HYPOKALEMIC PERIODIC PARALYSIS (HypoKPP)

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/home/daytona/skills/docx

~/hypoKPP-doc/generate.js

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// ═══════════════════════════════════════════════════════════════════════════════
//  DOCUMENT CONTENT
// ═══════════════════════════════════════════════════════════════════════════════
const children = [];

// ── COVER / TITLE ──────────────────────────────────────────────────────────────
children.push(
  new Paragraph({ spacing: { before: 600, after: 100 }, alignment: AlignmentType.CENTER,
    children: [new TextRun({ text: "HYPOKALEMIC PERIODIC PARALYSIS", bold: true, size: 52,
      color: BLUE_DARK, font: "Calibri" })] }),
  new Paragraph({ alignment: AlignmentType.CENTER, spacing: { before: 80, after: 80 },
    children: [new TextRun({ text: "MD Medicine — Quick Reference Notes", size: 30,
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  new Paragraph({ alignment: AlignmentType.CENTER, spacing: { before: 40, after: 400 },
    children: [new TextRun({ text: "Rounds & Examination Guide  |  Based on Harrison's • Adams & Victor's • Goldman-Cecil • Brenner & Rector's",
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  pageBreak(),
);

// ══════════════════════════════════════════════════════════════════════════════
// SECTION 1 — DEFINITION & OVERVIEW
// ══════════════════════════════════════════════════════════════════════════════
children.push(sectionHeading("1.  DEFINITION & OVERVIEW"));
children.push(para(
  "Hypokalemic Periodic Paralysis (HypoKPP) is a skeletal muscle channelopathy characterised by " +
  "episodic attacks of flaccid muscle weakness or paralysis associated with a FALL in serum " +
  "potassium — due to shift of K⁺ into cells, NOT total body depletion.", { size: 20 }
));
children.push(para("Most common form of periodic paralysis. Prevalence ≈ 1 in 100,000.", { size: 20 }));

children.push(tipBox("K+ shifts INWARD during attack — urinary K+ excretion is NOT significantly elevated. This distinguishes it from renal/GI K+ loss."));

// ══════════════════════════════════════════════════════════════════════════════
// SECTION 2 — CLASSIFICATION / TYPES
// ══════════════════════════════════════════════════════════════════════════════
children.push(sectionHeading("2.  CLASSIFICATION"));
children.push(subHeading("A. Primary (Familial / Genetic) Forms"));

children.push(makeTable(
  ["Feature", "Type I (HypoKPP-1)", "Type II (HypoKPP-2)", "Andersen-Tawil Syndrome"],
  [
    ["Gene", "CACNA1S  (chr 1q31-32)", "SCN4A", "KCNJ2"],
    ["Channel", "L-type Ca²⁺ channel\n(DHP receptor, α1 subunit)", "Nav1.4 (skeletal Na⁺ channel)", "Kir2.1 (inwardly rectifying K⁺)"],
    ["Inheritance", "Autosomal Dominant", "Autosomal Dominant", "Autosomal Dominant"],
    ["Frequency", "~70% of cases", "~10% of cases", "Rare"],
    ["Mutation", "Arg→His in S4 voltage sensor", "Arg→His/Cys in S4 domain", "Loss-of-function"],
    ["Muscle biopsy", "Vacuoles", "Tubular aggregates", "Variable"],
    ["Acetazolamide", "GOOD response", "May WORSEN — avoid!", "Special management"],
    ["Triad", "–", "–", "Paralysis + Arrhythmia + Dysmorphic features"],
  ],
  [1900, 2200, 2200, 2400]
));

