27AE60" },
    { label: "~10%", title: "RADICULAR\n(SCIATICA)", sub: "Nerve root irritation\nLeg pain below knee\nDermatomal pattern", color: "E67E22" },
    { label: "~5%", title: "RED FLAG\nCONDITION", sub: "Cancer · Infection\nFracture · Cauda Equina\nRequires urgent workup", color: CRM },
  ];
  const xs = [0.25, 3.55, 6.85];
  buckets.forEach((b, i) => {
    card(s, xs[i], 1.2, 3.1, 3.8, NAV2);
    s.addShape(pres.shapes.OVAL, { x: xs[i] + 0.9, y: 1.35, w: 1.3, h: 0.55, fill: { color: b.color }, line: { color: b.color } });
    s.addText(b.label, { x: xs[i] + 0.9, y: 1.35, w: 1.3, h: 0.55, fontSize: 16, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addText(b.title, { x: xs[i] + 0.1, y: 2.0, w: 2.9, h: 0.75, fontSize: 14, bold: true, color: WHT, align: "center", fontFace: "Calibri", margin: 0 });
    s.addShape(pres.shapes.RECTANGLE, { x: xs[i] + 0.6, y: 2.75, w: 1.9, h: 0.03, fill: { color: b.color }, line: { color: b.color } });
    s.addText(b.sub, { x: xs[i] + 0.1, y: 2.85, w: 2.9, h: 1.0, fontSize: 11, color: LGR, align: "center", fontFace: "Calibri", margin: 0 });
  });

  s.addText("Your primary task: RULE OUT Bucket 3 first, then manage the rest", { x: 0.3, y: 5.1, w: 9.4, h: 0.38, fontSize: 13, bold: true, color: GLD, align: "center", fontFace: "Calibri", margin: 0 });
}

// ─────────────────────────────────────────────
// SLIDE 3 — DIFFERENTIAL DIAGNOSIS TABLE
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "DIFFERENTIAL DIAGNOSIS", "Organised by category");

  const rows = [
    ["MECHANICAL", "Muscle strain · Ligament sprain · Disc herniation · Facet joint pain · Spondylolysis · Spondylolisthesis", "27AE60"],
    ["DEGENERATIVE", "Degenerative disc disease · Spondylosis · Spinal stenosis (neurogenic claudication)", "2ECC71"],
    ["INFLAMMATORY", "Ankylosing spondylitis · Psoriatic arthritis · Reactive arthritis", "E67E22"],
    ["INFECTIOUS", "Vertebral osteomyelitis · Discitis · Epidural abscess · TB spine (Pott's disease)", CRM],
    ["NEOPLASTIC", "Spinal metastases · Multiple myeloma · Primary spinal tumours · Leukaemia/Lymphoma", "9B59B6"],
    ["VASCULAR", "AAA · Aortic dissection · Spinal epidural haematoma · Spinal AVM", "E74C3C"],
    ["REFERRED / VISCERAL", "Renal colic · Pyelonephritis · Pancreatitis · Ovarian/testicular · Ectopic pregnancy · MI · PE", "3498DB"],
  ];

  rows.forEach((r, i) => {
    const y = 1.15 + i * 0.6;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.15, y, w: 2.1, h: 0.5, fill: { color: r[2] }, line: { color: r[2] } });
    s.addText(r[0], { x: 0.15, y, w: 2.1, h: 0.5, fontSize: 9.5, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addShape(pres.shapes.RECTANGLE, { x: 2.3, y, w: 7.5, h: 0.5, fill: { color: NAV2 }, line: { color: r[2], width: 0.8 } });
    s.addText(r[1], { x: 2.35, y, w: 7.4, h: 0.5, fontSize: 10.5, color: WHT, valign: "middle", fontFace: "Calibri", margin: 0 });
  });
}

// ─────────────────────────────────────────────
// SLIDE 4 — CLINICAL CLUES
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "CLINICAL CLUES AT A GLANCE", "Pain pattern → likely cause");

