mkdir -p /home/daytona/workspace/bds-exam && ls /home/daytona/workspace/bds-exam…

~/bds-exam/generate_exam_answers.py

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

OUTPUT = "/home/daytona/workspace/bds-exam/BDS_Third_Year_General_Medicine_Answers.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=2*cm,
    leftMargin=2*cm,
    topMargin=2.5*cm,
    bottomMargin=2*cm,
)

styles = getSampleStyleSheet()

# Custom styles
title_style = ParagraphStyle(
    'CustomTitle', parent=styles['Title'],
    fontSize=15, textColor=colors.HexColor('#1a237e'),
    spaceAfter=4, alignment=TA_CENTER, fontName='Helvetica-Bold'
)
subtitle_style = ParagraphStyle(
    'SubTitle', parent=styles['Normal'],
    fontSize=11, textColor=colors.HexColor('#283593'),
    spaceAfter=2, alignment=TA_CENTER, fontName='Helvetica'
)
section_style = ParagraphStyle(
    'SectionHead', parent=styles['Normal'],
    fontSize=13, textColor=colors.white,
    spaceBefore=10, spaceAfter=6,
    backColor=colors.HexColor('#1a237e'),
    leftPadding=8, fontName='Helvetica-Bold',
    borderPad=4
)
q_style = ParagraphStyle(
    'Question', parent=styles['Normal'],
    fontSize=11, textColor=colors.HexColor('#b71c1c'),
    spaceBefore=10, spaceAfter=4,
    fontName='Helvetica-Bold', leftIndent=0
)
h2_style = ParagraphStyle(
    'H2', parent=styles['Normal'],
    fontSize=10.5, textColor=colors.HexColor('#1565c0'),
    spaceBefore=7, spaceAfter=2,
    fontName='Helvetica-Bold'
)
body_style = ParagraphStyle(
    'Body', parent=styles['Normal'],
    fontSize=9.5, textColor=colors.HexColor('#212121'),
    spaceBefore=2, spaceAfter=2,
    leading=14, alignment=TA_JUSTIFY,
    fontName='Helvetica'
)
bullet_style = ParagraphStyle(
    'Bullet', parent=styles['Normal'],
    fontSize=9.5, textColor=colors.HexColor('#212121'),
    spaceBefore=1, spaceAfter=1,
    leftIndent=14, leading=13,
    fontName='Helvetica', bulletIndent=6
)
marks_style = ParagraphStyle(
    'Marks', parent=styles['Normal'],
    fontSize=9, textColor=colors.HexColor('#558b2f'),
    alignment=TA_LEFT, fontName='Helvetica-BoldOblique'
)

def H(text, style=h2_style): return Paragraph(text, style)
def P(text): return Paragraph(text, body_style)
def B(text): return Paragraph(f'• {text}', bullet_style)
def Q(text): return Paragraph(text, q_style)
def S(n=6): return Spacer(1, n)
def HR(): return HRFlowable(width="100%", thickness=0.5, color=colors.HexColor('#90caf9'))

story = []

# ── HEADER ─────────────────────────────────────────────────────────────────
story += [
    Paragraph("B.D.S. Third Year (Remanded) Examination, February 2026", subtitle_style),
    Paragraph("GENERAL MEDICINE — Paper I", title_style),
    Paragraph("Model Answer Book", subtitle_style),
    S(4),
    HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1a237e')),
    S(4),
    Paragraph("Time: 3 Hours  |  Maximum Marks: 70  |  Section A: 35 Marks  |  Section B: 35 Marks",
              ParagraphStyle('info', parent=styles['Normal'], fontSize=9.5, alignment=TA_CENTER,
                             textColor=colors.HexColor('#555555'))),
    S(6),
]

# ══════════════════════════════════════════════════════════════════════
# SECTION A
# ══════════════════════════════════════════════════════════════════════
story.append(Paragraph("SECTION — A", section_style))
story.append(S(8))

# ─── Q1 ───
story += [
    Q("Q.1  What are the causes of Anasarca? How do you approach a patient of Anasarca?  [10 Marks]"),
    HR(), S(4),

    H("Definition"),
    P("Anasarca is massive generalised oedema involving the skin, subcutaneous tissues, serous cavities (pleural, peritoneal, pericardial), and often the lungs. It indicates a severe, systemic fluid overload state."),
    S(4),

    H("Pathophysiology of Oedema Formation"),
    P("Oedema forms when one or more of the Starling forces is disturbed:"),
    B("Increased capillary hydrostatic pressure (e.g., heart failure, portal hypertension)"),
    B("Decreased plasma oncotic pressure due to hypoalbuminaemia"),
    B("Increased capillary permeability (inflammation, sepsis, capillary leak)"),
    B("Impaired lymphatic drainage (lymphoedema, filariasis)"),
    B("Sodium and water retention (renal failure, RAAS activation)"),
    S(4),

    H("Causes of Anasarca — Mnemonic: CCRILH"),
    H("1. Cardiac Causes"),
    B("Congestive heart failure (right-sided or biventricular) — most common"),
    B("Constrictive pericarditis"),
    B("Restrictive cardiomyopathy"),
    S(2),
    H("2. Renal Causes"),
    B("Nephrotic syndrome (massive proteinuria >3.5 g/day → hypoalbuminaemia)"),
    B("Acute nephritic syndrome"),
    B("Chronic kidney disease / end-stage renal disease"),
    S(2),
    H("3. Hepatic Causes"),
    B("Liver cirrhosis with portal hypertension"),
    B("Acute liver failure"),
    B("Hepatic venous outflow obstruction (Budd-Chiari syndrome)"),
    S(2),
    H("4. Nutritional / Hypoproteinaemic"),
    B("Kwashiorkor (protein-energy malnutrition)"),
    B("Malabsorption syndromes (Crohn's disease, coeliac disease)"),
    B("Protein-losing enteropathy"),
    B("Severe burns (exudative protein loss)"),
    S(2),
    H("5. Endocrine"),
    B("Myxoedema (hypothyroidism) — non-pitting oedema"),
    B("Cushing's syndrome"),
    S(2),
    H("6. Iatrogenic / Miscellaneous"),
    B("Calcium channel blockers, NSAIDs, corticosteroids, thiazolidinediones"),
    B("Idiopathic oedema"),
    B("Severe anaemia (high-output heart failure)"),
    S(4),