children.push(para(""));
children.push(subHeading("B. Secondary (Acquired) Causes"));
children.push(makeTable(
  ["Cause", "Mechanism / Notes"],
  [
    ["Thyrotoxic Periodic Paralysis (TPP)", "Most important secondary cause; predominantly Asian/Hispanic males; KCNJ18 (Kir2.6) susceptibility; treat hyperthyroidism to cure"],
    ["Hyperaldosteronism (Conn's)", "True K⁺ depletion; elevated aldosterone"],
    ["Distal Renal Tubular Acidosis", "Urinary K⁺ wasting + non-anion-gap metabolic acidosis"],
    ["Gitelman Syndrome", "Renal K⁺ and Mg²⁺ wasting"],
    ["Fanconi Syndrome", "Proximal tubular dysfunction"],
    ["Barium Poisoning", "Blocks K⁺ efflux channels"],
    ["GI Losses (diarrhoea, fistulas)", "True K⁺ depletion"],
    ["Insulin + Glucose Infusion", "K⁺ shift into cells; can unmask susceptibility"],
  ],
  [3000, 5600]
));

children.push(tipBox("Newly diagnosed HypoKPP → ALWAYS check TFTs to rule out thyrotoxic periodic paralysis."));

// ══════════════════════════════════════════════════════════════════════════════
// SECTION 3 — EPIDEMIOLOGY
// ══════════════════════════════════════════════════════════════════════════════
children.push(sectionHeading("3.  EPIDEMIOLOGY"));
children.push(makeTable(
  ["Parameter", "Details"],
  [
    ["Prevalence", "~1 in 100,000"],
    ["Onset age", "2nd decade (most common); can start before age 10"],
    ["Sex ratio", "Male : Female = 3–4 : 1 (reduced penetrance in females)"],
    ["Attack peak", "3rd–4th decade; frequency decreases with advancing age"],
    ["TPP", "Young Asian males; also Hispanic; in setting of hyperthyroidism"],
  ],
  [3000, 5600]
));

// ══════════════════════════════════════════════════════════════════════════════
// SECTION 4 — PATHOPHYSIOLOGY
// ══════════════════════════════════════════════════════════════════════════════
children.push(pageBreak());
children.push(sectionHeading("4.  PATHOPHYSIOLOGY"));

children.push(subHeading("4.1  Core Mechanism — Voltage Sensor (S4) Mutation"));
children.push(para(
  "~90% of HypoKPP mutations involve SUBSTITUTION OF ARGININE in the S4 voltage-sensor " +
  "domain of L-type Ca²⁺ channels (Type I) or skeletal Na⁺ channels (Type II). This generates " +
  "an aberrant GATING PORE CURRENT — a cation leak through the voltage sensor — distinct from " +
  "the main ion-conducting pore.", { size: 20 }
));

children.push(subHeading("4.2  Step-by-Step Cascade"));
children.push(makeTable(
  ["Step", "Event", "Result"],
  [
    ["1", "Trigger factor (carb meal / rest after exercise / insulin / catecholamines)", "K⁺ shifts from ECF → ICF"],
    ["2", "Serum K⁺ falls to 1.8–3.0 mEq/L", "Urinary K⁺ NOT significantly raised (shift, not loss)"],
    ["3", "Mutant channel → gating pore cation leak", "Paradoxic depolarisation of membrane"],
    ["4", "Membrane potential shifts toward Cl⁻ equilibrium (~–50 mV)", "Voltage-gated Na⁺ channels (Nav1.4) become INACTIVATED"],
    ["5", "Reduced KATP channel activity (Type I) → unopposed Na⁺/K⁺-ATPase", "Further K⁺ influx into muscle; potentiated by insulin"],
    ["6", "Muscle electrically and mechanically inexcitable", "PARALYSIS — no EMG activity, absent CMAPs"],
  ],
  [600, 3600, 3000]
));

children.push(para(""));
children.push(subHeading("4.3  Thyrotoxic PP — Distinct Mechanism"));
children.push(para(
  "Thyroid hormones + adrenergic surge → ↑ Na⁺/K⁺-ATPase activity → massive K⁺ shift " +
  "into cells → paralysis. KCNJ18 (Kir2.6) gene confers susceptibility. " +
  "Thyroxine has NO effect on primary HypoKPP.", { size: 20 }
));
children.push(para(""));

