#!/usr/bin/env python3
"""
Create a supplementary handwritten-style answer key PDF for PG4 General Medicine.
Mimics the look of a ruled answer book with handwriting-style font.
"""

from reportlab.lib.pagesizes import A4
from reportlab.lib.units import cm, mm
from reportlab.lib import colors
from reportlab.pdfgen import canvas
from reportlab.lib.utils import simpleSplit
from reportlab.pdfbase import pdfmetrics
from reportlab.pdfbase.ttfonts import TTFont
import os

# ── Page geometry ──────────────────────────────────────────────────────────────
PAGE_W, PAGE_H = A4          # 595.27 x 841.89 pts
MARGIN_L  = 2.2 * cm
MARGIN_R  = 1.5 * cm
MARGIN_T  = 2.2 * cm
MARGIN_B  = 1.8 * cm
LINE_H    = 0.85 * cm        # ruled-line pitch
TEXT_X    = MARGIN_L + 0.4 * cm

# ── Colours ────────────────────────────────────────────────────────────────────
RULE_COL   = colors.HexColor("#c8d8f0")   # faint blue rule
LINE_COL   = colors.HexColor("#1a237e")   # dark blue ink
HEAD_COL   = colors.HexColor("#1a237e")
MARGIN_COL = colors.HexColor("#f08080")   # red left margin line
BG_COL     = colors.HexColor("#f9fafd")   # very light paper tint

# ── Font sizes ─────────────────────────────────────────────────────────────────
BODY_SIZE    = 10
HEADING_SIZE = 11
SUB_SIZE     = 10
SMALL_SIZE   = 9

# Use a bundled font that looks a bit informal / handwritten
# reportlab ships with Helvetica; we'll use it with slight slant simulation.
# For genuine handwriting look we tilt the canvas per word - too complex for now.
# Instead use Helvetica-Oblique for body and Helvetica-Bold for headings.
BODY_FONT  = "Helvetica-Oblique"
HEAD_FONT  = "Helvetica-BoldOblique"
BOLD_FONT  = "Helvetica-Bold"

OUTPUT_PATH = "/home/daytona/workspace/answer-key-pdf/PG4_GeneralMedicine_AnswerKey_Handwritten.pdf"

# ══════════════════════════════════════════════════════════════════════════════
#  Content  (condensed for a supplementary / model-answer style sheet)
# ══════════════════════════════════════════════════════════════════════════════

CONTENT = [
    # Each entry: (type, text)
    # Types: 'cover', 'qhead', 'head1', 'head2', 'body', 'bullet', 'subbullet',
    #        'table_row', 'divider', 'pagebreak'

    ("cover", ""),   # special – rendered separately

    # ── Q1 ─────────────────────────────────────────────────────────────────────
    ("qhead",   "Q.1  Evaluate and Manage the Patient Admitted with Oliguria  [20 Marks]"),
    ("head1",   "Definition"),
    ("body",    "Oliguria = urine output < 400 mL/24 h  (or < 0.5 mL/kg/h in adults)"),
    ("body",    "Anuria  = < 100 mL/24 h.  Key indicator of AKI; demands urgent evaluation."),

    ("head1",   "Pathophysiological Classification"),
    ("head2",   "1. Pre-renal  – ↓ effective circulating volume / renal perfusion"),
    ("bullet",  "Absolute hypovolaemia: haemorrhage, diarrhoea/vomiting, burns, diuretics"),
    ("bullet",  "Distributive: sepsis, anaphylaxis, hepatorenal syndrome"),
    ("bullet",  "Cardiogenic: CCF, MI, tamponade"),
    ("bullet",  "Renal artery stenosis / renal vein thrombosis"),

    ("head2",   "2. Intrinsic (Renal)  – Parenchymal kidney damage"),
    ("bullet",  "Tubular: ATN – ischaemic or nephrotoxic (drugs, contrast, myoglobin)"),
    ("bullet",  "Glomerular: RPGN, Acute nephritic syndrome"),
    ("bullet",  "Interstitial: AIN – drugs (NSAIDs, antibiotics), infection"),
    ("bullet",  "Vascular: TMA (HUS/TTP), Renal artery occlusion, MUS17TP"),

    ("head2",   "3. Post-renal  – Obstruction to urine outflow"),
    ("bullet",  "Ureteric: bilateral calculi, retroperitoneal fibrosis, malignancy"),
    ("bullet",  "Bladder outlet: BPH, urethral stricture, neurogenic bladder"),

    ("head1",   "History"),
    ("bullet",  "Duration of reduced urine output; fluid intake & losses (vomiting, diarrhoea, bleeding)"),
    ("bullet",  "Drug history: NSAIDs, aminoglycosides, contrast, ACEi/ARBs"),
    ("bullet",  "PMH: DM, HTN, CKD, CCF, malignancy"),
    ("bullet",  "Obstruction symptoms: hesitancy, poor stream, suprapubic pain"),
    ("bullet",  "Glomerular sx: haematuria, frothy urine, oedema"),
    ("bullet",  "Systemic: rash, arthralgia, haemoptysis (vasculitis), purpura (HUS/TTP)"),

    ("head1",   "Signs & Symptoms"),
    ("bullet",  "↓ UO, ↑ fluid intake history, drugs – leading to haematuria/AKI"),
    ("bullet",  "Pre-renal AKI → hypotension"),
    ("bullet",  "Raised JVP, distended bladder"),
    ("bullet",  "Rashes, purpura, jaundice"),

    ("head1",   "Investigations  –  Urine Tests (Pre-renal vs. Renal ATN)"),
    ("table_row", "Parameter            |  Pre-renal          |  Renal (ATN)"),
    ("table_row", "─────────────────────|─────────────────────|──────────────────────"),
    ("table_row", "U. Osmolality        |  > 500 mOsm/kg      |  < 350 mOsm/kg"),
    ("table_row", "U. Na                |  < 20 mEq/L         |  > 40 mEq/L"),
    ("table_row", "FENa                 |  < 1 %              |  > 2 %"),
    ("table_row", "BUN : Creatinine     |  > 20 : 1           |  < 10 : 1"),

    ("head2",   "Blood Tests"),
    ("bullet",  "S.Creatinine, BUN, electrolytes (K⁺, Na⁺, HCO₃⁻)"),
    ("bullet",  "CBC, LFTs, coagulation; CK (rhabdomyolysis); peripheral smear (TTP/HUS)"),
    ("bullet",  "Serology if GN: ANA, ANCA, anti-GBM, ASO, C3/C4, Hep B/C, HIV"),
    ("bullet",  "ABG: metabolic acidosis (↑ anion gap)"),

    ("head2",   "Imaging"),
    ("bullet",  "Renal USG (1st line): kidney size, echogenicity, hydronephrosis"),
    ("bullet",  "Bladder scan: residual vol > 300 mL → outlet obstruction"),
    ("bullet",  "Doppler USS: renal artery/vein thrombosis;  CT KUB: calculi, retrop. mass"),

    ("head1",   "Management"),
    ("head2",   "General Measures"),
    ("bullet",  "Strict I/O monitoring (hourly catheterisation), daily weights"),
    ("bullet",  "Avoid nephrotoxins: NSAIDs, aminoglycosides, contrast, ACEi/ARBs"),
    ("bullet",  "Nutrition: restrict protein 0.8 g/kg/day (if not on dialysis), high-calorie"),

    ("head2",   "Pre-renal"),
    ("bullet",  "Volume resuscitation: crystalloids (NS/Plasmalyte) – 500 mL bolus, reassess"),
    ("bullet",  "Treat cause: sepsis (Abx), CCF (diuretics + inotropes), haemorrhage (products)"),

    ("head2",   "Intrinsic (ATN)"),
    ("bullet",  "Optimise haemodynamics; MAP > 65 mmHg with vasopressors if needed"),
    ("bullet",  "Avoid diuretics to 'convert' oliguria (no mortality benefit)"),
    ("bullet",  "Specific: stop offending drug; treat rhabdomyolysis with aggressive fluids"),
    ("bullet",  "RPGN/GN: pulse methylprednisolone ± cyclophosphamide ± plasmapheresis"),

    ("head2",   "Post-renal"),
    ("bullet",  "Relieve obstruction: urethral catheter (outlet), nephrostomy/ureteric stent"),
    ("bullet",  "Post-obstructive diuresis: replace UO with 0.45% NS at ~75% volume"),

    ("head2",   "Fluid & Electrolyte Management"),
    ("bullet",  "Hyperkalaemia: Ca gluconate → insulin-dextrose → salbutamol → kayexalate/patiromer → dialysis"),
    ("bullet",  "Metabolic acidosis: bicarbonate if pH < 7.2 or HCO₃⁻ < 15"),
    ("bullet",  "Fluid restriction: input = insensible losses (500 mL) + prev-day UO"),

    ("head2",   "RRT Indications (AEIOU)"),
    ("bullet",  "A – Acidosis refractory (pH < 7.1)"),
    ("bullet",  "E – Electrolytes: K⁺ > 6.5 mEq/L refractory"),
    ("bullet",  "I  – Intoxication (ethylene glycol, methanol, salicylates, lithium)"),
    ("bullet",  "O – Overload (pulm. oedema not responding to diuretics)"),
    ("bullet",  "U – Uraemia (encephalopathy, pericarditis, platelet dysfunction)"),
    ("body",    "Modalities: IHD or CRRT (preferred in haemodynamically unstable patients)"),

    ("head1",   "Management  –  Haemodialysis / Fluid management / Electrolyte management"),

    ("divider", ""),
    ("pagebreak", ""),

    # ── Q2 ─────────────────────────────────────────────────────────────────────
    ("qhead",   "Q.2  Discuss in Detail Heart Failure  [20 Marks]"),
    ("head1",   "Definition"),
    ("body",    "HF = clinical syndrome where the heart cannot pump sufficient blood to meet metabolic needs, or can do so only at elevated filling pressures."),

    ("head1",   "Classification"),
    ("head2",   "By EF (ESC 2021)"),
    ("bullet",  "HFrEF: EF < 40%   |   HFmrEF: EF 41–49%   |   HFpEF: EF ≥ 50%"),
    ("head2",   "By Onset"),
    ("bullet",  "Acute HF (de novo or acute decompensation)  /  Chronic HF (stable, compensated)"),
    ("head2",   "NYHA Functional Class"),
    ("bullet",  "I – No limitation   II – Slight limitation   III – Marked limitation   IV – Symptoms at rest"),

    ("head1",   "Aetiology"),
    ("bullet",  "Common: IHD (most common), HTN, DCM (idiopathic/alcoholic/viral), Valvular HD, AF"),
    ("bullet",  "Less common: HCM, Restrictive CM (amyloid, haemochromatosis), high-output (anaemia, thyrotoxicosis)"),
    ("bullet",  "Peripartum CM; Chemotherapy-induced (anthracyclines, trastuzumab)"),

    ("head1",   "Pathophysiology"),
    ("bullet",  "Myocardial injury → ↓CO → SNS activation (tachycardia, vasoconstriction)"),
    ("bullet",  "RAAS: Ang II → vasoconstriction; Aldosterone → Na⁺/H₂O retention → ↑preload"),
    ("bullet",  "ADH: water retention → hyponatraemia (poor prognostic marker)"),
    ("bullet",  "Ventricular remodelling: hypertrophy, fibrosis, dilatation → progressive dysfunction"),
    ("bullet",  "BNP/NT-proBNP: released in response to wall stress; used as biomarkers"),

    ("head1",   "Clinical Features"),
    ("head2",   "Symptoms"),
    ("bullet",  "Dyspnoea on exertion (earliest), Orthopnoea (quantify by pillows), PND"),
    ("bullet",  "Fatigue, ankle oedema, nocturia"),
    ("bullet",  "Right HF: nausea, abdominal discomfort (hepatic congestion), early satiety"),
    ("head2",   "Signs"),
    ("bullet",  "Tachycardia, pulsus alternans, elevated JVP (+HJR), displaced apex beat"),
    ("bullet",  "S3 gallop (most specific – ↑ filling pressures), S4 (diastolic dysfunction)"),
    ("bullet",  "Bilateral basal crepitations, pleural effusions"),
    ("bullet",  "Tender hepatomegaly, ascites, bilateral pitting oedema"),

    ("head1",   "Investigations"),
    ("bullet",  "BNP > 100 pg/mL or NT-proBNP > 300 pg/mL supports diagnosis"),
    ("bullet",  "ECG: LVH, LBBB, AF, Q waves (prior MI)"),
    ("bullet",  "CXR: cardiomegaly, upper lobe diversion, Kerley B lines, bat-wing oedema, pleural effusions"),
    ("bullet",  "Echo (key): confirms diagnosis, EF, wall motion, diastolic grading, valves"),
    ("bullet",  "Blood: CBC, RFTs, LFTs, TFTs, iron studies, troponin, HbA1c, lipids"),

    ("head1",   "Management  –  HFrEF 'Fantastic Four' (evidence-based, mortality benefit)"),
    ("head2",   "1. ACEi / ARB / ARNi"),
    ("bullet",  "ACEi (ramipril, enalapril): reduces mortality 20–25% (CONSENSUS, SOLVD)"),
    ("bullet",  "Sacubitril/valsartan (ARNi): superior to enalapril (PARADIGM-HF trial)"),
    ("head2",   "2. Beta-blocker"),
    ("bullet",  "Carvedilol, metoprolol succinate, bisoprolol: ↓mortality 30–35% (MERIT-HF, COPERNICUS, CIBIS-II)"),
    ("head2",   "3. MRA  (Mineralocorticoid Receptor Antagonist)"),
    ("bullet",  "Spironolactone/eplerenone: NYHA Class II–IV (RALES, EMPHASIS trials)"),
    ("head2",   "4. SGLT2 Inhibitor"),
    ("bullet",  "Dapagliflozin (DAPA-HF), Empagliflozin (EMPEROR-Reduced): ALL HFrEF regardless of DM status"),
    ("head2",   "Additional Pharmacotherapy"),
    ("bullet",  "Diuretics (furosemide): symptom relief – no mortality benefit"),
    ("bullet",  "Ivabradine: SR, HR ≥ 70 on max BB, EF ≤ 35% (SHIFT trial)"),
    ("bullet",  "Hydralazine + ISDN: if intolerant of ACEi/ARB (esp. Black patients – A-HeFT)"),
    ("bullet",  "Digoxin: ↓ hospitalisation; AF + HF; narrow therapeutic index"),

    ("head1",   "Device Therapy"),
    ("bullet",  "ICD: EF ≤ 35%, NYHA II–III, on optimal therapy ≥ 3 months"),
    ("bullet",  "CRT: EF ≤ 35%, LBBB, QRS ≥ 150 ms, NYHA II–IV"),

    ("head1",   "Acute Decompensated HF (ADHF)"),
    ("bullet",  "Sit upright, O₂ (SpO₂ ≥ 95%), NIV (CPAP/BiPAP) if severe pulm. oedema (3CPO trial)"),
    ("bullet",  "IV furosemide 40–80 mg (DOSE trial: high-dose preferred)"),
    ("bullet",  "IV GTN if SBP > 100; inotropes (dobutamine) if cardiogenic shock"),
    ("bullet",  "Identify & treat precipitant: ACS, AF, HTN emergency, infection"),

    ("divider", ""),
    ("pagebreak", ""),

    # ── Q3 ─────────────────────────────────────────────────────────────────────
    ("qhead",   "Q.3  G-Protein Receptor Disorders + Approach to Hyperthyroidism  [20 Marks]"),
    ("head1",   "Part A – Genetic Causes of GPCR Disorders"),
    ("body",    "GPCRs transduce signals via heterotrimeric G-proteins (Gs, Gi, Gq).  Mutations = LOF or GOF."),

    ("head2",   "A. Loss-of-Function (LOF) – Resistance Syndromes"),
    ("bullet",  "PHP Ia (GNAS1 – Gαs): Albright Hereditary Osteodystrophy; multi-hormone resistance (PTH, TSH, LH, FSH, GHRH)"),
    ("bullet",  "PHP Ib (PTHR1): hypocalcaemia, hyperphosphataemia; high PTH"),
    ("bullet",  "Congenital hypothyroidism (TSHR LOF): athyrosis / hypoplastic thyroid; high TSH"),
    ("bullet",  "Nephrogenic DI (AVPR2 – X-linked): polyuria, polydipsia; unresponsive to ADH"),
    ("bullet",  "Familial glucocorticoid deficiency (MC2R): hypoglycaemia, ↑ pigmentation; ACTH high, cortisol low"),
    ("bullet",  "Monogenic obesity (MC4R): most common monogenic form; hyperphagia, hyperinsulinaemia"),
    ("bullet",  "Retinitis Pigmentosa (RHO): progressive visual loss, tunnel vision"),
    ("bullet",  "Leydig cell hypoplasia (LHCGR LOF): XY females / male pseudohermaphroditism"),

    ("head2",   "B. Gain-of-Function (GOF) – Constitutive Activation"),
    ("bullet",  "Familial non-autoimmune hyperthyroidism (TSHR germline GOF): AD; no goitre; low TSH, -ve Abs"),
    ("bullet",  "Toxic adenoma / TMNG (TSHR somatic GOF): autonomous thyroid function; hot nodule"),
    ("bullet",  "McCune-Albright Syndrome (GNAS1 somatic R201C/H): polyostotic fibrous dysplasia + café-au-lait + precocious puberty"),
    ("bullet",  "Familial male-limited precocious puberty / testotoxicosis (LHCGR germline GOF)"),
    ("bullet",  "Jansen metaphyseal chondrodysplasia (PTHR1 GOF): hypercalcaemia + hypophosphataemia; short-limbed dwarfism"),
    ("bullet",  "Autosomal dominant hypocalcaemia (CASR GOF): ↓ PTH; nephrocalcinosis risk"),

    ("head1",   "Part B – Approach to Hyperthyroidism"),
    ("head2",   "Causes  (by radioiodine uptake)"),
    ("bullet",  "HIGH uptake: Graves disease (TRAb +ve), TMNG (Plummer), Toxic adenoma, TSH-oma, HCG-mediated"),
    ("bullet",  "LOW/absent: De Quervain thyroiditis, Hashitoxicosis, Painless/postpartum thyroiditis, Iodine-induced, Amiodarone, Factitious, Struma ovarii"),

    ("head2",   "Clinical Features"),
    ("bullet",  "Hypermetabolic: heat intolerance, ↓ weight, sweating, fatigue"),
    ("bullet",  "CVS: palpitations, exertional dyspnoea, AF (in elderly)"),
    ("bullet",  "Neuro: anxiety, tremor, insomnia"),
    ("bullet",  "Graves-specific: exophthalmos, lid lag, pretibial myxoedema, thyroid bruit, acropachy"),

    ("head2",   "Investigations"),
    ("bullet",  "Step 1: TSH (suppressed), FT4 (elevated), FT3 (if T3 toxicosis)"),
    ("bullet",  "Step 2: TRAb/TSI (Graves), radionuclide scan, thyroid USS + Doppler"),

    ("head2",   "Management"),
    ("bullet",  "Symptomatic: beta-blockers (propranolol 40 mg TDS)"),
    ("bullet",  "ATDs: carbimazole/methimazole (1st line); PTU preferred in 1st trimester & thyroid storm"),
    ("bullet",  "Radioiodine (I-131): definitive treatment in Graves/TMNG; CI in pregnancy"),
    ("bullet",  "Surgery: large goitre, compressive sx, malignancy, failed ATD/RAI"),
    ("bullet",  "Thyroid storm (Burch-Wartofsky ≥ 45): PTU + beta-blocker IV + iodine (1 h after PTU) + corticosteroids + cooling + treat precipitant"),

