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)

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

OUTPUT = "/home/daytona/workspace/bds-exam/BDS_GM_Oct2025_Model_Answers.pdf"

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

styles = getSampleStyleSheet()

title_style = ParagraphStyle('T', parent=styles['Title'], fontSize=15,
    textColor=colors.HexColor('#1a237e'), spaceAfter=4,
    alignment=TA_CENTER, fontName='Helvetica-Bold')
subtitle_style = ParagraphStyle('S', parent=styles['Normal'], fontSize=11,
    textColor=colors.HexColor('#283593'), spaceAfter=2,
    alignment=TA_CENTER, fontName='Helvetica')
section_style = ParagraphStyle('Sec', 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('Q', parent=styles['Normal'], fontSize=11,
    textColor=colors.HexColor('#b71c1c'), spaceBefore=10, spaceAfter=4,
    fontName='Helvetica-Bold')
h2_style = ParagraphStyle('H2', parent=styles['Normal'], fontSize=10.5,
    textColor=colors.HexColor('#1565c0'), spaceBefore=7, spaceAfter=2,
    fontName='Helvetica-Bold')
body_style = ParagraphStyle('Bd', parent=styles['Normal'], fontSize=9.5,
    textColor=colors.HexColor('#212121'), spaceBefore=2, spaceAfter=2,
    leading=14, alignment=TA_JUSTIFY, fontName='Helvetica')
bullet_style = ParagraphStyle('Bu', parent=styles['Normal'], fontSize=9.5,
    textColor=colors.HexColor('#212121'), spaceBefore=1, spaceAfter=1,
    leftIndent=14, leading=13, fontName='Helvetica', bulletIndent=6)

def H(t): return Paragraph(t, h2_style)
def P(t): return Paragraph(t, body_style)
def B(t): return Paragraph(f'• {t}', bullet_style)
def Q(t): return Paragraph(t, 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 (Main) Examination, October 2025", 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  Causes and Management of Hypertension. Precautions before Tooth Extraction in a Patient on Anti-platelet and Anti-coagulant Therapy.  [10 Marks]"),
    HR(), S(4),

    H("Definition of Hypertension"),
    P("Hypertension is defined as a persistently elevated blood pressure of ≥140/90 mmHg on two separate occasions (JNC 8 / BHS guidelines). The 2017 ACC/AHA guidelines define it as ≥130/80 mmHg."),
    S(3),

    H("Classification (JNC 8 / WHO)"),
    B("Normal: <120/80 mmHg"),
    B("Elevated: 120–129 / <80 mmHg"),
    B("Stage 1 HTN: 130–139 / 80–89 mmHg"),
    B("Stage 2 HTN: ≥140 / ≥90 mmHg"),
    B("Hypertensive crisis: >180/120 mmHg"),
    S(4),

    H("Causes of Hypertension"),
    H("A. Primary (Essential) Hypertension — 90–95% of all cases"),
    P("No identifiable single cause. Risk factors include:"),
    B("Genetic predisposition / family history"),
    B("High dietary sodium intake"),
    B("Obesity and physical inactivity"),
    B("Excessive alcohol consumption"),
    B("Psychological stress"),
    B("Ageing (loss of arterial compliance)"),
    B("Insulin resistance / metabolic syndrome"),
    B("Dyslipidaemia"),
    S(3),
    H("B. Secondary Hypertension — 5–10% of cases"),
    H("Renal Causes (most common secondary cause)"),
    B("Renal parenchymal disease: Chronic glomerulonephritis, polycystic kidney disease, diabetic nephropathy, chronic pyelonephritis"),
    B("Renovascular hypertension: Renal artery stenosis (atherosclerotic in elderly; fibromuscular dysplasia in young women)"),
    H("Endocrine Causes"),
    B("Primary hyperaldosteronism (Conn's syndrome) — hypertension + hypokalaemia"),
    B("Phaeochromocytoma — episodic hypertension + headache + palpitations + sweating ('5 Ps')"),
    B("Cushing's syndrome — moon face, buffalo hump, striae"),
    B("Hyperthyroidism — systolic hypertension, wide pulse pressure"),
    B("Hyperparathyroidism, acromegaly"),
    H("Other Causes"),
    B("Coarctation of aorta — upper limb hypertension, radio-femoral delay"),
    B("Obstructive sleep apnoea"),
    B("Drugs: OCP, NSAIDs, corticosteroids, sympathomimetics, cyclosporine, erythropoietin"),
    B("Pregnancy-induced hypertension / Pre-eclampsia"),
    S(4),

    H("Management of Hypertension"),
    H("1. Lifestyle Modifications (First-line for all stages)"),
    B("DASH diet (Dietary Approaches to Stop Hypertension): Rich in fruits, vegetables, low-fat dairy, low sodium (<2.3 g/day)"),
    B("Weight reduction: Each 1 kg loss reduces SBP by ~1 mmHg"),
    B("Regular aerobic exercise: 30 min moderate-intensity activity, 5 days/week"),
    B("Limit alcohol: <14 units/week (men), <7 units/week (women)"),
    B("Smoking cessation (reduces cardiovascular risk)"),
    B("Stress management / relaxation techniques"),
    S(3),
    H("2. Pharmacological Treatment"),
    H("First-line agents (A, B, C, D):"),
    B("A — ACE Inhibitors (Enalapril, Ramipril): First-line in DM, CKD with proteinuria, heart failure; avoid in pregnancy"),
    B("A — Angiotensin Receptor Blockers (Losartan, Telmisartan): Alternative to ACEi; better tolerated (no cough)"),
    B("B — Beta-blockers (Atenolol, Metoprolol): For HTN + angina, post-MI, heart failure with reduced EF; caution in asthma"),
    B("C — Calcium Channel Blockers (Amlodipine, Nifedipine): Elderly, isolated systolic HTN, Afro-Caribbean patients; causes pedal oedema"),
    B("D — Diuretics (Thiazide: Hydrochlorothiazide, Indapamide): First-line in elderly, Afro-Caribbean, isolated systolic HTN"),
    H("Step-up Therapy:"),
    B("Step 1: Single agent (usually ACEi/ARB or CCB)"),
    B("Step 2: ACEi/ARB + CCB"),
    B("Step 3: ACEi/ARB + CCB + Thiazide diuretic"),
    B("Step 4 (resistant HTN): Add spironolactone 25–50 mg/day, or alpha-blocker (doxazosin), or beta-blocker"),
    H("Hypertensive Emergency: IV labetalol, IV sodium nitroprusside, IV hydralazine"),
    S(5),

    H("Dental Precautions: Anti-platelet and Anti-coagulant Therapy"),
    H("Anti-platelet Drugs (Aspirin, Clopidogrel, Ticagrelor, Prasugrel)"),
    H("Assessment:"),
    B("Take detailed drug history — type of antiplatelet, indication (post-stent, post-MI, stroke prevention), duration"),
    B("Assess bleeding risk of planned dental procedure"),
    B("Consult prescribing physician / cardiologist"),
    H("General Principles:"),
    B("DO NOT routinely stop antiplatelet therapy for most dental procedures — risk of thrombotic events (stent thrombosis, MI, stroke) outweighs dental bleeding risk"),
    B("Most dental procedures are safe with aspirin ≤300 mg/day"),
    B("For patients on dual antiplatelet therapy (aspirin + clopidogrel, especially within 12 months of PCI/stent): NEVER stop — consult cardiologist"),
    H("Local Haemostatic Measures:"),
    B("Use vasoconstrictors in LA (adrenaline 1:80,000 or 1:100,000) — reduces surgical bleeding"),
    B("Pack socket with resorbable oxidised cellulose (Surgicel) or gelatin foam (Gelfoam)"),
    B("Apply tranexamic acid mouthwash (5%) post-extraction for 2 days"),
    B("Place sutures over socket"),
    B("Instruct patient to bite on gauze for 20–30 min post-extraction"),
    B("Avoid prescribing NSAIDs (potentiate antiplatelet effect)"),
    S(4),
    H("Anti-coagulant Drugs (Warfarin, Heparin, DOACs: Rivaroxaban, Apixaban, Dabigatran)"),
    H("Warfarin — INR Monitoring:"),
    B("Check INR within 24–72 hours before dental procedure"),
    B("INR ≤3.5: Safe to proceed with most simple dental extractions with local haemostatic measures"),
    B("INR >3.5: Postpone elective procedures; consult physician to reduce warfarin dose"),
    B("Do NOT routinely stop warfarin for simple extractions — risk of systemic thromboembolism"),
    H("Direct Oral Anticoagulants (DOACs):"),
    B("Low bleeding-risk procedures (1–3 simple extractions): No need to alter DOAC dose; time procedure when drug level lowest (12–24 hrs after last dose)"),
    B("High bleeding-risk procedures: Skip morning dose on day of procedure; resume evening after haemostasis achieved (consult physician)"),
    H("Heparin (IV/SC):"),
    B("Short-acting — can time dental procedure during trough; IV heparin can be reversed with protamine sulphate if needed"),
    H("General Local Measures for all anticoagulated patients:"),
    B("Minimise trauma — atraumatic extraction technique"),
    B("Pack socket with haemostatic agents, suture, tranexamic acid mouthwash"),
    B("Post-operative instructions: Avoid hot food/drinks, smoking; do not disturb clot"),
    B("Avoid aspirin / NSAIDs for pain relief — use paracetamol or codeine"),
    S(10),
]