// PATHOPHYSIOLOGY FLOWCHART
children.push(subHeading("4.4  Pathophysiology Flowchart"));
children.push(flowSpacer());
children.push(flowBox("TRIGGER FACTORS", BLUE_LIGHT, BLUE_MID, true));
children.push(new Paragraph({ alignment: AlignmentType.CENTER, children: [
  run("High-carb meal  |  Rest after exercise  |  Insulin  |  Catecholamines  |  Cold / NaCl load", { size: 18, italics: true, color: GREY_TEXT })
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children.push(flowArrow());
children.push(flowBox("K⁺ SHIFTS INTO MUSCLE CELLS  (serum K⁺ → 1.8–3.0 mEq/L)", TEAL_LIGHT, "00B0A0", true));
children.push(flowArrow());
children.push(flowBox("MUTANT CHANNEL — Gating Pore Cation Leak\n(S4 Arg→His mutation; L-type Ca²⁺ or Nav1.4)", TEAL_LIGHT, "00B0A0"));
children.push(flowArrow());
children.push(flowBox("PARADOXIC DEPOLARISATION\n(Membrane → ~ −50 mV, near Cl⁻ equilibrium)", TEAL_LIGHT, "00B0A0"));
children.push(flowArrow());
children.push(flowBox("Inactivation of Voltage-Gated Na⁺ Channels  +  ↓ KATP activity", TEAL_LIGHT, "00B0A0"));
children.push(flowArrow());
children.push(flowBox("MUSCLE INEXCITABILITY\n(No action potential, silent EMG, absent CMAPs)", RED_LIGHT, "C00000", true));
children.push(flowArrow());
children.push(flowBox("FLACCID PARALYSIS", "C00000", "C00000", true));
children.push(new Paragraph({ spacing: { before: 60, after: 60 },
  alignment: AlignmentType.CENTER,
  children: [run("(proximal > distal, legs before arms; cranial/respiratory muscles usually spared)", { size: 18, italics: true, color: GREY_TEXT })]
}));
children.push(flowSpacer());

// ══════════════════════════════════════════════════════════════════════════════
// SECTION 5 — TRIGGERS
// ══════════════════════════════════════════════════════════════════════════════
children.push(pageBreak());
children.push(sectionHeading("5.  PRECIPITATING FACTORS"));
children.push(makeTable(
  ["Trigger Category", "Specific Triggers"],
  [
    ["Dietary", "High-carbohydrate meal, high-sodium meal, large meals"],
    ["Exercise-related", "Strenuous exercise FOLLOWED BY rest or sleep"],
    ["Hormonal", "Insulin secretion, corticosteroids, epinephrine, norepinephrine"],
    ["Sleep-related", "Ion shifts across muscle membrane during sleep → morning attacks"],
    ["Environmental", "Cold exposure"],
    ["Iatrogenic", "IV glucose infusion, beta-agonists, thiazide diuretics"],
  ],
  [3000, 5600]
));

// ══════════════════════════════════════════════════════════════════════════════
// SECTION 6 — CLINICAL FEATURES
// ══════════════════════════════════════════════════════════════════════════════
children.push(sectionHeading("6.  CLINICAL FEATURES"));
children.push(subHeading("6.1  Prodrome (may precede attack)"));
[
  "Excessive hunger or thirst, dry mouth",
  "Palpitations, sweating",
  "Sense of weariness, fatigue, nervousness",
  "Diarrhoea (occasional)",
].forEach(t => children.push(bullet(t)));

children.push(para(""));
children.push(subHeading("6.2  During the Attack"));
children.push(makeTable(
  ["Feature", "Description"],
  [
    ["Onset timing", "Typically 2nd half of night or early morning; also after daytime nap following a large meal"],
    ["Onset speed", "Evolves over minutes to several hours"],
    ["Weakness pattern", "Proximal > Distal;  Legs before Arms (usually);  bulbar/respiratory spared"],
    ["Severity", "Mild weakness → complete paralysis (unable to call for help)"],
    ["Reflexes", "Reduced or ABSENT tendon reflexes AND cutaneous reflexes at peak"],
    ["Myotonia", "ABSENT — if present, diagnosis of HypoKPP is excluded"],
    ["Duration", "Few hours (mild) to several days (severe)"],
    ["Serum K⁺", "1.8–3.0 mEq/L during attack"],
    ["Muscle feel", "May feel swollen, firm to palpation"],
    ["Recovery order", "Strength returns to LAST affected muscles first"],
    ["Post-attack", "Headache, exhaustion, diuresis, occasional diarrhoea"],
  ],
  [2800, 5800]
));