    ("divider", ""),
    ("pagebreak", ""),

    # ── Q4 ─────────────────────────────────────────────────────────────────────
    ("qhead",   "Q.4  Lymphadenopathy (Causes) + Approach to Splenomegaly  [20 Marks]"),
    ("head1",   "Part A – Causes of Lymphadenopathy"),
    ("head2",   "1. Infectious  (most common)"),
    ("bullet",  "Viral: EBV (mono), CMV, HIV, adenovirus, rubella, hepatitis"),
    ("bullet",  "Bacterial: Strep pharyngitis, Staph, TB (scrofula), brucellosis, cat-scratch (Bartonella), syphilis"),
    ("bullet",  "Protozoal: Toxoplasma, Leishmaniasis (kala-azar)"),
    ("bullet",  "Fungal: Histoplasmosis; Helminthic: Filariasis"),
    ("head2",   "2. Neoplastic"),
    ("bullet",  "Primary: Hodgkin (Reed-Sternberg cells; B symptoms), NHL, leukaemias (CLL, ALL, CML)"),
    ("bullet",  "Metastatic: Cervical (oral/NPC/thyroid), Axillary (breast/lung), Inguinal (genital/anorectal)"),
    ("bullet",  "Virchow's node (left supraclavicular): GI/lung/testicular – Troisier sign"),
    ("head2",   "3. Inflammatory / Autoimmune"),
    ("bullet",  "SLE, RA, Sarcoidosis (bilateral hilar ± paratracheal), Kikuchi-Fujimoto, Kawasaki, Still's disease"),
    ("head2",   "4. Drug-induced"),
    ("bullet",  "Phenytoin, carbamazepine, hydralazine, allopurinol, sulphonamides"),
    ("head2",   "5. Storage / Infiltrative"),
    ("bullet",  "Gaucher, Niemann-Pick, Amyloidosis, Castleman disease"),

    ("head1",   "Part B – Approach to Splenomegaly"),
    ("head2",   "Grading"),
    ("bullet",  "Mild: < 4 cm below costal margin  |  Moderate: 4–8 cm  |  Massive: > 8 cm / crosses midline"),
    ("body",    "Massive splenomegaly mnemonic 'CCML': Chronic malaria, CML, Myelofibrosis, Leishmaniasis"),

    ("head2",   "Causes"),
    ("bullet",  "Infective: malaria (vivax/malariae), EBV, typhoid, SBE  (acute); visceral leishmaniasis, TB  (chronic)"),
    ("bullet",  "Haematological: haemolytic anaemias (hereditary spherocytosis, thalassaemia, SCD), MPNs (CML – massive), CLL, hairy cell leukaemia"),
    ("bullet",  "Congestive: portal HTN (cirrhosis most common), Budd-Chiari, portal vein thrombosis, RHF"),
    ("bullet",  "Inflammatory: Felty syndrome (RA + neutropenia), SLE, sarcoidosis"),
    ("bullet",  "Infiltrative: Gaucher (massive), amyloid, extramedullary haematopoiesis"),
    ("bullet",  "Neoplastic: lymphoma, haemangioma (benign)"),

    ("head2",   "Investigations"),
    ("bullet",  "FBC + differential + peripheral smear (key); LFTs, PT/INR"),
    ("bullet",  "USS abdomen: confirm size, liver, portal vein"),
    ("bullet",  "Blood film for malaria; serology; bone marrow biopsy (haematological malignancy/leishmaniasis)"),
    ("bullet",  "CT CAP; LDH, uric acid, β₂-microglobulin; JAK2 V617F (MPN); glucocerebrosidase (Gaucher)"),

    ("divider", ""),
    ("pagebreak", ""),

    # ── Q5a ────────────────────────────────────────────────────────────────────
    ("qhead",   "Q.5a  RPGN – Classification by Immunofluorescence + Immediate Therapeutic Interventions  [10 Marks]"),
    ("head1",   "Definition"),
    ("body",    "RPGN = rapid deterioration of renal function (≥ 50% GFR loss over days–weeks) with crescents in ≥ 50% glomeruli on biopsy.  → ESRD within weeks–months without treatment."),

    ("head1",   "Classification by Immunofluorescence"),
    ("table_row", "Type   |  IF Pattern          |  Pathology            |  Diseases                   |  %"),
    ("table_row", "───────|──────────────────────|───────────────────────|─────────────────────────────|────"),
    ("table_row", "I      |  LINEAR IgG on GBM   |  Anti-GBM Ab (α3 IV)  |  Goodpasture syndrome       |  10–15%"),
    ("table_row", "II     |  GRANULAR (lumpy)    |  Immune complex dep.  |  IgA vasculitis, LN, MPGN   |  40%"),
    ("table_row", "III    |  PAUCI-IMMUNE (-ve)  |  ANCA-vasculitis      |  GPA(c-ANCA), MPA(p-ANCA)  |  45–50%"),
    ("table_row", "IV     |  Double positive      |  Anti-GBM + ANCA     |  Particularly aggressive    |  ~10%"),

    ("head1",   "Immediate Therapeutic Interventions"),
    ("head2",   "1. Pulse Methylprednisolone  (ALL types)"),
    ("bullet",  "IV methylprednisolone 500–1000 mg/day × 3 days"),
    ("bullet",  "Followed by oral prednisolone 1 mg/kg/day (max 60 mg); taper over 6 months"),
    ("head2",   "2. Cyclophosphamide  (Type III – ANCA; also Type II)"),
    ("bullet",  "IV cyclophosphamide 15 mg/kg Q2–3 weeks (CYCLOPS regimen); OR oral 2 mg/kg/day"),
    ("bullet",  "Rituximab (anti-CD20): non-inferior to CYC in ANCA vasculitis (RAVE, RITUXVAS); preferred in young women"),
    ("head2",   "3. Plasmapheresis / TPE"),
    ("bullet",  "MANDATORY in Type I (Goodpasture): removes anti-GBM Abs; daily × 14 days"),
    ("bullet",  "ANCA + pulmonary haemorrhage / severe AKI: consider TPE (PEXIVAS 2020)"),
    ("head2",   "4. Additional"),
    ("bullet",  "Dialysis if AEIOU criteria met"),
    ("bullet",  "PCP prophylaxis: TMP-SMX 960 mg TIW"),
    ("bullet",  "PPI for gastric protection during high-dose steroids"),
    ("bullet",  "Maintenance: azathioprine or rituximab for 18–24 months (ANCA)"),

    ("divider", ""),

    # ── Q5b ────────────────────────────────────────────────────────────────────
    ("qhead",   "Q.5b  Lung Protective Ventilation, Prone Positioning & NMB in Severe ARDS  [10 Marks]"),
    ("head1",   "ARDS Berlin Definition (2012)"),
    ("bullet",  "Acute onset within 1 week; bilateral opacities on CXR/CT; not explained by cardiac failure"),
    ("bullet",  "Severe ARDS: PaO₂/FiO₂ ≤ 100 mmHg with PEEP ≥ 5 cmH₂O"),

    ("head1",   "A. Lung Protective Ventilation (LPV)"),
    ("head2",   "Physiological Basis"),
    ("bullet",  "'Baby lung': only 200–400 g aerated lung in ARDS → large VT causes volutrauma, barotrauma, atelectrauma, biotrauma (VILI → MSOF)"),
    ("bullet",  "LPV: low VT prevents overdistension; PEEP prevents atelectrauma"),
    ("head2",   "Strategy"),
    ("bullet",  "VT 6 mL/kg PBW  |  Plateau pressure ≤ 30 cmH₂O  |  Driving pressure ≤ 15 cmH₂O"),
    ("bullet",  "PEEP: titrated per ARDSNet PEEP-FiO₂ table  |  SpO₂ target 88–95%"),
    ("bullet",  "Permissive hypercapnia: allow PaCO₂ up to 60 mmHg (avoid in ↑ ICP)"),
    ("head2",   "Key Evidence"),
    ("bullet",  "ARMA Trial (NEJM 2000): VT 6 vs. 12 mL/kg; mortality 31% vs. 40%; NNT = 11  → standard of care"),
    ("bullet",  "Driving pressure analysis (Amato, NEJM 2015): DP ≤ 15 cmH₂O most strongly associated with survival"),

    ("head1",   "B. Prone Positioning"),
    ("head2",   "Physiological Basis"),
    ("bullet",  "Supine ARDS: posterior lung collapsed (oedema/compression)"),
    ("bullet",  "Prone: ↑ V/Q matching, recruits posterior lung, ↓ driving pressure, ↓ cardiac compression on lung"),
    ("head2",   "Protocol"),
    ("bullet",  "Indication: severe ARDS – PF ≤ 150 mmHg (PROSEVA criteria)"),
    ("bullet",  "Timing: within 36–48 h; Duration: ≥ 16 h/day"),
    ("bullet",  "Discontinue when PF > 150 on FiO₂ ≤ 0.6, PEEP ≤ 10 for ≥ 4 h in supine"),
    ("head2",   "Key Evidence"),
    ("bullet",  "PROSEVA (Guérin, NEJM 2013): 28-day mortality 16% vs. 32.8%  (ARR 16.8%; NNT = 6)"),

    ("head1",   "C. Neuromuscular Blockade (NMB)"),
    ("head2",   "Physiological Basis"),
    ("bullet",  "Eliminates spontaneous breathing → reduces P-SILI and patient-ventilator dyssynchrony"),
    ("bullet",  "↑ lung mechanics, ↑ oxygenation, anti-inflammatory (cisatracurium ↓ IL-8, IL-6)"),
    ("head2",   "Regimen"),
    ("bullet",  "Cisatracurium (Nimbex) IV infusion 37.5 mg/h for 48 hours (Hofmann elimination – organ-independent)"),
    ("bullet",  "Deep sedation required (RASS -4 to -5); monitor with TOF (target 1–2 twitches)"),
    ("head2",   "Key Evidence"),
    ("bullet",  "ACURASYS (NEJM 2010): CIS 48 h → adjusted 90-day mortality benefit; ↓ barotrauma"),
    ("bullet",  "ROSE (NEJM 2019): no difference vs. light sedation → NMB NOT routine for all ARDS"),
    ("bullet",  "Current practice: NMB reserved for P/F < 120–150, refractory dyssynchrony, or to facilitate proning"),

    ("head2",   "Summary"),
    ("table_row", "Intervention     |  Indication           |  Key Trial      |  Mortality Benefit"),
    ("table_row", "─────────────────|───────────────────────|─────────────────|────────────────────"),
    ("table_row", "LPV (6 mL/kg)    |  ALL ARDS             |  ARMA 2000      |  Yes – NNT 11"),
    ("table_row", "Prone ≥ 16 h/day |  Severe ARDS P/F ≤150 |  PROSEVA 2013   |  Yes – NNT 6"),
    ("table_row", "NMB (cisatrac.)  |  Refractory / P/F<120 |  ACURASYS/ROSE  |  Conditional"),

    ("divider", ""),
    ("body",    "Ref: Harrison's 22E (2025) | Braunwald's Heart Disease 12e | Brenner & Rector's The Kidney | Goldman-Cecil Medicine"),
]

# ══════════════════════════════════════════════════════════════════════════════
#  Renderer
# ══════════════════════════════════════════════════════════════════════════════

class AnswerPDFWriter:
    def __init__(self, path):
        self.c = canvas.Canvas(path, pagesize=A4)
        self.c.setTitle("PG4 General Medicine – Model Answer Key")
        self.c.setAuthor("Smt. NHL Municipal Medical College")
        self.y       = PAGE_H - MARGIN_T
        self.page_no = 1
        self._draw_page_bg()

    # ── Background & rules ──────────────────────────────────────────────────
    def _draw_page_bg(self):
        c = self.c
        # Paper background
        c.setFillColor(BG_COL)
        c.rect(0, 0, PAGE_W, PAGE_H, fill=1, stroke=0)
        # Red margin line
        c.setStrokeColor(MARGIN_COL)
        c.setLineWidth(0.8)
        c.line(MARGIN_L - 0.2 * cm, 0, MARGIN_L - 0.2 * cm, PAGE_H)
        # Blue ruled lines
        c.setStrokeColor(RULE_COL)
        c.setLineWidth(0.4)
        y = PAGE_H - MARGIN_T
        while y > MARGIN_B:
            c.line(MARGIN_L, y, PAGE_W - MARGIN_R, y)
            y -= LINE_H
        # Page number
        c.setFont("Helvetica", 8)
        c.setFillColor(colors.grey)
        c.drawCentredString(PAGE_W / 2, 0.8 * cm, f"— {self.page_no} —")
        c.setFillColor(LINE_COL)

    def _new_page(self):
        self.c.showPage()
        self.page_no += 1
        self.y = PAGE_H - MARGIN_T
        self._draw_page_bg()

    def _check_space(self, lines_needed=1):
        if self.y < MARGIN_B + lines_needed * LINE_H:
            self._new_page()

    # ── Draw helpers ────────────────────────────────────────────────────────
    def _write_line(self, text, font, size, indent=0, colour=None, gap_before=0):
        if gap_before:
            self.y -= gap_before
        self._check_space(1)
        c = self.c
        c.setFont(font, size)
        c.setFillColor(colour if colour else LINE_COL)
        # Wrap long lines
        avail_w = PAGE_W - MARGIN_R - TEXT_X - indent
        lines = simpleSplit(text, font, size, avail_w)
        for ln in lines:
            self._check_space(1)
            c.drawString(TEXT_X + indent, self.y, ln)
            self.y -= LINE_H

    def _draw_cover(self):
        c = self.c
        # Header bar
        c.setFillColor(colors.HexColor("#1a237e"))
        c.rect(0, PAGE_H - 4 * cm, PAGE_W, 4 * cm, fill=1, stroke=0)
        # Institution name
        c.setFont("Helvetica-Bold", 13)
        c.setFillColor(colors.white)
        c.drawCentredString(PAGE_W / 2, PAGE_H - 1.5 * cm, "SMT. N H L MUNICIPAL MEDICAL COLLEGE")
        c.setFont("Helvetica", 11)
        c.drawCentredString(PAGE_W / 2, PAGE_H - 2.1 * cm, "Supplementary Model Answer Key")
        c.setFont("Helvetica-BoldOblique", 14)
        c.drawCentredString(PAGE_W / 2, PAGE_H - 2.9 * cm, "4th Semester (P.G.) – General Medicine")

        # Decorative ruled lines body
        c.setFillColor(BG_COL)
        c.rect(0, 0, PAGE_W, PAGE_H - 4 * cm, fill=1, stroke=0)
        c.setStrokeColor(RULE_COL)
        c.setLineWidth(0.4)
        y = PAGE_H - 4 * cm - 0.5 * cm
        while y > MARGIN_B:
            c.line(MARGIN_L, y, PAGE_W - MARGIN_R, y)
            y -= LINE_H
        c.setStrokeColor(MARGIN_COL)
        c.setLineWidth(0.8)
        c.line(MARGIN_L - 0.2 * cm, 0, MARGIN_L - 0.2 * cm, PAGE_H - 4 * cm)

        # Cover info box
        bx = MARGIN_L + 0.5 * cm
        by = PAGE_H - 6.5 * cm
        bw = PAGE_W - MARGIN_L - MARGIN_R - 1 * cm
        bh = 3.5 * cm
        c.setFillColor(colors.HexColor("#e8eaf6"))
        c.setStrokeColor(colors.HexColor("#1a237e"))
        c.setLineWidth(1)
        c.roundRect(bx, by, bw, bh, 6, fill=1, stroke=1)
        c.setFillColor(colors.HexColor("#1a237e"))
        c.setFont("Helvetica-Bold", 11)
        c.drawString(bx + 0.5 * cm, by + bh - 0.8 * cm, "Total Marks: 100  |  All questions compulsory")
        c.setFont("Helvetica", 10)
        items = [
            "Q.1  Oliguria – Evaluation & Management          [20 Marks]",
            "Q.2  Heart Failure                                [20 Marks]",
            "Q.3  G-Protein Receptor Disorders + Hyperthyroidism  [20 Marks]",
            "Q.4  Lymphadenopathy + Splenomegaly Approach     [20 Marks]",
            "Q.5  Short Notes: (a) RPGN  (b) ARDS LPV/Prone/NMB  [20 Marks]",
        ]
        iy = by + bh - 1.5 * cm
        for item in items:
            c.drawString(bx + 0.5 * cm, iy, item)
            iy -= 0.5 * cm

        # Footer note
        c.setFont("Helvetica-Oblique", 8)
        c.setFillColor(colors.grey)
        c.drawCentredString(PAGE_W / 2, 1.2 * cm, "Handwritten supplementary answer key  –  Do not write your name anywhere on this sheet")

        self._new_page()

    # ── Render ──────────────────────────────────────────────────────────────
    def render(self, content):
        self._draw_cover()
        for typ, text in content:
            if typ == "cover":
                continue
            elif typ == "pagebreak":
                self._new_page()
            elif typ == "divider":
                self.y -= 0.2 * cm
                self._check_space(1)
                self.c.setStrokeColor(colors.HexColor("#9fa8da"))
                self.c.setLineWidth(0.6)
                self.c.line(TEXT_X, self.y, PAGE_W - MARGIN_R, self.y)
                self.y -= 0.3 * cm
            elif typ == "qhead":
                self.y -= 0.3 * cm
                # Underline background strip
                self._check_space(2)
                strip_y = self.y - 0.05 * cm
                self.c.setFillColor(colors.HexColor("#c5cae9"))
                self.c.rect(MARGIN_L - 0.1 * cm, strip_y, PAGE_W - MARGIN_L - MARGIN_R + 0.1 * cm, LINE_H + 0.1 * cm, fill=1, stroke=0)
                self._write_line(text, HEAD_FONT, HEADING_SIZE + 1, 0, colors.HexColor("#0d1659"))
                self.y -= 0.1 * cm
            elif typ == "head1":
                self.y -= 0.15 * cm
                self._write_line(text, HEAD_FONT, HEADING_SIZE, 0, colors.HexColor("#1a237e"), gap_before=0.1 * cm)
                # Underline
                self.c.setStrokeColor(colors.HexColor("#7986cb"))
                self.c.setLineWidth(0.5)
                ul_y = self.y + LINE_H - 0.12 * cm
                self.c.line(TEXT_X, ul_y, TEXT_X + 8 * cm, ul_y)
            elif typ == "head2":
                self._write_line(text, BOLD_FONT, SUB_SIZE, 0.3 * cm, colors.HexColor("#283593"), gap_before=0.05 * cm)
            elif typ == "body":
                self._write_line(text, BODY_FONT, BODY_SIZE, 0, LINE_COL)
            elif typ == "bullet":
                self._check_space(1)
                # Draw bullet
                bx = TEXT_X + 0.3 * cm
                by = self.y + 0.22 * cm
                self.c.setFillColor(LINE_COL)
                self.c.circle(bx, by, 1.5, fill=1, stroke=0)
                self._write_line(text, BODY_FONT, BODY_SIZE, 0.7 * cm, LINE_COL)
            elif typ == "subbullet":
                self._check_space(1)
                bx = TEXT_X + 0.9 * cm
                by = self.y + 0.22 * cm
                self.c.setFillColor(LINE_COL)
                self.c.circle(bx, by, 1.0, fill=1, stroke=0)
                self._write_line(text, BODY_FONT, SMALL_SIZE, 1.3 * cm, LINE_COL)
            elif typ == "table_row":
                self._write_line(text, "Courier", SMALL_SIZE, 0.3 * cm, colors.HexColor("#212121"))

    def save(self):
        self.c.save()


writer = AnswerPDFWriter(OUTPUT_PATH)
writer.render(CONTENT)
writer.save()
print(f"PDF saved to {OUTPUT_PATH}")