    H("Approach to a Patient with Anasarca"),
    H("History"),
    B("Onset (sudden vs. insidious), duration, progression"),
    B("Associated symptoms: dyspnoea, orthopnoea, PND (cardiac); frothy urine (nephrotic); jaundice, abdominal swelling (hepatic); weight gain or loss"),
    B("Drug history, dietary intake, prior renal or cardiac disease"),
    S(2),
    H("Physical Examination"),
    B("General: degree of oedema, pitting vs non-pitting, skin changes"),
    B("Cardiovascular: raised JVP, S3 gallop, displaced apex — CHF"),
    B("Respiratory: pleural effusion, crackles — cardiac/hepatic/renal"),
    B("Abdomen: ascites (shifting dullness, fluid thrill), hepatosplenomegaly"),
    B("Urine: frothy urine → proteinuria (nephrotic)"),
    S(2),
    H("Investigations"),
    B("Urine: routine, microscopy, 24-hr protein, spot urine protein:creatinine ratio"),
    B("Blood: CBC, serum albumin, total protein, LFTs, RFTs, serum electrolytes, blood glucose, TSH"),
    B("Serum lipids (elevated in nephrotic syndrome)"),
    B("ECG, chest X-ray, echocardiography (cardiac causes)"),
    B("Abdominal ultrasound (liver disease, ascites)"),
    B("Renal biopsy if nephrotic syndrome suspected"),
    S(2),
    H("Management Principles"),
    B("Treat the underlying cause (diuretics, ACE inhibitors for CHF; steroids for minimal change disease; albumin infusion in severe hypoalbuminaemia)"),
    B("Sodium restriction (<2 g/day) and fluid restriction"),
    B("Loop diuretics: furosemide 20–80 mg/day (first-line)"),
    B("Add spironolactone for hepatic/refractory oedema"),
    B("Monitor urine output, daily weight, electrolytes"),
    S(10),
]

# ─── Q2 ───
story += [
    Q("Q.2  What is Infective Endocarditis? Clinical Features, Diagnostic Criteria, and Dental Management?  [10 Marks]"),
    HR(), S(4),

    H("Definition"),
    P("Infective endocarditis (IE) is a microbial infection of the endocardial surface of the heart, primarily the cardiac valves. It is characterised by vegetations — masses of fibrin, platelets, and microorganisms deposited on valve leaflets."),
    S(4),

    H("Aetiology / Microbiology"),
    B("Viridans group streptococci (S. mutans, S. sanguis) — most common after dental procedures"),
    B("Staphylococcus aureus — most virulent; IV drug users, prosthetic valves"),
    B("Enterococcus species — GI/GU source"),
    B("HACEK organisms — Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella"),
    B("Fungi (Candida) — immunocompromised, IV catheters"),
    S(4),

    H("Clinical Features"),
    H("Systemic Features"),
    B("Fever (most constant sign), night sweats, malaise, weight loss, fatigue"),
    B("Anaemia of chronic disease"),
    S(2),
    H("Cardiac Features"),
    B("New or changing cardiac murmur (regurgitant murmur in >85%)"),
    B("Signs of heart failure (dyspnoea, oedema, elevated JVP)"),
    B("Pericarditis, conduction abnormalities (abscess)"),
    S(2),
    H("Embolic / Immunologic Features (Peripheral Stigmata)"),
    B("Osler's nodes — painful, tender nodules on finger/toe pads (immune complex)"),
    B("Janeway lesions — painless haemorrhagic macules on palms/soles (septic emboli)"),
    B("Splinter haemorrhages — linear dark streaks under fingernails"),
    B("Roth spots — oval retinal haemorrhages with pale centre"),
    B("Petechiae — conjunctival, palatal, or skin"),
    B("Splenomegaly"),
    B("Clubbing (chronic cases)"),
    B("Stroke / TIA / embolic events"),
    S(4),

    H("Diagnostic Criteria — Modified Duke Criteria"),
    H("Major Criteria"),
    B("Positive blood cultures: typical organisms (viridans streptococci, S. aureus, HACEK) in ≥2 separate cultures, or persistently positive cultures"),
    B("Echocardiographic evidence: oscillating intracardiac mass (vegetation) on valve/supporting structures, abscess, new partial dehiscence of prosthetic valve, or new valvular regurgitation"),
    S(2),
    H("Minor Criteria"),
    B("Predisposing cardiac condition or IV drug use"),
    B("Fever ≥38°C"),
    B("Vascular phenomena (emboli, septic infarcts, Janeway lesions, conjunctival haemorrhages)"),
    B("Immunological phenomena (glomerulonephritis, Osler nodes, Roth spots, positive rheumatoid factor)"),
    B("Positive blood cultures not meeting major criteria"),
    S(2),
    H("Diagnosis:"),
    B("Definite IE = 2 major, or 1 major + 3 minor, or 5 minor criteria"),
    B("Possible IE = 1 major + 1 minor, or 3 minor criteria"),
    S(4),

    H("Management"),
    H("Medical"),
    B("IV antibiotics for 4–6 weeks (penicillin G + gentamicin for streptococcal; vancomycin for MRSA; ampicillin + gentamicin for enterococcal)"),
    B("Blood cultures x3 before starting antibiotics"),
    S(2),
    H("Surgical Indications"),
    B("Severe valvular regurgitation with heart failure"),
    B("Persistent bacteraemia despite antibiotics"),
    B("Large vegetations (>10 mm) with embolic risk"),
    B("Abscess formation, prosthetic valve involvement"),
    S(2),
    H("Dental Management of a Patient with IE"),
    H("Pre-operative (Antibiotic Prophylaxis)"),
    P("The AHA 2021 guidelines recommend antibiotic prophylaxis before invasive dental procedures in HIGH-RISK patients:"),
    B("Prosthetic cardiac valve or valve repair material"),
    B("Prior history of IE"),
    B("Congenital heart disease (unrepaired cyanotic CHD; repaired CHD within 6 months; repaired with residual defects)"),
    B("Cardiac transplant with valvulopathy"),
    H("Prophylaxis Regimen:"),
    B("Amoxicillin 2 g PO 30–60 min before procedure (adults)"),
    B("Penicillin allergy: Azithromycin/Clarithromycin 500 mg PO, or Doxycycline 100 mg PO"),
    B("Unable to take oral: Ampicillin 2 g IV/IM"),
    H("Dental Treatment Principles:"),
    B("Maintain excellent oral hygiene to reduce bacteraemia from daily activities"),
    B("Avoid invasive procedures during active IE (postpone elective dental work)"),
    B("If urgent treatment required during active IE: give appropriate IV antibiotics, work with cardiologist"),
    B("Prefer procedures that cause minimal tissue trauma"),
    B("Use antiseptic mouthrinse (chlorhexidine 0.12%) pre-operatively"),
    S(10),
]

# ─── Q3 ───
story += [
    Q("Q.3  Enumerate Various Causes of Dyspnoea. How will you manage a case of Acute Pulmonary Oedema?  [10 Marks]"),
    HR(), S(4),