# ─── Q2 ─────────────────────────────────────────────────────────────
story += [
    Q("Q.2  Clinical Features of Hypothyroidism. Its Diagnosis, Management and Complications.  [10 Marks]"),
    HR(), S(4),

    H("Definition"),
    P("Hypothyroidism is a clinical syndrome resulting from deficiency of thyroid hormones (T3/T4), leading to slowing of metabolic processes. Primary hypothyroidism (failure of the thyroid gland) accounts for >95% of cases."),
    S(3),

    H("Aetiology"),
    B("Autoimmune thyroiditis (Hashimoto's thyroiditis) — most common cause in iodine-sufficient areas"),
    B("Iodine deficiency — most common cause worldwide (endemic goitre)"),
    B("Post-thyroidectomy / Post-radioiodine ablation"),
    B("Drug-induced: Amiodarone, lithium, interferon-alpha, antithyroid drugs (over-treatment)"),
    B("Secondary hypothyroidism: Pituitary failure (low TSH)"),
    B("Tertiary hypothyroidism: Hypothalamic failure (low TRH)"),
    B("Congenital hypothyroidism (cretinism)"),
    S(4),

    H("Clinical Features"),
    H("Symptoms (Result of Reduced Metabolic Rate)"),
    B("Fatigue, lethargy, excessive sleepiness"),
    B("Weight gain despite reduced appetite"),
    B("Cold intolerance — patient feels cold when others are comfortable"),
    B("Constipation"),
    B("Bradycardia, exertional dyspnoea"),
    B("Menorrhagia (heavy periods), infertility"),
    B("Depression, poor memory, slow cognition"),
    B("Hoarseness of voice (myxoedematous infiltration of larynx)"),
    B("Muscle cramps, weakness (proximal myopathy)"),
    B("Deafness (rare)"),
    S(3),
    H("Signs"),
    B("General: Puffy face, periorbital oedema (myxoedema — non-pitting)"),
    B("Skin: Dry, coarse, scaly skin; yellowish tinge (carotenaemia); cool, pale skin"),
    B("Hair: Coarse, brittle hair; hair loss including outer third of eyebrow (madarosis)"),
    B("Nails: Brittle nails"),
    B("Thyroid: Goitre present (Hashimoto's) or absent (post-ablation)"),
    B("Cardiovascular: Bradycardia, pericardial effusion, diastolic hypertension"),
    B("Neurological: Slow relaxing reflexes (delayed ankle jerk — 'hung-up reflex'), carpal tunnel syndrome, cerebellar ataxia"),
    B("Tongue: Macroglossia (enlarged tongue)"),
    B("Oedema: Generalised myxoedema — non-pitting oedema"),
    S(4),

    H("Investigations (Diagnosis)"),
    H("Thyroid Function Tests (TFTs) — Gold Standard"),
    B("TSH: ELEVATED (↑) — most sensitive test for primary hypothyroidism; even before T4 falls"),
    B("Free T4 (FT4): Low (↓) — confirms overt hypothyroidism"),
    B("Free T3 (FT3): Low or normal"),
    B("Subclinical hypothyroidism: TSH ↑ but FT4 normal"),
    H("Autoimmune Markers"),
    B("Anti-thyroid peroxidase (anti-TPO) antibodies: Positive in Hashimoto's (>95%)"),
    B("Anti-thyroglobulin antibodies"),
    H("Other Tests"),
    B("CBC: Normochromic normocytic or macrocytic anaemia (B12 deficiency in autoimmune)"),
    B("Serum cholesterol: Elevated (due to reduced LDL receptor activity)"),
    B("Serum creatine kinase (CK): Elevated (myopathy)"),
    B("ECG: Bradycardia, low voltage complexes, T-wave flattening/inversion"),
    B("Thyroid ultrasound: Heterogeneous echogenicity (Hashimoto's)"),
    S(4),

    H("Management"),
    H("Levothyroxine (L-T4) — Mainstay of Treatment"),
    B("Starting dose: 25–50 mcg/day in young healthy adults; 12.5–25 mcg/day in elderly or cardiac patients"),
    B("Target dose: Typically 1.6 mcg/kg/day (average 100–150 mcg/day)"),
    B("Monitor: TSH 6–8 weeks after starting or any dose change; adjust by 25 mcg increments"),
    B("Administer on empty stomach, 30 min before breakfast for best absorption"),
    B("Target TSH: 0.5–2.5 mIU/L (normal range); elderly: 1–4 mIU/L"),
    B("Lifelong treatment required in most cases"),
    H("Special Situations"),
    B("Pregnancy: Increase dose by 30–50% as soon as pregnancy confirmed; target TSH <2.5 mIU/L in 1st trimester"),
    B("Subclinical hypothyroidism: Treat if TSH >10 mIU/L, or if symptomatic, or if pregnant / planning pregnancy"),
    S(4),

    H("Complications of Hypothyroidism"),
    B("Myxoedema coma: Life-threatening decompensation — hypothermia, severe altered consciousness, hypoventilation, bradycardia, hypotension; precipitated by cold exposure, infection, sedatives; Treat with IV T3/T4 + IV hydrocortisone + supportive care"),
    B("Cardiovascular: Coronary artery disease (hyperlipidaemia), cardiomegaly, pericardial effusion, heart failure"),
    B("Neurological: Peripheral neuropathy, cerebellar ataxia, depression, dementia, carpal tunnel syndrome"),
    B("Reproductive: Infertility, recurrent miscarriage, menorrhagia"),
    B("Congenital hypothyroidism (untreated): Cretinism — intellectual disability, growth failure, deaf-mutism, coarse features"),
    B("Metabolic: Hyponatraemia (SIADH-like), hyperlipidaemia"),
    B("Haematological: Macrocytic / normocytic anaemia"),
    S(10),
]

# ─── Q3 ─────────────────────────────────────────────────────────────
story += [
    Q("Q.3  Clinical Features, Complication and Management of Diabetes Mellitus Type 2.  [10 Marks]"),
    HR(), S(4),

    H("Definition"),
    P("Type 2 Diabetes Mellitus (T2DM) is a chronic metabolic disorder characterised by hyperglycaemia due to progressive insulin secretory defect (relative insulin deficiency) superimposed on a background of insulin resistance, in contrast to absolute insulin deficiency in T1DM."),
    S(3),

    H("Clinical Features of T2DM"),
    H("Classic Symptoms (from hyperglycaemia)"),
    B("Polyuria — osmotic diuresis due to glycosuria"),
    B("Polydipsia — secondary to polyuria and dehydration"),
    B("Polyphagia — cellular glucose deprivation despite hyperglycaemia"),
    B("Weight loss — fat and muscle catabolism (less pronounced than T1DM)"),
    B("Fatigue and generalised weakness"),
    B("Blurring of vision — osmotic changes in lens"),
    H("Often Asymptomatic — Detected on Screening"),
    B("Many T2DM patients are detected incidentally during routine health checks or investigation of complications"),
    H("Other Features"),
    B("Recurrent infections: Skin (furunculosis), urinary tract infections, oral candidiasis, vulvovaginitis"),
    B("Slow-healing wounds"),
    B("Paraesthesia / tingling in hands and feet (early neuropathy)"),
    B("Erectile dysfunction"),
    B("Acanthosis nigricans — dark velvety skin folds at neck, axilla (insulin resistance marker)"),
    S(4),