children.push(para(""));
children.push(subHeading("6.3  Cardiac Manifestations (ECG Changes)"));
children.push(para("ECG changes begin when K⁺ falls to ~3 mEq/L:", { size: 20 }));
children.push(makeTable(
  ["ECG Finding", "Significance"],
  [
    ["Prolonged PR interval", "First-degree AV block — conduction slowing"],
    ["QRS widening", "Intraventricular conduction delay"],
    ["Prolonged QT interval", "Risk of ventricular arrhythmia"],
    ["T-wave flattening", "Classic hypokalemia sign"],
    ["Prominent U waves", "Hallmark of hypokalemia"],
    ["Bradycardia (rare)", "Severe attacks; potentially fatal (pre-ICU era)"],
  ],
  [3200, 5400]
));
children.push(cautionBox("U waves + T-wave flattening on ECG in a young male with morning paralysis → THINK HypoKPP until proven otherwise."));

children.push(para(""));
children.push(subHeading("6.4  Chronic / Long-Term Features"));
[
  "Attacks most frequent in 3rd–4th decade, then decrease in frequency with age",
  "Progressive PROXIMAL MYOPATHY may develop in middle adult life (vacuolated fibres)",
  "Permanent weakness may ensue after repeated severe attacks",
  "Fatality is rare (respiratory paralysis / cardiac arrhythmia — mostly pre-ICU era)",
].forEach(t => children.push(bullet(t)));

// ══════════════════════════════════════════════════════════════════════════════
// SECTION 7 — INVESTIGATIONS
// ══════════════════════════════════════════════════════════════════════════════
children.push(pageBreak());
children.push(sectionHeading("7.  INVESTIGATIONS"));

children.push(subHeading("7.1  Blood & Urine Tests"));
children.push(makeTable(
  ["Investigation", "Expected Finding", "Significance"],
  [
    ["Serum K⁺", "↓ (1.8–3.0 mEq/L during attack)", "Confirms hypokalemia during attack"],
    ["Urinary K⁺", "NOT significantly increased", "Distinguishes shift from renal/GI loss"],
    ["Serum Na⁺", "Usually normal", "Baseline"],
    ["Serum Mg²⁺", "Check (hypomagnesaemia worsens hypokalemia)", "Important in refractory cases"],
    ["TFTs (TSH, T3, T4)", "Abnormal in TPP; normal in primary HypoKPP", "MANDATORY in all new cases"],
    ["Aldosterone / Renin", "Elevated in Conn's syndrome", "Rule out secondary causes"],
    ["Arterial Blood Gas", "Metabolic alkalosis in Conn's / Gitelman; non-AG acidosis in dRTA", "Aetiology"],
    ["Serum CK", "Normal or mildly elevated", "Distinguishes from myositis"],
    ["Blood glucose / Insulin", "Usually normal", "Can unmask susceptibility"],
    ["Genetic testing", "CACNA1S (Type I), SCN4A (Type II), KCNJ2 (ATS)", "Confirms subtype"],
  ],
  [2400, 2800, 3200]
));

children.push(para(""));
children.push(subHeading("7.2  Electrodiagnostic Studies"));
children.push(makeTable(
  ["Test", "Findings in HypoKPP"],
  [
    ["EMG (during attack)", "SILENT — no motor unit action potentials (MUAPs); muscle electrically inexcitable"],
    ["Nerve Conduction (during attack)", "Reduced or ABSENT CMAP amplitudes; motor conduction velocity preserved"],
    ["Long-Exercise NCS (McManis test)", "CMAP increment during exercise (50% of patients); then SIGNIFICANT DECREMENT 10–20 min post-exercise"],
    ["EMG (between attacks)", "Myopathic changes in chronic disease; NO myotonic discharges"],
  ],
  [2800, 5800]
));

