mkdir -p /home/daytona/workspace/rguhs-paediatrics && ls /home/daytona/workspace…

~/rguhs-paediatrics/create_df.js

const {
  Document, Packer, Paragraph, TextRun, Table, TableRow, TableCell,
  HeadingLevel, AlignmentType, BorderStyle, WidthType, ShadingType,
  VerticalAlign, PageNumber, Header, Footer
} = require('docx');
const fs = require('fs');

// ─── Helper functions ────────────────────────────────────────────────────────
const bold = (text, size = 22) => new TextRun({ text, bold: true, size });
const normal = (text, size = 20) => new TextRun({ text, size });
const italic = (text, size = 20) => new TextRun({ text, italics: true, size });

function heading1(text) {
  return new Paragraph({
    children: [new TextRun({ text, bold: true, size: 28, color: '1F3864' })],
    heading: HeadingLevel.HEADING_1,
    spacing: { before: 300, after: 150 },
    border: { bottom: { color: '1F3864', size: 6, style: BorderStyle.SINGLE } }
  });
}

function heading2(text) {
  return new Paragraph({
    children: [new TextRun({ text, bold: true, size: 24, color: '2E75B6' })],
    heading: HeadingLevel.HEADING_2,
    spacing: { before: 200, after: 100 }
  });
}

function heading3(text) {
  return new Paragraph({
    children: [new TextRun({ text, bold: true, size: 22, color: '404040' })],
    heading: HeadingLevel.HEADING_3,
    spacing: { before: 150, after: 80 }
  });
}

function para(text, indent = false) {
  return new Paragraph({
    children: [new TextRun({ text, size: 20 })],
    spacing: { after: 80 },
    indent: indent ? { left: 360 } : undefined
  });
}

function bullet(text, level = 0) {
  return new Paragraph({
    children: [new TextRun({ text, size: 20 })],
    bullet: { level },
    spacing: { after: 60 }
  });
}

function boldPara(label, text) {
  return new Paragraph({
    children: [new TextRun({ text: label, bold: true, size: 20 }), new TextRun({ text, size: 20 })],
    spacing: { after: 80 }
  });
}

function blankLine() {
  return new Paragraph({ children: [new TextRun('')], spacing: { after: 80 } });
}

function sectionTitle(qNum, marks, title) {
  return new Paragraph({
    children: [
      new TextRun({ text: `Q${qNum}. `, bold: true, size: 26, color: 'C00000' }),
      new TextRun({ text: title, bold: true, size: 24, color: '1F3864' }),
      new TextRun({ text: `  [${marks} Marks]`, bold: true, size: 22, color: 'C00000' })
    ],
    spacing: { before: 300, after: 120 },
    border: {
      bottom: { color: '2E75B6', size: 4, style: BorderStyle.SINGLE },
      left: { color: 'C00000', size: 12, style: BorderStyle.SINGLE }
    },
    indent: { left: 120 }
  });
}

function flowBox(text, isDecision = false) {
  const bg = isDecision ? 'FFF2CC' : 'DEEAF1';
  return new Paragraph({
    children: [new TextRun({ text: isDecision ? `◆ ${text}` : `[ ${text} ]`, bold: true, size: 20, color: isDecision ? '7F6000' : '1F3864' })],
    spacing: { before: 60, after: 60 },
    indent: { left: 720 },
    shading: { type: ShadingType.CLEAR, fill: bg }
  });
}

function flowArrow() {
  return new Paragraph({
    children: [new TextRun({ text: '         ↓', size: 20, color: '595959' })],
    spacing: { before: 20, after: 20 }
  });
}

function makeTable(headers, rows, colWidths) {
  const headerCells = headers.map((h, i) => new TableCell({
    children: [new Paragraph({ children: [new TextRun({ text: h, bold: true, size: 20, color: 'FFFFFF' })], alignment: AlignmentType.CENTER })],
    shading: { type: ShadingType.CLEAR, fill: '1F3864' },
    width: { size: colWidths[i], type: WidthType.PERCENTAGE },
    verticalAlign: VerticalAlign.CENTER
  }));

  const dataRows = rows.map((row, ri) => new TableRow({
    children: row.map((cell, ci) => new TableCell({
      children: [new Paragraph({ children: [new TextRun({ text: cell, size: 20 })], alignment: AlignmentType.LEFT })],
      shading: { type: ShadingType.CLEAR, fill: ri % 2 === 0 ? 'DEEAF1' : 'FFFFFF' },
      width: { size: colWidths[ci], type: WidthType.PERCENTAGE }
    }))
  }));

  return new Table({
    rows: [new TableRow({ children: headerCells, tableHeader: true }), ...dataRows],
    width: { size: 100, type: WidthType.PERCENTAGE },
    margins: { top: 80, bottom: 80, left: 120, right: 120 }
  });
}

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

// Cover
children.push(
  new Paragraph({
    children: [new TextRun({ text: 'RGUHS PAEDIATRICS - QP CODE: 1044', bold: true, size: 36, color: '1F3864' })],
    alignment: AlignmentType.CENTER,
    spacing: { before: 400, after: 200 }
  }),
  new Paragraph({
    children: [new TextRun({ text: 'MBBS Phase III Part II CBME Examination - March 2024', bold: true, size: 26, color: '2E75B6' })],
    alignment: AlignmentType.CENTER,
    spacing: { after: 100 }
  }),
  new Paragraph({
    children: [new TextRun({ text: 'Model Answers as per Ghai Essential Pediatrics', italics: true, size: 24, color: '595959' })],
    alignment: AlignmentType.CENTER,
    spacing: { after: 100 }
  }),
  new Paragraph({
    children: [new TextRun({ text: 'Max Marks: 100  |  Duration: 3 Hours', bold: true, size: 22 })],
    alignment: AlignmentType.CENTER,
    spacing: { after: 400 }
  })
);

// Marks Distribution Table
children.push(heading1('MARKS DISTRIBUTION OVERVIEW'));
children.push(
  makeTable(
    ['Section', 'No. of Questions', 'Marks Each', 'Total Marks'],
    [
      ['Long Essays (LE)', '2', '10', '20'],
      ['Short Essays (SE)', '8', '5', '40'],
      ['Short Answers (SA)', '10', '3', '30'],
      ['TOTAL', '20', '-', '100']
    ],
    [35, 22, 22, 21]
  )
);
children.push(blankLine());

// ─── LONG ESSAYS ─────────────────────────────────────────────────────────────
children.push(heading1('SECTION A: LONG ESSAYS (2 x 10 = 20 Marks)'));

// Q1 - Rheumatic Fever
children.push(sectionTitle(1, 10, 'Rheumatic Fever (RF) - Diagnosis & Management'));
children.push(heading2('(a) Most Probable Diagnosis'));
children.push(para('Acute Rheumatic Fever (ARF) with Rheumatic Heart Disease (Mitral Regurgitation)'));
children.push(boldPara('Reasoning: ', 'Migratory polyarthritis (knee → ankle → wrist), pansystolic murmur at mitral area, history of Group A Streptococcal sore throat 3 weeks prior, tachycardia.'));

children.push(heading2('(b) Jones Criteria for Diagnosis of ARF'));
children.push(para('PREREQUISITE: Evidence of preceding GAS infection (ASO titer raised / throat culture / rapid antigen test positive)'));
children.push(para('Diagnosis: 2 Major OR 1 Major + 2 Minor criteria + evidence of GAS infection'));

children.push(
  makeTable(
    ['Major Criteria (JONES)', 'Minor Criteria', 'Evidence of GAS Infection'],
    [
      ['J - Joints (Migratory Polyarthritis) - Most common', 'Fever (> 38.5°C)', 'Elevated ASO titer / anti-DNase B'],
      ['O - carditis (pan-carditis = endo+myo+pericarditis)', 'Raised ESR / CRP', 'Positive throat culture for GAS'],
      ['N - Nodules (subcutaneous)', 'Prolonged PR interval on ECG', 'Recent documented GAS infection'],
      ['E - Erythema marginatum', 'Arthralgia (if arthritis not used as major)', ''],
      ['S - Sydenham Chorea', 'Previous RF / Established RHD', '']
    ],
    [38, 32, 30]
  )
);
children.push(blankLine());

children.push(heading2('(b-i) FLOWCHART: Approach to Diagnose ARF'));
children.push(flowBox('Child with Migratory Polyarthritis / Fever / Sore Throat'));
children.push(flowArrow());
children.push(flowBox('Evidence of preceding GAS infection?', true));
children.push(flowArrow());
children.push(flowBox('Apply Modified Jones Criteria 2015 (AHA)'));
children.push(flowArrow());
children.push(flowBox('2 Major OR 1 Major + 2 Minor criteria met?', true));
children.push(flowArrow());
children.push(flowBox('DIAGNOSIS: Acute Rheumatic Fever CONFIRMED'));
children.push(blankLine());

children.push(heading2('(c) Management of Acute Rheumatic Fever'));
children.push(
  makeTable(
    ['Component', 'Drug/Intervention', 'Dose & Duration'],
    [
      ['Eradication of GAS', 'Benzathine Penicillin G (preferred)', '1.2 mega units IM single dose (>27 kg)'],
      ['Eradication of GAS (oral)', 'Amoxicillin', '50 mg/kg/day x 10 days; OR Penicillin V x 10 days'],
      ['Arthritis (mild)', 'Aspirin (anti-inflammatory)', '80-100 mg/kg/day in 4 divided doses x 2 weeks'],
      ['Carditis (moderate-severe)', 'Prednisolone', '2 mg/kg/day x 2-3 weeks, then taper'],
      ['Chorea', 'Haloperidol / Valproate / Carbamazepine', 'Symptomatic treatment'],
      ['Bed rest', 'Strict bed rest', 'Until ESR normalizes & carditis resolves'],
      ['CHF (if present)', 'Diuretics + Digoxin + ACE inhibitors', 'As per severity'],
      ['Secondary prophylaxis', 'Benzathine Penicillin G', '1.2 MU IM every 3-4 weeks (duration per RHD status)']
    ],
    [28, 35, 37]
  )
);
children.push(blankLine());

children.push(heading3('Secondary Prophylaxis Duration (Ghai)'));
children.push(
  makeTable(
    ['Condition', 'Duration of Prophylaxis'],
    [
      ['RF without carditis', '5 years or until 21 years age (whichever longer)'],
      ['RF with mild carditis, no residual RHD', '10 years or until 21 years'],
      ['RF with residual RHD', '10 years or until 40 years; sometimes lifelong'],
      ['Severe RHD requiring surgery', 'Lifelong']
    ],
    [50, 50]
  )
);
children.push(blankLine());

// Q2 - Measles
children.push(sectionTitle(2, 10, 'Measles - Clinical Features, Complications & Management'));
children.push(heading2('(a) Viruses Causing Maculopapular Rash'));
children.push(
  makeTable(
    ['Virus', 'Disease', 'Rash Characteristics'],
    [
      ['Measles virus (Paramyxovirus)', 'Measles (Rubeola)', 'Face → downward, blotchy, starts Day 4 of fever'],
      ['Rubella virus (Togavirus)', 'German measles', 'Face → trunk, pink macules, Day 1-2, fades fast'],
      ['HHV-6 / HHV-7', 'Roseola infantum (Exanthem subitum)', 'Rose-pink macules, appears as fever subsides'],
      ['Parvovirus B19', 'Erythema infectiosum (5th disease)', 'Slapped cheek, lacy reticular pattern'],
      ['Enterovirus (Echo/Coxsackie)', 'Non-specific viral exanthem', 'Variable distribution'],
      ['EBV', 'Infectious mononucleosis', 'Maculopapular, especially with ampicillin'],
      ['Dengue virus', 'Dengue fever', 'Maculopapular, islands of sparing']
    ],
    [32, 30, 38]
  )
);
children.push(blankLine());

children.push(heading2('(b) Clinical Features of Measles'));
children.push(heading3('FLOWCHART: Clinical Progression of Measles'));
children.push(flowBox('INCUBATION PERIOD: 10-14 days (range 7-18 days)'));
children.push(flowArrow());
children.push(flowBox('PRODROMAL / CATARRHAL PHASE (Day 1-4 of fever)'));
children.push(para('• High fever, malaise, coryza, cough, conjunctivitis (3Cs)', true));
children.push(para('• KOPLIK SPOTS: Pathognomonic - bluish-white spots on buccal mucosa opposite lower molars', true));
children.push(para('• Photophobia, lacrimation', true));
children.push(flowArrow());
children.push(flowBox('EXANTHEM / ERUPTIVE PHASE (Day 4-5)'));
children.push(para('• Maculopapular rash starts behind ears and hairline → face → trunk → limbs (cephalocaudal)', true));
children.push(para('• Fever at peak when rash appears, begins to fall as rash spreads', true));
children.push(para('• Rash is blotchy and coalescent', true));
children.push(flowArrow());
children.push(flowBox('RECOVERY PHASE (Day 7-10)'));
children.push(para('• Rash fades in same order: branny desquamation, brownish pigmentation', true));
children.push(para('• Fever subsides, symptoms resolve', true));
children.push(blankLine());

