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, PageBreak
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY

doc = SimpleDocTemplate(
    "/tmp/workspace/bds-notes/General_Medicine_Short_Notes_BDS.pdf",
    pagesize=A4,
    leftMargin=2*cm, rightMargin=2*cm,
    topMargin=2*cm, bottomMargin=2*cm
)

styles = getSampleStyleSheet()

title_style = ParagraphStyle(
    'MainTitle', parent=styles['Title'],
    fontSize=18, textColor=colors.HexColor('#1a237e'),
    spaceAfter=4, alignment=TA_CENTER, fontName='Helvetica-Bold'
)
subtitle_style = ParagraphStyle(
    'SubTitle', parent=styles['Normal'],
    fontSize=10, textColor=colors.HexColor('#4a4a4a'),
    spaceAfter=12, alignment=TA_CENTER, fontName='Helvetica-Oblique'
)
body_style = ParagraphStyle(
    'Body', parent=styles['Normal'],
    fontSize=9.5, textColor=colors.HexColor('#212121'),
    spaceAfter=3, spaceBefore=1,
    leading=14, alignment=TA_JUSTIFY, fontName='Helvetica'
)
bullet_style = ParagraphStyle(
    'Bullet', parent=styles['Normal'],
    fontSize=9.5, textColor=colors.HexColor('#212121'),
    spaceAfter=2, spaceBefore=1,
    leading=13, leftIndent=14, bulletIndent=4,
    fontName='Helvetica'
)
bold_label = ParagraphStyle(
    'BoldLabel', parent=styles['Normal'],
    fontSize=9.5, textColor=colors.HexColor('#1a237e'),
    spaceAfter=1, spaceBefore=3,
    fontName='Helvetica-Bold'
)
footer_style = ParagraphStyle(
    'Footer', parent=styles['Normal'],
    fontSize=8, textColor=colors.HexColor('#757575'),
    alignment=TA_CENTER
)

def topic_banner(title, number):
    data = [[Paragraph('<font color="white"><b>TOPIC %s: %s</b></font>' % (number, title), ParagraphStyle(
        'banner', fontSize=13, textColor=colors.white,
        fontName='Helvetica-Bold', alignment=TA_LEFT
    ))]]
    t = Table(data, colWidths=[17*cm])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), colors.HexColor('#1a237e')),
        ('TOPPADDING', (0,0), (-1,-1), 8),
        ('BOTTOMPADDING', (0,0), (-1,-1), 8),
        ('LEFTPADDING', (0,0), (-1,-1), 10),
    ]))
    return t

def section_box(title):
    data = [[Paragraph('<b>%s</b>' % title, ParagraphStyle(
        'sbox', fontSize=10, textColor=colors.HexColor('#1a237e'),
        fontName='Helvetica-Bold'
    ))]]
    t = Table(data, colWidths=[17*cm])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), colors.HexColor('#e8eaf6')),
        ('TOPPADDING', (0,0), (-1,-1), 4),
        ('BOTTOMPADDING', (0,0), (-1,-1), 4),
        ('LEFTPADDING', (0,0), (-1,-1), 8),
        ('BOX', (0,0), (-1,-1), 0.5, colors.HexColor('#3949ab')),
    ]))
    return t

def make_table(data_list, col_widths, header=True):
    t = Table(data_list, colWidths=col_widths)
    style_cmds = [
        ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#9fa8da')),
        ('VALIGN', (0,0), (-1,-1), 'TOP'),
        ('TOPPADDING', (0,0), (-1,-1), 4),
        ('BOTTOMPADDING', (0,0), (-1,-1), 4),
        ('LEFTPADDING', (0,0), (-1,-1), 6),
    ]
    if header:
        style_cmds.append(('BACKGROUND', (0,0), (-1,0), colors.HexColor('#e8eaf6')))
    style_cmds.append(('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.white, colors.HexColor('#f5f5f5')]))
    t.setStyle(TableStyle(style_cmds))
    return t

def bp(text):
    return '<b>%s</b>' % text

story = []

# HEADER
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph("GENERAL MEDICINE", title_style))
story.append(Paragraph("Short Notes for BDS 3rd Year | Gujarat University Examinations", subtitle_style))
story.append(Paragraph("Based on Anil K. Tripathi - General Medicine for BDS", ParagraphStyle(
    'ref', fontSize=9, textColor=colors.HexColor('#757575'),
    alignment=TA_CENTER, fontName='Helvetica-Oblique', spaceAfter=4
)))
story.append(Paragraph("Each topic: 7-8 Marks | Concise, Precise, Exam-Oriented", ParagraphStyle(
    'info', fontSize=9, textColor=colors.HexColor('#e53935'),
    alignment=TA_CENTER, fontName='Helvetica-Bold', spaceAfter=10
)))
story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1a237e')))
story.append(Spacer(1, 0.3*cm))

toc_data = [
    [Paragraph(bp("No."), body_style), Paragraph(bp("Topic"), body_style), Paragraph(bp("Marks"), body_style)],
    [Paragraph("1.", body_style), Paragraph("Syncope", body_style), Paragraph("7-8", body_style)],
    [Paragraph("2.", body_style), Paragraph("Arrhythmia", body_style), Paragraph("7-8", body_style)],
    [Paragraph("3.", body_style), Paragraph("Pneumonia", body_style), Paragraph("7-8", body_style)],
    [Paragraph("4.", body_style), Paragraph("Lung Abscess", body_style), Paragraph("7-8", body_style)],
    [Paragraph("5.", body_style), Paragraph("Bronchial Asthma", body_style), Paragraph("7-8", body_style)],
]
toc_table = Table(toc_data, colWidths=[1.5*cm, 13*cm, 2.5*cm])
toc_table.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#e8eaf6')),
    ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#9fa8da')),
    ('ALIGN', (2,0), (2,-1), 'CENTER'),
    ('TOPPADDING', (0,0), (-1,-1), 4),
    ('BOTTOMPADDING', (0,0), (-1,-1), 4),
    ('LEFTPADDING', (0,0), (-1,-1), 8),
]))
story.append(toc_table)
story.append(Spacer(1, 0.5*cm))
story.append(PageBreak())

# ============================================================
# TOPIC 1: SYNCOPE
# ============================================================
story.append(topic_banner("SYNCOPE", "1"))
story.append(Spacer(1, 0.2*cm))

story.append(section_box("Definition"))
story.append(Paragraph(
    "Syncope is a transient, self-limited loss of consciousness (TLOC) due to global cerebral hypoperfusion, "
    "characterized by a rapid onset, short duration, and spontaneous complete recovery, without neurological deficit.",
    body_style))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Etiology / Classification"))
etiology_data = [
    [Paragraph(bp("Type"), body_style), Paragraph(bp("Causes"), body_style)],
    [Paragraph("Vasovagal (Neurocardiogenic)", body_style),
     Paragraph("Most common. Triggered by emotional stress, pain, prolonged standing, sight of blood. Due to paradoxical bradycardia + hypotension.", body_style)],
    [Paragraph("Cardiac", body_style),
     Paragraph("Arrhythmias (VT, VF, sick sinus syndrome, complete heart block), aortic stenosis, HOCM, massive MI, cardiac tamponade.", body_style)],
    [Paragraph("Orthostatic Hypotension", body_style),
     Paragraph("Drop in SBP >20 mmHg on standing. Causes: dehydration, drugs (antihypertensives, diuretics), autonomic neuropathy (diabetes), Addison's disease.", body_style)],
    [Paragraph("Situational", body_style),
     Paragraph("Micturition syncope, cough syncope, swallowing syncope, defecation syncope.", body_style)],
    [Paragraph("Carotid Sinus", body_style),
     Paragraph("Hypersensitive carotid sinus reflex; provoked by neck turning, tight collar.", body_style)],
    [Paragraph("Neurological", body_style),
     Paragraph("Vertebrobasilar TIA, subclavian steal syndrome (rare causes).", body_style)],
]
story.append(make_table(etiology_data, [5*cm, 12*cm]))
story.append(Spacer(1, 0.15*cm))

story.append(section_box("Clinical Features"))
story.append(Paragraph(bp("Pre-syncopal Prodrome (Warning symptoms):"), bold_label))
for item in [
    "Dizziness, lightheadedness, nausea, sweating",
    "Blurring / greying out of vision, ringing in ears (tinnitus)",
    "Pallor, generalized weakness - lasts seconds to minutes",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("During syncope:"), bold_label))
for item in [
    "Sudden loss of consciousness and postural tone",
    "Patient falls - may sustain injury",
    "Brief tonic-clonic jerks possible (not a true seizure) if ischemia prolonged",
    "Pallor, slow weak pulse, dilated pupils",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Post-syncopal:"), bold_label))
for item in [
    "Rapid spontaneous recovery on becoming supine (within seconds)",
    "No post-ictal confusion (key differentiator from epileptic seizure)",
    "Mild fatigue or headache may persist briefly",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Investigations"))
for item in [
    bp("History") + " - detailed history of trigger, prodrome, duration, recovery (most important diagnostic tool)",
    bp("ECG") + " - detect arrhythmias, heart block, QT prolongation, Brugada syndrome",
    bp("Holter Monitor / Event Recorder") + " - paroxysmal arrhythmias; implantable loop recorder for recurrent unexplained syncope",
    bp("Echocardiography") + " - structural heart disease (aortic stenosis, HOCM)",
    bp("Tilt Table Test") + " - suspected vasovagal / orthostatic syncope",
    bp("Carotid Sinus Massage") + " - carotid sinus hypersensitivity (monitored setting only)",
    bp("Blood Tests") + " - CBC, blood glucose, electrolytes to exclude metabolic causes",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Treatment"))
story.append(Paragraph(bp("General / Vasovagal:"), bold_label))
for item in [
    "Place patient supine, elevate legs to restore cerebral perfusion",
    "Patient education: avoid triggers, dehydration",
    "Physical counter-pressure maneuvers (leg crossing, hand gripping)",
    "Increased salt and fluid intake",
    "Beta-blockers (atenolol) in selected cases; midodrine for orthostatic type",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Cardiac Syncope:"), bold_label))
for item in [
    "Treat underlying arrhythmia - pacemaker for bradyarrhythmias",
    "ICD (implantable cardioverter-defibrillator) for VT/VF",
    "Surgery for structural lesions (aortic stenosis, HOCM)",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Dental Relevance:"), bold_label))
story.append(Paragraph(
    bp("Vasovagal syncope is the most common medical emergency in dental practice.") + " "
    "Prevention: treat anxious patients in supine/semi-reclined position, adequate analgesia, minimize waiting time. "
    "Management: lay patient flat, elevate legs, loosen tight clothing, ensure airway patent. "
    "Atropine 0.6 mg IV if persistent bradycardia.",
    body_style))

story.append(PageBreak())

# ============================================================
# TOPIC 2: ARRHYTHMIA
# ============================================================
story.append(topic_banner("ARRHYTHMIA", "2"))
story.append(Spacer(1, 0.2*cm))

story.append(section_box("Definition"))
story.append(Paragraph(
    "Arrhythmia (or dysrhythmia) is any disturbance in the normal rate, rhythm, site of origin, or conduction "
    "of the cardiac electrical impulse. Normal sinus rhythm: rate 60-100 bpm, P wave precedes every QRS complex.",
    body_style))

story.append(section_box("Classification"))
class_data = [
    [Paragraph(bp("Category"), body_style), Paragraph(bp("Types"), body_style)],
    [Paragraph("By Rate", body_style),
     Paragraph("Bradyarrhythmia (<60 bpm) | Tachyarrhythmia (>100 bpm)", body_style)],
    [Paragraph("Supraventricular\n(above Bundle of His)", body_style),
     Paragraph("Sinus tachycardia, Sinus bradycardia, SVT, Atrial fibrillation (AF), Atrial flutter, AVNRT, WPW syndrome, Junctional rhythm", body_style)],
    [Paragraph("Ventricular", body_style),
     Paragraph("PVCs, Ventricular tachycardia (VT), Ventricular fibrillation (VF), Torsades de pointes", body_style)],
    [Paragraph("Conduction Defects", body_style),
     Paragraph("1st, 2nd (Mobitz I & II), 3rd degree AV block; Bundle branch blocks (LBBB, RBBB); Sick sinus syndrome", body_style)],
]
story.append(make_table(class_data, [5*cm, 12*cm]))
story.append(Spacer(1, 0.15*cm))

story.append(section_box("Important Arrhythmias - Key Features"))

story.append(Paragraph(bp("1. Atrial Fibrillation (AF)"), bold_label))
for item in [
    "Most common sustained cardiac arrhythmia",
    "Chaotic, irregular atrial activity at 350-600 impulses/min",
    bp("ECG") + ": absent P waves, irregularly irregular QRS, fibrillatory baseline",
    bp("Causes") + ": hypertension, rheumatic heart disease, thyrotoxicosis, IHD, alcohol ('holiday heart')",
    bp("Risks") + ": embolic stroke (thrombus in left atrial appendage), heart failure",
    bp("Treatment") + ": Rate control (beta-blockers, digoxin, CCBs) | Rhythm control (cardioversion, amiodarone) | Anticoagulation (warfarin/NOAC) to prevent stroke",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("2. Ventricular Tachycardia (VT)"), bold_label))
for item in [
    "3 or more consecutive ventricular beats at rate >100 bpm",
    bp("ECG") + ": wide QRS (>0.12s), AV dissociation, fusion beats, capture beats",
    bp("Causes") + ": MI, cardiomyopathy, electrolyte disturbances (hypokalemia, hypomagnesemia)",
    bp("Treatment") + ": Stable VT - IV amiodarone/lignocaine; Unstable VT - DC cardioversion; ICD for recurrent VT",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("3. Complete Heart Block (3rd Degree AV Block)"), bold_label))
for item in [
    "Complete dissociation between atrial and ventricular activity",
    bp("ECG") + ": P waves and QRS complexes independent of each other; slow ventricular escape rhythm (20-40 bpm)",
    bp("Symptoms") + ": Stokes-Adams attacks (sudden transient LOC), heart failure, severe bradycardia",
    bp("Treatment") + ": Permanent pacemaker implantation",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("4. Sick Sinus Syndrome"), bold_label))
for item in [
    "Dysfunction of SA node: bradycardia, SA block, sinus arrest",
    "Brady-tachy syndrome: alternates with tachyarrhythmias",
    bp("Treatment") + ": Permanent pacemaker",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Investigations"))
for item in [
    bp("ECG (12-lead)") + " - single most important investigation",
    bp("Holter Monitor") + " - 24-48 hour ambulatory ECG for paroxysmal arrhythmias",
    bp("Electrophysiological Study (EPS)") + " - for complex arrhythmias, pre-ablation",
    bp("Echocardiography") + " - assess structural heart disease",
    bp("Blood tests") + " - electrolytes (K+, Mg2+), thyroid function tests (TFTs), cardiac enzymes",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Treatment Summary"))
treat_data = [
    [Paragraph(bp("Approach"), body_style), Paragraph(bp("Details"), body_style)],
    [Paragraph("Rate Control", body_style), Paragraph("Beta-blockers, CCBs (verapamil, diltiazem), digoxin", body_style)],
    [Paragraph("Rhythm Control", body_style), Paragraph("Antiarrhythmics: amiodarone, flecainide, sotalol; DC cardioversion", body_style)],
    [Paragraph("Pacemakers", body_style), Paragraph("Bradyarrhythmias, complete heart block, sick sinus syndrome", body_style)],
    [Paragraph("ICD", body_style), Paragraph("VT/VF; high-risk patients with structural heart disease", body_style)],
    [Paragraph("Catheter Ablation", body_style), Paragraph("SVT, WPW syndrome, AF - radiofrequency ablation", body_style)],
    [Paragraph("Anticoagulation", body_style), Paragraph("AF - warfarin (INR 2-3) or NOACs (rivaroxaban, apixaban, dabigatran)", body_style)],
]
story.append(make_table(treat_data, [4*cm, 13*cm]))

story.append(Paragraph(bp("Dental Relevance:"), bold_label))
story.append(Paragraph(
    "Patients on " + bp("warfarin") + ": check INR before extraction (safe if INR <3.5 for minor dental surgery). "
    "Avoid epinephrine-containing LA in severe arrhythmias or digoxin toxicity. "
    bp("Erythromycin / clarithromycin") + " can prolong QT interval - use cautiously. "
    "Epinephrine in LA is safe in controlled arrhythmia if used in low dose (max 2 cartridges).",
    body_style))

story.append(PageBreak())