    H("Diagnostic Criteria (ADA / WHO)"),
    B("Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) on two occasions"),
    B("Random plasma glucose ≥200 mg/dL (11.1 mmol/L) + classic symptoms"),
    B("2-hour plasma glucose ≥200 mg/dL during OGTT (75g glucose load)"),
    B("HbA1c ≥6.5% (48 mmol/mol)"),
    S(4),

    H("Complications of T2DM"),
    H("Microvascular Complications"),
    B("Diabetic nephropathy: Microalbuminuria → proteinuria → CKD → ESRD; leading cause of CKD worldwide"),
    B("Diabetic retinopathy: Non-proliferative (dot haemorrhages, hard exudates, cotton-wool spots) → Proliferative (neovascularisation → vitreous haemorrhage, retinal detachment); leading cause of blindness in working-age adults"),
    B("Diabetic neuropathy: Peripheral (stocking-glove sensory loss, painful neuropathy), autonomic (gastroparesis, orthostatic hypotension, bladder dysfunction, ED), mononeuropathy"),
    S(2),
    H("Macrovascular Complications"),
    B("Coronary artery disease (CAD): 2–4x increased risk of MI; often 'silent MI' due to autonomic neuropathy"),
    B("Cerebrovascular disease: Ischaemic stroke, TIA"),
    B("Peripheral arterial disease: Claudication, critical limb ischaemia → diabetic foot ulcers, gangrene"),
    S(2),
    H("Other Complications"),
    B("Diabetic foot: Combination of neuropathy + vascular insufficiency + infection → non-healing ulcers, Charcot's arthropathy, osteomyelitis, amputation"),
    B("Diabetic ketoacidosis (DKA): Rare in T2DM; Hyperosmolar Hyperglycaemic State (HHS) more common"),
    B("Infections: Increased susceptibility to TB, UTI, mucormycosis, malignant otitis externa"),
    B("Oral complications: Periodontal disease (accelerated), dry mouth, burning mouth, delayed healing"),
    S(4),

    H("Management of T2DM"),
    H("Treatment Goals"),
    B("HbA1c target: <7% (53 mmol/mol) for most patients; <8% for elderly/complex patients"),
    B("BP target: <130/80 mmHg"),
    B("LDL-cholesterol: <70 mg/dL (if cardiovascular disease present)"),
    S(3),
    H("1. Lifestyle Modification (cornerstone of management)"),
    B("Diet: Calorie-restricted, low glycaemic index, high fibre; reduce saturated fats and refined sugars; Mediterranean diet preferred"),
    B("Exercise: 150 min/week moderate-intensity aerobic activity + resistance training 2–3 days/week"),
    B("Weight loss: 5–10% weight reduction significantly improves glycaemic control and insulin sensitivity"),
    B("Smoking cessation, alcohol moderation"),
    S(3),
    H("2. Pharmacological Treatment"),
    H("First-line: Metformin"),
    B("Mechanism: Reduces hepatic glucose output (inhibits gluconeogenesis); improves insulin sensitivity"),
    B("Dose: Start 500 mg BD with meals, titrate to 1000 mg BD"),
    B("Benefits: Weight neutral/modest weight loss, cardioprotective, cheap, no hypoglycaemia"),
    B("Contraindications: eGFR <30, IV contrast use, hepatic failure, heavy alcohol use"),
    H("Second-line Agents (add to metformin):"),
    B("SGLT2 inhibitors (Empagliflozin, Dapagliflozin, Canagliflozin): Preferred if cardiovascular disease, heart failure, or CKD; cause glucosuria, reduce weight and BP; risk of UTI/genital infections"),
    B("GLP-1 receptor agonists (Semaglutide, Liraglutide, Dulaglutide): Preferred if cardiovascular disease or obesity; significant weight loss, reduce MACE; once weekly injection; nausea common"),
    B("DPP-4 inhibitors (Sitagliptin, Vildagliptin): Well tolerated, weight neutral; no hypoglycaemia; less potent"),
    B("Sulphonylureas (Glipizide, Glibenclamide, Gliclazide): Stimulate insulin secretion; risk of hypoglycaemia and weight gain; cheap"),
    B("Thiazolidinediones (Pioglitazone): Improve insulin sensitivity; weight gain, fluid retention, fracture risk; contraindicated in heart failure"),
    H("Insulin Therapy"),
    B("Indications: HbA1c >10%, symptomatic hyperglycaemia, failure of oral agents, pregnancy, acute illness, surgery"),
    B("Types: Basal insulin (NPH, Glargine, Detemir) + Bolus (Rapid-acting: Aspart, Lispro, Glulisine) — basal-bolus regimen"),
    H("3. Management of Complications"),
    B("Nephropathy: ACEi/ARB (reduce proteinuria), BP control; SGLT2i (renoprotective)"),
    B("Retinopathy: Annual fundoscopy; laser photocoagulation; anti-VEGF (ranibizumab) for macular oedema"),
    B("Neuropathy: Glycaemic control; gabapentin, pregabalin, duloxetine for painful neuropathy; foot care education"),
    B("Cardiovascular: Statins (all T2DM >40 yrs), antiplatelet therapy, BP control; revascularisation if needed"),
    S(10),
]

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

story += [
    H("(a) Clinical Features of Aortic Regurgitation (AR)"),
    P("Aortic regurgitation (AR) is incompetence of the aortic valve allowing regurgitation of blood from the aorta back into the left ventricle during diastole, causing volume overload of the LV."),
    S(2),
    H("Causes:"),
    H("Acute AR: Infective endocarditis, aortic dissection, trauma — surgical emergency"),
    H("Chronic AR: Rheumatic heart disease (most common in developing world), Bicuspid aortic valve, Marfan's syndrome, Syphilitic aortitis, Ankylosing spondylitis"),
    S(2),
    H("Symptoms:"),
    B("Asymptomatic for many years (compensated — LV dilates and hypertrophies)"),
    B("Exertional dyspnoea (most common presenting symptom)"),
    B("Orthopnoea and paroxysmal nocturnal dyspnoea"),
    B("Palpitations — awareness of forceful heartbeat (especially when lying on left side)"),
    B("Angina pectoris (reduced diastolic coronary filling pressure)"),
    B("Exertional syncope (severe cases)"),
    S(2),
    H("Signs (Peripheral Signs — due to wide pulse pressure):"),
    B("Water-hammer / Corrigan's pulse — sharp, forceful, rapid upstroke that collapses quickly"),
    B("De Musset's sign — head nodding with each heartbeat"),
    B("Quincke's sign — capillary pulsations in fingernails"),
    B("Traube's sign — pistol-shot sounds over femoral artery"),
    B("Duroziez's sign — to-and-fro murmur over femoral artery with slight compression"),
    B("Müller's sign — pulsation of uvula"),
    B("High-volume, wide pulse pressure (SBP elevated, DBP reduced)"),
    B("Displaced, hyperdynamic, thrusting apex beat (LV volume overload)"),
    H("Auscultation:"),
    B("Early diastolic murmur (high-pitched, blowing) at left sternal edge, accentuated leaning forward in held expiration"),
    B("Austin-Flint murmur — low-pitched mid-diastolic rumble at apex (jet of AR hitting anterior mitral leaflet)"),
    B("Ejection systolic flow murmur at aortic area (increased flow volume)"),
    S(2),
    H("Investigations: Echo (definitive), CXR (cardiomegaly, dilated aortic root), ECG (LVH), cardiac catheterisation"),
    H("Treatment: Vasodilators (nifedipine, ACEi) for chronic AR; Aortic valve replacement (AVR) when symptomatic or LVEF <50% or LVESD >50 mm"),
    S(6),