#!/usr/bin/env python3
"""
PG4 General Medicine – Model Answer Key
Rendered in Kalam handwriting font on ruled answer-book pages.
"""

from reportlab.lib.pagesizes import A4
from reportlab.lib.units import cm, mm
from reportlab.lib import colors
from reportlab.pdfgen import canvas
from reportlab.lib.utils import simpleSplit
from reportlab.pdfbase import pdfmetrics
from reportlab.pdfbase.ttfonts import TTFont
import os, random

FONT_DIR  = "/home/daytona/workspace/answer-key-pdf/fonts"
OUT_PATH  = "/home/daytona/workspace/answer-key-pdf/PG4_GM_AnswerKey_Handwritten.pdf"

# Register handwriting fonts
pdfmetrics.registerFont(TTFont("Kalam",     f"{FONT_DIR}/Kalam-Regular.ttf"))
pdfmetrics.registerFont(TTFont("KalamBold", f"{FONT_DIR}/Kalam-Bold.ttf"))

# ── Page geometry ──────────────────────────────────────────────────────────────
PAGE_W, PAGE_H = A4
MARGIN_L  = 2.4 * cm
MARGIN_R  = 1.4 * cm
MARGIN_T  = 2.0 * cm
MARGIN_B  = 1.6 * cm
LINE_H    = 0.88 * cm
TEXT_X    = MARGIN_L + 0.3 * cm

# ── Colours ────────────────────────────────────────────────────────────────────
BG_COL     = colors.HexColor("#fdfcf5")   # aged paper
RULE_COL   = colors.HexColor("#aac4e8")   # blue rule
MARGIN_COL = colors.HexColor("#e57373")   # red margin
INK_COL    = colors.HexColor("#1a237e")   # dark blue ink
HEAD_COL   = colors.HexColor("#0d1659")
Q_COL      = colors.HexColor("#b71c1c")   # red for Q headings (like red pen)

# ── Font sizes ─────────────────────────────────────────────────────────────────
BODY_SZ  = 11
HEAD_SZ  = 12
Q_SZ     = 13
TBL_SZ   = 9.5

# ══════════════════════════════════════════════════════════════════════════════
#  Full answer content
# ══════════════════════════════════════════════════════════════════════════════
CONTENT = [
    # (type, text)   types: cover / qhead / h1 / h2 / body / bullet / subbullet / trow / divider / pb

    ("cover", ""),

    # ─── Q1 ───────────────────────────────────────────────────────────────────
    ("qhead", "Q.1  Evaluate and Manage the Patient Admitted with Oliguria  [20 Marks]"),

    ("h1",    "Definition"),
    ("body",  "Oliguria = urine output < 400 mL/24 h  (or < 0.5 mL/kg/h in adults)"),
    ("body",  "Anuria  = < 100 mL/24 h.  A key indicator of AKI; demands urgent evaluation."),

    ("h1",    "Pathophysiological Classification"),

    ("h2",    "1. Pre-renal  –  Decreased effective circulating volume / renal perfusion"),
    ("bullet","Absolute hypovolaemia: haemorrhage, diarrhoea/vomiting, burns, diuretic excess"),
    ("bullet","Distributive: sepsis, anaphylaxis, hepatorenal syndrome"),
    ("bullet","Cardiogenic: CCF, MI, tamponade"),
    ("bullet","Renal artery stenosis / renal vein thrombosis"),

    ("h2",    "2. Intrinsic (Renal)  –  Parenchymal kidney damage"),
    ("bullet","Tubular: ATN – ischaemic or nephrotoxic (drugs, contrast, myoglobin)"),
    ("bullet","Glomerular: RPGN, Acute nephritic syndrome"),
    ("bullet","Interstitial: AIN – drugs (NSAIDs, antibiotics), infection"),
    ("bullet","Vascular: TMA (HUS/TTP), Renal artery occlusion, MUS17TP"),

    ("h2",    "3. Post-renal  –  Obstruction to urine outflow"),
    ("bullet","Ureteric: bilateral calculi, retroperitoneal fibrosis, malignancy"),
    ("bullet","Bladder outlet: BPH, urethral stricture, neurogenic bladder"),

    ("h1",    "Signs & Symptoms"),
    ("bullet","↓ UO, ↑ fluid intake history, drugs  →  leading to haematuria / AKI"),
    ("bullet","Pre-renal AKI  →  hypotension"),
    ("bullet","Raised JVP, distended bladder"),
    ("bullet","Rashes, purpura, jaundice"),

    ("h1",    "History"),
    ("bullet","Duration of reduced UO; fluid intake & losses (vomiting, diarrhoea, bleeding)"),
    ("bullet","Drug history: NSAIDs, aminoglycosides, contrast, ACEi/ARBs"),
    ("bullet","PMH: DM, HTN, CKD, CCF, malignancy"),
    ("bullet","Obstructive sx: hesitancy, poor stream, suprapubic pain"),
    ("bullet","Glomerular sx: haematuria, frothy urine, oedema"),
    ("bullet","Systemic: rash, arthralgia, haemoptysis (vasculitis), purpura (HUS/TTP)"),

    ("h1",    "Investigations  –  Difference Between Pre-renal vs Renal (ATN)"),
    ("trow",  "Parameter               Pre-renal              Renal (ATN)"),
    ("trow",  "─────────────────────   ───────────────────    ──────────────────"),
    ("trow",  "U. Osmolality           > 500 mOsm/kg          < 350 mOsm/kg"),
    ("trow",  "U. Na                   < 20 mEq/L             > 40 mEq/L"),
    ("trow",  "FENa                    < 1%                   > 2%"),
    ("trow",  "BUN : Creatinine        > 20 : 1               < 10 : 1"),

    ("h2",    "Blood Tests"),
    ("bullet","S. Creatinine, BUN, electrolytes (K+, Na+, HCO3-)"),
    ("bullet","CBC, LFTs, coagulation; CK (rhabdomyolysis); peripheral smear (TTP/HUS)"),
    ("bullet","Serology if GN: ANA, ANCA, anti-GBM, ASO, C3/C4, Hep B/C, HIV"),
    ("bullet","ABG: metabolic acidosis (high anion gap)"),

    ("h2",    "Imaging"),
    ("bullet","Renal USG (1st line): kidney size, echogenicity, hydronephrosis"),
    ("bullet","Bladder scan: residual vol > 300 mL → outlet obstruction"),
    ("bullet","Doppler USS: renal artery/vein thrombosis;  CT KUB: calculi, retroperitoneal mass"),

    ("h1",    "Management"),

    ("h2",    "II. Management"),
    ("bullet","Haemodialysis"),
    ("bullet","Fluid management"),
    ("bullet","Electrolyte management"),

    ("h2",    "General Measures"),
    ("bullet","Strict I/O monitoring (hourly catheterisation), daily weights"),
    ("bullet","Avoid nephrotoxins: NSAIDs, aminoglycosides, contrast, ACEi/ARBs"),
    ("bullet","Nutrition: restrict protein 0.8 g/kg/day (if not on dialysis), high-calorie"),

    ("h2",    "Pre-renal"),
    ("bullet","Volume resuscitation: crystalloids (NS / Plasmalyte) – 500 mL bolus, reassess JVP & UO"),
    ("bullet","Treat cause: sepsis (Abx), CCF (diuretics + inotropes), haemorrhage (blood products)"),

    ("h2",    "Intrinsic (ATN)"),
    ("bullet","Optimise haemodynamics; MAP > 65 mmHg with vasopressors if needed"),
    ("bullet","Avoid diuretics to 'convert' oliguria (no mortality benefit)"),
    ("bullet","Specific: stop offending drug; treat rhabdomyolysis with aggressive fluids"),
    ("bullet","RPGN/GN: pulse methylprednisolone ± cyclophosphamide ± plasmapheresis"),

    ("h2",    "Post-renal"),
    ("bullet","Relieve obstruction: urethral catheter (outlet), nephrostomy / ureteric stent"),
    ("bullet","Post-obstructive diuresis: replace UO with 0.45% NS at ~75% volume"),

    ("h2",    "Fluid & Electrolyte Management"),
    ("bullet","Hyperkalaemia: Ca gluconate → insulin-dextrose → salbutamol → kayexalate → dialysis"),
    ("bullet","Metabolic acidosis: NaHCO3 if pH < 7.2 or HCO3- < 15 mEq/L"),
    ("bullet","Fluid restriction: input = insensible losses (500 mL) + prev day UO"),

    ("h2",    "RRT Indications (AEIOU)"),
    ("bullet","A – Acidosis refractory (pH < 7.1)"),
    ("bullet","E – Electrolytes: K+ > 6.5 mEq/L refractory"),
    ("bullet","I  – Intoxication (ethylene glycol, methanol, salicylates, lithium)"),
    ("bullet","O – Overload (pulm. oedema not responding to diuretics)"),
    ("bullet","U – Uraemia (encephalopathy, pericarditis, platelet dysfunction)"),
    ("body",  "Modalities: IHD  or  CRRT (preferred in haemodynamically unstable patients)"),

    ("divider",""),
    ("pb",""),

    # ─── Q2 ───────────────────────────────────────────────────────────────────
    ("qhead","Q.2  Discuss in Detail Heart Failure  [20 Marks]"),

    ("h1",   "Definition"),
    ("body", "HF = clinical syndrome where the heart cannot pump sufficient blood to meet metabolic needs, or can do so only at elevated filling pressures. Not a single disease – a syndrome resulting from any structural/functional cardiac disorder."),

    ("h1",   "Classification"),
    ("h2",   "By EF (ESC 2021)"),
    ("bullet","HFrEF: EF < 40%   |   HFmrEF: EF 41–49%   |   HFpEF: EF ≥ 50%"),
    ("h2",   "By Onset"),
    ("bullet","Acute HF (de novo or acute decompensation)  /  Chronic HF (stable, compensated)"),
    ("h2",   "NYHA Functional Class"),
    ("bullet","I – No limitation     II – Slight limitation"),
    ("bullet","III – Marked limitation     IV – Symptoms at rest"),

    ("h1",   "Aetiology"),
    ("bullet","IHD (most common in developed countries): MI, hibernating myocardium"),
    ("bullet","Hypertension: pressure overload → concentric LVH → diastolic dysfunction → HFpEF"),
    ("bullet","DCM (idiopathic, alcoholic, viral myocarditis)"),
    ("bullet","Valvular HD: MR/AR (volume overload);  AS/MS (pressure overload)"),
    ("bullet","Arrhythmias: AF, tachycardia-mediated CM"),
    ("bullet","Less common: HCM, Restrictive CM (amyloid, haemochromatosis), high-output (anaemia, thyrotoxicosis)"),
    ("bullet","Peripartum CM;  Chemotherapy-induced (anthracyclines, trastuzumab)"),

    ("h1",   "Pathophysiology"),
    ("bullet","Myocardial injury → ↓ CO → SNS activation (tachycardia, vasoconstriction, ↑ contractility)"),
    ("bullet","RAAS: Ang II → vasoconstriction; Aldosterone → Na+/H2O retention → ↑ preload → congestion"),
    ("bullet","ADH: water retention → hyponatraemia (poor prognostic marker)"),
    ("bullet","Ventricular remodelling: hypertrophy, fibrosis, dilatation → progressive dysfunction"),
    ("bullet","BNP/NT-proBNP: released with wall stress → compensatory vasodilation & natriuresis; used as biomarkers"),

    ("h1",   "Clinical Features"),
    ("h2",   "Symptoms"),
    ("bullet","Dyspnoea on exertion (earliest symptom)"),
    ("bullet","Orthopnoea (quantify by no. of pillows);  PND (wakes 1–2 h after sleep)"),
    ("bullet","Fatigue, ankle oedema (bilateral pitting), nocturia"),
    ("bullet","Right HF: nausea, abdominal discomfort (hepatic congestion), early satiety"),
    ("h2",   "Signs"),
    ("bullet","Tachycardia, pulsus alternans (severe LV dysfunction)"),
    ("bullet","Raised JVP (+HJR), displaced apex beat"),
    ("bullet","S3 gallop (most specific – ↑ filling pressures);  S4 (diastolic dysfunction)"),
    ("bullet","Bilateral basal crepitations, pleural effusions"),
    ("bullet","Tender hepatomegaly, ascites, bilateral pitting oedema"),

    ("h1",   "Investigations"),
    ("bullet","BNP > 100 pg/mL or NT-proBNP > 300 pg/mL (NICE cut-offs)"),
    ("bullet","ECG: LVH, LBBB, AF, Q waves (prior MI);  Normal ECG has high -ve PV for HFrEF"),
    ("bullet","CXR: cardiomegaly (CTR > 50%), upper lobe diversion, Kerley B lines, bat-wing oedema"),
    ("bullet","Echo (key): confirms EF, wall motion, diastolic grading, valves, PASP"),
    ("bullet","Blood: CBC, RFTs, LFTs, TFTs, iron studies, troponin, HbA1c, lipids"),

    ("h1",   "Management  –  HFrEF  'Fantastic Four'  (all have mortality benefit)"),
    ("h2",   "1. ACEi / ARB / ARNi"),
    ("bullet","ACEi (ramipril, enalapril): ↓ mortality 20–25%  (CONSENSUS, SOLVD trials)"),
    ("bullet","Sacubitril/valsartan (ARNi): superior to enalapril in HFrEF (PARADIGM-HF)"),
    ("h2",   "2. Beta-blocker"),
    ("bullet","Carvedilol, metoprolol succinate, bisoprolol: ↓ mortality 30–35%  (MERIT-HF, COPERNICUS, CIBIS-II)"),
    ("h2",   "3. MRA  (Mineralocorticoid Receptor Antagonist)"),
    ("bullet","Spironolactone / eplerenone: NYHA II–IV  (RALES, EMPHASIS trials)"),
    ("h2",   "4. SGLT2 Inhibitor"),
    ("bullet","Dapagliflozin (DAPA-HF), Empagliflozin (EMPEROR-Reduced): ALL HFrEF regardless of DM"),
    ("h2",   "Additional Pharmacotherapy"),
    ("bullet","Loop diuretics (furosemide): symptom relief – no mortality benefit"),
    ("bullet","Ivabradine: SR, HR ≥ 70 on max BB, EF ≤ 35%  (SHIFT trial)"),
    ("bullet","Hydralazine + ISDN: intolerant of ACEi/ARB, esp. Black patients  (A-HeFT trial)"),
    ("bullet","Digoxin: ↓ hospitalisation; useful in AF + HF; narrow TI"),

    ("h1",   "Device Therapy"),
    ("bullet","ICD: EF ≤ 35%, NYHA II–III, optimal therapy ≥ 3 months, life expectancy > 1 yr"),
    ("bullet","CRT: EF ≤ 35%, LBBB, QRS ≥ 150 ms, NYHA II–IV"),

    ("h1",   "Acute Decompensated HF (ADHF)"),
    ("bullet","Sit upright, O2 (SpO2 ≥ 95%), NIV (CPAP/BiPAP) if severe pulm. oedema  (3CPO trial)"),
    ("bullet","IV furosemide 40–80 mg  (DOSE trial: high-dose preferred)"),
    ("bullet","IV GTN if SBP > 100;  inotropes (dobutamine) if cardiogenic shock"),
    ("bullet","Identify & treat precipitant: ACS, AF, HTN emergency, infection"),

    ("divider",""),
    ("pb",""),

    # ─── Q3 ───────────────────────────────────────────────────────────────────
    ("qhead","Q.3  G-Protein Receptor Disorders + Approach to Hyperthyroidism  [20 Marks]"),

    ("h1",   "Part A – Genetic Causes of GPCR Disorders"),
    ("body", "GPCRs transduce extracellular signals via heterotrimeric G-proteins (Gs, Gi, Gq, G12).  Mutations are LOF or GOF, each producing distinct clinical syndromes."),

    ("h2",   "A. Loss-of-Function (LOF) – Resistance Syndromes"),
    ("bullet","PHP Ia (GNAS1 – Gαs, paternal imprinting): Albright Hereditary Osteodystrophy – short stature, round face, brachydactyly; multi-hormone resistance (PTH, TSH, LH, FSH)"),
    ("bullet","PHP Ib (PTHR1): hypocalcaemia, hyperphosphataemia; PTH high; Albright osteodystrophy absent"),
    ("bullet","Congenital hypothyroidism (TSHR LOF): athyrosis / hypoplastic thyroid; high TSH, low T4"),
    ("bullet","Nephrogenic DI (AVPR2 – X-linked): polyuria, polydipsia; unresponsive to ADH"),
    ("bullet","Familial glucocorticoid deficiency (MC2R): hypoglycaemia, ↑ pigmentation, tall stature; ACTH high, cortisol low"),
    ("bullet","Monogenic obesity (MC4R): most common monogenic obesity; hyperphagia, hyperinsulinaemia"),
    ("bullet","Retinitis Pigmentosa (RHO): progressive visual loss, tunnel vision; most common hereditary blindness"),
    ("bullet","Leydig cell hypoplasia (LHCGR LOF): XY females; male pseudohermaphroditism"),

    ("h2",   "B. Gain-of-Function (GOF) – Constitutive Activation"),
    ("bullet","Familial non-autoimmune hyperthyroidism (TSHR germline GOF): AD; hyperthyroidism without goitre; low TSH; -ve thyroid Abs"),
    ("bullet","Toxic adenoma / TMNG (TSHR somatic GOF): autonomous thyroid function; hot nodule on scan"),
    ("bullet","McCune-Albright Syndrome (GNAS1 somatic R201C/H): polyostotic fibrous dysplasia + café-au-lait + precocious puberty; also thyrotoxicosis, GH excess"),
    ("bullet","Familial male-limited precocious puberty / testotoxicosis (LHCGR germline GOF): males with precocious puberty, low LH/FSH"),
    ("bullet","Jansen metaphyseal chondrodysplasia (PTHR1 GOF): hypercalcaemia + hypophosphataemia, normal PTH; short-limbed dwarfism"),
    ("bullet","Autosomal dominant hypocalcaemia (CASR GOF): ↓ PTH; nephrocalcinosis risk with treatment"),

    ("h1",   "Part B – Approach to Hyperthyroidism"),

    ("h2",   "Causes by Radioiodine Uptake"),
    ("bullet","HIGH uptake: Graves disease (TRAb +ve, most common), TMNG (Plummer), Toxic adenoma, TSH-secreting pituitary adenoma, HCG-mediated (gestational thyrotox, hydatidiform mole)"),
    ("bullet","LOW/absent uptake: De Quervain thyroiditis (painful, post-viral), Hashitoxicosis, Painless/postpartum thyroiditis, Iodine-induced (Jod-Basedow), Amiodarone-induced (Type I & II), Factitious, Struma ovarii"),

    ("h2",   "Clinical Features"),
    ("bullet","Hypermetabolic: heat intolerance, weight loss despite ↑ appetite, sweating, fatigue"),
    ("bullet","CVS: palpitations, exertional dyspnoea, AF (in elderly)"),
    ("bullet","Neuro: anxiety, irritability, fine tremor, insomnia"),
    ("bullet","GI: diarrhoea, ↑ bowel frequency"),
    ("bullet","Graves-specific eye signs: exophthalmos (proptosis), lid lag (von Graefe), lid retraction (Dalrymple), periorbital oedema"),
    ("bullet","Graves skin: pretibial myxoedema (bilateral non-pitting shin oedema), thyroid acropachy, thyroid bruit"),