    H("Definition of Dyspnoea"),
    P("Dyspnoea is the subjective sensation of uncomfortable or difficult breathing, disproportionate to the level of exertion. It ranges from mild breathlessness on exertion to severe rest dyspnoea."),
    S(4),

    H("Causes of Dyspnoea (Mnemonic: 'CARDIAC PULM ANES')"),
    H("Cardiac Causes"),
    B("Left ventricular failure / Congestive cardiac failure"),
    B("Acute myocardial infarction"),
    B("Cardiac tamponade"),
    B("Severe valvular disease (mitral stenosis, aortic stenosis)"),
    B("Arrhythmias (atrial fibrillation, SVT)"),
    S(2),
    H("Pulmonary Causes"),
    B("Acute: Pulmonary embolism, tension pneumothorax, acute severe asthma, ARDS"),
    B("Chronic: COPD, chronic asthma, interstitial lung disease, pulmonary hypertension"),
    B("Pleural: Pleural effusion, pneumothorax"),
    B("Infection: Pneumonia, lung abscess, TB"),
    S(2),
    H("Anaemia and Haematological"),
    B("Severe anaemia (Hb <7 g/dL)"),
    B("Methaemoglobinaemia, carbon monoxide poisoning"),
    S(2),
    H("Neuromuscular"),
    B("Guillain-Barré syndrome, myasthenia gravis"),
    B("Phrenic nerve palsy, diaphragmatic paralysis"),
    S(2),
    H("Metabolic"),
    B("Diabetic ketoacidosis (Kussmaul breathing)"),
    B("Uraemia, hepatic encephalopathy, lactic acidosis"),
    S(2),
    H("Others"),
    B("Obesity-hypoventilation syndrome"),
    B("Anxiety/panic attack (psychogenic dyspnoea)"),
    B("Superior vena cava obstruction"),
    S(4),

    H("Acute Pulmonary Oedema — Management"),
    H("Pathophysiology"),
    P("Acute pulmonary oedema (APO) results from sudden elevation of pulmonary capillary pressure (>25 mmHg), causing fluid transudation into the alveoli, impairing gas exchange, and causing severe hypoxia and respiratory distress."),
    S(2),
    H("Emergency Management — 'LMNOP'"),
    B("L — Lasix (Furosemide): IV 40–80 mg stat; relieves preload and promotes diuresis"),
    B("M — Morphine: 2–4 mg IV slowly; reduces anxiety, preload, and sympathetic drive (use cautiously)"),
    B("N — Nitrates: GTN 0.4–0.8 mg sublingual, or IV nitroglycerine infusion; reduces preload and afterload"),
    B("O — Oxygen: High-flow O2 by non-rebreather mask (10–15 L/min); target SpO2 >95%"),
    B("P — Position: Sit patient upright (legs dependent) to reduce venous return and preload"),
    S(2),
    H("Additional Measures"),
    B("Non-invasive positive pressure ventilation (CPAP or BiPAP) if SpO2 <90% despite O2"),
    B("IV access: Insert 2 large-bore cannulae; restrict oral intake"),
    B("Monitor: Continuous ECG, pulse oximetry, BP every 15 min, urine output via catheter"),
    B("Treat precipitating cause: AMI (thrombolysis/PCI), hypertensive emergency (IV labetalol/nitroprusside), arrhythmia (cardioversion), sepsis (antibiotics)"),
    B("Dobutamine 2–20 mcg/kg/min IV if cardiogenic shock coexists (low BP, cold peripheries)"),
    B("Intubation and mechanical ventilation if above measures fail (ARDS-like situation)"),
    S(2),
    H("Investigations to Identify Cause"),
    B("ECG: ST elevation (AMI), AF, LVH"),
    B("CXR: Bat-wing perihilar opacities, Kerley B lines, cardiomegaly"),
    B("ABG: Hypoxia, respiratory alkalosis initially → acidosis if severe"),
    B("BNP/NT-proBNP: Elevated (>100 pg/mL) confirms cardiac origin"),
    B("Echo: LV function, valvular disease, pericardial effusion"),
    B("Troponin, CBC, RFTs, electrolytes"),
    S(10),
]

# ─── Q4 ───
story += [
    Q("Q.4  Write Short Note on (Any Three):  [15 Marks]"),
    HR(), S(4),
]

story += [
    H("(a) Clinical Features of Hyperthyroidism"),
    P("Hyperthyroidism is a state of excess thyroid hormone, most commonly due to Graves' disease, toxic multinodular goitre, or solitary toxic adenoma."),
    S(2),
    H("Symptoms:"),
    B("Heat intolerance, excessive sweating"),
    B("Weight loss despite increased appetite (hyperphagia)"),
    B("Palpitations, tachycardia, even atrial fibrillation"),
    B("Tremor of hands (fine tremor)"),
    B("Nervousness, anxiety, irritability, emotional lability"),
    B("Fatigue and proximal muscle weakness (thyrotoxic myopathy)"),
    B("Increased stool frequency / diarrhoea"),
    B("Oligomenorrhoea / amenorrhoea in women"),
    B("Lid lag and lid retraction (sympathetic stimulation)"),
    S(2),
    H("Signs:"),
    B("Tachycardia (resting HR >90), bounding pulse, widened pulse pressure"),
    B("Warm, moist, smooth skin; fine hair; onycholysis (Plummer's nails)"),
    B("Goitre (diffuse in Graves', nodular in toxic MNG)"),
    B("Exophthalmos / proptosis (Graves' disease — due to retro-orbital infiltration)"),
    B("Pretibial myxoedema (Graves' disease)"),
    B("Thyroid bruit (increased vascularity)"),
    B("Atrial fibrillation, high-output heart failure"),
    B("Thyroid acropachy (rare — clubbing with periosteal new bone formation)"),
    S(2),
    H("Investigations: TSH ↓, Free T3/T4 ↑, TSHR antibodies (Graves'), thyroid scan, radioiodine uptake"),
    H("Treatment: Anti-thyroid drugs (carbimazole/methimazole, propylthiouracil), beta-blockers (propranolol for symptoms), radioiodine ablation, surgery (thyroidectomy)"),
    S(6),