  const clues = [
    ["Movement ↑ pain, rest relieves, no neurology", "Mechanical / Muscle strain", "27AE60"],
    ["Leg pain below knee, dermatomal, worse with Valsalva", "Disc herniation / Sciatica", "E67E22"],
    ["Bilateral leg pain walking, shopping cart sign", "Spinal stenosis", "3498DB"],
    ["Young man, morning stiffness >1hr, improves with exercise", "Ankylosing spondylitis", "E67E22"],
    ["Age >50, night pain, weight loss", "Malignancy ⚠", CRM],
    ["Fever + back pain + IVDU/DM/immunocompromised", "Osteomyelitis / Epidural abscess ⚠", CRM],
    ["Saddle numbness + urinary retention", "Cauda Equina — EMERGENCY 🚨", "8E44AD"],
    ["Colicky flank → groin + haematuria", "Renal colic (referred)", "3498DB"],
    ["Tearing back pain + pulsatile mass + hypotension", "Ruptured AAA — EMERGENCY 🚨", "8E44AD"],
    ["Back pain in a CHILD", "Always red flag — investigate", CRM],
  ];

  clues.forEach((c, i) => {
    const col = i < 5 ? 0 : 1;
    const row = i < 5 ? i : i - 5;
    const x = col === 0 ? 0.15 : 5.1;
    const y = 1.15 + row * 0.82;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w: 4.8, h: 0.72, fill: { color: NAV2 }, line: { color: c[2], width: 1 }, rectRadius: 0.06 });
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 0.08, h: 0.72, fill: { color: c[2] }, line: { color: c[2] } });
    s.addText(c[0], { x: x + 0.15, y: y + 0.03, w: 4.6, h: 0.32, fontSize: 9.5, color: LGR, fontFace: "Calibri", margin: 0 });
    s.addText("→ " + c[1], { x: x + 0.15, y: y + 0.35, w: 4.6, h: 0.3, fontSize: 10, bold: true, color: WHT, fontFace: "Calibri", margin: 0 });
  });
}

// ─────────────────────────────────────────────
// SLIDE 5 — DISC HERNIATION + MRI IMAGE
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "DISC HERNIATION & RADICULOPATHY", "Most important specific cause to understand");

  // Left content
  const steps = [
    "Ageing → loss of nucleus water content",
    "Annulus fibrosus thins and tears",
    "Nucleus pulposus herniates — usually posterolateral",
    "Compresses and inflames adjacent nerve root",
    "→ RADICULOPATHY (pain + numbness + weakness)",
  ];
  const stepColors = [TEA, TEA, TEA, CRM, GLD];
  steps.forEach((st, i) => {
    const y = 1.25 + i * 0.6;
    s.addShape(pres.shapes.OVAL, { x: 0.2, y: y + 0.05, w: 0.4, h: 0.4, fill: { color: stepColors[i] }, line: { color: stepColors[i] } });
    s.addText(`${i + 1}`, { x: 0.2, y: y + 0.05, w: 0.4, h: 0.4, fontSize: 11, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addText(st, { x: 0.7, y, w: 4.8, h: 0.55, fontSize: 12, color: i >= 3 ? GLD : WHT, fontFace: "Calibri", valign: "middle", bold: i >= 3, margin: 0 });
  });

  // Nerve root table
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 4.25, w: 5.1, h: 0.25, fill: { color: CRM }, line: { color: CRM } });
  s.addText("Nerve Root Map", { x: 0.2, y: 4.25, w: 5.1, h: 0.25, fontSize: 10, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
  const nrRows = [
    ["L4", "Knee extension", "Medial shin", "Knee jerk ↓"],
    ["L5 (most common)", "Foot dorsiflexion", "Dorsum foot", "No reliable reflex"],
    ["S1", "Plantarflexion", "Lateral foot/sole", "Ankle jerk ↓"],
  ];
  const nrW = [0.9, 1.4, 1.3, 1.5];
  const nrX = [0.2, 1.1, 2.5, 3.8];
  nrRows.forEach((row, ri) => {
    const y = 4.5 + ri * 0.35;
    const bg2 = ri % 2 === 0 ? NAV2 : "152638";
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 5.1, h: 0.33, fill: { color: bg2 }, line: { color: bg2 } });
    row.forEach((cell, ci) => {
      s.addText(cell, { x: nrX[ci], y, w: nrW[ci], h: 0.33, fontSize: 9, color: ci === 0 ? GLD : WHT, bold: ci === 0, fontFace: "Calibri", valign: "middle", margin: 3 });
    });
  });

  // Right: MRI image
  if (img[0]) {
    s.addImage({ data: img[0], x: 5.55, y: 1.2, w: 4.2, h: 4.1 });
    s.addShape(pres.shapes.RECTANGLE, { x: 5.55, y: 5.1, w: 4.2, h: 0.2, fill: { color: DGR }, line: { color: DGR } });
    s.addText("MRI axial — L4/5 disc herniation compressing right L5 nerve root", { x: 5.55, y: 5.1, w: 4.2, h: 0.22, fontSize: 7.5, color: LGR, italic: true, align: "center", fontFace: "Calibri", margin: 0 });
  }
}