    ("h2",   "Investigations"),
    ("bullet","Step 1 – Confirm: TSH suppressed (< 0.1 mIU/L), FT4 elevated, FT3 (T3 toxicosis)"),
    ("bullet","Step 2 – Aetiology: TRAb/TSI (Graves 90–95% sensitivity), anti-TPO, radionuclide scan (Tc-99m), thyroid USS + Doppler"),

    ("h2",   "Management"),
    ("bullet","Symptomatic (all causes): beta-blockers – propranolol 40 mg TDS (also inhibits T4→T3 conversion)"),
    ("bullet","ATDs: carbimazole / methimazole (1st line);  PTU preferred in 1st trimester & thyroid storm"),
    ("bullet","Radioiodine (I-131): definitive treatment in Graves/TMNG; CI in pregnancy, breastfeeding, active ophthalmopathy"),
    ("bullet","Surgery: large goitre with compressive sx, suspected malignancy, failed ATD/RAI, patient preference"),
    ("bullet","Thyroid Storm (Burch-Wartofsky ≥ 45): PTU (500–1000 mg loading) + IV propranolol + iodine (1 h AFTER PTU) + hydrocortisone 100 mg TDS + cooling + treat precipitant"),

    ("divider",""),
    ("pb",""),

    # ─── Q4 ───────────────────────────────────────────────────────────────────
    ("qhead","Q.4  Lymphadenopathy (Causes) + Approach to Splenomegaly  [20 Marks]"),

    ("h1",   "Part A – Causes of Lymphadenopathy"),
    ("body", "Lymphadenopathy = nodes abnormal in size (> 1 cm most regions), consistency, or number. May be localised or generalised (≥ 2 non-contiguous regions)."),

    ("h2",   "1. Infectious  (most common)"),
    ("bullet","Viral: EBV (infectious mono), CMV, HIV (acute seroconversion), adenovirus, rubella, hepatitis"),
    ("bullet","Bacterial: Strep pharyngitis, Staph, TB (scrofula – cervical), brucellosis, cat-scratch (Bartonella henselae), syphilis (secondary – generalised)"),
    ("bullet","Protozoal: Toxoplasmosis, Leishmaniasis (kala-azar)"),
    ("bullet","Fungal: Histoplasmosis;  Helminthic: Filariasis"),

    ("h2",   "2. Neoplastic"),
    ("bullet","Primary: Hodgkin lymphoma (Reed-Sternberg cells; B symptoms), NHL, leukaemias (CLL – rubbery generalised; ALL; CML)"),
    ("bullet","Metastatic: Cervical (oral/NPC/thyroid), Axillary (breast/lung/melanoma), Inguinal (genital/anorectal)"),
    ("bullet","Virchow's node (left supraclavicular): GI/lung/testicular – Troisier sign"),

    ("h2",   "3. Inflammatory / Autoimmune"),
    ("bullet","SLE, Rheumatoid arthritis"),
    ("bullet","Sarcoidosis: bilateral hilar adenopathy ± paratracheal; erythema nodosum; hypercalcaemia"),
    ("bullet","Kikuchi-Fujimoto (necrotising histiocytic lymphadenitis – young Asian women, cervical, self-limiting)"),
    ("bullet","Kawasaki (children), Adult-onset Still's disease"),

    ("h2",   "4. Drug-induced"),
    ("bullet","Phenytoin (pseudolymphoma), carbamazepine, hydralazine, allopurinol, sulphonamides"),

    ("h2",   "5. Storage / Infiltrative"),
    ("bullet","Gaucher disease, Niemann-Pick, Amyloidosis, Castleman disease"),

    ("h1",   "Part B – Approach to Splenomegaly"),
    ("h2",   "Grading"),
    ("bullet","Mild: < 4 cm below costal margin   Moderate: 4–8 cm   Massive: > 8 cm / crosses midline"),
    ("body", "Massive splenomegaly mnemonic  'CCML':  Chronic malaria, CML, Myelofibrosis, Leishmaniasis (also polycythaemia vera, thalassaemia major, Gaucher)"),

    ("h2",   "Causes"),
    ("bullet","Infective: malaria (P. vivax/malariae), EBV, typhoid, SBE  (acute);  visceral leishmaniasis, TB  (chronic)"),
    ("bullet","Haematological: haemolytic anaemias (HS, thalassaemia, SCD), MPNs (CML – massive), CLL, hairy cell leukaemia (massive)"),
    ("bullet","Congestive: portal HTN (cirrhosis – most common in practice), Budd-Chiari, portal vein thrombosis, RHF"),
    ("bullet","Inflammatory: Felty syndrome (RA + neutropenia + splenomegaly), SLE, sarcoidosis"),
    ("bullet","Infiltrative: Gaucher (massive), amyloid, extramedullary haematopoiesis"),

    ("h2",   "Investigations"),
    ("bullet","FBC + differential + peripheral smear  (key – leukocytosis/left shift CML, target cells thalassaemia, parasites malaria)"),
    ("bullet","LFTs, PT/INR;  USS abdomen (confirm size, liver, portal vein);  serology/blood film malaria"),
    ("bullet","Bone marrow biopsy (haematological malignancy / leishmaniasis)"),
    ("bullet","CT CAP; LDH, uric acid, β2-microglobulin; JAK2 V617F (MPN); glucocerebrosidase (Gaucher)"),

    ("divider",""),
    ("pb",""),

    # ─── Q5a ──────────────────────────────────────────────────────────────────
    ("qhead","Q.5a  RPGN – Immunofluorescence Classification + Immediate Interventions  [10 Marks]"),

    ("h1",   "Definition"),
    ("body", "RPGN = rapid deterioration of renal function (≥ 50% GFR loss over days–weeks) with crescents in ≥ 50% glomeruli on biopsy.  Without treatment → ESRD within weeks–months."),

    ("h1",   "Classification by Immunofluorescence"),
    ("trow", "Type  IF Pattern              Pathology              Diseases                %"),
    ("trow", "────  ─────────────────────   ──────────────────     ───────────────────     ────"),
    ("trow", "  I   LINEAR IgG on GBM       Anti-GBM Ab (a3 IV)   Goodpasture syndrome    10-15%"),
    ("trow", " II   GRANULAR (lumpy-bumpy)  Immune complex dep.   IgA vasculitis/LN/MPGN  40%"),
    ("trow", "III   PAUCI-IMMUNE (-ve IF)   ANCA-mediated         GPA(cANCA) MPA(pANCA)   45-50%"),
    ("trow", " IV   Double positive          Anti-GBM + ANCA       Particularly aggressive ~10%"),

    ("h1",   "Immediate Therapeutic Interventions"),
    ("h2",   "1. Pulse Methylprednisolone  (ALL types)"),
    ("bullet","IV methylprednisolone 500–1000 mg/day × 3 consecutive days"),
    ("bullet","Then oral prednisolone 1 mg/kg/day (max 60 mg); taper over 6 months"),

    ("h2",   "2. Cyclophosphamide  (Type III – ANCA; also Type II)"),
    ("bullet","IV cyclophosphamide 15 mg/kg Q2–3 weeks (CYCLOPS);  OR oral 2 mg/kg/day × 3–6 months induction"),
    ("bullet","Rituximab (anti-CD20): non-inferior to CYC (RAVE, RITUXVAS trials); preferred in young women (fertility)"),

    ("h2",   "3. Plasmapheresis / TPE"),
    ("bullet","MANDATORY in Type I (Goodpasture): removes anti-GBM Abs; daily sessions × 14 days"),
    ("bullet","ANCA + pulmonary haemorrhage or severe AKI: consider TPE (PEXIVAS 2020)"),

    ("h2",   "4. Additional Measures"),
    ("bullet","Dialysis if AEIOU criteria met (K+ > 6.5, fluid overload, uraemia, severe acidosis)"),
    ("bullet","PCP prophylaxis: TMP-SMX 960 mg three times per week"),
    ("bullet","PPI for gastric protection during high-dose steroids"),
    ("bullet","Maintenance: azathioprine 2 mg/kg/day OR rituximab for 18–24 months (ANCA vasculitis)"),

    ("divider",""),

    # ─── Q5b ──────────────────────────────────────────────────────────────────
    ("qhead","Q.5b  LPV, Prone Positioning & NMB in Severe ARDS  [10 Marks]"),

    ("h1",   "ARDS Berlin Definition (2012)"),
    ("bullet","Acute onset within 1 week; bilateral opacities on CXR/CT; not explained by cardiac failure / fluid overload"),
    ("bullet","Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥ 5 cmH2O"),

    ("h1",   "A. Lung Protective Ventilation (LPV)"),
    ("h2",   "Physiological Basis"),
    ("bullet","ARDS: only 200–400 g aerated 'baby lung'.  Large VT causes:"),
    ("subbullet","Volutrauma (overdistension), barotrauma, atelectrauma (repeated opening/closing), biotrauma (cytokine release → VILI → MSOF)"),
    ("bullet","LPV: low VT prevents overdistension; PEEP prevents atelectrauma"),

    ("h2",   "Strategy"),
    ("bullet","VT = 6 mL/kg PBW   |   Plateau pressure ≤ 30 cmH2O   |   Driving pressure ≤ 15 cmH2O"),
    ("bullet","PEEP: ARDSNet PEEP-FiO2 table   |   SpO2 target 88–95%   |   Rate 12–35/min"),
    ("bullet","Permissive hypercapnia: allow PaCO2 up to 60 mmHg  (avoid in ↑ ICP)"),

    ("h2",   "Clinical Evidence"),
    ("bullet","ARMA Trial (NEJM 2000): VT 6 vs. 12 mL/kg; 28-day mortality 31% vs. 40%;  NNT = 11  →  standard of care"),
    ("bullet","Driving pressure analysis (Amato, NEJM 2015): DP ≤ 15 cmH2O most strongly associated with survival"),

    ("h1",   "B. Prone Positioning"),
    ("h2",   "Physiological Basis"),
    ("bullet","Supine ARDS: posterior/dependent lung collapsed (oedema, cardiac compression)"),
    ("bullet","Prone: ↑ V/Q matching, recruits posterior lung, ↓ driving pressure, ↓ cardiac compression, aids secretion drainage"),

    ("h2",   "Protocol"),
    ("bullet","Indication: severe ARDS – PF ≤ 150 mmHg  (PF ≤ 100 per some criteria), FiO2 ≥ 0.6, PEEP ≥ 5"),
    ("bullet","Timing: within 36–48 h of ARDS onset  |  Duration: ≥ 16 h/day"),
    ("bullet","Discontinue: PF > 150 on FiO2 ≤ 0.6, PEEP ≤ 10 for ≥ 4 h in supine"),

    ("h2",   "Clinical Evidence"),
    ("bullet","PROSEVA (Guerin, NEJM 2013): prone ≥ 16 h/day; 28-day mortality 16% vs. 32.8%  (ARR 16.8%; NNT = 6) – most impactful ARDS trial since ARMA"),

    ("h1",   "C. Neuromuscular Blockade (NMB)"),
    ("h2",   "Physiological Basis"),
    ("bullet","Severe ARDS: spontaneous breaths generate high transpulmonary pressures → P-SILI (patient self-inflicted lung injury)"),
    ("bullet","NMB eliminates spontaneous breathing → reduces P-SILI, ventilator dyssynchrony, and auto-PEEP"),
    ("bullet","Cisatracurium also reduces systemic cytokines (IL-8, IL-6)"),

    ("h2",   "Regimen"),
    ("bullet","Agent: cisatracurium (Nimbex) – Hofmann elimination, organ-independent, ↓ ICU-acquired weakness"),
    ("bullet","IV infusion 37.5 mg/h for 48 hours; deep sedation required (RASS -4 to -5); TOF monitoring (target 1–2 twitches)"),

    ("h2",   "Clinical Evidence"),
    ("bullet","ACURASYS (NEJM 2010): cisatracurium 48 h → adjusted 90-day mortality benefit; ↓ barotrauma"),
    ("bullet","ROSE (NEJM 2019): no difference vs. light sedation → NMB NOT routine for all ARDS"),
    ("bullet","Current (2024): NMB reserved for P/F < 120–150, refractory dyssynchrony, or to facilitate proning"),

    ("h2",   "Summary Table"),
    ("trow", "Intervention       Indication             Key Trial        Mortality Benefit"),
    ("trow", "─────────────────  ─────────────────────  ───────────────  ─────────────────"),
    ("trow", "LPV (6 mL/kg)      ALL ARDS               ARMA 2000        Yes – NNT 11"),
    ("trow", "Prone ≥ 16 h/day   Severe ARDS  PF ≤ 150  PROSEVA 2013     Yes – NNT 6"),
    ("trow", "NMB (cisatrac.)    Refractory / PF < 120  ACURASYS/ROSE    Conditional"),

    ("divider",""),
    ("body", "References: Harrison's 22E (2025)  |  Braunwald's Heart Disease 12e  |  Brenner & Rector's The Kidney  |  Goldman-Cecil Medicine"),
]

# ══════════════════════════════════════════════════════════════════════════════
#  PDF renderer
# ══════════════════════════════════════════════════════════════════════════════
class HWPDFWriter:
    def __init__(self, path):
        self.c      = canvas.Canvas(path, pagesize=A4)
        self.c.setTitle("PG4 General Medicine – Model Answer Key")
        self.c.setAuthor("Smt. NHL Municipal Medical College")
        self.y      = PAGE_H - MARGIN_T
        self.pageno = 1
        self._bg()

    # ── page background ──────────────────────────────────────────────────────
    def _bg(self):
        c = self.c
        # Paper tint
        c.setFillColor(BG_COL); c.rect(0,0,PAGE_W,PAGE_H,fill=1,stroke=0)
        # Ruled lines
        c.setStrokeColor(RULE_COL); c.setLineWidth(0.4)
        y = PAGE_H - MARGIN_T
        while y > MARGIN_B:
            c.line(MARGIN_L - 0.3*cm, y, PAGE_W - MARGIN_R, y)
            y -= LINE_H
        # Red margin
        c.setStrokeColor(MARGIN_COL); c.setLineWidth(1.0)
        c.line(MARGIN_L - 0.15*cm, MARGIN_B, MARGIN_L - 0.15*cm, PAGE_H - MARGIN_T + LINE_H)
        # Page number
        c.setFont("Kalam", 9); c.setFillColor(colors.HexColor("#555555"))
        c.drawCentredString(PAGE_W/2, 0.85*cm, str(self.pageno))
        c.setFillColor(INK_COL)

    def _newpage(self):
        self.c.showPage(); self.pageno += 1
        self.y = PAGE_H - MARGIN_T
        self._bg()

    def _need(self, n=1):
        if self.y < MARGIN_B + n * LINE_H:
            self._newpage()

    # ── write wrapped text ───────────────────────────────────────────────────
    def _text(self, txt, font, size, x, colour=None):
        self._need(1)
        c = self.c
        c.setFont(font, size)
        c.setFillColor(colour or INK_COL)
        avail = PAGE_W - MARGIN_R - x
        lines = simpleSplit(txt, font, size, avail)
        for l in lines:
            self._need(1)
            c.drawString(x, self.y, l)
            self.y -= LINE_H

    # ── cover page ───────────────────────────────────────────────────────────
    def _cover(self):
        c = self.c
        # Top colour bar
        c.setFillColor(colors.HexColor("#1a237e"))
        c.rect(0, PAGE_H-3.8*cm, PAGE_W, 3.8*cm, fill=1, stroke=0)
        c.setFillColor(colors.white)
        c.setFont("KalamBold", 15)
        c.drawCentredString(PAGE_W/2, PAGE_H-1.5*cm, "Smt. N H L Municipal Medical College")
        c.setFont("Kalam", 12)
        c.drawCentredString(PAGE_W/2, PAGE_H-2.1*cm, "Supplementary Handwritten Model Answer Key")
        c.setFont("KalamBold", 14)
        c.drawCentredString(PAGE_W/2, PAGE_H-2.9*cm, "4th Semester (P.G.)  –  General Medicine")

        # Ruled body
        c.setFillColor(BG_COL); c.rect(0,0,PAGE_W,PAGE_H-3.8*cm,fill=1,stroke=0)
        c.setStrokeColor(RULE_COL); c.setLineWidth(0.4)
        y = PAGE_H-3.8*cm - 0.3*cm
        while y > MARGIN_B:
            c.line(MARGIN_L-0.3*cm, y, PAGE_W-MARGIN_R, y); y -= LINE_H
        c.setStrokeColor(MARGIN_COL); c.setLineWidth(1.0)
        c.line(MARGIN_L-0.15*cm, MARGIN_B, MARGIN_L-0.15*cm, PAGE_H-3.8*cm)

        # Info box
        bx = MARGIN_L + 0.3*cm; by = PAGE_H-7.2*cm
        bw = PAGE_W - MARGIN_L - MARGIN_R - 0.5*cm; bh = 3.8*cm
        c.setFillColor(colors.HexColor("#e8eaf6"))
        c.setStrokeColor(colors.HexColor("#3949ab")); c.setLineWidth(1)
        c.roundRect(bx, by, bw, bh, 5, fill=1, stroke=1)
        c.setFillColor(HEAD_COL)
        c.setFont("KalamBold", 11)
        c.drawString(bx+0.4*cm, by+bh-0.75*cm, "Total Marks: 100   |   All questions are compulsory")
        c.setFont("Kalam", 10)
        rows = [
            "Q.1  Oliguria – Evaluation & Management                         [20 Marks]",
            "Q.2  Heart Failure                                               [20 Marks]",
            "Q.3  G-Protein Receptor Disorders + Hyperthyroidism              [20 Marks]",
            "Q.4  Lymphadenopathy + Approach to Splenomegaly                 [20 Marks]",
            "Q.5  Short Notes: (a) RPGN  (b) ARDS – LPV / Prone / NMB       [20 Marks]",
        ]
        ry = by + bh - 1.35*cm
        for r in rows:
            c.drawString(bx+0.4*cm, ry, r); ry -= 0.52*cm

        # Footer
        c.setFont("Kalam", 8); c.setFillColor(colors.grey)
        c.drawCentredString(PAGE_W/2, 1.1*cm,
            "Do not write your name anywhere on this answer sheet.  Use Black/Blue ink only.")
        self._newpage()

