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

// ─── Helper: bold text run ──────────────────────────────────────────────────
const bold = (text, size = 22) => new TextRun({ text, bold: true, size, font: "Times New Roman" });
const normal = (text, size = 22) => new TextRun({ text, size, font: "Times New Roman" });
const italic = (text, size = 22) => new TextRun({ text, italics: true, size, font: "Times New Roman" });
const underlineBold = (text, size = 22) => new TextRun({ text, bold: true, underline: { type: UnderlineType.SINGLE }, size, font: "Times New Roman" });

// ─── Helper: simple paragraph ─────────────────────────────────────────────
const para = (children, opts = {}) => new Paragraph({
  children: Array.isArray(children) ? children : [children],
  spacing: { after: 80, before: 0 },
  ...opts
});

// ─── Helper: spacing paragraph ─────────────────────────────────────────────
const spacer = () => new Paragraph({ children: [new TextRun("")], spacing: { after: 60 } });

// ─── Helper: section heading ───────────────────────────────────────────────
const sectionHead = (text) => new Paragraph({
  children: [new TextRun({ text, bold: true, size: 24, underline: { type: UnderlineType.SINGLE }, font: "Times New Roman" })],
  spacing: { before: 200, after: 100 }
});

// ─── Helper: sub-heading ──────────────────────────────────────────────────
const subHead = (text) => new Paragraph({
  children: [new TextRun({ text, bold: true, size: 22, font: "Times New Roman" })],
  spacing: { before: 120, after: 60 }
});

// ─── Helper: table cell ───────────────────────────────────────────────────
const cell = (text, opts = {}) => new TableCell({
  children: [new Paragraph({
    children: [new TextRun({ text, size: 20, font: "Times New Roman", bold: opts.bold || false })],
    spacing: { after: 60, before: 60 },
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  })],
  width: opts.width ? { size: opts.width, type: WidthType.DXA } : undefined,
  shading: opts.shade ? { fill: opts.shade, type: ShadingType.CLEAR } : undefined,
  verticalAlign: VerticalAlign.CENTER,
  margins: { top: 80, bottom: 80, left: 120, right: 120 }
});

const headerCell = (text, width) => new TableCell({
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    children: [new TextRun({ text, size: 20, bold: true, font: "Times New Roman" })],
    spacing: { after: 60, before: 60 },
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  width: width ? { size: width, type: WidthType.DXA } : undefined,
  shading: { fill: "D9E1F2", type: ShadingType.CLEAR },
  verticalAlign: VerticalAlign.CENTER,
  margins: { top: 80, bottom: 80, left: 120, right: 120 }
});

// ─── Table border ─────────────────────────────────────────────────────────
const thinBorder = { style: BorderStyle.SINGLE, size: 6, color: "000000" };
const tableBorders = {
  top: thinBorder, bottom: thinBorder, left: thinBorder, right: thinBorder,
  insideHorizontal: thinBorder, insideVertical: thinBorder
};

// ═══════════════════════════════════════════════════════════════════════════
// DOCUMENT CONTENT
// ═══════════════════════════════════════════════════════════════════════════

const content = [

  // ── TITLE ──────────────────────────────────────────────────────────────
  new Paragraph({
    children: [new TextRun({ text: "INTERNAL MEDICINE MEDICAL RECORD", bold: true, size: 28, font: "Times New Roman" })],
    alignment: AlignmentType.CENTER,
    spacing: { after: 60 }
  }),
  new Paragraph({
    children: [italic("(Internal Medicine / Endocrinology Department — Trung Vuong Hospital, HCMC)", 22)],
    alignment: AlignmentType.CENTER,
    spacing: { after: 200 }
  }),

  // ── I. ADMINISTRATIVE SECTION ─────────────────────────────────────────
  sectionHead("I. ADMINISTRATIVE SECTION"),

  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Field", 2400), headerCell("Details", 6960)] }),
      new TableRow({ children: [cell("Full Name", { bold: true }), cell("Chau Thi Bich Diep")] }),
      new TableRow({ children: [cell("Gender", { bold: true }), cell("Female")] }),
      new TableRow({ children: [cell("Date of Birth", { bold: true }), cell("16/05/1971 (Age: 55)")] }),
      new TableRow({ children: [cell("Address", { bold: true }), cell("Ap 1, Xa Vinh Loc, Ho Chi Minh City")] }),
      new TableRow({ children: [cell("BHYT No.", { bold: true }), cell("GD4797936717703790 26")] }),
      new TableRow({ children: [cell("PID", { bold: true }), cell("70131126012722")] }),
      new TableRow({ children: [cell("Admission No.", { bold: true }), cell("26/014363")] }),
      new TableRow({ children: [cell("Ward / Room", { bold: true }), cell("Khoa Noi Tiet - Tong Hop / Room 8")] }),
      new TableRow({ children: [cell("Admitting Doctor", { bold: true }), cell("BS. Cao Thi Minh")] }),
      new TableRow({ children: [cell("Date and Time of Admission", { bold: true }), cell("22/06/2026 at 07:18 (via Emergency)")] }),
      new TableRow({ children: [cell("Date of Medical Record", { bold: true }), cell("22–23 June 2026")] }),
    ]
  }),

  spacer(),

  // ── II. MEDICAL INQUIRY SECTION ───────────────────────────────────────
  sectionHead("II. MEDICAL INQUIRY SECTION"),

  subHead("1. Reason for Hospitalisation"),
  para([normal("Fatigue, weakness of arms and legs, and poor glycaemic control in known Type 2 Diabetes Mellitus not previously on insulin.")]),

  spacer(),
  subHead("2. Medical History (by patient and family)"),

  subHead("Onset and Progression:"),
  para([normal("The patient is a 55-year-old woman with a known history of Type 2 Diabetes Mellitus who presented with progressively worsening glycaemic control, fatigue, and generalised weakness of the upper and lower limbs. She was not previously on insulin. Her current admission was prompted by persistent hyperglycaemic symptoms and limb weakness necessitating further evaluation and management.")]),

  spacer(),
  subHead("Classical Diabetic Symptoms:"),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Symptom", 3000), headerCell("Details", 6360)] }),
      new TableRow({ children: [cell("Polyuria", { bold: true }), cell("3–4 voids per day plus 1 at night; urine volume correlates with fluid intake; urine colour dark (consistent with hyperglycaemic concentration and mild dehydration)")] }),
      new TableRow({ children: [cell("Polydipsia", { bold: true }), cell("Thirst present; drinking approximately 2 litres per day")] }),
      new TableRow({ children: [cell("Polyphagia", { bold: true }), cell("3 meals per day (rice, fish, meat, sweet potato)")] }),
      new TableRow({ children: [cell("Weight Loss", { bold: true }), cell("Approximately 10 kg over 2 years (unintentional)")] }),
    ]
  }),