// ─────────────────────────────────────────────
// SLIDE 6 — SPINAL STENOSIS
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "SPINAL STENOSIS", "Neurogenic claudication — common in the elderly");

  // Left content
  s.addText("What happens:", { x: 0.2, y: 1.15, w: 5.1, h: 0.35, fontSize: 13, bold: true, color: TEA, fontFace: "Calibri", margin: 0 });
  const causes = ["Thickened ligamentum flavum", "Facet joint hypertrophy + osteophytes", "Disc bulging centrally", "→ Narrows spinal canal / neural foramina", "→ Compresses cauda equina nerve roots"];
  causes.forEach((c, i) => {
    s.addText((i < 3 ? "• " : "") + c, { x: 0.3, y: 1.55 + i * 0.38, w: 5.1, h: 0.35, fontSize: 11.5, color: i >= 3 ? GLD : WHT, bold: i >= 3, fontFace: "Calibri", margin: 0 });
  });

  s.addText("Neurogenic Claudication", { x: 0.2, y: 3.55, w: 5.1, h: 0.35, fontSize: 13, bold: true, color: CRM, fontFace: "Calibri", margin: 0 });
  const claudRows = [
    ["Worse with", "Walking, standing, back extension"],
    ["Better with", "Sitting, bending forward (shopping cart sign)"],
    ["Pulses", "Normal (unlike vascular claudication)"],
    ["Imaging", "MRI shows canal narrowing"],
  ];
  claudRows.forEach((row, i) => {
    const y = 3.95 + i * 0.38;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 1.3, h: 0.33, fill: { color: CRM }, line: { color: CRM } });
    s.addText(row[0], { x: 0.2, y, w: 1.3, h: 0.33, fontSize: 10, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addShape(pres.shapes.RECTANGLE, { x: 1.55, y, w: 3.75, h: 0.33, fill: { color: NAV2 }, line: { color: NAV2 } });
    s.addText(row[1], { x: 1.6, y, w: 3.7, h: 0.33, fontSize: 10.5, color: WHT, valign: "middle", fontFace: "Calibri", margin: 0 });
  });

  // Right: MRI image
  if (img[1]) {
    s.addImage({ data: img[1], x: 5.55, y: 1.2, w: 4.2, h: 3.8 });
    s.addText("MRI — central canal stenosis (A=normal, B=stenosis with ligamentum flavum thickening)", { x: 5.55, y: 5.05, w: 4.2, h: 0.32, fontSize: 7.5, color: LGR, italic: true, align: "center", fontFace: "Calibri", margin: 0 });
  }
}

// ─────────────────────────────────────────────
// SLIDE 7 — ANKYLOSING SPONDYLITIS
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "ANKYLOSING SPONDYLITIS", "Inflammatory back pain — axial spondyloarthritis");

  // Content left
  const features = [
    ["Patient", "Young male, onset <40 years"],
    ["Onset", "Insidious, gradual over months"],
    ["Pain", "Lower back, buttocks, sacroiliac joints"],
    ["Morning stiffness", ">1 hour — hallmark feature"],
    ["Improves with", "Exercise, movement — NOT rest"],
    ["Night pain", "Wakes patient, improves on getting up"],
    ["HLA-B27", "Positive in ~90%"],
    ["Hallmark imaging", "Bilateral sacroiliitis → bamboo spine"],
  ];
  features.forEach((f, i) => {
    const y = 1.2 + i * 0.51;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 2.2, h: 0.43, fill: { color: "E67E22" }, line: { color: "E67E22" } });
    s.addText(f[0], { x: 0.2, y, w: 2.2, h: 0.43, fontSize: 10, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addShape(pres.shapes.RECTANGLE, { x: 2.45, y, w: 3.05, h: 0.43, fill: { color: NAV2 }, line: { color: NAV2 } });
    s.addText(f[1], { x: 2.5, y, w: 3.0, h: 0.43, fontSize: 10.5, color: WHT, valign: "middle", fontFace: "Calibri", margin: 0 });
  });

  // Right: AS/bamboo spine image
  if (img[4]) {
    s.addImage({ data: img[4], x: 5.7, y: 1.2, w: 4.1, h: 4.0 });
    s.addText("X-ray: Bamboo spine (syndesmophytes) + bilateral sacroiliitis", { x: 5.7, y: 5.2, w: 4.1, h: 0.25, fontSize: 7.5, color: LGR, italic: true, align: "center", fontFace: "Calibri", margin: 0 });
  }
}