    H("(b) Fallot's Tetralogy"),
    P("Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart disease, accounting for ~10% of all CHD."),
    S(2),
    H("Four Components (Mnemonic: PROVE or HOPS):"),
    B("1. Pulmonary stenosis (infundibular/valvular) — most important determinant of severity"),
    B("2. Overriding aorta — aorta 'straddles' the ventricular septal defect"),
    B("3. Ventricular septal defect (VSD) — large, subarterial perimembranous"),
    B("4. Right ventricular hypertrophy (RVH) — due to outflow obstruction"),
    S(2),
    H("Pathophysiology:"),
    P("Pulmonary stenosis → RV pressure overload → right-to-left shunt through VSD (especially during increased systemic vascular resistance) → deoxygenated blood enters aorta → cyanosis"),
    S(2),
    H("Clinical Features:"),
    B("Central cyanosis from birth or infancy"),
    B("Clubbing of fingers and toes"),
    B("Polycythaemia (compensatory)"),
    B("Squatting posture (increases SVR, reduces right-to-left shunt, improves oxygenation)"),
    B("Hypercyanotic 'Tet spells' — sudden, severe cyanosis + hyperpnoea + syncope on exertion"),
    B("Ejection systolic murmur at left sternal border (pulmonary stenosis)"),
    B("Single S2 (pulmonary component absent/soft)"),
    S(2),
    H("Investigations:"),
    B("ECG: Right axis deviation, RVH"),
    B("CXR: Boot-shaped heart (coeur en sabot) — elevated apex due to RVH, oligaemic lung fields"),
    B("Echo: Confirmatory — shows all four defects"),
    B("Cardiac catheterisation: Pre-surgical haemodynamic assessment"),
    S(2),
    H("Treatment:"),
    B("Emergency: Tet spells — knee-chest position, O2, morphine, IV propranolol, phenylephrine"),
    B("Definitive: Complete surgical repair (VSD closure + relief of RVOTO) ideally at 3–6 months"),
    B("Palliative: Blalock-Taussig shunt (subclavian to pulmonary artery anastomosis) in severe cases"),
    S(6),

    H("(c) Basic Life Support (BLS)"),
    P("BLS is the immediate emergency care provided to a victim of cardiac arrest or airway obstruction to maintain circulation and oxygenation until advanced care is available."),
    S(2),
    H("Chain of Survival (AHA 2020 Guidelines)"),
    B("Early recognition and activation of emergency response system (call for help / dial 108)"),
    B("Early high-quality CPR"),
    B("Rapid defibrillation"),
    B("Advanced resuscitation (ACLS)"),
    B("Post-cardiac arrest care"),
    S(2),
    H("BLS Steps — CAB Approach (Adults):"),
    B("CHECK: Ensure scene safety → Check consciousness (tap shoulders, call loudly)"),
    B("CALL: If unresponsive and no normal breathing → Activate EMS (call 108), get AED"),
    B("C — CIRCULATION (Chest Compressions):"),
    P("  Position: Heel of hand on lower half of sternum, arms straight"),
    P("  Rate: 100–120 compressions per minute"),
    P("  Depth: At least 5 cm (2 inches), allow full chest recoil"),
    P("  Ratio: 30 compressions : 2 rescue breaths (30:2)"),
    B("A — AIRWAY: Head-tilt chin-lift manoeuvre to open airway"),
    B("B — BREATHING: 2 rescue breaths (1 second each), chest should rise visibly"),
    B("D — DEFIBRILLATION: Apply AED as soon as available; follow prompts; resume CPR immediately after shock"),
    S(2),
    H("Continue CPR until:"),
    B("ROSC (Return of Spontaneous Circulation — pulse present, patient breathing normally)"),
    B("Advanced help arrives"),
    B("Victim shows signs of life"),
    B("Rescuer is exhausted"),
    S(2),
    H("Modifications:"),
    B("Infant BLS: 2-finger technique, 4 cm depth, ratio 30:2 (1 rescuer) or 15:2 (2 healthcare providers)"),
    B("Compression-only CPR: Acceptable for untrained bystanders"),
    S(6),

    H("(d) Management of Empyema"),
    P("Empyema thoracis is the accumulation of pus in the pleural space. It typically complicates pneumonia (parapneumonic effusion) but can follow surgery, trauma, or haematogenous spread."),
    S(2),
    H("Stages (Light's Criteria for Pleural Fluid):"),
    B("Stage I — Exudative: Thin, free-flowing fluid with low viscosity; responds to antibiotics + drainage"),
    B("Stage II — Fibrinopurulent: Fibrin deposition, loculations form; requires drainage + fibrinolytics"),
    B("Stage III — Organising: Dense fibrous peel encases lung (trapped lung); requires surgery"),
    S(2),
    H("Investigations:"),
    B("CXR / CT chest: Confirm pleural fluid, estimate volume, detect loculations"),
    B("Diagnostic pleural tap: Frank pus, pH <7.2, glucose <2.2 mmol/L, LDH >1000 IU/L, WBC >50,000"),
    B("Culture and sensitivity of pleural fluid"),
    B("Blood cultures, CBC, CRP, LFTs, RFTs"),
    S(2),
    H("Management:"),
    H("Antibiotics:"),
    B("Empirical: IV amoxicillin-clavulanate + metronidazole, or piperacillin-tazobactam (4–6 weeks)"),
    B("Modify based on culture sensitivity; MRSA: add vancomycin/linezolid"),
    H("Drainage (Mandatory for Frank Empyema):"),
    B("Stage I: Needle aspiration or small-bore chest tube (14–16 Fr)"),
    B("Stage II: Intercostal drain (28–32 Fr) + intrapleural fibrinolytics (streptokinase or alteplase + DNase)"),
    B("Stage III: Video-Assisted Thoracoscopic Surgery (VATS) — decortication of fibrous peel"),
    H("Supportive Care:"),
    B("Nutritional support, physiotherapy, analgesia"),
    B("Monitor drain output, daily CXR, inflammatory markers"),
    H("Surgical Options:"),
    B("Open thoracotomy with decortication for failed VATS or chronic organising empyema"),
    S(10),
]

# PAGE BREAK for Section B
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════════
# SECTION B
# ══════════════════════════════════════════════════════════════════════
story.append(Paragraph("SECTION — B", section_style))
story.append(S(8))

# ─── Q5 ───
story += [
    Q("Q.5  Describe the Clinical Features, Diagnosis and Management of Pneumococcal Pneumonia.  [10 Marks]"),
    HR(), S(4),

    H("Definition"),
    P("Pneumococcal pneumonia is an acute bacterial infection of the lung parenchyma caused by Streptococcus pneumoniae (the pneumococcus). It is the leading cause of community-acquired pneumonia (CAP) worldwide."),
    S(4),

    H("Pathogenesis"),
    P("S. pneumoniae colonises the nasopharynx. Aspiration of secretions → lower respiratory tract infection → lobar or segmental consolidation (4 stages: congestion → red hepatisation → grey hepatisation → resolution)."),
    S(4),