    H("(b) Management of Acute Left Ventricular Failure (Acute LVF)"),
    P("Acute LVF is a cardiac emergency where sudden failure of the left ventricle to eject blood effectively causes pulmonary venous congestion, alveolar flooding, and life-threatening respiratory failure (acute pulmonary oedema)."),
    S(2),
    H("Precipitating Causes:"),
    B("Acute MI / ACS (most common), acute valvular rupture, arrhythmias (AF, VT), hypertensive crisis, acute myocarditis, fluid overload"),
    S(2),
    H("Clinical Presentation:"),
    B("Acute onset severe dyspnoea, orthopnoea, sense of suffocation"),
    B("Frothy pink sputum (haemoptysis-like)"),
    B("Diaphoresis, pallor, cold clammy skin"),
    B("SpO2 <90%, cyanosis"),
    B("Bilateral basal crepitations, wheeze ('cardiac asthma')"),
    S(2),
    H("Immediate Management — 'LMNOP + ABCD':"),
    B("L — Lasix (Furosemide): IV 40–80 mg stat (up to 160–240 mg in resistant cases); reduces preload via diuresis and direct venodilation"),
    B("M — Morphine: 2–4 mg IV slowly (with antiemetic); reduces anxiety, preload, dyspnoea; use cautiously (may cause respiratory depression)"),
    B("N — Nitrates: GTN 0.4 mg sublingual every 5 min (3 doses) or IV nitroglycerine 10–20 mcg/min infusion — potent vasodilator, reduces preload and afterload; avoid if SBP <90 mmHg"),
    B("O — Oxygen: High-flow O2 via non-rebreather mask 10–15 L/min; target SpO2 >95%"),
    B("P — Position: Sit patient upright with legs dangling — reduces venous return and preload"),
    B("A — Airway: Ensure airway is patent; suction if needed"),
    B("B — BiPAP/CPAP: Non-invasive positive pressure ventilation if SpO2 <90% despite high-flow O2; CPAP 5–10 cmH2O reduces work of breathing and improves oxygenation"),
    B("C — Catheterise: Insert urinary catheter to monitor urine output (target >30 mL/hr)"),
    B("D — Dopamine/Dobutamine: If cardiogenic shock (SBP <90 mmHg, cold peripheries) — dobutamine 2–20 mcg/kg/min IV to improve cardiac output"),
    S(2),
    H("Investigations and Monitoring:"),
    B("Continuous ECG monitoring — identify and treat arrhythmias, AMI (STEMI → emergency PCI)"),
    B("ABG: Hypoxia, respiratory alkalosis → acidosis"),
    B("BNP/NT-proBNP: Markedly elevated (>500 pg/mL)"),
    B("CXR: Bat-wing perihilar oedema, Kerley B lines, cardiomegaly, pleural effusions"),
    B("Echo: Assess LV function (EF), valvular disease, wall motion abnormalities"),
    B("Troponin, CBC, RFTs, electrolytes"),
    S(2),
    H("Treat precipitating cause:"),
    B("STEMI: Emergency PCI or thrombolysis"),
    B("Hypertensive emergency: IV labetalol, nitroprusside"),
    B("Arrhythmia: Electrical cardioversion or rate control"),
    B("Mechanical ventilation (intubation): If above fails — acidotic coma, apnoea, exhaustion"),
    S(6),

    H("(c) Enumerate Causes of Glossitis"),
    P("Glossitis is inflammation of the tongue characterised by redness, swelling, smoothness of the tongue surface (loss of filiform papillae), and soreness/burning sensation."),
    S(2),
    H("Causes:"),
    H("1. Nutritional Deficiencies (most common group)"),
    B("Iron deficiency: Smooth, pale tongue; angular stomatitis; associated with dysphagia (Plummer-Vinson syndrome)"),
    B("Vitamin B12 (cobalamin) deficiency: Smooth, beefy-red, sore tongue — Hunter's/Moeller's glossitis; associated with megaloblastic anaemia"),
    B("Folate (Vitamin B9) deficiency: Similar to B12 glossitis"),
    B("Niacin (Vitamin B3) deficiency (Pellagra): Bright red, swollen tongue + stomatitis ('raw beef' tongue)"),
    B("Riboflavin (Vitamin B2) deficiency: Magenta-coloured tongue, angular stomatitis"),
    B("Pyridoxine (B6) deficiency: Glossitis + cheilitis"),
    B("Zinc deficiency: Smooth tongue, impaired taste"),
    S(2),
    H("2. Infections"),
    B("Candidiasis (thrush): White pseudomembranous plaques on tongue; erythematous glossitis under patches"),
    B("Herpes simplex virus (HSV-1): Multiple vesicles/ulcers on tongue"),
    B("Syphilis: Primary — painless chancre; Secondary — mucous patches; Tertiary — gumma"),
    B("Vincent's infection (ANUG): Acute necrotising ulcerative gingivostomatitis"),
    B("Scarlet fever: 'Strawberry tongue' (erythematous, swollen papillae)"),
    B("HIV: Hairy leukoplakia (EBV) on lateral tongue border"),
    S(2),
    H("3. Inflammatory / Autoimmune"),
    B("Lichen planus: White striae, erosive glossitis"),
    B("Pemphigus vulgaris: Erosions on tongue"),
    B("Benign migratory glossitis (Geographic tongue): Irregular red patches with white borders that 'migrate'; usually asymptomatic; inflammatory in origin"),
    B("Median rhomboid glossitis: Rhomboid-shaped, smooth, red area anterior to circumvallate papillae; associated with Candida"),
    S(2),
    H("4. Systemic Diseases"),
    B("Pernicious anaemia (autoimmune atrophic gastritis + B12 deficiency)"),
    B("Hypothyroidism: Macroglossia"),
    B("Amyloidosis: Macroglossia"),
    B("Sjögren's syndrome: Dry, fissured tongue (xerostomia)"),
    S(2),
    H("5. Local Irritants"),
    B("Tobacco, alcohol, spicy foods, hot beverages"),
    B("Trauma from sharp teeth, ill-fitting dentures"),
    B("Allergic reaction (contact stomatitis) — toothpaste, mouthwash, dental materials"),
    S(2),
    H("6. Idiopathic"),
    B("Burning mouth syndrome — burning sensation in tongue/lips without visible changes; more common in post-menopausal women"),
    B("Atrophic glossitis with no identifiable cause"),
    S(6),

    H("(d) Management of Nephrotic Syndrome"),
    P("Nephrotic syndrome is a clinical complex characterised by: massive proteinuria (>3.5 g/day in adults), hypoalbuminaemia (<3.5 g/dL), generalised oedema (anasarca), hyperlipidaemia, and lipiduria."),
    S(2),
    H("Common Causes:"),
    B("Primary: Minimal change disease (MCD — children), focal segmental glomerulosclerosis (FSGS), membranous nephropathy (adults), IgA nephropathy"),
    B("Secondary: Diabetic nephropathy, SLE (lupus nephritis), amyloidosis, hepatitis B/C, drugs (gold, penicillamine, NSAIDs)"),
    S(2),
    H("Management"),
    H("A. General Measures"),
    B("Rest during acute phase; ambulation as tolerated"),
    B("Fluid restriction if severe oedema"),
    B("Low-sodium diet (<2 g/day) to reduce oedema"),
    B("Moderate protein diet (0.8–1 g/kg/day) — high protein does not correct albuminaemia"),
    B("Skin care: Prevent pressure sores, elevate oedematous limbs"),
    S(2),
    H("B. Treatment of Oedema"),
    B("Loop diuretics: Furosemide 40–120 mg/day PO or IV; first-line for oedema"),
    B("Combine with spironolactone 100–200 mg/day (reduce potassium wasting)"),
    B("IV albumin infusion (20%): For severe hypoalbuminaemia (<2 g/dL) with refractory oedema — followed immediately by IV furosemide"),
    B("Monitor daily weight, urine output, electrolytes"),
    S(2),
    H("C. Specific Treatment (by Cause)"),
    B("Minimal Change Disease: Prednisolone 1 mg/kg/day (max 60 mg) for 4–8 weeks → taper; 90% respond; relapse treated with repeat steroids"),
    B("FSGS: High-dose prednisolone ± cyclosporine or mycophenolate mofetil (MMF)"),
    B("Membranous Nephropathy: Conservative management for mild-moderate cases; Ponticelli protocol (alternating prednisolone and chlorambucil/cyclophosphamide) for nephrotic-range; Rituximab increasingly used"),
    B("Diabetic Nephropathy: Tight glycaemic control + ACEi/ARB (reduce proteinuria + renoprotective); SGLT2i (renoprotective)"),
    B("Lupus Nephritis: Hydroxychloroquine + high-dose steroids + MMF or cyclophosphamide"),
    S(2),
    H("D. Treatment of Complications"),
    B("Hyperlipidaemia: Statins (rosuvastatin/atorvastatin); reduces cardiovascular risk"),
    B("Thromboembolism: High risk (especially membranous nephropathy); anticoagulation with heparin/warfarin if albumin <2.5 g/dL or prior thrombosis; prophylactic LMWH in severe cases"),
    B("Infections: Increased risk due to immunoglobulin loss; pneumococcal vaccination; treat infections promptly"),
    B("ACEi/ARB: Reduce intraglomerular pressure and proteinuria; standard in all causes"),
    S(10),
]