children.push(heading2('(c) Complications of Measles'));
children.push(
  makeTable(
    ['System', 'Complication', 'Notes'],
    [
      ['Respiratory', 'Pneumonia (most common cause of death)', 'Giant cell (Hecht) pneumonia; secondary bacterial'],
      ['Neurological', 'Acute encephalitis', '1 in 1000 cases; during or after rash'],
      ['Neurological', 'SSPE (Subacute Sclerosing Panencephalitis)', 'Late complication; fatal; years later'],
      ['Eyes', 'Corneal ulceration / keratitis', 'Esp. with Vitamin A deficiency → blindness'],
      ['GI', 'Diarrhea, malnutrition', 'Major cause of morbidity'],
      ['Ear', 'Otitis media', 'Common secondary bacterial infection'],
      ['Immune', 'Immune suppression (measles anergy)', 'Reactivation of TB; lasts weeks'],
      ['Skin', 'Cancrum oris (noma)', 'Gangrenous stomatitis in malnourished']
    ],
    [22, 35, 43]
  )
);
children.push(blankLine());

children.push(heading2('(c-ii) Management of Measles'));
children.push(
  makeTable(
    ['Aspect', 'Treatment', 'Details'],
    [
      ['Supportive', 'Antipyretics, fluids, nutrition', 'Paracetamol, ORS for diarrhea, adequate feeds'],
      ['Vitamin A (MANDATORY)', 'Vit A supplementation', '< 6 months: 50,000 IU; 6-11 mo: 100,000 IU; > 12 mo: 200,000 IU - single dose IM/oral; repeat next day if malnourished'],
      ['Antibiotics', 'If secondary bacterial infection', 'Amoxicillin/Co-amoxiclav for pneumonia, otitis media'],
      ['Encephalitis', 'Supportive + anticonvulsants', 'No specific antiviral; manage ICP'],
      ['Isolation', 'Respiratory isolation', 'Until 4 days after rash onset'],
      ['Prevention', 'MR vaccine / MMR', '9-12 months (EPI), 16-24 months (booster)']
    ],
    [18, 30, 52]
  )
);
children.push(blankLine());

// ─── SHORT ESSAYS ─────────────────────────────────────────────────────────────
children.push(heading1('SECTION B: SHORT ESSAYS (8 x 5 = 40 Marks)'));

// Q3 - Developmental Delay
children.push(sectionTitle(3, 5, 'Global Developmental Delay (GDD)'));
children.push(heading2('(a) Define Development'));
children.push(para('Development is the acquisition of skills and functions as a result of maturation of the nervous system and interactions with the environment. It is a continuous process that proceeds in a cephalocaudal and proximal-to-distal direction.'));
children.push(heading3('Domains of Development:'));
children.push(
  makeTable(
    ['Domain', 'Skills Assessed', 'Key Milestones (Examples)'],
    [
      ['Gross Motor', 'Head control, sitting, standing, walking', 'Walks alone by 15 months'],
      ['Fine Motor / Adaptive', 'Grasping, pincer grasp, drawing', 'Scribbles by 15 mo; copies circle by 3 yr'],
      ['Language / Speech', 'Vocalization, words, sentences', '1 word by 12 mo; 2-word phrases by 24 mo'],
      ['Personal-Social', 'Smiling, feeding, dressing, playing', 'Social smile by 6 weeks']
    ],
    [25, 40, 35]
  )
);

children.push(heading2('(b) Causes of Delayed Development'));
children.push(
  makeTable(
    ['Category', 'Examples'],
    [
      ['Prenatal - Genetic', 'Down syndrome, Fragile X, Turner syndrome, metabolic disorders'],
      ['Prenatal - Structural CNS', 'Neural tube defects, hydrocephalus, lissencephaly, microcephaly'],
      ['Prenatal - Infections', 'TORCH infections (Toxoplasma, Rubella, CMV, HSV)'],
      ['Prenatal - Toxic', 'Fetal alcohol syndrome, drugs, radiation'],
      ['Perinatal', 'Birth asphyxia (HIE), prematurity, neonatal hypoglycemia, kernicterus'],
      ['Postnatal - Infections', 'Meningitis, encephalitis'],
      ['Postnatal - Nutritional', 'Severe malnutrition (stunting), iodine deficiency, Fe deficiency'],
      ['Postnatal - Psychosocial', 'Deprivation, neglect, autism spectrum disorder'],
      ['Endocrine', 'Hypothyroidism (commonest treatable cause)'],
      ['Neurodegenerative', 'Metachromatic leukodystrophy, Batten disease']
    ],
    [35, 65]
  )
);
children.push(blankLine());

// Q4 - AFP
children.push(sectionTitle(4, 5, 'Acute Flaccid Paralysis (AFP)'));
children.push(heading2('(a) Definition of Acute Flaccid Paralysis'));
children.push(para('AFP is defined as sudden onset of flaccid (lower motor neuron type) paralysis in a child under 15 years of age, or any person in whom polio is suspected, occurring within 28 days, with no other obvious cause identified.'));
children.push(para('Features: Rapid onset, muscle flaccidity, hypotonia, decreased/absent deep tendon reflexes, no sensory deficit (in polio).'));

children.push(heading2('(b) Three Differential Diagnoses of AFP'));
children.push(
  makeTable(
    ['Diagnosis', 'Key Distinguishing Features', 'Investigation'],
    [
      ['Guillain-Barre Syndrome (GBS)', 'Ascending symmetrical weakness, areflexia, respiratory compromise, albuminocytologic dissociation in CSF, preceded by URTI/GI illness', 'CSF: High protein, normal cells; NCV: demyelination'],
      ['Poliomyelitis', 'Asymmetric, fever at onset, flaccid paralysis, no sensory loss, bulbar involvement possible, unimmunized child', 'Stool virus isolation; CSF: mild pleocytosis'],
      ['Transverse Myelitis', 'Acute paraplegia, sensory level, bladder/bowel involvement, preceding viral illness', 'MRI spine: cord lesion at specific level']
    ],
    [25, 45, 30]
  )
);
children.push(blankLine());

// Q5 - TBM
children.push(sectionTitle(5, 5, 'Tubercular Meningitis (TBM)'));
children.push(heading2('Clinical Features of TBM'));
children.push(heading3('FLOWCHART: Stages of TBM (Bhargava & Lincoln Staging)'));
children.push(flowBox('STAGE I: Prodromal (1-4 weeks)'));
children.push(para('Fever, headache, irritability, behavioral changes, vomiting - NO neurological deficit', true));
children.push(flowArrow());
children.push(flowBox('STAGE II: Meningitic (Weeks 2-8)'));
children.push(para('Signs of meningeal irritation: neck stiffness, Kernig + Brudzinski positive', true));
children.push(para('Cranial nerve palsies (VI most common → squint/diplopia), fever', true));
children.push(para('Altered consciousness (confusion, stupor)', true));
children.push(flowArrow());
children.push(flowBox('STAGE III: Encephalitic'));
children.push(para('Coma, decerebrate/decorticate posturing, focal deficits, hemiplegia', true));
children.push(para('Hydrocephalus, vasculitis, high mortality', true));
children.push(blankLine());

children.push(heading2('Investigations of TBM'));
children.push(
  makeTable(
    ['Investigation', 'Finding in TBM', 'Significance'],
    [
      ['CSF - Appearance', 'Clear/xanthochromic (cobweb clot)', 'Fibrin clot on standing'],
      ['CSF - Cell count', '10-500 cells, predominantly lymphocytes', 'Early: neutrophils; later: lymphocytes'],
      ['CSF - Protein', 'Elevated: 100-500 mg/dL (markedly)', 'Diagnostic pointer'],
      ['CSF - Glucose', 'Decreased: < 45 mg/dL (CSF:serum < 0.5)', 'Key feature: low sugar'],
      ['CSF - AFB smear', 'Positive in 10-40%', 'Centrifuge pellet - scan multiple fields'],
      ['CSF - Culture', 'LJ medium - positive in 45-90%', 'Gold standard but takes 4-8 weeks'],
      ['CSF - ADA', 'Elevated (> 10 U/L)', 'Useful diagnostic marker'],
      ['CSF - Gene Xpert MTB/RIF', 'Positive; detects rifampicin resistance', 'Rapid, highly specific'],
      ['Chest X-ray', 'Primary complex, miliary TB', 'Present in 50% cases'],
      ['CT Head', 'Basal exudates, hydrocephalus, infarcts', 'Staging and complication assessment'],
      ['Tuberculin test (TST/Mantoux)', 'Often negative (anergy) in severe TBM', 'Negative does NOT rule out TBM'],
      ['IGRA (Interferon Gamma Release)', 'Positive', 'Better specificity than Mantoux']
    ],
    [28, 38, 34]
  )
);
children.push(blankLine());

// Q6 - Portal Hypertension
children.push(sectionTitle(6, 5, 'Portal Hypertension in Children'));
children.push(heading2('Clinical Features'));
children.push(
  makeTable(
    ['Feature', 'Details'],
    [
      ['Splenomegaly', 'Most common presenting sign in children; massive, firm, non-tender'],
      ['Gastrointestinal Bleeding', 'Hematemesis / melena from esophageal / gastric varices - can be massive'],
      ['Ascites', 'More common in hepatic causes (intra-hepatic portal hypertension)'],
      ['Hypersplenism', 'Pancytopenia - anemia, thrombocytopenia, leukopenia'],
      ['Dilated abdominal veins', 'Caput medusae (periumbilical veins)'],
      ['Hepatomegaly', 'In intra-hepatic causes (cirrhosis, hepatic fibrosis)'],
      ['Jaundice', 'In hepatic and post-hepatic causes']
    ],
    [35, 65]
  )
);

children.push(heading2('Investigation Approach to Confirm Portal Hypertension'));
children.push(heading3('FLOWCHART: Diagnostic Approach'));
children.push(flowBox('Child with Splenomegaly ± Hematemesis / Ascites'));
children.push(flowArrow());
children.push(flowBox('Step 1: Basic Investigations'));
children.push(para('CBC (pancytopenia), LFTs (ALT/AST/ALP/Bilirubin), Coagulation screen (PT/INR), Serum proteins/Albumin', true));
children.push(flowArrow());
children.push(flowBox('Step 2: USG Abdomen with Doppler (KEY)'));
children.push(para('• Liver size/echotexture, spleen size, ascites', true));
children.push(para('• Portal vein diameter (> 13 mm in children is significant)', true));
children.push(para('• Portal vein flow direction (hepatofugal = reversed = diagnostic)', true));
children.push(para('• Collaterals, thrombus in portal vein (EHPVO)', true));
children.push(flowArrow());
children.push(flowBox('Step 3: Upper GI Endoscopy (Gold Standard)', true));
children.push(para('• Esophageal / gastric varices (grades I-IV)', true));
children.push(para('• Portal hypertensive gastropathy', true));
children.push(flowArrow());
children.push(flowBox('Step 4: Liver Biopsy (if intra-hepatic cause suspected)'));
children.push(para('• Cirrhosis, congenital hepatic fibrosis, NASH', true));
children.push(flowArrow());
children.push(flowBox('Step 5: CT/MRI Angiography (if EHPVO / surgical planning)'));
children.push(para('• Portal vein anatomy for shunt surgery', true));
children.push(blankLine());

children.push(
  makeTable(
    ['Cause Type', 'Pre-hepatic (EHPVO)', 'Hepatic (Cirrhosis/CHF)', 'Post-hepatic (Budd-Chiari)'],
    [
      ['Most common cause', 'Umbilical sepsis / PVT (neonatal)', 'Wilson disease, biliary atresia, NAFLD', 'Hepatic vein thrombosis'],
      ['Liver size', 'Normal', 'Small / enlarged', 'Enlarged, tender'],
      ['LFTs', 'Normal', 'Deranged', 'Deranged (ALT raised)'],
      ['USG Doppler', 'Portal vein thrombosis / cavernoma', 'Coarse echotexture', 'Hepatic vein occlusion'],
      ['Prognosis', 'Best', 'Depends on cause', 'Variable']
    ],
    [25, 25, 25, 25]
  )
);
children.push(blankLine());