  spacer(),
  subHead("Additional Symptoms:"),
  para([bold("Fatigue and Weakness: "), normal("Generalised; involving arms and legs.")]),
  para([bold("Peripheral Neuropathy Symptoms: "), normal("Numbness and tingling on the plantar surface of both feet (stocking distribution); leg pain on prolonged walking; occasional loss of balance; sweating and shakiness when meals are missed (hypoglycaemic episodes).")]),
  para([bold("Oedema: "), normal("Bilateral swelling from mid-lower leg to toes after prolonged ambulation.")]),
  para([bold("Skin: "), normal("Intermittent itching (arms and whole body); mild dehydration; no acanthosis nigricans.")]),

  spacer(),
  subHead("Negative Findings:"),
  para([normal("No blurred vision. No recurrent infections. Normal wound healing. No nausea, vomiting, or abdominal pain. No gestational diabetes history.")]),

  spacer(),
  subHead("Thyroid:"),
  para([normal("Known thyroid disease (hyperthyroidism/toxic thyroid). On treatment prior to admission.")]),

  spacer(),

  // ── III. PAST MEDICAL HISTORY ─────────────────────────────────────────
  subHead("3. Past Medical History"),

  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Condition", 6360), headerCell("Status", 3000)] }),
      new TableRow({ children: [cell("Type 2 Diabetes Mellitus (uncontrolled, not on insulin)"), cell("Known")] }),
      new TableRow({ children: [cell("Hyperthyroidism (Toxic Thyroid Disease)"), cell("Known")] }),
      new TableRow({ children: [cell("Hypertension"), cell("Known")] }),
      new TableRow({ children: [cell("Ischaemic Heart Disease"), cell("Known")] }),
      new TableRow({ children: [cell("Mixed Dyslipidaemia"), cell("Known")] }),
    ]
  }),

  spacer(),
  subHead("Past Medications (3 Outpatient Prescriptions — Trung Vuong Hospital)"),

  para([bold("Prescription 1 — 26 March 2026 (28-day supply, Bs. Nguyen Thi Thu Van):")]),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Drug", 4000), headerCell("Dose & Frequency", 3360), headerCell("Timing", 2000)] }),
      new TableRow({ children: [cell("Humulin 30/70 Kwikpen (Insulin 30% soluble + 70% NPH)"), cell("12 IU SC twice daily"), cell("Morning + Evening, 30 min before meals")] }),
      new TableRow({ children: [cell("Empaton 10mg (Empagliflozin)"), cell("1 tablet once daily"), cell("Morning")] }),
      new TableRow({ children: [cell("Sitagliptin-5A Farma 50mg (Sitagliptin)"), cell("1 tablet once daily"), cell("Morning")] }),
      new TableRow({ children: [cell("Thiamazole 5mg"), cell("2 tablets twice daily (10 mg/dose)"), cell("Morning and Afternoon")] }),
      new TableRow({ children: [cell("Vixcar 75mg (Clopidogrel)"), cell("1 tablet once daily"), cell("Afternoon after meals")] }),
      new TableRow({ children: [cell("Ibartain MR 150mg (Irbesartan)"), cell("1 tablet once daily"), cell("Morning")] }),
      new TableRow({ children: [cell("Danapha-Rosu 20mg (Rosuvastatin)"), cell("1 tablet once daily"), cell("Afternoon after meals")] }),
    ]
  }),

  spacer(),
  para([bold("Prescription 2 — 9 June 2026 (7-day supply, Bs. Truong Anh Minh):")]),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Drug", 4000), headerCell("Dose & Frequency", 3360), headerCell("Timing", 2000)] }),
      new TableRow({ children: [cell("Humalog Mix50 300U/3mL Kwikpen (Insulin Lispro 50/50)"), cell("16 units SC twice daily"), cell("Morning and Afternoon, 5 min before meals")] }),
      new TableRow({ children: [cell("Thyrozol 5mg (Thiamazole)"), cell("2 tablets once daily (10 mg)"), cell("Morning")] }),
    ]
  }),

  spacer(),
  para([bold("Prescription 3 — 9 June 2026 (28-day supply, Bs. Phan Tan Tai — Cardiology Dept.):")]),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Drug", 4000), headerCell("Dose & Frequency", 3360), headerCell("Timing", 2000)] }),
      new TableRow({ children: [cell("Agirovastin 20mg (Rosuvastatin)"), cell("1 tablet once daily"), cell("Afternoon/Evening")] }),
      new TableRow({ children: [cell("Clopalvix 75mg (Clopidogrel)"), cell("1 tablet once daily"), cell("Morning")] }),
      new TableRow({ children: [cell("Ibartain MR 150mg (Irbesartan)"), cell("1 tablet once daily"), cell("Morning")] }),
    ]
  }),

  spacer(),
  subHead("4. Family and Social History"),
  para([bold("Family History: "), normal("Sister with Type 2 Diabetes Mellitus.")]),
  para([bold("Smoking: "), normal("None.")]),
  para([bold("Alcohol: "), normal("None.")]),
  para([bold("Diet: "), normal("Rice-based diet; 3 meals per day; fish, meat, sweet potato.")]),
  para([bold("Functional Status: "), normal("Normal to mildly limited ADLs; independent in eating, bathing, dressing, and ambulation.")]),
  para([bold("Allergies: "), normal("None documented.")]),

  spacer(),

  // ── IV. CLINICAL EXAMINATION ──────────────────────────────────────────
  sectionHead("III. CLINICAL EXAMINATION"),

  subHead("Vital Signs — Admission 22/06/2026"),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Parameter", 3000), headerCell("Value", 3180), headerCell("Status", 3180)] }),
      new TableRow({ children: [cell("Temperature"), cell("37.0 °C"), cell("Normal")] }),
      new TableRow({ children: [cell("Heart Rate"), cell("100 bpm"), cell("Tachycardic (likely hyperglycaemia/dehydration)")] }),
      new TableRow({ children: [cell("Blood Pressure"), cell("130/60 mmHg"), cell("Acceptable; monitor diastolic")] }),
      new TableRow({ children: [cell("Respiratory Rate"), cell("20 breaths/min"), cell("Normal")] }),
      new TableRow({ children: [cell("SpO2"), cell("98% (room air)"), cell("Normal")] }),
      new TableRow({ children: [cell("Weight / BMI"), cell("55 kg / 21.5 kg/m²"), cell("Normal BMI")] }),
      new TableRow({ children: [cell("GCS"), cell("15/15"), cell("Fully conscious")] }),
    ]
  }),

