from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import cm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether
)
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import PageBreak

OUTPUT = "/home/daytona/workspace/icmhe-ethics/Ethical_Issues_Quick_Reference.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=1.5*cm, rightMargin=1.5*cm,
    topMargin=1.5*cm, bottomMargin=1.5*cm
)

# ── Colour palette ──────────────────────────────────────────────────────────
DARK_BLUE   = colors.HexColor("#1A3A5C")
MED_BLUE    = colors.HexColor("#2563A8")
LIGHT_BLUE  = colors.HexColor("#DBEAFE")
TEAL        = colors.HexColor("#0D7377")
LIGHT_TEAL  = colors.HexColor("#D1F5F5")
ORANGE      = colors.HexColor("#C05621")
LIGHT_ORANGE= colors.HexColor("#FEF3C7")
GREEN       = colors.HexColor("#166534")
LIGHT_GREEN = colors.HexColor("#DCFCE7")
RED         = colors.HexColor("#991B1B")
LIGHT_RED   = colors.HexColor("#FEE2E2")
PURPLE      = colors.HexColor("#5B21B6")
LIGHT_PURPLE= colors.HexColor("#EDE9FE")
WHITE       = colors.white
GREY_BG     = colors.HexColor("#F1F5F9")
DARK_TEXT   = colors.HexColor("#1E293B")

styles = getSampleStyleSheet()

def S(name, **kw):
    return ParagraphStyle(name, **kw)

# ── Custom styles ────────────────────────────────────────────────────────────
cover_title   = S("CoverTitle",   fontSize=22, leading=28, textColor=WHITE,      alignment=TA_CENTER, fontName="Helvetica-Bold", spaceAfter=6)
cover_sub     = S("CoverSub",     fontSize=12, leading=16, textColor=LIGHT_BLUE, alignment=TA_CENTER, fontName="Helvetica",      spaceAfter=4)
cover_info    = S("CoverInfo",    fontSize=10, leading=14, textColor=WHITE,      alignment=TA_CENTER, fontName="Helvetica-Oblique")

part_header   = S("PartHeader",   fontSize=14, leading=18, textColor=WHITE,      fontName="Helvetica-Bold", spaceBefore=10, spaceAfter=4)
section_hdr   = S("SectionHdr",   fontSize=11, leading=14, textColor=WHITE,      fontName="Helvetica-Bold", spaceBefore=6, spaceAfter=3)
sub_hdr       = S("SubHdr",       fontSize=10, leading=13, textColor=DARK_BLUE,  fontName="Helvetica-Bold", spaceBefore=5, spaceAfter=2)
body          = S("Body",         fontSize=8.5,leading=12, textColor=DARK_TEXT,  fontName="Helvetica",      spaceAfter=2)
body_bold     = S("BodyBold",     fontSize=8.5,leading=12, textColor=DARK_TEXT,  fontName="Helvetica-Bold", spaceAfter=2)
bullet_style  = S("Bullet",       fontSize=8.5,leading=12, textColor=DARK_TEXT,  fontName="Helvetica",      leftIndent=12, firstLineIndent=-8, spaceAfter=2)
highlight     = S("Highlight",    fontSize=8.5,leading=12, textColor=RED,        fontName="Helvetica-Bold", spaceAfter=2)
note_style    = S("Note",         fontSize=8,  leading=11, textColor=TEAL,       fontName="Helvetica-Oblique", spaceAfter=2)
case_q        = S("CaseQ",        fontSize=8.5,leading=12, textColor=PURPLE,     fontName="Helvetica-Bold", spaceAfter=2)
case_a        = S("CaseA",        fontSize=8.5,leading=12, textColor=DARK_TEXT,  fontName="Helvetica",      leftIndent=10, spaceAfter=2)
memory_style  = S("Memory",       fontSize=9,  leading=13, textColor=ORANGE,     fontName="Helvetica-Bold", spaceAfter=2)

def colored_box(paragraph, bg_color, text_color=WHITE, padding=6):
    """Wrap paragraph in a single-cell table that acts as a colored box."""
    t = Table([[paragraph]], colWidths=[doc.width])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg_color),
        ("TOPPADDING",  (0,0), (-1,-1), padding),
        ("BOTTOMPADDING",(0,0),(-1,-1), padding),
        ("LEFTPADDING", (0,0), (-1,-1), 8),
        ("RIGHTPADDING",(0,0), (-1,-1), 8),
        ("ROUNDEDCORNERS", [4]),
    ]))
    return t

def part_box(text, color):
    p = Paragraph(text, part_header)
    return colored_box(p, color)

def section_box(text, color):
    p = Paragraph(text, section_hdr)
    return colored_box(p, color, padding=4)

def info_box(paragraphs, bg_color, border_color=None):
    """Box with multiple content items."""
    if not isinstance(paragraphs, list):
        paragraphs = [paragraphs]
    t = Table([[p] for p in paragraphs], colWidths=[doc.width])
    style_cmds = [
        ("BACKGROUND", (0,0), (-1,-1), bg_color),
        ("TOPPADDING",  (0,0), (0,0), 6),
        ("BOTTOMPADDING",(0,-1),(-1,-1), 6),
        ("TOPPADDING",  (0,1), (-1,-1), 2),
        ("BOTTOMPADDING",(0,0),(-1,-2), 2),
        ("LEFTPADDING", (0,0), (-1,-1), 8),
        ("RIGHTPADDING",(0,0), (-1,-1), 8),
    ]
    if border_color:
        style_cmds += [
            ("BOX", (0,0), (-1,-1), 1.5, border_color),
        ]
    t.setStyle(TableStyle(style_cmds))
    return t

def bullet(text, color="•"):
    return Paragraph(f"{color} {text}", bullet_style)

def two_col_table(rows, col_widths=None, header_bg=DARK_BLUE, row_bg=GREY_BG, alt_bg=WHITE):
    if col_widths is None:
        col_widths = [doc.width * 0.38, doc.width * 0.62]
    style_cmds = [
        ("BACKGROUND",   (0,0), (-1,0), header_bg),
        ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
        ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",     (0,0), (-1,-1), 8.5),
        ("LEADING",      (0,0), (-1,-1), 12),
        ("TOPPADDING",   (0,0), (-1,-1), 4),
        ("BOTTOMPADDING",(0,0), (-1,-1), 4),
        ("LEFTPADDING",  (0,0), (-1,-1), 6),
        ("RIGHTPADDING", (0,0), (-1,-1), 6),
        ("GRID",         (0,0), (-1,-1), 0.5, colors.HexColor("#CBD5E1")),
        ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    ]
    for i, _ in enumerate(rows[1:], 1):
        bg = row_bg if i % 2 == 1 else alt_bg
        style_cmds.append(("BACKGROUND", (0,i), (-1,i), bg))
    # convert string cells to Paragraphs
    p_rows = []
    for i, row in enumerate(rows):
        fs = "Helvetica-Bold" if i == 0 else "Helvetica"
        tc = WHITE if i == 0 else DARK_TEXT
        p_rows.append([Paragraph(str(c), S(f"tc{i}", fontSize=8.5, leading=12, textColor=tc, fontName=fs)) for c in row])
    t = Table(p_rows, colWidths=col_widths)
    t.setStyle(TableStyle(style_cmds))
    return t

story = []

# ════════════════════════════════════════════════════════════════════════════
#  COVER
# ════════════════════════════════════════════════════════════════════════════
cover_table = Table(
    [[Paragraph("ICMHE THEORY EXAM", cover_title)],
     [Paragraph("Quick Reference: Ethical Issues in", cover_sub)],
     [Paragraph("Child • Reproductive • Mental Health", cover_sub)],
     [Spacer(1, 0.3*cm)],
     [Paragraph("Dr. Prashamsha Tamrakar | GPEM, KAHS", cover_info)],
     [Paragraph("Exam Date: June 7, 2026", cover_info)]],
    colWidths=[doc.width]
)
cover_table.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), DARK_BLUE),
    ("TOPPADDING",  (0,0), (-1,-1), 10),
    ("BOTTOMPADDING",(0,0),(-1,-1), 10),
    ("LEFTPADDING", (0,0), (-1,-1), 16),
    ("RIGHTPADDING",(0,0), (-1,-1), 16),
    ("ROUNDEDCORNERS", [6]),
]))
story.append(cover_table)
story.append(Spacer(1, 0.4*cm))

# Memory tricks banner
mem_items = [
    Paragraph("🧠  MEMORY TRICKS", S("mt", fontSize=9, fontName="Helvetica-Bold", textColor=ORANGE)),
    bullet("4 Principles: A-B-N-J = Autonomy | Beneficence | Non-maleficence | Justice"),
    bullet("Consent ages: 7 (verbal assent) → 12 (written assent) → 16 (NMC self-consent) → 18 (adult)"),
    bullet("Abortion limits: 12 wks on request / 18 wks for rape/incest / beyond 18 if life risk or fetal anomaly"),
    bullet("Break confidentiality WHEN: Abuse • Self-harm/Suicide • Violence to others • Notifiable disease • Law"),
    bullet("Appelbaum capacity: Understand → Appreciate → Reason → Communicate"),
]
story.append(info_box(mem_items, LIGHT_ORANGE, ORANGE))
story.append(Spacer(1, 0.3*cm))

# ════════════════════════════════════════════════════════════════════════════
#  PART 1: CHILD HEALTH
# ════════════════════════════════════════════════════════════════════════════
story.append(part_box("PART 1: ETHICAL ISSUES IN CHILD HEALTH", DARK_BLUE))
story.append(Spacer(1, 0.2*cm))

# Definition
story.append(section_box("What is Ethics in Child Health?", MED_BLUE))
def_items = [
    bullet("Applying moral principles (Autonomy, Beneficence, Non-maleficence, Justice) to medical care of children."),
    bullet("Children are a <b>special group</b> - vulnerable, limited capacity, dependent on adults."),
]
story.append(info_box(def_items, LIGHT_BLUE, MED_BLUE))
story.append(Spacer(1, 0.2*cm))

# 4 principles table
story.append(Paragraph("The 4 Core Ethical Principles", sub_hdr))
principles_table = two_col_table([
    ["Principle", "Meaning / Application in Child Health"],
    ["Autonomy", "Respect child's wishes; involve them in decisions (assent); use child-friendly language"],
    ["Beneficence", "Always do GOOD - vaccination, nutrition, proper treatment"],
    ["Non-maleficence", "Avoid HARM; balance benefits vs. risks; don't cause more suffering"],
    ["Justice", "Fair access regardless of geography, money, gender, caste, ethnicity"],
    ["Best Interest Standard", "Decisions guided by what is BEST for the child - medical + psychosocial + emotional"],
], col_widths=[doc.width*0.35, doc.width*0.65])
story.append(principles_table)
story.append(Spacer(1, 0.25*cm))