// ─────────────────────────────────────────────
// SLIDE 8 — SPINAL INFECTION
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "SPINAL INFECTION", "Osteomyelitis · Discitis · Epidural Abscess");

  // Left: risk factors + features
  s.addText("Risk Factors", { x: 0.2, y: 1.15, w: 4.8, h: 0.35, fontSize: 13, bold: true, color: CRM, fontFace: "Calibri", margin: 0 });
  const risks = ["IV drug use (IVDU)", "Diabetes mellitus", "Immunosuppression / HIV", "Recent spinal surgery / UTI", "TB history (endemic areas)"];
  risks.forEach((r, i) => {
    s.addShape(pres.shapes.OVAL, { x: 0.2, y: 1.55 + i * 0.38, w: 0.22, h: 0.22, fill: { color: CRM }, line: { color: CRM } });
    s.addText(r, { x: 0.5, y: 1.52 + i * 0.38, w: 4.5, h: 0.3, fontSize: 11, color: WHT, fontFace: "Calibri", margin: 0 });
  });

  s.addText("Clinical Features", { x: 0.2, y: 3.55, w: 4.8, h: 0.35, fontSize: 13, bold: true, color: GLD, fontFace: "Calibri", margin: 0 });
  const feats = ["Fever + severe, localised back pain", "Point tenderness over spinous process", "Progressive neurological deficit (late)", "↑ ESR, ↑ CRP, ↑ WBC"];
  feats.forEach((f, i) => {
    s.addShape(pres.shapes.OVAL, { x: 0.2, y: 3.95 + i * 0.38, w: 0.22, h: 0.22, fill: { color: GLD }, line: { color: GLD } });
    s.addText(f, { x: 0.5, y: 3.92 + i * 0.38, w: 4.5, h: 0.3, fontSize: 11, color: WHT, fontFace: "Calibri", margin: 0 });
  });

  // Right: MRI infection image
  if (img[5]) {
    s.addImage({ data: img[5], x: 5.4, y: 1.2, w: 4.4, h: 4.1 });
    s.addText("MRI — Discitis-osteomyelitis L2/3 with endplate destruction + psoas involvement", { x: 5.4, y: 5.3, w: 4.4, h: 0.28, fontSize: 7.5, color: LGR, italic: true, align: "center", fontFace: "Calibri", margin: 0 });
  }
}

// ─────────────────────────────────────────────
// SLIDE 9 — CAUDA EQUINA SYNDROME
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  // Red urgency header
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 1.0, fill: { color: "8E0000" }, line: { color: "8E0000" } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 1.0, w: 10, h: 0.05, fill: { color: GLD }, line: { color: GLD } });
  s.addText("⚠  CAUDA EQUINA SYNDROME — SURGICAL EMERGENCY", { x: 0.2, y: 0.08, w: 9.6, h: 0.85, fontSize: 22, bold: true, color: WHT, fontFace: "Calibri", valign: "middle", margin: 0 });

  // Left: Features
  s.addText("Features — ALL must be screened for:", { x: 0.2, y: 1.15, w: 4.9, h: 0.38, fontSize: 12, bold: true, color: GLD, fontFace: "Calibri", margin: 0 });
  const cesFeats = [
    ["SADDLE ANAESTHESIA", "Numbness around anus, perineum, genitals — pathognomonic"],
    ["URINARY RETENTION", "Painless — patient cannot feel a full bladder"],
    ["URINARY INCONTINENCE", "Or altered urinary sensation"],
    ["FAECAL INCONTINENCE", "Loss of rectal fullness sensation"],
    ["BILATERAL LEG WEAKNESS", "Major motor deficit: hip flexors, knee, foot"],
    ["REDUCED ANAL TONE", "On digital rectal examination"],
  ];
  cesFeats.forEach((f, i) => {
    const y = 1.6 + i * 0.56;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 2.0, h: 0.48, fill: { color: "8E0000" }, line: { color: "8E0000" } });
    s.addText(f[0], { x: 0.2, y, w: 2.0, h: 0.48, fontSize: 8.5, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addShape(pres.shapes.RECTANGLE, { x: 2.25, y, w: 2.8, h: 0.48, fill: { color: NAV2 }, line: { color: NAV2 } });
    s.addText(f[1], { x: 2.3, y, w: 2.75, h: 0.48, fontSize: 10, color: LGR, valign: "middle", fontFace: "Calibri", margin: 0 });
  });