  spacer(),
  para([bold("23/06/2026 (Follow-up): "), normal("HR 78–82 bpm, BP 120/60 mmHg, Temperature 37 °C, SpO2 98% — stable and improving.")]),

  spacer(),
  subHead("Systemic Examination"),
  para([bold("General: "), normal("Alert, oriented, no acute distress, mild dehydration.")]),
  para([bold("Skin: "), normal("Dry, itchy; no acanthosis nigricans; mucous membranes pink.")]),
  para([bold("Cardiovascular: "), normal("Regular rhythm; no murmurs documented.")]),
  para([bold("Respiratory: "), normal("Normal pattern; no supplemental oxygen required.")]),
  para([bold("Abdomen: "), normal("Soft; ultrasound normal — no hepatomegaly, no gallstones, no ascites.")]),
  para([bold("Neurological: "), normal("GCS 15; peripheral neuropathy symptoms by history; occasional loss of balance.")]),
  para([bold("Lower Limbs: "), normal("Bilateral pitting oedema from mid-lower leg to toes.")]),

  spacer(),
  subHead("Diabetic Hand and Foot Assessment"),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Test", 4680), headerCell("Result", 4680)] }),
      new TableRow({ children: [cell("Prayer's Sign"), cell("Normal")] }),
      new TableRow({ children: [cell("Shoulder Range of Motion"), cell("Normal")] }),
      new TableRow({ children: [cell("Tabletop Sign"), cell("Normal")] }),
      new TableRow({ children: [cell("Dupuytren's Contracture"), cell("Negative")] }),
      new TableRow({ children: [cell("Charcot's Foot"), cell("Absent")] }),
    ]
  }),

  spacer(),

  // ── V. CASE SUMMARY ──────────────────────────────────────────────────
  sectionHead("IV. CASE SUMMARY"),

  para([normal("A 55-year-old woman with a known background of Type 2 Diabetes Mellitus (not previously on insulin), Hyperthyroidism, Hypertension, Ischaemic Heart Disease, and Mixed Dyslipidaemia was admitted to Trung Vuong Hospital on 22 June 2026 via the Emergency Department. She presented with fatigue, generalised weakness of the arms and legs, and symptoms of uncontrolled hyperglycaemia including polyuria, polydipsia, polyphagia, and unintentional weight loss of approximately 10 kg over 2 years. She also reported peripheral neuropathic symptoms — bilateral plantar numbness and tingling (stocking distribution), leg pain on prolonged walking, occasional loss of balance, and hypoglycaemic episodes when meals are skipped.")]),
  spacer(),
  subHead("Subjective Symptoms:"),
  para([normal("Fatigue and limb weakness. Polyuria (3–4 voids/day + nocturia). Polydipsia (approximately 2 L/day). Polyphagia (3 meals/day). Unintentional weight loss of 10 kg over 2 years. Bilateral plantar numbness and tingling. Leg pain on walking. Occasional loss of balance. Hypoglycaemic episodes (sweating, shakiness) on meal skipping. Bilateral lower limb oedema. Generalised skin itching. Known hyperthyroidism on thiamazole.")]),
  spacer(),
  subHead("Objective Signs:"),
  para([normal("Heart rate 100 bpm on admission. BP 130/60 mmHg. BMI 21.5 kg/m². Mild dehydration. Bilateral pitting oedema mid-leg to toes. No acanthosis nigricans. Suppressed TSH (0.0027 uIU/mL). HbA1c 12.6%. Fasting blood glucose 251 mg/dL. Glycosuria on urinalysis.")]),

  spacer(),

  // ── VI. INVESTIGATIONS ────────────────────────────────────────────────
  sectionHead("V. PARACLINICAL INVESTIGATIONS"),

  subHead("A. Full Blood Count — 22/06/2026 (All Normal)"),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Test", 2600), headerCell("Result", 2200), headerCell("Reference", 2300), headerCell("Status", 2260)] }),
      new TableRow({ children: [cell("WBC"), cell("9.69 × 10⁹/L"), cell("4–10"), cell("Normal")] }),
      new TableRow({ children: [cell("Haemoglobin"), cell("14.2 g/dL"), cell("12–16"), cell("Normal")] }),
      new TableRow({ children: [cell("Haematocrit"), cell("43.6%"), cell("36–46"), cell("Normal")] }),
      new TableRow({ children: [cell("Platelets"), cell("212 × 10⁹/L"), cell("150–400"), cell("Normal")] }),
      new TableRow({ children: [cell("MCV"), cell("92 fL"), cell("80–100"), cell("Normal")] }),
    ]
  }),

  spacer(),
  subHead("B. Biochemistry — 22/06/2026"),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Test", 2600), headerCell("Result", 2200), headerCell("Reference", 2300), headerCell("Status", 2260)] }),
      new TableRow({ children: [cell("Creatinine"), cell("61 µmol/L"), cell("45–84"), cell("Normal")] }),
      new TableRow({ children: [cell("eGFR"), cell("94 mL/min/1.73m²"), cell(">90"), cell("Normal")] }),
      new TableRow({ children: [cell("Sodium (Na)"), cell("135 mmol/L"), cell("135–145"), cell("Normal")] }),
      new TableRow({ children: [cell("Potassium (K)"), cell("4.0 mmol/L"), cell("3.5–5.1"), cell("Normal")] }),
      new TableRow({ children: [cell("Chloride (Cl)"), cell("102 mmol/L"), cell("98–108"), cell("Normal")] }),
      new TableRow({ children: [cell("AST"), cell("10 U/L"), cell("<35"), cell("Normal")] }),
      new TableRow({ children: [cell("ALT"), cell("4 U/L"), cell("<35"), cell("Normal")] }),
      new TableRow({ children: [
        new TableCell({
          children: [new Paragraph({ children: [new TextRun({ text: "HbA1c", bold: true, size: 20, font: "Times New Roman" })], spacing: { after: 60, before: 60 } })],
          shading: { fill: "FFE0E0", type: ShadingType.CLEAR },
          margins: { top: 80, bottom: 80, left: 120, right: 120 }
        }),
        new TableCell({
          children: [new Paragraph({ children: [new TextRun({ text: "12.6%", bold: true, size: 20, font: "Times New Roman" })], spacing: { after: 60, before: 60 } })],
          shading: { fill: "FFE0E0", type: ShadingType.CLEAR },
          margins: { top: 80, bottom: 80, left: 120, right: 120 }
        }),
        new TableCell({
          children: [new Paragraph({ children: [new TextRun({ text: "<7%", size: 20, font: "Times New Roman" })], spacing: { after: 60, before: 60 } })],
          shading: { fill: "FFE0E0", type: ShadingType.CLEAR },
          margins: { top: 80, bottom: 80, left: 120, right: 120 }
        }),
        new TableCell({
          children: [new Paragraph({ children: [new TextRun({ text: "CRITICALLY HIGH", bold: true, size: 20, font: "Times New Roman" })], spacing: { after: 60, before: 60 } })],
          shading: { fill: "FFE0E0", type: ShadingType.CLEAR },
          margins: { top: 80, bottom: 80, left: 120, right: 120 }
        })
      ]}),
      new TableRow({ children: [
        new TableCell({
          children: [new Paragraph({ children: [new TextRun({ text: "Fasting Blood Glucose", bold: true, size: 20, font: "Times New Roman" })], spacing: { after: 60, before: 60 } })],
          shading: { fill: "FFE0E0", type: ShadingType.CLEAR },
          margins: { top: 80, bottom: 80, left: 120, right: 120 }
        }),
        new TableCell({
          children: [new Paragraph({ children: [new TextRun({ text: "251 mg/dL (13.9 mmol/L)", bold: true, size: 20, font: "Times New Roman" })], spacing: { after: 60, before: 60 } })],
          shading: { fill: "FFE0E0", type: ShadingType.CLEAR },
          margins: { top: 80, bottom: 80, left: 120, right: 120 }
        }),
        new TableCell({
          children: [new Paragraph({ children: [new TextRun({ text: "80–130 mg/dL", size: 20, font: "Times New Roman" })], spacing: { after: 60, before: 60 } })],
          shading: { fill: "FFE0E0", type: ShadingType.CLEAR },
          margins: { top: 80, bottom: 80, left: 120, right: 120 }
        }),
        new TableCell({
          children: [new Paragraph({ children: [new TextRun({ text: "CRITICALLY HIGH", bold: true, size: 20, font: "Times New Roman" })], spacing: { after: 60, before: 60 } })],
          shading: { fill: "FFE0E0", type: ShadingType.CLEAR },
          margins: { top: 80, bottom: 80, left: 120, right: 120 }
        })
      ]}),
    ]
  }),