// Q7 - Rickets
children.push(sectionTitle(7, 5, 'Nutritional Rickets'));
children.push(heading2('Clinical Features of Nutritional Rickets'));
children.push(
  makeTable(
    ['System / Region', 'Clinical Sign', 'Notes'],
    [
      ['Head', 'Craniotabes (ping-pong ball sensation)', 'Earliest sign - seen in first 6 months'],
      ['Head', 'Frontal / parietal bossing, "Hot cross bun" skull', 'Caput quadratum'],
      ['Head', 'Delayed closure of anterior fontanelle', 'Beyond 18 months'],
      ['Dentition', 'Delayed dentition, dental enamel hypoplasia', ''],
      ['Chest', 'Rachitic rosary (costochondral beading)', 'Rows of beads along ribs'],
      ['Chest', "Harrison's sulcus", 'Horizontal groove at diaphragm attachment'],
      ['Chest', 'Pigeon chest / funnel chest', 'Deformity of sternum'],
      ['Spine', 'Kyphosis, scoliosis', 'In severe cases'],
      ['Pelvis', 'Pelvic deformity', 'Triradiate, obstructed labor later in life'],
      ['Lower limbs', 'Genu varum (bow legs) or genu valgum (knock knees)', 'After weight bearing begins'],
      ['Lower limbs', 'Tibial torsion, coxa vara', ''],
      ['Wrists / Ankles', 'Widened, cupped metaphyses (rachitic wrist / double malleoli)', 'Characteristic swelling'],
      ['Muscles', 'Hypotonia, protuberant abdomen (frog belly)', 'Gross motor delay'],
      ['Growth', 'Short stature, failure to thrive', ''],
      ['Hypocalcemia signs', 'Tetany, carpopedal spasm, seizures, laryngospasm', 'In florid vitamin D deficiency']
    ],
    [22, 42, 36]
  )
);

children.push(heading2('Radiological Features of Nutritional Rickets'));
children.push(heading3('(Diagram description - as per Ghai)'));
children.push(
  makeTable(
    ['X-ray Finding', 'Region', 'Description'],
    [
      ['Cupping', 'Metaphysis', 'Concave / cup-shaped appearance of metaphysis'],
      ['Fraying', 'Metaphysis', 'Irregular, ragged, brush-like fraying of metaphyseal margin'],
      ['Widening of growth plate', 'Physis', 'Wide, irregular zone between epiphysis and metaphysis'],
      ['Delayed epiphyseal ossification', 'Epiphysis', 'Epiphyses appear late, faint, fuzzy'],
      ['Loss of zone of provisional calcification', 'Metaphysis', 'Normal dense white line absent'],
      ['Osteopenia', 'Entire bone', 'Decreased bone density, coarse trabecular pattern'],
      ['Looser zones (Milkman fractures)', 'Shaft', 'Pseudofractures in severe osteomalacia'],
      ['Deformities', 'Long bones', 'Bowing of femur/tibia/radius/ulna']
    ],
    [28, 20, 52]
  )
);
children.push(blankLine());

// Q8 - Neonatal Seizures
children.push(sectionTitle(8, 5, 'Neonatal Seizures & Hypoglycemia Management'));
children.push(heading2('Causes of Seizures in a 3-Day Old Neonate'));
children.push(
  makeTable(
    ['Cause', 'Timing', 'Key Features'],
    [
      ['Hypoxic Ischemic Encephalopathy (HIE) - MC', 'Day 1 (0-3 days)', 'Birth asphyxia history, multisystem involvement'],
      ['Hypoglycemia', 'Day 1-3', 'Jitteriness, lethargy; blood glucose < 40 mg/dL'],
      ['Hypocalcemia (early type)', 'Day 2-3', 'Preterm, IDM, birth asphyxia; Ca < 7 mg/dL'],
      ['Intracranial hemorrhage', 'Day 1-3', 'SDH, IVH - especially preterm; tense fontanelle'],
      ['Neonatal meningitis / Sepsis', 'Day 3 onwards', 'Fever/hypothermia, bulging fontanelle, CSF abnormal'],
      ['Pyridoxine deficiency', 'Day 1-7', 'Refractory seizures; dramatic response to B6'],
      ['Hypomagnesemia', 'Day 2-3', 'Associated with hypocalcemia; Mg < 1.5 mg/dL'],
      ['Inborn errors of metabolism', 'Day 2-7', 'Refractory, abnormal metabolic screen'],
      ['Drug withdrawal', 'Day 1-3', 'Maternal opioid/barbiturate use'],
      ['Benign neonatal convulsions (5th day fits)', 'Day 5', 'Self-limiting, normal outcome']
    ],
    [40, 15, 45]
  )
);

children.push(heading2('Management of Hypoglycemia Seizures in Neonate'));
children.push(heading3('FLOWCHART: Hypoglycemia Seizure Management'));
children.push(flowBox('Neonate with Seizure + Blood Glucose < 40 mg/dL'));
children.push(flowArrow());
children.push(flowBox('Step 1: IMMEDIATE IV Glucose Bolus'));
children.push(para('Dextrose 10% - 2 mL/kg IV bolus over 1-2 minutes', true));
children.push(para('Target: Blood glucose > 45 mg/dL', true));
children.push(flowArrow());
children.push(flowBox('Step 2: Continuous Glucose Infusion (GIR)'));
children.push(para('Start D10% at GIR = 6-8 mg/kg/min', true));
children.push(para('If persistent hypoglycemia → increase GIR to 10-12 mg/kg/min', true));
children.push(flowArrow());
children.push(flowBox('Step 3: Treat Seizures'));
children.push(para('Phenobarbitone 20 mg/kg IV loading dose (1st line antiepileptic)', true));
children.push(para('If persists → Phenytoin 20 mg/kg IV (2nd line)', true));
children.push(flowArrow());
children.push(flowBox('Step 4: Address Underlying Cause', true));
children.push(para('If refractory: Hydrocortisone 5 mg/kg/day (to ↑ gluconeogenesis)', true));
children.push(para('Glucagon 0.1-0.3 mg/kg IM/IV (if no IV access)', true));
children.push(para('Diazoxide for hyperinsulinism', true));
children.push(flowArrow());
children.push(flowBox('Step 5: Monitor & Wean'));
children.push(para('Recheck glucose every 30 min → 1 hour → stabilize → introduce feeds', true));
children.push(para('Wean IV glucose gradually when oral feeds established', true));
children.push(blankLine());

// Q9 - Beta Thalassemia Major
children.push(sectionTitle(9, 5, 'Beta Thalassemia Major - Investigations'));
children.push(heading2('Investigations & Interpretation'));
children.push(
  makeTable(
    ['Investigation', 'Finding in Beta Thal Major', 'Interpretation'],
    [
      ['CBC - Hemoglobin', 'Severe anemia: Hb 2-7 g/dL', 'Transfusion-dependent anemia from 6-24 months'],
      ['CBC - MCV / MCH', 'Microcytic: MCV < 70 fL, MCH < 20 pg', 'Defective beta-chain synthesis → ↓ HbA'],
      ['CBC - RBC count', 'High-normal (numerous small cells)', 'Compensatory erythroid hyperplasia'],
      ['Peripheral Blood Smear', 'Microcytic hypochromic cells, target cells, nucleated RBCs (NRBCs), tear drop cells, basophilic stippling, anisopoikilocytosis', 'Marker of ineffective erythropoiesis'],
      ['Reticulocyte count', 'Elevated (5-15%)', 'Compensatory but ineffective'],
      ['Serum Ferritin', 'Elevated (> 500-1000 ng/mL and rising)', 'Iron overload from repeated transfusions'],
      ['Serum Iron / TIBC', 'Iron elevated, TIBC low/normal', 'Iron overload state'],
      ['Hb Electrophoresis (KEY)', 'HbF: 10-98%, HbA2: variable, HbA: absent (0%) in beta0 thalassemia', 'DIAGNOSTIC: absence/near-absence of HbA with HbF predominance'],
      ['HPLC (High Performance Liquid Chromatography)', 'Quantifies HbA, HbA2, HbF accurately', 'Gold standard for Hb variant analysis'],
      ['X-ray Skull', '"Hair on end" / "sun-ray" appearance', 'Expansion of marrow cavity due to hyperplasia'],
      ['X-ray Long bones', 'Thinning of cortex, "Erlenmeyer flask" deformity of femur', 'Cortical thinning from marrow expansion'],
      ['USG Abdomen', 'Massive hepatosplenomegaly', 'EMH (Extra-medullary hematopoiesis)'],
      ['LFTs', 'Elevated bilirubin (indirect), elevated transaminases', 'Hemolysis + iron overload hepatopathy'],
      ['Echocardiography', 'Cardiomyopathy, LV dysfunction', 'Iron deposition in heart - major cause of death'],
      ['Serum calcium / Thyroid / Glucose', 'Hypothyroidism, hypoparathyroidism, DM possible', 'Iron deposition in endocrine glands'],
      ['Genetic analysis (DNA)', 'Beta-globin gene mutation identified', 'Confirms type: beta0 vs beta+; prenatal diagnosis']
    ],
    [28, 38, 34]
  )
);
children.push(blankLine());

// Q10 - Anemia Classification
children.push(sectionTitle(10, 5, 'Classification of Anemia & Megaloblastic Anemia'));
children.push(heading2('Classification of Anemia'));
children.push(heading3('FLOWCHART: Etiological Classification'));
children.push(flowBox('ANEMIA (Hb below age-specific lower limit of normal)'));
children.push(flowArrow());
children.push(flowBox('Classify by Mechanism', true));
children.push(blankLine());

children.push(
  makeTable(
    ['Type', 'Mechanism', 'Examples'],
    [
      ['DECREASED PRODUCTION', 'Nutritional deficiency', 'Iron deficiency (most common), Vit B12/Folate (megaloblastic), Vit C'],
      ['DECREASED PRODUCTION', 'Bone marrow failure', 'Aplastic anemia, pure RBC aplasia (Diamond-Blackfan)'],
      ['DECREASED PRODUCTION', 'Chronic disease / Renal', 'Anemia of inflammation, EPO deficiency'],
      ['INCREASED DESTRUCTION (Hemolytic)', 'Intrinsic (corpuscular)', 'Sickle cell disease, G6PD deficiency, spherocytosis, thalassemia'],
      ['INCREASED DESTRUCTION (Hemolytic)', 'Extrinsic (extracorpuscular)', 'Immune (ABO/Rh incompatibility, AIHA), Microangiopathic, infections, hypersplenism'],
      ['BLOOD LOSS', 'Acute hemorrhage', 'Trauma, GI bleed'],
      ['BLOOD LOSS', 'Chronic blood loss', 'Hookworm, GI lesions → iron deficiency']
    ],
    [27, 30, 43]
  )
);

children.push(heading3('Morphological Classification (Ghai)'));
children.push(
  makeTable(
    ['Type', 'MCV', 'MCH', 'Causes'],
    [
      ['Microcytic Hypochromic', '< 80 fL', '< 27 pg', 'Iron deficiency, thalassemia, sideroblastic, chronic disease'],
      ['Normocytic Normochromic', '80-100 fL', '27-33 pg', 'Acute hemorrhage, hemolytic, aplastic, early chronic disease'],
      ['Macrocytic (Megaloblastic)', '> 100 fL', '> 33 pg', 'Vit B12 / Folate deficiency, drugs (methotrexate)'],
      ['Macrocytic (Non-Megaloblastic)', '> 100 fL', 'Normal', 'Liver disease, hypothyroidism, reticulocytosis']
    ],
    [28, 12, 12, 48]
  )
);

children.push(heading2('Short Note: Investigation of Megaloblastic Anemia'));
children.push(
  makeTable(
    ['Investigation', 'Finding', 'Significance'],
    [
      ['CBC - Hemoglobin', 'Low (can be severely low)', 'Macrocytic anemia'],
      ['CBC - MCV', '> 100 fL (often > 110-120 fL)', 'Macrocytosis - cardinal feature'],
      ['Peripheral Blood Smear', 'Oval macrocytes, hypersegmented neutrophils (> 5 lobes in > 5% cells = PATHOGNOMONIC), anisocytosis, poikilocytosis', 'Diagnostic hallmark of megaloblastic anemia'],
      ['Reticulocyte count', 'Low (reticulocytopenia)', 'Ineffective erythropoiesis'],
      ['WBC / Platelets', 'Pancytopenia in severe cases', 'Affects all cell lines'],
      ['Serum Vit B12', '< 200 pg/mL (normal 200-900)', 'Confirms B12 deficiency'],
      ['Serum Folate', '< 3 ng/mL', 'Confirms folate deficiency'],
      ['RBC Folate', '< 150 ng/mL', 'Better marker of tissue folate stores'],
      ['Serum Homocysteine', 'Elevated in both B12 and folate deficiency', 'Sensitive marker; rises before overt deficiency'],
      ['Serum Methylmalonic acid', 'Elevated only in B12 deficiency', 'Differentiates B12 from folate deficiency'],
      ['LDH', 'Markedly elevated', 'Reflects ineffective erythropoiesis (cell destruction)'],
      ['Serum Bilirubin (indirect)', 'Mildly elevated', 'Intramedullary hemolysis'],
      ['Bone marrow aspiration', 'Megaloblasts, giant metamyelocytes, hypersegmented neutrophils', 'Confirms megaloblastic hematopoiesis (if diagnosis unclear)'],
      ['Schilling test', 'Differentiates pernicious anemia (intrinsic factor deficiency) from dietary B12 lack', 'Rarely done now; replaced by anti-IF antibodies'],
      ['Anti-Intrinsic Factor antibody', 'Positive in pernicious anemia', 'Autoimmune gastritis diagnosis']
    ],
    [28, 38, 34]
  )
);
children.push(blankLine());

// ─── SHORT ANSWERS ────────────────────────────────────────────────────────────
children.push(heading1('SECTION C: SHORT ANSWERS (10 x 3 = 30 Marks)'));