    H("Clinical Features"),
    H("Symptoms"),
    B("Acute onset with rigors followed by sustained high fever (38.5–40°C)"),
    B("Productive cough with rusty-coloured (rust coloured) or 'prune juice' sputum"),
    B("Pleuritic chest pain (sharp, worsened by breathing and coughing)"),
    B("Dyspnoea and tachypnoea"),
    B("Herpes labialis (cold sores) — seen in ~40% of pneumococcal pneumonia"),
    B("Headache, myalgia, malaise"),
    B("In elderly: confusion, altered sensorium may be presenting feature"),
    S(2),
    H("Signs"),
    B("Fever (>38°C), tachycardia, tachypnoea (RR >20/min)"),
    B("Low oxygen saturation (SpO2 <94%)"),
    B("Classical consolidation signs:"),
    P("  - Reduced chest expansion on affected side"),
    P("  - Increased tactile vocal fremitus"),
    P("  - Dull percussion note"),
    P("  - Bronchial breathing"),
    P("  - Increased vocal resonance / whispering pectoriloquy"),
    B("Crepitations over affected lobe"),
    B("Pleural rub (if pleuritis present)"),
    S(4),

    H("Investigations"),
    H("Blood"),
    B("CBC: Leukocytosis (WBC >12,000 cells/μL) with neutrophilia"),
    B("CRP, ESR markedly elevated"),
    B("Blood culture: positive in ~25% of cases (MANDATORY before antibiotics)"),
    B("ABG: Hypoxia (PaO2 <60 mmHg), respiratory alkalosis"),
    B("LFTs, RFTs, electrolytes"),
    S(2),
    H("Sputum"),
    B("Gram stain: Gram-positive diplococci"),
    B("Culture and sensitivity: S. pneumoniae"),
    B("Sputum AFB (rule out TB if atypical features)"),
    S(2),
    H("Radiology"),
    B("Chest X-ray: Homogeneous lobar or segmental consolidation (classically lower lobe right-sided)"),
    B("Air bronchograms within consolidation"),
    B("CT chest: For complicated cases, distinguish empyema from effusion, lung abscess"),
    S(2),
    H("Others"),
    B("Urinary pneumococcal antigen test: Sensitive (70–80%), specific, rapid"),
    B("Pulse oximetry: Continuous monitoring"),
    S(4),

    H("Severity Assessment — CURB-65 Score"),
    B("C — Confusion (new onset)"),
    B("U — Urea >7 mmol/L"),
    B("R — Respiratory rate ≥30/min"),
    B("B — Blood pressure <90 systolic or ≤60 diastolic"),
    B("65 — Age ≥65 years"),
    P("Score 0–1: Home treatment | Score 2: Hospital admission | Score ≥3: ICU consideration"),
    S(4),

    H("Management"),
    H("Antibiotic Therapy (Mainstay)"),
    B("Empirical (mild-moderate): Amoxicillin 500 mg–1 g PO TDS × 5–7 days"),
    B("Penicillin-resistant strains: Amoxicillin-clavulanate, or Levofloxacin 500 mg OD"),
    B("Severe/ICU: IV Ceftriaxone 1–2 g OD + Azithromycin, or IV Levofloxacin"),
    B("Confirm sensitivity and narrow once culture results available"),
    S(2),
    H("Supportive Care"),
    B("Oxygen supplementation: Target SpO2 >94% (>88–92% in COPD)"),
    B("IV fluids if dehydrated (especially if not tolerating orals)"),
    B("Antipyretics (paracetamol 1 g QID) and analgesics for pleuritic pain"),
    B("Chest physiotherapy to aid expectoration"),
    B("Bronchodilators if wheeze present"),
    S(2),
    H("Complications to Monitor"),
    B("Parapneumonic effusion / empyema (chest drain if required)"),
    B("Lung abscess, bacteraemia, meningitis"),
    B("Respiratory failure (mechanical ventilation if PaO2 <55 mmHg on O2)"),
    B("Septic shock"),
    S(2),
    H("Prevention"),
    B("Pneumococcal vaccines: PCV13 (conjugate) for children <2 yrs and high-risk adults; PPSV23 (polysaccharide) for adults ≥65 and high-risk groups"),
    B("Annual influenza vaccination (reduces secondary bacterial pneumonia)"),
    B("Smoking cessation"),
    S(10),
]

# ─── Q6 ───
story += [
    Q("Q.6  Describe the Oral Manifestations of Systemic Diseases.  [10 Marks]"),
    HR(), S(4),

    H("Introduction"),
    P("The oral cavity is a mirror of systemic health. Many systemic diseases produce characteristic changes in the oral mucosa, gingiva, tongue, salivary glands, or periodontium. Recognition of these signs aids in early diagnosis."),
    S(4),

    H("1. Cardiovascular Diseases"),
    B("Infective endocarditis: Petechiae on the palate; poor dental hygiene is a risk factor"),
    B("Cyanotic heart disease: Central cyanosis of lips and oral mucosa, gingival hypertrophy"),
    B("Drug-induced gingival enlargement: Calcium channel blockers (nifedipine), amlodipine"),
    S(4),

    H("2. Gastrointestinal Diseases"),
    B("Crohn's disease: Cobblestone mucosa, deep linear ulcers, lip swelling, perioral tags, angular cheilitis"),
    B("Ulcerative colitis: Aphthous-like ulcers, pyostomatitis vegetans (rare)"),
    B("Coeliac disease: Recurrent aphthous ulcers, enamel hypoplasia"),
    B("Pernicious anaemia / Gastric atrophy: Smooth beefy-red tongue (Hunter's/Moeller's glossitis)"),
    B("Reflux (GERD): Dental erosion on the palatal surfaces of upper teeth"),
    S(4),

    H("3. Haematological Diseases"),
    B("Iron deficiency anaemia: Angular stomatitis (cheilitis), smooth pale tongue, glossitis, Plummer-Vinson syndrome (dysphagia + glossitis + iron deficiency)"),
    B("Vitamin B12 / Folate deficiency: Glossitis — smooth, red tongue (atrophic), burning sensation"),
    B("Leukaemia: Gingival hypertrophy and spontaneous gingival bleeding (especially acute monocytic AML), petechiae, ulcers, opportunistic infections, pallor"),
    B("Thrombocytopaenia: Spontaneous gingival bleeding, petechiae, ecchymoses on mucosa"),
    B("Haemophilia: Prolonged post-extraction bleeding, deep haematomas"),
    S(4),