  spacer(),
  subHead("C. Thyroid Function Tests — 22/06/2026"),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Test", 2600), headerCell("Result", 2200), headerCell("Reference", 2300), headerCell("Interpretation", 2260)] }),
      new TableRow({ children: [
        new TableCell({
          children: [new Paragraph({ children: [new TextRun({ text: "TSH", bold: true, size: 20, font: "Times New Roman" })], spacing: { after: 60, before: 60 } })],
          shading: { fill: "FFF2CC", type: ShadingType.CLEAR },
          margins: { top: 80, bottom: 80, left: 120, right: 120 }
        }),
        new TableCell({
          children: [new Paragraph({ children: [new TextRun({ text: "0.0027 uIU/mL", bold: true, size: 20, font: "Times New Roman" })], spacing: { after: 60, before: 60 } })],
          shading: { fill: "FFF2CC", type: ShadingType.CLEAR },
          margins: { top: 80, bottom: 80, left: 120, right: 120 }
        }),
        new TableCell({
          children: [new Paragraph({ children: [new TextRun({ text: "0.35–4.94", size: 20, font: "Times New Roman" })], spacing: { after: 60, before: 60 } })],
          shading: { fill: "FFF2CC", type: ShadingType.CLEAR },
          margins: { top: 80, bottom: 80, left: 120, right: 120 }
        }),
        new TableCell({
          children: [new Paragraph({ children: [new TextRun({ text: "Suppressed — Active Hyperthyroidism", bold: true, size: 20, font: "Times New Roman" })], spacing: { after: 60, before: 60 } })],
          shading: { fill: "FFF2CC", type: ShadingType.CLEAR },
          margins: { top: 80, bottom: 80, left: 120, right: 120 }
        })
      ]}),
      new TableRow({ children: [cell("Free T4"), cell("1.02 ng/dL"), cell("0.70–1.48"), cell("Normal (upper range)")] }),
    ]
  }),

  spacer(),
  subHead("D. Urinalysis — 22/06/2026"),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Parameter", 3120), headerCell("Result", 3120), headerCell("Status", 3120)] }),
      new TableRow({ children: [cell("Glucose"), cell("111 mmol/L"), cell("Glycosuria — consistent with hyperglycaemia")] }),
      new TableRow({ children: [cell("Protein"), cell("Negative"), cell("Normal")] }),
      new TableRow({ children: [cell("Ketones"), cell("Negative"), cell("Normal")] }),
      new TableRow({ children: [cell("Blood"), cell("Negative"), cell("Normal")] }),
      new TableRow({ children: [cell("Specific Gravity"), cell("1.032"), cell("Elevated — dehydration/concentration")] }),
    ]
  }),

  spacer(),
  subHead("E. Abdominal Ultrasound — 22/06/2026"),
  para([normal("No abnormal findings. Liver: normal size and echogenicity. Gallbladder: normal. Uterus: small/atrophic (postmenopausal). No ascites. Conclusion: No current abnormal findings.")]),

  spacer(),

  // ── VII. DIAGNOSES ────────────────────────────────────────────────────
  sectionHead("VI. DIAGNOSES"),

  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("No.", 600), headerCell("Diagnosis", 8760)] }),
      new TableRow({ children: [cell("1", { align: AlignmentType.CENTER }), cell("Type 2 Diabetes Mellitus, uncontrolled — HbA1c 12.6%, Fasting Blood Glucose 251 mg/dL")] }),
      new TableRow({ children: [cell("2", { align: AlignmentType.CENTER }), cell("Hyperthyroidism (Toxic Thyroid Disease) — TSH critically suppressed at 0.0027 uIU/mL")] }),
      new TableRow({ children: [cell("3", { align: AlignmentType.CENTER }), cell("Hypertension")] }),
      new TableRow({ children: [cell("4", { align: AlignmentType.CENTER }), cell("Ischaemic Heart Disease (Established ASCVD)")] }),
      new TableRow({ children: [cell("5", { align: AlignmentType.CENTER }), cell("Mixed Dyslipidaemia")] }),
      new TableRow({ children: [cell("6", { align: AlignmentType.CENTER }), cell("Peripheral Diabetic Neuropathy — symptomatic (bilateral plantar numbness, stocking distribution, balance loss)")] }),
    ]
  }),

  spacer(),
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    width: { size: 9360, type: WidthType.DXA },
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    rows: [
      new TableRow({ children: [headerCell("Risk Assessment", 4680), headerCell("Score", 4680)] }),
      new TableRow({ children: [cell("Fall Risk (Morse Scale)"), cell("Moderate — 35 points")] }),
      new TableRow({ children: [cell("Pressure Injury Risk (Braden Scale)"), cell("Low — 23 points")] }),
    ]
  }),

  spacer(),

  // ── VIII. TREATMENT & MANAGEMENT ──────────────────────────────────────
  sectionHead("VII. TREATMENT AND MANAGEMENT"),