# ============================================================
# TOPIC 3: PNEUMONIA
# ============================================================
story.append(topic_banner("PNEUMONIA", "3"))
story.append(Spacer(1, 0.2*cm))

story.append(section_box("Definition"))
story.append(Paragraph(
    "Pneumonia is an acute inflammatory condition of the lung parenchyma (alveoli, alveolar ducts, and respiratory bronchioles) "
    "caused by microbial infection, resulting in consolidation and impaired gas exchange.",
    body_style))

story.append(section_box("Classification"))
class2_data = [
    [Paragraph(bp("By Setting"), body_style), Paragraph(bp("By Etiology"), body_style), Paragraph(bp("By Anatomy"), body_style)],
    [Paragraph("- Community-Acquired (CAP)\n- Hospital-Acquired (HAP) - >48h after admission\n- Ventilator-Associated (VAP)\n- Aspiration Pneumonia\n- Immunocompromised Host", body_style),
     Paragraph("- Bacterial: S. pneumoniae (MC), Staphylococcus, Klebsiella, H. influenzae\n- Atypical: Mycoplasma, Chlamydia, Legionella\n- Viral: Influenza, COVID-19, RSV\n- Fungal: PCP (immunocompromised)", body_style),
     Paragraph("- Lobar pneumonia (entire lobe)\n- Bronchopneumonia (patchy, multifocal)\n- Interstitial pneumonia (alveolar walls)", body_style)],
]
story.append(make_table(class2_data, [5.5*cm, 7.5*cm, 4*cm]))
story.append(Spacer(1, 0.15*cm))

story.append(section_box("Pathology - Stages of Lobar Pneumonia"))
path_data = [
    [Paragraph(bp("Stage"), body_style), Paragraph(bp("Duration"), body_style), Paragraph(bp("Features"), body_style)],
    [Paragraph("1. Congestion", body_style), Paragraph("1-2 days", body_style),
     Paragraph("Vascular engorgement, edema fluid, bacteria; lung heavy, boggy", body_style)],
    [Paragraph("2. Red Hepatization", body_style), Paragraph("2-4 days", body_style),
     Paragraph("Lobe firm like liver; alveoli filled with RBCs, fibrin, PMNs", body_style)],
    [Paragraph("3. Grey Hepatization", body_style), Paragraph("4-8 days", body_style),
     Paragraph("RBCs lysed; alveoli filled with fibrin, PMNs, macrophages; grey-brown color", body_style)],
    [Paragraph("4. Resolution", body_style), Paragraph("8-9 days", body_style),
     Paragraph("Enzymatic digestion of exudate; normal lung architecture restored", body_style)],
]
story.append(make_table(path_data, [4.5*cm, 2.5*cm, 10*cm]))
story.append(Spacer(1, 0.15*cm))

story.append(section_box("Clinical Features"))
story.append(Paragraph(bp("Symptoms:"), bold_label))
for item in [
    bp("Sudden onset") + " high-grade fever (39-40 degrees C) with rigors/chills",
    bp("Productive cough") + " - rusty/blood-tinged sputum (characteristic of pneumococcal pneumonia)",
    bp("Pleuritic chest pain") + " - sharp, worse on deep inspiration",
    "Breathlessness, tachypnoea",
    "Herpes labialis (cold sores) on lips",
    "Malaise, anorexia, headache",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Physical Signs:"), bold_label))
exam_data = [
    [Paragraph(bp("Method"), body_style), Paragraph(bp("Finding"), body_style)],
    [Paragraph("Inspection", body_style), Paragraph("Reduced chest expansion on affected side, tachypnoea", body_style)],
    [Paragraph("Palpation", body_style), Paragraph("Increased vocal fremitus over consolidation", body_style)],
    [Paragraph("Percussion", body_style), Paragraph("Dull note over consolidated lobe", body_style)],
    [Paragraph("Auscultation", body_style), Paragraph("Bronchial breathing, increased vocal resonance, crepitations (crackles), pleural friction rub", body_style)],
]
story.append(make_table(exam_data, [4*cm, 13*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Investigations"))
for item in [
    bp("Chest X-ray") + " - consolidation (homogeneous opacity), air bronchogram sign; most important",
    bp("Sputum Gram stain and culture") + " - identify organism and sensitivity",
    bp("CBC") + " - neutrophilic leukocytosis (bacterial); lymphocytosis (viral/atypical)",
    bp("Blood culture") + " - bacteremia in severe cases",
    bp("ABG") + " - assess degree of hypoxemia",
    bp("Urine antigen tests") + " - Legionella and Streptococcal pneumococcal antigens",
    bp("Serology") + " - Mycoplasma, Chlamydia, Legionella (cold agglutinins in Mycoplasma)",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Treatment"))
story.append(Paragraph(bp("Severity Assessment - CURB-65 Score:"), bold_label))
story.append(Paragraph(
    bp("C") + "=Confusion | " + bp("U") + "=Urea >7 mmol/L | " + bp("R") + "=RR >=30/min | "
    + bp("B") + "=BP systolic <90 or diastolic <=60 | " + bp("65") + "=Age >=65 years. "
    "Score 0-1: treat at home; Score 2: hospital admission; Score >=3: consider ICU.",
    body_style))

story.append(Paragraph(bp("Antibiotic Therapy (CAP):"), bold_label))
for item in [
    bp("Mild/Outpatient") + ": Amoxicillin 500 mg TDS x 5-7 days; or Doxycycline/Clarithromycin for atypical cover",
    bp("Moderate/Hospital") + ": IV Co-amoxiclav + Clarithromycin",
    bp("Severe/ICU") + ": IV Piperacillin-tazobactam + IV Levofloxacin/Azithromycin",
    bp("Aspiration pneumonia") + ": Metronidazole + Co-amoxiclav (anaerobic coverage)",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Supportive Treatment:"), bold_label))
for item in [
    "Oxygen supplementation (target SpO2 >94%)",
    "IV fluids, antipyretics, analgesics",
    "Physiotherapy and postural drainage",
    "Mechanical ventilation if severe respiratory failure (ARDS)",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Complications:"), bold_label))
for item in [
    "Pleural effusion / Empyema",
    "Lung abscess",
    "Respiratory failure (ARDS)",
    "Septicemia, septic shock",
    "Hepatitis (atypical pneumonia - Mycoplasma)",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Dental Relevance:"), bold_label))
story.append(Paragraph(
    bp("Aspiration pneumonia") + " can result from dental procedures - especially in patients under GA or sedation "
    "with impaired gag reflex. Oral anaerobes from periodontal disease are common culprits. "
    "Good oral hygiene reduces aspiration pneumonia risk in hospitalized and elderly patients.",
    body_style))

story.append(PageBreak())

# ============================================================
# TOPIC 4: LUNG ABSCESS
# ============================================================
story.append(topic_banner("LUNG ABSCESS", "4"))
story.append(Spacer(1, 0.2*cm))

story.append(section_box("Definition"))
story.append(Paragraph(
    "Lung abscess is a localized area of suppuration (pus formation) within the pulmonary parenchyma, "
    "leading to necrosis and cavity formation (usually >2 cm in diameter) containing purulent material. "
    "May be " + bp("primary") + " (no pre-existing disease) or " + bp("secondary") + " (complication of existing disease).",
    body_style))

story.append(section_box("Etiology and Predisposing Factors"))
story.append(Paragraph(bp("Causative Organisms:"), bold_label))
for item in [
    bp("Anaerobes (most common)") + " - Bacteroides, Fusobacterium, Peptostreptococcus, Prevotella (oral commensals)",
    bp("Aerobes") + " - Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas, Streptococcus pyogenes",
    "Mixed flora in most cases; anaerobes present in 1/3 to 2/3 of cases as sole isolates",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Pathways of Infection:"), bold_label))
path2_data = [
    [Paragraph(bp("Mechanism"), body_style), Paragraph(bp("Details"), body_style)],
    [Paragraph("Aspiration (MC)", body_style),
     Paragraph("Infected material from carious teeth, periodontitis, sinuses, tonsils. Precipitated by: unconsciousness, GA, alcohol intoxication, epilepsy, dysphagia, debilitated state.", body_style)],
    [Paragraph("Complication of Pneumonia", body_style),
     Paragraph("Necrotizing bacterial pneumonia - S. aureus, Klebsiella, Pseudomonas, type 3 pneumococcus.", body_style)],
    [Paragraph("Bronchial Obstruction", body_style),
     Paragraph("Carcinoma of lung, foreign body - impaired drainage + distal infection.", body_style)],
    [Paragraph("Hematogenous Spread", body_style),
     Paragraph("Septic emboli from right-sided infective endocarditis, IV drug abuse - multiple bilateral abscesses.", body_style)],
    [Paragraph("Others", body_style),
     Paragraph("Subphrenic abscess (trans-diaphragmatic), penetrating chest trauma.", body_style)],
]
story.append(make_table(path2_data, [4.5*cm, 12.5*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Site of Predilection"))
story.append(Paragraph(
    bp("Right lung") + " more commonly affected (right bronchus more vertical). "
    "In " + bp("recumbent position") + " (most aspiration cases): posterior segment of right upper lobe and apical segment of right lower lobe. "
    "In " + bp("upright position") + ": basal segments of lower lobes. "
    "Hematogenous abscesses: multiple, bilateral, any lobe.",
    body_style))

story.append(section_box("Clinical Features"))
story.append(Paragraph(bp("Acute Phase (before bronchial rupture):"), bold_label))
for item in [
    "High-grade fever with rigors, drenching sweats, toxemia",
    "Pleuritic chest pain",
    "Dry cough, malaise, weight loss, anorexia",
    "No or minimal sputum production",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Drainage Phase (after cavity ruptures into bronchus):"), bold_label))
for item in [
    bp("Hallmark") + ": sudden expectoration of large amounts of " + bp("foul-smelling, purulent sputum") + " (copious - 'cupful' in 24h)",
    "Sputum settles into 3 layers: frothy (top) / watery (middle) / purulent necrotic (bottom) - characteristic",
    "Blood-stained sputum (hemoptysis)",
    "Improvement of fever after drainage",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Physical Signs:"), bold_label))
for item in [
    "Clubbing (chronic cases)",
    "Dullness to percussion over the abscess",
    bp("Amphoric / cavernous breathing") + " over the cavity (distinctive sign)",
    "Coarse crepitations",
    "Signs of surrounding consolidation",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Investigations"))
for item in [
    bp("Chest X-ray") + " - " + bp("thick-walled cavity with air-fluid level") + " (most characteristic finding); usually right-sided",
    bp("CT Chest") + " - better delineation; distinguishes from empyema and cavitating carcinoma",
    bp("Sputum") + " - Gram stain, aerobic + anaerobic culture and sensitivity; cytology for malignancy",
    bp("Bronchoscopy") + " - exclude underlying carcinoma or foreign body; obtain specimens",
    bp("CBC") + " - neutrophilic leukocytosis, raised ESR, anemia (chronic)",
    bp("Blood culture") + " - hematogenous cases",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Treatment"))
story.append(Paragraph(bp("Medical (First Line - most abscesses respond):"), bold_label))
for item in [
    bp("Antibiotics") + ": IV " + bp("Clindamycin") + " (drug of choice for aspiration/anaerobic lung abscess); or Co-amoxiclav + Metronidazole",
    "Duration: " + bp("6-8 weeks") + " (until radiological resolution)",
    bp("Postural drainage + chest physiotherapy") + " - position abscess uppermost to promote drainage",
    "Adequate nutrition (high protein diet), hydration",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Surgical (for failed/complicated cases):"), bold_label))
for item in [
    bp("Percutaneous CT-guided drainage") + " - large peripheral abscesses",
    bp("Bronchoscopic drainage") + " - if endobronchial obstruction",
    bp("Lobectomy/Pneumonectomy") + " - chronic non-resolving abscess, >6 cm, underlying malignancy",
    bp("Indications for surgery") + ": no response to 6 weeks antibiotics, abscess >6 cm, massive hemoptysis, malignancy",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Complications:"), bold_label))
for item in [
    "Empyema / Pyopneumothorax",
    "Massive hemoptysis",
    "Septicemia, metastatic abscess (brain abscess)",
    "Bronchiectasis (chronic)",
    "Respiratory failure",
    "Amyloidosis (very chronic cases)",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Dental Relevance:"), bold_label))
story.append(Paragraph(
    bp("Dental sepsis and poor oral hygiene are the most important predisposing factors for aspiration lung abscess.") + " "
    "Oral anaerobes (Bacteroides, Fusobacterium, Peptostreptococcus) are the principal organisms. "
    "Risk is highest during GA for dental procedures. "
    "Pre-operative oral hygiene optimization and antibiotic prophylaxis reduce risk.",
    body_style))

story.append(PageBreak())

# ============================================================
# TOPIC 5: BRONCHIAL ASTHMA
# ============================================================
story.append(topic_banner("BRONCHIAL ASTHMA", "5"))
story.append(Spacer(1, 0.2*cm))

story.append(section_box("Definition"))
story.append(Paragraph(
    "Bronchial asthma is a chronic inflammatory disease of the airways characterized by: "
    "(1) " + bp("Airway hyperresponsiveness") + " to various stimuli, "
    "(2) " + bp("Reversible airflow obstruction") + " (spontaneously or with treatment), and "
    "(3) " + bp("Chronic airway inflammation") + " with mucosal edema, mucus hypersecretion, and bronchoconstriction.",
    body_style))

story.append(section_box("Classification"))
class3_data = [
    [Paragraph(bp("Type"), body_style), Paragraph(bp("Features"), body_style)],
    [Paragraph("Extrinsic / Allergic / Atopic", body_style),
     Paragraph("Most common. IgE-mediated. Onset in childhood. Triggers: dust mites, pollen, animal dander, molds. Positive family history. Raised total IgE. Positive skin prick test.", body_style)],
    [Paragraph("Intrinsic / Non-allergic", body_style),
     Paragraph("No identifiable allergen. Adult onset. Triggers: viral URTI, cold air, exercise, aspirin/NSAIDs, occupational agents (isocyanates, latex), emotions. Normal IgE.", body_style)],
    [Paragraph("Occupational", body_style),
     Paragraph("Workplace sensitizers: isocyanates, flour dust, latex, formaldehyde.", body_style)],
    [Paragraph("Aspirin-sensitive\n(Samter's Triad)", body_style),
     Paragraph("Asthma + nasal polyps + aspirin/NSAID sensitivity.", body_style)],
    [Paragraph("Exercise-Induced", body_style),
     Paragraph("Bronchoconstriction triggered by vigorous exercise.", body_style)],
]
story.append(make_table(class3_data, [5*cm, 12*cm]))
story.append(Spacer(1, 0.15*cm))

story.append(section_box("Pathophysiology"))
story.append(Paragraph(bp("Early Phase Reaction (Immediate, 0-30 min):"), bold_label))
for item in [
    "Antigen binds IgE on mast cells and basophils - mast cell degranulation",
    "Release of: histamine, leukotrienes (LTC4, LTD4, LTE4), prostaglandins (PGD2), bradykinin",
    "Results in: bronchoconstriction, vasodilation, increased vascular permeability, mucus hypersecretion",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Late Phase Reaction (3-12 hours):"), bold_label))
for item in [
    "Recruitment of eosinophils, neutrophils, T-lymphocytes, basophils - chronic inflammation",
    "Eosinophil-derived major basic protein (MBP) causes epithelial damage",
    "Bronchial hyperresponsiveness established",
    bp("Airway remodeling") + ": subepithelial fibrosis, goblet cell hyperplasia, smooth muscle hypertrophy, angiogenesis - may lead to irreversible narrowing",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Clinical Features"))
story.append(Paragraph(bp("Classic Triad: Episodic Wheeze + Cough + Breathlessness"), bold_label))
for item in [
    bp("Wheeze") + " - expiratory (musical); worse at night and early morning",
    bp("Cough") + " - often nocturnal, dry or productive; can be the only symptom (cough-variant asthma)",
    bp("Breathlessness (dyspnoea)") + " - episodic, precipitated by triggers",
    "Symptoms are " + bp("reversible") + " and " + bp("episodic") + "; symptom-free between attacks",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("During an Acute Severe Attack:"), bold_label))
for item in [
    "Severe breathlessness, tachypnoea, use of accessory muscles",
    "Expiratory wheeze and prolonged expiration",
    "Tachycardia, patient sits upright unable to lie flat",
    "Pulsus paradoxus (>10 mmHg drop in systolic BP on inspiration)",
    bp("Danger signs") + ": cyanosis, inability to speak, " + bp("silent chest") + " (no wheeze - no air entry - ominous), bradycardia",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Investigations"))
story.append(Paragraph(bp("Pulmonary Function Tests (PFTs) - Most Important:"), bold_label))
pft_data = [
    [Paragraph(bp("Test"), body_style), Paragraph(bp("Finding"), body_style)],
    [Paragraph("Spirometry", body_style),
     Paragraph("FEV1/FVC ratio <70% (obstructive). Post-bronchodilator: >=12% AND >=200 mL rise in FEV1 = reversibility (diagnostic of asthma)", body_style)],
    [Paragraph("PEFR (Peak Flow)", body_style),
     Paragraph("Reduced during attack. >20% diurnal variation (morning dip) is diagnostic.", body_style)],
    [Paragraph("Methacholine Challenge", body_style),
     Paragraph("Provocation test to confirm airway hyperresponsiveness when diagnosis uncertain.", body_style)],
]
story.append(make_table(pft_data, [4.5*cm, 12.5*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(Paragraph(bp("Other Investigations:"), bold_label))
for item in [
    bp("CXR") + ": hyperinflation (flattened diaphragm) in chronic asthma; usually normal between attacks; pneumothorax in severe attack",
    bp("Sputum") + ": eosinophils, " + bp("Charcot-Leyden crystals") + ", " + bp("Curschmann's spirals") + " (mucus plugs) - characteristic",
    bp("Blood CBC") + ": eosinophilia (>400/microL)",
    bp("Total IgE and specific IgE/RAST") + ": elevated in atopic asthma",
    bp("ABG") + ": in severe attack - hypoxemia (low PaO2); initially hypocapnia; PaCO2 rising = impending respiratory failure",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Management - Stepwise Approach (GINA Guidelines)"))
step_data = [
    [Paragraph(bp("Step"), body_style), Paragraph(bp("Severity"), body_style), Paragraph(bp("Treatment"), body_style)],
    [Paragraph("Step 1", body_style), Paragraph("Intermittent", body_style),
     Paragraph("SABA (Salbutamol/Albuterol) PRN only - no regular controller needed", body_style)],
    [Paragraph("Step 2", body_style), Paragraph("Mild persistent", body_style),
     Paragraph("Low-dose ICS (Beclomethasone/Budesonide) + SABA PRN", body_style)],
    [Paragraph("Step 3", body_style), Paragraph("Moderate persistent", body_style),
     Paragraph("Low/Medium dose ICS + LABA (Salmeterol/Formoterol) combined inhaler", body_style)],
    [Paragraph("Step 4", body_style), Paragraph("Severe persistent", body_style),
     Paragraph("Medium/High dose ICS + LABA +/- LAMA (Tiotropium) +/- Montelukast", body_style)],
    [Paragraph("Step 5", body_style), Paragraph("Very severe", body_style),
     Paragraph("Oral corticosteroids / Biologic therapy: Omalizumab (anti-IgE, for atopic), Mepolizumab (anti-IL5, eosinophilic)", body_style)],
]
story.append(make_table(step_data, [2.5*cm, 4*cm, 10.5*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(Paragraph(bp("Key Drugs Summary:"), bold_label))
drug_data = [
    [Paragraph(bp("Drug"), body_style), Paragraph(bp("Class"), body_style), Paragraph(bp("Role / Note"), body_style)],
    [Paragraph("Salbutamol", body_style), Paragraph("SABA", body_style),
     Paragraph("Reliever; bronchodilator; first line in acute attack; onset 5 min", body_style)],
    [Paragraph("Salmeterol/Formoterol", body_style), Paragraph("LABA", body_style),
     Paragraph("Controller; never use alone (always with ICS)", body_style)],
    [Paragraph("Beclomethasone/Budesonide/Fluticasone", body_style), Paragraph("ICS", body_style),
     Paragraph("Mainstay prevention; most effective controller; rinse mouth after use to prevent candidiasis", body_style)],
    [Paragraph("Ipratropium", body_style), Paragraph("SAMA", body_style),
     Paragraph("Add-on bronchodilator in severe attack (nebulized)", body_style)],
    [Paragraph("Montelukast/Zafirlukast", body_style), Paragraph("LTRA", body_style),
     Paragraph("Useful in aspirin-sensitive asthma and exercise-induced", body_style)],
    [Paragraph("Theophylline", body_style), Paragraph("Methylxanthine", body_style),
     Paragraph("Add-on; narrow therapeutic index; drug interactions (erythromycin raises levels)", body_style)],
    [Paragraph("Prednisolone", body_style), Paragraph("Oral steroid", body_style),
     Paragraph("Acute severe attack (40-50 mg/day x 5 days) and Step 5 maintenance", body_style)],
    [Paragraph("Omalizumab", body_style), Paragraph("Anti-IgE biologic", body_style),
     Paragraph("SC injection; severe allergic asthma; expensive", body_style)],
]
story.append(make_table(drug_data, [5*cm, 2.7*cm, 9.3*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Management of Acute Severe Asthma / Status Asthmaticus"))
for item in [
    bp("Sit upright") + "; high-flow O2 (40-60%) to maintain SpO2 >94%",
    bp("Nebulized Salbutamol") + " 2.5-5 mg every 20 min x 3, then hourly",
    bp("Add Nebulized Ipratropium") + " 0.5 mg - if not responding to salbutamol",
    bp("IV/Oral Hydrocortisone") + " 200 mg IV stat or Prednisolone 40-50 mg oral",
    bp("IV Magnesium Sulphate") + " 1.2-2 g over 20 min - smooth muscle relaxant (if FEV1 <30% predicted)",
    bp("IV Aminophylline") + " - loading dose for those not already on theophylline",
    bp("NIV / Mechanical ventilation") + " - if deteriorating despite all measures",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Dental Relevance:"), bold_label))
story.append(Paragraph(
    "(1) Always have " + bp("salbutamol inhaler") + " available in the dental clinic - record asthma history. "
    "(2) " + bp("Avoid aspirin / NSAIDs") + " - use paracetamol for analgesia. "
    "(3) Avoid bisulfite-containing local anesthetics (rare but reported trigger). "
    "(4) Stress and anxiety can trigger bronchospasm - anxiolysis/pre-medication may be needed. "
    "(5) " + bp("Erythromycin raises theophylline levels") + " - risk of toxicity; use alternative antibiotic. "
    "(6) Inhaled steroids can cause oral candidiasis - advise rinsing mouth after every dose. "
    "(7) In an acute attack in the dental chair: stop procedure, sit upright, administer salbutamol inhaler (2-4 puffs), call emergency services if no improvement.",
    body_style))