# PAGE BREAK
story.append(PageBreak())

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

# ─── Q5 ─────────────────────────────────────────────────────────────
story += [
    Q("Q.5  Clinical Features, Diagnosis and Management of Iron Deficiency Anaemia.  [10 Marks]"),
    HR(), S(4),

    H("Definition"),
    P("Iron deficiency anaemia (IDA) is the most common nutritional anaemia worldwide, caused by depletion of iron stores leading to impaired haemoglobin synthesis, resulting in a hypochromic microcytic anaemia (low Hb, low MCV, low MCH)."),
    S(3),

    H("Causes"),
    H("1. Blood Loss (most common cause in adults)"),
    B("GI blood loss: Peptic ulcer, colorectal carcinoma, haemorrhoids, hookworm infestation, NSAIDs"),
    B("Menorrhagia (most common cause in premenopausal women)"),
    B("Post-surgical / traumatic blood loss"),
    B("Haematuria (renal carcinoma, schistosomiasis)"),
    H("2. Inadequate Intake"),
    B("Dietary insufficiency: Vegetarian/vegan diet (haem iron absent), poverty, fad diets"),
    B("Infants fed exclusively on breast milk beyond 6 months"),
    H("3. Malabsorption"),
    B("Coeliac disease (most common malabsorption cause), Crohn's disease"),
    B("Post-gastrectomy (loss of gastric acid needed for iron absorption)"),
    B("Helicobacter pylori infection (reduces gastric acid)"),
    H("4. Increased Demand"),
    B("Pregnancy (iron requirement triples)"),
    B("Rapid growth in infancy and adolescence"),
    S(4),

    H("Clinical Features"),
    H("Symptoms of Anaemia"),
    B("Fatigue, lethargy, exertional dyspnoea"),
    B("Pallor of skin, conjunctivae, palms"),
    B("Palpitations, tachycardia"),
    B("Headache, poor concentration"),
    H("Iron-Deficiency Specific Features"),
    B("Koilonychia — spoon-shaped nails (concave nails, ridging)"),
    B("Angular stomatitis (cheilitis) — fissuring at corners of mouth"),
    B("Atrophic glossitis — smooth, red, painful tongue (loss of papillae)"),
    B("Dysphagia — Plummer-Vinson syndrome (post-cricoid web + IDA)"),
    B("Pica — craving for non-food items (ice, clay, chalk, dirt — pagophagia for ice)"),
    B("Brittle nails and hair loss"),
    B("Restless leg syndrome"),
    S(4),

    H("Diagnosis — Investigations"),
    H("Blood Tests"),
    B("CBC: Hb ↓ (low), MCV ↓ (<80 fL — microcytic), MCH ↓ (<27 pg — hypochromic), MCHC ↓"),
    B("Peripheral blood film: Microcytic hypochromic RBCs, pencil cells (elliptocytes), target cells, anisocytosis and poikilocytosis"),
    B("Reticulocyte count: LOW (hypoproliferative)"),
    B("Platelet count: Often elevated (reactive thrombocytosis)"),
    H("Iron Studies (Gold Standard Panel)"),
    B("Serum iron: LOW (↓)"),
    B("Serum ferritin: LOW (<12–15 mcg/L) — EARLIEST and most sensitive indicator of iron depletion"),
    B("Total Iron Binding Capacity (TIBC): HIGH (↑) — reflects increased transferrin production"),
    B("Transferrin saturation: LOW (<15%)"),
    H("Bone Marrow (rarely needed):"),
    B("Absent stainable iron in marrow macrophages (Prussian blue stain) — gold standard but invasive"),
    H("Additional tests to find cause:"),
    B("Stool for occult blood (FOB test), endoscopy (upper/lower GI)"),
    B("Urine analysis, renal function"),
    B("Serology for coeliac disease (anti-tTG IgA)"),
    B("Gynaecological assessment if menorrhagia"),
    S(4),

    H("Management"),
    H("1. Treat Underlying Cause"),
    B("GI bleed: Endoscopy + appropriate treatment (PPI for PUD, surgery for carcinoma)"),
    B("Menorrhagia: Hormonal therapy, treat gynaecological cause"),
    B("Coeliac disease: Gluten-free diet"),
    B("Hookworm: Albendazole / mebendazole"),
    S(3),
    H("2. Iron Replacement"),
    H("Oral Iron (first-line):"),
    B("Ferrous sulphate 200 mg TDS (equivalent to 65 mg elemental iron per tablet) on empty stomach"),
    B("Alternatives: Ferrous gluconate, ferrous fumarate (fewer GI side effects)"),
    B("Continue for 3–6 months after Hb normalises to replenish iron stores"),
    B("Side effects: Nausea, constipation, black stools, epigastric discomfort — take with food if needed"),
    B("Vitamin C (ascorbic acid) with iron enhances absorption; avoid tea, milk, antacids"),
    B("Expected response: Reticulocytosis by day 7–10; Hb rises ~1–2 g/dL per 3 weeks"),
    H("Parenteral Iron (IV Iron — Ferric carboxymaltose, Iron sucrose, Iron dextran):"),
    B("Indications: Malabsorption (coeliac, post-gastrectomy), non-compliance/intolerance to oral iron, severe anaemia needing rapid repletion, CKD on dialysis, IBD with active disease"),
    B("Monitor for anaphylaxis (test dose for iron dextran)"),
    H("Blood Transfusion:"),
    B("Only if: Hb <6–7 g/dL with cardiovascular compromise, or pre-operative with urgent surgery"),
    B("Use packed red cells; target Hb >8 g/dL"),
    S(10),
]

# ─── Q6 ─────────────────────────────────────────────────────────────
story += [
    Q("Q.6  Causes, Clinical Features and Management of Pulmonary Tuberculosis.  [10 Marks]"),
    HR(), S(4),

    H("Definition"),
    P("Pulmonary tuberculosis (PTB) is a chronic infectious disease of the lungs caused by Mycobacterium tuberculosis, transmitted via respiratory droplets (airborne route). It is a major global health problem — India has the highest burden of TB globally (~26% of global TB cases)."),
    S(3),

    H("Aetiology"),
    B("Causative organism: Mycobacterium tuberculosis (Koch's bacillus) — gram-positive, non-motile, aerobic, acid-fast bacillus (AFB)"),
    B("Transmission: Inhalation of infectious droplet nuclei (<5 microns) — generated by coughing, sneezing, singing"),
    B("Risk factors: HIV/AIDS, diabetes mellitus, malnutrition, overcrowding, poverty, immunosuppression, alcoholism, silicosis"),
    S(4),

    H("Pathogenesis"),
    B("Primary TB: Initial infection — Ghon's focus (in lower/mid lung) + hilar lymphadenopathy = Ghon's complex; usually subclinical"),
    B("Latent TB: Bacteria walled off by granuloma; can reactivate"),
    B("Post-primary / Reactivation TB: Upper lobe predilection (high O2 tension); cavitation, fibrosis, bronchogenic spread"),
    S(4),