    # ── main render ──────────────────────────────────────────────────────────
    def render(self, content):
        self._cover()
        for typ, txt in content:
            if typ == "cover":
                continue
            elif typ == "pb":
                self._newpage()
            elif typ == "divider":
                self.y -= 0.15*cm; self._need(1)
                self.c.setStrokeColor(colors.HexColor("#9fa8da")); self.c.setLineWidth(0.5)
                self.c.line(TEXT_X, self.y, PAGE_W-MARGIN_R, self.y)
                self.y -= 0.4*cm
            elif typ == "qhead":
                self.y -= 0.2*cm; self._need(2)
                # highlight strip
                self.c.setFillColor(colors.HexColor("#c5cae9"))
                self.c.rect(MARGIN_L-0.2*cm, self.y-0.08*cm, PAGE_W-MARGIN_L-MARGIN_R+0.2*cm, LINE_H+0.08*cm, fill=1, stroke=0)
                self._text(txt, "KalamBold", Q_SZ, TEXT_X, Q_COL)
                self.y -= 0.05*cm
            elif typ == "h1":
                self.y -= 0.1*cm; self._need(2)
                self._text(txt, "KalamBold", HEAD_SZ, TEXT_X, HEAD_COL)
                # underline
                self.c.setStrokeColor(colors.HexColor("#5c6bc0")); self.c.setLineWidth(0.6)
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                self.c.line(TEXT_X, ul_y, TEXT_X + 9*cm, ul_y)
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                self.y -= 0.05*cm
                self._text(txt, "KalamBold", BODY_SZ+0.5, TEXT_X+0.3*cm, HEAD_COL)
            elif typ == "body":
                self._text(txt, "Kalam", BODY_SZ, TEXT_X, INK_COL)
            elif typ == "bullet":
                self._need(1)
                bx = TEXT_X + 0.35*cm; by = self.y + 0.25*cm
                self.c.setFillColor(INK_COL); self.c.circle(bx, by, 1.8, fill=1, stroke=0)
                self._text(txt, "Kalam", BODY_SZ, TEXT_X+0.75*cm, INK_COL)
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                self._need(1)
                bx = TEXT_X + 1.1*cm; by = self.y + 0.25*cm
                self.c.setFillColor(INK_COL); self.c.rect(bx-1.5, by-1.5, 3, 3, fill=1, stroke=0)
                self._text(txt, "Kalam", BODY_SZ-0.5, TEXT_X+1.5*cm, INK_COL)
            elif typ == "trow":
                self._text(txt, "Kalam", TBL_SZ, TEXT_X+0.2*cm, colors.HexColor("#1a1a2e"))

    def save(self):
        self.c.save()
        print(f"Saved: {OUT_PATH}")


writer = HWPDFWriter(OUT_PATH)
writer.render(CONTENT)
writer.save()

from pypdf import PdfReader
r = PdfReader(OUT_PATH)
print(f"Total pages: {len(r.pages)}")

#!/usr/bin/env python3
"""
PG4 General Medicine – Model Answer Key
Realistic handwritten look:
  - Kalam font (genuine handwriting)
  - Pure black ink  (#111111)
  - White paper, faint grey ruled lines, no red margin (plain)
  - Per-line random baseline jitter (+/- 2pt)
  - Per-line random font-size micro-variation (+/- 0.4pt)
  - Per-line slight horizontal start jitter
  - Headings underlined with a slightly wobbly hand-drawn line
  - Bullet dots drawn as small imperfect circles
  - No colour anywhere – pure greyscale
"""

import random, math
from reportlab.lib.pagesizes import A4
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.pdfgen import canvas
from reportlab.lib.utils import simpleSplit
from reportlab.pdfbase import pdfmetrics
from reportlab.pdfbase.ttfonts import TTFont

random.seed(42)   # reproducible "randomness"

FONT_DIR = "/home/daytona/workspace/answer-key-pdf/fonts"
OUT_PATH = "/home/daytona/workspace/answer-key-pdf/PG4_GM_AnswerKey_BW.pdf"

pdfmetrics.registerFont(TTFont("Kalam",     f"{FONT_DIR}/Kalam-Regular.ttf"))
pdfmetrics.registerFont(TTFont("KalamBold", f"{FONT_DIR}/Kalam-Bold.ttf"))

# ── Page geometry ──────────────────────────────────────────────────────────────
PAGE_W, PAGE_H = A4
MARGIN_L  = 2.2 * cm
MARGIN_R  = 1.3 * cm
MARGIN_T  = 2.0 * cm
MARGIN_B  = 1.8 * cm
LINE_H    = 0.90 * cm
TEXT_X    = MARGIN_L + 0.25 * cm

# ── Colours (greyscale only) ────────────────────────────────────────────────
PAPER     = colors.HexColor("#ffffff")          # pure white
RULE_COL  = colors.HexColor("#cccccc")          # faint grey lines
INK       = colors.HexColor("#111111")          # near-black ink
INK_HEAD  = colors.HexColor("#000000")          # pure black for headings
INK_DIM   = colors.HexColor("#333333")          # slightly lighter for sub

# ── Font sizes ─────────────────────────────────────────────────────────────────
BODY_SZ = 11.5
HEAD_SZ = 13.0
Q_SZ    = 13.5
TBL_SZ  = 10.0


# ══════════════════════════════════════════════════════════════════════════════
#  Content
# ══════════════════════════════════════════════════════════════════════════════
CONTENT = [
    ("cover",""),

    # ─── Q1 ───────────────────────────────────────────────────────────────────
    ("qhead","Q.1  Evaluate and Manage the Patient Admitted with Oliguria  [20 Marks]"),
    ("h1","Definition"),
    ("body","Oliguria = urine output < 400 mL/24 h  (or < 0.5 mL/kg/h in adults)"),
    ("body","Anuria = < 100 mL/24 h.  Key clinical indicator of AKI; demands urgent evaluation."),

    ("h1","Pathophysiological Classification"),

    ("h2","1.  Pre-renal  –  Decreased effective circulating volume / renal perfusion"),
    ("b","Absolute hypovolaemia: haemorrhage, diarrhoea/vomiting, burns, diuretic excess"),
    ("b","Distributive: sepsis, anaphylaxis, hepatorenal syndrome"),
    ("b","Cardiogenic: CCF, MI, tamponade"),
    ("b","Renal artery stenosis / renal vein thrombosis"),

    ("h2","2.  Intrinsic (Renal)  –  Parenchymal kidney damage"),
    ("b","Tubular: ATN – ischaemic or nephrotoxic (drugs, contrast, myoglobin)"),
    ("b","Glomerular: RPGN, Acute nephritic syndrome"),
    ("b","Interstitial: AIN – drugs (NSAIDs, antibiotics), infection"),
    ("b","Vascular: TMA (HUS/TTP), Renal artery occlusion, MUS17TP"),

    ("h2","3.  Post-renal  –  Obstruction"),
    ("b","Ureteric: bilateral calculi, retroperitoneal fibrosis, malignancy"),
    ("b","Bladder outlet: BPH, urethral stricture, neurogenic bladder"),

    ("h1","Signs & Symptoms"),
    ("b","Decreased UO, increased fluid intake history, drugs  ->  haematuria / AKI"),
    ("b","Pre-renal AKI  ->  hypotension"),
    ("b","Raised JVP, distended bladder"),
    ("b","Rashes, purpura, jaundice"),

    ("h1","History"),
    ("b","Duration of reduced UO; fluid intake & losses (vomiting, diarrhoea, bleeding)"),
    ("b","Drug history: NSAIDs, aminoglycosides, contrast, ACEi / ARBs"),
    ("b","PMH: DM, HTN, CKD, CCF, malignancy"),
    ("b","Obstruction symptoms: hesitancy, poor stream, suprapubic pain"),
    ("b","Glomerular symptoms: haematuria, frothy urine, oedema"),
    ("b","Systemic: rash, arthralgia, haemoptysis (vasculitis), purpura (HUS/TTP)"),

    ("h1","Investigations  –  Difference Between Pre-renal vs Renal (ATN)"),
    ("trow","Parameter              Pre-renal           Renal (ATN)"),
    ("trow","-------------------    ----------------    ----------------"),
    ("trow","U. Osmolality          > 500 mOsm/kg       < 350 mOsm/kg"),
    ("trow","U. Na                  < 20 mEq/L          > 40 mEq/L"),
    ("trow","FENa                   < 1%                > 2%"),
    ("trow","BUN : Creatinine       > 20 : 1            < 10 : 1"),

    ("h2","Blood Tests"),
    ("b","S.Creatinine, BUN, electrolytes (K+, Na+, HCO3-)"),
    ("b","CBC, LFTs, coagulation; CK (rhabdomyolysis); peripheral smear (TTP/HUS)"),
    ("b","Serology if GN suspected: ANA, ANCA, anti-GBM, ASO, C3/C4, Hep B/C, HIV"),
    ("b","ABG: metabolic acidosis (high anion gap)"),

    ("h2","Imaging"),
    ("b","Renal USG (1st line): kidney size, echogenicity, bilateral obstruction, hydronephrosis"),
    ("b","Bladder scan: residual volume > 300 mL suggests outlet obstruction"),
    ("b","Doppler USS: renal artery/vein thrombosis;  CT KUB: calculi, retroperitoneal mass"),

    ("h1","Management"),
    ("h2","II.  Management"),
    ("b","Haemodialysis"),
    ("b","Fluid management"),
    ("b","Electrolyte management"),

    ("h2","General Measures"),
    ("b","Strict I/O monitoring (hourly catheterisation), daily weights"),
    ("b","Avoid nephrotoxins: NSAIDs, aminoglycosides, contrast, ACEi/ARBs"),
    ("b","Nutrition: restrict protein 0.8 g/kg/day (if not on dialysis), high-calorie intake"),

    ("h2","Pre-renal"),
    ("b","Volume resuscitation: crystalloids (NS / Plasmalyte) – 500 mL bolus, reassess JVP & UO"),
    ("b","Treat cause: sepsis (Abx), CCF (diuretics + inotropes), haemorrhage (blood products)"),

    ("h2","Intrinsic (ATN)"),
    ("b","Optimise haemodynamics; MAP > 65 mmHg with vasopressors if needed"),
    ("b","Avoid diuretics to 'convert' oliguria (no mortality benefit)"),
    ("b","Specific: stop offending drug; treat rhabdomyolysis with aggressive fluids"),
    ("b","RPGN/GN: pulse methylprednisolone +/- cyclophosphamide +/- plasmapheresis"),

    ("h2","Post-renal"),
    ("b","Relieve obstruction: urethral catheter (outlet), nephrostomy / ureteric stent"),
    ("b","Post-obstructive diuresis: replace UO with 0.45% NS at ~75% volume"),

    ("h2","Fluid & Electrolyte Management"),
    ("b","Hyperkalaemia: Ca gluconate -> insulin-dextrose -> salbutamol -> kayexalate -> dialysis"),
    ("b","Metabolic acidosis: NaHCO3 if pH < 7.2 or HCO3- < 15 mEq/L"),
    ("b","Fluid restriction: input = insensible losses (500 mL) + prev day UO"),

    ("h2","RRT Indications  (AEIOU)"),
    ("b","A – Acidosis refractory (pH < 7.1)"),
    ("b","E – Electrolytes: K+ > 6.5 mEq/L refractory"),
    ("b","I  – Intoxication (ethylene glycol, methanol, salicylates, lithium)"),
    ("b","O – Overload (pulm. oedema not responding to diuretics)"),
    ("b","U – Uraemia (encephalopathy, pericarditis, platelet dysfunction)"),
    ("body","Modalities: IHD  or  CRRT (preferred in haemodynamically unstable patients)"),

    ("div",""),("pb",""),

    # ─── Q2 ───────────────────────────────────────────────────────────────────
    ("qhead","Q.2  Discuss in Detail Heart Failure  [20 Marks]"),
    ("h1","Definition"),
    ("body","HF = clinical syndrome where the heart cannot pump sufficient blood to meet metabolic needs, or can do so only at elevated filling pressures."),

    ("h1","Classification"),
    ("h2","By EF  (ESC 2021)"),
    ("b","HFrEF: EF < 40%   |   HFmrEF: EF 41-49%   |   HFpEF: EF >= 50%"),
    ("h2","By Onset"),
    ("b","Acute HF (de novo or acute decompensation)   /   Chronic HF (stable, compensated)"),
    ("h2","NYHA Functional Class"),
    ("b","I – No limitation     II – Slight limitation"),
    ("b","III – Marked limitation     IV – Symptoms at rest"),

    ("h1","Aetiology"),
    ("b","IHD (most common): MI, hibernating myocardium"),
    ("b","Hypertension: pressure overload -> LVH -> diastolic dysfunction -> HFpEF"),
    ("b","DCM (idiopathic, alcoholic, viral myocarditis)"),
    ("b","Valvular HD: MR/AR (volume overload);  AS/MS (pressure overload)"),
    ("b","Arrhythmias: AF, tachycardia-mediated CM"),
    ("b","Less common: HCM, Restrictive CM (amyloid, haemochromatosis), high-output HF (anaemia, thyrotoxicosis)"),
    ("b","Peripartum CM;  Chemotherapy-induced (anthracyclines, trastuzumab)"),

    ("h1","Pathophysiology"),
    ("b","Myocardial injury -> decreased CO -> SNS activation (tachycardia, vasoconstriction)"),
    ("b","RAAS: Ang II -> vasoconstriction; Aldosterone -> Na+/H2O retention -> increased preload"),
    ("b","ADH: water retention -> hyponatraemia (poor prognostic marker)"),
    ("b","Ventricular remodelling: hypertrophy, fibrosis, dilatation -> progressive dysfunction"),
    ("b","BNP/NT-proBNP: released with wall stress; used as biomarkers"),

    ("h1","Clinical Features"),
    ("h2","Symptoms"),
    ("b","Dyspnoea on exertion (earliest symptom)"),
    ("b","Orthopnoea (quantify by no. of pillows);  PND (wakes 1-2 h after sleep)"),
    ("b","Fatigue, ankle oedema, nocturia"),
    ("b","Right HF: nausea, abdominal discomfort (hepatic congestion), early satiety"),
    ("h2","Signs"),
    ("b","Tachycardia, pulsus alternans (severe LV dysfunction)"),
    ("b","Raised JVP + HJR, displaced apex beat"),
    ("b","S3 gallop (most specific – elevated filling pressures);  S4 (diastolic dysfunction)"),
    ("b","Bilateral basal crepitations, pleural effusions"),
    ("b","Tender hepatomegaly, ascites, bilateral pitting oedema"),

    ("h1","Investigations"),
    ("b","BNP > 100 pg/mL  or  NT-proBNP > 300 pg/mL  (NICE cut-offs)"),
    ("b","ECG: LVH, LBBB, AF, Q waves;  Normal ECG has high negative PV for HFrEF"),
    ("b","CXR: cardiomegaly (CTR > 50%), upper lobe diversion, Kerley B lines, bat-wing oedema"),
    ("b","Echo (key investigation): confirms EF, wall motion, diastolic grading, valves"),
    ("b","Blood: CBC, RFTs, LFTs, TFTs, iron studies, troponin, HbA1c, lipids"),

    ("h1","Management – HFrEF  'Fantastic Four'  (all have mortality benefit)"),
    ("h2","1.  ACEi / ARB / ARNi"),
    ("b","ACEi (ramipril, enalapril): reduces mortality 20-25%  (CONSENSUS, SOLVD)"),
    ("b","Sacubitril/valsartan (ARNi): superior to enalapril in HFrEF  (PARADIGM-HF)"),
    ("h2","2.  Beta-blocker"),
    ("b","Carvedilol, metoprolol succinate, bisoprolol: reduces mortality 30-35%  (MERIT-HF, COPERNICUS, CIBIS-II)"),
    ("h2","3.  MRA  (Mineralocorticoid Receptor Antagonist)"),
    ("b","Spironolactone / eplerenone: NYHA Class II-IV  (RALES, EMPHASIS trials)"),
    ("h2","4.  SGLT2 Inhibitor"),
    ("b","Dapagliflozin (DAPA-HF), Empagliflozin (EMPEROR-Reduced): ALL HFrEF regardless of DM"),
    ("h2","Additional Pharmacotherapy"),
    ("b","Loop diuretics (furosemide): symptom relief – no mortality benefit"),
    ("b","Ivabradine: SR, HR >= 70 on max BB, EF <= 35%  (SHIFT trial)"),
    ("b","Hydralazine + ISDN: intolerant of ACEi/ARB, esp. Black patients  (A-HeFT)"),
    ("b","Digoxin: reduces hospitalisation; useful in AF + HF; narrow therapeutic index"),

    ("h1","Device Therapy"),
    ("b","ICD: EF <= 35%, NYHA II-III, optimal therapy >= 3 months, life expectancy > 1 yr"),
    ("b","CRT: EF <= 35%, LBBB, QRS >= 150 ms, NYHA II-IV"),

    ("h1","Acute Decompensated HF (ADHF)"),
    ("b","Sit upright, O2 (SpO2 >= 95%), NIV (CPAP/BiPAP) if severe pulm. oedema  (3CPO trial)"),
    ("b","IV furosemide 40-80 mg  (DOSE trial: high-dose preferred)"),
    ("b","IV GTN if SBP > 100;  inotropes (dobutamine) if cardiogenic shock"),
    ("b","Identify & treat precipitant: ACS, AF, HTN emergency, infection"),

    ("div",""),("pb",""),

    # ─── Q3 ───────────────────────────────────────────────────────────────────
    ("qhead","Q.3  G-Protein Receptor Disorders + Approach to Hyperthyroidism  [20 Marks]"),
    ("h1","Part A – Genetic Causes of GPCR Disorders"),
    ("body","GPCRs transduce extracellular signals via heterotrimeric G-proteins (Gs, Gi, Gq). Mutations are LOF (loss-of-function) or GOF (gain-of-function), each producing distinct clinical syndromes."),

    ("h2","A.  Loss-of-Function (LOF) – Resistance Syndromes"),
    ("b","PHP Ia (GNAS1 – Gs-alpha, paternal imprinting): Albright Hereditary Osteodystrophy – short stature, round face, brachydactyly, subcutaneous ossification; multi-hormone resistance (PTH, TSH, LH, FSH, GHRH)"),
    ("b","PHP Ib (PTHR1): hypocalcaemia, hyperphosphataemia; PTH high; AHO features absent"),
    ("b","Congenital hypothyroidism (TSHR LOF): athyrosis / hypoplastic thyroid; high TSH, low T4"),
    ("b","Nephrogenic DI (AVPR2 – X-linked): polyuria, polydipsia; unresponsive to ADH"),
    ("b","Familial glucocorticoid deficiency (MC2R): hypoglycaemia, hyperpigmentation, tall stature; ACTH high, cortisol low"),
    ("b","Monogenic obesity (MC4R): most common monogenic form; hyperphagia, hyperinsulinaemia"),
    ("b","Retinitis Pigmentosa (RHO): progressive visual loss, nyctalopia, tunnel vision"),
    ("b","Leydig cell hypoplasia (LHCGR LOF): XY females / male pseudohermaphroditism"),

    ("h2","B.  Gain-of-Function (GOF) – Constitutive Activation"),
    ("b","Familial non-autoimmune hyperthyroidism (TSHR germline GOF): AD; hyperthyroidism without goitre; low TSH; negative thyroid antibodies"),
    ("b","Toxic adenoma / TMNG (TSHR somatic GOF): autonomous thyroid function; hot nodule on scan"),
    ("b","McCune-Albright Syndrome (GNAS1 somatic R201C/H): polyostotic fibrous dysplasia + cafe-au-lait spots + precocious puberty; also thyrotoxicosis, GH excess, Cushing"),
    ("b","Familial male-limited precocious puberty / testotoxicosis (LHCGR germline GOF)"),
    ("b","Jansen metaphyseal chondrodysplasia (PTHR1 GOF): hypercalcaemia + hypophosphataemia, normal PTH; short-limbed dwarfism"),
    ("b","Autosomal dominant hypocalcaemia (CASR GOF): low PTH; nephrocalcinosis risk with treatment"),

    ("h1","Part B – Approach to Hyperthyroidism"),
    ("h2","Causes  (by radioiodine uptake)"),
    ("b","HIGH uptake: Graves disease (TRAb +ve, most common overall), TMNG (Plummer), Toxic adenoma, TSH-secreting pituitary adenoma, HCG-mediated (gestational thyrotox, hydatidiform mole)"),
    ("b","LOW/absent: De Quervain thyroiditis (painful, post-viral), Hashitoxicosis, Painless/postpartum thyroiditis, Iodine-induced (Jod-Basedow), Amiodarone-induced (Type I & II), Factitious, Struma ovarii"),