children.push(para(""));
children.push(subHeading("7.3  Muscle Biopsy"));
children.push(makeTable(
  ["HypoKPP Type", "Histological Findings"],
  [
    ["General / Acute", "Uniform enlargement of muscle fibres; VACUOLES (round/oval, clear fluid ± PAS-positive granules) in sarcoplasm"],
    ["Type II (SCN4A)", "TUBULAR AGGREGATES — key distinguishing feature"],
    ["Chronic/Advanced", "Myopathic changes: segmental degeneration, necrosis"],
    ["Electron Microscopy", "Vacuoles arise from proliferation/degeneration of SR and T-tubule membranes"],
  ],
  [2400, 6200]
));

children.push(para(""));
children.push(subHeading("7.4  Provocative Test (Supervised, with ECG monitoring)"));
children.push(para("ONLY when diagnosis unclear and patient is between attacks:", { size: 20, bold: true }));
[
  "Oral glucose 50–100 g  OR  NaCl 2 g/hour × 7 doses + vigorous exercise",
  "Induces attack → terminated by oral KCl 2–4 g",
  "Opposite response in HyperKPP (KCl worsens, not terminates)",
].forEach(t => children.push(bullet(t)));
children.push(cautionBox("Provocative test must be done with continuous ECG monitoring and IV KCl ready at bedside."));

// ══════════════════════════════════════════════════════════════════════════════
// SECTION 8 — DIAGNOSTIC FLOWCHART
// ══════════════════════════════════════════════════════════════════════════════
children.push(pageBreak());
children.push(sectionHeading("8.  DIAGNOSTIC FLOWCHART"));
children.push(flowSpacer());

children.push(flowBox("Patient: Episodic Flaccid Weakness / Paralysis", BLUE_LIGHT, BLUE_MID, true));
children.push(flowArrow());
children.push(flowBox("Check Serum K⁺ DURING ATTACK", TEAL_LIGHT, "00B0A0", true));
children.push(flowArrow());

// Split decision
children.push(new Paragraph({ alignment: AlignmentType.CENTER, spacing: { before: 20, after: 20 },
  children: [
    run("K⁺ LOW  (<3.5 mEq/L)", { bold: true, color: "C00000", size: 20 }),
    run("                                   ", {}),
    run("K⁺ NORMAL / HIGH", { bold: true, color: BLUE_DARK, size: 20 }),
  ]
}));
children.push(new Paragraph({ alignment: AlignmentType.CENTER, children: [
  run("↓                                                             ↓", { size: 20, color: GREY_TEXT })
]}));
children.push(new Paragraph({ alignment: AlignmentType.CENTER, children: [
  run("HYPOKALEMIC PP                            HyperKPP / Paramyotonia Congenita", { size: 19, color: GREY_TEXT, italics: true })
]}));
children.push(flowArrow());
children.push(flowBox("Check: Urinary K⁺  |  TFTs  |  Aldosterone/Renin  |  ABG  |  Serum Mg²⁺", TEAL_LIGHT, "00B0A0"));
children.push(flowArrow());

children.push(new Paragraph({ alignment: AlignmentType.CENTER, spacing: { before: 20, after: 20 },
  children: [
    run("TFTs ABNORMAL", { bold: true, color: "C00000", size: 20 }),
    run("              ←——→             ", { size: 20 }),
    run("TFTs NORMAL", { bold: true, color: "007030", size: 20 }),
  ]
}));
children.push(new Paragraph({ alignment: AlignmentType.CENTER, children: [
  run("↓                                                                         ↓", { size: 20, color: GREY_TEXT })
]}));
children.push(new Paragraph({ alignment: AlignmentType.CENTER, children: [
  run("THYROTOXIC PP                                              PRIMARY (Familial) HypoKPP", { size: 19, italics: true, color: GREY_TEXT })
]}));

children.push(flowArrow());
children.push(flowBox("Genetic Testing:  CACNA1S → Type I  |  SCN4A → Type II  |  KCNJ2 → Andersen-Tawil Syndrome", BLUE_LIGHT, BLUE_MID));
children.push(flowSpacer());