  // Action box
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.2, y: 5.0, w: 5.1, h: 0.42, fill: { color: "8E0000" }, line: { color: GLD, width: 2 }, rectRadius: 0.06 });
  s.addText("ACTION: Same-day EMERGENCY MRI → Neurosurgical referral", { x: 0.2, y: 5.0, w: 5.1, h: 0.42, fontSize: 11, bold: true, color: GLD, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });

  // Right: CES classification table image
  if (img[3]) {
    s.addImage({ data: img[3], x: 5.45, y: 1.15, w: 4.4, h: 3.5 });
    s.addText("CES Classification — Bailey & Love's Surgery 28E", { x: 5.45, y: 4.7, w: 4.4, h: 0.25, fontSize: 7.5, color: LGR, italic: true, align: "center", fontFace: "Calibri", margin: 0 });
  }
}

// ─────────────────────────────────────────────
// SLIDE 10 — EXAMINATION
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "EXAMINATION OF THE BACK", "Look · Feel · Move · Special Tests");

  // 4 quadrant layout
  const quads = [
    {
      title: "LOOK", color: TEA,
      items: ["Scoliosis / kyphosis / lordosis loss", "Paraspinal muscle wasting or spasm", "Skin: hairy tuft/dimple = spina bifida", "Haematoma, bruising (trauma)"]
    },
    {
      title: "FEEL", color: "E67E22",
      items: ["Spinous process percussion tenderness", "  → fracture / infection / tumour", "Paraspinal muscle spasm", "Step-off deformity → spondylolisthesis"]
    },
    {
      title: "MOVE", color: "3498DB",
      items: ["Flexion 40–60° (pain = discogenic)", "Extension 20–35° (pain = facet/spondylolysis)", "Lateral bending, rotation", "Schober's test for ankylosing spondylitis"]
    },
    {
      title: "SPECIAL TESTS", color: CRM,
      items: ["SLR (Lasègue): 30–70° leg pain → L4/5/S1", "Crossed SLR: specific for disc extrusion", "Femoral stretch: L2/3/4 radiculopathy", "Saddle sensation + anal tone (CES screen)"]
    }
  ];
  const qx = [0.15, 5.1, 0.15, 5.1];
  const qy = [1.15, 1.15, 3.45, 3.45];
  quads.forEach((q, i) => {
    card(s, qx[i], qy[i], 4.7, 2.0, NAV2);
    s.addShape(pres.shapes.RECTANGLE, { x: qx[i], y: qy[i], w: 4.7, h: 0.38, fill: { color: q.color }, line: { color: q.color } });
    s.addText(q.title, { x: qx[i], y: qy[i], w: 4.7, h: 0.38, fontSize: 13, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    q.items.forEach((item, j) => {
      s.addText("• " + item, { x: qx[i] + 0.15, y: qy[i] + 0.45 + j * 0.37, w: 4.4, h: 0.35, fontSize: 10, color: WHT, fontFace: "Calibri", margin: 0 });
    });
  });
}

// ─────────────────────────────────────────────
// SLIDE 11 — SLR TEST + image
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "STRAIGHT LEG RAISE (SLR) TEST", "Lasègue's sign — the key test for radiculopathy");

  // Steps
  const steps = [
    "Patient lies SUPINE on examination table",
    "Examiner raises leg with knee FULLY EXTENDED",
    "Positive: pain radiates DOWN the leg (not just back) between 30°–70°",
    "Add ankle dorsiflexion → increases sciatic tension (confirms result)",
    "Tests L4, L5, S1 nerve roots",
  ];
  const sColors = [TEA, TEA, CRM, GLD, "3498DB"];
  steps.forEach((st, i) => {
    const y = 1.2 + i * 0.64;
    s.addShape(pres.shapes.OVAL, { x: 0.2, y: y + 0.1, w: 0.38, h: 0.38, fill: { color: sColors[i] }, line: { color: sColors[i] } });
    s.addText(`${i + 1}`, { x: 0.2, y: y + 0.1, w: 0.38, h: 0.38, fontSize: 11, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addText(st, { x: 0.7, y, w: 4.8, h: 0.58, fontSize: 11.5, color: i >= 2 ? GLD : WHT, bold: i >= 2, fontFace: "Calibri", valign: "middle", margin: 0 });
  });