    ("h2","Clinical Features"),
    ("b","Hypermetabolic: heat intolerance, weight loss despite increased appetite, sweating, fatigue"),
    ("b","CVS: palpitations, exertional dyspnoea, AF (in elderly)"),
    ("b","Neuro: anxiety, irritability, fine tremor of outstretched hands, insomnia"),
    ("b","GI: diarrhoea, increased bowel frequency"),
    ("b","Graves eye signs: exophthalmos (proptosis), lid lag (von Graefe), lid retraction (Dalrymple), periorbital oedema"),
    ("b","Graves skin: pretibial myxoedema (bilateral non-pitting shin oedema), thyroid acropachy, bruit over thyroid"),

    ("h2","Investigations"),
    ("b","Step 1 – Confirm: TSH suppressed (< 0.1 mIU/L), FT4 elevated, FT3 (T3 toxicosis if FT4 normal)"),
    ("b","Step 2 – Aetiology: TRAb/TSI (Graves 90-95% sensitivity), radionuclide scan, thyroid USS + Doppler"),

    ("h2","Management"),
    ("b","Symptomatic (all causes): beta-blockers – propranolol 40 mg TDS (also inhibits T4->T3 conversion)"),
    ("b","ATDs: carbimazole / methimazole (1st line);  PTU preferred in 1st trimester & thyroid storm"),
    ("b","Radioiodine (I-131): definitive in Graves/TMNG; contraindicated in pregnancy, breastfeeding, active ophthalmopathy"),
    ("b","Surgery: large goitre with compressive symptoms, suspected malignancy, failed ATD/RAI"),
    ("b","Thyroid storm (Burch-Wartofsky >= 45): PTU (500-1000 mg loading) + IV propranolol + iodine (1 h AFTER PTU) + hydrocortisone 100 mg TDS + cooling + treat precipitant"),

    ("div",""),("pb",""),

    # ─── Q4 ───────────────────────────────────────────────────────────────────
    ("qhead","Q.4  Lymphadenopathy (Causes) + Approach to Splenomegaly  [20 Marks]"),
    ("h1","Part A – Causes of Lymphadenopathy"),
    ("body","Lymphadenopathy = nodes abnormal in size (> 1 cm most regions, > 1.5 cm inguinal), consistency, or number."),

    ("h2","1.  Infectious  (most common)"),
    ("b","Viral: EBV (infectious mononucleosis), CMV, HIV (acute seroconversion), adenovirus, rubella, hepatitis"),
    ("b","Bacterial: Streptococcal pharyngitis, Staph, TB (scrofula – cervical), brucellosis, cat-scratch (Bartonella), syphilis (secondary – generalised)"),
    ("b","Protozoal: Toxoplasmosis, Leishmaniasis (kala-azar)"),
    ("b","Fungal: Histoplasmosis;  Helminthic: Filariasis"),

    ("h2","2.  Neoplastic"),
    ("b","Primary: Hodgkin lymphoma (Reed-Sternberg cells; B symptoms), NHL, leukaemias (CLL, ALL, CML)"),
    ("b","Metastatic: Cervical (oral/NPC/thyroid), Axillary (breast/lung/melanoma), Inguinal (genital/anorectal)"),
    ("b","Virchow's node (left supraclavicular): GI/lung/testicular – Troisier sign"),

    ("h2","3.  Inflammatory / Autoimmune"),
    ("b","SLE, Rheumatoid arthritis"),
    ("b","Sarcoidosis: bilateral hilar adenopathy +/- paratracheal; erythema nodosum; hypercalcaemia"),
    ("b","Kikuchi-Fujimoto (necrotising histiocytic lymphadenitis; young Asian women; cervical; self-limiting)"),
    ("b","Kawasaki disease (children);  Adult-onset Still's disease"),

    ("h2","4.  Drug-induced"),
    ("b","Phenytoin (pseudolymphoma), carbamazepine, hydralazine, allopurinol, sulphonamides"),

    ("h2","5.  Storage / Infiltrative"),
    ("b","Gaucher, Niemann-Pick, Amyloidosis, Castleman disease"),

    ("h1","Part B – Approach to Splenomegaly"),
    ("h2","Grading"),
    ("b","Mild: < 4 cm below costal margin   Moderate: 4-8 cm   Massive: > 8 cm / crosses midline"),
    ("body","Massive splenomegaly mnemonic 'CCML':  Chronic malaria, CML, Myelofibrosis, Leishmaniasis  (also polycythaemia vera, thalassaemia major, Gaucher)"),

    ("h2","Causes"),
    ("b","Infective: malaria (P. vivax/malariae), EBV, typhoid, SBE  (acute);  visceral leishmaniasis, TB  (chronic)"),
    ("b","Haematological: haemolytic anaemias (HS, thalassaemia, SCD – autosplenectomy in adults), MPNs (CML – massive), CLL, hairy cell leukaemia"),
    ("b","Congestive: portal HTN (cirrhosis – most common in clinical practice), Budd-Chiari, portal vein thrombosis, RHF"),
    ("b","Inflammatory: Felty syndrome (RA + neutropenia + splenomegaly), SLE, sarcoidosis"),
    ("b","Infiltrative: Gaucher (massive), amyloid, extramedullary haematopoiesis"),

    ("h2","Investigations"),
    ("b","FBC + differential + peripheral smear  (key: leukocytosis CML, target cells thalassaemia, parasites malaria)"),
    ("b","LFTs, PT/INR;  USS abdomen: confirm splenomegaly, liver, portal vein"),
    ("b","Blood cultures, blood film for malaria (if febrile), serology"),
    ("b","Bone marrow biopsy (haematological malignancy / leishmaniasis)"),
    ("b","CT CAP; LDH, uric acid, beta-2 microglobulin; JAK2 V617F (MPN); glucocerebrosidase (Gaucher)"),

    ("div",""),("pb",""),

    # ─── Q5a ──────────────────────────────────────────────────────────────────
    ("qhead","Q.5a  RPGN – Immunofluorescence Classification + Immediate Interventions  [10 Marks]"),
    ("h1","Definition"),
    ("body","RPGN = rapid deterioration of renal function (>= 50% GFR loss over days to weeks) with crescents in >= 50% glomeruli on renal biopsy.  Without treatment -> ESRD within weeks to months."),

    ("h1","Classification by Immunofluorescence"),
    ("trow","Type   IF Pattern              Pathology               Diseases                    %"),
    ("trow","----   -------------------     ------------------      -----------------------     ------"),
    ("trow","  I    LINEAR IgG on GBM       Anti-GBM Ab (a3 IV)    Goodpasture syndrome         10-15%"),
    ("trow"," II    GRANULAR (lumpy-bumpy)  Immune complex dep.    IgA vasculitis / LN / MPGN   40%"),
    ("trow","III    PAUCI-IMMUNE (-ve IF)   ANCA-mediated           GPA (cANCA), MPA (pANCA)    45-50%"),
    ("trow"," IV    Double positive          Anti-GBM + ANCA        Particularly aggressive      ~10%"),

    ("h1","Immediate Therapeutic Interventions"),
    ("h2","1.  Pulse Methylprednisolone  (ALL types)"),
    ("b","IV methylprednisolone 500-1000 mg/day x 3 consecutive days"),
    ("b","Then oral prednisolone 1 mg/kg/day (max 60 mg); taper over 6 months"),

    ("h2","2.  Cyclophosphamide  (Type III – ANCA; also Type II)"),
    ("b","IV cyclophosphamide 15 mg/kg Q2-3 weeks (CYCLOPS regimen);  OR oral 2 mg/kg/day"),
    ("b","Rituximab: non-inferior to CYC in ANCA vasculitis  (RAVE, RITUXVAS);  preferred in young women"),

    ("h2","3.  Plasmapheresis / TPE"),
    ("b","MANDATORY in Type I (Goodpasture): removes anti-GBM Abs; daily x 14 days"),
    ("b","ANCA + pulmonary haemorrhage or severe AKI: consider TPE  (PEXIVAS 2020)"),

    ("h2","4.  Additional"),
    ("b","Dialysis if AEIOU criteria met"),
    ("b","PCP prophylaxis: TMP-SMX 960 mg three times per week"),
    ("b","PPI for gastric protection during high-dose steroids"),
    ("b","Maintenance: azathioprine 2 mg/kg/day OR rituximab for 18-24 months  (ANCA vasculitis)"),

    ("div",""),

    # ─── Q5b ──────────────────────────────────────────────────────────────────
    ("qhead","Q.5b  LPV, Prone Positioning & NMB in Severe ARDS  [10 Marks]"),
    ("h1","ARDS  –  Berlin Definition (2012)"),
    ("b","Acute onset within 1 week; bilateral opacities on CXR/CT; not explained by cardiac failure"),
    ("b","Severe ARDS: PaO2/FiO2 <= 100 mmHg with PEEP >= 5 cmH2O"),

    ("h1","A.  Lung Protective Ventilation (LPV)"),
    ("h2","Physiological Basis"),
    ("b","ARDS 'baby lung': only 200-400 g of aerated lung tissue"),
    ("b","Large tidal volumes cause: volutrauma, barotrauma, atelectrauma, biotrauma (cytokine release -> VILI -> MSOF)"),
    ("b","LPV principle: low VT prevents overdistension; PEEP prevents atelectrauma"),
    ("h2","Strategy"),
    ("b","VT = 6 mL/kg PBW   |   Plateau pressure <= 30 cmH2O   |   Driving pressure <= 15 cmH2O"),
    ("b","PEEP: titrate per ARDSNet PEEP-FiO2 table   |   Target SpO2 88-95%"),
    ("b","Permissive hypercapnia: allow PaCO2 up to 60 mmHg  (avoid in raised ICP)"),
    ("h2","Clinical Evidence"),
    ("b","ARMA Trial (NEJM 2000): VT 6 vs 12 mL/kg; 28-day mortality 31% vs 40%;  NNT = 11  ->  standard of care"),
    ("b","Driving pressure analysis (Amato, NEJM 2015): DP <= 15 cmH2O most strongly associated with survival"),

    ("h1","B.  Prone Positioning"),
    ("h2","Physiological Basis"),
    ("b","Supine ARDS: posterior lung collapsed (oedema, cardiac compression by mediastinum)"),
    ("b","Prone: improves V/Q matching, recruits posterior lung, reduces driving pressure, aids secretion drainage"),
    ("h2","Protocol"),
    ("b","Indication: severe ARDS – PF <= 150 mmHg, FiO2 >= 0.6, PEEP >= 5"),
    ("b","Timing: within 36-48 h of ARDS onset   |   Duration: >= 16 h/day"),
    ("b","Discontinue when PF > 150 on FiO2 <= 0.6, PEEP <= 10 for >= 4 h in supine"),
    ("h2","Clinical Evidence"),
    ("b","PROSEVA (Guerin, NEJM 2013): 28-day mortality 16% vs 32.8%  (ARR 16.8%; NNT = 6) – most impactful ARDS trial since ARMA"),

    ("h1","C.  Neuromuscular Blockade (NMB)"),
    ("h2","Physiological Basis"),
    ("b","Severe ARDS: spontaneous breathing -> high transpulmonary pressures -> P-SILI (patient self-inflicted lung injury)"),
    ("b","NMB eliminates spontaneous breathing -> reduces P-SILI, ventilator dyssynchrony, auto-PEEP"),
    ("b","Cisatracurium also reduces systemic cytokines (IL-8, IL-6)"),
    ("h2","Regimen"),
    ("b","Agent: cisatracurium (Nimbex) – Hofmann elimination, organ-independent, reduced ICU-acquired weakness"),
    ("b","IV infusion 37.5 mg/h for 48 h; deep sedation required (RASS -4 to -5); TOF monitoring (target 1-2 twitches)"),
    ("h2","Clinical Evidence"),
    ("b","ACURASYS (NEJM 2010): cisatracurium 48 h -> adjusted 90-day mortality benefit; reduced barotrauma"),
    ("b","ROSE (NEJM 2019): no difference vs light sedation -> NMB NOT routine for all ARDS"),
    ("b","Current practice (2024): NMB reserved for P/F < 120-150, refractory dyssynchrony, or to facilitate proning"),

    ("h2","Summary"),
    ("trow","Intervention        Indication               Key Trial        Benefit"),
    ("trow","----------------    ---------------------    -------------    ----------------"),
    ("trow","LPV (6 mL/kg)       ALL ARDS                 ARMA 2000        Yes – NNT 11"),
    ("trow","Prone >= 16 h/day   Severe ARDS  PF <= 150   PROSEVA 2013     Yes – NNT 6"),
    ("trow","NMB (cisatrac.)     Refractory / PF < 120    ACURASYS/ROSE    Conditional"),

    ("div",""),
    ("body","Ref: Harrison's 22E (2025)  |  Braunwald's Heart Disease 12e  |  Brenner & Rector's The Kidney  |  Goldman-Cecil Medicine"),
]


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        c.drawCentredString(PAGE_W/2, PAGE_H - 2.0*cm, "Supplementary Handwritten Model Answer Key")
        c.setFont("KalamBold", 13)
        c.drawCentredString(PAGE_W/2, PAGE_H - 2.8*cm, "4th Semester (P.G.)  –  General Medicine")

        # White body with ruled lines
        c.setFillColor(PAPER)
        c.rect(0, 0, PAGE_W, PAGE_H - 3.6*cm, fill=1, stroke=0)
        c.setStrokeColor(RULE_COL); c.setLineWidth(0.35)
        y = PAGE_H - 3.6*cm - 0.2*cm
        while y > MARGIN_B:
            c.line(0.5*cm, y, PAGE_W - 0.4*cm, y); y -= LINE_H

        # Info box – simple black border
        bx = MARGIN_L; by = PAGE_H - 7.5*cm
        bw = PAGE_W - MARGIN_L - MARGIN_R; bh = 4.0*cm
        c.setFillColor(colors.HexColor("#f5f5f5"))
        c.setStrokeColor(colors.black); c.setLineWidth(0.8)
        c.rect(bx, by, bw, bh, fill=1, stroke=1)

        c.setFillColor(colors.black)
        c.setFont("KalamBold", 11)
        c.drawString(bx + 0.4*cm, by + bh - 0.8*cm, "Total Marks: 100   |   All questions are compulsory")
        c.setFont("Kalam", 10.5)
        items = [
            "Q.1  Oliguria – Evaluation & Management                     [20 Marks]",
            "Q.2  Heart Failure                                           [20 Marks]",
            "Q.3  G-Protein Receptor Disorders + Hyperthyroidism          [20 Marks]",
            "Q.4  Lymphadenopathy + Approach to Splenomegaly             [20 Marks]",
            "Q.5  Short Notes: (a) RPGN   (b) ARDS – LPV / Prone / NMB  [20 Marks]",
        ]
        ry = by + bh - 1.4*cm
        for item in items:
            c.drawString(bx + 0.4*cm, ry, item); ry -= 0.52*cm

        # Footer note
        c.setFont("Kalam", 8); c.setFillColor(colors.HexColor("#555555"))
        c.drawCentredString(PAGE_W/2, 1.0*cm,
            "Do not write your name anywhere on this sheet.   Use Black / Blue ink only.")
        self._newpage()

    # ── main render ──────────────────────────────────────────────────────────
    def render(self, content):
        self._cover()
        for typ, txt in content:
            if typ == "cover":
                continue
            elif typ == "pb":
                self._newpage()
            elif typ == "div":
                self.y -= 0.2*cm; self._need(1)
                # hand-drawn divider
                self._wobbly_underline(TEXT_X, PAGE_W - MARGIN_R, self.y, 0.5)
                self.y -= 0.45*cm
            elif typ == "qhead":
                self.y -= 0.25*cm; self._need(2)
                self._writeline(txt, "KalamBold", Q_SZ, TEXT_X, INK_HEAD)
                # full-width wobbly underline below
                ul_y = self.y + LINE_H - 0.05*cm
                self._wobbly_underline(TEXT_X - 0.1*cm, PAGE_W - MARGIN_R, ul_y, 0.7)
                self.y -= 0.1*cm
            elif typ == "h1":
                self.y -= 0.12*cm; self._need(2)
                self._writeline(txt, "KalamBold", HEAD_SZ, TEXT_X, INK_HEAD)
                ul_y = self.y + LINE_H - 0.1*cm
                self._wobbly_underline(TEXT_X, TEXT_X + 9*cm, ul_y, 0.55)
            elif typ == "h2":
                self.y -= 0.05*cm
                self._writeline(txt, "KalamBold", BODY_SZ + 0.5, TEXT_X + 0.3*cm, INK_DIM)
            elif typ == "body":
                self._writeline(txt, "Kalam", BODY_SZ, TEXT_X, INK)
            elif typ == "b":
                self._need(1)
                # imperfect bullet: small filled circle with slight position jitter
                bx = TEXT_X + 0.35*cm + random.uniform(-0.5, 0.5)
                by_ = self.y + 0.28*cm + random.uniform(-0.5, 0.5)
                self.c.setFillColor(INK)
                self.c.circle(bx, by_, 1.6 + random.uniform(-0.3, 0.3), fill=1, stroke=0)
                self._writeline(txt, "Kalam", BODY_SZ, TEXT_X + 0.75*cm, INK)
            elif typ == "trow":
                self._writeline(txt, "Kalam", TBL_SZ, TEXT_X + 0.2*cm, INK)

    def save(self):
        self.c.save()
        print(f"Saved to: {OUT_PATH}")


hw = HWPDF(OUT_PATH)
hw.render(CONTENT)
hw.save()

from pypdf import PdfReader
r = PdfReader(OUT_PATH)
print(f"Total pages: {len(r.pages)}")
import os; print(f"File size: {os.path.getsize(OUT_PATH)//1024} KB")

#!/usr/bin/env python3
"""
PG4 General Medicine – Model Answer Key
Maximum realism handwritten PDF.