// ══════════════════════════════════════════════════════════════════════════════
// SECTION 9 — MANAGEMENT
// ══════════════════════════════════════════════════════════════════════════════
children.push(pageBreak());
children.push(sectionHeading("9.  MANAGEMENT"));

children.push(subHeading("9.1  Acute Attack Treatment"));
children.push(makeTable(
  ["Situation", "Treatment", "Dose / Detail"],
  [
    ["Mild attack (can swallow)", "Oral KCl", "0.2–0.4 mmol/kg every 30 min; monitor K⁺ and ECG"],
    ["Severe attack / vomiting / dysphagia", "IV KCl (RARE)", "Slow IV in SALINE (NOT dextrose); continuous ECG monitoring"],
    ["Cardiac arrhythmia", "ECG monitoring + KCl replacement + consider ICU", "Treat K⁺ deficit promptly"],
    ["Thyrotoxic PP — acute", "Oral KCl + Propranolol", "Propranolol 40 mg stat; blocks adrenergic K⁺ shift"],
  ],
  [2400, 2400, 3800]
));
children.push(cautionBox("NEVER give IV K⁺ in dextrose solution — glucose + insulin will worsen K⁺ shift and deepen paralysis."));
children.push(cautionBox("IV KCl is very rarely needed. Oral route is preferred and sufficient in most cases."));

children.push(para(""));
children.push(subHeading("9.2  Long-Term Pharmacological Prevention"));
children.push(makeTable(
  ["Drug", "Dose", "Mechanism", "Use in subtype", "Key Notes"],
  [
    ["Acetazolamide", "250 mg TID", "Carbonic anhydrase inhibitor → mild metabolic acidosis", "Type I (FIRST LINE)", "AVOID in Type II — may worsen attacks; kaluretic but works via acidosis"],
    ["Dichlorphenamide", "50–150 mg/day", "More potent carbonic anhydrase inhibitor", "Type I & II (alternative)", "For acetazolamide non-responders or intolerance"],
    ["Spironolactone", "25–100 mg/day", "K⁺-sparing diuretic (aldosterone antagonist)", "Alternative for both types", "Caution with oral K⁺ supplements simultaneously"],
    ["Triamterene", "25–100 mg/day", "K⁺-sparing diuretic", "Alternative", "Same caution as spironolactone"],
    ["Propranolol", "160 mg/day divided", "Blocks adrenergic K⁺ shift (Na/K-ATPase)", "Thyrotoxic PP", "Prevents attacks; treat underlying thyroid disease"],
  ],
  [1600, 1200, 2200, 1600, 2400]
));
children.push(tipBox("Type II HypoKPP (SCN4A mutation) → use Dichlorphenamide, NOT Acetazolamide (which can worsen this type)."));

children.push(para(""));
children.push(subHeading("9.3  Non-Pharmacological Measures"));
children.push(makeTable(
  ["Measure", "Rationale"],
  [
    ["Low-carbohydrate diet", "Reduces insulin-mediated K⁺ shift into cells"],
    ["Low-sodium diet  (<160 mEq/day)", "Reduces osmotic and hormonal triggers"],
    ["Avoid large meals", "Prevents post-prandial insulin surge"],
    ["Avoid intense exercise followed by rest", "Classic trigger — exercise OK if no prolonged rest after"],
    ["Avoid cold exposure", "Cold can precipitate attacks, especially in TPP"],
    ["Avoid trigger drugs", "Insulin, corticosteroids, beta-agonists, thiazides, glucose infusion"],
    ["Treat thyroid disease (TPP)", "Definitive cure — abolishes attacks in >90%"],
  ],
  [3200, 5400]
));