# FOOTER
story.append(Spacer(1, 0.3*cm))
story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor('#9fa8da')))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "General Medicine Short Notes | BDS 3rd Year | Gujarat University | "
    "Based on Anil K. Tripathi - General Medicine for BDS | Prepared for 7-8 Mark Questions",
    footer_style))

doc.build(story)
print("PDF generated successfully!")

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

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, PageBreak
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY

doc = SimpleDocTemplate(
    "/tmp/workspace/bds-notes/General_Medicine_Short_Notes_BDS_Part2.pdf",
    pagesize=A4,
    leftMargin=2*cm, rightMargin=2*cm,
    topMargin=2*cm, bottomMargin=2*cm
)

styles = getSampleStyleSheet()

title_style = ParagraphStyle(
    'MainTitle', parent=styles['Title'],
    fontSize=18, textColor=colors.HexColor('#1b5e20'),
    spaceAfter=4, alignment=TA_CENTER, fontName='Helvetica-Bold'
)
subtitle_style = ParagraphStyle(
    'SubTitle', parent=styles['Normal'],
    fontSize=10, textColor=colors.HexColor('#4a4a4a'),
    spaceAfter=12, alignment=TA_CENTER, fontName='Helvetica-Oblique'
)
body_style = ParagraphStyle(
    'Body', parent=styles['Normal'],
    fontSize=9.5, textColor=colors.HexColor('#212121'),
    spaceAfter=3, spaceBefore=1,
    leading=14, alignment=TA_JUSTIFY, fontName='Helvetica'
)
bullet_style = ParagraphStyle(
    'Bullet', parent=styles['Normal'],
    fontSize=9.5, textColor=colors.HexColor('#212121'),
    spaceAfter=2, spaceBefore=1,
    leading=13, leftIndent=14, bulletIndent=4,
    fontName='Helvetica'
)
bold_label = ParagraphStyle(
    'BoldLabel', parent=styles['Normal'],
    fontSize=9.5, textColor=colors.HexColor('#1b5e20'),
    spaceAfter=1, spaceBefore=3,
    fontName='Helvetica-Bold'
)
footer_style = ParagraphStyle(
    'Footer', parent=styles['Normal'],
    fontSize=8, textColor=colors.HexColor('#757575'),
    alignment=TA_CENTER
)

def topic_banner(title, number):
    data = [[Paragraph('<font color="white"><b>TOPIC %s: %s</b></font>' % (number, title),
        ParagraphStyle('banner', fontSize=13, textColor=colors.white,
            fontName='Helvetica-Bold', alignment=TA_LEFT))]]
    t = Table(data, colWidths=[17*cm])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), colors.HexColor('#1b5e20')),
        ('TOPPADDING', (0,0), (-1,-1), 8),
        ('BOTTOMPADDING', (0,0), (-1,-1), 8),
        ('LEFTPADDING', (0,0), (-1,-1), 10),
    ]))
    return t

def section_box(title):
    data = [[Paragraph('<b>%s</b>' % title,
        ParagraphStyle('sbox', fontSize=10, textColor=colors.HexColor('#1b5e20'),
            fontName='Helvetica-Bold'))]]
    t = Table(data, colWidths=[17*cm])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), colors.HexColor('#e8f5e9')),
        ('TOPPADDING', (0,0), (-1,-1), 4),
        ('BOTTOMPADDING', (0,0), (-1,-1), 4),
        ('LEFTPADDING', (0,0), (-1,-1), 8),
        ('BOX', (0,0), (-1,-1), 0.5, colors.HexColor('#388e3c')),
    ]))
    return t

def make_table(data_list, col_widths):
    t = Table(data_list, colWidths=col_widths)
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#e8f5e9')),
        ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#81c784')),
        ('VALIGN', (0,0), (-1,-1), 'TOP'),
        ('TOPPADDING', (0,0), (-1,-1), 4),
        ('BOTTOMPADDING', (0,0), (-1,-1), 4),
        ('LEFTPADDING', (0,0), (-1,-1), 6),
        ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.white, colors.HexColor('#f1f8e9')]),
    ]))
    return t

def bp(text):
    return '<b>%s</b>' % text

story = []

# HEADER
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph("GENERAL MEDICINE", title_style))
story.append(Paragraph("Short Notes for BDS 3rd Year | Gujarat University Examinations", subtitle_style))
story.append(Paragraph("Based on Anil K. Tripathi - General Medicine for BDS", ParagraphStyle(
    'ref', fontSize=9, textColor=colors.HexColor('#757575'),
    alignment=TA_CENTER, fontName='Helvetica-Oblique', spaceAfter=4)))
story.append(Paragraph("Each topic: 7-8 Marks | Concise, Precise, Exam-Oriented", ParagraphStyle(
    'info', fontSize=9, textColor=colors.HexColor('#c62828'),
    alignment=TA_CENTER, fontName='Helvetica-Bold', spaceAfter=10)))
story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1b5e20')))
story.append(Spacer(1, 0.3*cm))

toc_data = [
    [Paragraph(bp("No."), body_style), Paragraph(bp("Topic"), body_style), Paragraph(bp("Marks"), body_style)],
    [Paragraph("1.", body_style), Paragraph("Chronic Obstructive Pulmonary Disease (COPD)", body_style), Paragraph("7-8", body_style)],
    [Paragraph("2.", body_style), Paragraph("Cor Pulmonale", body_style), Paragraph("7-8", body_style)],
    [Paragraph("3.", body_style), Paragraph("Tuberculosis (TB)", body_style), Paragraph("7-8", body_style)],
    [Paragraph("4.", body_style), Paragraph("Pleural Disease (Effusion + Empyema)", body_style), Paragraph("7-8", body_style)],
    [Paragraph("5.", body_style), Paragraph("Pneumothorax", body_style), Paragraph("7-8", body_style)],
]
toc_table = Table(toc_data, colWidths=[1.5*cm, 13*cm, 2.5*cm])
toc_table.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#e8f5e9')),
    ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#81c784')),
    ('ALIGN', (2,0), (2,-1), 'CENTER'),
    ('TOPPADDING', (0,0), (-1,-1), 4),
    ('BOTTOMPADDING', (0,0), (-1,-1), 4),
    ('LEFTPADDING', (0,0), (-1,-1), 8),
]))
story.append(toc_table)
story.append(Spacer(1, 0.5*cm))
story.append(PageBreak())

# ============================================================
# TOPIC 1: COPD
# ============================================================
story.append(topic_banner("CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)", "1"))
story.append(Spacer(1, 0.2*cm))

story.append(section_box("Definition"))
story.append(Paragraph(
    "COPD is a common, preventable, and treatable disease characterized by persistent respiratory symptoms "
    "and airflow limitation that is " + bp("not fully reversible") + ", usually progressive, and associated with "
    "enhanced chronic inflammatory response in the airways and lungs to noxious particles or gases (mainly cigarette smoke). "
    "It includes two major components: " + bp("Emphysema") + " and " + bp("Chronic Bronchitis") + ".",
    body_style))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Components of COPD"))
comp_data = [
    [Paragraph(bp("Component"), body_style), Paragraph(bp("Definition"), body_style), Paragraph(bp("Pathology"), body_style)],
    [Paragraph("Emphysema", body_style),
     Paragraph("Permanent enlargement of air spaces distal to terminal bronchioles due to destruction of alveolar walls", body_style),
     Paragraph("Destruction of alveolar elastic support by neutrophil-derived proteases (elastase). Loss of elastic recoil.", body_style)],
    [Paragraph("Chronic Bronchitis", body_style),
     Paragraph("Persistent productive cough for at least 3 consecutive months in at least 2 consecutive years (clinical definition)", body_style),
     Paragraph("Hypertrophy of mucus glands, goblet cell metaplasia, small airway inflammation (bronchiolitis), bronchiolar fibrosis", body_style)],
]
story.append(make_table(comp_data, [3.5*cm, 6.5*cm, 7*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Etiology / Risk Factors"))
for item in [
    bp("Cigarette smoking") + " - single most important cause (>90% of cases); dose-dependent",
    bp("Alpha-1 antitrypsin (AAT) deficiency") + " - genetic cause; panacinar emphysema predominantly in non-smokers",
    bp("Air pollution") + " - indoor (biomass fuel) and outdoor (PM2.5, sulfur dioxide)",
    bp("Occupational exposure") + " - coal dust, silica, cadmium",
    bp("Recurrent respiratory infections") + " in childhood",
    bp("Asthma-COPD overlap") + " - uncontrolled asthma leading to permanent airflow limitation",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Pathophysiology"))
story.append(Paragraph(
    "Inhaled noxious particles/smoke activate " + bp("macrophages") + " and " + bp("neutrophils") + " in the airways. "
    "Neutrophil elastase and matrix metalloproteinases (MMPs) destroy alveolar walls (emphysema). "
    "Chronic inflammation causes airway wall thickening, mucus hypersecretion, and bronchiolitis. "
    "Result: " + bp("irreversible airflow limitation") + ", air trapping, dynamic hyperinflation, V/Q mismatch, "
    "hypoxemia, and ultimately cor pulmonale.",
    body_style))

story.append(section_box("Classification - GOLD Staging (Spirometry)"))
gold_data = [
    [Paragraph(bp("GOLD Stage"), body_style), Paragraph(bp("FEV1 (post-bronchodilator)"), body_style), Paragraph(bp("Severity"), body_style)],
    [Paragraph("GOLD 1", body_style), Paragraph("FEV1 >= 80% predicted", body_style), Paragraph("Mild", body_style)],
    [Paragraph("GOLD 2", body_style), Paragraph("FEV1 50-79% predicted", body_style), Paragraph("Moderate", body_style)],
    [Paragraph("GOLD 3", body_style), Paragraph("FEV1 30-49% predicted", body_style), Paragraph("Severe", body_style)],
    [Paragraph("GOLD 4", body_style), Paragraph("FEV1 <30% predicted", body_style), Paragraph("Very severe", body_style)],
]
story.append(Paragraph("All stages require: " + bp("FEV1/FVC <0.70") + " post-bronchodilator (confirms airflow limitation)", bold_label))
story.append(make_table(gold_data, [3.5*cm, 8*cm, 5.5*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Clinical Features"))
story.append(Paragraph(bp("Emphysema (Type A - Pink Puffer):"), bold_label))
for item in [
    "Severe breathlessness (dyspnoea) - main complaint",
    "Minimal or no cough",
    bp("Barrel-shaped chest") + " (increased AP diameter), hyperinflation",
    bp("Pursed-lip breathing") + " (to maintain positive expiratory pressure)",
    "Thin, wasted appearance (weight loss)",
    "Normal/near normal PaO2; PaCO2 normal or low",
    "No cyanosis, no polycythemia",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Chronic Bronchitis (Type B - Blue Bloater):"), bold_label))
for item in [
    "Prominent cough with copious purulent sputum",
    "Breathlessness less prominent initially",
    "Cyanosis, polycythemia, peripheral edema (right heart failure)",
    "Repeated exacerbations (acute-on-chronic episodes)",
    "Hypoxemia (low PaO2) + Hypercapnia (raised PaCO2)",
    "Cor pulmonale - RV failure",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Physical Signs:"), bold_label))
exam_data = [
    [Paragraph(bp("Examination"), body_style), Paragraph(bp("Findings"), body_style)],
    [Paragraph("Inspection", body_style), Paragraph("Barrel chest, accessory muscle use, pursed lip breathing, cyanosis", body_style)],
    [Paragraph("Palpation", body_style), Paragraph("Reduced chest expansion bilaterally; loss of cardiac dullness (hyperinflation)", body_style)],
    [Paragraph("Percussion", body_style), Paragraph("Hyperresonance (emphysema); obliterated cardiac/liver dullness", body_style)],
    [Paragraph("Auscultation", body_style), Paragraph("Reduced breath sounds; prolonged expiration; expiratory wheeze; coarse crackles in bronchitis", body_style)],
]
story.append(make_table(exam_data, [4*cm, 13*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Investigations"))
for item in [
    bp("Spirometry") + " - " + bp("FEV1/FVC <0.70") + " post-bronchodilator (gold standard for diagnosis); FEV1 determines severity",
    bp("Chest X-ray") + " - hyperinflation, flattened diaphragm, increased retrosternal airspace, bullae; tubular heart",
    bp("HRCT Chest") + " - best for detecting and characterizing emphysema",
    bp("ABG") + " - type 1 (hypoxemia alone) or type 2 (hypoxemia + hypercapnia) respiratory failure",
    bp("CBC") + " - polycythemia (secondary erythrocytosis) in chronic hypoxemia",
    bp("Sputum culture") + " - in exacerbations (H. influenzae, S. pneumoniae, Pseudomonas MC)",
    bp("ECG/Echo") + " - right ventricular hypertrophy, pulmonary hypertension (cor pulmonale)",
    bp("AAT level") + " - if COPD in non-smoker <45 years",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Treatment"))
story.append(Paragraph(bp("Non-Pharmacological (Most Important):"), bold_label))
for item in [
    bp("Smoking cessation") + " - single most effective intervention that slows disease progression",
    "Pulmonary rehabilitation - exercise training, breathing techniques",
    bp("Long-term oxygen therapy (LTOT)") + " - if resting PaO2 <55 mmHg or SpO2 <88%; given >15 h/day; only intervention proven to improve survival",
    "Vaccination: annual influenza + pneumococcal vaccine",
    "Nutritional support",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Pharmacological - Stable COPD (Stepwise):"), bold_label))
rx_data = [
    [Paragraph(bp("Step"), body_style), Paragraph(bp("Drug"), body_style), Paragraph(bp("Examples"), body_style)],
    [Paragraph("All patients", body_style), Paragraph("SABA/SAMA (PRN reliever)", body_style),
     Paragraph("Salbutamol (SABA); Ipratropium (SAMA)", body_style)],
    [Paragraph("Mild-Moderate", body_style), Paragraph("LAMA (preferred) or LABA", body_style),
     Paragraph("Tiotropium (LAMA - 1st choice in COPD); Salmeterol, Formoterol (LABA)", body_style)],
    [Paragraph("Severe / Frequent exacerbations", body_style), Paragraph("LAMA + LABA +/- ICS", body_style),
     Paragraph("Triple therapy: Tiotropium + Salmeterol + Fluticasone", body_style)],
    [Paragraph("Add-on options", body_style), Paragraph("Roflumilast, Theophylline", body_style),
     Paragraph("Roflumilast (PDE4 inhibitor) in severe COPD with frequent exacerbations", body_style)],
]
story.append(make_table(rx_data, [4*cm, 5*cm, 8*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(Paragraph(bp("Acute Exacerbation of COPD (AECOPD) Management:"), bold_label))
for item in [
    "Controlled oxygen therapy: target SpO2 88-92% (avoid high flow - hypercapnic drive)",
    "Nebulized Salbutamol + Ipratropium",
    "Systemic Corticosteroids: Prednisolone 30-40 mg/day x 5 days",
    "Antibiotics if purulent sputum / infection: Amoxicillin / Doxycycline / Co-amoxiclav",
    "NIV (BiPAP) if type 2 respiratory failure (pH <7.35 with hypercapnia)",
    "Intubation/IMV as last resort",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Surgical:"), bold_label))
for item in [
    bp("Lung Volume Reduction Surgery (LVRS)") + " - in severe emphysema; improves FEV1 and quality of life",
    bp("Lung transplantation") + " - end-stage COPD",
    bp("Bullectomy") + " - giant bullae causing compression",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Dental Relevance:"), bold_label))
story.append(Paragraph(
    "(1) Use " + bp("caution with sedation and GA") + " - hypercapnic respiratory drive may be suppressed. "
    "(2) Avoid high-flow nasal oxygen (SpO2 target 88-92%). "
    "(3) " + bp("Erythromycin raises theophylline levels") + " - use amoxicillin or doxycycline instead. "
    "(4) Patients on ICS may have oral candidiasis. "
    "(5) NSAIDs may worsen respiratory function in overlap with asthma.",
    body_style))

story.append(PageBreak())