  subHead("A. Pharmacological Management"),

  para([underlineBold("1. Diabetes Mellitus — Inpatient Regimen:")]),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Drug", 3200), headerCell("Dose", 1600), headerCell("Route", 1000), headerCell("Timing", 2000), headerCell("Duration", 1560)] }),
      new TableRow({ children: [cell("Mixtard 30 (Biphasic Human Insulin 30/70, rDNA)"), cell("16 IU"), cell("SC"), cell("Morning + Evening, 30 min before meals"), cell("Continue; titrate to glucose logs")] }),
      new TableRow({ children: [cell("Glucophage XR (Metformin HCl) 750 mg"), cell("750 mg"), cell("PO"), cell("Evening with meal"), cell("Continue; safe with eGFR 94")] }),
      new TableRow({ children: [cell("Mebista 50 mg (Sitagliptin)"), cell("50 mg"), cell("PO"), cell("Morning"), cell("Continue")] }),
    ]
  }),

  spacer(),
  para([italic("Note: Given HbA1c of 12.6% with established cardiovascular disease, insulin initiation was appropriate. A GLP-1 receptor agonist with proven cardiovascular benefit (e.g., Semaglutide subcutaneous weekly) is strongly indicated for this patient profile and should be prioritised after initial glycaemic stabilisation. An SGLT2 inhibitor (e.g., Empagliflozin 10 mg daily) may also be considered after discharge for additional cardiovascular and renal protection, given eGFR 94 mL/min.")]),

  spacer(),
  para([underlineBold("2. Hypertension:")]),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Drug", 3200), headerCell("Dose", 1600), headerCell("Route", 1000), headerCell("Timing", 2000), headerCell("Duration", 1560)] }),
      new TableRow({ children: [cell("Irbesartan (Ibartain MR) 150 mg"), cell("150 mg"), cell("PO"), cell("Morning"), cell("28 days; review at follow-up")] }),
    ]
  }),
  para([italic("Monitor diastolic blood pressure closely (current diastolic 60 mmHg — avoid over-treatment). ARBs are preferred agents in diabetic patients with hypertension.")]),

  spacer(),
  para([underlineBold("3. Ischaemic Heart Disease — Antiplatelet Therapy:")]),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Drug", 3200), headerCell("Dose", 1600), headerCell("Route", 1000), headerCell("Timing", 2000), headerCell("Duration", 1560)] }),
      new TableRow({ children: [cell("Clopalvix 75 mg (Clopidogrel)"), cell("75 mg"), cell("PO"), cell("Afternoon, after meals"), cell("28 days; long-term")] }),
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  }),
  para([italic("Antiplatelet therapy is indicated for established atherosclerotic cardiovascular disease.")]),

  spacer(),
  para([underlineBold("4. Mixed Dyslipidaemia:")]),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Drug", 3200), headerCell("Dose", 1600), headerCell("Route", 1000), headerCell("Timing", 2000), headerCell("Duration", 1560)] }),
      new TableRow({ children: [cell("Sterolow / Agirovastin 20 mg (Rosuvastatin)"), cell("20 mg"), cell("PO"), cell("Evening after meals"), cell("28 days; review lipid panel")] }),
    ]
  }),
  para([italic("High-intensity statin therapy is recommended for patients with Type 2 Diabetes Mellitus and established ASCVD with an LDL-C target of <70 mg/dL. Uptitration to Rosuvastatin 40 mg or addition of Ezetimibe 10 mg should be considered at follow-up if LDL-C target is not achieved.")]),

  spacer(),
  para([underlineBold("5. Hyperthyroidism:")]),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Drug", 3200), headerCell("Dose", 1600), headerCell("Route", 1000), headerCell("Timing", 2000), headerCell("Duration", 1560)] }),
      new TableRow({ children: [cell("Thyrozol 5 mg (Thiamazole)"), cell("10 mg (2 tablets)"), cell("PO"), cell("Morning"), cell("28 days; recheck TSH/FT4 in 6–8 weeks")] }),
    ]
  }),
  para([italic("The suppressed TSH (0.0027 uIU/mL) indicates active hyperthyroidism which directly worsens glycaemic control by increasing hepatic glucose output and peripheral insulin resistance. Optimisation of thyroid function is essential for effective diabetes management. Endocrinology specialist review is recommended.")]),

  spacer(),
  para([underlineBold("6. Inpatient IV Fluid (Admission Day):")]),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
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      new TableRow({ children: [headerCell("Fluid", 4680), headerCell("Volume / Rate", 4680)] }),
      new TableRow({ children: [cell("Ringer Lactate (Calcium / Potassium / Sodium / Sodium Chloride)"), cell("500 mL IV on admission day — rehydration and electrolyte support")] }),
    ]
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  spacer(),
  subHead("B. Non-Pharmacological Management"),

  para([underlineBold("1. Medical Nutrition Therapy:")]),
  para([normal("Hospital diet: DD01-Com (diabetic rice diet). Reduce refined carbohydrates; limit rice to 1/2–3/4 cup per meal; avoid excess sweet potato. Distribute intake evenly across 3 meals — never skip meals (patient has documented hypoglycaemic episodes on meal skipping). Increase non-starchy vegetables; lean protein (fish is appropriate). Limit sodium to <2,300 mg/day; eliminate added sugars. Maintain fluid intake of approximately 2 litres per day.")]),

  spacer(),
  para([underlineBold("2. Physical Activity:")]),
  para([normal("Target: at least 150 minutes per week of moderate-intensity aerobic activity. Start with 30-minute daily low-impact walks on a flat surface (given leg pain). Seated exercises and resistance training 2–3 times per week when tolerated. Monitor blood glucose before and after exercise. Treat hypoglycaemia immediately with 15 g fast-acting carbohydrates (15-15 rule).")]),

  spacer(),
  para([underlineBold("3. Diabetes Self-Management Education (DSMES):")]),
  para([normal("Blood glucose self-monitoring (SMBG): fasting target 80–130 mg/dL; post-meal target <180 mg/dL. Hypoglycaemia recognition and management: symptoms include sweating and shakiness; treat with 15 g glucose. Insulin injection technique, site rotation, and proper storage. Daily foot inspection; appropriate footwear; no barefoot walking. Sick-day rules and medication adherence. All nurse educator (GDSK) documentation completed: diet, exercise, medication, warning signs, safety.")]),