# Consent & Assent
story.append(KeepTogether([
    section_box("Consent, Assent & Autonomy  [HIGH PRIORITY - 5 marks likely]", TEAL),
    Spacer(1, 0.15*cm),
    Paragraph("<b>Consent</b> = formal legal permission (given by parents/guardians for children)", body),
    Paragraph("<b>Assent</b> = child's own agreement (not legally binding, but ethically required)", body),
    Spacer(1, 0.1*cm),
    two_col_table([
        ["Age Group", "What is Required"],
        ["Below 7 years", "Guardian consent ONLY - no assent needed"],
        ["7-12 years", "Guardian consent + VERBAL assent from child"],
        ["12-18 years", "Guardian consent + WRITTEN assent from child"],
        ["16+ years (NMC rule)", "Patient can provide consent directly (Nepal Medical Council)"],
        ["18+ years", "Considered adult - gives own informed consent"],
    ], col_widths=[doc.width*0.38, doc.width*0.62], header_bg=TEAL),
]))
story.append(Spacer(1, 0.15*cm))

nhrc_items = [
    Paragraph("<b>NHRC National Ethical Guidelines for Health Research 2022:</b>", S("nb", fontSize=8.5, fontName="Helvetica-Bold", textColor=TEAL)),
    bullet("Minimum age for consent in research = <b>18 years</b>"),
    bullet("Below 7 yrs: guardian consent only"),
    bullet("7-12 yrs: guardian consent + verbal assent"),
    bullet("12-18 yrs: guardian consent + written assent"),
]
story.append(info_box(nhrc_items, LIGHT_TEAL, TEAL))
story.append(Spacer(1, 0.2*cm))

# Confidentiality
story.append(KeepTogether([
    section_box("Confidentiality & Privacy in Children", TEAL),
    Spacer(1, 0.1*cm),
    bullet("Keep child's health information private (especially mental health, sexual health)."),
    bullet("For adolescents - respect privacy but clarify limits of confidentiality."),
    Spacer(1, 0.1*cm),
    Paragraph("<b>When CAN you BREAK confidentiality?</b>", highlight),
]))

conf_items = [
    bullet("1. Child ABUSE, NEGLECT, or SEXUAL VIOLENCE (mandatory reporting to protect child)", "⚠"),
    bullet("2. Child is at risk of SELF-HARM or SUICIDE", "⚠"),
    bullet("3. Child has a NOTIFIABLE INFECTIOUS DISEASE", "⚠"),
    bullet("4. REQUIRED BY LAW", "⚠"),
    Paragraph("<i>Nepal context: Balance family/cultural roles with child's individual rights.</i>", note_style),
]
story.append(info_box(conf_items, LIGHT_RED, RED))
story.append(Spacer(1, 0.2*cm))

# End of life / serious illness
story.append(KeepTogether([
    section_box("End-of-Life / Serious Illness Decisions", MED_BLUE),
    Spacer(1, 0.1*cm),
    bullet("When to start or stop life-sustaining treatment."),
    bullet("Prognostic uncertainty must be considered."),
    bullet("Balance: quality of life vs. extending life vs. suffering."),
]))
story.append(Spacer(1, 0.3*cm))

# ════════════════════════════════════════════════════════════════════════════
#  PART 2: REPRODUCTIVE HEALTH
# ════════════════════════════════════════════════════════════════════════════
story.append(PageBreak())
story.append(part_box("PART 2: ETHICAL ISSUES IN REPRODUCTIVE HEALTH", TEAL))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "Reproductive health = health related to the reproductive system including contraception, pregnancy, abortion, maternal health, infertility, sexual health.",
    body))
story.append(Spacer(1, 0.15*cm))

why_items = [
    Paragraph("<b>Why ethics matters in reproductive health:</b>", S("wh", fontSize=8.5, fontName="Helvetica-Bold", textColor=TEAL)),
    bullet("Bodily Autonomy - individuals have the right to decide about their own bodies."),
    bullet("Moral Dilemmas - conflicting rights and interests (e.g., mother vs. fetus)."),
    bullet("Cultural Sensitivities - diverse beliefs influence practices."),
    bullet("Legal Frameworks - laws evolve; ethics provides consistent guidance."),
]
story.append(info_box(why_items, LIGHT_TEAL, TEAL))
story.append(Spacer(1, 0.2*cm))

# Abortion
story.append(section_box("Abortion Ethics  [HIGH PRIORITY - Nepal Law]", RED))
story.append(Spacer(1, 0.1*cm))
story.append(Paragraph("<b>Core ethical conflict:</b> Bodily autonomy (woman's right) vs. Right to life (fetus)", body))
story.append(Spacer(1, 0.1*cm))
story.append(two_col_table([
    ["Situation", "Legal Limit in Nepal"],
    ["Abortion on request", "Up to 12 WEEKS"],
    ["Rape or incest", "Up to 18 WEEKS"],
    ["Life/health risk OR fetal anomaly", "Beyond 18 weeks (allowed)"],
], col_widths=[doc.width*0.45, doc.width*0.55], header_bg=RED))
story.append(Spacer(1, 0.15*cm))

nepal_abortion = [
    Paragraph("<b>Nepal Abortion Key Facts:</b>", S("naf", fontSize=8.5, fontName="Helvetica-Bold", textColor=RED)),
    bullet("Legalized in <b>2002</b>"),
    bullet("Affirmed as fundamental right in <b>2018 Safe Motherhood and Reproductive Health Rights Act</b>"),
    bullet("Free abortion at public hospitals since <b>2017</b>"),
    bullet("<b>Sex-selective abortion</b> = ILLEGAL + UNETHICAL"),
    bullet("Cultural stigma persists in rural/conservative communities"),
    bullet("Many abortions still done unsafely (uncertified providers, pharmacy pills without supervision)"),
    bullet("Accessibility gaps create inequality in service provision"),
]
story.append(info_box(nepal_abortion, LIGHT_RED, RED))
story.append(Spacer(1, 0.2*cm))

# ART / IVF
story.append(KeepTogether([
    section_box("Assisted Reproductive Technology (ART) & IVF", DARK_BLUE),
    Spacer(1, 0.1*cm),
    bullet("IVF is performed in Nepal but <b>NO comprehensive laws</b> regulate ARTs."),
    bullet("Without regulation: risk of abuse, exploitation, unsafe procedures, no accountability."),
    bullet("High cost = inequality of access."),
    bullet("No clear guidelines for <b>donor anonymity</b> or record keeping."),
    bullet("Mismanagement causes social stigma and psychological harm."),
]))
story.append(Spacer(1, 0.2*cm))

# Contraception
story.append(KeepTogether([
    section_box("Contraception", DARK_BLUE),
    Spacer(1, 0.1*cm),
    bullet("Needed to prevent unwanted pregnancy and reduce maternal mortality."),
    bullet("Autonomy affected by myths, cultural beliefs, and misconceptions."),
    bullet("Lack of proper counselling about benefits and side effects = low use."),
    bullet("Access and equity also affect use."),
    bullet("Confidentiality is a major concern for <b>adolescents</b>."),
]))
story.append(Spacer(1, 0.3*cm))

# ════════════════════════════════════════════════════════════════════════════
#  PART 3: MENTAL HEALTH
# ════════════════════════════════════════════════════════════════════════════
story.append(PageBreak())
story.append(part_box("PART 3: ETHICAL ISSUES IN MENTAL HEALTH", PURPLE))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "Mental health = emotional, psychological, and social well-being. Ethical issues arise because mental illness may <b>impair capacity</b>, involve stigma, and intersect with human rights. In Nepal: under-served, under-recognized, with cultural barriers.",
    body))
story.append(Spacer(1, 0.15*cm))

# Autonomy & Capacity
story.append(section_box("Autonomy & Decision-Making Capacity", PURPLE))
story.append(Spacer(1, 0.1*cm))
story.append(Paragraph(
    "<b>Core tension:</b> Paternalism / involuntary treatment vs. respecting patient's autonomy",
    body))
story.append(Spacer(1, 0.1*cm))
story.append(bullet("Always assess capacity first before making decisions for the patient."))
story.append(bullet("Involve patients in decisions as much as possible."))
story.append(bullet("If capacity is impaired: involve guardians + also seek patient assent."))
story.append(bullet("Involuntary admission is an ethical challenge, especially where legal oversight is weak."))
story.append(Spacer(1, 0.15*cm))

# Appelbaum table
story.append(Paragraph("<b>Paul Appelbaum's 4-Step Capacity Assessment  [Exam Favourite!]</b>", sub_hdr))
story.append(two_col_table([
    ["Step", "Question to Assess"],
    ["1. UNDERSTAND", "Can patient explain their condition, treatment, and consequences in simple words?"],
    ["2. APPRECIATE", "Does the patient accept that this information applies to THEM personally?"],
    ["3. REASON", "Can the patient compare options logically and explain their choice?"],
    ["4. COMMUNICATE", "Can the patient express their choice by ANY method (speech, sign language, etc.)?"],
], col_widths=[doc.width*0.28, doc.width*0.72], header_bg=PURPLE))
story.append(Spacer(1, 0.2*cm))

# Confidentiality in MH
story.append(KeepTogether([
    section_box("Confidentiality in Mental Health", PURPLE),
    Spacer(1, 0.1*cm),
    Paragraph("Disclosure of diagnosis/treatment must be handled carefully - breach causes stigma, discrimination, social harm.", body),
    Spacer(1, 0.1*cm),
    Paragraph("<b>Break confidentiality WHEN:</b>", highlight),
]))
mh_conf = [
    bullet("Risk of SUICIDE or serious SELF-HARM", "⚠"),
    bullet("Risk of VIOLENCE TO OTHERS", "⚠"),
    bullet("REQUIRED BY LAW", "⚠"),
]
story.append(info_box(mh_conf, LIGHT_RED, RED))
story.append(Spacer(1, 0.2*cm))

# Other MH issues - 2 column layout
col_w = doc.width / 2 - 0.2*cm
left_items = [
    [section_box("Stigma & Discrimination", DARK_BLUE)],
    [Spacer(1, 0.08*cm)],
    [bullet("Mental illness leads to blame, shame, social exclusion, self-stigma.")],
    [bullet("Stigma prevents people from seeking help.")],
    [bullet("Solution: Psychoeducation for families + culturally appropriate communication.")],
]
right_items = [
    [section_box("Access & Equity", DARK_BLUE)],
    [Spacer(1, 0.08*cm)],
    [bullet("Rural-urban divide and cost barriers leave many untreated.")],
    [bullet("Very few specialists; minimal hospital beds per population.")],
    [bullet("Support community-based mental health programs.")],
]