# ============================================================
# TOPIC 2: COR PULMONALE
# ============================================================
story.append(topic_banner("COR PULMONALE", "2"))
story.append(Spacer(1, 0.2*cm))

story.append(section_box("Definition"))
story.append(Paragraph(
    "Cor pulmonale is defined as " + bp("right ventricular hypertrophy, dilation, and dysfunction") +
    " resulting from pulmonary hypertension caused by disorders of the " +
    bp("lung parenchyma, pulmonary vasculature, or chest wall") + " (NOT from left heart disease or congenital heart disease). "
    "It may be " + bp("acute") + " (e.g., massive pulmonary embolism) or " + bp("chronic") + " (e.g., COPD, fibrosis).",
    body_style))

story.append(section_box("Etiology - Causes of Pulmonary Hypertension Leading to Cor Pulmonale"))
etio_data = [
    [Paragraph(bp("Category"), body_style), Paragraph(bp("Conditions"), body_style)],
    [Paragraph("Lung Parenchymal\n(Most Common)", body_style),
     Paragraph("COPD (emphysema/chronic bronchitis) - MC cause of chronic cor pulmonale; "
               "Pulmonary fibrosis, bronchiectasis, severe pneumoconiosis", body_style)],
    [Paragraph("Pulmonary Vascular", body_style),
     Paragraph("Recurrent pulmonary thrombo-embolism (MC cause of ACUTE cor pulmonale), "
               "Primary pulmonary arterial hypertension, Vasculitis", body_style)],
    [Paragraph("Chest Wall / Neuromuscular", body_style),
     Paragraph("Kyphoscoliosis, obesity hypoventilation syndrome (Pickwickian), "
               "Obstructive sleep apnea (OSA), neuromuscular diseases", body_style)],
    [Paragraph("Hypoxia at Altitude", body_style),
     Paragraph("High altitude chronic mountain sickness - hypoxic pulmonary vasoconstriction", body_style)],
]
story.append(make_table(etio_data, [5*cm, 12*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Pathophysiology"))
story.append(Paragraph(
    bp("Key mechanism") + ": Chronic hypoxia (low PaO2) -> "
    bp("hypoxic pulmonary vasoconstriction") + " (HPV) -> pulmonary artery hypertension (PAH) -> "
    "increased right ventricular afterload -> RV hypertrophy (compensated) -> "
    bp("RV dilation and failure") + " (decompensated) -> tricuspid regurgitation, "
    "systemic venous hypertension, edema, ascites, hepatomegaly.",
    body_style))
story.append(Paragraph(
    bp("Additional mechanisms") + ": Destruction of alveolar capillary bed (emphysema) reduces vascular cross-section; "
    "hypercapnia and acidosis aggravate vasoconstriction; polycythemia increases blood viscosity.",
    body_style))

story.append(section_box("Clinical Features"))
story.append(Paragraph(bp("Symptoms:"), bold_label))
for item in [
    "Breathlessness (dyspnoea) - progressive; related to underlying lung disease",
    "Fatigue, exertional limitation",
    bp("Ankle edema") + " and leg swelling (bilateral pitting edema)",
    "Symptoms of underlying lung disease (cough, wheeze, sputum)",
    "Headache, drowsiness (CO2 retention in hypercapnic patients)",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Physical Signs:"), bold_label))
signs_data = [
    [Paragraph(bp("Sign"), body_style), Paragraph(bp("Significance"), body_style)],
    [Paragraph("Raised JVP", body_style), Paragraph("Right ventricular failure / elevated right atrial pressure", body_style)],
    [Paragraph("Prominent 'a' wave in JVP", body_style), Paragraph("RV hypertrophy / tricuspid stenosis", body_style)],
    [Paragraph("Parasternal heave", body_style), Paragraph("Right ventricular hypertrophy (left parasternal lift)", body_style)],
    [Paragraph("Loud P2 (pulmonic S2)", body_style), Paragraph("Pulmonary hypertension", body_style)],
    [Paragraph("Tricuspid regurgitation murmur", body_style), Paragraph("Pansystolic at left sternal edge; increases on inspiration (Carvallo's sign)", body_style)],
    [Paragraph("Hepatomegaly + pulsatile liver", body_style), Paragraph("Passive hepatic congestion; TR causing pulsation", body_style)],
    [Paragraph("Bilateral pitting pedal edema", body_style), Paragraph("Right heart failure", body_style)],
    [Paragraph("Ascites", body_style), Paragraph("Severe, prolonged right heart failure", body_style)],
    [Paragraph("Cyanosis", body_style), Paragraph("Peripheral (cold) and central (V/Q mismatch)", body_style)],
]
story.append(make_table(signs_data, [5.5*cm, 11.5*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Investigations"))
for item in [
    bp("ECG") + " - P pulmonale (tall peaked P wave >2.5 mm in II, III, aVF = right atrial hypertrophy); "
    "right axis deviation; RV hypertrophy pattern (R>S in V1); S1Q3T3 pattern (acute PE)",
    bp("Chest X-ray") + " - cardiomegaly (right-sided), prominent pulmonary arteries, oligemic peripheral lung fields; "
    "features of underlying lung disease",
    bp("Echocardiography (Echo)") + " - most useful investigation; shows RV dilation/hypertrophy, "
    "estimates pulmonary artery systolic pressure via Doppler; TR present",
    bp("ABG") + " - hypoxemia + hypercapnia (type 2 respiratory failure)",
    bp("CBC") + " - polycythemia (secondary erythrocytosis due to chronic hypoxia)",
    bp("RFT / LFT") + " - renal/hepatic dysfunction secondary to poor perfusion",
    bp("NT-proBNP / BNP") + " - elevated due to right ventricular wall stress",
    bp("Right heart catheterization") + " - gold standard: confirms pulmonary artery pressure (PAP >25 mmHg at rest)",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Treatment"))
story.append(Paragraph(bp("Treat Underlying Cause (Most Important):"), bold_label))
for item in [
    "COPD: bronchodilators, smoking cessation, pulmonary rehabilitation",
    "Pulmonary embolism: anticoagulation, thrombolysis",
    "Sleep apnea: CPAP/BiPAP",
    "Kyphoscoliosis: ventilatory support",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Specific Management:"), bold_label))
treat_data = [
    [Paragraph(bp("Treatment"), body_style), Paragraph(bp("Details"), body_style)],
    [Paragraph("Long-term Oxygen Therapy (LTOT)", body_style),
     Paragraph("Primary treatment; corrects hypoxia and reverses pulmonary vasoconstriction; "
               "target PaO2 >60 mmHg / SpO2 >90%; given >15 h/day; ONLY treatment proven to improve survival", body_style)],
    [Paragraph("Diuretics", body_style),
     Paragraph("Furosemide (frusemide) for edema/fluid overload; use cautiously (risk of metabolic alkalosis worsening hypercapnia)", body_style)],
    [Paragraph("Anticoagulation", body_style),
     Paragraph("If pulmonary thromboembolism is the cause; warfarin or NOAC", body_style)],
    [Paragraph("Phlebotomy", body_style),
     Paragraph("If severe polycythemia (PCV >55%) causing hyperviscosity symptoms", body_style)],
    [Paragraph("Pulmonary Vasodilators", body_style),
     Paragraph("Sildenafil (PDE5 inhibitor), Bosentan (endothelin antagonist) - in primary PAH; cautious use in COPD-related cor pulmonale", body_style)],
    [Paragraph("Digoxin", body_style),
     Paragraph("Limited role; only if concurrent LV failure or AF; risk of toxicity in hypoxia", body_style)],
    [Paragraph("Lung Transplantation", body_style),
     Paragraph("End-stage disease unresponsive to medical therapy", body_style)],
]
story.append(make_table(treat_data, [4.5*cm, 12.5*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(Paragraph(bp("Prognosis:"), bold_label))
story.append(Paragraph(
    "Poor once established. If PAP >25 mmHg, 5-year survival is reduced by 50%. "
    "LTOT is the only intervention shown to improve survival in COPD-related cor pulmonale.",
    body_style))

story.append(Paragraph(bp("Dental Relevance:"), bold_label))
story.append(Paragraph(
    "Patients with cor pulmonale are at high cardiovascular risk. "
    bp("Avoid GA") + " or heavy sedation. Dental treatment best done in semi-reclined (not fully supine) position. "
    "Avoid high-dose epinephrine - causes pulmonary vasoconstriction and tachycardia. "
    "Patients on diuretics and digoxin need drug interaction monitoring.",
    body_style))

story.append(PageBreak())

# ============================================================
# TOPIC 3: TUBERCULOSIS
# ============================================================
story.append(topic_banner("TUBERCULOSIS (TB)", "3"))
story.append(Spacer(1, 0.2*cm))

story.append(section_box("Definition"))
story.append(Paragraph(
    "Tuberculosis is a chronic granulomatous infectious disease caused by " +
    bp("Mycobacterium tuberculosis") + " (Koch's bacillus). "
    "It primarily affects the lungs (pulmonary TB) but can affect any organ (extrapulmonary TB). "
    "It is an " + bp("acid-fast bacillus (AFB)") + " - gram positive, non-motile, obligate aerobe, "
    "slow-growing (18-24 hour doubling time).",
    body_style))

story.append(section_box("Epidemiology"))
for item in [
    "India has the highest burden of TB globally (26% of world's TB cases - WHO 2023)",
    "Spread by " + bp("airborne droplet nuclei") + " (1-5 microns); produced by coughing, sneezing, talking",
    "Risk factors: poverty, malnutrition, HIV, DM, immunosuppression, overcrowding, silicosis, alcoholism",
    bp("HIV co-infection") + " is the strongest risk factor for progression from latent to active TB",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Pathogenesis"))
story.append(Paragraph(bp("Primary Tuberculosis (Ghon Complex):"), bold_label))
for item in [
    "Inhaled bacilli reach lower lobes / alveoli - phagocytosed by alveolar macrophages",
    "Bacteria multiply within macrophages",
    "Sensitization develops (4-8 weeks) - T cell mediated immunity",
    bp("Ghon focus") + ": subpleural caseous granuloma (primary focus) + ipsilateral hilar lymphadenopathy",
    "In most immunocompetent individuals: lesion heals, bacilli remain dormant (" + bp("latent TB") + ")",
    "Ranke complex = calcified Ghon focus + calcified hilar nodes",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Post-Primary / Reactivation Tuberculosis:"), bold_label))
for item in [
    "Reactivation of latent bacilli when immunity wanes",
    "Typically affects " + bp("upper lobes") + " (posterior segment - high oxygen tension favors bacilli)",
    "Granulomas undergo central caseation - liquefaction - cavity formation",
    "Spreads via bronchi (endobronchial spread), hematogenous (miliary TB), lymphatics",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Classification"))
class_data = [
    [Paragraph(bp("Type"), body_style), Paragraph(bp("Features"), body_style)],
    [Paragraph("Pulmonary TB\n(Most Common)", body_style),
     Paragraph("Upper lobe involvement with cavitation. Main forms: primary progressive, reactivation (post-primary)", body_style)],
    [Paragraph("Miliary TB", body_style),
     Paragraph("Hematogenous dissemination; 'millet seed' shadows on CXR; affects liver, spleen, meninges, kidneys", body_style)],
    [Paragraph("Extrapulmonary TB", body_style),
     Paragraph("Lymph node TB (scrofula - MC extrapulmonary site), pleural, pericardial, meningeal (TBM), "
               "genitourinary, spinal (Pott's disease), peritoneal", body_style)],
    [Paragraph("Latent TB Infection (LTBI)", body_style),
     Paragraph("Positive TST/IGRA but no symptoms, no active disease, not infectious; may reactivate", body_style)],
    [Paragraph("Drug-Resistant TB", body_style),
     Paragraph("MDR-TB: resistant to Isoniazid + Rifampicin. XDR-TB: additionally resistant to fluoroquinolones + injectables", body_style)],
]
story.append(make_table(class_data, [4*cm, 13*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Clinical Features"))
story.append(Paragraph(bp("Constitutional symptoms (B symptoms):"), bold_label))
for item in [
    bp("Fever") + " - low grade, afternoon rise (evening pyrexia), remittent",
    bp("Night sweats") + " (drenching, classical symptom)",
    bp("Weight loss") + " and loss of appetite (anorexia)",
    "Fatigue and weakness",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Respiratory Symptoms:"), bold_label))
for item in [
    bp("Cough") + " - persistent, >3 weeks; initially dry, then productive",
    bp("Hemoptysis") + " - frank blood-tinged sputum; in advanced/cavitatory disease",
    "Breathlessness - with extensive disease or effusion",
    "Pleuritic chest pain - with pleural involvement",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Physical Signs:"), bold_label))
for item in [
    "Post-tussive crackles (rales) in upper zones - elicited after coughing",
    bp("Amphoric breathing") + " - over a large cavity (hollow sound)",
    "Signs of consolidation, pleural effusion, or fibrosis in chronic cases",
    "Cervical lymphadenopathy (scrofula)",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Investigations"))
invest_data = [
    [Paragraph(bp("Investigation"), body_style), Paragraph(bp("Details"), body_style)],
    [Paragraph("Sputum Microscopy\n(Ziehl-Neelsen stain)", body_style),
     Paragraph("AFB (red rods) on ZN stain. At least 3 samples needed (early morning). Sensitivity 60-70%; Cheap, quick, widely available. Most important initial test.", body_style)],
    [Paragraph("Sputum Culture\n(LJ medium)", body_style),
     Paragraph("Gold standard for diagnosis and drug sensitivity. Takes 4-8 weeks for solid media; MGIT broth (2-3 weeks). Sensitivity ~80-85%.", body_style)],
    [Paragraph("Chest X-ray", body_style),
     Paragraph("Upper lobe infiltrates, cavitation, fibrosis, calcification. 'Simon's foci' = old healed apical lesions. Miliary pattern (1-2 mm nodules throughout both lungs).", body_style)],
    [Paragraph("Mantoux Test\n(Tuberculin Skin Test)", body_style),
     Paragraph("5 TU (2 TU in India) of PPD injected intradermally. Read at 48-72h. Positive: induration >=10 mm (>=5 mm in HIV/immunocompromised). Indicates infection, NOT active disease.", body_style)],
    [Paragraph("IGRA (Interferon-Gamma Release Assay)", body_style),
     Paragraph("QuantiFERON-TB Gold; more specific than TST; not affected by BCG vaccination; used for LTBI diagnosis.", body_style)],
    [Paragraph("GeneXpert MTB/RIF\n(CBNAAT)", body_style),
     Paragraph("WHO-endorsed rapid molecular test. Detects M. tuberculosis DNA and rifampicin resistance within 2 hours. High sensitivity (88%) and specificity (98%). India: NIKSHAY program.", body_style)],
    [Paragraph("CT Chest / HRCT", body_style),
     Paragraph("Better than CXR for extent of disease, cavitation, lymphadenopathy, miliary TB.", body_style)],
    [Paragraph("Pleural fluid analysis", body_style),
     Paragraph("Lymphocytic exudate; ADA (adenosine deaminase) >40 IU/L strongly suggests TB pleuritis.", body_style)],
]
story.append(make_table(invest_data, [4.5*cm, 12.5*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Treatment - RNTCP/WHO Regimen (Drug-Sensitive TB)"))
story.append(Paragraph(
    "First-line drugs: " + bp("R") + "ifampicin (R) | " + bp("I") + "soniazid (H) | " +
    bp("P") + "yrazinamide (Z) | " + bp("E") + "thambutol (E) | [Streptomycin (S) - injectable]",
    body_style))
story.append(Spacer(1, 0.1*cm))

regimen_data = [
    [Paragraph(bp("Category"), body_style), Paragraph(bp("Regimen"), body_style), Paragraph(bp("Duration"), body_style)],
    [Paragraph("New Pulmonary TB", body_style),
     Paragraph("Intensive phase: 2HRZE (Isoniazid + Rifampicin + Pyrazinamide + Ethambutol)", body_style),
     Paragraph("2 months", body_style)],
    [Paragraph("", body_style),
     Paragraph("Continuation phase: 4HR (Isoniazid + Rifampicin)", body_style),
     Paragraph("4 months", body_style)],
    [Paragraph("TB Meningitis / Bone TB", body_style),
     Paragraph("2HRZE + 10HR (continuation phase extended)", body_style),
     Paragraph("12 months total", body_style)],
    [Paragraph("MDR-TB", body_style),
     Paragraph("Bedaquiline + Pretomanid + Linezolid (BPaL) regimen OR individualized based on DST", body_style),
     Paragraph("6-20 months", body_style)],
]
story.append(make_table(regimen_data, [4.5*cm, 8.5*cm, 4*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(Paragraph(bp("Key Drug Side Effects:"), bold_label))
se_data = [
    [Paragraph(bp("Drug"), body_style), Paragraph(bp("Major Side Effects"), body_style)],
    [Paragraph("Isoniazid (INH)", body_style),
     Paragraph("Peripheral neuropathy (prevented by Pyridoxine/Vit B6), hepatotoxicity, lupus-like syndrome", body_style)],
    [Paragraph("Rifampicin", body_style),
     Paragraph("Orange/red discoloration of urine/tears/sweat (warn patient!), hepatotoxicity, enzyme inducer (reduces OCP efficacy)", body_style)],
    [Paragraph("Pyrazinamide", body_style),
     Paragraph("Hyperuricemia (gout), hepatotoxicity, arthralgia", body_style)],
    [Paragraph("Ethambutol", body_style),
     Paragraph("Optic neuritis - color blindness (red-green), reduced visual acuity (dose-dependent, reversible)", body_style)],
]
story.append(make_table(se_data, [3.5*cm, 13.5*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(Paragraph(bp("Dental Relevance:"), bold_label))
story.append(Paragraph(
    bp("Active TB is a contraindication to elective dental treatment") + " until patient is non-infectious "
    "(minimum 2 weeks of therapy, 3 AFB-negative sputum smears). "
    "Wear " + bp("N95 mask") + " when treating TB patients; use negative pressure room. "
    bp("Rifampicin") + " is a potent CYP450 enzyme inducer - reduces effectiveness of many drugs including antifungals (fluconazole), "
    "analgesics, and corticosteroids. Isoniazid inhibits metabolism of carbamazepine (risk of toxicity). "
    "Oral lesions: TB ulcer (indurated, painful - usually tongue/palate), lupus vulgaris (skin/face).",
    body_style))

story.append(PageBreak())