  spacer(),
  subHead("C. Monitoring Schedule"),
  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Parameter", 4680), headerCell("Frequency", 4680)] }),
      new TableRow({ children: [cell("HbA1c"), cell("Every 3 months until target achieved, then 6-monthly")] }),
      new TableRow({ children: [cell("Fasting and post-meal blood glucose"), cell("Daily SMBG; CGM recommended for patients on insulin")] }),
      new TableRow({ children: [cell("TSH and Free T4"), cell("Every 3–6 months (currently critically suppressed — urgent recheck)")] }),
      new TableRow({ children: [cell("Renal function (Creatinine, eGFR, urine ACR)"), cell("Annually (urine ACR not yet done — order at first follow-up visit)")] }),
      new TableRow({ children: [cell("Lipid panel"), cell("Annually; 3-monthly after statin adjustment")] }),
      new TableRow({ children: [cell("Dilated fundoscopy (retinal exam)"), cell("Annually")] }),
      new TableRow({ children: [cell("Comprehensive foot exam"), cell("Every clinic visit; annual formal monofilament assessment")] }),
      new TableRow({ children: [cell("Blood pressure"), cell("Every clinic visit")] }),
      new TableRow({ children: [cell("Vaccinations"), cell("Influenza annually; Pneumococcal; COVID booster per local guidelines")] }),
    ]
  }),

  spacer(),

  // ── IX. DISCHARGE PLAN ────────────────────────────────────────────────
  sectionHead("VIII. DISCHARGE PLAN"),

  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Drug", 4000), headerCell("Dose", 1560), headerCell("Frequency / Timing", 3800)] }),
      new TableRow({ children: [cell("Mixtard 30 (Biphasic Human Insulin 30/70)"), cell("16 IU (titrate)"), cell("SC twice daily — morning + evening, 30 min before meals")] }),
      new TableRow({ children: [cell("Glucophage XR (Metformin HCl) 750 mg"), cell("750 mg"), cell("PO once daily — evening")] }),
      new TableRow({ children: [cell("Mebista (Sitagliptin) 50 mg"), cell("50 mg"), cell("PO once daily — morning")] }),
      new TableRow({ children: [cell("Irbesartan (Ibartain MR) 150 mg"), cell("150 mg"), cell("PO once daily — morning")] }),
      new TableRow({ children: [cell("Clopalvix (Clopidogrel) 75 mg"), cell("75 mg"), cell("PO once daily — afternoon after meals")] }),
      new TableRow({ children: [cell("Sterolow / Agirovastin (Rosuvastatin) 20 mg"), cell("20 mg"), cell("PO once daily — evening after meals")] }),
      new TableRow({ children: [cell("Thyrozol (Thiamazole) 5 mg"), cell("10 mg (2 tabs)"), cell("PO once daily — morning")] }),
    ]
  }),

  spacer(),
  subHead("Pending / Recommended at Follow-up:"),
  para([normal("GLP-1 receptor agonist (e.g., Semaglutide subcutaneous once weekly) — strongly indicated for T2DM with established ASCVD; add after stabilisation.")]),
  para([normal("Consider uptitration of Rosuvastatin to 40 mg, or addition of Ezetimibe 10 mg evening, to achieve LDL-C <70 mg/dL.")]),
  para([normal("Urine Albumin-to-Creatinine Ratio (ACR) — order at next visit to screen for diabetic nephropathy.")]),
  para([normal("Ophthalmology referral for annual dilated fundoscopy (diabetic retinopathy screening).")]),
  para([normal("Endocrinology review for hyperthyroidism management; thyroid ultrasound as per specialist guidance.")]),
  para([normal("Podiatry advice and appropriate diabetic footwear.")]),

  spacer(),
  subHead("Follow-up Schedule:"),
  para([normal("Outpatient Endocrinology: 2 weeks post-discharge. HbA1c recheck: 3 months.")]),

  spacer(),

  // ── X. KEY CLINICAL NOTES ─────────────────────────────────────────────
  sectionHead("IX. KEY CLINICAL NOTES"),

  new Table({
    width: { size: 9360, type: WidthType.DXA },
    borders: tableBorders,
    rows: [
      new TableRow({ children: [headerCell("Point", 600), headerCell("Clinical Note", 8760)] }),
      new TableRow({ children: [cell("1", { align: AlignmentType.CENTER }), cell("HbA1c 12.6% is critically elevated — insulin initiation was appropriate and urgent. Dual oral agent therapy (Metformin + Sitagliptin) continues alongside insulin for optimal glycaemic coverage.")] }),
      new TableRow({ children: [cell("2", { align: AlignmentType.CENTER }), cell("TSH 0.0027 uIU/mL indicates active hyperthyroidism which directly impairs glycaemic control. Thiamazole dose optimisation and endocrinology review are essential concurrent priorities.")] }),
      new TableRow({ children: [cell("3", { align: AlignmentType.CENTER }), cell("Established IHD is present — a GLP-1 receptor agonist with proven cardiovascular benefit (Semaglutide or Liraglutide) should be added as per guideline recommendations for T2DM with ASCVD. This has not yet been prescribed.")] }),
      new TableRow({ children: [cell("4", { align: AlignmentType.CENTER }), cell("Peripheral diabetic neuropathy is symptomatic — annual comprehensive foot exam, monofilament testing, and podiatry referral are indicated. Barefoot walking should be avoided.")] }),
      new TableRow({ children: [cell("5", { align: AlignmentType.CENTER }), cell("Urine microalbumin (ACR) was not measured during this admission — this should be ordered at the first outpatient follow-up to screen for diabetic nephropathy.")] }),
    ]
  }),

  spacer(),
  spacer(),

  // ── SIGNATURE ──────────────────────────────────────────────────────────
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    children: [bold("Attending Physician: BS. Cao Thi Minh", 22)],
    alignment: AlignmentType.RIGHT,
    spacing: { before: 400, after: 80 }
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  new Paragraph({
    children: [italic("Khoa Noi Tiet - Tong Hop, Trung Vuong Hospital, Ho Chi Minh City", 20)],
    alignment: AlignmentType.RIGHT,
    spacing: { after: 80 }
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  new Paragraph({
    children: [normal("Date: 22–23 June 2026", 20)],
    alignment: AlignmentType.RIGHT,
    spacing: { after: 200 }
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const content = [
  // TITLE
  new Paragraph({ children: [B("INTERNAL MEDICINE MEDICAL RECORD", 28)], alignment: AlignmentType.CENTER, spacing: { after: 60 } }),
  new Paragraph({ children: [I("(Internal Medicine / Endocrinology Department \u2014 Trung Vuong Hospital, HCMC)", 22)], alignment: AlignmentType.CENTER, spacing: { after: 240 } }),