// Q11
children.push(sectionTitle(11, 3, 'Prematurity, LBW and SGA - Definitions'));
children.push(
  makeTable(
    ['Term', 'Definition', 'Cut-off / Details'],
    [
      ['Prematurity', 'Birth before 37 completed weeks (< 37+0 weeks) of gestation', 'Extreme preterm: < 28 weeks; Very preterm: 28-32 weeks; Moderate-late preterm: 32-37 weeks'],
      ['Low Birth Weight (LBW)', 'Birth weight < 2500 g regardless of gestational age', 'VLBW: < 1500 g; ELBW: < 1000 g'],
      ['Small for Gestational Age (SGA)', 'Birth weight < 10th percentile for gestational age OR < 2 SD below mean for gestational age', 'Due to IUGR (intrauterine growth restriction); NOT synonymous with prematurity']
    ],
    [20, 45, 35]
  )
);
children.push(blankLine());

// Q12
children.push(sectionTitle(12, 3, 'Bloody Stools in a 5-Year-Old - Causative Organisms'));
children.push(
  makeTable(
    ['Organism', 'Type', 'Notes'],
    [
      ['Shigella spp. (S. dysenteriae)', 'Bacteria', 'Classic dysentery: mucus + blood + tenesmus; MC bacterial cause'],
      ['Entamoeba histolytica', 'Protozoa', 'Amoebic dysentery: blood-streaked, "anchovy paste" stools; can cause liver abscess'],
      ['Campylobacter jejuni', 'Bacteria', 'Bloody diarrhea; poultry source; can mimic IBD on colonoscopy']
    ],
    [35, 18, 47]
  )
);
children.push(blankLine());

// Q13
children.push(sectionTitle(13, 3, 'BCG Vaccine - Dose, Route & Schedule'));
children.push(
  makeTable(
    ['Parameter', 'Details'],
    [
      ['Vaccine type', 'Live attenuated Mycobacterium bovis (Bacille Calmette-Guerin)'],
      ['Dose', '0.05 mL for neonates / infants; 0.1 mL for children > 12 months'],
      ['Route', 'Intradermal (ID) - left deltoid (upper outer arm)'],
      ['Schedule (India / EPI)', 'At birth (or as early as possible) - ideally within 24 hours'],
      ['Reconstitution', 'Use within 4 hours of opening; discard unused portion'],
      ['Expected reaction', 'Induces papule → pustule → ulcer → scar (Bacille scar) in 6-12 weeks'],
      ['Efficacy', 'Protects against miliary TB and TB meningitis (80%); variable against pulmonary TB'],
      ['Contraindications', 'HIV (symptomatic), immunodeficiency, generalized eczema, fever']
    ],
    [30, 70]
  )
);
children.push(blankLine());

// Q14
children.push(sectionTitle(14, 3, 'Preventing Bleeding in a School Boy with Hemophilia'));
children.push(
  makeTable(
    ['Measure', 'Details'],
    [
      ['Primary prophylaxis (gold standard)', 'Regular infusion of Factor concentrate (Factor VIII for hemophilia A, Factor IX for B): 25-40 IU/kg 3x/week (Hemo A) or 2x/week (Hemo B) starting before first joint bleed (before age 2-3)'],
      ['Secondary prophylaxis', 'After 2+ joint bleeds - regular factor infusions to prevent target joint damage'],
      ['Home therapy training', 'Parents/patient trained in self-infusion - reduces delay to treatment'],
      ['Activity restrictions', 'Avoid high-contact sports (football, boxing); encourage swimming, cycling, walking'],
      ['Protective gear', 'Helmets, knee/elbow pads for cycling'],
      ['Avoid NSAIDs / aspirin', 'Use Paracetamol for pain (NSAIDs worsen platelet function)'],
      ['Avoid IM injections', 'Use SC route; apply pressure for > 5 min after venipuncture'],
      ['Dental hygiene', 'Regular dental visits; use Tranexamic acid mouthwash before dental procedures'],
      ['Desmopressin (DDAVP)', 'For mild Hemophilia A; 0.3 mcg/kg IV - releases stored FVIII from endothelium'],
      ['Tranexamic acid', 'Antifibrinolytic; 25 mg/kg orally for mucosal bleeds, dental work'],
      ['Medical alert bracelet', 'For emergency identification'],
      ['School counseling', 'Inform school staff of condition and emergency protocol']
    ],
    [35, 65]
  )
);
children.push(blankLine());

// Q15
children.push(sectionTitle(15, 3, 'Three Drugs for Congestive Cardiac Failure in Children'));
children.push(
  makeTable(
    ['Drug', 'Class', 'Dose', 'Mechanism / Role'],
    [
      ['Furosemide (Frusemide)', 'Loop Diuretic', '1-2 mg/kg/dose IV/oral 6-12 hourly', 'Reduces preload by diuresis; first-line for acute CCF'],
      ['Digoxin', 'Cardiac Glycoside', 'Maintenance: 5-8 mcg/kg/day (total digitalizing dose as per age)', 'Positive inotrope; reduces heart rate; increases contractility; useful in systolic failure'],
      ['Captopril / Enalapril', 'ACE Inhibitor', 'Captopril: 0.1-0.5 mg/kg/dose 8 hourly', 'Reduces afterload + preload; neurohormonal blockade; improves long-term outcomes']
    ],
    [22, 18, 22, 38]
  )
);
children.push(blankLine());

// Q16
children.push(sectionTitle(16, 3, 'Three Drugs for Acute Severe Asthma'));
children.push(
  makeTable(
    ['Drug', 'Class', 'Dose & Route', 'Notes'],
    [
      ['Salbutamol (Albuterol)', 'Short-Acting Beta-2 Agonist', '2.5-5 mg nebulized every 20 min x3; then 1-4 hourly; or MDI 4-8 puffs via spacer', 'First-line bronchodilator; rapid acting (onset < 5 min)'],
      ['Ipratropium bromide', 'Anticholinergic bronchodilator', '0.25-0.5 mg nebulized with salbutamol every 20 min x3 (first hour only)', 'Added to salbutamol in severe/life-threatening; reduces admission rates'],
      ['Systemic Corticosteroids', 'Anti-inflammatory', 'Prednisolone oral 1-2 mg/kg/day x 3-5 days; OR Hydrocortisone 4 mg/kg IV in severe cases', 'Reduces airway inflammation; should be given within 1 hour; IV if cannot swallow']
    ],
    [22, 18, 28, 32]
  )
);
children.push(blankLine());

// Q17
children.push(sectionTitle(17, 3, 'Three Causes of Respiratory Distress in Neonates'));
children.push(
  makeTable(
    ['Cause', 'Type', 'Key Features'],
    [
      ['Respiratory Distress Syndrome (RDS / Hyaline Membrane Disease)', 'Most common in preterm', 'Surfactant deficiency; onset within hours of birth; X-ray: ground-glass opacification, air bronchograms; management: surfactant, CPAP/ventilation'],
      ['Transient Tachypnea of the Newborn (TTN)', 'Most common overall (term/near-term)', 'Delayed absorption of fetal lung fluid; cesarean section birth; tachypnea, mild grunting; resolves in 24-72 hrs; X-ray: perihilar streaking, fluid in fissures'],
      ['Meconium Aspiration Syndrome (MAS)', 'Term / post-term infant', 'Post-date pregnancy, fetal distress, thick meconium staining of liquor; ball-valve obstruction; chemical pneumonitis; X-ray: coarse patchy infiltrates, hyperinflation, pneumothorax']
    ],
    [35, 18, 47]
  )
);

children.push(blankLine());
children.push(new Paragraph({
  children: [new TextRun({ text: 'Source: Ghai Essential Pediatrics (9th Edition) | RGUHS MBBS Phase III Paediatrics QP 1044 March 2024', italics: true, size: 18, color: '595959' })],
  alignment: AlignmentType.CENTER,
  spacing: { before: 300 }
}));

// ─── BUILD DOCUMENT ────────────────────────────────────────────────────────────
const doc = new Document({
  creator: 'Orris AI - Ghai Pediatrics',
  title: 'RGUHS Paediatrics QP 1044 - March 2024 Model Answers',
  description: 'Comprehensive answers with flowcharts and tables based on Ghai Essential Pediatrics',
  sections: [{
    properties: {
      page: {
        margin: { top: 720, right: 720, bottom: 720, left: 720 }
      }
    },
    headers: {
      default: new Header({
        children: [new Paragraph({
          children: [
            new TextRun({ text: 'RGUHS Paediatrics QP 1044 (March 2024) | ', bold: true, size: 18, color: '1F3864' }),
            new TextRun({ text: 'Ghai Essential Pediatrics - Model Answers', size: 18, color: '595959' })
          ],
          alignment: AlignmentType.RIGHT
        })]
      })
    },
    footers: {
      default: new Footer({
        children: [new Paragraph({
          children: [
            new TextRun({ text: 'Page ', size: 18 }),
            new TextRun({ children: [PageNumber.CURRENT], size: 18 }),
            new TextRun({ text: ' | RGUHS Paediatrics Model Answers', size: 18, color: '595959' })
          ],
          alignment: AlignmentType.CENTER
        })]
      })
    },
    children
  }]
});

Packer.toBuffer(doc).then(buffer => {
  fs.writeFileSync('/home/daytona/workspace/rguhs-paediatrics/RGUHS_Paediatrics_QP1044_ModelAnswers.docx', buffer);
  console.log('SUCCESS: Document created!');
}).catch(err => {
  console.error('ERROR:', err.message);
});

cd /home/daytona/workspace/rguhs-paediatrics && node create_df.js

python3 /home/daytona/scripts/office/validate.py /home/daytona/workspace/rguhs-p…

ls -lh /home/daytona/workspace/rguhs-paediatrics/ && python3 -c "import zipfile;…

mkdir -p /home/daytona/workspace/rguhs-paediatrics && python3 -c "from reportlab…

~/rguhs-paediatrics/create_pdf.py

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

# ── Colour palette ────────────────────────────────────────────────────────────
NAVY    = HexColor('#1F3864')
BLUE    = HexColor('#2E75B6')
RED     = HexColor('#C00000')
LTYELL  = HexColor('#FFF2CC')
LTBLUE  = HexColor('#DEEAF1')
LTGRN   = HexColor('#E2EFDA')
LTRED   = HexColor('#FCE4D6')
GREY    = HexColor('#595959')
DGREY   = HexColor('#404040')
MIDGREY = HexColor('#D9D9D9')
TBLHDR  = HexColor('#1F3864')
TBLALT  = HexColor('#DEEAF1')

W, H = A4   # 595.27 x 841.89 pt

# ── Styles ────────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

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

cover_title  = S('ct', fontSize=20, textColor=NAVY, alignment=TA_CENTER, leading=26, fontName='Helvetica-Bold')
cover_sub    = S('cs', fontSize=13, textColor=BLUE, alignment=TA_CENTER, leading=18, fontName='Helvetica-Bold')
cover_note   = S('cn', fontSize=10, textColor=GREY, alignment=TA_CENTER, leading=14, fontName='Helvetica-Oblique')

sec_head     = S('sh', fontSize=14, textColor=white, alignment=TA_LEFT, leading=20,
                 fontName='Helvetica-Bold', backColor=NAVY,
                 leftIndent=6, rightIndent=6, spaceBefore=14, spaceAfter=6,
                 borderPad=4)

q_head       = S('qh', fontSize=12, textColor=NAVY, alignment=TA_LEFT, leading=16,
                 fontName='Helvetica-Bold', spaceBefore=10, spaceAfter=4,
                 leftIndent=4, borderPad=3)

sub_head     = S('subh', fontSize=11, textColor=BLUE, alignment=TA_LEFT, leading=15,
                 fontName='Helvetica-Bold', spaceBefore=7, spaceAfter=3)

body         = S('body', fontSize=9, textColor=DGREY, alignment=TA_JUSTIFY, leading=13,
                 fontName='Helvetica', spaceBefore=2, spaceAfter=3)

body_b       = S('bodyb', fontSize=9, textColor=DGREY, alignment=TA_LEFT, leading=13,
                 fontName='Helvetica-Bold', spaceBefore=2, spaceAfter=3)

bullet_s     = S('bull', fontSize=9, textColor=DGREY, alignment=TA_LEFT, leading=13,
                 fontName='Helvetica', leftIndent=14, firstLineIndent=-8,
                 spaceBefore=1, spaceAfter=1)

flow_box_s   = S('fb', fontSize=9, textColor=NAVY, alignment=TA_LEFT, leading=13,
                 fontName='Helvetica-Bold', leftIndent=6)

note_s       = S('note', fontSize=8, textColor=GREY, alignment=TA_CENTER, leading=11,
                 fontName='Helvetica-Oblique')

def tbl_hdr_style(extra_col_widths=None):
    return TableStyle([
        ('BACKGROUND', (0,0), (-1,0), TBLHDR),
        ('TEXTCOLOR',  (0,0), (-1,0), white),
        ('FONTNAME',   (0,0), (-1,0), 'Helvetica-Bold'),
        ('FONTSIZE',   (0,0), (-1,0), 9),
        ('ALIGN',      (0,0), (-1,0), 'CENTER'),
        ('ROWBACKGROUNDS', (0,1), (-1,-1), [TBLALT, white]),
        ('FONTNAME',   (0,1), (-1,-1), 'Helvetica'),
        ('FONTSIZE',   (0,1), (-1,-1), 8.5),
        ('VALIGN',     (0,0), (-1,-1), 'TOP'),
        ('GRID',       (0,0), (-1,-1), 0.4, HexColor('#AAAAAA')),
        ('LEFTPADDING',(0,0), (-1,-1), 5),
        ('RIGHTPADDING',(0,0),(-1,-1), 5),
        ('TOPPADDING', (0,0), (-1,-1), 4),
        ('BOTTOMPADDING',(0,0),(-1,-1), 4),
        ('WORDWRAP',   (0,0), (-1,-1), True),
    ])