    H("Clinical Features"),
    H("Constitutional/Systemic Symptoms (classic tetrad)"),
    B("Chronic cough >2 weeks (most common symptom)"),
    B("Haemoptysis — blood-streaked or frank blood in sputum"),
    B("Low-grade fever (usually evening rise) and night sweats"),
    B("Weight loss, anorexia, fatigue (cachexia)"),
    H("Respiratory Symptoms"),
    B("Breathlessness (with extensive disease, effusion, or pneumothorax)"),
    B("Chest pain (pleuritic — pleural involvement)"),
    H("Signs (variable)"),
    B("Upper lobe signs: Reduced expansion, dullness on percussion, bronchial breathing, coarse crepitations"),
    B("Signs of complications: Pleural effusion, empyema, pneumothorax, clubbing (chronic)"),
    B("Signs of dissemination: Lymphadenopathy (cervical), hepatosplenomegaly (miliary TB)"),
    S(4),

    H("Diagnosis"),
    H("Sputum Studies (most important)"),
    B("Sputum smear for AFB (Ziehl-Neelsen stain): 3 samples (spot/morning/spot); sensitivity ~60–70%; rapid, cheap"),
    B("Sputum culture (Löwenstein-Jensen medium or MGIT liquid culture): Gold standard; sensitivity >90%; takes 6–8 weeks (solid) or 2–3 weeks (liquid)"),
    B("GeneXpert MTB/RIF (CBNAAT): Rapid molecular test (2 hours); detects MTB + rifampicin resistance; recommended first-line in India (RNTCP/NTEP)"),
    B("Line Probe Assay (LPA): Detects resistance to INH and rifampicin"),
    H("Chest X-ray"),
    B("Classic: Heterogeneous opacities in upper lobes with or without cavitation"),
    B("Miliary TB: Fine nodular 'millet seed' pattern throughout lung fields"),
    B("Old healed TB: Calcification, fibrosis, pleural thickening, elevated hila"),
    H("Other Investigations"),
    B("Mantoux test (tuberculin skin test, TST): ≥10 mm induration = positive (≥5 mm in immunocompromised); indicates TB exposure/latent infection, NOT active disease"),
    B("IGRA (Interferon Gamma Release Assay — QuantiFERON): More specific; not affected by BCG vaccination"),
    B("CBC: Mild anaemia, lymphocytosis (in miliary TB)"),
    B("Pleural fluid analysis (if effusion): Exudate, lymphocyte-predominant, low glucose, elevated ADA (>40 U/L strongly suggests TB)"),
    B("CT chest: Better delineation of cavities, lymphadenopathy, miliary pattern"),
    S(4),

    H("Management — RNTCP/NTEP (India) — DOTS"),
    H("Category I: New smear-positive / smear-negative (severe) PTB"),
    B("Intensive Phase (2 months): Daily HRZE — Isoniazid (H) + Rifampicin (R) + Pyrazinamide (Z) + Ethambutol (E)"),
    B("Continuation Phase (4 months): Daily HR — Isoniazid + Rifampicin"),
    B("Total duration: 6 months (2HRZE / 4HR)"),
    H("Drug Doses (Weight-based):"),
    B("Isoniazid (H): 5 mg/kg/day; add Pyridoxine (B6) 10–25 mg/day to prevent peripheral neuropathy"),
    B("Rifampicin (R): 10 mg/kg/day; turns urine, saliva, tears orange; induces liver enzymes (drug interactions)"),
    B("Pyrazinamide (Z): 25 mg/kg/day; hepatotoxic, causes hyperuricaemia/gout"),
    B("Ethambutol (E): 15–20 mg/kg/day; visual side effect — retrobulbar neuritis (colour vision, visual acuity)"),
    H("MDR-TB (Multidrug Resistant — resistant to H + R):"),
    B("Treat with second-line drugs: Bedaquiline, Pretomanid, Linezolid, Clofazimine (BPaL/C regimen)"),
    B("Duration: 6–9 months (shorter new regimens) or 18–24 months (older regimens)"),
    H("Special Considerations:"),
    B("HIV co-infection: Start TB treatment first; ART after 2–8 weeks; use efavirenz-based ART"),
    B("Pregnancy: HRZE safe; avoid streptomycin (ototoxic to fetus)"),
    B("Hepatotoxicity: Monitor LFTs; suspend drugs if LFTs >3x ULN with symptoms"),
    B("DOTS (Directly Observed Treatment Short-course): Supervised therapy to ensure compliance and prevent resistance"),
    S(10),
]

# ─── Q7 ─────────────────────────────────────────────────────────────
story += [
    Q("Q.7  Clinical Features, Complication and Management of Plasmodium vivax Malaria.  [10 Marks]"),
    HR(), S(4),

    H("Introduction"),
    P("Plasmodium vivax is one of the five species of malaria parasites infecting humans (P. vivax, P. falciparum, P. malariae, P. ovale, P. knowlesi). P. vivax causes 'benign tertian malaria' and is the most common cause of malaria in India and most non-African countries."),
    S(3),

    H("Life Cycle and Transmission"),
    B("Vector: Female Anopheles mosquito (bite between dusk and dawn)"),
    B("Unique to vivax: Formation of HYPNOZOITES — dormant liver stage parasites that cause relapse months/years after initial infection"),
    B("Erythrocytic cycle: 48-hour cycle (tertian pattern) → paroxysms every 3rd day"),
    S(4),

    H("Clinical Features"),
    H("Prodrome (1–2 days before paroxysms)"),
    B("Malaise, fatigue, headache, myalgia, anorexia, nausea"),
    S(2),
    H("Classic Malarial Paroxysm (every 48 hours — tertian)"),
    B("Stage 1 — Cold Stage (15–60 min): Sudden rigors, shivering, feeling intensely cold, teeth chattering despite rising temperature"),
    B("Stage 2 — Hot Stage (2–6 hrs): High fever (40–41°C), dry skin, headache, delirium, vomiting"),
    B("Stage 3 — Sweating Stage (2–4 hrs): Profuse sweating, temperature falls rapidly to normal, patient feels exhausted but relieved"),
    S(2),
    H("Between Paroxysms"),
    B("Patient appears relatively well (differentiates P. vivax from P. falciparum)"),
    B("Anaemia develops gradually (haemolysis of parasitised RBCs)"),
    B("Splenomegaly — tender in acute phase; progressive in chronic/recurrent infection"),
    B("Hepatomegaly, jaundice (haemolytic)"),
    S(4),

    H("Investigations"),
    B("Peripheral blood smear (Gold Standard): Thick film (diagnosis — detection of parasites) + Thin film (speciation)"),
    P("  P. vivax: Enlarged RBCs, Schüffner's dots, amoeboid trophozoites, ring forms"),
    B("Rapid Diagnostic Tests (RDT / malaria antigen test): pLDH or HRP-2 based; quick, field-friendly"),
    B("PCR: Most sensitive; confirms species; used in low parasitaemia"),
    B("CBC: Anaemia (normocytic haemolytic), thrombocytopaenia (common in vivax), leukopenia"),
    B("Peripheral smear: Haemolytic picture — reticulocytosis, indirect bilirubin ↑, haptoglobin ↓, LDH ↑"),
    B("Liver function tests: Elevated unconjugated (indirect) bilirubin"),
    B("Blood glucose: Hypoglycaemia (in severe disease or with quinine treatment)"),
    S(4),

    H("Complications of P. vivax Malaria"),
    P("Traditionally considered 'benign' — but P. vivax CAN cause severe complications:"),
    B("Severe anaemia: Haemolytic; Hb <7 g/dL requiring transfusion"),
    B("Thrombocytopaenia: Often significant (<50,000/μL); rarely causes spontaneous bleeding"),
    B("Splenomegaly and splenic rupture: Most dangerous complication; spontaneous rupture → life-threatening haemoperitoneum"),
    B("Respiratory failure / Acute lung injury: Rare but documented"),
    B("Cerebral malaria (rare in vivax, common in falciparum): Altered consciousness, seizures"),
    B("Hyperreactive malarial splenomegaly (tropical splenomegaly syndrome): Chronic massive splenomegaly from repeated infections"),
    B("Relapse: Due to hypnozoites — occurs at 3 weeks to 2 years after primary attack; characteristic of vivax (and ovale)"),
    B("Glomerulonephritis: Immune-complex mediated"),
    B("G6PD-triggered haemolysis: Primaquine triggers haemolytic crisis in G6PD-deficient patients"),
    S(4),