  // Stats box
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.2, y: 4.55, w: 4.9, h: 0.75, fill: { color: NAV2 }, line: { color: TEA, width: 1.5 }, rectRadius: 0.08 });
  s.addText([
    { text: "Sensitivity: ", options: { color: LGR } },
    { text: "85–91%  ", options: { color: GLD, bold: true } },
    { text: "  Specificity: ", options: { color: LGR } },
    { text: "26–52%", options: { color: GLD, bold: true } },
  ], { x: 0.2, y: 4.55, w: 4.9, h: 0.4, fontSize: 12, fontFace: "Calibri", align: "center", valign: "middle", margin: 0 });
  s.addText("Crossed SLR — sensitivity 23–34%, specificity 86–90% (specific for extrusion)", { x: 0.2, y: 4.95, w: 4.9, h: 0.32, fontSize: 9.5, color: LGR, italic: true, align: "center", fontFace: "Calibri", margin: 0 });

  // Right: SLR image
  if (img[2]) {
    s.addImage({ data: img[2], x: 5.4, y: 1.2, w: 4.4, h: 4.1 });
    s.addText("Clinical illustration — Straight Leg Raise (Lasègue's test)", { x: 5.4, y: 5.3, w: 4.4, h: 0.25, fontSize: 7.5, color: LGR, italic: true, align: "center", fontFace: "Calibri", margin: 0 });
  }
}

// ─────────────────────────────────────────────
// SLIDE 12 — INVESTIGATIONS
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "INVESTIGATIONS", "When to investigate and what to order");

  // Imaging rule banner
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.2, y: 1.1, w: 9.6, h: 0.5, fill: { color: "1A5276" }, line: { color: TEA, width: 1.5 }, rectRadius: 0.06 });
  s.addText("⚠  DO NOT IMAGE in first 6 weeks if NO red flags — 1 in 4 asymptomatic adults have MRI disc findings (false positives lead to harm)", { x: 0.25, y: 1.1, w: 9.5, h: 0.5, fontSize: 10.5, bold: true, color: GLD, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });

  const invRows = [
    ["BLOODS\n(FBC, ESR, CRP,\nCa²⁺, PSA, LFTs)", "Suspected infection or malignancy\nor inflammatory disease", "↑ ESR/CRP in infection & malignancy;\nPSA for prostate; Ca²⁺ for mets", "27AE60"],
    ["X-RAY SPINE", "Trauma (alignment), scoliosis,\nosteoporotic fracture", "Cannot detect early infection/tumour —\nneeds 40–60% bone destruction first", "E67E22"],
    ["MRI SPINE ✅\n(Investigation of choice)", "Any red flag present;\n>6 wks no improvement;\nSuspected cord/cauda equina", "Sensitivity & specificity >90% for\nmalignancy, infection, epidural lesions;\nUse with contrast for abscess/mets", CRM],
    ["CT SPINE", "Trauma (best for bone detail);\nMRI contraindicated", "Radiation = 300 chest X-rays;\nnot first-line", "9B59B6"],
    ["USS / CT ABDOMEN", "Suspected AAA", "Urgent USS if stable;\nCT angiogram if urgent", "3498DB"],
    ["URINE DIPSTICK/\nCULTURE", "Suspected pyelonephritis\nor renal colic", "Simple, fast, first-line for\nreferred causes", TEA],
  ];

  invRows.forEach((row, i) => {
    const y = 1.7 + i * 0.61;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.15, y, w: 1.85, h: 0.53, fill: { color: row[3] }, line: { color: row[3] } });
    s.addText(row[0], { x: 0.15, y, w: 1.85, h: 0.53, fontSize: 8.5, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addShape(pres.shapes.RECTANGLE, { x: 2.05, y, w: 3.6, h: 0.53, fill: { color: NAV2 }, line: { color: row[3], width: 0.5 } });
    s.addText(row[1], { x: 2.1, y, w: 3.55, h: 0.53, fontSize: 9.5, color: WHT, valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addShape(pres.shapes.RECTANGLE, { x: 5.7, y, w: 4.1, h: 0.53, fill: { color: "152638" }, line: { color: row[3], width: 0.5 } });
    s.addText(row[2], { x: 5.75, y, w: 4.0, h: 0.53, fontSize: 9.5, color: LGR, valign: "middle", fontFace: "Calibri", italic: true, margin: 0 });
  });
}

// ─────────────────────────────────────────────
// SLIDE 13 — EVALUATION ALGORITHM (with flowchart image)
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "EVALUATION ALGORITHM", "Goldman-Cecil Medicine — acute & subacute back pain");

  if (img[6]) {
    s.addImage({ data: img[6], x: 0.5, y: 1.1, w: 9.0, h: 4.3 });
  }
  s.addText("If red flags detected → urgent MRI ± specialist referral. No red flags → treat conservatively; image if not improved at 6 weeks", { x: 0.3, y: 5.2, w: 9.4, h: 0.28, fontSize: 9.5, color: LGR, italic: true, align: "center", fontFace: "Calibri", margin: 0 });
}