def make_table(headers, rows, col_widths_cm):
    col_w = [c*cm for c in col_widths_cm]
    data = [[Paragraph(f'<b>{h}</b>', S('th', fontSize=9, textColor=white,
             fontName='Helvetica-Bold', alignment=TA_CENTER, leading=12)) for h in headers]]
    for row in rows:
        data.append([Paragraph(str(cell), S('td', fontSize=8.5, fontName='Helvetica',
                     leading=12, alignment=TA_LEFT)) for cell in row])
    t = Table(data, colWidths=col_w, repeatRows=1)
    t.setStyle(tbl_hdr_style())
    return t

def flow_block(lines, bg=LTBLUE, text_color=NAVY):
    """Renders a flowchart box as a coloured table cell."""
    content = '<br/>'.join(lines)
    p = Paragraph(content, S('fbs', fontSize=9, textColor=text_color,
                  fontName='Helvetica-Bold', leading=13, leftIndent=4))
    t = Table([[p]], colWidths=[14.5*cm])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), bg),
        ('BOX',        (0,0), (-1,-1), 1, BLUE),
        ('LEFTPADDING',(0,0), (-1,-1), 8),
        ('RIGHTPADDING',(0,0),(-1,-1), 8),
        ('TOPPADDING', (0,0), (-1,-1), 6),
        ('BOTTOMPADDING',(0,0),(-1,-1), 6),
    ]))
    return t

def arrow():
    return Paragraph('&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#x2193;',
                     S('arr', fontSize=14, textColor=BLUE, alignment=TA_LEFT,
                       fontName='Helvetica-Bold', leading=16))

def sp(h=4):
    return Spacer(1, h)

def hr():
    return HRFlowable(width='100%', thickness=0.5, color=MIDGREY, spaceAfter=4, spaceBefore=4)

def bullet(txt):
    return Paragraph(f'&#8226; {txt}', bullet_s)

def marks_badge(text):
    """Red marks label."""
    return Paragraph(f'<font color="#C00000"><b>[{text}]</b></font>',
                     S('mb', fontSize=10, fontName='Helvetica-Bold',
                       alignment=TA_LEFT, leading=14))

# ── Page template ─────────────────────────────────────────────────────────────
def on_page(canvas, doc):
    canvas.saveState()
    # Header bar
    canvas.setFillColor(NAVY)
    canvas.rect(0, H-28, W, 28, fill=1, stroke=0)
    canvas.setFillColor(white)
    canvas.setFont('Helvetica-Bold', 9)
    canvas.drawString(18, H-18, 'RGUHS Paediatrics QP 1044 | March 2024')
    canvas.setFont('Helvetica', 9)
    canvas.drawRightString(W-18, H-18, 'Ghai Essential Pediatrics - Model Answers')
    # Footer
    canvas.setFillColor(NAVY)
    canvas.rect(0, 0, W, 18, fill=1, stroke=0)
    canvas.setFillColor(white)
    canvas.setFont('Helvetica', 8)
    canvas.drawCentredString(W/2, 5, f'Page {doc.page}  |  RGUHS MBBS Phase III Paediatrics')
    canvas.restoreState()

# ── Build story ───────────────────────────────────────────────────────────────
story = []

# ── COVER PAGE ────────────────────────────────────────────────────────────────
story += [
    Spacer(1, 2*cm),
    Paragraph('RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES', cover_title),
    Paragraph('Karnataka', cover_title),
    sp(8),
    Paragraph('MBBS Phase III (Part II) CBME Degree Examination', cover_sub),
    Paragraph('13 - March - 2024', cover_sub),
    sp(12),
    HRFlowable(width='80%', thickness=2, color=RED, hAlign='CENTER'),
    sp(12),
    Paragraph('PAEDIATRICS (RS-4)', S('ct2', fontSize=18, textColor=RED,
              alignment=TA_CENTER, fontName='Helvetica-Bold', leading=24)),
    Paragraph('QP CODE: 1044', S('ct3', fontSize=14, textColor=NAVY,
              alignment=TA_CENTER, fontName='Helvetica-Bold', leading=20)),
    sp(8),
    HRFlowable(width='80%', thickness=2, color=RED, hAlign='CENTER'),
    sp(20),
    Paragraph('MODEL ANSWERS', S('ct4', fontSize=16, textColor=NAVY,
              alignment=TA_CENTER, fontName='Helvetica-Bold', leading=22)),
    Paragraph('with Flowcharts &amp; Tabular Format', S('ct5', fontSize=13,
              textColor=BLUE, alignment=TA_CENTER, fontName='Helvetica-BoldOblique', leading=18)),
    sp(8),
    Paragraph('As per <b>Ghai Essential Pediatrics, 9th Edition</b>', cover_note),
    sp(40),
]

# Marks distribution table
story.append(Paragraph('MARKS DISTRIBUTION', S('mdt', fontSize=12, textColor=NAVY,
             alignment=TA_CENTER, fontName='Helvetica-Bold', leading=16)))
story.append(sp(6))
story.append(make_table(
    ['Section', 'Questions', 'Marks Each', 'Total'],
    [['Long Essays (LE)', '2', '10', '20'],
     ['Short Essays (SE)', '8', '5', '40'],
     ['Short Answers (SA)', '10', '3', '30'],
     ['TOTAL', '20', '—', '100']],
    [7, 4, 4, 3]
))
story.append(PageBreak())

# ═════════════════════════════════════════════════════════════════════════════
# SECTION A: LONG ESSAYS
# ═════════════════════════════════════════════════════════════════════════════
story.append(Paragraph('SECTION A: LONG ESSAYS (2 × 10 = 20 Marks)', sec_head))
story.append(sp(6))

# ── Q1 ────────────────────────────────────────────────────────────────────────
story.append(KeepTogether([
    Paragraph('Q1. Acute Rheumatic Fever (ARF)   [10 Marks]', q_head),
    hr(),
]))

story.append(Paragraph('(a) Most Probable Diagnosis', sub_head))
story.append(Paragraph('<b>Acute Rheumatic Fever (ARF) with Rheumatic Heart Disease (Mitral Regurgitation)</b>', body))
story.append(bullet('Migratory polyarthritis: knee → ankle → wrist (1 week each)'))
story.append(bullet('Pansystolic murmur at mitral area → Mitral regurgitation'))
story.append(bullet('Tachycardia HR 120/min, afebrile'))
story.append(bullet('Preceding GAS sore throat 3 weeks ago (latent period 2-4 weeks)'))
story.append(sp(6))

story.append(Paragraph('(b) Jones Criteria 2015 (Modified AHA) — PREREQUISITE: Evidence of preceding GAS infection', sub_head))
story.append(Paragraph('<b>Diagnosis = 2 Major  OR  1 Major + 2 Minor criteria  + Evidence of GAS infection</b>', body_b))
story.append(sp(4))
story.append(make_table(
    ['MAJOR CRITERIA (Mnemonic: JONES)', 'MINOR CRITERIA', 'GAS Evidence'],
    [['J – Joints: Migratory Polyarthritis (most common, 75%)', 'Fever (> 38.5°C)', 'Elevated / rising ASO titer (> 333 IU in children)'],
     ['O – cOnsider Carditis: Pancarditis (endo + myo + pericardium); subclinical on Echo', 'Elevated ESR (> 60 mm/hr) or CRP', 'Elevated anti-DNase B'],
     ['N – Nodules: Subcutaneous nodules (firm, painless, over bony prominences)', 'Prolonged PR interval on ECG', 'Positive throat culture for GAS'],
     ['E – Erythema marginatum (trunk / proximal limbs; never face)', 'Arthralgia (only if arthritis NOT used as major)', 'Positive RADT (Rapid Antigen Detection Test)'],
     ['S – Sydenham's Chorea (purposeless involuntary movements)', 'Previous RF / Established RHD', '']],
    [6.5, 4.5, 6.5]
))
story.append(sp(6))

story.append(Paragraph('Diagnostic Flowchart — ARF', sub_head))
story += [
    flow_block(['Child with Migratory Arthritis + Fever + History of Sore Throat (3 weeks prior)']),
    arrow(),
    flow_block(['Confirm preceding GAS infection:', '  • ASO titer / Anti-DNase B   • Throat swab culture   • Rapid Antigen Detection Test (RADT)']),
    arrow(),
    flow_block(['Apply Modified Jones Criteria 2015']),
    arrow(),
    flow_block(['2 MAJOR  OR  1 MAJOR + 2 MINOR criteria fulfilled?'], bg=LTYELL, text_color=HexColor('#7F6000')),
    arrow(),
    flow_block(['Assess for Carditis → Echocardiography (mandatory)', 'Subclinical carditis on Echo = accepted as a Major criterion (2015 update)']),
    arrow(),
    flow_block(['DIAGNOSIS: ACUTE RHEUMATIC FEVER CONFIRMED'], bg=LTGRN, text_color=HexColor('#375623')),
    sp(8),
]

story.append(Paragraph('(c) Management of Acute Rheumatic Fever', sub_head))
story.append(make_table(
    ['Component', 'Drug', 'Dose & Duration'],
    [['Eradicate GAS (preferred)', 'Benzathine Penicillin G IM', '1.2 MU IM single dose (> 27 kg); 0.6 MU (< 27 kg)'],
     ['Eradicate GAS (oral)', 'Amoxicillin', '50 mg/kg/day × 10 days'],
     ['Penicillin allergy', 'Azithromycin', '12 mg/kg/day × 5 days'],
     ['Arthritis', 'Aspirin (anti-inflammatory)', '80–100 mg/kg/day in 4 divided doses × 2–4 weeks; monitor salicylate toxicity'],
     ['Carditis (moderate-severe)', 'Prednisolone', '2 mg/kg/day (max 60 mg) × 2–3 weeks, then taper over 2 weeks'],
     ['Chorea', 'Haloperidol / Valproate / Carbamazepine', 'Symptomatic; haloperidol 0.01–0.03 mg/kg/day in 2–3 doses'],
     ['Bed rest', '—', 'Strict rest until ESR normalises and carditis settles'],
     ['CCF (if present)', 'Furosemide + Digoxin + ACE inhibitor', 'As per severity']],
    [4.5, 4.5, 8.5]
))
story.append(sp(6))

story.append(Paragraph('Secondary Prophylaxis (Most Critical Component)', sub_head))
story.append(Paragraph('<b>Drug:</b> Benzathine Penicillin G <b>1.2 MU IM every 3–4 weeks</b> (preferred)  |  Alt: Penicillin V 250 mg BD oral  |  Allergy: Erythromycin', body))
story.append(sp(4))
story.append(make_table(
    ['Category', 'Duration of Prophylaxis'],
    [['RF without carditis', '5 years or until age 21 years (whichever is longer)'],
     ['RF with carditis, no residual RHD', '10 years or until age 21 years'],
     ['RF with residual RHD (valve disease)', '10 years or until age 40 years; sometimes lifelong'],
     ['Post-valve surgery', 'Lifelong']],
    [9, 8.5]
))
story.append(PageBreak())