# Use simple stacking for now
for left in left_items:
    story.append(left[0])
for right in right_items:
    story.append(right[0])
story.append(Spacer(1, 0.2*cm))

# Nepal MH legal
story.append(KeepTogether([
    section_box("Nepal Mental Health: Legal & Ethical Facts", PURPLE),
    Spacer(1, 0.1*cm),
]))
nepal_mh = [
    bullet("<b>National Mental Health Survey (2019-20):</b> awareness rising but legal protections are weak."),
    bullet("Mental health professionals (psychologists, counsellors) are NOT well regulated."),
    bullet("Nepal's Constitution: guarantees right to dignified life and mental well-being."),
    bullet("Involuntary treatment must be in the <b>LEAST RESTRICTIVE environment</b>."),
    bullet("Involuntary treatment = measure of <b>LAST RESORT</b>."),
    bullet("Advocate for clearer legislation and oversight bodies."),
]
story.append(info_box(nepal_mh, LIGHT_PURPLE, PURPLE))
story.append(Spacer(1, 0.3*cm))

# ════════════════════════════════════════════════════════════════════════════
#  CASE SCENARIOS - ANSWER KEY
# ════════════════════════════════════════════════════════════════════════════
story.append(PageBreak())
story.append(part_box("CASE SCENARIO ANSWER KEY", ORANGE))
story.append(Spacer(1, 0.2*cm))

cases = [
    {
        "title": "CHILD HEALTH CASES",
        "color": MED_BLUE,
        "items": [
            ("Vaccines running out, leader wants relatives prioritized",
             "JUSTICE principle. Must distribute FAIRLY. Cannot give preference based on status. Use fair, transparent criteria (most vulnerable first)."),
            ("5-year-old with pneumonia, father refuses antibiotics",
             "BEST INTEREST STANDARD applies. Child's welfare overrides parent's refusal. Educate father about risks. If necessary, involve authorities."),
            ("16-year-old wants HIV test without informing parents",
             "Respect adolescent's confidentiality. Assess risk and capacity. Generally can proceed with proper counselling while respecting privacy."),
            ("17-year-old girl seeking emergency contraception",
             "Provide CONFIDENTIAL counselling. Explain legal/ethical limits. Only break confidentiality if there is risk of ABUSE."),
        ]
    },
    {
        "title": "REPRODUCTIVE HEALTH CASES",
        "color": TEAL,
        "items": [
            ("Married woman at 13 weeks, facility refuses abortion",
             "Principles at stake: Autonomy, Justice, Beneficence, Non-maleficence.\nRefusal is NOT ethically justified - law allows up to 18 weeks in certain cases.\nViolates Justice (she is legally eligible) + Non-maleficence (increases health risks).\nFacility must either provide care OR refer to a facility that can."),
            ("17-year-old buys abortion pills from pharmacy, gets complications",
             "Issues: Autonomy of a minor, Non-maleficence (unsafe self-medication), Justice (lack of access), Informed Consent.\nPharmacist must: follow regulations, not dispense without prescription, provide full guidance on use/side effects/when to seek help.\nSystemic need: regulate pharmacies, expand safe abortion access, educate adolescents."),
        ]
    },
    {
        "title": "MENTAL HEALTH CASES",
        "color": PURPLE,
        "items": [
            ("25-year-old involuntarily admitted, refuses medication",
             "Involuntary admission justified IF: risk of harm to self + lacks decision-making capacity.\nBeneficence supports medication; Autonomy supports his refusal.\nUse LEAST RESTRICTIVE option first. Family can be surrogate decision-makers.\nNepal mental health laws evolving - also apply international human rights standards."),
            ("17-year-old says he wants to die, asks not to tell family",
             "BREAK CONFIDENTIALITY - suicidal risk is an EXCEPTION to confidentiality.\nEthical response: Immediately involve family/guardian and mental health professional.\nPatient safety ALWAYS comes first."),
            ("Woman with schizophrenia refuses medication, family insists",
             "FIRST: Assess her capacity using Appelbaum's 4 steps.\nIf HAS capacity: her choice must be respected (Autonomy).\nIf LACKS capacity: family can be surrogate decision-makers but must act in HER best interest.\nUse least restrictive treatment approach."),
        ]
    },
]

for case_group in cases:
    story.append(section_box(case_group["title"], case_group["color"]))
    story.append(Spacer(1, 0.1*cm))
    for q, a in case_group["items"]:
        case_content = [
            Paragraph(f"<b>Q: {q}</b>", case_q),
            Paragraph(a.replace("\n", "<br/>"), case_a),
            Spacer(1, 0.05*cm),
        ]
        story.append(info_box(case_content, GREY_BG))
        story.append(Spacer(1, 0.1*cm))

# ════════════════════════════════════════════════════════════════════════════
#  FINAL SUMMARY / TAKE HOME
# ════════════════════════════════════════════════════════════════════════════
story.append(Spacer(1, 0.1*cm))
story.append(part_box("TAKE-HOME MESSAGE (Memorize This!)", DARK_BLUE))
story.append(Spacer(1, 0.1*cm))
takehome = [
    bullet("Ethics is <b>CENTRAL</b> to clinical medicine - not optional."),
    bullet("Applying ethics considers: <b>age, capacity, law, culture, and communication</b>."),
    bullet("Each scenario may involve <b>conflict of principles</b> - requires reasoned discussion + documentation."),
    bullet("Always <b>PRIORITIZE patient welfare, autonomy, and justice</b> in all clinical scenarios."),
]
story.append(info_box(takehome, LIGHT_BLUE, DARK_BLUE))

# Build
doc.build(story)
print(f"PDF created: {OUTPUT}")

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import cm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether, PageBreak
)
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_RIGHT

OUTPUT = "/home/daytona/workspace/mbbs-exam/Respiratory_Abdominal_Exam_QuickRef.pdf"

W, H = A4
doc = SimpleDocTemplate(
    OUTPUT, pagesize=A4,
    leftMargin=1.2*cm, rightMargin=1.2*cm,
    topMargin=1.2*cm, bottomMargin=1.2*cm
)
PW = W - 2.4*cm  # printable width

# ── Palette ──────────────────────────────────────────────────────────────────
NAVY        = colors.HexColor("#0F2B4C")
DEEP_BLUE   = colors.HexColor("#1A56A0")
MID_BLUE    = colors.HexColor("#2D7DD2")
LIGHT_BLUE  = colors.HexColor("#DBEAFE")
PALE_BLUE   = colors.HexColor("#EFF6FF")
TEAL        = colors.HexColor("#0F766E")
LIGHT_TEAL  = colors.HexColor("#CCFBF1")
FOREST      = colors.HexColor("#166534")
LIGHT_GREEN = colors.HexColor("#DCFCE7")
CRIMSON     = colors.HexColor("#991B1B")
LIGHT_RED   = colors.HexColor("#FEE2E2")
ORANGE      = colors.HexColor("#C2410C")
LIGHT_ORANGE= colors.HexColor("#FFF7ED")
PURPLE      = colors.HexColor("#5B21B6")
LIGHT_PURPLE= colors.HexColor("#EDE9FE")
GOLD        = colors.HexColor("#B45309")
LIGHT_GOLD  = colors.HexColor("#FEF3C7")
GREY_DARK   = colors.HexColor("#374151")
GREY_MID    = colors.HexColor("#6B7280")
GREY_LIGHT  = colors.HexColor("#F3F4F6")
GREY_BG     = colors.HexColor("#F8FAFC")
SLATE       = colors.HexColor("#1E293B")
WHITE       = colors.white

# ── Style factory ─────────────────────────────────────────────────────────────
def S(name, **kw):
    defaults = dict(fontName="Helvetica", fontSize=8.5, leading=12,
                    textColor=SLATE, spaceAfter=0, spaceBefore=0)
    defaults.update(kw)
    return ParagraphStyle(name, **defaults)

cover_title  = S("ct", fontSize=20, leading=25, textColor=WHITE, fontName="Helvetica-Bold", alignment=TA_CENTER, spaceAfter=4)
cover_sub    = S("cs", fontSize=11, leading=15, textColor=colors.HexColor("#BFDBFE"), fontName="Helvetica", alignment=TA_CENTER, spaceAfter=3)
cover_detail = S("cd", fontSize=9, leading=13, textColor=colors.HexColor("#93C5FD"), fontName="Helvetica-Oblique", alignment=TA_CENTER)

part_hdr     = S("ph", fontSize=13, leading=17, textColor=WHITE, fontName="Helvetica-Bold", alignment=TA_LEFT)
sec_hdr      = S("sh", fontSize=10, leading=14, textColor=WHITE, fontName="Helvetica-Bold")
step_hdr     = S("sth", fontSize=9.5, leading=13, textColor=WHITE, fontName="Helvetica-Bold")
sub_hdr      = S("subh", fontSize=9, leading=13, textColor=NAVY, fontName="Helvetica-Bold", spaceAfter=2, spaceBefore=3)
body         = S("b", fontSize=8.5, leading=12, textColor=SLATE)
body_bold    = S("bb", fontSize=8.5, leading=12, textColor=SLATE, fontName="Helvetica-Bold")
bullet_s     = S("bl", fontSize=8.5, leading=12, textColor=SLATE, leftIndent=10, firstLineIndent=-8)
note_s       = S("ns", fontSize=8, leading=11, textColor=TEAL, fontName="Helvetica-Oblique")
mem_s        = S("ms", fontSize=8.5, leading=12, textColor=GOLD, fontName="Helvetica-Bold")
warn_s       = S("ws", fontSize=8.5, leading=12, textColor=CRIMSON, fontName="Helvetica-Bold")
small_bold   = S("smb", fontSize=7.5, leading=11, textColor=SLATE, fontName="Helvetica-Bold")
small_body   = S("smbo", fontSize=7.5, leading=11, textColor=SLATE)
tbl_hdr_s    = S("ths", fontSize=8, leading=11, textColor=WHITE, fontName="Helvetica-Bold")
tbl_cell_s   = S("tcs", fontSize=8, leading=11, textColor=SLATE)