// ─────────────────────────────────────────────
// SLIDE 14 — MANAGEMENT: MECHANICAL BACK PAIN
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "MANAGEMENT — MECHANICAL BACK PAIN", "The majority of patients — treat conservatively");

  const steps = [
    { num: "1", title: "REASSURE", body: "90% resolve in 6–12 weeks\nBack pain = rarely serious\nAvoid over-investigation and labelling", color: "27AE60" },
    { num: "2", title: "STAY ACTIVE", body: "Bed rest is HARMFUL and delays recovery\nEncourage normal activity as tolerated\nAerobic exercise + core strengthening", color: TEA },
    { num: "3", title: "ANALGESIA", body: "1st line: Paracetamol + NSAIDs (ibuprofen/diclofenac)\nAdd: Short-course muscle relaxant (spasm)\nAvoid: Long-term opioids (dependency risk)", color: "E67E22" },
    { num: "4", title: "PHYSIOTHERAPY", body: "Manual therapy, stretching, posture correction\nNICE guideline recommends as 1st-line\nAcupuncture: some evidence for chronic pain", color: "3498DB" },
    { num: "5", title: "REVIEW AT 6 WEEKS", body: "If not improving → MRI and re-assess\nScreen for yellow flags (psychosocial)\nCBT if central sensitisation suspected", color: "9B59B6" },
  ];

  steps.forEach((st, i) => {
    const col = i < 3 ? 0 : (i === 3 ? 0 : 1);
    const x = [0.2, 5.15, 0.2, 5.15, 2.65][i];
    const y = [1.15, 1.15, 3.15, 3.15, 1.15][i];
    const w = i === 4 ? 4.7 : 4.7;
    const h = 1.8;
    card(s, x, y, w, h, NAV2);
    s.addShape(pres.shapes.RECTANGLE, { x, y, w, h: 0.38, fill: { color: st.color }, line: { color: st.color } });
    s.addText(`${st.num}. ${st.title}`, { x: x, y, w, h: 0.38, fontSize: 12, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addText(st.body, { x: x + 0.15, y: y + 0.45, w: w - 0.25, h: 1.25, fontSize: 10, color: WHT, fontFace: "Calibri", margin: 0 });
  });

  // Bottom note
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 5.1, w: 9.6, h: 0.35, fill: { color: "1A5276" }, line: { color: "1A5276" } });
  s.addText("Radiculopathy (sciatica): add Gabapentin/Pregabalin for neuropathic pain  •  Epidural steroid injection if no improvement  •  Surgery only if progressive deficit", { x: 0.25, y: 5.1, w: 9.5, h: 0.35, fontSize: 9.5, color: LGR, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
}

// ─────────────────────────────────────────────
// SLIDE 15 — MANAGEMENT: SPECIFIC RED FLAG CONDITIONS
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "MANAGEMENT — RED FLAG CONDITIONS", "Specific urgency and treatment for each cause");

  const conditions = [
    { title: "CAUDA EQUINA", action: "Emergency MRI same day → neurosurgery → surgical decompression within hours", urgency: "EMERGENCY", color: "8E0000" },
    { title: "MALIGNANCY", action: "Oncology referral (2-week cancer pathway) · MRI with contrast · Radiotherapy / chemotherapy / surgical decompression", urgency: "URGENT", color: "9B59B6" },
    { title: "SPINAL INFECTION", action: "Urgent MRI + blood cultures + FBC/CRP/ESR · IV antibiotics (after cultures) · Neurosurgical referral if abscess or neuro deficit", urgency: "URGENT", color: CRM },
    { title: "VERTEBRAL FRACTURE (stable)", action: "Analgesia · Orthopaedic review · Osteoporosis treatment · Consider vertebroplasty/kyphoplasty for ongoing pain", urgency: "SEMI-URGENT", color: "E67E22" },
    { title: "RUPTURED AAA", action: "Do NOT delay for imaging if unstable · Urgent vascular surgery · IV access + resuscitation · CT aortogram if stable", urgency: "LIFE-THREATENING", color: "8E0000" },
    { title: "ANKYLOSING SPONDYLITIS", action: "Rheumatology referral · NSAIDs (1st line) · DMARDs (sulfasalazine) · Biologics (TNF inhibitors, IL-17 inhibitors) if refractory · Physio", urgency: "PLANNED", color: "E67E22" },
  ];