# ── Q2 ────────────────────────────────────────────────────────────────────────
story.append(KeepTogether([
    Paragraph('Q2. Measles — Viruses, Clinical Features, Complications & Management   [10 Marks]', q_head),
    hr(),
]))

story.append(Paragraph('(a) Viruses Causing Maculopapular Rash', sub_head))
story.append(make_table(
    ['Virus', 'Disease', 'Rash Pattern'],
    [['Measles virus (Paramyxovirus – Morbillivirus)', 'Measles (Rubeola)', 'Cephalocaudal, blotchy, coalescent — Day 4 of fever'],
     ['Rubella virus (Togavirus)', 'German Measles (Rubella)', 'Face → trunk, pink macules, Day 1–2, fades fast'],
     ['HHV-6 / HHV-7', 'Roseola infantum (Exanthem subitum)', 'Rose-pink macules appear as fever BREAKS'],
     ['Parvovirus B19', 'Erythema infectiosum (5th disease)', '"Slapped cheek" + lacy reticular rash on limbs'],
     ['Coxsackie / Enterovirus', 'Non-specific viral exanthem', 'Variable distribution'],
     ['EBV', 'Infectious mononucleosis', 'Maculopapular; dramatically worse with ampicillin'],
     ['Dengue virus', 'Dengue fever', 'Maculopapular with "islands of white" (sparing)']],
    [5, 4.5, 8]
))
story.append(sp(6))

story.append(Paragraph('(b) Clinical Features of Measles', sub_head))
story.append(Paragraph('Flowchart — Progression of Measles', sub_head))
story += [
    flow_block(['INCUBATION PERIOD: 10–14 days (range 7–18 days)']),
    arrow(),
    flow_block(['PRODROMAL / CATARRHAL PHASE (Day 1–4 of fever)',
                '• High fever (39–40°C), malaise',
                '• 3 Cs: Coryza, Cough, Conjunctivitis (with photophobia, lacrimation)',
                '• KOPLIK SPOTS (PATHOGNOMONIC): Bluish-white spots on buccal mucosa opposite lower 1st molars (Day 2–3 of prodrome)']),
    arrow(),
    flow_block(['ERUPTIVE / EXANTHEM PHASE (Day 4–5)',
                '• Maculopapular rash: CEPHALOCAUDAL spread',
                '  Face (behind ears / hairline) → trunk → upper limbs → lower limbs',
                '• Rash is BLOTCHY, COALESCENT',
                '• Fever peaks when rash appears',
                '• Koplik spots disappear as rash erupts']),
    arrow(),
    flow_block(['RECOVERY PHASE (Day 7–10)',
                '• Rash fades in same cephalocaudal order',
                '• Branny desquamation + brown pigmentation (staining)',
                '• Fever subsides; symptoms resolve']),
    sp(8),
]

story.append(Paragraph('(c) Complications of Measles', sub_head))
story.append(make_table(
    ['System', 'Complication', 'Notes'],
    [['Respiratory', 'Bronchopneumonia (most common cause of DEATH)', 'Secondary bacterial (Pneumococcus, Staph); Giant cell (Hecht) pneumonia'],
     ['Respiratory', 'Laryngotracheobronchitis (Croup)', 'Stridor, bark-like cough'],
     ['CNS', 'Acute encephalitis', '1:1000 cases; during or 2–4 days after rash'],
     ['CNS', 'SSPE (Subacute Sclerosing Panencephalitis)', '7–10 years post-infection; dementia + seizures; invariably fatal'],
     ['CNS', 'Post-infectious encephalomyelitis', 'Autoimmune; 1–2 weeks after rash'],
     ['Eye', 'Corneal ulceration / Keratitis → Blindness', 'Especially with Vitamin A deficiency'],
     ['GI', 'Severe diarrhoea, malnutrition', 'Worsens pre-existing malnutrition'],
     ['Ear', 'Otitis media', 'Common secondary bacterial superinfection'],
     ['Immune', 'Measles anergy (immune suppression)', 'Lasts 4–6 weeks; reactivates latent TB'],
     ['Mouth', 'Cancrum oris (Noma)', 'Gangrenous stomatitis in severely malnourished']],
    [3, 6, 8.5]
))
story.append(sp(4))

story.append(Paragraph('Management of Measles', sub_head))
story.append(make_table(
    ['Aspect', 'Treatment', 'Details'],
    [['Supportive care', 'Antipyretics, fluids, nutrition', 'Paracetamol; continue breastfeeding; ORS for diarrhoea'],
     ['Vitamin A (MANDATORY — WHO)', 'Single oral/IM dose', '< 6 months: 50,000 IU; 6–11 months: 1,00,000 IU; ≥ 12 months: 2,00,000 IU; Repeat next day + at 4 weeks if malnourished/blind'],
     ['Antibiotics', 'Amoxicillin / Co-amoxiclav', 'For bacterial secondary infections (pneumonia, otitis media)'],
     ['Encephalitis', 'Supportive + anticonvulsants', 'No specific antiviral; manage raised ICP'],
     ['Isolation', 'Respiratory droplet precautions', 'Until 4 days after rash onset'],
     ['Prevention', 'MR vaccine / MMR', '9–12 months; booster at 16–24 months (India NIS)']],
    [3.5, 4.5, 9.5]
))
story.append(PageBreak())

# ═════════════════════════════════════════════════════════════════════════════
# SECTION B: SHORT ESSAYS
# ═════════════════════════════════════════════════════════════════════════════
story.append(Paragraph('SECTION B: SHORT ESSAYS (8 × 5 = 40 Marks)', sec_head))
story.append(sp(6))

# ── Q3 ────────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q3. Global Developmental Delay (GDD)   [5 Marks]', q_head))
story.append(hr())
story.append(Paragraph('(a) Definition of Development (Ghai)', sub_head))
story.append(Paragraph(
    '<b>Development</b> = Acquisition of skills and functions as a result of maturation of the CNS '
    'and interaction with the environment. It proceeds in a <b>cephalocaudal</b> and '
    '<b>proximal-to-distal</b> direction and is a <b>continuous, orderly, sequential</b> process.',
    body))
story.append(sp(4))
story.append(make_table(
    ['Domain', 'Skills Assessed', 'Key Milestone Example'],
    [['Gross Motor', 'Head control, sitting, standing, walking, running', 'Walks alone by 15 months'],
     ['Fine Motor / Adaptive', 'Grasping, pincer grasp, drawing, stacking', 'Mature pincer by 9–10 months'],
     ['Language / Speech', 'Cooing, babbling, words, sentences', '2-word phrases by 24 months'],
     ['Personal-Social', 'Social smiling, feeding, dressing, play', 'Social smile by 6 weeks']],
    [4, 7, 6.5]
))
story.append(sp(6))

story.append(Paragraph('(b) Causes of Delayed Development — Timing-Based Overview', sub_head))
story += [
    flow_block(['GLOBAL DEVELOPMENTAL DELAY — CAUSES BY TIMING']),
    arrow(),
    flow_block(['PRENATAL  |  PERINATAL  |  POSTNATAL  |  UNKNOWN (Idiopathic ~30%)'], bg=LTBLUE),
    sp(4),
]
story.append(make_table(
    ['Category', 'Specific Causes'],
    [['Prenatal – Genetic', 'Down syndrome (Trisomy 21), Fragile X, Angelman, Rett syndrome, PKU, Hypothyroidism'],
     ['Prenatal – Structural CNS', 'Neural tube defects, microcephaly, hydrocephalus, lissencephaly, holoprosencephaly'],
     ['Prenatal – Infections', 'TORCH: Toxoplasma, Rubella, CMV (most common TORCH), HSV, Syphilis'],
     ['Prenatal – Toxic / Teratogenic', 'Fetal alcohol syndrome, maternal drugs (phenytoin, valproate), radiation'],
     ['Perinatal', 'Birth asphyxia / HIE (commonest overall cause), prematurity, neonatal hypoglycaemia, kernicterus'],
     ['Postnatal – Infections', 'Bacterial meningitis, viral encephalitis'],
     ['Postnatal – Nutritional', 'SAM, iodine deficiency, iron deficiency anaemia'],
     ['Postnatal – Psychosocial', 'Severe deprivation/neglect, abuse, autism spectrum disorder'],
     ['Endocrine', 'Hypothyroidism — commonest TREATABLE cause (congenital or acquired)'],
     ['Neurodegenerative', 'Metachromatic leukodystrophy, Batten disease, Niemann-Pick disease']],
    [5, 12.5]
))
story.append(sp(8))

# ── Q4 ────────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q4. Acute Flaccid Paralysis (AFP)   [5 Marks]', q_head))
story.append(hr())
story.append(Paragraph('(a) Definition', sub_head))
story.append(Paragraph(
    '<b>AFP</b> = Sudden onset of <b>flaccid (LMN-type) paralysis</b> in any child <b>under 15 years</b> '
    'of age, occurring within <b>28 days</b>, where no other obvious cause is identified. '
    'Characterized by: flaccidity, hypotonia, hyporeflexia/areflexia, rapid onset. '
    '<i>(WHO/Polio surveillance: any AFP in &lt;15 years must be reported and investigated)</i>',
    body))
story.append(sp(6))
story.append(Paragraph('(b) Three Differential Diagnoses of AFP', sub_head))
story.append(make_table(
    ['Feature', 'Guillain-Barré Syndrome (GBS)', 'Poliomyelitis', 'Transverse Myelitis'],
    [['Onset', 'Subacute (days–weeks)', 'Acute (hours–days)', 'Acute (hours–days)'],
     ['Distribution', 'Ascending, SYMMETRICAL', 'ASYMMETRICAL, focal', 'Paraplegia (both legs)'],
     ['Reflexes', 'Areflexia (universal)', 'Areflexia in affected limb', 'Absent acutely; may return'],
     ['Sensory', 'Mild paraesthesia in some', 'NO sensory loss', 'SENSORY LEVEL present'],
     ['Bladder/Bowel', 'Occasional autonomic involvement', 'Absent', 'Bladder/bowel INVOLVED'],
     ['Fever at onset', 'No (prior URTI/GI illness)', 'YES — fever at onset', 'No (or prior viral illness)'],
     ['CSF findings', 'Albuminocytologic dissociation: HIGH protein, NORMAL cells', 'Pleocytosis, mild protein rise', 'Normal or mild changes'],
     ['NCV / EMG', 'Demyelinating (↓ velocity, ↑ latency)', 'Normal NCV; anterior horn EMG changes', 'Normal NCV'],
     ['MRI', 'Nerve root enhancement', 'Normal brain/spine MRI', 'Cord signal change at level'],
     ['Respiratory risk', 'HIGH — monitor closely (VC < 20 mL/kg = intubate)', 'Only in bulbar type', 'Rare unless cervical level']],
    [3.5, 5, 4, 5]
))
story.append(sp(8))

# ── Q5 ────────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q5. Tubercular Meningitis (TBM) — Clinical Features & Investigations   [5 Marks]', q_head))
story.append(hr())
story.append(Paragraph('Clinical Stages — Bhargava &amp; Lincoln Staging', sub_head))
story += [
    flow_block(['STAGE I — Prodromal (1–4 weeks)',
                '• Fever, malaise, headache, irritability, behavioural changes, vomiting',
                '• NO neurological signs; GCS = 15 (fully conscious)']),
    arrow(),
    flow_block(['STAGE II — Meningitic (Weeks 2–8)',
                '• Meningeal signs: Neck stiffness, Kernig +ve, Brudzinski +ve',
                '• Cranial nerve palsies: CN VI (most common → squint/diplopia); CN III, IV, VII',
                '• Mild altered consciousness (confusion/drowsiness); GCS 10–14',
                '• Focal signs may appear (hemiparesis from vasculitis/infarcts)']),
    arrow(),
    flow_block(['STAGE III — Encephalitic (Advanced)',
                '• Coma; GCS < 10',
                '• Decerebrate / decorticate posturing',
                '• Hemiplegia, seizures (common)',
                '• Hydrocephalus, cerebral oedema',
                '• High mortality; severe sequelae in survivors']),
    sp(6),
]

story.append(Paragraph('Investigations of TBM', sub_head))
story.append(make_table(
    ['Investigation', 'Finding in TBM', 'Significance'],
    [['CSF — Appearance', 'Clear / xanthochromic; cobweb clot on standing', 'High fibrin content'],
     ['CSF — Cell count', '10–500 cells/mm³; predominantly LYMPHOCYTES', 'Early = neutrophils; shifts to lymphocytes'],
     ['CSF — Protein', 'Markedly ELEVATED: 100–500 mg/dL', 'Key feature; > 500 mg/dL = poor prognosis'],
     ['CSF — Glucose', 'DECREASED < 45 mg/dL; CSF:serum ratio < 0.5', 'MTB consuming glucose'],
     ['CSF — AFB Smear', 'Positive in 10–40%', 'Centrifuge large volume; scan multiple fields'],
     ['CSF — Culture (LJ medium)', 'Positive in 45–90% — GOLD STANDARD', 'Takes 4–8 weeks'],
     ['CSF — Gene Xpert MTB/RIF', 'Positive; detects rifampicin resistance', 'Rapid (2 hours); highly specific'],
     ['CSF — ADA', 'Elevated (> 10 U/L)', 'Useful supportive marker'],
     ['Mantoux / TST', 'May be NEGATIVE (anergy in severe TBM)', 'Negative does NOT rule out TBM'],
     ['Chest X-ray', 'Primary complex / miliary pattern', 'Present in ~50% of TBM cases'],
     ['CT Head', 'Basal exudates, hydrocephalus, infarcts', 'Stage assessment + complication detection'],
     ['MRI Brain (preferred)', 'Basal meningeal enhancement, vasculitic infarcts', 'More sensitive than CT']],
    [4, 5.5, 7]
))
story.append(PageBreak())