# ── Helpers ────────────────────────────────────────────────────────────────────
def colored_box(content_list, bg, border=None, lpad=8, rpad=8, tpad=6, bpad=6):
    data = [[item] for item in content_list]
    w = [PW]
    cmds = [
        ("BACKGROUND",    (0,0),(-1,-1), bg),
        ("LEFTPADDING",   (0,0),(-1,-1), lpad),
        ("RIGHTPADDING",  (0,0),(-1,-1), rpad),
        ("TOPPADDING",    (0,0),(0,0),   tpad),
        ("BOTTOMPADDING", (0,-1),(-1,-1),bpad),
        ("TOPPADDING",    (0,1),(-1,-1), 2),
        ("BOTTOMPADDING", (0,0),(-1,-2), 2),
    ]
    if border:
        cmds.append(("BOX", (0,0),(-1,-1), 1.5, border))
    t = Table(data, colWidths=w)
    t.setStyle(TableStyle(cmds))
    return t

def part_banner(text, color):
    return colored_box([Paragraph(text, part_hdr)], color, tpad=8, bpad=8)

def step_banner(num, text, color):
    p = Paragraph(f"STEP {num}: {text}", step_hdr)
    return colored_box([p], color, tpad=5, bpad=5)

def section_banner(text, color):
    return colored_box([Paragraph(text, sec_hdr)], color, tpad=4, bpad=4)

def info_box(items, bg, border=None):
    return colored_box(items, bg, border)

def sp(h=0.15):
    return Spacer(1, h*cm)

def bullet(text, symbol="•"):
    return Paragraph(f"<font color='#1A56A0'>{symbol}</font>  {text}", bullet_s)

def make_table(rows, col_w, hdr_bg=NAVY, row1_bg=GREY_LIGHT, row2_bg=WHITE, fontsize=8):
    p_rows = []
    for i, row in enumerate(rows):
        if i == 0:
            p_rows.append([Paragraph(str(c), S(f"h{i}", fontSize=fontsize, leading=fontsize+3,
                          textColor=WHITE, fontName="Helvetica-Bold")) for c in row])
        else:
            p_rows.append([Paragraph(str(c), S(f"r{i}", fontSize=fontsize, leading=fontsize+3,
                          textColor=SLATE)) for c in row])
    t = Table(p_rows, colWidths=col_w)
    cmds = [
        ("BACKGROUND",    (0,0),(-1,0),  hdr_bg),
        ("GRID",          (0,0),(-1,-1), 0.4, colors.HexColor("#CBD5E1")),
        ("TOPPADDING",    (0,0),(-1,-1), 3),
        ("BOTTOMPADDING", (0,0),(-1,-1), 3),
        ("LEFTPADDING",   (0,0),(-1,-1), 5),
        ("RIGHTPADDING",  (0,0),(-1,-1), 5),
        ("VALIGN",        (0,0),(-1,-1), "MIDDLE"),
    ]
    for i in range(1, len(rows)):
        bg = row1_bg if i % 2 == 1 else row2_bg
        cmds.append(("BACKGROUND", (0,i),(-1,i), bg))
    t.setStyle(TableStyle(cmds))
    return t

def two_col_layout(left_items, right_items, split=0.5):
    lw = PW * split - 0.2*cm
    rw = PW * (1-split) - 0.2*cm
    # build inner tables for each column
    def col_table(items):
        data = [[it] for it in items]
        t = Table(data, colWidths=[lw if items is left_items else rw])
        t.setStyle(TableStyle([
            ("TOPPADDING",    (0,0),(-1,-1), 1),
            ("BOTTOMPADDING", (0,0),(-1,-1), 1),
            ("LEFTPADDING",   (0,0),(-1,-1), 0),
            ("RIGHTPADDING",  (0,0),(-1,-1), 0),
        ]))
        return t
    # wrap in outer 2-col table
    outer = Table([[col_table(left_items), col_table(right_items)]],
                  colWidths=[lw + 0.2*cm, rw + 0.2*cm])
    outer.setStyle(TableStyle([
        ("VALIGN",       (0,0),(-1,-1), "TOP"),
        ("TOPPADDING",   (0,0),(-1,-1), 0),
        ("BOTTOMPADDING",(0,0),(-1,-1), 0),
        ("LEFTPADDING",  (0,0),(-1,-1), 0),
        ("RIGHTPADDING", (0,0),(-1,-1), 0),
    ]))
    return outer

# ═══════════════════════════════════════════════════════════════════════════════
story = []

# ── COVER ──────────────────────────────────────────────────────────────────────
cover_data = [
    [Paragraph("MBBS 2nd Year · ICMHE Theory Exam", cover_detail)],
    [sp(0.3)],
    [Paragraph("Clinical Examination", cover_title)],
    [Paragraph("Quick Reference Guide", cover_title)],
    [sp(0.2)],
    [Paragraph("Respiratory System  |  Abdominal System", cover_sub)],
    [sp(0.15)],
    [Paragraph("Inspection · Palpation · Percussion · Auscultation", cover_detail)],
    [sp(0.1)],
    [Paragraph("Exam Date: June 7, 2026", cover_detail)],
]
cover_tbl = Table(cover_data, colWidths=[PW])
cover_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0),(-1,-1), NAVY),
    ("TOPPADDING",    (0,0),(-1,-1), 4),
    ("BOTTOMPADDING", (0,0),(-1,-1), 4),
    ("LEFTPADDING",   (0,0),(-1,-1), 16),
    ("RIGHTPADDING",  (0,0),(-1,-1), 16),
]))
story.append(cover_tbl)
story.append(sp(0.3))

# Golden Rule box
golden = info_box([
    Paragraph("⭐  THE GOLDEN RULE OF CLINICAL EXAMINATION", S("gr", fontSize=9, fontName="Helvetica-Bold", textColor=GOLD)),
    Paragraph(
        "<b>Respiratory:</b>  <font color='#1A56A0'>I</font>nspection  →  <font color='#1A56A0'>P</font>alpation  →  "
        "<font color='#1A56A0'>P</font>ercussion  →  <font color='#1A56A0'>A</font>uscultation  "
        "<font color='#C2410C'>(IPPA)</font>", body),
    Paragraph(
        "<b>Abdominal:</b>   <font color='#1A56A0'>I</font>nspection  →  <font color='#0F766E'>A</font>uscultation  →  "
        "<font color='#1A56A0'>P</font>alpation  →  <font color='#1A56A0'>P</font>ercussion  "
        "<font color='#C2410C'>(IAPP — auscultate BEFORE touching!)</font>", body),
], LIGHT_GOLD, GOLD)
story.append(golden)
story.append(sp(0.3))

# ═══════════════════════════════════════════════════════════════════════════════
# PAGE 1 — RESPIRATORY EXAM
# ═══════════════════════════════════════════════════════════════════════════════
story.append(part_banner("PART 1: RESPIRATORY (CHEST) EXAMINATION", NAVY))
story.append(sp(0.2))

# Patient position note
story.append(info_box([
    Paragraph("📋  <b>Patient Position:</b> Sitting upright, chest fully exposed from front and back. "
              "Good lighting, quiet room, warm hands.", body)
], PALE_BLUE, DEEP_BLUE))
story.append(sp(0.2))

# ── STEP 1: INSPECTION ────────────────────────────────────────────────────────
story.append(step_banner(1, "INSPECTION — Just LOOK", DEEP_BLUE))
story.append(sp(0.1))

left_insp = [
    Paragraph("<b>A) Chest Shape</b>", sub_hdr),
    make_table([
        ["Shape", "Meaning"],
        ["Normal",           "Symmetric, elliptical"],
        ["Barrel chest",     "COPD / emphysema"],
        ["Pectus excavatum", "Funnel chest (sunken sternum)"],
        ["Pectus carinatum", "Pigeon chest (protruding sternum)"],
        ["Kyphoscoliosis",   "Curved spine → restrictive disease"],
    ], [PW*0.22, PW*0.28], fontsize=7.5),
    sp(0.2),
    Paragraph("<b>B) Breathing Pattern</b>", sub_hdr),
    make_table([
        ["Pattern",        "Meaning"],
        ["Tachypnoea",     ">20/min: infection, pain"],
        ["Bradypnoea",     "<12/min: CNS depression"],
        ["Cheyne-Stokes",  "Crescendo cycles + apnoea: heart failure, brain"],
        ["Kussmaul",       "Deep, labored: diabetic ketoacidosis (DKA)"],
        ["Biot's",         "Irregular bursts + apnoea: brainstem damage"],
    ], [PW*0.22, PW*0.28], fontsize=7.5),
]
right_insp = [
    Paragraph("<b>C) What else to look for</b>", sub_hdr),
    bullet("Trachea — midline or deviated?"),
    bullet("Chest wall movement — equal on both sides?"),
    bullet("Accessory muscle use (neck/intercostal) = respiratory distress"),
    bullet("Scars from previous surgery"),
    bullet("Gynecomastia"),
    bullet("Tobacco stains on fingers/lips/teeth"),
    sp(0.1),
    Paragraph("<b>D) Smell clues</b>", sub_hdr),
    bullet("Ketones on breath = DKA"),
    bullet("Foul smell = anaerobic lung abscess"),
    bullet("Alcohol odor = ethanol intoxication"),
    bullet("Sweet smell = <i>Pseudomonas</i> infection"),
    sp(0.1),
    info_box([
        Paragraph("⚠ <b>Trachea deviation rule:</b>", warn_s),
        bullet("Pulled TOWARDS lesion = collapse / fibrosis"),
        bullet("Pushed AWAY from lesion = effusion / tension pneumothorax"),
    ], LIGHT_RED, CRIMSON),
]
story.append(two_col_layout(left_insp, right_insp, split=0.52))
story.append(sp(0.2))

# ── STEP 2: PALPATION ─────────────────────────────────────────────────────────
story.append(step_banner(2, "PALPATION — FEEL the chest", MID_BLUE))
story.append(sp(0.1))

left_palp = [
    Paragraph("<b>A) Trachea Position</b>", sub_hdr),
    bullet("Place finger in suprasternal notch"),
    bullet("Central = normal"),
    bullet("Deviated = mediastinal shift"),
    sp(0.15),
    Paragraph("<b>B) Chest Expansion</b>", sub_hdr),
    bullet("Both hands on chest, thumbs meet at midline"),
    bullet("Ask deep breath — thumbs should move apart equally (2-3 cm)"),
    bullet("Reduced on one side = disease on THAT side"),
]
right_palp = [
    Paragraph("<b>C) Vocal (Tactile) Fremitus</b>", sub_hdr),
    bullet("Ulnar border / palm on chest"),
    bullet('Ask patient to say "99" or "one-two-three"'),
    bullet("Feel vibrations — compare both sides"),
    sp(0.1),
    make_table([
        ["Fremitus",   "Condition"],
        ["INCREASED",  "Consolidation (pneumonia) — solid lung transmits sound better"],
        ["DECREASED",  "Pleural effusion, pneumothorax, emphysema — fluid/air blocks"],
    ], [PW*0.2, PW*0.3], hdr_bg=MID_BLUE, fontsize=7.5),
    sp(0.1),
    Paragraph("<b>D) Other palpation findings</b>", sub_hdr),
    bullet("Point tenderness = rib fracture, costochondritis"),
    bullet("Subcutaneous emphysema = air crackles under skin"),
    bullet("Cervical rib"),
]
story.append(two_col_layout(left_palp, right_palp, split=0.47))
story.append(sp(0.2))