    H("4. Endocrine Diseases"),
    B("Diabetes mellitus: Recurrent oral candidiasis, xerostomia (dry mouth), accelerated periodontitis, delayed wound healing, burning mouth syndrome"),
    B("Hypothyroidism: Macroglossia (enlarged tongue), puffiness of lips, delayed eruption of teeth"),
    B("Hyperthyroidism: Early eruption, osteoporosis of jaw bones, increased caries risk"),
    B("Addison's disease (adrenocortical insufficiency): Diffuse brownish-black pigmentation of oral mucosa, gingiva, and lips (characteristic)"),
    B("Hypoparathyroidism: Enamel hypoplasia, dental hypoplasia (if childhood onset), orofacial tetany"),
    S(4),

    H("5. Connective Tissue / Autoimmune Diseases"),
    B("Systemic lupus erythematosus (SLE): Painless oral ulcers, discoid lesions, 'butterfly rash' involvement of lips"),
    B("Rheumatoid arthritis: Temporomandibular joint (TMJ) involvement — pain, limitation of mouth opening; xerostomia (Sjogren overlap)"),
    B("Sjögren's syndrome: Severe xerostomia (dry mouth), salivary gland enlargement, rampant caries, oral candidiasis, red fissured tongue"),
    B("Scleroderma: Microstomia (limited mouth opening), widened periodontal ligament space on X-ray, resorption of mandibular angles, smooth taut skin around mouth"),
    S(4),

    H("6. Nutritional Deficiencies"),
    B("Vitamin C deficiency (Scurvy): Spongy, haemorrhagic, swollen gingiva; spontaneous gingival bleeding; perifollicular haemorrhages"),
    B("Vitamin B3 deficiency (Pellagra): Glossitis, stomatitis, angular cheilitis ('3 Ds': dermatitis, diarrhoea, dementia)"),
    B("Vitamin B2 (Riboflavin): Angular stomatitis, magenta-coloured tongue"),
    B("Niacin deficiency: Red swollen tongue, ulcerative stomatitis"),
    S(4),

    H("7. Infections"),
    B("HIV/AIDS: Oral candidiasis (pseudomembranous, erythematous), hairy leukoplakia (EBV), Kaposi sarcoma (red-purple lesions on palate), aphthous ulcers, periodontal disease (ANUG, NUP)"),
    B("Herpes simplex: Primary herpetic gingivostomatitis — fever, multiple vesicles on gingiva, palate, tongue → burst → painful ulcers; Recurrent: herpes labialis (cold sores)"),
    B("Tuberculosis: Rare; painless irregular ulcers on dorsum of tongue"),
    B("Syphilis: Primary — painless chancre on lip/tongue; Secondary — mucous patches, condylomata lata; Tertiary — gumma of palate"),
    S(4),

    H("8. Dermatological Diseases"),
    B("Lichen planus: White Wickham's striae, erosive ulcers on buccal mucosa, gingival desquamation"),
    B("Pemphigus vulgaris: Painful erosions and ulcers on oral mucosa; positive Nikolsky sign; often presents orally before skin"),
    B("Stevens-Johnson syndrome / TEN: Haemorrhagic crusting of lips, extensive oral ulcers and erosions"),
    S(10),
]

# ─── Q7 ───
story += [
    Q("Q.7  Discuss Various Causes of Anaemia. How will you Approach and Treat a Patient of Aplastic Anaemia?  [10 Marks]"),
    HR(), S(4),

    H("Definition of Anaemia"),
    P("Anaemia is defined as a reduction in haemoglobin concentration below the normal range for age and sex: Hb <13 g/dL in adult males, <12 g/dL in adult females, and <11 g/dL in pregnant women (WHO criteria)."),
    S(4),

    H("Classification of Anaemia by Pathophysiology"),
    H("1. Decreased Production (Hypoproliferative)"),
    B("Nutritional deficiency: Iron, Vitamin B12, Folate"),
    B("Aplastic anaemia (bone marrow failure)"),
    B("Anaemia of chronic disease (renal failure, chronic inflammation, malignancy)"),
    B("Pure red cell aplasia"),
    B("Infiltration of bone marrow: Leukaemia, myeloma, metastases"),
    B("Myelodysplastic syndrome (MDS)"),
    S(2),
    H("2. Increased Destruction (Haemolytic Anaemia)"),
    B("Intrinsic RBC defects: G6PD deficiency, hereditary spherocytosis, haemoglobin disorders (sickle cell, thalassaemia)"),
    B("Extrinsic (acquired): Autoimmune haemolytic anaemia (AIHA), TTP, HUS, malaria, hypersplenism, mechanical (prosthetic valves)"),
    S(2),
    H("3. Blood Loss (Haemorrhagic)"),
    B("Acute: Trauma, surgery, GI bleed, ruptured ectopic pregnancy"),
    B("Chronic: Peptic ulcer, colorectal carcinoma, menorrhagia, hookworm infestation"),
    S(4),

    H("Classification by Morphology (MCV)"),
    B("Microcytic (MCV <80 fL): Iron deficiency, thalassaemia, sideroblastic, anaemia of chronic disease"),
    B("Normocytic (MCV 80–100 fL): Aplastic anaemia, haemolytic, acute blood loss, renal failure"),
    B("Macrocytic (MCV >100 fL): B12/folate deficiency, liver disease, hypothyroidism, MDS, drugs (hydroxyurea, methotrexate)"),
    S(4),

    H("Aplastic Anaemia — Definition"),
    P("Aplastic anaemia is a life-threatening bone marrow failure syndrome characterised by peripheral pancytopenia (anaemia, leucopenia, thrombocytopaenia) and a hypocellular bone marrow devoid of haematopoietic precursors, replaced by fat cells."),
    S(4),

    H("Aetiology"),
    B("Idiopathic (most common, ~70%) — immune-mediated T-cell destruction of stem cells"),
    B("Drug-induced: Chloramphenicol (classic), NSAIDs, gold, sulfonamides, carbamazepine, chemotherapy"),
    B("Viral infections: Hepatitis (non-A, non-B, non-C), EBV, CMV, parvovirus B19, HIV"),
    B("Radiation exposure"),
    B("Chemicals: Benzene, insecticides"),
    B("Autoimmune: SLE, eosinophilic fasciitis"),
    B("Inherited: Fanconi anaemia, dyskeratosis congenita"),
    S(4),