# ============================================================
# TOPIC 4: PLEURAL DISEASE
# ============================================================
story.append(topic_banner("PLEURAL DISEASE (Pleural Effusion and Empyema)", "4"))
story.append(Spacer(1, 0.2*cm))

story.append(section_box("Pleural Effusion - Definition"))
story.append(Paragraph(
    "Pleural effusion is defined as an abnormal accumulation of fluid in the pleural space (normally <15 mL). "
    "Fluid accumulates when production exceeds absorption. Classified as " +
    bp("transudate") + " (protein <30 g/L) or " + bp("exudate") + " (protein >30 g/L) using " +
    bp("Light's criteria") + ".",
    body_style))

story.append(section_box("Light's Criteria (Exudate if ANY one met)"))
light_data = [
    [Paragraph(bp("Criterion"), body_style), Paragraph(bp("Threshold"), body_style)],
    [Paragraph("Pleural fluid protein / Serum protein ratio", body_style), Paragraph("> 0.5", body_style)],
    [Paragraph("Pleural fluid LDH / Serum LDH ratio", body_style), Paragraph("> 0.6", body_style)],
    [Paragraph("Pleural fluid LDH", body_style), Paragraph("> 2/3 of upper limit of normal serum LDH", body_style)],
]
story.append(make_table(light_data, [10*cm, 7*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Etiology - Transudate vs Exudate"))
tve_data = [
    [Paragraph(bp("TRANSUDATE"), body_style), Paragraph(bp("EXUDATE"), body_style)],
    [Paragraph("Congestive cardiac failure (CCF) - MC overall cause\nNephrotic syndrome\nLiver cirrhosis (hepatic hydrothorax)\nHypoalbuminemia (malnutrition)\nHypothyroidism", body_style),
     Paragraph("Pneumonia / Para-pneumonic effusion - MC exudative cause\nTuberculosis - MC exudate in developing countries\nMalignancy (lung, breast, mesothelioma)\nPulmonary embolism\nSubphrenic abscess\nRheumatoid / SLE\nPancreatitis (left-sided)", body_style)],
]
story.append(make_table(tve_data, [8.5*cm, 8.5*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Clinical Features"))
story.append(Paragraph(bp("Symptoms:"), bold_label))
for item in [
    "Breathlessness (dyspnoea) - proportional to volume; main symptom",
    "Pleuritic chest pain - sharp, worse on breathing (pleuritis); may be absent when effusion large",
    "Dry cough",
    "Features of underlying disease (fever in infection/TB; weight loss in malignancy)",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Physical Signs (Classical):"), bold_label))
signs2_data = [
    [Paragraph(bp("Sign"), body_style), Paragraph(bp("Description"), body_style)],
    [Paragraph("Inspection", body_style), Paragraph("Fullness of intercostal spaces on affected side; reduced chest movement", body_style)],
    [Paragraph("Tracheal deviation", body_style), Paragraph("Away from the effusion if massive (>1000 mL); toward if with collapse", body_style)],
    [Paragraph("Palpation", body_style), Paragraph("Reduced chest expansion; decreased tactile vocal fremitus / VF (fluid damps vibrations)", body_style)],
    [Paragraph("Percussion", body_style), Paragraph(bp("Stony dull") + " - the most characteristic sign (dullest note in medicine)", body_style)],
    [Paragraph("Auscultation", body_style), Paragraph("Absent breath sounds; reduced VR; " + bp("Aegophony") + " (bleating quality) at fluid upper level; bronchial breathing above fluid", body_style)],
]
story.append(make_table(signs2_data, [4*cm, 13*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Investigations"))
for item in [
    bp("Chest X-ray (PA)") + " - blunting of costophrenic angle (>200 mL); homogeneous opacity with curved (concave meniscus) upper border; "
    "trachea deviated away if large; supine CXR may show only diffuse haze (layering)",
    bp("Ultrasound chest") + " - detects even small effusions (>100 mL); guides thoracocentesis (reduces complications); detects loculations",
    bp("CT chest") + " - defines extent; distinguishes effusion from consolidation; detects underlying malignancy, empyema",
    bp("Diagnostic thoracocentesis (pleural tap)") + " - " + bp("most important investigation") + "; aspirate 30-50 mL for analysis",
    bp("Pleural fluid analysis") + ": protein, LDH (Light's criteria), glucose, pH, cytology (malignant cells), "
    "culture (bacteria + AFB), ADA (>40 IU/L = TB), triglycerides (chylothorax)",
    bp("Pleural biopsy") + " - closed/Abrams needle or CT-guided/VATS; for TB and malignancy",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Treatment of Pleural Effusion"))
for item in [
    bp("Treat underlying cause") + ": diuretics for CCF; antibiotics for infection; anti-TB drugs for TB",
    bp("Therapeutic thoracocentesis") + ": drain not more than 1.5 L at one time (risk of re-expansion pulmonary edema)",
    bp("Intercostal drain (ICD) / chest tube") + ": for large symptomatic effusions, empyema, malignant effusions",
    bp("Pleurodesis") + ": talc/chemical pleurodesis via ICD for recurrent malignant effusions; prevents re-accumulation",
    bp("VATS (Video-Assisted Thoracoscopic Surgery)") + ": for loculated/non-draining effusions; allows direct visualization and biopsy",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Empyema Thoracis"))
story.append(Paragraph(
    bp("Definition") + ": Frank pus in the pleural space. "
    "Stages: (1) " + bp("Exudative") + " (free-flowing thin fluid), "
    "(2) " + bp("Fibrinopurulent") + " (thick turbid fluid, fibrin deposits, loculations), "
    "(3) " + bp("Organizing") + " (fibrous cortex/peel over lung).",
    body_style))

story.append(Paragraph(bp("Causes:"), bold_label))
for item in [
    "Para-pneumonic (complication of pneumonia) - MC cause",
    "Post-surgical / Post-traumatic",
    "Rupture of lung abscess into pleural space",
    "Subphrenic abscess (trans-diaphragmatic spread)",
    "Esophageal perforation",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Diagnosis:"), bold_label))
story.append(Paragraph(
    "Suspected when pleural fluid is: " + bp("pH <7.2") + ", glucose <2.2 mmol/L, LDH >1000 IU/L, positive Gram stain/culture, or frank pus on aspiration.",
    body_style))

story.append(Paragraph(bp("Treatment:"), bold_label))
for item in [
    "IV antibiotics (broad spectrum - covering anaerobes: Piperacillin-tazobactam + Metronidazole)",
    bp("Urgent intercostal drainage (ICD)") + " - definitive management; large bore drain",
    "Intrapleural fibrinolytics (streptokinase/urokinase or tPA+DNase) for loculated empyema",
    bp("Surgical decortication (VATS or open)") + " - stage III empyema with organizing fibrous peel",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Dental Relevance:"), bold_label))
story.append(Paragraph(
    "Dental infections (Ludwig's angina, deep space infections) can rarely spread to mediastinum and pleural space causing empyema. "
    "Patients with pleural effusion have impaired respiratory reserve - "
    "ensure optimal positioning (semi-upright) and limit LA volume and sedation.",
    body_style))

story.append(PageBreak())

# ============================================================
# TOPIC 5: PNEUMOTHORAX
# ============================================================
story.append(topic_banner("PNEUMOTHORAX", "5"))
story.append(Spacer(1, 0.2*cm))

story.append(section_box("Definition"))
story.append(Paragraph(
    "Pneumothorax is the presence of " + bp("air in the pleural space") + ", causing lung collapse. "
    "It disrupts the negative intrapleural pressure, allowing the lung to recoil and collapse. "
    "May range from a small rim of air to complete lung collapse with mediastinal shift.",
    body_style))

story.append(section_box("Classification / Types"))
types_data = [
    [Paragraph(bp("Type"), body_style), Paragraph(bp("Description"), body_style), Paragraph(bp("Features"), body_style)],
    [Paragraph("Spontaneous\nPrimary (PSP)", body_style),
     Paragraph("No underlying lung disease; rupture of subpleural blebs/bullae", body_style),
     Paragraph("Young, tall, thin males; smokers; M:F = 6:1; recurrence rate 50%. Usually right-sided.", body_style)],
    [Paragraph("Spontaneous\nSecondary (SSP)", body_style),
     Paragraph("Complicates existing lung disease", body_style),
     Paragraph("COPD (MC cause), asthma, TB, Pneumocystis pneumonia, cystic fibrosis, Marfan syndrome, malignancy. Older patients, more serious.", body_style)],
    [Paragraph("Traumatic", body_style),
     Paragraph("Due to penetrating or blunt chest trauma", body_style),
     Paragraph("Rib fractures, penetrating wounds, iatrogenic (subclavian line, mechanical ventilation, thoracocentesis, CPR)", body_style)],
    [Paragraph("Tension\nPneumothorax", body_style),
     Paragraph("Life-threatening; air enters pleural space but cannot escape (one-way valve)", body_style),
     Paragraph("Progressive pressure rise, mediastinal shift away, compression of heart/great vessels, cardiovascular collapse. EMERGENCY.", body_style)],
]
story.append(make_table(types_data, [3.5*cm, 5*cm, 8.5*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(section_box("Clinical Features"))
story.append(Paragraph(bp("Symptoms:"), bold_label))
for item in [
    bp("Sudden onset") + " unilateral pleuritic chest pain - sharp, stabbing",
    bp("Breathlessness") + " (dyspnoea) - may be minimal in PSP but severe in SSP and tension",
    "Dry cough",
    "In large/tension pneumothorax: severe respiratory distress, cyanosis, cardiovascular compromise",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Physical Signs:"), bold_label))
psigns_data = [
    [Paragraph(bp("Sign"), body_style), Paragraph(bp("Pneumothorax"), body_style)],
    [Paragraph("Tracheal position", body_style), Paragraph("Central (small) or deviated TOWARD affected side (in collapse). In TENSION: deviated AWAY from affected side.", body_style)],
    [Paragraph("Chest movement", body_style), Paragraph("Reduced on affected side", body_style)],
    [Paragraph("Palpation - VF/TVF", body_style), Paragraph("Decreased / absent on affected side (air dampens transmission)", body_style)],
    [Paragraph("Percussion", body_style), Paragraph(bp("Hyperresonant") + " (tympanic) on affected side - key distinguishing sign", body_style)],
    [Paragraph("Auscultation", body_style), Paragraph("Absent / markedly reduced breath sounds on affected side", body_style)],
]
story.append(make_table(psigns_data, [4.5*cm, 12.5*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(Paragraph(bp("Tension Pneumothorax - Classical Signs (EMERGENCY):"), bold_label))
for item in [
    "Severe respiratory distress + hypoxia",
    bp("Tracheal deviation AWAY from affected side"),
    "Absent breath sounds + hyperresonance on affected side",
    "Raised JVP (impaired venous return)",
    "Hypotension + tachycardia (cardiogenic shock)",
    "Cyanosis",
    bp("Do NOT wait for X-ray if tension pneumothorax suspected") + " - immediate needle decompression",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Investigations"))
for item in [
    bp("Chest X-ray (CXR)") + " - " + bp("investigation of choice") + "; shows: absence of lung markings beyond the visceral pleura edge, "
    "visible pleural line (white line), collapsed lung margin, mediastinal shift (tension). "
    "Expiratory film enhances small pneumothorax detection.",
    bp("CT Chest") + " - most accurate; quantifies size precisely; detects blebs/bullae; differentiates from bulla (mistaken for pneumothorax)",
    bp("Ultrasound") + " - 'lung sliding' absent in pneumothorax; quick bedside diagnosis; useful in trauma bay",
    bp("ABG") + " - hypoxemia; hypocapnia initially; hypercapnia in severe cases",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(section_box("Management"))
story.append(Paragraph(bp("Size Assessment:"), bold_label))
story.append(Paragraph(
    "British Thoracic Society (BTS): Small = rim of air <2 cm; Large = rim of air >=2 cm "
    "(measured at level of hilum). American College of Chest Physicians (ACCP): Small <3 cm apex-to-cupola.",
    body_style))

mgmt_data = [
    [Paragraph(bp("Type / Size"), body_style), Paragraph(bp("Management"), body_style)],
    [Paragraph("PSP - Small (<2 cm)\nMinimal symptoms", body_style),
     Paragraph("Observation + high-flow O2 (100% - accelerates reabsorption x4 times); "
               "discharge with review in 2-4 weeks if stable", body_style)],
    [Paragraph("PSP - Large (>=2 cm)\nor symptomatic", body_style),
     Paragraph(bp("Aspiration") + " with 16G Venflon at 2nd ICS midclavicular line; "
               "if successful (lung re-expands) discharge with follow-up", body_style)],
    [Paragraph("SSP (all sizes)", body_style),
     Paragraph(bp("Intercostal drain (ICD)") + " insertion - connected to underwater seal "
               "(2nd ICS MCL or 5th ICS anterior axillary line - 'safe triangle'). All secondary pneumothoraces need admission.", body_style)],
    [Paragraph("Tension Pneumothorax\n(EMERGENCY)", body_style),
     Paragraph(bp("IMMEDIATE") + ": Large-bore needle (14G cannula) at 2nd ICS MCL - emergency decompression. "
               "Followed by ICD insertion. Do NOT delay for investigations.", body_style)],
    [Paragraph("Persistent air leak\n(>5 days)", body_style),
     Paragraph("VATS with surgical bullectomy + pleurodesis (abrasion/talc). "
               "Success rate >95% for preventing recurrence.", body_style)],
    [Paragraph("Recurrent PSP", body_style),
     Paragraph(bp("Pleurodesis") + ": talc (insufflation via VATS) or chemical (tetracycline/bleomycin via ICD). "
               "Prevents ipsilateral recurrence.", body_style)],
]
story.append(make_table(mgmt_data, [4.5*cm, 12.5*cm]))
story.append(Spacer(1, 0.1*cm))

story.append(Paragraph(bp("High-Flow O2 in Pneumothorax:"), bold_label))
story.append(Paragraph(
    "Breathing 100% O2 via non-rebreather mask " + bp("accelerates pleural air absorption 4-fold") +
    " by creating an inert gas pressure gradient. Used as definitive treatment in small PSP "
    "and as adjunct during observation.",
    body_style))

story.append(Paragraph(bp("Complications:"), bold_label))
for item in [
    bp("Tension pneumothorax") + " - life-threatening; mediastinal shift, cardiac compression",
    "Haemopneumothorax - blood + air in pleural space",
    bp("Re-expansion pulmonary edema") + " - if large pneumothorax drained too rapidly",
    "Chronic/persistent pneumothorax",
    "Empyema (after ICD insertion)",
    bp("Recurrence") + " - PSP: 50% risk; SSP: even higher",
]:
    story.append(Paragraph("- %s" % item, bullet_style))

story.append(Paragraph(bp("Dental Relevance:"), bold_label))
story.append(Paragraph(
    "(1) " + bp("N2O (nitrous oxide) is contraindicated") + " in patients with known pneumothorax - "
    "N2O diffuses into the air-containing cavity 34x faster than nitrogen exits, rapidly expanding the pneumothorax. "
    "(2) Avoid " + bp("positive pressure ventilation") + " in patients with COPD or blebs - risk of barotrauma. "
    "(3) Patients who have had a recent pneumothorax should NOT receive GA or N2O until fully resolved and reviewed. "
    "(4) Marfan syndrome patients (tall, thin) at higher risk - check before elective procedures.",
    body_style))

# FOOTER
story.append(Spacer(1, 0.3*cm))
story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor('#81c784')))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "General Medicine Short Notes | BDS 3rd Year | Gujarat University | "
    "Based on Anil K. Tripathi - General Medicine for BDS | Prepared for 7-8 Mark Questions",
    footer_style))

doc.build(story)
print("PDF generated successfully!")