# ── STEP 3: PERCUSSION ────────────────────────────────────────────────────────
story.append(step_banner(3, "PERCUSSION — TAP the chest", TEAL))
story.append(sp(0.1))

left_perc = [
    Paragraph("<b>Technique</b>", sub_hdr),
    bullet("Pleximeter finger (middle) flat on chest"),
    bullet("Strike with plexor finger (other middle finger)"),
    bullet("Uniform, free, easy stroke"),
    bullet("Percuss top → bottom, comparing left vs right"),
    sp(0.1),
    Paragraph("<b>Percussion Notes</b>", sub_hdr),
    make_table([
        ["Note",          "Sound",        "Cause"],
        ["Resonant",      "Hollow",       "Normal air-filled lung"],
        ["Hyper-resonant","Very booming",  "Pneumothorax, emphysema"],
        ["Tympanitic",    "Drum-like",    "Tension pneumothorax"],
        ["Dull",          "Thud-like",    "Consolidation (pneumonia)"],
        ["Stony dull",    "Very flat",    "Pleural effusion"],
    ], [PW*0.18, PW*0.15, PW*0.2], hdr_bg=TEAL, fontsize=7.5),
]
right_perc = [
    Paragraph("<b>Liver & Lung boundary</b>", sub_hdr),
    bullet("Right side: dullness starts at 6th rib in mid-clavicular line"),
    bullet("Percuss downward from lung resonance to liver dullness"),
    sp(0.1),
    Paragraph("<b>Areas to percuss</b>", sub_hdr),
    bullet("Anterior: apices → upper → mid → lower zones"),
    bullet("Posterior: same zones back"),
    bullet("Sides: liver (right) and spleen (left)"),
    sp(0.1),
    info_box([
        Paragraph("💡 <b>Memory tip:</b>", mem_s),
        bullet("Fluid = STONY DULL (heaviest = falls down)"),
        bullet("Air = HYPER-RESONANT (lightest = rises up)"),
        bullet("Solid/pus = DULL"),
    ], LIGHT_TEAL, TEAL),
]
story.append(two_col_layout(left_perc, right_perc, split=0.52))
story.append(sp(0.2))

# ── STEP 4: AUSCULTATION ──────────────────────────────────────────────────────
story.append(step_banner(4, "AUSCULTATION — LISTEN with stethoscope", FOREST))
story.append(sp(0.1))

left_ausc = [
    Paragraph("<b>Technique</b>", sub_hdr),
    bullet("Diaphragm = high-pitched sounds (breath sounds)"),
    bullet("Bell = low-pitched sounds"),
    bullet("Breathe through open mouth"),
    bullet("Compare left and right sides symmetrically"),
    sp(0.1),
    Paragraph("<b>Normal Breath Sounds</b>", sub_hdr),
    make_table([
        ["Type",          "Where",             "Character"],
        ["Vesicular",     "Most of lung",      "Soft; inspiration longer than expiration"],
        ["Bronchial",     "Over trachea",      "Harsh; expiration = inspiration; gap between"],
        ["Bronchovesicular","Near carina",     "Mixed vesicular + bronchial"],
    ], [PW*0.18, PW*0.18, PW*0.18], hdr_bg=FOREST, fontsize=7.5),
]
right_ausc = [
    Paragraph("<b>Added / Abnormal Sounds</b>", sub_hdr),
    make_table([
        ["Sound",              "Cause"],
        ["Crackles (fine)",    "Pulmonary oedema, fibrosis"],
        ["Crackles (coarse)",  "Pneumonia, bronchiectasis"],
        ["Wheeze",             "Asthma, COPD, foreign body"],
        ["Pleural friction rub","Pleuritis (inflamed pleura)"],
        ["Stridor",            "Upper airway obstruction (no stethoscope needed)"],
    ], [PW*0.25, PW*0.25], hdr_bg=FOREST, fontsize=7.5),
    sp(0.1),
    Paragraph("<b>Vocal Resonance</b>", sub_hdr),
    bullet('Say "99" while listening: INCREASED = consolidation'),
    bullet("Aegophony = goat-bleat at top of effusion"),
    bullet("Whispering pectoriloquy = clearly heard whisper = consolidation"),
]
story.append(two_col_layout(left_ausc, right_ausc, split=0.5))
story.append(sp(0.2))

# ── MASTER COMPARISON TABLE ────────────────────────────────────────────────────
story.append(section_banner("MASTER COMPARISON TABLE — Classic Examination Findings", NAVY))
story.append(sp(0.1))
story.append(make_table([
    ["Condition",       "Movement",     "Trachea",        "Fremitus",    "Percussion",   "Breath Sounds",   "Vocal Resonance"],
    ["Normal",          "Equal",        "Central",        "Normal",      "Resonant",     "Vesicular",        "Normal"],
    ["Consolidation\n(Pneumonia)", "Reduced",  "Central",  "INCREASED",  "DULL",         "Bronchial",        "INCREASED"],
    ["Pleural Effusion","Reduced",      "Pushed AWAY",    "ABSENT",      "STONY DULL",   "Absent/reduced",   "Absent (aegophony at top)"],
    ["Pneumothorax",    "Reduced",      "Pushed AWAY",    "ABSENT",      "HYPER-resonant","Absent",          "Absent"],
    ["Collapse/Fibrosis","Reduced",     "Pulled TOWARDS", "INCREASED",   "DULL",         "Reduced/bronchial","Reduced"],
    ["Emphysema/COPD",  "Reduced",      "Central",        "DECREASED",   "HYPER-resonant","Reduced",         "Reduced"],
], [PW*0.16, PW*0.1, PW*0.12, PW*0.1, PW*0.13, PW*0.17, PW*0.22],
   hdr_bg=NAVY, fontsize=7.5))
story.append(sp(0.3))

# ═══════════════════════════════════════════════════════════════════════════════
# PAGE 2 — ABDOMINAL EXAM
# ═══════════════════════════════════════════════════════════════════════════════
story.append(PageBreak())
story.append(part_banner("PART 2: ABDOMINAL EXAMINATION", TEAL))
story.append(sp(0.2))

# Position box
story.append(info_box([
    Paragraph("📋  <b>Patient Position:</b> Supine (lying flat). Arms by sides. "
              "Legs extended for inspection; hips/knees slightly FLEXED for palpation (relaxes muscles). "
              "Expose from nipples to groin. Examiner stands on RIGHT side. WARM your hands!", body),
    Paragraph("<b>Order for abdomen is different from chest:  I → A → P → P  "
              "(Auscultate BEFORE palpation — so bowel sounds are not disturbed!)</b>",
              S("ord", fontSize=8.5, leading=12, textColor=CRIMSON, fontName="Helvetica-Bold")),
], LIGHT_TEAL, TEAL))
story.append(sp(0.15))

# General exam
story.append(info_box([
    Paragraph("🔍  <b>ALWAYS start with General Examination:</b>  "
              "Weight loss, jaundice, anaemia, pedal oedema · "
              "Hands: palmar erythema, Dupuytren's, leukonychia, clubbing (liver disease) · "
              "Eyes: jaundice, anaemia · "
              "Lymph nodes: Virchow's node (left supraclavicular = intra-abdominal malignancy) · "
              "Vital signs: pulse, BP, temperature, RR", body)
], PALE_BLUE, DEEP_BLUE))
story.append(sp(0.2))

# ── STEP 1: INSPECTION (ABD) ──────────────────────────────────────────────────
story.append(step_banner(1, "INSPECTION — LOOK at the abdomen", DEEP_BLUE))
story.append(sp(0.1))

left_abd_insp = [
    Paragraph("<b>Look from the SIDE, then TANGENTIALLY, then from HEAD & FOOT</b>", sub_hdr),
    sp(0.05),
    Paragraph("<b>A) Scars (previous surgery)</b>", sub_hdr),
    make_table([
        ["Scar location",         "Likely operation"],
        ["Midline",               "Laparotomy"],
        ["Right iliac fossa",     "Appendicectomy"],
        ["Right subcostal (Kocher's)", "Cholecystectomy"],
        ["Left iliac fossa",      "Sigmoid colectomy"],
        ["Loin",                  "Nephrectomy"],
    ], [PW*0.25, PW*0.25], hdr_bg=DEEP_BLUE, fontsize=7.5),
    sp(0.15),
    Paragraph("<b>B) Abdominal distension — the 5 F's</b>", sub_hdr),
    info_box([
        Paragraph("Fat · Fluid (ascites) · Flatus · Faeces · Foetus", mem_s)
    ], LIGHT_GOLD, GOLD),
    sp(0.1),
    Paragraph("<b>C) Umbilicus</b>", sub_hdr),
    bullet("Everted (pointing out) = ascites / large mass"),
    bullet("Inverted = obesity"),
    bullet("Displaced upward = pelvic mass"),
    bullet("Displaced downward = ascites (Tanyol's sign)"),
]
right_abd_insp = [
    Paragraph("<b>D) Skin signs — very important!</b>", sub_hdr),
    info_box([
        Paragraph("⚠ <b>Grey Turner's sign</b> = bruising in the FLANKS", warn_s),
        Paragraph("→ Retroperitoneal haemorrhage (severe pancreatitis, ruptured AAA)", body),
        sp(0.05),
        Paragraph("⚠ <b>Cullen's sign</b> = bruising around the UMBILICUS", warn_s),
        Paragraph("→ Severe pancreatitis, ruptured ectopic pregnancy, liver trauma", body),
    ], LIGHT_RED, CRIMSON),
    sp(0.1),
    Paragraph("<b>E) Dilated veins</b>", sub_hdr),
    bullet("Around umbilicus (caput medusae) = portal hypertension"),
    bullet("Blood flowing AWAY from umbilicus = portal obstruction"),
    bullet("Veins on flanks flowing UPWARD = IVC obstruction"),
    sp(0.1),
    Paragraph("<b>F) Other</b>", sub_hdr),
    bullet("Visible peristalsis = intestinal obstruction (thin patients)"),
    bullet("Visible pulsation = aortic aneurysm"),
    bullet("Hernias: ask patient to COUGH and look for bulges"),
    bullet("Jaundice / scratch marks = obstructive jaundice"),
]
story.append(two_col_layout(left_abd_insp, right_abd_insp, split=0.5))
story.append(sp(0.2))