  // I. ADMIN
  secHead("I. ADMINISTRATIVE SECTION"),
  p([B("Full name: "), N("Chau Thi Bich Diep")]),
  p([B("Gender: "), N("Female")]),
  p([B("Date of birth: "), N("16/05/1971 (Age: 55)")]),
  p([B("Address: "), N("Ap 1, Xa Vinh Loc, Ho Chi Minh City")]),
  p([B("Ethnicity: "), N("Kinh")]),
  p([B("BHYT (Health Insurance) Number: "), N("GD4797936717703790 26")]),
  p([B("Date and time of admission: "), N("22 June 2026, 07:18 (admitted via Emergency)")]),
  p([B("Date of medical record: "), N("22\u201323 June 2026")]),
  p([B("Attending Physician: "), N("BS. Cao Thi Minh")]),
  p([B("Ward / Room / Bed: "), N("Khoa Noi Tiet - Tong Hop / Room 8")]),
  sp(),

  // II. MEDICAL INQUIRY
  secHead("II. MEDICAL INQUIRY SECTION"),
  subHead("1. Reason for Hospitalization"),
  p([N("Fatigue, weakness of arms and legs, and poor glycaemic control in known Type 2 Diabetes Mellitus not previously on insulin.")]),
  sp(),

  subHead("2. Medical History (by patient and family)"),
  subHead("Onset and Progression:"),
  p([N("The patient is a 55-year-old woman with a known background of Type 2 Diabetes Mellitus who presented with progressively worsening glycaemic control, fatigue, and generalised weakness of the upper and lower limbs. She had not been on insulin prior to this admission. Symptoms of hyperglycaemia including polyuria, polydipsia, polyphagia, and unintentional weight loss of approximately 10 kg over 2 years had been worsening progressively. She also reported bilateral peripheral neuropathic symptoms and lower limb oedema appearing after prolonged ambulation.")]),
  sp(),
  p([B("Polyuria: "), N("3\u20134 voids per day plus 1 void at night. Urine volume correlates with fluid intake. Urine colour dark \u2014 consistent with hyperglycaemic concentration and mild dehydration.")]),
  p([B("Polydipsia: "), N("Thirst present; drinking approximately 2 litres per day.")]),
  p([B("Polyphagia: "), N("3 meals per day (rice, fish, meat, sweet potato).")]),
  p([B("Weight loss: "), N("Approximately 10 kg over 2 years, unintentional.")]),
  p([B("Fatigue and weakness: "), N("Generalised; involving both arms and legs.")]),
  sp(),
  subHead("Peripheral Neuropathy Symptoms:"),
  bullet("Numbness and tingling on the plantar surface of both feet (stocking distribution)."),
  bullet("Leg pain on prolonged walking."),
  bullet("Occasional loss of balance."),
  bullet("Sweating and shakiness when meals are missed (hypoglycaemic episodes)."),
  sp(),
  p([B("Oedema: "), N("Bilateral swelling from mid-lower leg to toes appearing after prolonged ambulation.")]),
  p([B("Skin: "), N("Intermittent itching (arms and whole body); mild dehydration; no acanthosis nigricans.")]),
  p([B("Negative findings: "), N("No blurred vision. No recurrent infections. Normal wound healing. No nausea, vomiting, or abdominal pain. No gestational diabetes history.")]),
  p([B("Thyroid: "), N("Known hyperthyroidism (toxic thyroid disease); on thiamazole prior to admission. TSH suppressed on current testing.")]),
  sp(),

  subHead("3. Past Medical History"),
  bullet("Type 2 Diabetes Mellitus: Diagnosed prior to this admission. Not previously on insulin. Progressive deterioration in glycaemic control prompting current admission."),
  bullet("Hyperthyroidism (Toxic Thyroid Disease): Known. On thiamazole."),
  bullet("Hypertension: Known. On antihypertensive therapy."),
  bullet("Family history: Sister with Type 2 Diabetes Mellitus."),
  bullet("No history of previous surgeries."),
  bullet("No history of allergies to food or medications."),
  bullet("No history of alcohol or smoking."),
  sp(),

  subHead("4. Clinical Examination"),
  p([I("Performed: 22/06/2026, follow-up 23/06/2026")]),
  sp(),
  subHead("General:"),
  bullet("Patient conscious, cooperative, alert. GCS 15/15."),
  bullet("Weight: 55 kg | BMI: 21.5 kg/m\u00B2"),
  bullet("Temperature: 37.0 \u00B0C | HR: 100 bpm | RR: 20/min"),
  bullet("BP: 130/60 mmHg | SpO\u2082: 98% (room air)"),
  bullet("Mild dehydration noted."),
  p([B("23/06/2026 (follow-up): "), N("HR 78\u201382 bpm, BP 120/60 mmHg, Temperature 37 \u00B0C, SpO\u2082 98% \u2014 stable and improving.")]),
  sp(),
  p([B("Skin: "), N("Dry and itchy. No acanthosis nigricans. Mucous membranes pink.")]),
  p([B("Cardiovascular: "), N("Heart sounds S1/S2 present, regular rhythm. No murmurs documented.")]),
  p([B("Respiratory: "), N("Clear to auscultation bilaterally. No crackles or wheeze. No supplemental oxygen required.")]),
  p([B("Abdomen: "), N("Soft, non-tender. No hepatosplenomegaly. Ultrasound: normal liver, normal gallbladder, uterus small/atrophic (postmenopausal), no ascites.")]),
  p([B("Neurological: "), N("Conscious and oriented. GCS 15. Peripheral neuropathy symptoms by history (bilateral plantar numbness and tingling, stocking distribution, occasional balance loss).")]),
  p([B("Lower limbs: "), N("Bilateral pitting oedema from mid-lower leg to toes.")]),
  sp(),
  subHead("Diabetic Hand and Foot Assessment:"),
  tbl([
    new TableRow({ children: [hc("Test", 4680), hc("Result", 4680)] }),
    new TableRow({ children: [tc("Prayer's Sign"), tc("Normal")] }),
    new TableRow({ children: [tc("Shoulder Range of Motion"), tc("Normal")] }),
    new TableRow({ children: [tc("Tabletop Sign"), tc("Normal")] }),
    new TableRow({ children: [tc("Dupuytren's Contracture"), tc("Negative")] }),
    new TableRow({ children: [tc("Charcot's Foot"), tc("Absent")] }),
  ]),
  sp(),