    H("Management"),
    H("Causal Prophylaxis / Treatment — WHO / NVBDCP (India) Guidelines"),
    H("1. Blood Schizonticide (kills blood-stage parasites):"),
    B("Chloroquine (CQ): Drug of choice for P. vivax (except CQ-resistant strains)"),
    P("  Dose: 10 mg base/kg on Day 1 + Day 2; 5 mg base/kg on Day 3"),
    P("  Total: 25 mg base/kg over 3 days"),
    B("CQ-resistant vivax: Artemisinin-based Combination Therapy (ACT) — Artesunate + Mefloquine, or Artesunate + Sulphadoxine-Pyrimethamine"),
    S(2),
    H("2. Anti-relapse Treatment (Radical Cure — kills hypnozoites):"),
    B("Primaquine: 0.25 mg base/kg/day × 14 days (standard) OR 0.5 mg/kg/day × 7 days (alternative)"),
    B("MANDATORY to prevent relapse in all P. vivax cases"),
    B("Check G6PD status before giving primaquine — can cause severe haemolysis in G6PD deficiency"),
    B("Contraindicated in pregnancy and infancy (<6 months)"),
    H("3. Supportive Care:"),
    B("Antipyretics: Paracetamol 500–1000 mg for fever and rigors (avoid aspirin in thrombocytopaenic patients)"),
    B("Adequate hydration: Oral fluids; IV if vomiting or severe disease"),
    B("Treat anaemia: Iron supplements; blood transfusion if Hb <7 g/dL"),
    B("Treat thrombocytopaenia: Platelet transfusion only if active bleeding + platelets <10,000/μL"),
    H("4. Prevention:"),
    B("Vector control: Insecticide-treated bed nets (ITNs), indoor residual spraying (IRS), larval source management"),
    B("Chemoprophylaxis for travellers: Chloroquine 300 mg weekly (CQ-sensitive areas)"),
    B("Surveillance and case notification (NVBDCP programme in India)"),
    S(10),
]

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

story += [
    H("(a) Organophosphorus Poisoning"),
    P("Organophosphorus (OP) compounds are cholinesterase inhibitors used as pesticides (malathion, parathion, chlorpyrifos) and chemical warfare agents (nerve agents: sarin, tabun, VX). OP poisoning is a major cause of suicidal and accidental poisoning in India."),
    S(2),
    H("Mechanism:"),
    P("OP compounds irreversibly inhibit acetylcholinesterase (AChE) enzyme → accumulation of acetylcholine (ACh) at all cholinergic synapses → excessive cholinergic stimulation"),
    S(2),
    H("Clinical Features — Cholinergic Toxidrome:"),
    H("Muscarinic Effects (SLUDGE / DUMBELS):"),
    B("Salivation, Lacrimation, Urination, Defaecation, GI distress (nausea, vomiting, diarrhoea), Emesis"),
    B("Bronchospasm + Bronchorrhoea (excess secretions) — most dangerous; leads to respiratory failure"),
    B("Bradycardia, hypotension"),
    B("Miosis (pinpoint pupils — very characteristic)"),
    H("Nicotinic Effects (skeletal muscle):"),
    B("Muscle fasciculations, weakness → flaccid paralysis"),
    B("Respiratory muscle paralysis → apnoea"),
    B("Tachycardia, hypertension (initial sympathetic activation)"),
    H("CNS Effects:"),
    B("Anxiety, restlessness, confusion, seizures, coma"),
    H("Intermediate Syndrome (24–96 hrs post-exposure):"),
    B("Weakness of proximal limb muscles, neck flexors, and respiratory muscles; can cause delayed respiratory failure"),
    S(2),
    H("Investigations:"),
    B("Red blood cell (RBC) cholinesterase activity: Most specific — markedly reduced (<50% of normal = significant; <20% = severe)"),
    B("Plasma pseudocholinesterase: Rapidly falls (less specific)"),
    B("ABG: Hypoxia, respiratory acidosis"),
    B("ECG: QT prolongation, bradycardia"),
    S(2),
    H("Management:"),
    H("1. Remove from exposure: Remove contaminated clothing; wash skin with soap and water; eye irrigation"),
    H("2. Airway and Ventilation (PRIORITY):"),
    B("Oxygen 100% via tight-fitting mask or intubate + mechanical ventilation if respiratory failure"),
    H("3. Antidotes:"),
    B("Atropine (specific muscarinic antidote): 2–4 mg IV stat; REPEAT every 5–10 min until bronchospasm and secretions are controlled (endpoint = dry secretions, HR >80, pupils mid-dilated); titrate — may need hundreds of mg in severe cases"),
    B("Pralidoxime (PAM — 2-PAM — oxime — AChE reactivator): 1–2 g IV over 15–30 min, then 500 mg/hr infusion; MUST be given within 24–48 hrs before 'ageing' (irreversible AChE inhibition)"),
    H("4. Supportive care:"),
    B("Benzodiazepines (diazepam) for seizures"),
    B("Activated charcoal if ingested within 1 hr + GI lavage"),
    B("Monitor cholinesterase levels, urine output, vital signs"),
    S(6),

    H("(b) Oral Anti-Diabetic Drugs (OADs)"),
    P("OADs are pharmacological agents used in T2DM to achieve glycaemic control. They work through different mechanisms to reduce blood glucose."),
    S(2),
    H("Classification and Mechanisms:"),
    H("1. Biguanides — Metformin"),
    B("MOA: Activates AMPK → inhibits hepatic gluconeogenesis + improves peripheral insulin sensitivity"),
    B("Dose: 500–2000 mg/day with meals"),
    B("Advantages: No hypoglycaemia, weight neutral/loss, cardioprotective (UKPDS), cheap, FIRST LINE"),
    B("Side effects: GI (nausea, diarrhoea), lactic acidosis (rare; in renal failure)"),
    B("CI: eGFR <30, hepatic failure, alcoholism, IV contrast"),
    S(2),
    H("2. Sulphonylureas (SUs) — Glipizide, Gliclazide, Glibenclamide, Glimepiride"),
    B("MOA: Bind SU receptor on beta-cell K+-ATP channel → depolarisation → insulin secretion (insulin secretagogues)"),
    B("Side effects: Hypoglycaemia (major; especially glibenclamide), weight gain"),
    B("Use: When rapid glucose lowering needed; affordable; widely used"),
    S(2),
    H("3. DPP-4 Inhibitors (Gliptins) — Sitagliptin, Vildagliptin, Saxagliptin, Teneligliptin"),
    B("MOA: Inhibit DPP-4 enzyme → prevent GLP-1/GIP degradation → enhanced incretin effect → increased insulin, reduced glucagon"),
    B("Advantages: No hypoglycaemia, weight neutral, once daily, well tolerated"),
    B("Side effects: Nasopharyngitis, rare pancreatitis; saxagliptin — heart failure risk"),
    S(2),
    H("4. SGLT2 Inhibitors (Gliflozins) — Empagliflozin, Dapagliflozin, Canagliflozin"),
    B("MOA: Block sodium-glucose cotransporter-2 (SGLT-2) in proximal renal tubule → glucosuria → blood glucose reduction"),
    B("Advantages: Weight loss, BP reduction, cardioprotective (reduce MACE), renoprotective (reduce CKD progression), reduce hospitalisation for HFrEF"),
    B("Side effects: UTI, genital mycotic infections, volume depletion, DKA (rare, normoglycaemic), SGLT2i toe amputation (canagliflozin)"),
    S(2),
    H("5. GLP-1 Receptor Agonists — Semaglutide, Liraglutide, Dulaglutide, Exenatide"),
    B("MOA: Stimulate GLP-1R → glucose-dependent insulin secretion + glucagon suppression + delayed gastric emptying + central satiety"),
    B("Route: Subcutaneous injection (semaglutide also available orally)"),
    B("Advantages: Significant weight loss, cardioprotective, once weekly"),
    B("Side effects: Nausea, vomiting (especially initial), pancreatitis (rare), C-cell thyroid tumours (rodents)"),
    S(2),
    H("6. Thiazolidinediones (TZDs/Glitazones) — Pioglitazone"),
    B("MOA: Bind PPAR-gamma nuclear receptor → enhance peripheral insulin sensitivity (in muscle, fat, liver)"),
    B("Side effects: Weight gain, fluid retention/oedema, heart failure, osteoporotic fractures, bladder cancer risk"),
    S(2),
    H("7. Alpha-glucosidase Inhibitors — Acarbose, Voglibose"),
    B("MOA: Inhibit intestinal alpha-glucosidase → delayed carbohydrate absorption → blunt post-prandial hyperglycaemia"),
    B("Side effects: Flatulence, bloating, diarrhoea; no systemic absorption"),
    S(2),
    H("8. Meglitinides / Glinides — Repaglinide, Nateglinide"),
    B("MOA: Short-acting insulin secretagogues (target post-prandial glucose); taken with meals"),
    B("Side effects: Hypoglycaemia (less than SUs), weight gain"),
    S(6),