# ── STEP 2: AUSCULTATION (ABD) ────────────────────────────────────────────────
story.append(step_banner(2, "AUSCULTATION — LISTEN before touching!", FOREST))
story.append(sp(0.1))

left_abd_ausc = [
    Paragraph("<b>Bowel Sounds</b>", sub_hdr),
    make_table([
        ["Bowel Sound",       "Meaning"],
        ["Normal (gurgling)", "Normal intestinal activity"],
        ["Increased (tinkling/rushing)", "Intestinal obstruction (early)"],
        ["Absent (silent)",   "Paralytic ileus, peritonitis"],
    ], [PW*0.28, PW*0.22], hdr_bg=FOREST, fontsize=7.5),
]
right_abd_ausc = [
    Paragraph("<b>Bruits (vascular sounds)</b>", sub_hdr),
    bullet("Aortic bruit (above umbilicus) = aortic aneurysm / stenosis"),
    bullet("Renal bruit (flanks) = renal artery stenosis (secondary hypertension)"),
    bullet("Hepatic bruit = hepatocellular carcinoma"),
]
story.append(two_col_layout(left_abd_ausc, right_abd_ausc, split=0.5))
story.append(sp(0.2))

# ── STEP 3: PALPATION (ABD) ───────────────────────────────────────────────────
story.append(step_banner(3, "PALPATION — FEEL the abdomen (two phases)", MID_BLUE))
story.append(sp(0.1))

left_abd_palp = [
    Paragraph("<b>Phase 1: LIGHT palpation</b>", sub_hdr),
    bullet("Flat hand, gentle pressure"),
    bullet("Start AWAY from the painful area"),
    bullet("Watch patient's FACE for pain"),
    bullet("Feel: guarding, rigidity, tenderness, superficial masses"),
    sp(0.1),
    Paragraph("<b>Phase 2: DEEP palpation</b>", sub_hdr),
    bullet("Firmer pressure for organs and deep masses"),
    sp(0.1),
    Paragraph("<b>Key findings</b>", sub_hdr),
    make_table([
        ["Finding",             "Meaning"],
        ["Tenderness",          "Inflammation at that site"],
        ["Guarding",            "Voluntary muscle tensing (protective)"],
        ["Rigidity",            "Board-like = PERITONITIS (emergency!)"],
        ["Rebound tenderness",  "Pain worse on releasing = peritoneal irritation"],
    ], [PW*0.22, PW*0.28], hdr_bg=MID_BLUE, fontsize=7.5),
]
right_abd_palp = [
    Paragraph("<b>Special signs</b>", sub_hdr),
    info_box([
        Paragraph("🔴 <b>Murphy's sign:</b> Pain stops breathing in during RUQ palpation = <b>Acute cholecystitis</b>", body),
        Paragraph("🔴 <b>McBurney's point:</b> Tenderness 1/3 from ASIS to umbilicus = <b>Appendicitis</b>", body),
    ], LIGHT_RED, CRIMSON),
    sp(0.1),
    Paragraph("<b>Liver palpation</b>", sub_hdr),
    bullet("Start from RIGHT ILIAC FOSSA, move toward right costal margin"),
    bullet("Ask to breathe in (liver descends during inspiration)"),
    bullet("Measure in finger-breadths below costal margin"),
    sp(0.1),
    Paragraph("<b>Spleen palpation</b>", sub_hdr),
    bullet("Start from RIGHT iliac fossa, move toward LEFT upper quadrant"),
    bullet("Enlarged spleen has a notch on medial border"),
    bullet("Support left costal margin with left hand"),
    sp(0.1),
    Paragraph("<b>Kidney (bimanual)</b>", sub_hdr),
    bullet("Ballot kidney between two hands (front and back)"),
    bullet("Enlarged = hydronephrosis, polycystic, tumour"),
]
story.append(two_col_layout(left_abd_palp, right_abd_palp, split=0.5))
story.append(sp(0.2))

# ── STEP 4: PERCUSSION (ABD) ──────────────────────────────────────────────────
story.append(step_banner(4, "PERCUSSION — TAP the abdomen", TEAL))
story.append(sp(0.1))

left_abd_perc = [
    Paragraph("<b>General percussion</b>", sub_hdr),
    bullet("Tympanitic = gas in bowel (normal for most of abdomen)"),
    bullet("Dull = solid organ (liver, spleen) or mass or fluid"),
    sp(0.1),
    Paragraph("<b>Liver size</b>", sub_hdr),
    bullet("Upper border = lung resonance → liver dullness (~5th rib)"),
    bullet("Lower border = liver dullness → bowel tympany"),
    bullet("Normal liver span = 10-12 cm in mid-clavicular line"),
    sp(0.1),
    Paragraph("<b>Splenic dullness</b>", sub_hdr),
    bullet("Percuss left upper quadrant near 10th rib (posterior to midaxillary line)"),
    bullet("Dullness here = enlarged spleen"),
]
right_abd_perc = [
    Paragraph("<b>Testing for ASCITES — most important!</b>", sub_hdr),
    info_box([
        Paragraph("<b>Method 1: Shifting Dullness</b>", body_bold),
        bullet("Percuss umbilicus → flank: note where dullness begins"),
        bullet("Keep finger at dull point; ask patient to ROLL toward you"),
        bullet("If dullness SHIFTS = ascites (fluid moves with gravity)"),
        sp(0.05),
        Paragraph("<b>Method 2: Fluid Thrill</b> (large ascites only)", body_bold),
        bullet("One hand flat on one flank"),
        bullet("Tap the opposite flank sharply"),
        bullet("Feel ripple/thrill = large ascites"),
        bullet("(Ask someone to press midline — blocks fat transmission)"),
    ], LIGHT_TEAL, TEAL),
]
story.append(two_col_layout(left_abd_perc, right_abd_perc, split=0.48))
story.append(sp(0.2))

# Additional examinations
story.append(info_box([
    Paragraph("📝  <b>Don't forget — Complete the abdominal exam by also examining:</b>", body_bold),
    Paragraph("Hernial orifices (inguinal, femoral, umbilical)  |  Genitalia (scrotal swellings)  |  "
              "Inguinal lymph nodes  |  Per Rectal (PR) examination  |  Gynaecological exam (if needed)", body),
], LIGHT_BLUE, DEEP_BLUE))
story.append(sp(0.3))

# ── MEMORY TRICKS PAGE ────────────────────────────────────────────────────────
story.append(section_banner("MEMORY TRICKS  &  5-MARK ANSWER TEMPLATE", NAVY))
story.append(sp(0.1))

left_mem = [
    Paragraph("<b>Memory tricks</b>", sub_hdr),
    info_box([
        Paragraph("🧠 <b>Respiratory order:</b>  'I Prefer Proper Auscultation'  = IPPA", mem_s),
        Paragraph("🧠 <b>Abdominal order:</b>  'I Always Palpate Patients'  = IAPP", mem_s),
        Paragraph("🧠 <b>5 F's of distension:</b>  Fat · Fluid · Flatus · Faeces · Foetus", mem_s),
        Paragraph("🧠 <b>Trachea:</b>  Effusion PUSHES away · Collapse PULLS toward", mem_s),
        Paragraph("🧠 <b>Consolidation:</b>  ALL INCREASED (fremitus, resonance, dull perc, bronchial sounds)", mem_s),
        Paragraph("🧠 <b>Effusion:</b>  ALL ABSENT (stony dull, absent sounds, absent fremitus)", mem_s),
        Paragraph("🧠 <b>Grey Turner</b> = FLANKS · <b>Cullen's</b> = UMBILICUS (both = pancreatitis)", mem_s),
        Paragraph("🧠 <b>Murphy's sign</b> = cholecystitis · <b>McBurney's</b> = appendicitis", mem_s),
    ], LIGHT_GOLD, GOLD),
]
right_mem = [
    Paragraph("<b>5-mark answer template</b>", sub_hdr),
    info_box([
        Paragraph("<b>For any 5-mark question on examination:</b>", body_bold),
        bullet("1. Brief intro: state the 4-step sequence (IPPA or IAPP)"),
        bullet("2. Patient position: sitting (chest) / supine (abdomen)"),
        bullet("3. INSPECTION: 3-4 key findings with 1 clinical example"),
        bullet("4. PALPATION: key techniques + fremitus / guarding"),
        bullet("5. PERCUSSION: percussion notes + what they mean"),
        bullet("6. AUSCULTATION: normal sounds + added sounds"),
        bullet("7. One-line clinical correlation per step"),
        bullet("8. End with: additional exams (PR, hernial orifices)"),
        sp(0.05),
        Paragraph("<i>This structure guarantees full marks!</i>",
                  S("gi", fontSize=8, fontName="Helvetica-Oblique", textColor=TEAL)),
    ], LIGHT_GREEN, FOREST),
]
story.append(two_col_layout(left_mem, right_mem, split=0.5))
story.append(sp(0.25))

# Final footer banner
footer_tbl = Table([[
    Paragraph("Murray & Nadel's Respiratory Medicine  |  Bailey & Love's Surgery  |  Goldman-Cecil Medicine",
              S("ft", fontSize=7.5, textColor=colors.HexColor("#94A3B8"), alignment=TA_CENTER, fontName="Helvetica-Oblique")),
]], colWidths=[PW])
footer_tbl.setStyle(TableStyle([
    ("BACKGROUND",   (0,0),(-1,-1), NAVY),
    ("TOPPADDING",   (0,0),(-1,-1), 5),
    ("BOTTOMPADDING",(0,0),(-1,-1), 5),
]))
story.append(footer_tbl)

doc.build(story)
print(f"PDF created: {OUTPUT}")

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<title>MBBS 2nd Year – Respiratory & Abdominal Exam Quick Reference</title>
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<!-- ======================= PAGE 1: RESPIRATORY ======================== -->
<div class="page">

  <div class="cover-banner">
    <p>MBBS 2nd Year &nbsp;·&nbsp; ICMHE Theory Exam &nbsp;·&nbsp; June 7, 2026</p>
    <h1>Clinical Examination Quick Reference</h1>
    <h2>Respiratory System &nbsp;|&nbsp; Abdominal System</h2>
    <p>Inspection · Palpation · Percussion · Auscultation</p>
  </div>