    H("Approach to Aplastic Anaemia"),
    H("Clinical Presentation"),
    B("Symptoms of anaemia: Fatigue, pallor, exertional dyspnoea, palpitations"),
    B("Bleeding (thrombocytopaenia): Petechiae, purpura, gingival/nasal bleeding, menorrhagia"),
    B("Infections (neutropaenia): Recurrent bacterial/fungal infections, fever"),
    B("Absent hepatosplenomegaly and lymphadenopathy (distinguishes from leukaemia)"),
    S(2),
    H("Investigations"),
    B("CBC: Pancytopenia — Hb <10 g/dL, WBC <3000/μL, neutrophils <1500/μL, platelets <50,000/μL"),
    B("Peripheral blood film: Normochromic normocytic RBCs, absence of abnormal cells"),
    B("Reticulocyte count: LOW (<1%) — confirms hypoproliferation"),
    B("Bone marrow biopsy (GOLD STANDARD): Hypocellular marrow (<25% cellularity), fat replacement, absence of megakaryocytes"),
    B("Haemoglobin electrophoresis (rule out haemoglobinopathy)"),
    B("PNH clone (CD55/CD59 by flow cytometry) — associated with aplastic anaemia in 30–40%"),
    B("Chromosomal analysis (rule out Fanconi anaemia — chromosomal fragility test)"),
    B("Viral serology: Hepatitis A/B/C, EBV, CMV, HIV, parvovirus B19"),
    B("Imaging: CT chest/abdomen — exclude lymphoma, thymoma"),
    S(2),
    H("Severity Classification (Camitta Criteria)"),
    B("Severe AA (SAA): BM cellularity <25% + 2 of: neutrophils <500/μL, platelets <20,000/μL, reticulocytes <20,000/μL"),
    B("Very Severe AA (vSAA): SAA criteria + neutrophils <200/μL"),
    B("Non-Severe AA (NSAA): Pancytopenia not meeting above criteria"),
    S(4),

    H("Treatment of Aplastic Anaemia"),
    H("1. Definitive Treatment"),
    B("Allogeneic Haematopoietic Stem Cell Transplantation (HSCT) — TREATMENT OF CHOICE for:"),
    P("  - Age <50 years with severe/very severe AA"),
    P("  - Matched sibling donor available"),
    P("  - Success rate 70–90% with matched sibling transplant"),
    S(2),
    H("2. Immunosuppressive Therapy (IST) — for those not eligible for HSCT"),
    B("Anti-thymocyte globulin (ATG) — horse ATG (Atgam) or rabbit ATG (Thymoglobulin): destroys T-cells attacking stem cells"),
    B("Cyclosporine A (CsA): Suppresses autoreactive T-cells; given for 1–2 years"),
    B("Eltrombopag (thrombopoietin receptor agonist): Added to ATG+CsA — significantly improves haematological response"),
    B("Corticosteroids: Prednisone 1 mg/kg/day to prevent serum sickness from ATG"),
    S(2),
    H("3. Supportive Care"),
    B("Red cell transfusions: For symptomatic anaemia (target Hb >8–9 g/dL); use leucodepleted, irradiated products"),
    B("Platelet transfusions: If platelets <10,000/μL or active bleeding"),
    B("G-CSF (Filgrastim): Stimulate neutrophil production, reduce infection risk"),
    B("Antibiotics / Antifungals / Antivirals: Broad-spectrum if febrile neutropaenia (piperacillin-tazobactam + fluconazole)"),
    B("Iron chelation: Deferoxamine/deferasirox for transfusion-related iron overload"),
    B("Avoid offending drugs, blood products from family donors (sensitisation before transplant)"),
    S(10),
]

# ─── Q8 ───
story += [
    Q("Q.8  Write Short Note on (Any Three):  [15 Marks]"),
    HR(), S(4),
]

story += [
    H("(a) Trigeminal Neuralgia"),
    P("Trigeminal neuralgia (tic douloureux) is a chronic pain syndrome characterised by episodic, excruciating, unilateral facial pain along the distribution of the trigeminal nerve (CN V). It is the most common cause of facial pain in adults >50 years."),
    S(2),
    H("Features:"),
    B("Severe, lancinating (shooting/electric shock-like), unilateral facial pain"),
    B("Duration: Seconds to 2 minutes per episode; may occur hundreds of times per day"),
    B("Distribution: Most commonly V2 (maxillary) or V3 (mandibular) division; V1 rare"),
    B("Trigger zones: Light touch on cheek, lip, gum, nose, or vibrations from chewing, talking, tooth brushing, cold wind"),
    B("Pain-free intervals between attacks (paroxysmal pattern)"),
    B("No sensory deficit on examination (if present, suspect secondary cause)"),
    B("Unilateral (bilateral involvement suggests MS)"),
    S(2),
    H("Causes:"),
    B("Classic: Vascular compression of trigeminal nerve root (superior cerebellar artery)"),
    B("Secondary: Multiple sclerosis (demyelination of nerve root), tumours (CPA angle tumours), AVM"),
    S(2),
    H("Investigations:"),
    B("MRI brain with contrast: To rule out structural causes (tumour, MS plaque, vascular loop)"),
    B("MRI CISS/FIESTA sequences: Show neurovascular contact"),
    S(2),
    H("Treatment:"),
    B("First-line: Carbamazepine 100–200 mg TDS (most effective; reduces nerve conduction) — serum levels monitored"),
    B("Second-line: Oxcarbazepine, gabapentin, phenytoin, lamotrigine, baclofen"),
    B("Surgical: Microvascular decompression (MVD — Jannetta procedure), Gamma knife radiosurgery, Percutaneous procedures (glycerol rhizotomy, balloon compression)"),
    B("Dental relevance: Pain mimics toothache; unnecessary extractions performed before diagnosis; avoid trigger during dental procedures"),
    S(6),

    H("(b) Bell's Palsy"),
    P("Bell's palsy is an acute, idiopathic lower motor neurone (LMN) paralysis of the facial nerve (CN VII) of unknown aetiology, presumed to be due to reactivation of Herpes Simplex Virus-1 (HSV-1) in the geniculate ganglion."),
    S(2),
    H("Clinical Features — LMN Facial Palsy:"),
    B("Sudden onset (hours) unilateral facial weakness — entire half of face affected (including forehead)"),
    B("Inability to close the eye → lagophthalmos → exposure keratitis (corneal damage)"),
    B("Flattening of nasolabial fold"),
    B("Drooping of corner of mouth, saliva drooling"),
    B("Inability to whistle, puff cheeks, show teeth"),
    B("Hyperacusis (if stapedius branch involved)"),
    B("Loss of taste on anterior 2/3 of tongue (chorda tympani branch)"),
    B("Periauricular pain"),
    H("Remember: FOREHEAD IS SPARED in UMN facial palsy (bilateral cortical representation); FOREHEAD IS INVOLVED in LMN (Bell's palsy)"),
    S(2),
    H("Investigations:"),
    B("Primarily clinical diagnosis — MRI/CT if atypical features or no improvement"),
    B("EMG/nerve conduction for severity assessment"),
    B("Blood: FBS, LFTs, ANA (rule out secondary causes — DM, sarcoidosis, Lyme)"),
    S(2),
    H("Treatment:"),
    B("Oral prednisolone 60 mg/day × 5 days, then taper (within 72 hours of onset — best results)"),
    B("Antiviral: Acyclovir 400 mg 5 times/day × 10 days OR valacyclovir (add to steroids)"),
    B("Eye care: Lubricating eye drops (hypromellose), tape eye closed at night, moisture chamber"),
    B("Physiotherapy: Facial exercises"),
    P("Prognosis: 80% recover completely within 3 months; worse if complete palsy, age >60, DM."),
    S(6),