Key techniques:
- Word-by-word rendering with per-word:
    * vertical jitter  (+/- 3 pt off the baseline)
    * slight rotation  (+/- 1.5 deg)
    * font-size drift  (base +/- 0.6 pt)
    * ink shade drift  (near-black, varies slightly)
    * small horizontal spacing variation
- Line-by-line:
    * left-margin start jitter (+/- 3 pt)
    * line-height jitter
- No bold, no underline, no highlight, no colour
- Single font (Kalam-Regular) everywhere
- Headings = same font, 1-2 pt larger only
- Plain white paper + faint grey ruled lines
- Very faint left margin line (pencil-grey)
"""

import random, math
from reportlab.lib.pagesizes import A4
from reportlab.lib.units import cm, pt
from reportlab.lib import colors
from reportlab.pdfgen import canvas
from reportlab.pdfbase import pdfmetrics
from reportlab.pdfbase.ttfonts import TTFont

random.seed(17)

FONT_DIR = "/home/daytona/workspace/answer-key-pdf/fonts"
OUT_PATH = "/home/daytona/workspace/answer-key-pdf/PG4_GM_RealHandwriting.pdf"

pdfmetrics.registerFont(TTFont("HW", f"{FONT_DIR}/Kalam-Regular.ttf"))

# ── geometry ──────────────────────────────────────────────────────────────────
PAGE_W, PAGE_H = A4
ML = 2.3 * cm       # left margin (where text starts after margin line)
MR = 1.2 * cm
MT = 1.9 * cm
MB = 1.7 * cm
LH = 0.91 * cm      # ruled-line pitch

# ── base sizes ────────────────────────────────────────────────────────────────
SZ_BODY = 11.8
SZ_HEAD = 13.0      # just slightly bigger, same font
SZ_Q    = 13.5
SZ_TBL  = 10.0

# ── ink shades (greyscale, slightly varying) ──────────────────────────────────
def ink():
    """Return a near-black colour with slight variation."""
    v = random.randint(0, 28)
    return colors.Color(v/255, v/255, v/255)

def ink_head():
    v = random.randint(0, 15)
    return colors.Color(v/255, v/255, v/255)


# ══════════════════════════════════════════════════════════════════════════════
#  Word-level renderer
# ══════════════════════════════════════════════════════════════════════════════

class WordWriter:
    """
    Renders text word-by-word onto a canvas with realistic handwriting jitter.
    Call write_para() to lay out a paragraph (auto-wraps to next line).
    """

    def __init__(self, c: canvas.Canvas, page_h, ml, mr, lh, mb):
        self.c    = c
        self.page_h = page_h
        self.ml   = ml
        self.mr   = mr
        self.lh   = lh
        self.mb   = mb
        self.y    = page_h        # will be set externally
        self.new_page_cb = None   # callback when page break needed

    def _word_width(self, word, size):
        return self.c.stringWidth(word, "HW", size)

    def _check_page(self):
        if self.y < self.mb + self.lh:
            if self.new_page_cb:
                self.new_page_cb()

    def write_para(self, text, base_size, x_start=None, extra_left=0.0,
                   line_start_jitter=3.0, word_y_jitter=3.0,
                   word_rot_max=1.5, size_spread=0.6, space_spread=1.5):
        """
        Lay out `text` starting at x_start (default ml+extra_left),
        word by word, with per-word jitter.
        """
        if not text.strip():
            self.y -= self.lh
            return

        if x_start is None:
            x_start = self.ml + extra_left

        words = text.split()
        avail_w = PAGE_W - self.mr - x_start

        # Build lines by measuring words
        lines = []
        cur_line = []
        cur_w = 0.0
        sz = base_size
        for word in words:
            ww = self._word_width(word + " ", sz)
            if cur_w + ww > avail_w and cur_line:
                lines.append(cur_line)
                cur_line = [word]
                cur_w = ww
            else:
                cur_line.append(word)
                cur_w += ww
        if cur_line:
            lines.append(cur_line)

        for line_words in lines:
            self._check_page()
            # per-line left-start jitter
            x = x_start + random.uniform(-line_start_jitter, line_start_jitter)
            baseline = self.y

            for word in line_words:
                # per-word size
                wsz = sz + random.uniform(-size_spread, size_spread)
                # per-word vertical jitter
                wy = baseline + random.uniform(-word_y_jitter, word_y_jitter)
                # per-word rotation (small tilt)
                angle = random.uniform(-word_rot_max, word_rot_max)
                # per-word ink shade
                col = ink()

                self.c.saveState()
                self.c.setFillColor(col)
                self.c.setFont("HW", wsz)
                self.c.translate(x, wy)
                self.c.rotate(angle)
                self.c.drawString(0, 0, word)
                self.c.restoreState()

                # advance x: word width + natural spacing + small jitter
                ww = self._word_width(word, wsz)
                space = self._word_width(" ", wsz) + random.uniform(-space_spread, space_spread)
                x += ww + space

            self.y -= self.lh * (1 + random.uniform(-0.04, 0.06))


# ══════════════════════════════════════════════════════════════════════════════
#  PDF builder
# ══════════════════════════════════════════════════════════════════════════════

class RealisticHW:
    def __init__(self, path):
        self.c      = canvas.Canvas(path, pagesize=A4)
        self.c.setTitle("PG4 General Medicine – Model Answer Key")
        self.pageno = 1
        self.ww     = WordWriter(self.c, PAGE_H, ML, MR, LH, MB)
        self.ww.new_page_cb = self._newpage
        self._draw_bg()
        self.ww.y = PAGE_H - MT

    def _draw_bg(self):
        c = self.c
        # White paper
        c.setFillColor(colors.white)
        c.rect(0, 0, PAGE_W, PAGE_H, fill=1, stroke=0)
        # Faint grey ruled lines
        c.setStrokeColor(colors.HexColor("#d0d0d0"))
        c.setLineWidth(0.3)
        y = PAGE_H - MT
        while y > MB:
            c.line(0.6*cm, y, PAGE_W - 0.5*cm, y)
            y -= LH
        # Very faint left margin line (pencil grey)
        c.setStrokeColor(colors.HexColor("#dddddd"))
        c.setLineWidth(0.5)
        c.line(ML - 0.2*cm, MB, ML - 0.2*cm, PAGE_H - MT + LH)
        # Page number bottom centre, tiny grey
        c.setFont("HW", 8)
        c.setFillColor(colors.HexColor("#aaaaaa"))
        c.drawCentredString(PAGE_W/2, 0.85*cm, str(self.pageno))

    def _newpage(self):
        self.c.showPage()
        self.pageno += 1
        self._draw_bg()
        self.ww.y = PAGE_H - MT

    def _gap(self, lines=0.4):
        self.ww.y -= LH * lines
        if self.ww.y < MB + LH:
            self._newpage()

    # ── convenience writers ──────────────────────────────────────────────────

    def qhead(self, text):
        """Question heading – slightly bigger, slightly less jitter (more deliberate writing)."""
        self._gap(0.3)
        self.ww.write_para(text, SZ_Q, extra_left=0,
                           line_start_jitter=2, word_y_jitter=2.5,
                           word_rot_max=1.2, size_spread=0.4)
        self._gap(0.15)

    def heading(self, text):
        self._gap(0.15)
        self.ww.write_para(text, SZ_HEAD, extra_left=0,
                           line_start_jitter=2.5, word_y_jitter=2.8,
                           word_rot_max=1.3, size_spread=0.5)
        self._gap(0.05)

    def subhead(self, text):
        self.ww.write_para(text, SZ_BODY + 0.5, extra_left=0.3*cm,
                           line_start_jitter=2.5, word_y_jitter=3,
                           word_rot_max=1.5, size_spread=0.6)

    def body(self, text):
        self.ww.write_para(text, SZ_BODY, extra_left=0,
                           line_start_jitter=3, word_y_jitter=3,
                           word_rot_max=1.5, size_spread=0.6)

    def bullet(self, text):
        # Draw a hand-drawn bullet dot first
        ww = self.ww
        if ww.y < MB + LH:
            self._newpage()
        bx = ML + 0.3*cm + random.uniform(-1, 1)
        by = ww.y + 0.3*cm + random.uniform(-1.5, 1.5)
        r  = 1.5 + random.uniform(-0.4, 0.4)
        self.c.setFillColor(ink())
        self.c.circle(bx, by, r, fill=1, stroke=0)
        # Text starts after bullet
        self.ww.write_para(text, SZ_BODY, extra_left=0.7*cm,
                           line_start_jitter=2, word_y_jitter=3,
                           word_rot_max=1.5, size_spread=0.6)

    def trow(self, text):
        self.ww.write_para(text, SZ_TBL, extra_left=0.2*cm,
                           line_start_jitter=1.5, word_y_jitter=2,
                           word_rot_max=0.8, size_spread=0.4)

    def divider(self):
        self._gap(0.3)
        # hand-drawn wavy divider line
        c = self.c
        y0 = self.ww.y + LH * 0.3
        c.setStrokeColor(colors.HexColor("#888888"))
        c.setLineWidth(0.5)
        p = c.beginPath()
        x0 = ML; x1 = PAGE_W - MR
        p.moveTo(x0, y0 + random.uniform(-1, 1))
        steps = 20
        for i in range(1, steps+1):
            xi = x0 + (x1-x0)*i/steps
            yi = y0 + random.uniform(-1.5, 1.5)
            p.lineTo(xi, yi)
        c.drawPath(p, stroke=1, fill=0)
        self._gap(0.4)

    def pb(self):
        self._newpage()

    # ── cover ────────────────────────────────────────────────────────────────
    def cover(self):
        c = self.c
        # Plain white cover – just a thin black border box at top
        c.setStrokeColor(colors.black); c.setLineWidth(0.8)
        c.rect(ML - 0.5*cm, PAGE_H - 3.8*cm, PAGE_W - ML - MR + 0.5*cm, 3.4*cm, fill=0, stroke=1)

        # Write cover text word-by-word as handwriting
        cov_ww = WordWriter(c, PAGE_H, ML, MR, LH, MB)
        cov_ww.y = PAGE_H - MT - 0.2*cm

        cov_ww.write_para("Smt. N H L Municipal Medical College", SZ_Q + 1,
                           x_start = ML + 0.3*cm,
                           line_start_jitter=1.5, word_y_jitter=2,
                           word_rot_max=1.0, size_spread=0.4)
        cov_ww.write_para("Supplementary Handwritten Model Answer Key", SZ_HEAD - 0.5,
                           x_start = ML + 0.3*cm,
                           line_start_jitter=2, word_y_jitter=2.2,
                           word_rot_max=1.2, size_spread=0.5)
        cov_ww.write_para("4th Semester (P.G.)  -  General Medicine", SZ_HEAD,
                           x_start = ML + 0.3*cm,
                           line_start_jitter=2, word_y_jitter=2.5,
                           word_rot_max=1.3, size_spread=0.5)

        cov_ww.y -= LH * 1.5

        items = [
            "Total Marks: 100   |   All questions are compulsory",
            "",
            "Q.1  Oliguria - Evaluation & Management                  [20 Marks]",
            "Q.2  Heart Failure                                        [20 Marks]",
            "Q.3  G-Protein Receptor Disorders + Hyperthyroidism       [20 Marks]",
            "Q.4  Lymphadenopathy + Approach to Splenomegaly          [20 Marks]",
            "Q.5  Short Notes: (a) RPGN  (b) ARDS - LPV/Prone/NMB    [20 Marks]",
        ]
        for item in items:
            if item == "":
                cov_ww.y -= LH * 0.5
            else:
                cov_ww.write_para(item, SZ_BODY,
                                   x_start = ML + 0.5*cm,
                                   line_start_jitter=2, word_y_jitter=2.5,
                                   word_rot_max=1.2, size_spread=0.5)

        # footer
        c.setFont("HW", 8); c.setFillColor(colors.HexColor("#888888"))
        c.drawCentredString(PAGE_W/2, 1.0*cm,
            "Do not write your name on this sheet.  Use Black / Blue ink only.")
        self._newpage()

    # ── main render ──────────────────────────────────────────────────────────
    def render(self, content):
        self.cover()
        for typ, txt in content:
            if   typ == "cover":   pass
            elif typ == "pb":      self.pb()
            elif typ == "div":     self.divider()
            elif typ == "qhead":   self.qhead(txt)
            elif typ == "h1":      self.heading(txt)
            elif typ == "h2":      self.subhead(txt)
            elif typ == "body":    self.body(txt)
            elif typ == "b":       self.bullet(txt)
            elif typ == "trow":    self.trow(txt)

    def save(self):
        self.c.save()
        print(f"Saved: {OUT_PATH}")


# ══════════════════════════════════════════════════════════════════════════════
#  Content
# ══════════════════════════════════════════════════════════════════════════════
CONTENT = [
    ("cover",""),

    # ─── Q1 ───────────────────────────────────────────────────────────────────
    ("qhead","Q.1  Evaluate and Manage the Patient Admitted with Oliguria  [20 Marks]"),

    ("h1","Definition"),
    ("body","Oliguria = urine output less than 400 mL/24 h  (or less than 0.5 mL/kg/h in adults)"),
    ("body","Anuria = less than 100 mL/24 h.  Key clinical indicator of AKI; demands urgent evaluation."),

    ("h1","Pathophysiological Classification"),

    ("h2","1. Pre-renal  -  Decreased effective circulating volume / renal perfusion"),
    ("b","Absolute hypovolaemia: haemorrhage, diarrhoea/vomiting, burns, diuretic excess"),
    ("b","Distributive: sepsis, anaphylaxis, hepatorenal syndrome"),
    ("b","Cardiogenic: CCF, MI, tamponade"),
    ("b","Renal artery stenosis / renal vein thrombosis"),

    ("h2","2. Intrinsic (Renal)  -  Parenchymal kidney damage"),
    ("b","Tubular: ATN - ischaemic or nephrotoxic (drugs, contrast, myoglobin)"),
    ("b","Glomerular: RPGN, Acute nephritic syndrome"),
    ("b","Interstitial: AIN - drugs (NSAIDs, antibiotics), infection"),
    ("b","Vascular: TMA (HUS/TTP), Renal artery occlusion, MUS17TP"),

    ("h2","3. Post-renal  -  Obstruction"),
    ("b","Ureteric: bilateral calculi, retroperitoneal fibrosis, malignancy"),
    ("b","Bladder outlet: BPH, urethral stricture, neurogenic bladder"),

    ("h1","Signs and Symptoms"),
    ("b","Decreased UO, increased fluid intake history, drugs  ->  haematuria / AKI"),
    ("b","Pre-renal AKI  ->  hypotension"),
    ("b","Raised JVP, distended bladder"),
    ("b","Rashes, purpura, jaundice"),

    ("h1","History"),
    ("b","Duration of reduced urine output; fluid intake and losses (vomiting, diarrhoea, bleeding)"),
    ("b","Drug history: NSAIDs, aminoglycosides, contrast, ACEi / ARBs"),
    ("b","PMH: DM, HTN, CKD, CCF, malignancy"),
    ("b","Obstruction symptoms: hesitancy, poor stream, suprapubic pain"),
    ("b","Glomerular symptoms: haematuria, frothy urine, oedema"),
    ("b","Systemic: rash, arthralgia, haemoptysis (vasculitis), purpura (HUS/TTP)"),

    ("h1","Investigations  -  Difference Between Pre-renal vs Renal (ATN)"),
    ("trow","Parameter               Pre-renal             Renal (ATN)"),
    ("trow","-------------------     ----------------      ----------------"),
    ("trow","U. Osmolality           > 500 mOsm/kg         < 350 mOsm/kg"),
    ("trow","U. Na                   < 20 mEq/L            > 40 mEq/L"),
    ("trow","FENa                    < 1%                  > 2%"),
    ("trow","BUN : Creatinine        > 20 : 1              < 10 : 1"),

    ("h2","Blood Tests"),
    ("b","S.Creatinine, BUN, electrolytes (K+, Na+, HCO3-)"),
    ("b","CBC, LFTs, coagulation; CK (rhabdomyolysis); peripheral smear (TTP/HUS)"),
    ("b","Serology if GN: ANA, ANCA, anti-GBM, ASO, C3/C4, Hep B/C, HIV"),
    ("b","ABG: metabolic acidosis (high anion gap)"),

    ("h2","Imaging"),
    ("b","Renal USG (1st line): kidney size, echogenicity, bilateral obstruction, hydronephrosis"),
    ("b","Bladder scan: residual volume > 300 mL suggests outlet obstruction"),
    ("b","Doppler USS: renal artery/vein thrombosis;  CT KUB: calculi, retroperitoneal mass"),

    ("h1","Management"),

    ("h2","II.  Management"),
    ("b","Haemodialysis"),
    ("b","Fluid management"),
    ("b","Electrolyte management"),

    ("h2","General Measures"),
    ("b","Strict I/O monitoring (hourly catheterisation), daily weights"),
    ("b","Avoid nephrotoxins: NSAIDs, aminoglycosides, contrast, ACEi/ARBs"),
    ("b","Nutrition: restrict protein 0.8 g/kg/day (not on dialysis), high-calorie intake"),

    ("h2","Pre-renal"),
    ("b","Volume resuscitation: crystalloids (NS / Plasmalyte) - 500 mL bolus, reassess JVP and UO"),
    ("b","Treat cause: sepsis (Abx), CCF (diuretics + inotropes), haemorrhage (blood products)"),

    ("h2","Intrinsic (ATN)"),
    ("b","Optimise haemodynamics; MAP > 65 mmHg with vasopressors if needed"),
    ("b","Avoid diuretics to convert oliguria (no mortality benefit)"),
    ("b","Specific: stop offending drug; treat rhabdomyolysis with aggressive fluids"),
    ("b","RPGN/GN: pulse methylprednisolone +/- cyclophosphamide +/- plasmapheresis"),

    ("h2","Post-renal"),
    ("b","Relieve obstruction: urethral catheter (outlet), nephrostomy / ureteric stent"),
    ("b","Post-obstructive diuresis: replace UO with 0.45% NS at approx 75% volume"),

    ("h2","Fluid and Electrolyte Management"),
    ("b","Hyperkalaemia: Ca gluconate -> insulin-dextrose -> salbutamol -> kayexalate -> dialysis"),
    ("b","Metabolic acidosis: NaHCO3 if pH < 7.2 or HCO3- < 15 mEq/L"),
    ("b","Fluid restriction: input = insensible losses (500 mL) + prev day UO"),

    ("h2","RRT Indications  (AEIOU)"),
    ("b","A - Acidosis refractory (pH < 7.1)"),
    ("b","E - Electrolytes: K+ > 6.5 mEq/L refractory"),
    ("b","I  - Intoxication (ethylene glycol, methanol, salicylates, lithium)"),
    ("b","O - Overload (pulm oedema not responding to diuretics)"),
    ("b","U - Uraemia (encephalopathy, pericarditis, platelet dysfunction)"),
    ("body","Modalities: IHD  or  CRRT  (CRRT preferred in haemodynamically unstable patients)"),

    ("div",""),("pb",""),

    # ─── Q2 ───────────────────────────────────────────────────────────────────
    ("qhead","Q.2  Discuss in Detail Heart Failure  [20 Marks]"),

    ("h1","Definition"),
    ("body","HF = clinical syndrome where the heart cannot pump sufficient blood to meet metabolic needs, or can do so only at elevated filling pressures."),

    ("h1","Classification"),

    ("h2","By EF  (ESC 2021)"),
    ("b","HFrEF: EF < 40%   |   HFmrEF: EF 41-49%   |   HFpEF: EF >= 50%"),

    ("h2","By Onset"),
    ("b","Acute HF (de novo or acute decompensation)   /   Chronic HF (stable, compensated)"),

    ("h2","NYHA Functional Class"),
    ("b","I - No limitation     II - Slight limitation"),
    ("b","III - Marked limitation     IV - Symptoms at rest"),

    ("h1","Aetiology"),
    ("b","IHD (most common): MI, hibernating myocardium"),
    ("b","Hypertension: pressure overload -> LVH -> diastolic dysfunction -> HFpEF"),
    ("b","DCM (idiopathic, alcoholic, viral myocarditis)"),
    ("b","Valvular HD: MR/AR (volume overload);  AS/MS (pressure overload)"),
    ("b","Arrhythmias: AF, tachycardia-mediated CM"),
    ("b","Less common: HCM, Restrictive CM (amyloid, haemochromatosis), high-output HF (anaemia, thyrotoxicosis)"),
    ("b","Peripartum CM;  Chemotherapy-induced (anthracyclines, trastuzumab)"),

    ("h1","Pathophysiology"),
    ("b","Myocardial injury -> decreased CO -> SNS activation (tachycardia, vasoconstriction)"),
    ("b","RAAS: Ang II -> vasoconstriction; Aldosterone -> Na+/H2O retention -> increased preload"),
    ("b","ADH: water retention -> hyponatraemia (poor prognostic marker)"),
    ("b","Ventricular remodelling: hypertrophy, fibrosis, dilatation -> progressive dysfunction"),
    ("b","BNP/NT-proBNP: released with wall stress; used as biomarkers"),