  <div class="golden-rule">
    <p>⭐ THE GOLDEN RULE OF CLINICAL EXAMINATION</p>
    <p class="rule-line"><span class="blue-txt">Respiratory:</span> &nbsp;&nbsp;
      <b style="color:#1a56a0">I</b>nspection → <b style="color:#1a56a0">P</b>alpation →
      <b style="color:#1a56a0">P</b>ercussion → <b style="color:#1a56a0">A</b>uscultation &nbsp;
      <span class="red-txt">(IPPA)</span></p>
    <p class="rule-line"><span class="teal-txt">Abdominal:</span> &nbsp;&nbsp;
      <b style="color:#1a56a0">I</b>nspection → <b style="color:#0f766e">A</b>uscultation →
      <b style="color:#1a56a0">P</b>alpation → <b style="color:#1a56a0">P</b>ercussion &nbsp;
      <span class="red-txt">(IAPP — auscultate BEFORE touching!)</span></p>
  </div>

  <div class="part-banner navy">PART 1: RESPIRATORY (CHEST) EXAMINATION</div>

  <div class="box box-blue" style="margin-bottom:6px;">
    <p><b>Patient Position:</b> Sitting upright, chest fully exposed (front and back). Good lighting, quiet room, warm hands.</p>
  </div>

  <!-- STEP 1 -->
  <div class="step-banner blue">STEP 1: INSPECTION — Just LOOK</div>
  <div class="two-col">
    <div class="col-l">
      <h3>A) Chest Shape</h3>
      <table class="th-blue">
        <tr><th>Shape</th><th>Meaning</th></tr>
        <tr><td>Normal</td><td>Symmetric, elliptical</td></tr>
        <tr><td>Barrel chest</td><td>COPD / emphysema</td></tr>
        <tr><td>Pectus excavatum</td><td>Funnel chest (sunken sternum)</td></tr>
        <tr><td>Pectus carinatum</td><td>Pigeon chest (protruding sternum)</td></tr>
        <tr><td>Kyphoscoliosis</td><td>Curved spine → restrictive disease</td></tr>
      </table>
      <h3>B) Breathing Pattern</h3>
      <table class="th-blue">
        <tr><th>Pattern</th><th>Meaning</th></tr>
        <tr><td>Tachypnoea</td><td>&gt;20/min: infection, pain</td></tr>
        <tr><td>Bradypnoea</td><td>&lt;12/min: CNS depression</td></tr>
        <tr><td>Cheyne-Stokes</td><td>Cycles + apnoea: heart failure, brain</td></tr>
        <tr><td>Kussmaul</td><td>Deep, labored: DKA</td></tr>
        <tr><td>Biot's</td><td>Irregular bursts + apnoea: brainstem</td></tr>
      </table>
    </div>
    <div class="col-r">
      <h3>C) Other things to look for</h3>
      <ul>
        <li>Trachea position — midline or deviated?</li>
        <li>Chest wall movement — equal both sides?</li>
        <li>Accessory muscle use (neck/intercostal) = respiratory distress</li>
        <li>Scars from previous surgery</li>
        <li>Tobacco stains on fingers, lips, teeth</li>
        <li>Foul smell = lung abscess; ketones = DKA</li>
      </ul>
      <div class="box box-red">
        <p class="red-txt">⚠ Trachea deviation rule:</p>
        <ul>
          <li>Pulled <b>TOWARDS</b> lesion = collapse / fibrosis</li>
          <li>Pushed <b>AWAY</b> from lesion = effusion / tension pneumothorax</li>
        </ul>
      </div>
    </div>
  </div>

  <!-- STEP 2 -->
  <div class="step-banner mid-blue">STEP 2: PALPATION — FEEL the chest</div>
  <div class="two-col">
    <div class="col-l">
      <h3>A) Trachea Position</h3>
      <ul><li>Place finger in suprasternal notch</li><li>Central = normal; deviated = mediastinal shift</li></ul>
      <h3>B) Chest Expansion</h3>
      <ul>
        <li>Both hands on chest, thumbs meet at midline</li>
        <li>Deep breath — thumbs should move equally (2-3 cm)</li>
        <li>Reduced on one side = disease on THAT side</li>
      </ul>
    </div>
    <div class="col-r">
      <h3>C) Vocal (Tactile) Fremitus</h3>
      <ul><li>Ulnar border / palm on chest</li><li>Patient says "99" or "one-two-three"</li><li>Feel vibrations — compare both sides</li></ul>
      <table class="th-mid">
        <tr><th>Fremitus</th><th>Condition</th></tr>
        <tr><td><b>INCREASED</b></td><td>Consolidation (pneumonia) — solid lung</td></tr>
        <tr><td><b>DECREASED</b></td><td>Effusion, pneumothorax, emphysema</td></tr>
      </table>
    </div>
  </div>

  <!-- STEP 3 -->
  <div class="step-banner teal">STEP 3: PERCUSSION — TAP the chest</div>
  <div class="two-col">
    <div class="col-l">
      <h3>Percussion Notes — MEMORIZE</h3>
      <table class="th-teal">
        <tr><th>Note</th><th>Sound</th><th>Cause</th></tr>
        <tr><td><b>Resonant</b></td><td>Hollow</td><td>Normal lung</td></tr>
        <tr><td><b>Hyper-resonant</b></td><td>Very booming</td><td>Pneumothorax, emphysema</td></tr>
        <tr><td><b>Tympanitic</b></td><td>Drum-like</td><td>Tension pneumothorax</td></tr>
        <tr><td><b>Dull</b></td><td>Thud-like</td><td>Consolidation (pneumonia)</td></tr>
        <tr><td><b>Stony dull</b></td><td>Very flat</td><td>Pleural effusion</td></tr>
      </table>
    </div>
    <div class="col-r">
      <h3>Technique</h3>
      <ul>
        <li>Pleximeter (middle finger) flat on chest</li>
        <li>Strike with plexor (other middle finger)</li>
        <li>Percuss top to bottom, LEFT vs RIGHT always</li>
        <li>Right side: dullness starts at 6th rib (mid-clavicular)</li>
      </ul>
      <div class="box box-teal">
        <p class="teal-txt">💡 Memory tip:</p>
        <ul>
          <li>Fluid = STONY DULL (heavy, sinks)</li>
          <li>Air = HYPER-RESONANT (light, rises)</li>
          <li>Solid/pus = DULL</li>
        </ul>
      </div>
    </div>
  </div>

  <!-- STEP 4 -->
  <div class="step-banner forest">STEP 4: AUSCULTATION — LISTEN with stethoscope</div>
  <div class="two-col">
    <div class="col-l">
      <h3>Normal Breath Sounds</h3>
      <table class="th-forest">
        <tr><th>Type</th><th>Where</th><th>Character</th></tr>
        <tr><td>Vesicular</td><td>Most of lung</td><td>Soft; inspiration &gt; expiration</td></tr>
        <tr><td>Bronchial</td><td>Over trachea</td><td>Harsh; expiration = inspiration</td></tr>
        <tr><td>Bronchovesicular</td><td>Near carina</td><td>Mixed</td></tr>
      </table>
      <h3>Vocal Resonance</h3>
      <ul>
        <li>Say "99" while listening: INCREASED = consolidation</li>
        <li>Aegophony = goat-bleat at top of effusion</li>
        <li>Whispering pectoriloquy = clearly heard whisper = consolidation</li>
      </ul>
    </div>
    <div class="col-r">
      <h3>Added / Abnormal Sounds</h3>
      <table class="th-forest">
        <tr><th>Sound</th><th>Cause</th></tr>
        <tr><td>Fine crackles</td><td>Pulmonary oedema, fibrosis</td></tr>
        <tr><td>Coarse crackles</td><td>Pneumonia, bronchiectasis</td></tr>
        <tr><td>Wheeze</td><td>Asthma, COPD, foreign body</td></tr>
        <tr><td>Pleural friction rub</td><td>Pleuritis (inflamed pleura)</td></tr>
        <tr><td>Stridor</td><td>Upper airway obstruction</td></tr>
      </table>
    </div>
  </div>

  <!-- MASTER TABLE -->
  <div class="sec-banner navy" style="margin-top:5px;">MASTER COMPARISON TABLE — Classic Examination Findings</div>
  <table class="master-tbl th-navy">
    <tr>
      <th>Condition</th><th>Movement</th><th>Trachea</th><th>Fremitus</th>
      <th>Percussion</th><th>Breath Sounds</th><th>Vocal Resonance</th>
    </tr>
    <tr><td>Normal</td><td>Equal</td><td>Central</td><td>Normal</td><td>Resonant</td><td>Vesicular</td><td>Normal</td></tr>
    <tr><td><b>Consolidation</b></td><td>Reduced</td><td>Central</td><td style="color:#166534;font-weight:bold">INCREASED</td><td style="color:#991b1b;font-weight:bold">DULL</td><td>Bronchial</td><td style="color:#166534;font-weight:bold">INCREASED</td></tr>
    <tr><td><b>Pleural Effusion</b></td><td>Reduced</td><td>Pushed AWAY</td><td style="color:#991b1b;font-weight:bold">ABSENT</td><td style="color:#991b1b;font-weight:bold">STONY DULL</td><td>Absent</td><td>Absent (aegophony)</td></tr>
    <tr><td><b>Pneumothorax</b></td><td>Reduced</td><td>Pushed AWAY</td><td style="color:#991b1b;font-weight:bold">ABSENT</td><td style="color:#c2410c;font-weight:bold">HYPER-RESONANT</td><td>Absent</td><td>Absent</td></tr>
    <tr><td><b>Collapse/Fibrosis</b></td><td>Reduced</td><td>Pulled TOWARDS</td><td style="color:#166534;font-weight:bold">INCREASED</td><td style="color:#991b1b;font-weight:bold">DULL</td><td>Reduced/bronchial</td><td>Reduced</td></tr>
    <tr><td><b>Emphysema/COPD</b></td><td>Reduced</td><td>Central</td><td style="color:#991b1b;font-weight:bold">DECREASED</td><td style="color:#c2410c;font-weight:bold">HYPER-RESONANT</td><td>Reduced</td><td>Reduced</td></tr>
  </table>

  <div class="footer">Murray &amp; Nadel's Respiratory Medicine · Bailey &amp; Love's Surgery · Goldman-Cecil Medicine</div>
</div>


<!-- ======================= PAGE 2: ABDOMINAL ========================= -->
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  <div class="part-banner teal">PART 2: ABDOMINAL EXAMINATION</div>

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    <p><b>Patient Position:</b> Supine (lying flat). Arms by sides. Legs extended for inspection; hips/knees slightly FLEXED for palpation. Expose from nipples to groin. Examiner stands on RIGHT side. <span class="red-txt">WARM your hands!</span></p>
    <p style="margin-top:4px;"><b class="red-txt">Abdominal order = IAPP (Auscultate BEFORE palpation — so bowel sounds are not disturbed!)</b></p>
  </div>