    H("(c) Migraine"),
    P("Migraine is a primary headache disorder characterised by recurrent, severe, unilateral pulsating headaches lasting 4–72 hours, often associated with nausea/vomiting and sensitivity to light (photophobia) and sound (phonophobia). It is the second most common cause of disability worldwide."),
    S(2),
    H("Pathophysiology:"),
    B("Cortical spreading depression (CSD) → triggers aura"),
    B("Trigeminovascular pathway activation → release of CGRP (calcitonin gene-related peptide) → neurogenic inflammation and vasodilation of meningeal vessels → pain"),
    S(2),
    H("Classification:"),
    B("Migraine WITHOUT aura (common migraine): No preceding neurological symptoms — most common type"),
    B("Migraine WITH aura (classic migraine): Preceded by reversible focal neurological symptoms (visual aura — zig-zag fortification spectra, scintillating scotoma, flashing lights; sensory; speech disturbance)"),
    S(2),
    H("Triggers (CHOCOLATE mnemonic):"),
    B("Chocolate, cheese, wine (tyramine-containing foods)"),
    B("Hormonal changes (menstruation, OCP)"),
    B("Overwork, stress, sleep disruption"),
    B("Caffeine (excess or withdrawal)"),
    B("Oral contraceptives"),
    B("Lights (bright/flicker), noise, strong smells"),
    B("Alcohol, Altitude, fAsting"),
    B("Travel (motion), Tyramine"),
    S(2),
    H("Clinical Features (IHS Criteria for Migraine without Aura):"),
    B("At least 5 attacks fulfilling the following:"),
    B("Duration: 4–72 hours (untreated)"),
    B("Location: Unilateral (60%; can be bilateral in children)"),
    B("Quality: Pulsating/throbbing"),
    B("Intensity: Moderate to severe"),
    B("Aggravation by routine activity (climbing stairs, bending)"),
    B("Associated with: Nausea AND/OR vomiting, photophobia AND phonophobia"),
    S(2),
    H("Phases:"),
    B("Prodrome (hours-days before): Mood change, yawning, food craving, fatigue"),
    B("Aura (if present, 20–60 min): Visual, sensory, speech disturbance"),
    B("Headache phase (4–72 hrs): Pulsating, unilateral, severe"),
    B("Resolution / Postdrome: Fatigue, cognitive slowing ('migraine hangover')"),
    S(2),
    H("Management:"),
    H("Acute (Abortive) Treatment:"),
    B("Mild-moderate: NSAIDs (ibuprofen 400–800 mg, naproxen), aspirin + metoclopramide"),
    B("Moderate-severe: Triptans (Sumatriptan 50–100 mg PO; 6 mg SC; naratriptan, rizatriptan, zolmitriptan) — 5HT1B/1D agonists; MOST EFFECTIVE specific treatment; avoid in cardiovascular disease"),
    B("Antiemetics: Metoclopramide 10 mg IV/IM, or prochlorperazine (also has analgesic effect)"),
    B("Ergotamine tartrate: Older agent; significant side effects; largely replaced by triptans"),
    B("CGRP antagonists (Gepants — Rimegepant, Ubrogepant): Newer acute treatment"),
    H("Preventive Treatment (if ≥4 attacks/month or significant disability):"),
    B("Beta-blockers: Propranolol 40–80 mg BD (first-line), metoprolol"),
    B("Tricyclic antidepressants: Amitriptyline 10–75 mg nocte"),
    B("Anticonvulsants: Topiramate 25–100 mg/day, valproate (avoid in women of childbearing age)"),
    B("CCBs: Flunarizine, cinnarizine"),
    B("CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab): Monthly injections; newer, highly effective preventives"),
    H("Non-pharmacological: Identify and avoid triggers, regular sleep, hydration, relaxation techniques, biofeedback"),
    S(6),

    H("(d) Mumps"),
    P("Mumps is an acute, contagious viral infection caused by the Mumps virus (a paramyxovirus, single-stranded RNA), primarily affecting the salivary glands (parotid glands). It is a vaccine-preventable disease."),
    S(2),
    H("Transmission:"),
    B("Via respiratory droplets and direct contact with infected saliva"),
    B("Incubation period: 16–18 days (range 14–25 days)"),
    B("Infectious period: 1–2 days before parotid swelling to 5 days after onset"),
    S(2),
    H("Clinical Features:"),
    H("Prodrome (2–3 days):"),
    B("Fever (38–40°C), headache, malaise, myalgia, anorexia"),
    H("Salivary Gland Involvement:"),
    B("Parotitis: Painful swelling of one or both parotid glands (bilateral in 70%); swelling below/in front of ear → raises earlobe; tender on palpation"),
    B("Parotid duct (Stensen's duct) opening: Reddened and oedematous"),
    B("Trismus (limited mouth opening due to pain)"),
    B("Submandibular and sublingual glands may also be involved"),
    B("Swelling subsides in 7–10 days"),
    S(2),
    H("Complications:"),
    B("Orchitis (20–30% of post-pubertal males): Most feared; unilateral/bilateral testicular swelling + pain; can lead to testicular atrophy and subfertility (rarely infertility with bilateral)"),
    B("Oophoritis (5% of post-pubertal females)"),
    B("Meningitis / Meningoencephalitis (most common CNS complication): Usually benign, self-limiting; CSF — lymphocytes, normal glucose"),
    B("Sensorineural deafness: Can be permanent; usually unilateral"),
    B("Pancreatitis: Epigastric pain, vomiting, elevated serum amylase/lipase"),
    B("Myocarditis (rare), arthritis, thrombocytopaenia"),
    S(2),
    H("Diagnosis:"),
    B("Clinical: Typical parotid swelling in an unvaccinated child/young adult"),
    B("Serology: Mumps-specific IgM (acute infection) or 4-fold rise in IgG"),
    B("RT-PCR: Buccal swab / CSF / urine — most sensitive"),
    B("Serum amylase: Elevated (from parotid and/or pancreas)"),
    S(2),
    H("Management:"),
    B("No specific antiviral therapy — treatment is supportive"),
    B("Analgesics/antipyretics: Paracetamol for fever and pain"),
    B("Soft diet and adequate fluids"),
    B("Local warm/cold compress to parotid"),
    B("Bed rest during acute phase"),
    B("Orchitis: Bed rest, scrotal support, analgesics (NSAIDs); corticosteroids (prednisolone) in severe cases"),
    B("Isolation: Avoid contact with unimmunised individuals for 5 days from parotid swelling"),
    H("Prevention:"),
    B("MMR vaccine (Measles-Mumps-Rubella): 2 doses — 9–12 months and 15–18 months (India NIP); 95% protective"),
    B("Post-exposure prophylaxis: MMR vaccine within 72 hrs of exposure may provide some protection"),
    S(8),
]

# ── FOOTER ──────────────────────────────────────────────────────────
story += [
    HRFlowable(width="100%", thickness=1.5, color=colors.HexColor('#1a237e')),
    S(4),
    Paragraph(
        "Model Answers — BDS Third Year (Main) General Medicine Paper I, October 2025  |  "
        "Prepared with reference to Harrison's Principles of Internal Medicine 22E, "
        "Davidson's Principles & Practice of Medicine, Braunwald's Heart Disease, "
        "Murray & Nadel's Respiratory Medicine, and WHO/RNTCP/NVBDCP Guidelines.",
        ParagraphStyle('footer', parent=styles['Normal'], fontSize=8,
            textColor=colors.HexColor('#757575'), alignment=TA_CENTER)
    ),
]

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