// MANAGEMENT FLOWCHART
children.push(para(""));
children.push(subHeading("9.4  Management Flowchart"));
children.push(flowSpacer());
children.push(flowBox("HYPOKALEMIC PERIODIC PARALYSIS — CONFIRMED", BLUE_LIGHT, BLUE_MID, true));
children.push(flowArrow());
children.push(new Paragraph({ alignment: AlignmentType.CENTER, children: [
  run("ACUTE ATTACK                                                     BETWEEN ATTACKS", { bold: true, size: 20, color: BLUE_DARK })
]}));
children.push(new Paragraph({ alignment: AlignmentType.CENTER, children: [
  run("↓                                                                            ↓", { size: 20, color: GREY_TEXT })
]}));
children.push(new Paragraph({ alignment: AlignmentType.CENTER, children: [
  run("ECG monitoring + Serum K⁺                      Lifestyle + Pharmacoprevention", { size: 19, italics: true, color: GREY_TEXT })
]}));
children.push(new Paragraph({ alignment: AlignmentType.CENTER, children: [
  run("↓", { size: 20, color: GREY_TEXT })
]}));
children.push(new Paragraph({ alignment: AlignmentType.CENTER, children: [
  run("Mild: Oral KCl 0.2–0.4 mmol/kg q30 min     Type I → Acetazolamide 250 mg TID", { size: 19, color: GREY_TEXT })
]}));
children.push(new Paragraph({ alignment: AlignmentType.CENTER, children: [
  run("Severe: IV KCl (saline, slow, ECG monitor)   Type II → Dichlorphenamide 50–150 mg/day", { size: 19, color: GREY_TEXT })
]}));
children.push(new Paragraph({ alignment: AlignmentType.CENTER, children: [
  run("TPP: Oral KCl + Propranolol                  TPP → Treat hyperthyroidism", { size: 19, color: GREY_TEXT })
]}));
children.push(flowSpacer());

// ══════════════════════════════════════════════════════════════════════════════
// SECTION 10 — COMPARISON TABLES
// ══════════════════════════════════════════════════════════════════════════════
children.push(pageBreak());
children.push(sectionHeading("10.  COMPARISON TABLES"));

children.push(subHeading("10.1  Primary HypoKPP vs Thyrotoxic PP"));
children.push(makeTable(
  ["Feature", "Primary HypoKPP", "Thyrotoxic PP"],
  [
    ["Inheritance", "Autosomal Dominant", "NOT familial"],
    ["Age of onset", "2nd decade (adolescence)", "Early adulthood"],
    ["Sex", "Male >> Female (3–4:1)", "Predominantly Asian males"],
    ["Ethnicity", "Any", "Asian, Hispanic predominantly"],
    ["TFTs", "NORMAL", "ABNORMAL (hyperthyroidism)"],
    ["Gene involved", "CACNA1S / SCN4A", "KCNJ18 (Kir2.6 susceptibility)"],
    ["Serum K⁺ in attack", "Low", "Low"],
    ["Acute treatment", "Oral KCl", "Oral KCl + Propranolol"],
    ["Prevention", "Acetazolamide / Dichlorphenamide", "Treat hyperthyroidism (>90% cure)"],
    ["Effect of thyroxine", "NO effect", "Definitive treatment"],
  ],
  [2400, 3300, 3300]
));

children.push(para(""));
children.push(subHeading("10.2  HypoKPP vs HyperKPP — Key Distinctions"));
children.push(makeTable(
  ["Feature", "HypoKPP", "HyperKPP"],
  [
    ["Gene", "CACNA1S (I), SCN4A (II)", "SCN4A"],
    ["Channel", "Ca²⁺ (Type I), Na⁺ (Type II)", "Na⁺"],
    ["Serum K⁺", "LOW (<3.5 mEq/L)", "HIGH or NORMAL"],
    ["Trigger", "Carbs, rest after exercise", "Fasting, rest, K⁺ intake"],
    ["Myotonia", "ABSENT", "PRESENT (EMG myotonic discharges)"],
    ["Attack duration", "Hours to days", "30 min to hours"],
    ["Onset age", "2nd decade", "1st decade (infancy/childhood)"],
    ["Acute Rx", "KCl (oral/IV)", "Ca²⁺ gluconate, salbutamol inhaled; AVOID KCl"],
    ["Prevention", "Acetazolamide (Type I)", "Acetazolamide, Mexiletine (for myotonia)"],
  ],
  [2400, 2800, 2800]
));