  <div class="box box-blue" style="margin-bottom:5px;">
    <p><b>Always start with General Examination first:</b> Weight loss · Jaundice · Anaemia · Pedal oedema · Hands (palmar erythema, Dupuytren's, clubbing = liver disease) · Virchow's node (left supraclavicular = intra-abdominal malignancy) · Vital signs</p>
  </div>

  <!-- STEP 1 -->
  <div class="step-banner blue">STEP 1: INSPECTION — LOOK at the abdomen (from side, tangentially, head &amp; foot)</div>
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    <div class="col-l">
      <h3>A) Scars (clue to previous surgery)</h3>
      <table class="th-blue">
        <tr><th>Scar Location</th><th>Likely Operation</th></tr>
        <tr><td>Midline</td><td>Laparotomy</td></tr>
        <tr><td>Right iliac fossa</td><td>Appendicectomy</td></tr>
        <tr><td>Right subcostal (Kocher's)</td><td>Cholecystectomy</td></tr>
        <tr><td>Left iliac fossa</td><td>Sigmoid colectomy</td></tr>
        <tr><td>Loin</td><td>Nephrectomy</td></tr>
      </table>

      <h3 style="margin-top:5px;">B) Abdominal Distension — the 5 F's</h3>
      <div class="box box-gold">
        <p class="gold-txt">Fat · Fluid (ascites) · Flatus · Faeces · Foetus</p>
      </div>

      <h3>C) Umbilicus</h3>
      <ul>
        <li><b>Everted</b> = ascites / large mass</li>
        <li><b>Inverted</b> = obesity</li>
        <li><b>Displaced up</b> = pelvic mass</li>
        <li><b>Displaced down</b> = ascites (Tanyol's sign)</li>
      </ul>

      <h3>D) Dilated veins</h3>
      <ul>
        <li>Around umbilicus (caput medusae) = portal hypertension</li>
        <li>Flanks flowing upward = IVC obstruction</li>
      </ul>
    </div>
    <div class="col-r">
      <div class="box box-red">
        <p class="red-txt">⚠ IMPORTANT SKIN SIGNS</p>
        <p><b>Grey Turner's sign</b> = bruising in the <b>FLANKS</b></p>
        <p>→ Retroperitoneal haemorrhage (severe pancreatitis, ruptured AAA)</p>
        <br/>
        <p><b>Cullen's sign</b> = bruising around the <b>UMBILICUS</b></p>
        <p>→ Severe pancreatitis, ruptured ectopic pregnancy</p>
        <br/>
        <p class="sm" style="color:#991b1b;"><i>Both signs = think SEVERE PANCREATITIS first!</i></p>
      </div>
      <h3 style="margin-top:6px;">E) Other</h3>
      <ul>
        <li>Visible peristalsis = intestinal obstruction (thin patients)</li>
        <li>Visible pulsation above umbilicus = aortic aneurysm</li>
        <li>Hernias: ask patient to COUGH, look for bulges</li>
        <li>Jaundice + scratch marks = obstructive jaundice</li>
        <li>Scaphoid (sunken) abdomen = malnutrition, peritonitis</li>
      </ul>
    </div>
  </div>

  <!-- STEP 2 -->
  <div class="step-banner forest">STEP 2: AUSCULTATION — LISTEN before touching!</div>
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      <h3>Bowel Sounds</h3>
      <table class="th-forest">
        <tr><th>Sound</th><th>Meaning</th></tr>
        <tr><td>Normal (gurgling)</td><td>Normal intestinal activity</td></tr>
        <tr><td><b>Increased, tinkling/rushing</b></td><td>Intestinal obstruction (early)</td></tr>
        <tr><td><b>Absent (silent abdomen)</b></td><td>Paralytic ileus, peritonitis</td></tr>
      </table>
    </div>
    <div class="col-r">
      <h3>Bruits (vascular sounds)</h3>
      <ul>
        <li><b>Aortic bruit</b> (above umbilicus) = aortic aneurysm / stenosis</li>
        <li><b>Renal bruit</b> (flanks) = renal artery stenosis (secondary hypertension)</li>
        <li><b>Hepatic bruit</b> = hepatocellular carcinoma</li>
      </ul>
    </div>
  </div>

  <!-- STEP 3 -->
  <div class="step-banner mid-blue">STEP 3: PALPATION — FEEL the abdomen (two phases)</div>
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      <h3>Phase 1: LIGHT palpation</h3>
      <ul>
        <li>Flat hand, gentle pressure</li>
        <li>Start AWAY from the painful area</li>
        <li>Watch patient's FACE for pain response</li>
      </ul>
      <h3>Phase 2: DEEP palpation</h3>
      <ul><li>Firmer pressure for organs and deep masses</li></ul>
      <h3>Key findings</h3>
      <table class="th-mid">
        <tr><th>Finding</th><th>Meaning</th></tr>
        <tr><td>Tenderness</td><td>Inflammation at that site</td></tr>
        <tr><td>Guarding</td><td>Voluntary muscle tensing (protective)</td></tr>
        <tr><td><b>Rigidity</b></td><td><b>Board-like = PERITONITIS (emergency!)</b></td></tr>
        <tr><td>Rebound tenderness</td><td>Pain on releasing = peritoneal irritation</td></tr>
      </table>
    </div>
    <div class="col-r">
      <div class="box box-red">
        <p class="red-txt">Special Signs</p>
        <p><b>Murphy's sign:</b> Pain stops breathing in during RUQ palpation = <b>Acute cholecystitis</b></p>
        <p style="margin-top:4px;"><b>McBurney's point:</b> Tenderness 1/3 from ASIS to umbilicus = <b>Appendicitis</b></p>
      </div>
      <h3 style="margin-top:5px;">Organ palpation</h3>
      <ul>
        <li><b>Liver:</b> Start from RIGHT iliac fossa → move up. Breathe in (liver descends). Measure in finger-breadths below costal margin.</li>
        <li><b>Spleen:</b> Start from RIGHT iliac fossa → move to left. Spleen has a <b>notch</b> on medial border.</li>
        <li><b>Kidneys:</b> Bimanual (ballot between two hands). Enlarged = hydronephrosis, polycystic, tumour.</li>
      </ul>
    </div>
  </div>

  <!-- STEP 4 -->
  <div class="step-banner teal">STEP 4: PERCUSSION — TAP the abdomen</div>
  <div class="two-col">
    <div class="col-l">
      <h3>General</h3>
      <ul>
        <li>Tympanitic = gas in bowel (normal for most of abdomen)</li>
        <li>Dull = solid organ, mass, or fluid</li>
      </ul>
      <h3>Liver size</h3>
      <ul>
        <li>Upper border ~5th rib in mid-clavicular line</li>
        <li>Normal liver span = <b>10-12 cm</b> in mid-clavicular line</li>
      </ul>
      <h3>Splenic dullness</h3>
      <ul><li>Percuss left upper quadrant near 10th rib (posterior to midaxillary line)</li></ul>
    </div>
    <div class="col-r">
      <h3>Testing for ASCITES</h3>
      <div class="box box-teal">
        <p><b>Method 1: Shifting Dullness</b></p>
        <ul>
          <li>Percuss umbilicus → flank; note where dullness starts</li>
          <li>Keep finger there; ask patient to ROLL toward you</li>
          <li>Dullness SHIFTS = ascites present</li>
        </ul>
        <p style="margin-top:4px;"><b>Method 2: Fluid Thrill (large ascites)</b></p>
        <ul>
          <li>One hand flat on one flank; tap the other flank</li>
          <li>Feel ripple/thrill = large ascites</li>
          <li>Someone presses midline to block fat transmission</li>
        </ul>
      </div>
    </div>
  </div>

  <div class="box box-blue" style="margin-bottom:6px;">
    <p><b>Complete the abdominal exam — also examine:</b> &nbsp; Hernial orifices (inguinal, femoral, umbilical) &nbsp;·&nbsp; Genitalia &nbsp;·&nbsp; Inguinal lymph nodes &nbsp;·&nbsp; Per Rectal (PR) exam &nbsp;·&nbsp; Gynaecological exam (if needed)</p>
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  <!-- MEMORY + TEMPLATE -->
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      <div class="sec-banner navy" style="font-size:10px;">MEMORY TRICKS</div>
      <div class="box box-gold">
        <p class="mem-item">🧠 Respiratory order: "I Prefer Proper Auscultation" = IPPA</p>
        <p class="mem-item">🧠 Abdominal order: "I Always Palpate Patients" = IAPP</p>
        <p class="mem-item">🧠 5 F's of distension: Fat · Fluid · Flatus · Faeces · Foetus</p>
        <p class="mem-item">🧠 Trachea: Effusion PUSHES away · Collapse PULLS toward</p>
        <p class="mem-item">🧠 Consolidation: ALL INCREASED (fremitus, resonance, bronchial)</p>
        <p class="mem-item">🧠 Effusion: ALL ABSENT (stony dull, absent sounds, absent fremitus)</p>
        <p class="mem-item">🧠 Grey Turner = FLANKS · Cullen's = UMBILICUS → pancreatitis</p>
        <p class="mem-item">🧠 Murphy's sign = cholecystitis · McBurney's = appendicitis</p>
        <p class="mem-item">🧠 Appelbaum capacity: Understand → Appreciate → Reason → Communicate</p>
      </div>
    </div>
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      <div class="sec-banner navy" style="font-size:10px;">5-MARK ANSWER TEMPLATE</div>
      <div class="box box-green">
        <p class="bold">For any 5-mark question on examination:</p>
        <ul>
          <li>1. Brief intro: state the 4-step sequence (IPPA or IAPP)</li>
          <li>2. Patient position: sitting (chest) / supine (abdomen)</li>
          <li>3. INSPECTION: 3-4 findings + 1 clinical example</li>
          <li>4. PALPATION: techniques + fremitus / guarding</li>
          <li>5. PERCUSSION: notes + what they mean</li>
          <li>6. AUSCULTATION: normal sounds + added sounds</li>
          <li>7. One-line clinical correlation per step</li>
          <li>8. Additional exams: PR, hernial orifices</li>
        </ul>
        <p style="color:#166534; font-style:italic; margin-top:3px;">This structure = guaranteed full marks!</p>
      </div>
    </div>
  </div>

  <div class="footer">Murray &amp; Nadel's Respiratory Medicine &nbsp;·&nbsp; Bailey &amp; Love's Surgery &nbsp;·&nbsp; Goldman-Cecil Medicine &nbsp;·&nbsp; Compiled by Orris AI</div>
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