  conditions.forEach((c, i) => {
    const y = 1.15 + i * 0.72;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.15, y, w: 0.8, h: 0.62, fill: { color: c.color }, line: { color: c.color } });
    s.addText(c.urgency, { x: 0.15, y, w: 0.8, h: 0.62, fontSize: 7, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addShape(pres.shapes.RECTANGLE, { x: 1.0, y, w: 2.3, h: 0.62, fill: { color: c.color }, line: { color: c.color } });
    s.addText(c.title, { x: 1.0, y, w: 2.3, h: 0.62, fontSize: 11, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addShape(pres.shapes.RECTANGLE, { x: 3.35, y, w: 6.45, h: 0.62, fill: { color: NAV2 }, line: { color: c.color, width: 0.8 } });
    s.addText(c.action, { x: 3.4, y, w: 6.35, h: 0.62, fontSize: 10, color: WHT, valign: "middle", fontFace: "Calibri", margin: 0 });
  });

  s.addShape(pres.shapes.RECTANGLE, { x: 0.15, y: 5.25, w: 9.7, h: 0.22, fill: { color: NAV2 }, line: { color: NAV2 } });
  s.addText("Chronic LBP: Multimodal — exercise + CBT (cognitive behavioural therapy) + analgesia + address yellow flags (psychosocial)", { x: 0.2, y: 5.25, w: 9.6, h: 0.22, fontSize: 9, color: LGR, align: "center", fontFace: "Calibri", margin: 0 });
}

// ─────────────────────────────────────────────
// SLIDE 16 — WHEN TO REFER
// ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  bg(s);
  header(s, "WHEN & WHERE TO REFER", "Matching the patient to the right team");

  const refs = [
    { who: "Neurosurgery", when: "Cauda equina symptoms\nProgressive neurological deficit", urgent: "SAME DAY", color: "8E0000" },
    { who: "Vascular Surgery", when: "Suspected ruptured AAA\nAortic dissection", urgent: "IMMEDIATE", color: "8E0000" },
    { who: "Oncology", when: "Suspected malignancy\n(weight loss + night pain + age >50)", urgent: "2-WEEK PATHWAY", color: "9B59B6" },
    { who: "Infectious Disease /\nNeurosurgery", when: "Spinal infection (abscess, osteomyelitis)\nEspecially if neurological deficit", urgent: "URGENT", color: CRM },
    { who: "Rheumatology", when: "Ankylosing spondylitis\nInflammatory back pain", urgent: "PLANNED", color: "E67E22" },
    { who: "Orthopaedics /\nNeurosurgery", when: "Spinal stenosis refractory to conservative Rx\nDisc herniation > 6–12 weeks, failing Rx", urgent: "PLANNED", color: "3498DB" },
    { who: "Physiotherapy\n± Pain Clinic", when: "Mechanical back pain failing 6 weeks Rx\nChronic LBP — multimodal needed", urgent: "ROUTINE", color: "27AE60" },
  ];

  const cols = [0, 0, 0, 1, 1, 1, 1];
  const xPos = [0.2, 0.2, 0.2, 5.1, 5.1, 5.1, 5.1];
  let leftRow = 0, rightRow = 0;
  refs.forEach((r, i) => {
    const col = cols[i];
    const row = col === 0 ? leftRow++ : rightRow++;
    const x = xPos[i];
    const y = 1.15 + row * 1.38;
    const h = 1.28;
    card(s, x, y, 4.75, h, NAV2);
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 4.75, h: 0.3, fill: { color: r.color }, line: { color: r.color } });
    s.addText(r.who + "  |  " + r.urgent, { x, y, w: 4.75, h: 0.3, fontSize: 10, bold: true, color: WHT, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addText(r.when, { x: x + 0.15, y: y + 0.36, w: 4.45, h: 0.88, fontSize: 10.5, color: WHT, fontFace: "Calibri", margin: 0 });
  });
}

// ─────────────────────────────────────────────
// Write file
// ─────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/back-pain-pptx/BackPain_FamilyMedicine.pptx" })
  .then(() => console.log("✅ DONE: BackPain_FamilyMedicine.pptx"))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });

lumbar spine anatomy disc herniation vertebral cross section diagram

aortic aneurysm renal colic referred back pain visceral

spine physical examination straight leg raise FABER test clinical

back pain management algorithm conservative treatment NSAIDs physiotherapy

spinal surgery discectomy laminectomy operative back pain

mkdir -p /home/daytona/workspace/back-pain-v2 && node /home/daytona/skills/share…