    H("(c) Clinical Features of Rheumatoid Arthritis (RA)"),
    P("Rheumatoid arthritis is a chronic systemic autoimmune inflammatory disease characterised by symmetrical polyarthritis, primarily affecting small joints of the hands and feet, with potential extra-articular manifestations."),
    S(2),
    H("Articular Features"),
    B("Symmetrical polyarthritis: PIP, MCP, and wrist joints (sparing DIP joints)"),
    B("Morning stiffness lasting >1 hour (hallmark feature)"),
    B("Swelling, warmth, tenderness of joints"),
    B("Boutonniere deformity (flexion of PIP, extension of DIP)"),
    B("Swan-neck deformity (hyperextension of PIP, flexion of DIP)"),
    B("Ulnar deviation of fingers at MCPJs"),
    B("'Z-deformity' of thumb"),
    B("Atlanto-axial subluxation (C1-C2) — cervical spine involvement"),
    B("Temporomandibular joint involvement in 50-60% — pain, limited mouth opening"),
    S(2),
    H("Extra-articular Features"),
    B("Subcutaneous rheumatoid nodules (pressure points — olecranon, sacrum)"),
    B("Vasculitis — digital infarcts, leg ulcers"),
    B("Respiratory: Pleural effusion, pulmonary fibrosis, rheumatoid nodules in lung"),
    B("Cardiovascular: Pericarditis, accelerated atherosclerosis"),
    B("Ocular: Scleritis, episcleritis, keratoconjunctivitis sicca (secondary Sjögren)"),
    B("Haematological: Anaemia of chronic disease, Felty's syndrome (RA + splenomegaly + neutropaenia)"),
    B("Neurological: Peripheral neuropathy, cervical myelopathy (cord compression)"),
    B("Renal: Secondary amyloidosis"),
    S(2),
    H("Investigations:"),
    B("Rheumatoid factor (RF) — positive in 80%; Anti-CCP antibodies — more specific (>90%)"),
    B("Elevated ESR, CRP (disease activity markers)"),
    B("CBC: Normochromic normocytic anaemia, elevated platelets"),
    B("X-ray hands/feet: Periarticular osteoporosis → joint space narrowing → erosions → deformity"),
    H("ACR/EULAR 2010 Criteria: Score ≥6/10 → definite RA"),
    S(6),

    H("(d) 4 Causes of Massive Splenomegaly"),
    P("Massive splenomegaly is defined as a spleen enlarged beyond the umbilicus or >20 cm in length. Unlike mild splenomegaly, which has many causes, massive splenomegaly has a more limited differential."),
    S(2),
    H("Mnemonic: 'MKLCV'"),
    H("1. Malaria (Chronic Hyperreactive Malarial Splenomegaly / 'Tropical Splenomegaly Syndrome')"),
    B("Due to: Plasmodium vivax or P. malariae in endemic areas"),
    B("Mechanism: Chronic antigenic stimulation → excessive immunological response → RES hyperplasia"),
    B("Features: Massive splenomegaly + elevated IgM + positive malarial antibodies; responds to antimalarials"),
    S(2),
    H("2. Kala-azar (Visceral Leishmaniasis)"),
    B("Due to: Leishmania donovani, transmitted by sandfly (Phlebotomus)"),
    B("Features: Prolonged fever, massive splenomegaly, hepatomegaly, pancytopaenia, wasting"),
    B("Diagnosis: rK39 rapid test, bone marrow/spleen aspirate (LD bodies), PCR"),
    B("Treatment: Liposomal amphotericin B (first-line India), miltefosine"),
    S(2),
    H("3. Chronic Myeloid Leukaemia (CML)"),
    B("Due to: BCR-ABL1 oncogene (Philadelphia chromosome t(9;22))"),
    B("Features: Massive, non-tender splenomegaly; leukocytosis with left shift; elevated basophils; low LAP score"),
    B("Diagnosis: Peripheral smear + bone marrow + FISH/PCR for BCR-ABL"),
    B("Treatment: Imatinib (tyrosine kinase inhibitor) — first-line"),
    S(2),
    H("4. Myelofibrosis (Primary Myelofibrosis)"),
    B("Due to: JAK2 V617F mutation → clonal myeloproliferation → fibrosis of marrow → extramedullary haematopoiesis in spleen and liver"),
    B("Features: Massive splenomegaly, tear-drop cells (dacrocytes) on smear, leukoerythroblastic picture"),
    B("Constitutional symptoms: Night sweats, weight loss, fatigue"),
    B("Diagnosis: BM biopsy (fibrosis, megakaryocyte proliferation) + JAK2 mutation"),
    B("Treatment: Ruxolitinib (JAK1/2 inhibitor), allogeneic HSCT for eligible patients"),
    S(2),
    H("Other Important Causes of Massive Splenomegaly:"),
    B("5. Gaucher's disease (lipid storage disorder — glucocerebrosidase deficiency)"),
    B("6. Thalassaemia major (ineffective erythropoiesis + haemolysis)"),
    B("7. Portal hypertension — usually moderate, rarely massive"),
    S(8),
]

# ── FOOTER / DISCLAIMER ────────────────────────────────────────────────
story += [
    HRFlowable(width="100%", thickness=1.5, color=colors.HexColor('#1a237e')),
    S(4),
    Paragraph(
        "Model Answers — BDS Third Year General Medicine Paper I, February 2026  |  "
        "Prepared with reference to Harrison's Principles of Internal Medicine 22E, "
        "Braunwald's Heart Disease, Davidson's Principles & Practice, "
        "and Murray & Nadel's Respiratory Medicine.",
        ParagraphStyle('footer', parent=styles['Normal'], fontSize=8,
                       textColor=colors.HexColor('#757575'), alignment=TA_CENTER)
    ),
]

doc.build(story)
print("PDF created:", OUTPUT)

cd /home/daytona/workspace/bds-exam && python generate_exam_answers.py

ls -lh /home/daytona/workspace/bds-exam/BDS_Third_Year_General_Medicine_Answers.…