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/bds-notes/generate_notes2.py'

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/bds-notes/generate_notes2.py'

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, PageBreak
)
from reportlab.lib.enums import TA_CENTER, TA_JUSTIFY

doc = SimpleDocTemplate(
    "/tmp/workspace/bds-notes/General_Medicine_Short_Notes_BDS_Part3.pdf",
    pagesize=A4,
    leftMargin=2*cm, rightMargin=2*cm,
    topMargin=2*cm, bottomMargin=2*cm
)

styles = getSampleStyleSheet()

title_style = ParagraphStyle('T', fontSize=18, textColor=colors.HexColor('#4a148c'),
    spaceAfter=4, alignment=TA_CENTER, fontName='Helvetica-Bold')
subtitle_style = ParagraphStyle('S', fontSize=10, textColor=colors.HexColor('#4a4a4a'),
    spaceAfter=10, alignment=TA_CENTER, fontName='Helvetica-Oblique')
body_style = ParagraphStyle('B', fontSize=9.5, textColor=colors.HexColor('#212121'),
    spaceAfter=3, spaceBefore=1, leading=14, alignment=TA_JUSTIFY, fontName='Helvetica')
bullet_style = ParagraphStyle('BL', fontSize=9.5, textColor=colors.HexColor('#212121'),
    spaceAfter=2, spaceBefore=1, leading=13, leftIndent=14, fontName='Helvetica')
bold_label = ParagraphStyle('BLD', fontSize=9.5, textColor=colors.HexColor('#4a148c'),
    spaceAfter=1, spaceBefore=3, fontName='Helvetica-Bold')
footer_style = ParagraphStyle('F', fontSize=8, textColor=colors.HexColor('#757575'), alignment=TA_CENTER)

def topic_banner(title, number):
    data = [[Paragraph('<font color="white"><b>TOPIC %s: %s</b></font>' % (number, title),
        ParagraphStyle('bn', fontSize=12, textColor=colors.white, fontName='Helvetica-Bold', alignment=TA_CENTER))]]
    t = Table(data, colWidths=[17*cm])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), colors.HexColor('#4a148c')),
        ('TOPPADDING', (0,0), (-1,-1), 8),
        ('BOTTOMPADDING', (0,0), (-1,-1), 8),
        ('LEFTPADDING', (0,0), (-1,-1), 10),
    ]))
    return t

def section_box(title):
    data = [[Paragraph('<b>%s</b>' % title, ParagraphStyle('sb', fontSize=10,
        textColor=colors.HexColor('#4a148c'), fontName='Helvetica-Bold'))]]
    t = Table(data, colWidths=[17*cm])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), colors.HexColor('#f3e5f5')),
        ('TOPPADDING', (0,0), (-1,-1), 4), ('BOTTOMPADDING', (0,0), (-1,-1), 4),
        ('LEFTPADDING', (0,0), (-1,-1), 8),
        ('BOX', (0,0), (-1,-1), 0.5, colors.HexColor('#7b1fa2')),
    ]))
    return t

def mk_table(data_list, col_widths):
    t = Table(data_list, colWidths=col_widths)
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#f3e5f5')),
        ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#ce93d8')),
        ('VALIGN', (0,0), (-1,-1), 'TOP'),
        ('TOPPADDING', (0,0), (-1,-1), 4), ('BOTTOMPADDING', (0,0), (-1,-1), 4),
        ('LEFTPADDING', (0,0), (-1,-1), 6),
        ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.white, colors.HexColor('#fce4ec')]),
    ]))
    return t

def bp(t): return '<b>%s</b>' % t
def it(t): return '<i>%s</i>' % t
def b(lbl): return Paragraph(bp(lbl), bold_label)
def p(txt): return Paragraph(txt, body_style)
def bl(txt): return Paragraph('- %s' % txt, bullet_style)
def sp(h=0.1): return Spacer(1, h*cm)

story = []

# HEADER
story += [sp(0.3),
    Paragraph("GENERAL MEDICINE", title_style),
    Paragraph("Short Notes for BDS 3rd Year | Gujarat University Examinations", subtitle_style),
    Paragraph("Based on Anil K. Tripathi - General Medicine for BDS", ParagraphStyle(
        'ref', fontSize=9, textColor=colors.HexColor('#757575'), alignment=TA_CENTER,
        fontName='Helvetica-Oblique', spaceAfter=4)),
    Paragraph("Each topic: 7-8 Marks | Concise, Precise, Exam-Oriented", ParagraphStyle(
        'info', fontSize=9, textColor=colors.HexColor('#c62828'), alignment=TA_CENTER,
        fontName='Helvetica-Bold', spaceAfter=10)),
    HRFlowable(width="100%", thickness=2, color=colors.HexColor('#4a148c')),
    sp(0.3)]

toc = mk_table([
    [Paragraph(bp("No."), body_style), Paragraph(bp("Topic"), body_style), Paragraph(bp("Marks"), body_style)],
    [p("1."), p("Nephrotic Syndrome"), p("7-8")],
    [p("2."), p("Acute and Rapidly Progressive Glomerulonephritis"), p("7-8")],
    [p("3."), p("Acute Kidney Injury (AKI)"), p("7-8")],
    [p("4."), p("Chronic Kidney Disease (CKD)"), p("7-8")],
    [p("5."), p("Kidney Failure (End-Stage Renal Disease)"), p("7-8")],
    [p("6."), p("Indications for Liver and Kidney Transplant"), p("7-8")],
], [1.5*cm, 13*cm, 2.5*cm])
story += [toc, sp(0.5), PageBreak()]

# ============================================================
# TOPIC 1: NEPHROTIC SYNDROME
# ============================================================
story += [topic_banner("NEPHROTIC SYNDROME", "1"), sp(0.2)]

story += [section_box("Definition")]
story += [p("Nephrotic syndrome is a clinical syndrome characterized by the tetrad of: "
    + bp("(1) Heavy proteinuria (>3.5 g/day in adults; >40 mg/m2/hr in children)") + ", "
    + bp("(2) Hypoalbuminemia (<30 g/L)") + ", "
    + bp("(3) Generalized edema (anasarca)") + ", and "
    + bp("(4) Hyperlipidemia + lipiduria") + ". "
    "It results from increased glomerular permeability to proteins."), sp()]

story += [section_box("Etiology / Causes")]
story += [mk_table([
    [Paragraph(bp("Primary (Idiopathic) GN"), body_style), Paragraph(bp("Secondary Causes"), body_style)],
    [Paragraph("- " + bp("Minimal Change Disease (MCD)") + " - MC in children (80%)\n"
        "- " + bp("Focal Segmental Glomerulosclerosis (FSGS)") + " - MC in adults\n"
        "- Membranous Nephropathy - MC in middle-aged adults\n"
        "- Membranoproliferative GN (MPGN)\n"
        "- Mesangial proliferative GN", body_style),
     Paragraph("- " + bp("Diabetes mellitus") + " (Diabetic nephropathy - MC secondary cause)\n"
        "- " + bp("Systemic Lupus Erythematosus") + " (Lupus nephritis)\n"
        "- Amyloidosis\n"
        "- Infections: Hepatitis B, C; HIV; Malaria (P. malariae - quartan)\n"
        "- Drugs: Gold, penicillamine, NSAIDs, heroin\n"
        "- Malignancy: Hodgkin lymphoma (MCD), solid tumors (memb. nephropathy)", body_style)],
], [8.5*cm, 8.5*cm]), sp()]

story += [section_box("Pathophysiology")]
story += [p(bp("Loss of glomerular charge barrier") + " (loss of polyanion - heparan sulfate) + structural defect "
    "in glomerular filtration membrane (podocyte injury) leads to massive proteinuria. "
    "Hypoalbuminemia reduces plasma oncotic pressure, causing fluid shift to interstitium (edema). "
    "Liver compensates with increased lipoprotein synthesis causing hyperlipidemia. "
    "Lipiduria occurs when lipoprotein particles cross damaged GBM."), sp()]

story += [section_box("Clinical Features")]
story += [b("Symptoms:")]
for x in ["Puffiness of face - early morning periorbital edema (characteristic first symptom)",
    bp("Pitting edema") + " - bilateral, dependent; progresses to anasarca (generalized edema)",
    bp("Ascites") + " - abdominal distension; pleural effusions (dyspnoea)",
    "Frothy urine (heavy proteinuria - foam persists)",
    "Reduced urine output",
    "Symptoms of underlying cause (e.g. rash in SLE, hyperglycemia in DM)"]:
    story.append(bl(x))

story += [b("Complications:")]
comp_data = mk_table([
    [Paragraph(bp("Complication"), body_style), Paragraph(bp("Mechanism / Notes"), body_style)],
    [p("Infections"), p("Hypogammaglobulinemia (IgG loss in urine); impaired opsonization. "
        "Spontaneous bacterial peritonitis, cellulitis, pneumococcal sepsis (children).")],
    [p("Thromboembolism"), p("Loss of antithrombin III, protein C, S; increased clotting factors. "
        "Deep vein thrombosis, renal vein thrombosis (flank pain, hematuria), pulmonary embolism.")],
    [p("Hyperlipidemia / Atherosclerosis"), p("Increased LDL, VLDL synthesis; decreased HDL. Accelerated atherosclerosis.")],
    [p("Acute Kidney Injury"), p("Reduced renal perfusion (underfill), nephrotoxic drugs, renal vein thrombosis.")],
    [p("Hypothyroidism"), p("Loss of thyroxine-binding globulin in urine (low total T4; free T4 often normal).")],
    [p("Vitamin D deficiency / Osteoporosis"), p("Loss of Vitamin D binding protein and 25-OH Vit D in urine.")],
], [4*cm, 13*cm])
story += [comp_data, sp()]

story += [section_box("Investigations")]
for x in [
    bp("Urine Routine") + " - " + bp("3+ or 4+ proteinuria") + " on dipstick; fatty casts, oval fat bodies, maltese crosses on polarized light; lipiduria",
    bp("24-hour urine protein") + " > 3.5 g/day (or spot urine protein:creatinine ratio >3500 mg/g)",
    bp("Serum albumin") + " < 30 g/L (often < 20 g/L in severe cases)",
    bp("Serum lipids") + " - elevated total cholesterol, LDL, VLDL; triglycerides raised",
    bp("Serum creatinine / BUN") + " - assess renal function",
    bp("Renal biopsy") + " - " + bp("definitive diagnosis") + "; indicated in adults, secondary NS, steroid-resistant NS. Electron microscopy key for MCD (foot process effacement)",
    bp("ANA, anti-dsDNA") + " - SLE; Hep B/C serology; HIV; serum complement (C3/C4)",
    bp("Chest X-ray") + " - pleural effusions; CXR/Echo for cardiomegaly",
]:
    story.append(bl(x))

story += [section_box("Treatment")]
story += [b("General Measures:")]
for x in ["Low-sodium diet (< 2 g/day) - reduces edema",
    "Moderate protein diet (0.8-1.0 g/kg/day) - high protein increases proteinuria",
    bp("Diuretics") + ": Furosemide (loop) + Spironolactone (aldosterone antagonist) for edema",
    bp("ACE inhibitors / ARBs") + " (Ramipril / Losartan) - reduce proteinuria and slow progression",
    "Statins - treat hyperlipidemia",
    bp("Anticoagulation") + " - if renal vein thrombosis or serum albumin <20 g/L (high thrombosis risk)",
    "Vaccinations: Pneumococcal, Influenza (infection risk)"]:
    story.append(bl(x))

story += [b("Specific Treatment by Cause:")]
rx_data = mk_table([
    [Paragraph(bp("Cause"), body_style), Paragraph(bp("Specific Treatment"), body_style)],
    [p("Minimal Change Disease (MCD)"), p(bp("Oral prednisolone 1 mg/kg/day") + " x 4-8 weeks; 90% respond. "
        "Relapse common - cyclophosphamide or cyclosporine for steroid-dependent/resistant cases.")],
    [p("FSGS"), p("Prednisolone - slower response than MCD. Cyclosporine/tacrolimus for steroid-resistant.")],
    [p("Membranous Nephropathy"), p("ACE inhibitor first. Immunosuppression (cyclophosphamide + prednisolone) "
        "for high-risk patients (Ponticelli regimen).")],
    [p("Diabetic Nephropathy"), p("Strict glycemic control, RAAS blockade (ACE-I/ARB), SGLT2 inhibitors (fludgliflozin).")],
    [p("Lupus Nephritis"), p("Hydroxychloroquine + Mycophenolate mofetil + steroids.")],
], [5*cm, 12*cm])
story += [rx_data, sp()]

story += [b("Dental Relevance:")]
story += [p("(1) Patients on " + bp("corticosteroids") + " need steroid cover before dental procedures (adrenal suppression risk). "
    "(2) Increased " + bp("infection risk") + " (immunosuppressed) - prophylactic antibiotics if needed. "
    "(3) " + bp("NSAIDs are contraindicated") + " - worsen renal function and proteinuria. Use paracetamol. "
    "(4) Cyclosporine causes " + bp("gingival hyperplasia") + " - important oral side effect; needs regular dental review. "
    "(5) Edematous patients - check BP before procedures.")]

story.append(PageBreak())

# ============================================================
# TOPIC 2: ACUTE AND RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS
# ============================================================
story += [topic_banner("ACUTE AND RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS", "2"), sp(0.2)]

story += [section_box("Definitions")]
story += [mk_table([
    [Paragraph(bp("Type"), body_style), Paragraph(bp("Definition"), body_style)],
    [p("Acute Nephritic Syndrome (ANS)"), p("Sudden onset of hematuria (smoky/cola-coloured urine), oliguria, "
        "hypertension, proteinuria (<3.5 g/day), and edema with declining GFR. "
        "Hallmark: " + bp("red cell casts in urine") + " (pathognomonic of glomerular bleeding).")],
    [p("Rapidly Progressive GN (RPGN)"), p("Clinical syndrome with rapid deterioration in renal function (loss of 50% GFR "
        "within weeks to months), with nephritic features. Histology shows " + bp("crescents in >50% of glomeruli") +
        " (crescent = proliferating parietal epithelial cells + macrophages filling Bowman's capsule).")],
], [4.5*cm, 12.5*cm]), sp()]

story += [section_box("Acute Nephritic Syndrome - Etiology")]
story += [mk_table([
    [Paragraph(bp("Category"), body_style), Paragraph(bp("Causes"), body_style)],
    [p("Post-Infectious (MC overall)"), p(bp("Post-streptococcal GN (PSGN)") + " - " + bp("MC cause in children") +
        "; follows Group A beta-hemolytic Streptococcal (GABHS) pharyngitis (1-3 weeks) or skin infection (3-6 weeks). "
        "Immune complex deposition. C3 low, C4 normal. ASO titre elevated.")],
    [p("IgA Nephropathy\n(Berger's disease)"), p(bp("MC primary GN worldwide") + ". Hematuria within 24-48 hours of URTI "
        "(synpharyngitic hematuria - unlike PSGN which is latent). IgA deposits in mesangium. Normal complement.")],
    [p("Other Infections"), p("Infective endocarditis, visceral abscess, hepatitis B/C, HIV, malaria")],
    [p("Systemic"), p("SLE (lupus nephritis - anti-dsDNA, low C3 C4), HSP (Henoch-Schonlein Purpura), "
        "polyarteritis nodosa, Wegener's granulomatosis (ANCA positive)")],
    [p("Hereditary"), p("Alport syndrome (X-linked; thin basement membrane disease; deafness + eye anomalies + hematuria)")],
], [4.5*cm, 12.5*cm]), sp()]

story += [section_box("Post-Streptococcal GN - Key Features")]
for x in [
    bp("Latent period") + ": 1-3 weeks after throat infection; 3-6 weeks after skin (impetigo)",
    bp("Age") + ": children 5-15 years; boys > girls",
    bp("Classic presentation") + ": Cola-coloured urine (hematuria), periorbital puffiness, hypertension, oliguria",
    bp("Lab") + ": Red cell casts (pathognomonic); low C3 (returns to normal by 6-8 weeks); normal C4; raised ASO titre; proteinuria (<2 g/day)",
    bp("Biopsy") + ": Diffuse proliferative GN; subepithelial 'humps' on EM (immune complex deposits)",
    bp("Prognosis") + ": Excellent in children (>95% recover fully); adults have worse prognosis",
    bp("Treatment") + ": Supportive - salt/fluid restriction, antihypertensives, diuretics; penicillin to eradicate streptococcus",
]:
    story.append(bl(x))

story += [sp(), section_box("Rapidly Progressive GN (RPGN) - Classification")]
rpgn_data = mk_table([
    [Paragraph(bp("Type"), body_style), Paragraph(bp("Immunology"), body_style), Paragraph(bp("Examples"), body_style)],
    [p("Type I\n(Anti-GBM)"), p("Linear IgG along GBM on IF"), p(bp("Goodpasture syndrome") + " - anti-GBM antibody causes pulmonary hemorrhage + nephritis. "
        "Young males (pulmonary) or older females (renal only). EMERGENCY.")],
    [p("Type II\n(Immune complex)"), p("Granular immune deposits on IF (lumpy bumpy)"), p("Post-streptococcal GN, lupus nephritis, IgA nephropathy, MPGN, "
        "cryoglobulinemia, endocarditis-related GN")],
    [p("Type III\n(Pauci-immune / ANCA)"), p("No / minimal Ig deposits on IF; ANCA positive"), p(bp("Microscopic polyangiitis") + " (p-ANCA / anti-MPO), "
        bp("Granulomatosis with polyangiitis") + " (GPA/Wegener's - c-ANCA / anti-PR3), "
        "Eosinophilic GPA (Churg-Strauss)")],
], [3*cm, 5*cm, 9*cm])
story += [rpgn_data, sp()]

story += [section_box("RPGN - Clinical Features and Treatment")]
story += [p(bp("Clinical") + ": Rapid decline in GFR over days-weeks; hematuria, proteinuria, hypertension, oliguria/anuria; "
    "systemic features (fever, arthralgia, rash) depending on cause. "
    "Goodpasture: hemoptysis + renal failure. Wegener's/MPA: saddle-nose deformity, sinusitis, pulmonary infiltrates.")]
story += [b("Investigations:")]
for x in [
    bp("Urinalysis") + ": Red cell casts, proteinuria",
    bp("Serology") + ": ANCA (c-ANCA/p-ANCA), anti-GBM antibody, ANA, complement (C3/C4), ASO, cryoglobulins, hepatitis serology",
    bp("Renal biopsy (urgent)") + ": crescents in >50% glomeruli; IF pattern (linear vs granular vs pauci-immune)",
    bp("CXR") + ": pulmonary hemorrhage (Goodpasture, Wegener's)",
]:
    story.append(bl(x))

story += [b("Treatment (URGENT - Renal function declines rapidly):")]
for x in [
    bp("Pulsed IV methylprednisolone") + " (1g/day x 3 days) then oral prednisolone 1 mg/kg/day",
    bp("Cyclophosphamide") + " (oral or IV) - immunosuppression; used with steroids for ANCA-RPGN",
    bp("Plasma exchange (Plasmapheresis)") + " - first line in Goodpasture syndrome (removes anti-GBM antibodies); "
    "also ANCA-RPGN with pulmonary hemorrhage",
    bp("Rituximab") + " - alternative to cyclophosphamide for ANCA vasculitis (non-inferior, less toxic)",
    "Dialysis support if severe AKI develops",
    bp("Monitor closely") + ": renal biopsy guides prognosis; crescents <50% = better prognosis",
]:
    story.append(bl(x))

story += [b("Dental Relevance:")]
story += [p("(1) " + bp("Streptococcal throat infections") + " can trigger post-streptococcal GN - aggressive treatment with penicillin for GABHS throat infection important. "
    "(2) Patients with RPGN on immunosuppressants (cyclophosphamide) have severe " + bp("myelosuppression and infection risk") + " - check CBC before any dental procedure. "
    "(3) Avoid NSAIDs in all glomerulonephritis patients. "
    "(4) Dental infections can trigger exacerbations of IgA nephropathy.")]

story.append(PageBreak())