// ══════════════════════════════════════════════════════════════════════════════
// SECTION 11 — EXAM HIGH-YIELD SUMMARY
// ══════════════════════════════════════════════════════════════════════════════
children.push(pageBreak());
children.push(sectionHeading("11.  HIGH-YIELD EXAM SUMMARY"));

const examPoints = [
  "HypoKPP Type I = CACNA1S (Ca²⁺ channel); Type II = SCN4A (Na⁺ channel) — both autosomal dominant",
  "Male >> Female (3–4:1); onset in 2nd decade; attacks worst in 3rd–4th decade, then improve",
  "Mechanism: K⁺ shifts INTO cells (NOT total body depletion) + gating pore cation leak from S4 mutation",
  "Classic triggers: carbohydrate meal, rest after exercise, insulin, corticosteroids, catecholamines",
  "Attacks: proximal > distal, legs before arms; SPARES cranial, respiratory, sphincter muscles (usually)",
  "MYOTONIA IS ABSENT — presence of myotonia EXCLUDES the diagnosis of HypoKPP",
  "ECG: prolonged PR + QT, T-wave flattening, PROMINENT U WAVES (hallmark of hypokalemia)",
  "K⁺ during attack: 1.8–3.0 mEq/L; returns to NORMAL between attacks",
  "Acute Rx: ORAL KCl 0.2–0.4 mmol/kg q30 min; IV only when oral route impossible",
  "NEVER give K⁺ in dextrose — worsens paralysis!",
  "Prevention: Acetazolamide (Type I first-line); AVOID acetazolamide in Type II (use Dichlorphenamide)",
  "All new cases → MANDATORY TFTs to exclude Thyrotoxic PP",
  "TPP: treated with Propranolol + treat hyperthyroidism (abolishes attacks in >90%)",
  "Muscle biopsy: vacuoles (Type I); tubular aggregates (Type II)",
  "Andersen-Tawil Syndrome (KCNJ2): Triad = Paralysis + Cardiac arrhythmias (long QT, bidirectional VT) + Dysmorphic features",
];

examPoints.forEach((pt, i) => {
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});

// ── SOURCES ───────────────────────────────────────────────────────────────────
children.push(para(""));
children.push(subHeading("References"));
[
  "Adams and Victor's Principles of Neurology, 12th Edition",
  "Harrison's Principles of Internal Medicine, 22nd Edition (2025)",
  "Brenner and Rector's The Kidney, 2-Volume Set",
  "Bradley and Daroff's Neurology in Clinical Practice",
  "Goldman-Cecil Medicine, International Edition",
].forEach(r => children.push(bullet(r)));

// ═══════════════════════════════════════════════════════════════════════════════
//  ASSEMBLE DOCUMENT
// ═══════════════════════════════════════════════════════════════════════════════
const doc = new Document({
  creator: "Orris MD Notes",
  title: "Hypokalemic Periodic Paralysis — MD Medicine Quick Reference",
  description: "Comprehensive MD Medicine exam notes on HypoKPP",
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Packer.toBuffer(doc).then(buf => {
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  console.log("SUCCESS: File written.");
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cd /home/daytona/workspace/hypoKPP-doc && node generate.js 2>&1

python3 /home/daytona/skills/docx/scripts/office/validate.py /home/daytona/works…

cd /home/daytona/workspace/hypoKPP-doc && python3 -c " import zipfile, os z = zi…

ls -lh /home/daytona/workspace/hypoKPP-doc/HypoKPP_MD_Medicine_Notes.docx

mkdir -p /home/daytona/workspace/mpmc-exam && echo "dir ready"