# ── Q6 ────────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q6. Portal Hypertension — Clinical &amp; Investigation Approach   [5 Marks]', q_head))
story.append(hr())
story.append(Paragraph('Clinical Features', sub_head))
story.append(make_table(
    ['Feature', 'Details'],
    [['Splenomegaly', 'Most common sign in children; massive, firm, painless'],
     ['Haematemesis / Melaena', 'From oesophageal/gastric varices — can be torrential and life-threatening'],
     ['Ascites', 'More common in intrahepatic portal hypertension (cirrhosis)'],
     ['Hypersplenism', 'Pancytopenia: anaemia + thrombocytopenia + leukopenia'],
     ['Dilated abdominal veins', 'Caput medusae (periumbilical collaterals)'],
     ['Hepatomegaly', 'In intrahepatic and posthepatic causes'],
     ['Jaundice', 'In hepatic (cirrhosis) and posthepatic causes'],
     ['Porto-systemic encephalopathy', 'In chronic / decompensated liver disease']],
    [5.5, 12]
))
story.append(sp(6))

story.append(Paragraph('Diagnostic Flowchart — Investigation Approach', sub_head))
story += [
    flow_block(['Child with Splenomegaly  ±  Haematemesis  ±  Ascites']),
    arrow(),
    flow_block(['STEP 1: Basic Blood Investigations',
                '• CBC (pancytopenia from hypersplenism)',
                '• LFTs: ALT, AST, ALP, GGT, Bilirubin',
                '• Serum Albumin + Total Protein',
                '• Coagulation: PT / INR']),
    arrow(),
    flow_block(['STEP 2: USG Abdomen + DOPPLER (KEY INVESTIGATION)',
                '• Liver size, echogenicity; spleen size; ascites',
                '• Portal vein diameter (> 13 mm significant in children)',
                '• Portal vein flow: Hepatofugal = DIAGNOSTIC of PHT',
                '• Collaterals, portal vein thrombus / cavernoma']),
    arrow(),
    flow_block(['STEP 3: Upper GI Endoscopy (GOLD STANDARD for varices)',
                '• Oesophageal varices (Grade I–IV)',
                '• Gastric varices; Portal hypertensive gastropathy'], bg=LTYELL, text_color=HexColor('#7F6000')),
    arrow(),
    flow_block(['STEP 4: Liver Biopsy (if intrahepatic cause suspected)',
                '• Cirrhosis, congenital hepatic fibrosis, Wilson disease, biliary atresia']),
    arrow(),
    flow_block(['STEP 5: CT / MRI Angiography (pre-surgical planning for EHPVO)',
                '• Portal vein anatomy for shunt surgery']),
    sp(6),
]

story.append(Paragraph('Types Comparison Table', sub_head))
story.append(make_table(
    ['Parameter', 'Pre-hepatic (EHPVO)', 'Hepatic (Cirrhosis)', 'Post-hepatic (Budd-Chiari)'],
    [['Common cause', 'Umbilical sepsis → portal vein thrombosis (neonatal)', 'Wilson disease, biliary atresia, NAFLD', 'Hepatic vein thrombosis'],
     ['Liver size', 'Normal', 'Small / fibrotic', 'Enlarged, tender'],
     ['LFTs', 'Normal', 'Deranged', 'ALT elevated'],
     ['Ascites', 'Absent / mild', 'Present', 'Present (major feature)'],
     ['USG Doppler', 'PVT / cavernoma', 'Coarse echogenicity', 'Hepatic vein occlusion'],
     ['Prognosis', 'Best', 'Depends on cause', 'Variable']],
    [4, 5, 5, 4]
))
story.append(PageBreak())

# ── Q7 ────────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q7. Nutritional Rickets — Clinical &amp; Radiological Features   [5 Marks]', q_head))
story.append(hr())
story.append(Paragraph('Clinical Features', sub_head))
story.append(make_table(
    ['Region', 'Clinical Sign', 'Notes'],
    [['Head', 'Craniotabes (ping-pong ball feel)', 'EARLIEST sign; first 6 months of life'],
     ['Head', 'Frontal / parietal bossing; "Hot cross bun skull" (caput quadratum)', 'Cranial vault deformity'],
     ['Head', 'Delayed closure of anterior fontanelle (beyond 18 months)', ''],
     ['Teeth', 'Delayed dentition; enamel hypoplasia', ''],
     ['Chest', 'Rachitic rosary (beading at costochondral junctions)', 'Row of beads along chest wall'],
     ['Chest', "Harrison's sulcus", 'Horizontal groove at diaphragm insertion level'],
     ['Chest', 'Pigeon chest / pectus carinatum or funnel chest', ''],
     ['Spine', 'Kyphoscoliosis', 'In severe cases'],
     ['Pelvis', 'Pelvic deformity (triradiate pelvis)', 'May cause obstructed labour later in life'],
     ['Lower limbs', 'Genu varum (bow legs) — before 2 years', 'Weight-bearing deformity'],
     ['Lower limbs', 'Genu valgum (knock knees) — after 2 years', ''],
     ['Wrists / Ankles', 'Widened, cupped metaphyses (rachitic rosette / double malleoli)', 'Characteristic visible swelling'],
     ['Muscles', 'Hypotonia; protuberant abdomen (pot belly / frog belly)', ''],
     ['Growth', 'Short stature, failure to thrive', ''],
     ['Hypocalcaemia signs', 'Tetany, carpopedal spasm, Trousseau/Chvostek signs, laryngospasm, seizures', 'In florid Vitamin D deficiency rickets']],
    [3, 7, 7.5]
))
story.append(sp(6))

story.append(Paragraph('Radiological Features (X-ray Wrist / Long Bones)', sub_head))
story.append(make_table(
    ['X-ray Sign', 'Region', 'Description'],
    [['Cupping', 'Metaphysis', 'Concave / cup-shaped appearance of the metaphysis'],
     ['Fraying', 'Metaphysis', 'Irregular, ragged, brush-like (paintbrush) fraying of metaphyseal margin'],
     ['Widening of physis', 'Growth plate', 'Wide irregular zone between epiphysis and metaphysis (> 2 mm)'],
     ['Haziness of epiphysis', 'Epiphysis', 'Epiphyses appear late, faint, fuzzy, ill-defined'],
     ['Loss of zone of provisional calcification', 'Metaphysis', 'Normal dense white line at metaphyseal margin is ABSENT'],
     ['Osteopenia', 'Entire bone', 'Decreased density; coarse, woolly trabecular pattern'],
     ['Looser zones (Milkman pseudo-fractures)', 'Diaphysis', 'Radiolucent bands perpendicular to cortex — severe osteomalacia'],
     ['Bowing deformities', 'Long bones', 'Anterior and lateral bowing of femur, tibia, radius, ulna']],
    [4, 3.5, 10]
))
story.append(sp(8))

# ── Q8 ────────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q8. Neonatal Seizures &amp; Hypoglycaemia Management   [5 Marks]', q_head))
story.append(hr())
story.append(Paragraph('Causes of Seizures in a 3-Day Old Neonate', sub_head))
story.append(make_table(
    ['Cause', 'Onset Timing', 'Key Features'],
    [['HIE (Hypoxic Ischaemic Encephalopathy) — MC overall', 'Day 1 (0–3 days)', 'Birth asphyxia history; multisystem involvement; Sarnat staging'],
     ['Hypoglycaemia', 'Day 1–3', 'Blood glucose < 40 mg/dL; jitteriness, lethargy, apnoea'],
     ['Hypocalcaemia (early neonatal)', 'Day 2–3', 'Preterm, IDM, asphyxia; Ca < 7 mg/dL; jitteriness'],
     ['Intracranial Haemorrhage', 'Day 1–3', 'SDH/IVH (esp. preterm); tense bulging fontanelle; CT diagnostic'],
     ['Neonatal Meningitis', 'Day 3 onwards', 'Fever/hypothermia, bulging fontanelle; E. coli, GBS; CSF abnormal'],
     ['Hypomagnesaemia', 'Day 2–3', 'Mg < 1.5 mg/dL; often with hypocalcaemia'],
     ['Pyridoxine (B6) dependency', 'Day 1–7', 'Refractory seizures; dramatic response to IV B6 (50–100 mg)'],
     ['Drug withdrawal', 'Day 1–3', 'Maternal opioid/barbiturate use; irritability, high-pitched cry'],
     ['Inborn errors of metabolism', 'Day 2–7', 'Refractory seizures; metabolic acidosis; abnormal metabolic screen'],
     ['Benign neonatal convulsions ("5th day fits")', 'Day 5', 'Clonic seizures; self-limiting; normal developmental outcome']],
    [5.5, 2.5, 9.5]
))
story.append(sp(6))

story.append(Paragraph('Flowchart — Management of Hypoglycaemia Seizures in Neonate', sub_head))
story += [
    flow_block(['Neonate (3 days old) with SEIZURES',
                'Bedside glucometer: Blood Glucose < 40 mg/dL']),
    arrow(),
    flow_block(['STEP 1: IMMEDIATE IV Glucose BOLUS',
                '• 10% Dextrose → 2 mL/kg IV bolus over 1–2 minutes  (= 200 mg/kg glucose)',
                '• Do NOT delay — glucose must be given immediately',
                '• Recheck blood glucose after 15–30 minutes; TARGET: > 45–50 mg/dL']),
    arrow(),
    flow_block(['STEP 2: Continuous IV Glucose Infusion (GIR)',
                '• Start D10% at GIR = 6–8 mg/kg/min',
                '• GIR formula: (% Dextrose × rate mL/hr) ÷ (6 × weight in kg)',
                '• Persistent hypoglycaemia → increase GIR to 10–12 mg/kg/min']),
    arrow(),
    flow_block(['STEP 3: Treat Seizures (Antiepileptics)',
                '• 1st line: Phenobarbitone 20 mg/kg IV slow bolus',
                '• 2nd line: Phenytoin 20 mg/kg IV (if refractory)',
                '• 3rd line: Midazolam / Levetiracetam']),
    arrow(),
    flow_block(['STEP 4: Refractory / Persistent Hypoglycaemia',
                '• Hydrocortisone 5 mg/kg/day IV (↑ gluconeogenesis)',
                '• Glucagon 0.1–0.3 mg/kg IM/IV (if no IV access)',
                '• Diazoxide (if hyperinsulinism suspected)',
                '• Investigate cause: Serum insulin, cortisol, GH, IEM screen'], bg=LTYELL, text_color=HexColor('#7F6000')),
    arrow(),
    flow_block(['STEP 5: MONITOR + WEAN',
                '• Recheck glucose every 30 min; target consistently > 45 mg/dL',
                '• Introduce early feeds (breast milk preferred)',
                '• Wean IV glucose by 1–2 mg/kg/min every 2–4 hours once feeds established'],
               bg=LTGRN, text_color=HexColor('#375623')),
    sp(8),
]

story.append(PageBreak())

# ── Q9 ────────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q9. Beta Thalassaemia Major — Investigations &amp; Interpretation   [5 Marks]', q_head))
story.append(hr())
story.append(make_table(
    ['Investigation', 'Finding', 'Interpretation'],
    [['Haemoglobin', 'Severe anaemia: Hb 2–7 g/dL', 'Transfusion-dependent; presents at 6–24 months of life'],
     ['MCV / MCH', 'Microcytic: MCV < 70 fL; MCH < 20 pg', 'Defective β-chain → ↓ HbA production; ↑ α-chain excess'],
     ['RBC count', 'High-normal (numerically)', 'Compensatory erythroid hyperplasia'],
     ['Peripheral Blood Smear', 'Microcytic hypochromic cells, TARGET CELLS, NUCLEATED RBCs (NRBCs), tear-drop cells, basophilic stippling, anisopoikilocytosis', 'Marker of INEFFECTIVE erythropoiesis'],
     ['Reticulocyte count', 'Elevated (5–15%)', 'Compensatory but ineffective haemopoiesis'],
     ['Serum Ferritin', 'Markedly elevated (> 500–1000 ng/mL, rising)', 'Iron overload from repeated transfusions'],
     ['Serum Iron / TIBC', 'Iron ↑; TIBC low/normal', 'Iron overload state (opposite of IDA)'],
     ['Hb Electrophoresis (KEY)', 'HbF: 10–98%; HbA2: variable; HbA: ABSENT (0%) in β0 thal', 'DIAGNOSTIC — absence of HbA with HbF predominance'],
     ['HPLC', 'Quantifies HbA, HbA2, HbF accurately', 'Gold standard for Hb variant quantification'],
     ['LFTs', '↑ Indirect bilirubin; ↑ transaminases', 'Haemolysis + iron overload hepatopathy'],
     ['X-ray Skull', '"Hair-on-end" / sun-ray appearance', 'Expansion of diploe due to marrow hyperplasia'],
     ['X-ray Long bones', 'Cortical thinning; "Erlenmeyer flask" femur', 'Medullary expansion from erythroid hyperplasia'],
     ['USG Abdomen', 'Massive hepatosplenomegaly', 'Extramedullary haematopoiesis (EMH)'],
     ['Echocardiography', 'LV dysfunction, cardiomyopathy', 'Iron deposition in myocardium — leading cause of death'],
     ['Endocrine screen', '↓ T4/TSH; ↓ Ca/PTH; ↑ glucose (DM)', 'Iron deposition in thyroid, parathyroid, pancreas'],
     ['DNA / Molecular analysis', 'β-globin gene mutation identified', 'Confirms β0 vs β+; essential for prenatal diagnosis']],
    [4, 5.5, 7]
))
story.append(sp(8))