# ============================================================
# TOPIC 3: ACUTE KIDNEY INJURY
# ============================================================
story += [topic_banner("ACUTE KIDNEY INJURY (AKI)", "3"), sp(0.2)]

story += [section_box("Definition - KDIGO Criteria (Any ONE of the following)")]
story += [mk_table([
    [Paragraph(bp("Criterion"), body_style), Paragraph(bp("Threshold"), body_style)],
    [p("Rise in serum creatinine"), p(">=0.3 mg/dL (26.5 micromol/L) within 48 hours OR >=1.5x baseline within 7 days")],
    [p("Reduced urine output"), p("< 0.5 mL/kg/hr for >= 6 hours")],
], [6*cm, 11*cm]), sp()]

story += [section_box("KDIGO Staging of AKI")]
story += [mk_table([
    [Paragraph(bp("Stage"), body_style), Paragraph(bp("Serum Creatinine"), body_style), Paragraph(bp("Urine Output"), body_style)],
    [p("Stage 1"), p("1.5-1.9x baseline OR rise of >=0.3 mg/dL"), p("<0.5 mL/kg/hr for 6-12 hours")],
    [p("Stage 2"), p("2.0-2.9x baseline"), p("<0.5 mL/kg/hr for >=12 hours")],
    [p("Stage 3"), p(">=3x baseline OR >=4.0 mg/dL OR initiation of KRT"), p("<0.3 mL/kg/hr for >=24h OR anuria >=12h")],
], [2.5*cm, 8.5*cm, 6*cm]), sp()]

story += [section_box("Etiology / Classification")]
story += [mk_table([
    [Paragraph(bp("Type"), body_style), Paragraph(bp("Mechanism"), body_style), Paragraph(bp("Causes"), body_style)],
    [p(bp("Pre-renal AKI") + "\n(~55-60%)"), p("Reduced renal perfusion (low blood flow to kidneys); GFR drops due to hypovolemia or low cardiac output; tubules intact"), p(
        "- Volume depletion: vomiting, diarrhea, burns, hemorrhage\n"
        "- Hypotension: septic shock, cardiogenic shock\n"
        "- Cardiac failure, liver failure, nephrotic syndrome\n"
        "- NSAIDs, ACE-I/ARBs (reduce efferent arteriolar tone)\n"
        "- Renal artery stenosis (bilateral)")],
    [p(bp("Intrinsic Renal AKI") + "\n(~40%)"), p("Direct damage to renal parenchyma (tubules, glomeruli, interstitium, vessels)"), p(
        "- " + bp("Acute Tubular Necrosis (ATN)") + " - MC cause of intrinsic AKI\n"
        "  Ischemic ATN (prolonged pre-renal state)\n"
        "  Nephrotoxic ATN: aminoglycosides, contrast dye (CIAKI), cisplatin, myoglobinuria, hemoglobinuria\n"
        "- " + bp("Acute Interstitial Nephritis (AIN)") + ": drugs (NSAIDs, penicillins, PPIs), infections\n"
        "- Glomerulonephritis (RPGN)\n"
        "- Renal vessel disease: renal artery thrombosis, HUS/TTP")],
    [p(bp("Post-renal AKI") + "\n(~5%)"), p("Obstruction to urine outflow; increases back pressure; tubular function initially preserved"), p(
        "- " + bp("BPH (MC in elderly males)") + " - bilateral ureteral obstruction\n"
        "- Renal stones (bilateral, or solitary kidney)\n"
        "- Pelvic malignancy (cervix, bladder, prostate, colon)\n"
        "- Urethral stricture\n"
        "- Retroperitoneal fibrosis")],
], [3.5*cm, 4.5*cm, 9*cm]), sp()]

story += [section_box("Pre-renal vs Intrinsic (ATN) - Key Differentiation")]
story += [mk_table([
    [Paragraph(bp("Parameter"), body_style), Paragraph(bp("Pre-renal"), body_style), Paragraph(bp("ATN (Intrinsic)"), body_style)],
    [p("Urine Na"), p("< 20 mEq/L (kidneys conserve Na)"), p("> 40 mEq/L (tubules damaged, cannot conserve)")],
    [p("FENa (Fractional excretion of Na)"), p("< 1%"), p("> 2%")],
    [p("Urine osmolality"), p("> 500 mOsm/kg"), p("< 350 mOsm/kg (isosthenuria)")],
    [p("Urine specific gravity"), p("> 1.020"), p("~1.010 (fixed)")],
    [p("Urine sediment"), p("Bland / hyaline casts"), p(bp("Muddy brown (granular) casts") + " (ATN)")],
    [p("Response to fluids"), p("GFR improves rapidly"), p("No improvement with fluids")],
    [p("BUN:Creatinine ratio"), p("> 20:1 (increased urea reabsorption)"), p("10-15:1")],
], [5*cm, 6*cm, 6*cm]), sp()]

story += [section_box("Clinical Features")]
story += [b("Oliguric Phase (0-2 weeks):")]
for x in [
    bp("Oliguria") + " (<400 mL/day) or anuria (<100 mL/day)",
    bp("Fluid overload") + ": edema, pulmonary edema, hypertension",
    bp("Uremia") + ": nausea, vomiting, lethargy, confusion, hiccups, pericarditis",
    bp("Hyperkalemia") + ": peaked T waves on ECG, arrhythmias, cardiac arrest",
    bp("Metabolic acidosis") + ": Kussmaul breathing",
    "Anemia (normochromic, normocytic)",
]:
    story.append(bl(x))

story += [b("Diuretic / Polyuric Phase (2-3 weeks):")]
for x in [
    "Urine output >1-2 L/day (tubular function recovering but concentration ability impaired)",
    "Risk of " + bp("hypokalemia, hyponatremia, dehydration"),
    "Gradual improvement in creatinine",
]:
    story.append(bl(x))

story += [b("Recovery Phase (up to 12 months):")]
for x in [
    "GFR returns toward normal; some patients develop permanent CKD",
    "Complete recovery in most ischemic ATN; nephrotoxic ATN has better prognosis",
]:
    story.append(bl(x))

story += [section_box("Investigations")]
for x in [
    bp("Serum creatinine and BUN") + " - rise (creatinine rises ~1-2 mg/dL/day in oliguric ATN)",
    bp("Serum electrolytes") + " - hyperkalemia, hyponatremia, hypocalcemia, hyperphosphatemia",
    bp("ABG") + " - metabolic acidosis (raised anion gap)",
    bp("Urine analysis + microscopy") + " - see FENa table; casts; specific gravity",
    bp("Renal ultrasound") + " - " + bp("first imaging") + "; rules out obstruction; assess kidney size (small in CKD, normal/large in AKI)",
    bp("ECG") + " - hyperkalemia changes (peaked T, widened QRS, sine wave pattern)",
    bp("CBC") + " - anemia; raised WBC if sepsis",
    bp("Blood culture") + " - if sepsis-related AKI",
]:
    story.append(bl(x))

story += [section_box("Management")]
story += [b("General Principles:")]
for x in [
    bp("Identify and treat the cause") + ": correct hypovolemia (IV fluids), relieve obstruction, stop nephrotoxic drugs",
    bp("Fluid balance") + ": fluid challenge if pre-renal; restrict if oliguric overloaded (ins/outs chart)",
    bp("Treat hyperkalemia") + " - URGENT: calcium gluconate (stabilize membrane), insulin+dextrose (shift K in), salbutamol nebulization, sodium bicarbonate, kayexalate (resin), dialysis",
    bp("Treat metabolic acidosis") + ": sodium bicarbonate if pH <7.2",
    "Nutritional support: adequate calories; avoid excess protein",
    "Careful drug dosing - adjust for eGFR; avoid nephrotoxins",
]:
    story.append(bl(x))

story += [b("Renal Replacement Therapy (RRT) - Indications (AEIOU):")]
story += [mk_table([
    [Paragraph(bp("Mnemonic"), body_style), Paragraph(bp("Indication"), body_style), Paragraph(bp("Details"), body_style)],
    [p("A"), p("Acidosis"), p("Metabolic acidosis pH <7.1 not responding to bicarbonate")],
    [p("E"), p("Electrolytes"), p("Refractory hyperkalemia (K+ >6.5 mEq/L with ECG changes or not responding to treatment)")],
    [p("I"), p("Ingestion"), p("Drug/toxin overdose (e.g. methanol, ethylene glycol, salicylates, lithium)")],
    [p("O"), p("Overload"), p("Fluid overload with pulmonary edema not responding to diuretics")],
    [p("U"), p("Uremia"), p("Uremic pericarditis, encephalopathy, bleeding, serum urea >30 mmol/L with symptoms")],
], [1*cm, 3*cm, 13*cm]), sp()]

story += [p(bp("Modalities") + ": Intermittent hemodialysis (IHD) - stable patients; "
    "Continuous RRT (CRRT - CVVHDF) - hemodynamically unstable ICU patients; "
    "Peritoneal dialysis (PD) - where HD/CRRT unavailable.")]

story += [b("Dental Relevance:")]
story += [p("(1) " + bp("NSAIDs and COX-2 inhibitors are contraindicated") + " in AKI risk patients (reduce renal prostaglandins, cause vasoconstriction). "
    "(2) " + bp("Contrast dye (iodinated)") + " for dental radiographic procedures not relevant, but IV contrast for CT scans in patients with renal impairment needs N-acetylcysteine pre-treatment and hydration. "
    "(3) Dental infections causing " + bp("sepsis") + " are a precipitating cause of AKI. "
    "(4) Antibiotics: avoid aminoglycosides (gentamicin) in renal impairment. Metronidazole and amoxicillin are safe; adjust penicillin doses.")]

story.append(PageBreak())

# ============================================================
# TOPIC 4: CHRONIC KIDNEY DISEASE
# ============================================================
story += [topic_banner("CHRONIC KIDNEY DISEASE (CKD)", "4"), sp(0.2)]

story += [section_box("Definition (KDIGO 2012)")]
story += [p("CKD is defined as " + bp("abnormalities of kidney structure or function, present for >3 months, with implications for health") + ". "
    "Requires ANY ONE of: "
    bp("GFR <60 mL/min/1.73m2") + " for >3 months; OR "
    bp("markers of kidney damage") + " (albuminuria, hematuria, abnormal imaging/biopsy) for >3 months.")]

story += [section_box("GFR-based Staging (KDIGO)")]
story += [mk_table([
    [Paragraph(bp("Stage (G)"), body_style), Paragraph(bp("GFR (mL/min/1.73m2)"), body_style), Paragraph(bp("Description"), body_style)],
    [p("G1"), p(">= 90"), p("Normal/High GFR + markers of kidney damage")],
    [p("G2"), p("60-89"), p("Mildly decreased (with markers of damage)")],
    [p("G3a"), p("45-59"), p("Mildly-moderately decreased")],
    [p("G3b"), p("30-44"), p("Moderately-severely decreased")],
    [p("G4"), p("15-29"), p("Severely decreased - prepare for RRT")],
    [p("G5 (ESKD)"), p("< 15"), p("Kidney failure - RRT or transplant required")],
], [2.5*cm, 5.5*cm, 9*cm]), sp()]

story += [section_box("Common Causes of CKD")]
story += [mk_table([
    [Paragraph(bp("Cause"), body_style), Paragraph(bp("Details"), body_style)],
    [p(bp("Diabetic Nephropathy") + " (MC cause worldwide)"),
     p("Occurs in ~40% of type 1 and type 2 DM; Kimmelstiel-Wilson nodules (nodular glomerulosclerosis) on biopsy; proteinuria precedes GFR decline")],
    [p(bp("Hypertensive Nephrosclerosis") + " (2nd MC)"),
     p("Benign nephrosclerosis (afferent arteriolar hyalinosis) vs malignant (fibrinoid necrosis)")],
    [p("Chronic GN"),
     p("FSGS, IgA nephropathy, MPGN, lupus nephritis, RPGN")],
    [p("Polycystic Kidney Disease (ADPKD)"),
     p("Autosomal dominant; PKD1 (chr 16) or PKD2 (chr 4); MC genetic cause; bilateral cysts; flank pain, hypertension, hematuria")],
    [p("Chronic Pyelonephritis / Reflux Nephropathy"),
     p("Recurrent UTI with reflux causing progressive scarring")],
    [p("Obstructive Uropathy"), p("BPH, stones, malignancy - chronic back pressure injury")],
    [p("Others"), p("Amyloidosis, SLE, sickle cell disease, analgesic nephropathy, contrast nephropathy")],
], [5*cm, 12*cm]), sp()]

story += [section_box("Pathophysiology - Progression of CKD")]
story += [p("Regardless of initial cause, CKD progresses via: "
    "(1) " + bp("Hyperfiltration") + " - remaining nephrons hyperfiltrate (adaptive but ultimately injurious). "
    "(2) " + bp("Intraglomerular hypertension") + " - activates TGF-beta, causing glomerulosclerosis. "
    "(3) " + bp("Proteinuria") + " - tubular proteinuria causes tubular injury and interstitial fibrosis. "
    "(4) Progressive loss of nephrons - irreversible scarring.")]

story += [section_box("Clinical Features - Uremic Syndrome")]
story += [mk_table([
    [Paragraph(bp("System"), body_style), Paragraph(bp("Features"), body_style)],
    [p("General"), p("Fatigue, weakness, weight loss, pruritis (itch), 'uremic frost' (urea crystal deposits on skin in severe uremia)")],
    [p("CVS"), p(bp("Hypertension") + " (renin excess, fluid overload); accelerated atherosclerosis; "
        "Uremic pericarditis (friction rub); LVH; cardiac failure")],
    [p("Hematological"), p(bp("Normochromic normocytic anemia") + " (reduced EPO production); "
        "bleeding tendency (platelet dysfunction); thrombocytopenia")],
    [p("Neurological"), p("Uremic encephalopathy: confusion, seizures, coma; Peripheral neuropathy (restless legs, burning feet, glove-stocking pattern); asterixis (flapping tremor)")],
    [p("GI"), p("Nausea, vomiting, anorexia, hiccups, peptic ulceration, uremic fetor (ammonia breath), GI bleeding")],
    [p("Bones (Renal Osteodystrophy)"), p(bp("Secondary hyperparathyroidism") + ": low Vit D (kidneys fail to convert 25-OH-D3 to active 1,25-OH-D3) + hyperphosphatemia + hypocalcemia -> PTH rises -> bone resorption. "
        "Osteitis fibrosa cystica, osteomalacia, adynamic bone disease, vascular calcification")],
    [p("Metabolic"), p("Metabolic acidosis, hyperkalemia, hyponatremia, hyperphosphatemia, hypocalcemia, hyperuricemia (gout)")],
    [p("Endocrine"), p("Impaired glucose tolerance, hypothyroidism, hypogonadism, infertility, impotence, amenorrhoea")],
    [p("Respiratory"), p("Kussmaul breathing (acidosis), pulmonary edema, pleuritis")],
], [4*cm, 13*cm]), sp()]

story += [section_box("Investigations")]
for x in [
    bp("Serum creatinine, BUN, eGFR (CKD-EPI)") + " - assess degree of kidney function",
    bp("Urinalysis + 24-hr urine protein") + " - proteinuria, hematuria, casts; albuminuria staging (A1/A2/A3)",
    bp("Serum electrolytes") + " - hyperkalemia, hyperphosphatemia, hypocalcemia",
    bp("CBC") + " - normochromic normocytic anemia (reduced EPO)",
    bp("Serum PTH") + " - elevated secondary hyperparathyroidism",
    bp("Renal ultrasound") + " - small, echogenic kidneys bilaterally (CKD); large kidneys in DM, ADPKD, amyloid",
    bp("Renal biopsy") + " - if cause unclear; avoid if small kidneys (advanced scarring)",
    bp("Lipid profile") + " - dyslipidemia common; increased CVS risk",
]:
    story.append(bl(x))

story += [section_box("Management")]
story += [b("Slow CKD Progression:")]
for x in [
    bp("BP control") + " - target <130/80 mmHg; " + bp("ACE inhibitors / ARBs") + " first line (reduce proteinuria and intraglomerular pressure)",
    bp("Glycemic control") + " - HbA1c <7% in diabetic CKD; SGLT2 inhibitors (empagliflozin) have proven renoprotective benefit",
    "Treat underlying cause (immunosuppression for GN)",
    bp("Avoid nephrotoxins") + ": NSAIDs, contrast dye, aminoglycosides, herbal remedies",
    "Low-protein diet: 0.6-0.8 g/kg/day (reduces hyperfiltration and uremic toxin load)",
    "Smoking cessation, weight reduction",
]:
    story.append(bl(x))

story += [b("Manage Complications:")]
for x in [
    bp("Anemia") + ": Erythropoiesis-stimulating agents (ESA) - Erythropoietin/darbepoetin + IV iron (when eGFR <30 or Hb <10 g/dL)",
    bp("Renal Osteodystrophy") + ": Active Vit D (calcitriol/alfacalcidol), phosphate binders (calcium carbonate, sevelamer), cinacalcet (calcimimetic for hyperparathyroidism)",
    bp("Hyperkalemia") + ": low K+ diet, avoid RAAS drugs if severe K+, patiromer/sodium zirconium cyclosilicate",
    bp("Metabolic acidosis") + ": oral sodium bicarbonate (target serum bicarb >22 mEq/L)",
    bp("Hypertension") + ": RAAS blockade + loop diuretics + CCBs",
    bp("Dyslipidemia") + ": statins",
]:
    story.append(bl(x))

story += [b("Renal Replacement Therapy (RRT) - Plan for GFR <15-20:")]
for x in [
    bp("Hemodialysis (HD)") + " - 3 sessions/week x 4-5 h; needs AV fistula (created 3-6 months before)",
    bp("Peritoneal dialysis (PD)") + " - CAPD or APD; home-based; peritoneum as dialysis membrane",
    bp("Kidney transplantation") + " - best option for eligible patients (see Topic 6)",
]:
    story.append(bl(x))

story += [b("Dental Relevance:")]
story += [p("(1) " + bp("Uremic platelet dysfunction") + " -> prolonged bleeding time -> significant bleeding risk after extractions; plan with nephrologist. "
    "(2) " + bp("Oral manifestations of CKD") + ": uremic stomatitis (mucosal ulceration/pseudomembrane), uremic fetor (ammonia smell), pallor (anemia), "
    "gingival bleeding, enamel hypoplasia in children, periodontal disease, jaw metastatic calcifications (secondary HPT). "
    "(3) " + bp("Drug dose adjustment") + " essential: metronidazole safe; amoxicillin dose-reduce in eGFR <10; avoid NSAIDs; avoid tetracycline. "
    "(4) Patients on dialysis - schedule dental treatment the day " + bp("after") + " HD (heparin effect wanes, patient optimally cleared). "
    "(5) AV fistula: do NOT take BP from fistula arm.")]