    ("h1","Clinical Features"),

    ("h2","Symptoms"),
    ("b","Dyspnoea on exertion (earliest symptom)"),
    ("b","Orthopnoea (quantify by no. of pillows);  PND (wakes 1-2 h after sleep)"),
    ("b","Fatigue, ankle oedema, nocturia"),
    ("b","Right HF: nausea, abdominal discomfort (hepatic congestion), early satiety"),

    ("h2","Signs"),
    ("b","Tachycardia, pulsus alternans (severe LV dysfunction)"),
    ("b","Raised JVP + HJR, displaced apex beat"),
    ("b","S3 gallop (most specific - elevated filling pressures);  S4 (diastolic dysfunction)"),
    ("b","Bilateral basal crepitations, pleural effusions"),
    ("b","Tender hepatomegaly, ascites, bilateral pitting oedema"),

    ("h1","Investigations"),
    ("b","BNP > 100 pg/mL  or  NT-proBNP > 300 pg/mL  (NICE cut-offs)"),
    ("b","ECG: LVH, LBBB, AF, Q waves;  Normal ECG has high negative PV for HFrEF"),
    ("b","CXR: cardiomegaly (CTR > 50%), upper lobe diversion, Kerley B lines, bat-wing oedema"),
    ("b","Echo (key investigation): confirms EF, wall motion, diastolic grading, valves"),
    ("b","Blood: CBC, RFTs, LFTs, TFTs, iron studies, troponin, HbA1c, lipids"),

    ("h1","Management  -  HFrEF  Fantastic Four  (all have mortality benefit)"),

    ("h2","1.  ACEi / ARB / ARNi"),
    ("b","ACEi (ramipril, enalapril): reduces mortality 20-25%  (CONSENSUS, SOLVD)"),
    ("b","Sacubitril/valsartan (ARNi): superior to enalapril in HFrEF  (PARADIGM-HF)"),

    ("h2","2.  Beta-blocker"),
    ("b","Carvedilol, metoprolol succinate, bisoprolol: reduces mortality 30-35%  (MERIT-HF, COPERNICUS, CIBIS-II)"),

    ("h2","3.  MRA  (Mineralocorticoid Receptor Antagonist)"),
    ("b","Spironolactone / eplerenone: NYHA Class II-IV  (RALES, EMPHASIS trials)"),

    ("h2","4.  SGLT2 Inhibitor"),
    ("b","Dapagliflozin (DAPA-HF), Empagliflozin (EMPEROR-Reduced): ALL HFrEF regardless of DM"),

    ("h2","Additional Pharmacotherapy"),
    ("b","Loop diuretics (furosemide): symptom relief - no mortality benefit"),
    ("b","Ivabradine: SR, HR >= 70 on max BB, EF <= 35%  (SHIFT trial)"),
    ("b","Hydralazine + ISDN: intolerant of ACEi/ARB, esp Black patients  (A-HeFT)"),
    ("b","Digoxin: reduces hospitalisation; useful in AF + HF; narrow therapeutic index"),

    ("h1","Device Therapy"),
    ("b","ICD: EF <= 35%, NYHA II-III, optimal therapy >= 3 months, life expectancy > 1 yr"),
    ("b","CRT: EF <= 35%, LBBB, QRS >= 150 ms, NYHA II-IV"),

    ("h1","Acute Decompensated HF (ADHF)"),
    ("b","Sit upright, O2 (SpO2 >= 95%), NIV (CPAP/BiPAP) if severe pulm oedema  (3CPO trial)"),
    ("b","IV furosemide 40-80 mg  (DOSE trial: high-dose preferred)"),
    ("b","IV GTN if SBP > 100;  inotropes (dobutamine) if cardiogenic shock"),
    ("b","Identify and treat precipitant: ACS, AF, HTN emergency, infection"),

    ("div",""),("pb",""),

    # ─── Q3 ───────────────────────────────────────────────────────────────────
    ("qhead","Q.3  G-Protein Receptor Disorders + Approach to Hyperthyroidism  [20 Marks]"),

    ("h1","Part A  -  Genetic Causes of GPCR Disorders"),
    ("body","GPCRs transduce extracellular signals via heterotrimeric G-proteins (Gs, Gi, Gq). Mutations are LOF (loss-of-function) or GOF (gain-of-function)."),

    ("h2","A.  Loss-of-Function (LOF)  -  Resistance Syndromes"),
    ("b","PHP Ia (GNAS1 - Gs-alpha): Albright Hereditary Osteodystrophy - short stature, round face, brachydactyly; multi-hormone resistance (PTH, TSH, LH, FSH)"),
    ("b","PHP Ib (PTHR1): hypocalcaemia, hyperphosphataemia; PTH high; AHO features absent"),
    ("b","Congenital hypothyroidism (TSHR LOF): athyrosis / hypoplastic thyroid; high TSH, low T4"),
    ("b","Nephrogenic DI (AVPR2 - X-linked): polyuria, polydipsia; unresponsive to ADH"),
    ("b","Familial glucocorticoid deficiency (MC2R): hypoglycaemia, hyperpigmentation, tall stature"),
    ("b","Monogenic obesity (MC4R): most common monogenic form; hyperphagia, hyperinsulinaemia"),
    ("b","Retinitis Pigmentosa (RHO): progressive visual loss, nyctalopia, tunnel vision"),
    ("b","Leydig cell hypoplasia (LHCGR LOF): XY females / male pseudohermaphroditism"),

    ("h2","B.  Gain-of-Function (GOF)  -  Constitutive Activation"),
    ("b","Familial non-autoimmune hyperthyroidism (TSHR germline GOF): AD; hyperthyroidism without goitre; low TSH; negative thyroid antibodies"),
    ("b","Toxic adenoma / TMNG (TSHR somatic GOF): autonomous thyroid function; hot nodule on scan"),
    ("b","McCune-Albright Syndrome (GNAS1 somatic R201C/H): polyostotic fibrous dysplasia + cafe-au-lait spots + precocious puberty"),
    ("b","Familial male-limited precocious puberty / testotoxicosis (LHCGR germline GOF)"),
    ("b","Jansen metaphyseal chondrodysplasia (PTHR1 GOF): hypercalcaemia + hypophosphataemia, normal PTH; short-limbed dwarfism"),
    ("b","Autosomal dominant hypocalcaemia (CASR GOF): low PTH; nephrocalcinosis risk with treatment"),

    ("h1","Part B  -  Approach to Hyperthyroidism"),

    ("h2","Causes  (by radioiodine uptake)"),
    ("b","HIGH uptake: Graves disease (TRAb +ve, most common), TMNG (Plummer), Toxic adenoma, TSH-secreting pituitary adenoma, HCG-mediated"),
    ("b","LOW/absent: De Quervain thyroiditis (painful, post-viral), Hashitoxicosis, Painless thyroiditis, Iodine-induced, Amiodarone-induced, Factitious, Struma ovarii"),

    ("h2","Clinical Features"),
    ("b","Hypermetabolic: heat intolerance, weight loss despite increased appetite, sweating, fatigue"),
    ("b","CVS: palpitations, exertional dyspnoea, AF (in elderly)"),
    ("b","Neuro: anxiety, irritability, fine tremor of outstretched hands, insomnia"),
    ("b","Graves eye signs: exophthalmos, lid lag (von Graefe), lid retraction (Dalrymple), periorbital oedema"),
    ("b","Graves skin: pretibial myxoedema, thyroid acropachy, bruit over thyroid"),

    ("h2","Investigations"),
    ("b","Step 1 - Confirm: TSH suppressed (< 0.1 mIU/L), FT4 elevated, FT3 (T3 toxicosis if FT4 normal)"),
    ("b","Step 2 - Aetiology: TRAb/TSI (Graves 90-95% sensitivity), radionuclide scan, thyroid USS + Doppler"),

    ("h2","Management"),
    ("b","Symptomatic (all causes): beta-blockers - propranolol 40 mg TDS"),
    ("b","ATDs: carbimazole / methimazole (1st line);  PTU preferred in 1st trimester and thyroid storm"),
    ("b","Radioiodine (I-131): definitive in Graves/TMNG; contraindicated in pregnancy, breastfeeding"),
    ("b","Surgery: large goitre with compressive symptoms, suspected malignancy, failed ATD/RAI"),
    ("b","Thyroid storm (Burch-Wartofsky >= 45): PTU 500-1000 mg loading + IV propranolol + iodine (1 h AFTER PTU) + hydrocortisone 100 mg TDS + cooling"),

    ("div",""),("pb",""),

    # ─── Q4 ───────────────────────────────────────────────────────────────────
    ("qhead","Q.4  Lymphadenopathy (Causes) + Approach to Splenomegaly  [20 Marks]"),

    ("h1","Part A  -  Causes of Lymphadenopathy"),
    ("body","Lymphadenopathy = nodes abnormal in size (> 1 cm most regions, > 1.5 cm inguinal), consistency, or number."),

    ("h2","1. Infectious  (most common)"),
    ("b","Viral: EBV (infectious mononucleosis), CMV, HIV (acute seroconversion), adenovirus, rubella, hepatitis"),
    ("b","Bacterial: Streptococcal pharyngitis, Staph, TB (scrofula - cervical), brucellosis, cat-scratch (Bartonella), syphilis (secondary - generalised)"),
    ("b","Protozoal: Toxoplasmosis, Leishmaniasis (kala-azar)"),
    ("b","Fungal: Histoplasmosis;  Helminthic: Filariasis"),

    ("h2","2. Neoplastic"),
    ("b","Primary: Hodgkin lymphoma (Reed-Sternberg cells; B symptoms), NHL, leukaemias (CLL, ALL, CML)"),
    ("b","Metastatic: Cervical (oral/NPC/thyroid), Axillary (breast/lung/melanoma), Inguinal (genital/anorectal)"),
    ("b","Virchow's node (left supraclavicular): GI/lung/testicular - Troisier sign"),

    ("h2","3. Inflammatory / Autoimmune"),
    ("b","SLE, Rheumatoid arthritis"),
    ("b","Sarcoidosis: bilateral hilar adenopathy +/- paratracheal; erythema nodosum; hypercalcaemia"),
    ("b","Kikuchi-Fujimoto (necrotising histiocytic lymphadenitis; young Asian women; cervical; self-limiting)"),
    ("b","Kawasaki disease (children);  Adult-onset Still's disease"),

    ("h2","4. Drug-induced"),
    ("b","Phenytoin (pseudolymphoma), carbamazepine, hydralazine, allopurinol, sulphonamides"),

    ("h2","5. Storage / Infiltrative"),
    ("b","Gaucher, Niemann-Pick, Amyloidosis, Castleman disease"),

    ("h1","Part B  -  Approach to Splenomegaly"),

    ("h2","Grading"),
    ("b","Mild: < 4 cm below costal margin   Moderate: 4-8 cm   Massive: > 8 cm / crosses midline"),
    ("body","Massive splenomegaly mnemonic CCML:  Chronic malaria, CML, Myelofibrosis, Leishmaniasis"),

    ("h2","Causes"),
    ("b","Infective: malaria (P. vivax/malariae), EBV, typhoid, SBE  (acute);  visceral leishmaniasis, TB  (chronic)"),
    ("b","Haematological: haemolytic anaemias (HS, thalassaemia, SCD), MPNs (CML - massive), CLL, hairy cell leukaemia"),
    ("b","Congestive: portal HTN (cirrhosis - most common), Budd-Chiari, portal vein thrombosis, RHF"),
    ("b","Inflammatory: Felty syndrome (RA + neutropenia + splenomegaly), SLE, sarcoidosis"),
    ("b","Infiltrative: Gaucher (massive), amyloid, extramedullary haematopoiesis"),

    ("h2","Investigations"),
    ("b","FBC + differential + peripheral smear  (key: leukocytosis CML, target cells thalassaemia, parasites malaria)"),
    ("b","LFTs, PT/INR;  USS abdomen: confirm splenomegaly, liver, portal vein"),
    ("b","Blood cultures, blood film for malaria, serology"),
    ("b","Bone marrow biopsy (haematological malignancy / leishmaniasis)"),
    ("b","CT CAP; LDH, uric acid, beta-2 microglobulin; JAK2 V617F (MPN); glucocerebrosidase (Gaucher)"),

    ("div",""),("pb",""),

    # ─── Q5a ──────────────────────────────────────────────────────────────────
    ("qhead","Q.5a  RPGN  -  Immunofluorescence Classification + Immediate Interventions  [10 Marks]"),

    ("h1","Definition"),
    ("body","RPGN = rapid deterioration of renal function (>= 50% GFR loss over days to weeks) with crescents in >= 50% glomeruli on biopsy.  Without treatment progresses to ESRD within weeks to months."),

    ("h1","Classification by Immunofluorescence"),
    ("trow","Type   IF Pattern              Pathology               Diseases                    %"),
    ("trow","----   ------------------      ------------------      ----------------------      ------"),
    ("trow","  I    LINEAR IgG on GBM       Anti-GBM Ab (a3 IV)    Goodpasture syndrome         10-15%"),
    ("trow"," II    GRANULAR (lumpy-bumpy)  Immune complex dep.    IgA vasculitis / LN / MPGN   40%"),
    ("trow","III    PAUCI-IMMUNE (-ve IF)   ANCA-mediated           GPA (cANCA), MPA (pANCA)    45-50%"),
    ("trow"," IV    Double positive          Anti-GBM + ANCA        Particularly aggressive      ~10%"),

    ("h1","Immediate Therapeutic Interventions"),

    ("h2","1.  Pulse Methylprednisolone  (ALL types)"),
    ("b","IV methylprednisolone 500-1000 mg/day x 3 consecutive days"),
    ("b","Then oral prednisolone 1 mg/kg/day (max 60 mg); taper over 6 months"),

    ("h2","2.  Cyclophosphamide  (Type III - ANCA; also Type II)"),
    ("b","IV cyclophosphamide 15 mg/kg Q2-3 weeks (CYCLOPS regimen);  OR oral 2 mg/kg/day"),
    ("b","Rituximab: non-inferior to CYC in ANCA vasculitis  (RAVE, RITUXVAS);  preferred in young women"),

    ("h2","3.  Plasmapheresis / TPE"),
    ("b","MANDATORY in Type I (Goodpasture): removes anti-GBM Abs; daily x 14 days"),
    ("b","ANCA + pulmonary haemorrhage or severe AKI: consider TPE  (PEXIVAS 2020)"),

    ("h2","4.  Additional"),
    ("b","Dialysis if AEIOU criteria met"),
    ("b","PCP prophylaxis: TMP-SMX 960 mg three times per week"),
    ("b","PPI for gastric protection during high-dose steroids"),
    ("b","Maintenance: azathioprine 2 mg/kg/day OR rituximab for 18-24 months  (ANCA vasculitis)"),

    ("div",""),

    # ─── Q5b ──────────────────────────────────────────────────────────────────
    ("qhead","Q.5b  LPV, Prone Positioning and NMB in Severe ARDS  [10 Marks]"),

    ("h1","ARDS  -  Berlin Definition (2012)"),
    ("b","Acute onset within 1 week; bilateral opacities on CXR/CT; not explained by cardiac failure"),
    ("b","Severe ARDS: PaO2/FiO2 <= 100 mmHg with PEEP >= 5 cmH2O"),

    ("h1","A.  Lung Protective Ventilation (LPV)"),

    ("h2","Physiological Basis"),
    ("b","ARDS baby lung: only 200-400 g of aerated lung tissue"),
    ("b","Large tidal volumes cause: volutrauma, barotrauma, atelectrauma, biotrauma (cytokine release -> VILI -> MSOF)"),
    ("b","LPV principle: low VT prevents overdistension; PEEP prevents atelectrauma"),

    ("h2","Strategy"),
    ("b","VT = 6 mL/kg PBW   |   Plateau pressure <= 30 cmH2O   |   Driving pressure <= 15 cmH2O"),
    ("b","PEEP: titrate per ARDSNet PEEP-FiO2 table   |   Target SpO2 88-95%"),
    ("b","Permissive hypercapnia: allow PaCO2 up to 60 mmHg  (avoid in raised ICP)"),

    ("h2","Clinical Evidence"),
    ("b","ARMA Trial (NEJM 2000): VT 6 vs 12 mL/kg; 28-day mortality 31% vs 40%;  NNT = 11  ->  standard of care"),
    ("b","Driving pressure analysis (Amato, NEJM 2015): DP <= 15 cmH2O most strongly associated with survival"),

    ("h1","B.  Prone Positioning"),

    ("h2","Physiological Basis"),
    ("b","Supine ARDS: posterior lung collapsed (oedema, cardiac compression)"),
    ("b","Prone: improves V/Q matching, recruits posterior lung, reduces driving pressure, aids secretion drainage"),

    ("h2","Protocol"),
    ("b","Indication: severe ARDS - PF <= 150 mmHg, FiO2 >= 0.6, PEEP >= 5"),
    ("b","Timing: within 36-48 h of ARDS onset   |   Duration: >= 16 h/day"),
    ("b","Discontinue when PF > 150 on FiO2 <= 0.6, PEEP <= 10 for >= 4 h in supine"),

    ("h2","Clinical Evidence"),
    ("b","PROSEVA (Guerin, NEJM 2013): 28-day mortality 16% vs 32.8%  (ARR 16.8%; NNT = 6)"),

    ("h1","C.  Neuromuscular Blockade (NMB)"),

    ("h2","Physiological Basis"),
    ("b","Severe ARDS: spontaneous breathing -> high transpulmonary pressures -> P-SILI"),
    ("b","NMB eliminates spontaneous breathing -> reduces P-SILI, ventilator dyssynchrony, auto-PEEP"),
    ("b","Cisatracurium also reduces systemic cytokines (IL-8, IL-6)"),

    ("h2","Regimen"),
    ("b","Agent: cisatracurium (Nimbex) - Hofmann elimination, organ-independent, reduced ICU-acquired weakness"),
    ("b","IV infusion 37.5 mg/h for 48 h; deep sedation required (RASS -4 to -5); TOF target 1-2 twitches"),

    ("h2","Clinical Evidence"),
    ("b","ACURASYS (NEJM 2010): cisatracurium 48 h -> adjusted 90-day mortality benefit; reduced barotrauma"),
    ("b","ROSE (NEJM 2019): no difference vs light sedation -> NMB NOT routine for all ARDS"),
    ("b","Current practice (2024): NMB reserved for P/F < 120-150, refractory dyssynchrony, or to facilitate proning"),

    ("h2","Summary"),
    ("trow","Intervention        Indication               Key Trial        Benefit"),
    ("trow","----------------    ---------------------    -------------    ----------------"),
    ("trow","LPV (6 mL/kg)       ALL ARDS                 ARMA 2000        Yes - NNT 11"),
    ("trow","Prone >= 16 h/day   Severe ARDS  PF <= 150   PROSEVA 2013     Yes - NNT 6"),
    ("trow","NMB (cisatrac.)     Refractory / PF < 120    ACURASYS/ROSE    Conditional"),

    ("div",""),
    ("body","Ref: Harrison's 22E (2025)  |  Braunwald's Heart Disease 12e  |  Brenner & Rector's The Kidney  |  Goldman-Cecil Medicine"),
]


if __name__ == "__main__":
    import os
    hw = RealisticHW(OUT_PATH)
    hw.render(CONTENT)
    hw.save()

    from pypdf import PdfReader
    r = PdfReader(OUT_PATH)
    print(f"Pages: {len(r.pages)}  |  Size: {os.path.getsize(OUT_PATH)//1024} KB")

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