# ── Q10 ────────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q10. Classification of Anaemia &amp; Investigation of Megaloblastic Anaemia   [5 Marks]', q_head))
story.append(hr())
story.append(Paragraph('Etiological Classification — Flowchart', sub_head))
story += [
    flow_block(['ANAEMIA  (Hb below age-specific lower limit of normal)']),
    arrow(),
    flow_block(['Classify by Mechanism'], bg=LTYELL, text_color=HexColor('#7F6000')),
    arrow(),
    flow_block(['1. DECREASED PRODUCTION          2. INCREASED DESTRUCTION          3. BLOOD LOSS']),
    sp(4),
]
story.append(make_table(
    ['Type', 'Mechanism', 'Examples'],
    [['Decreased Production', 'Nutritional deficiency', 'Iron deficiency (most common), Vit B12/Folate (megaloblastic), Vit C'],
     ['Decreased Production', 'Bone marrow failure', 'Aplastic anaemia, Diamond-Blackfan anaemia (pure RBC aplasia)'],
     ['Decreased Production', 'Chronic disease / Renal', 'Anaemia of inflammation; EPO deficiency in CKD'],
     ['Increased Destruction — Intrinsic (corpuscular)', 'Haemolytic', 'Sickle cell disease, G6PD deficiency, thalassaemia, spherocytosis'],
     ['Increased Destruction — Extrinsic (extracorpuscular)', 'Haemolytic', 'Immune (ABO/Rh incompatibility, AIHA), MAHA, infections, hypersplenism'],
     ['Blood Loss', 'Acute haemorrhage', 'Trauma, GI bleed'],
     ['Blood Loss', 'Chronic blood loss', 'Hookworm, GI lesions → secondary iron deficiency anaemia']],
    [5, 4, 8.5]
))
story.append(sp(4))
story.append(Paragraph('Morphological Classification', sub_head))
story.append(make_table(
    ['Type', 'MCV', 'Causes'],
    [['Microcytic Hypochromic', '< 80 fL', 'Iron deficiency (most common), Thalassaemia, Sideroblastic, Chronic disease'],
     ['Normocytic Normochromic', '80–100 fL', 'Acute haemorrhage, Haemolytic (most), Aplastic anaemia, Early chronic disease'],
     ['Macrocytic — Megaloblastic', '> 100 fL', 'Vitamin B12 deficiency, Folate deficiency, Drugs (methotrexate, hydroxyurea)'],
     ['Macrocytic — Non-megaloblastic', '> 100 fL', 'Liver disease, Hypothyroidism, Reticulocytosis']],
    [5, 2.5, 10]
))
story.append(sp(6))

story.append(Paragraph('Investigations of Megaloblastic Anaemia', sub_head))
story.append(make_table(
    ['Investigation', 'Finding', 'Significance'],
    [['Haemoglobin', 'Low (may be severely low)', 'Macrocytic anaemia'],
     ['MCV', '> 100 fL (often 110–130 fL)', 'Macrocytosis — cardinal feature'],
     ['Peripheral Blood Smear', 'OVAL MACROCYTES + HYPERSEGMENTED NEUTROPHILS (> 5 lobes in > 5% = PATHOGNOMONIC) + anisopoikilocytosis', 'Diagnostic hallmark of megaloblastic anaemia'],
     ['Reticulocyte count', 'LOW (reticulocytopenia)', 'Ineffective erythropoiesis'],
     ['WBC / Platelets', 'Pancytopenia in severe cases', 'All cell lines affected'],
     ['Serum Vitamin B12', '< 200 pg/mL (normal 200–900)', 'Confirms B12 deficiency'],
     ['Serum Folate', '< 3 ng/mL', 'Confirms folate deficiency'],
     ['RBC Folate', '< 150 ng/mL', 'Better marker of tissue folate stores than serum folate'],
     ['Serum Homocysteine', 'ELEVATED in BOTH B12 and folate deficiency', 'Sensitive early marker'],
     ['Methylmalonic acid (MMA)', 'Elevated ONLY in B12 deficiency', 'Differentiates B12 from folate deficiency'],
     ['LDH', 'Markedly elevated', 'Intramedullary haemolysis / ineffective erythropoiesis'],
     ['Serum Bilirubin (indirect)', 'Mildly elevated', 'Intramedullary red cell destruction'],
     ['Bone Marrow Aspiration', 'Megaloblasts, giant metamyelocytes, hypersegmented neutrophils', 'Confirms megaloblastic haemopoiesis (if diagnosis unclear)'],
     ['Anti-Intrinsic Factor antibody', 'Positive in Pernicious Anaemia', 'Autoimmune gastritis → IF deficiency → B12 malabsorption']],
    [4, 5.5, 7]
))
story.append(PageBreak())

# ═════════════════════════════════════════════════════════════════════════════
# SECTION C: SHORT ANSWERS
# ═════════════════════════════════════════════════════════════════════════════
story.append(Paragraph('SECTION C: SHORT ANSWERS (10 × 3 = 30 Marks)', sec_head))
story.append(sp(6))

# ── Q11 ───────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q11. Prematurity, LBW and SGA — Definitions   [3 Marks]', q_head))
story.append(hr())
story.append(make_table(
    ['Term', 'Definition', 'Cut-off / Subclassification'],
    [['Prematurity', 'Birth before 37 completed weeks (< 37+0 wks) of gestation', 'Extreme preterm: < 28 wks; Very preterm: 28–32 wks; Moderate-late preterm: 32–37 wks'],
     ['Low Birth Weight (LBW)', 'Birth weight < 2500 g regardless of gestational age', 'VLBW: < 1500 g; ELBW: < 1000 g'],
     ['Small for Gestational Age (SGA)', 'Birth weight < 10th percentile for GA OR < 2 SD below mean for GA', 'Due to IUGR; NOT synonymous with prematurity; may be term or preterm']],
    [3.5, 6.5, 7.5]
))
story.append(sp(8))

# ── Q12 ───────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q12. Bloody Stools in 5-Year-Old — Three Causative Organisms   [3 Marks]', q_head))
story.append(hr())
story.append(make_table(
    ['Organism', 'Type', 'Key Features'],
    [['Shigella dysenteriae', 'Gram-negative bacterium', 'Classic bacillary dysentery; mucus + blood + tenesmus; most common bacterial cause'],
     ['Entamoeba histolytica', 'Protozoan', 'Amoebic dysentery; "anchovy sauce" stools; can cause amoebic liver abscess'],
     ['Campylobacter jejuni', 'Gram-negative bacterium', 'Poultry source; frank bloody diarrhoea; can mimic IBD on colonoscopy']],
    [5, 3.5, 9]
))
story.append(sp(8))

# ── Q13 ───────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q13. BCG Vaccine — Dose, Route &amp; Schedule   [3 Marks]', q_head))
story.append(hr())
story.append(make_table(
    ['Parameter', 'Details'],
    [['Type', 'Live attenuated Mycobacterium bovis (Bacille Calmette-Guérin)'],
     ['Dose', '0.05 mL for neonates/infants up to 12 months;  0.1 mL for children > 12 months'],
     ['Route', 'Intradermal (ID) — left deltoid region (upper outer arm)'],
     ['Schedule (India NIS)', 'AT BIRTH — as early as possible, ideally within 24 hours of delivery'],
     ['Expected reaction', 'Papule → pustule → ulcer → BCG scar (Bacillus scar) in 6–12 weeks'],
     ['Efficacy', '80% protection against miliary TB and TB meningitis; variable against pulmonary TB'],
     ['Contraindications', 'Symptomatic HIV, primary immunodeficiency, generalised eczema, high fever']],
    [4, 13.5]
))
story.append(sp(8))

# ── Q14 ───────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q14. Preventing Bleeding in a School Boy with Haemophilia   [3 Marks]', q_head))
story.append(hr())
story.append(make_table(
    ['Measure', 'Details'],
    [['Primary prophylaxis (gold standard)', 'Regular Factor VIII concentrate 25–40 IU/kg, 3×/week (Haemophilia A); start before age 2–3, before first joint bleed'],
     ['Secondary prophylaxis', 'After 2+ joint bleeds — regular factor infusions to prevent target joint damage'],
     ['Avoid contact sports', 'No football, rugby, boxing; encourage swimming, cycling, walking'],
     ['Protective gear', 'Helmets, knee/elbow pads during physical activities'],
     ['Avoid NSAIDs / Aspirin', 'Use Paracetamol only (NSAIDs impair platelet function)'],
     ['Avoid IM injections', 'Use SC/oral routes; apply pressure > 5 min after venepuncture'],
     ['DDAVP (Desmopressin)', '0.3 mcg/kg IV or intranasal — mild Haemophilia A (releases stored FVIII from endothelium)'],
     ['Tranexamic acid', '25 mg/kg orally — mucosal bleeds and before dental procedures (antifibrinolytic)'],
     ['Medical alert bracelet', 'For emergency identification of condition'],
     ['School counselling', 'Inform teachers of condition and emergency protocol']],
    [5, 12.5]
))
story.append(sp(8))

# ── Q15 ───────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q15. Three Drugs for Congestive Cardiac Failure in Children   [3 Marks]', q_head))
story.append(hr())
story.append(make_table(
    ['Drug', 'Class', 'Dose', 'Mechanism / Role'],
    [['Furosemide', 'Loop diuretic', '1–2 mg/kg/dose IV or oral, 6–12 hourly', '↓ Preload via diuresis; first-line for acute CCF; rapid onset'],
     ['Digoxin', 'Cardiac glycoside', 'Maintenance: 5–8 mcg/kg/day in 2 divided doses (age-dependent)', 'Positive inotrope + negative chronotrope; ↑ contractility; inhibits Na-K ATPase'],
     ['Captopril / Enalapril', 'ACE inhibitor', 'Captopril: 0.1–0.5 mg/kg/dose 8 hourly', '↓ Afterload + preload; neurohormonal blockade; improves long-term cardiac outcomes']],
    [3.5, 3, 4, 7]
))
story.append(sp(8))

# ── Q16 ───────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q16. Three Drugs for Acute Severe Asthma   [3 Marks]', q_head))
story.append(hr())
story.append(make_table(
    ['Drug', 'Class', 'Dose &amp; Route', 'Notes'],
    [['Salbutamol (Albuterol)', 'Short-acting β2-agonist', '2.5–5 mg nebulised every 20 min × 3, then 1–4 hourly; OR 4–8 puffs MDI via spacer', 'First-line bronchodilator; rapid onset (< 5 min)'],
     ['Ipratropium bromide', 'Anticholinergic bronchodilator', '0.25–0.5 mg nebulised with salbutamol every 20 min × 3 (first hour only)', 'Added in severe/life-threatening; reduces hospital admissions'],
     ['Systemic Corticosteroids', 'Anti-inflammatory', 'Prednisolone oral 1–2 mg/kg/day × 3–5 days; OR Hydrocortisone 4 mg/kg IV (severe cases)', 'Reduces airway inflammation; give within 1 hour of presentation']],
    [3.5, 3, 5, 6]
))
story.append(sp(8))

# ── Q17 ───────────────────────────────────────────────────────────────────────
story.append(Paragraph('Q17. Three Causes of Respiratory Distress in Neonates   [3 Marks]', q_head))
story.append(hr())
story.append(make_table(
    ['Cause', 'Type', 'Key Features'],
    [['Respiratory Distress Syndrome (RDS / HMD)', 'Most common in PRETERM neonates', 'Surfactant deficiency; onset within 4 hours of birth; worsens over 48–72 hrs; X-ray: ground-glass opacification + air bronchograms; Rx: exogenous surfactant + CPAP/ventilation'],
     ['Transient Tachypnoea of Newborn (TTN)', 'Most common cause OVERALL (term/near-term)', 'Delayed resorption of fetal lung fluid; after caesarean section; tachypnoea + mild grunting; self-resolving in 24–72 hrs; X-ray: perihilar streaking, fluid in horizontal fissure'],
     ['Meconium Aspiration Syndrome (MAS)', 'Post-term / term (fetal distress)', 'Thick meconium-stained liquor + distress from birth; ball-valve obstruction → air trapping; chemical pneumonitis; X-ray: coarse patchy infiltrates + hyperinflation ± pneumothorax']],
    [4, 3.5, 10]
))

story += [
    sp(20),
    HRFlowable(width='100%', thickness=1, color=NAVY),
    sp(6),
    Paragraph(
        '<b>Reference:</b> Ghai O.P., Paul V.K., Bagga A. — <i>Essential Pediatrics, 9th Edition</i>  |  '
        'RGUHS MBBS Phase III Part II CBME  |  QP Code: 1044  |  March 2024  |  Max Marks: 100',
        note_s),
]

# ── Build PDF ──────────────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    '/home/daytona/workspace/rguhs-paediatrics/RGUHS_Paediatrics_QP1044_ModelAnswers.pdf',
    pagesize=A4,
    rightMargin=1.8*cm, leftMargin=1.8*cm,
    topMargin=2.2*cm, bottomMargin=1.6*cm,
    title='RGUHS Paediatrics QP 1044 - March 2024 Model Answers',
    author='Ghai Essential Pediatrics'
)

doc.build(story, onFirstPage=on_page, onLaterPages=on_page)
print("PDF created successfully!")

cd /home/daytona/workspace/rguhs-paediatrics && python3 create_pdf.py 2>&1

~/rguhs-paediatrics/create_pdf.py

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/rguhs-paediatrics/create_pdf.py'

cd /home/daytona/workspace/rguhs-paediatrics && python3 create_pdf.py 2>&1

ls -lh /home/daytona/workspace/rguhs-paediatrics/*.pdf && python3 -c " from pypd…