story.append(PageBreak())

# ============================================================
# TOPIC 5: KIDNEY FAILURE (ESKD)
# ============================================================
story += [topic_banner("KIDNEY FAILURE (End-Stage Renal Disease - ESKD)", "5"), sp(0.2)]

story += [section_box("Definition")]
story += [p("Kidney failure (ESKD / Stage G5 CKD) is defined as " + bp("GFR <15 mL/min/1.73m2") + " or dependence on "
    "renal replacement therapy (RRT) for survival. It is the final common endpoint of progressive CKD "
    "from any cause. Also termed " + bp("end-stage renal disease (ESRD)") + " or uremia.")]

story += [section_box("Features / Uremic Syndrome (see CKD - all features more pronounced)")]
story += [mk_table([
    [Paragraph(bp("System"), body_style), Paragraph(bp("Key Manifestations at ESKD Stage"), body_style)],
    [p("Cardiovascular"), p(bp("LVH, accelerated atherosclerosis") + " - leading cause of death in ESKD. "
        "Uremic pericarditis (pericardial friction rub - urgent dialysis indication). "
        "Increased risk of sudden cardiac death.")],
    [p("Hematological"), p(bp("Severe anemia") + " (Hb often <8 g/dL); "
        bp("Platelet dysfunction") + " - impaired aggregation (uremic toxins impair GP IIb/IIIa); "
        "Bleeding tendency (GI bleed, post-surgical bleeding).")],
    [p("Neurological"), p("Uremic encephalopathy (asterixis, confusion, seizures); "
        "peripheral neuropathy; dialysis disequilibrium syndrome (cerebral edema after rapid dialysis).")],
    [p("Bones"), p(bp("Renal osteodystrophy") + " - Osteitis fibrosa cystica (Brown tumors) from severe 2ndary HPT; "
        "pathological fractures; calciphylaxis (vascular calcification causing tissue necrosis).")],
    [p("Fluids/Electrolytes"), p("Hyperkalemia (life-threatening - arrhythmias); "
        "Hyperphosphatemia; Hypocalcemia; Metabolic acidosis (AG type); "
        "Fluid overload - hypertension, pulmonary edema.")],
    [p("GI"), p("Uremic fetor, anorexia, nausea, vomiting; uremic gastritis/peptic ulcers; "
        "malnutrition (protein-energy wasting).")],
    [p("Skin"), p("Pruritus (uremic itch - MC complaint); sallow yellow/grey discoloration; "
        "uremic frost (white urea crystals); purpura; ecchymoses.")],
], [3.5*cm, 13.5*cm]), sp()]

story += [section_box("Indications for RRT in ESKD (AEIOU mnemonic - same as AKI + chronic indications)")]
for x in [
    bp("A - Acidosis") + ": refractory metabolic acidosis (pH <7.1)",
    bp("E - Electrolytes") + ": refractory hyperkalemia (K >6.5 mEq/L, ECG changes)",
    bp("I - Intoxication") + ": uremic pericarditis, uremic encephalopathy, uremic bleeding (platelet dysfunction)",
    bp("O - Overload") + ": volume overload, pulmonary edema not responding to diuretics",
    bp("U - Uremia") + ": symptoms of uremia (encephalopathy, pericarditis, neuropathy)",
    bp("GFR <10 mL/min") + ": asymptomatic initiation in diabetics; <5 ml/min in non-diabetics",
]:
    story.append(bl(x))

story += [section_box("Renal Replacement Therapy Options")]
story += [mk_table([
    [Paragraph(bp("Modality"), body_style), Paragraph(bp("Mechanism"), body_style), Paragraph(bp("Advantages / Disadvantages"), body_style)],
    [p(bp("Hemodialysis (HD)")), p("Blood filtered through artificial kidney (dialyzer) using semipermeable membrane; solute removal by diffusion + ultrafiltration"), p(
        "3x/week x 4-5 h in center. Rapid solute clearance. Needs: AV fistula (preferred), AV graft, or central venous catheter. "
        "Heparin anticoagulation required. Risk: hypotension, cramps, infection.")],
    [p(bp("Peritoneal Dialysis (PD)")), p("Peritoneum as dialysis membrane; dialysate instilled via catheter; solutes diffuse across"), p(
        "CAPD: 4 exchanges/day. CCPD: automated overnight. "
        "Home-based, gentler, preserves residual renal function. "
        "Risk: peritonitis (MC complication), hyperglycemia, malnutrition.")],
    [p(bp("Kidney Transplantation")), p("Functioning donor kidney provides near-normal renal function"), p(
        "Best quality of life and survival. Requires lifelong immunosuppression. "
        "Risk: rejection, infections, malignancy. See Topic 6 for indications.")],
], [3.5*cm, 5*cm, 8.5*cm]), sp()]

story += [b("Dental Relevance in ESKD:")]
story += [p("(1) " + bp("Hemodialysis patients") + ": "
    "DO NOT take BP or perform venepuncture on AV fistula arm. "
    "Treat day-after HD (heparin cleared, stable electrolytes). "
    "Check Hb and platelets before extractions (severe anemia and platelet dysfunction). "
    "Heparin rebound may cause post-procedure bleeding. "
    "(2) " + bp("CAPD patients") + ": dental bacteremia may cause peritonitis - prophylactic antibiotics controversial but consider for high-risk procedures. "
    "(3) " + bp("Renal osteodystrophy") + ": Brown tumors (giant cell lesions) can appear in jaw - may mimic ameloblastoma or giant cell granuloma on OPG. "
    "(4) " + bp("Drug prescribing") + ": avoid NSAIDs, tetracyclines, nephrotoxic drugs. "
    "Amoxicillin, metronidazole, lignocaine: dose adjustment needed in ESKD. "
    "(5) Uremic fetor (ammonia breath smell); pallor, bleeding gums.")]

story.append(PageBreak())

# ============================================================
# TOPIC 6: INDICATIONS FOR LIVER AND KIDNEY TRANSPLANT
# ============================================================
story += [topic_banner("INDICATIONS FOR LIVER AND KIDNEY TRANSPLANT", "6"), sp(0.2)]

story += [section_box("KIDNEY TRANSPLANTATION")]
story += [p(bp("Definition") + ": Surgical placement of a functioning kidney from a donor (living or deceased/cadaveric) "
    "into a recipient with ESKD. The native kidneys are usually left in place. "
    "The transplant kidney is placed in the " + bp("iliac fossa") + " (heterotopic transplant).")]

story += [b("Indications for Kidney Transplantation:")]
story += [mk_table([
    [Paragraph(bp("Category"), body_style), Paragraph(bp("Conditions"), body_style)],
    [p("Diabetic Nephropathy"), p("Type 1 DM: simultaneous pancreas-kidney transplant (SPK) preferred. Type 2 DM: kidney alone.")],
    [p("Glomerulonephritis"), p("FSGS, IgA nephropathy, MPGN, lupus nephritis reaching ESKD")],
    [p("Hypertensive Nephrosclerosis"), p("Chronic hypertension leading to ESKD")],
    [p("Hereditary Disease"), p("ADPKD (MC genetic indication), Alport syndrome, cystinosis, oxalosis (combined liver-kidney)")],
    [p("Chronic Pyelonephritis / Reflux Nephropathy"), p("Recurrent UTI-related ESKD")],
    [p("Obstructive Uropathy"), p("After correction of obstruction; GFR does not recover to adequate levels")],
    [p("Congenital Anomalies"), p("Renal agenesis/hypoplasia, posterior urethral valves")],
    [p("Other CKD Causes"), p("Analgesic nephropathy, sickle cell nephropathy, systemic vasculitis")],
], [4.5*cm, 12.5*cm]), sp()]

story += [b("General Eligibility Criteria:")]
for x in [
    bp("GFR <15-20 mL/min") + " with irreversible renal failure (or dialysis-dependent)",
    "Good cardiovascular reserve and surgical fitness",
    "No active malignancy (cancer-free for 2-5 years depending on type)",
    "No active infection (must be treated before transplant)",
    "No active/untreated psychiatric illness",
    "No active substance abuse",
    "Compliance with medications and follow-up",
    "ABO blood group compatibility and cross-match negative",
]:
    story.append(bl(x))

story += [b("Absolute Contraindications to Kidney Transplant:")]
for x in [
    "Active untreated malignancy",
    "Active systemic infection (sepsis, active TB, HIV with poor control)",
    "Severe cardiac disease / irreversible cardiac failure",
    "Severe irreversible pulmonary disease",
    "Active autoimmune disease uncontrolled (SLE in flare)",
    "Positive cross-match (recipient has preformed antibodies against donor HLA)",
    "Chronic active hepatitis B/C with ongoing liver damage (unless combined liver-kidney)",
    "Non-compliance / active drug abuse",
]:
    story.append(bl(x))

story += [b("Sources of Donor Kidney:")]
story += [mk_table([
    [Paragraph(bp("Type"), body_style), Paragraph(bp("Details"), body_style), Paragraph(bp("Outcome"), body_style)],
    [p("Living Related Donor (LRD)"), p("Parent, sibling, child, spouse; voluntary donation after full workup"), p("Best outcomes; immediate function; shorter cold ischemia time")],
    [p("Living Unrelated Donor (LURD)"), p("Spouse, friend, altruistic donor"), p("Good outcomes; regulated by law to prevent organ trafficking")],
    [p("Deceased/Cadaveric Donor"), p("Brain-dead donor (DBD) or DCD (donation after circulatory death)"), p("Longer wait time; delayed graft function more common")],
], [3.5*cm, 7*cm, 6.5*cm]), sp()]

story += [b("Complications of Kidney Transplant:")]
story += [mk_table([
    [Paragraph(bp("Complication"), body_style), Paragraph(bp("Time"), body_style), Paragraph(bp("Details"), body_style)],
    [p(bp("Hyperacute rejection")), p("Minutes-hours"), p("ABO incompatibility or preformed antibodies; complement activation; thrombosis of graft vessels; graft must be removed")],
    [p(bp("Acute rejection")), p("Days-weeks (peak 5-14 days)"), p("T-cell mediated (cellular) or antibody-mediated; oliguria, graft tenderness, fever; treat with pulsed steroids/ATG/plasmapheresis")],
    [p(bp("Chronic rejection")), p("Months-years"), p("Insidious GFR decline; fibrosis; poorly responsive to treatment; main cause of late graft loss")],
    [p("Infections"), p("Early: bacterial. Late: CMV, PCP, fungal"), p("Due to lifelong immunosuppression; CMV prophylaxis with valganciclovir")],
    [p("Malignancy"), p("Years"), p("Skin cancers (MC), PTLD (post-transplant lymphoproliferative disorder - EBV-related)")],
    [p("CVS disease"), p("Ongoing"), p("MC cause of death with functioning graft")],
], [3.5*cm, 3.5*cm, 10*cm]), sp()]

story += [b("Immunosuppression Protocol:")]
for x in [
    bp("Induction") + ": Basiliximab (anti-IL2R) or anti-thymocyte globulin (ATG)",
    bp("Maintenance triple therapy") + ": Tacrolimus (calcineurin inhibitor) + Mycophenolate mofetil (MMF) + Low-dose prednisolone",
    "Alternative CNIs: Cyclosporine (causes gingival hyperplasia - dental relevance)",
    bp("mTOR inhibitors") + ": Sirolimus/Everolimus - used as alternatives; reduce malignancy risk",
]:
    story.append(bl(x))

story += [sp(), section_box("LIVER TRANSPLANTATION")]
story += [p(bp("Definition") + ": Replacement of a diseased liver with a healthy donor liver. "
    "Types: " + bp("Orthotopic liver transplant (OLT)") + " (MC - native liver removed and donor placed in same position); "
    "Living donor LT (LDLT) - partial liver from living donor; Split LT; Domino LT.")]

story += [b("Indications for Liver Transplantation:")]
story += [mk_table([
    [Paragraph(bp("Category"), body_style), Paragraph(bp("Specific Conditions"), body_style)],
    [p(bp("Chronic Liver Disease with End-Stage Failure") + "\n(MC indication overall)"),
     p("- " + bp("Cirrhosis from any cause") + " with complications (decompensation)\n"
        "- " + bp("Hepatitis C cirrhosis") + " - historically MC indication in Western countries\n"
        "- " + bp("Hepatitis B cirrhosis") + "\n"
        "- " + bp("Alcoholic liver disease (ALD)") + " - requires 6 months sobriety before listing\n"
        "- " + bp("Non-alcoholic steatohepatitis (NASH) / NAFLD cirrhosis") + " - now MC indication\n"
        "- Primary biliary cholangitis (PBC)\n"
        "- Primary sclerosing cholangitis (PSC)")],
    [p(bp("Acute Liver Failure (Fulminant Hepatic Failure)")),
     p("- Drug-induced ALF: " + bp("Paracetamol overdose (MC cause of ALF in UK)") + "\n"
        "- Acute hepatitis A, B (fulminant)\n"
        "- Wilson's disease (acute)\n"
        "- Budd-Chiari syndrome (acute)\n"
        "- Indeterminate ALF\n"
        "- Listed using " + bp("King's College Criteria") + " for prognosis")],
    [p(bp("Hepatocellular Carcinoma (HCC)")),
     p(bp("Milan Criteria") + " for listing: Single lesion <=5 cm OR up to 3 lesions each <=3 cm, "
        "no vascular invasion, no extrahepatic spread. "
        "Extended criteria: UCSF criteria.")],
    [p(bp("Metabolic / Genetic Liver Disease")),
     p("- Wilson's disease (chronic)\n"
        "- Alpha-1 antitrypsin deficiency\n"
        "- Hereditary hemochromatosis\n"
        "- Glycogen storage disorders\n"
        "- Crigler-Najjar syndrome type 1 (biliary)\n"
        "- Oxalosis (combined liver-kidney)")],
    [p("Cholestatic Liver Disease"),
     p("Primary biliary cholangitis (PBC), Primary sclerosing cholangitis (PSC), biliary atresia (MC indication in children - Kasai operation failure)")],
    [p("Retransplantation"), p("Chronic rejection (hepatic artery thrombosis), primary non-function of graft, recurrent disease")],
], [5*cm, 12*cm]), sp()]

story += [b("Severity Scoring - MELD Score (Model for End-stage Liver Disease):")]
story += [p(bp("MELD score") + " = 10 x [0.957 x ln(Creatinine) + 0.378 x ln(Bilirubin) + 1.12 x ln(INR)] + 6.43. "
    "Score 6-40; higher = worse prognosis; " + bp("MELD >=15") + " = benefit from transplant outweighs surgical risk. "
    "Used to prioritize patients on the waiting list. "
    bp("Child-Pugh score") + " also used: parameters = encephalopathy, ascites, bilirubin, albumin, PT.")]

story += [b("Absolute Contraindications to Liver Transplant:")]
for x in [
    "Active extrahepatic malignancy",
    "Active uncontrolled infection / sepsis",
    "Severe cardiopulmonary disease (unable to survive surgery)",
    "Active alcohol / substance abuse (must be abstinent for min 6 months for ALD)",
    "Uncontrolled psychiatric disease or non-compliance",
    "AIDS (relative - but HIV+ve now acceptable at many centers with good CD4)",
    "Anatomical contraindications (extensive portal vein thrombosis in some)",
]:
    story.append(bl(x))

story += [b("Complications of Liver Transplant:")]
story += [mk_table([
    [Paragraph(bp("Complication"), body_style), Paragraph(bp("Details"), body_style)],
    [p("Primary non-function (PNF)"), p("Graft fails immediately post-transplant; requires urgent retransplantation")],
    [p("Hepatic artery thrombosis (HAT)"), p("MC vascular complication; graft ischemia; biliary necrosis")],
    [p("Rejection (acute/chronic)"), p("Acute: raised LFTs at day 5-10; treat with steroids. Chronic: vanishing bile duct syndrome")],
    [p("Infections"), p("Bacterial (early), CMV (commonest viral - 2-6 weeks), fungal (Candida, Aspergillus)")],
    [p("Recurrent disease"), p("Recurrence of HCV (universal before DAAs), HBV, NASH, HCC, PBC, PSC")],
    [p("Biliary complications"), p("Bile leak, biliary strictures - most common technical complication")],
], [4.5*cm, 12.5*cm]), sp()]

story += [b("Dental Relevance - Transplant Patients (Kidney and Liver):")]
story += [p("(1) " + bp("Immunosuppression") + " causes severe infection risk and impaired wound healing - "
    "plan dental treatment carefully; use prophylactic antibiotics for invasive procedures (per protocol). "
    "(2) " + bp("Cyclosporine-induced gingival overgrowth") + " - common (30-50% of patients); "
    "can be severe; requires meticulous oral hygiene and regular dental review; surgical gingivectomy if needed. "
    "(3) " + bp("Tacrolimus") + " - check drug levels before procedures (many dental drugs alter tacrolimus levels). "
    "Clarithromycin, fluconazole, metronidazole " + bp("raise tacrolimus levels") + " (CYP3A4 inhibition) - risk of toxicity and rejection. "
    "(4) " + bp("Steroid-induced adrenal suppression") + " - double steroid dose on day of stressful dental procedure. "
    "(5) Increased risk of " + bp("oral candidiasis, HSV stomatitis, HPV-related oral lesions, PTLD lymphoma") + ". "
    "(6) Anticoagulation: tacrolimus and mycophenolate can affect platelets; check CBC + PT. "
    "(7) " + bp("INR monitoring") + " important in post-transplant patients on warfarin.")]

# FOOTER
story += [sp(0.3), HRFlowable(width="100%", thickness=1, color=colors.HexColor('#ce93d8')), sp(0.2),
    Paragraph("General Medicine Short Notes | BDS 3rd Year | Gujarat University | "
        "Based on Anil K. Tripathi - General Medicine for BDS | Part 3: Nephrology & Transplantation",
        footer_style)]

doc.build(story)
print("PDF generated successfully!")