  // III. CASE SUMMARY
  secHead("III. CASE SUMMARY"),
  p([N("A 55-year-old woman with a known history of Type 2 Diabetes Mellitus (not previously on insulin), Hyperthyroidism, and Hypertension was admitted to Trung Vuong Hospital on 22 June 2026 via the Emergency Department with fatigue, generalised limb weakness, and critically uncontrolled hyperglycaemia (HbA1c 12.6%, fasting glucose 251 mg/dL). She had the full triad of classical diabetic symptoms \u2014 polyuria, polydipsia, and polyphagia \u2014 alongside 10 kg of unintentional weight loss over 2 years. Peripheral diabetic neuropathy was symptomatic with bilateral plantar numbness in a stocking distribution and episodic loss of balance. Active hyperthyroidism (TSH 0.0027 uIU/mL) was identified as a concurrent driver of poor glycaemic control. Glycosuria was confirmed on urinalysis. Renal and hepatic function were within normal limits.")]),
  sp(),
  p([BU("Subjective Symptoms:")]),
  bullet("Fatigue and generalised limb weakness."),
  bullet("Polyuria (3\u20134 voids/day + nocturia x1)."),
  bullet("Polydipsia (approximately 2 L/day)."),
  bullet("Polyphagia (3 meals/day)."),
  bullet("Unintentional weight loss 10 kg over 2 years."),
  bullet("Bilateral plantar numbness and tingling (stocking distribution)."),
  bullet("Leg pain on prolonged walking."),
  bullet("Occasional loss of balance."),
  bullet("Hypoglycaemic episodes (sweating, shakiness) when meals are skipped."),
  bullet("Bilateral lower limb oedema after prolonged ambulation."),
  bullet("Generalised skin itching."),
  sp(),
  p([BU("Objective Signs:")]),
  bullet("HR 100 bpm on admission (improving to 78\u201382 bpm by day 2)."),
  bullet("BP 130/60 mmHg."),
  bullet("BMI 21.5 kg/m\u00B2."),
  bullet("Mild dehydration on examination."),
  bullet("Bilateral pitting oedema mid-lower leg to toes."),
  bullet("No acanthosis nigricans."),
  bullet("Suppressed TSH 0.0027 uIU/mL."),
  bullet("HbA1c 12.6%; Fasting blood glucose 251 mg/dL."),
  bullet("Glycosuria 111 mmol/L on urinalysis."),
  bullet("Elevated urine specific gravity 1.032 (concentration/dehydration)."),
  sp(),

  // IV. PROBLEM STATEMENT
  secHead("IV. PROBLEM STATEMENT"),
  bullet("Type 2 Diabetes Mellitus \u2014 critically uncontrolled (HbA1c 12.6%)."),
  bullet("Hyperthyroidism \u2014 active (TSH 0.0027 uIU/mL); directly worsening glycaemic control."),
  bullet("Hypertension \u2014 on treatment; diastolic currently 60 mmHg, requires monitoring."),
  bullet("Peripheral Diabetic Neuropathy \u2014 symptomatic; bilateral stocking distribution."),
  bullet("Fall risk \u2014 moderate (Morse Scale 35 points)."),
  bullet("Urine ACR not yet checked \u2014 diabetic nephropathy screening pending."),
  sp(),

  // V. DIAGNOSES & DIFFERENTIALS
  secHead("V. PRELIMINARY DIAGNOSIS AND DIFFERENTIAL DIAGNOSES"),
  p([BU("Preliminary Diagnosis:")]),
  sp(),
  p([B("Type 2 Diabetes Mellitus, uncontrolled \u2014 "), N("HbA1c 12.6%, fasting blood glucose 251 mg/dL, glycosuria 111 mmol/L. Classic triad of polyuria, polydipsia, polyphagia with unintentional weight loss over 2 years. Insulin initiation indicated for HbA1c >10% with symptomatic hyperglycaemia.")]),
  sp(),
  p([B("Hyperthyroidism (Toxic Thyroid Disease) \u2014 "), N("TSH critically suppressed at 0.0027 uIU/mL (reference 0.35\u20134.94). Free T4 at upper normal range (1.02 ng/dL). Excess thyroid hormone causes increased hepatic glucose output and peripheral insulin resistance, directly compounding glycaemic failure.")]),
  sp(),
  p([B("Hypertension \u2014 "), N("Known; on ARB therapy. BP 130/60 mmHg on admission.")]),
  sp(),
  p([B("Peripheral Diabetic Neuropathy \u2014 "), N("Bilateral plantar numbness and tingling in a stocking distribution; leg pain on prolonged walking; episodic loss of balance; hypoglycaemic unawareness episodes. Consistent with distal symmetric polyneuropathy from chronic hyperglycaemia.")]),
  sp(),
  p([BU("Differential Diagnosis 1: Type 1 Diabetes Mellitus / LADA")]),
  p([B("Clinical reasoning:")]),
  bullet("For: Significant weight loss (10 kg), suboptimal response to oral agents, progressive insulin requirement."),
  bullet("Against: Age 55, gradual multi-year progression, positive family history of T2DM (sister), no ketoacidosis, no ketones on urinalysis."),
  bullet("Conclusion: T2DM remains the working diagnosis. LADA can be excluded with GAD-65 antibodies at follow-up if clinically indicated."),
  sp(),
  p([BU("Differential Diagnosis 2: Hyperthyroidism-Induced Hyperglycaemia as Primary Cause")]),
  p([B("Clinical reasoning:")]),
  bullet("For: Suppressed TSH 0.0027, tachycardia, weight loss, sweating \u2014 consistent with active hyperthyroidism independently causing hyperglycaemia via hepatic glucose output and insulin resistance."),
  bullet("Against: Patient has a longstanding T2DM diagnosis predating the current thyroid exacerbation. Hyperglycaemia is multifactorial; T2DM is the primary substrate and hyperthyroidism is a concurrent aggravating factor."),
  bullet("Conclusion: Both conditions must be treated simultaneously."),
  sp(),

  // VI. INVESTIGATIONS PROPOSED
  secHead("VI. PARACLINICAL INVESTIGATIONS PROPOSED"),
  p([BU("Routine:")]),
  bullet("Full Blood Count (FBC)"),
  bullet("Biochemistry: Na, K, Cl, Creatinine, eGFR"),
  bullet("Fasting blood glucose"),
  bullet("HbA1c"),
  bullet("Liver function tests (AST, ALT)"),
  bullet("Urinalysis"),
  sp(),
  p([BU("Endocrine / Diagnostic:")]),
  bullet("TSH, Free T4"),
  bullet("Urine Albumin-to-Creatinine Ratio (ACR) \u2014 diabetic nephropathy screening"),
  bullet("Lipid panel (LDL, HDL, TG, Total Cholesterol)"),
  bullet("Thyroid ultrasound"),
  sp(),
  p([BU("Screening / Monitoring:")]),
  bullet("Dilated fundoscopy \u2014 diabetic retinopathy screening"),
  bullet("10-g monofilament foot examination \u2014 peripheral neuropathy assessment"),
  bullet("Abdominal ultrasound"),
  bullet("Blood pressure monitoring"),
  sp(),

  // VII. INVESTIGATION RESULTS (ABNORMAL ONLY)
  secHead("VII. PARACLINICAL INVESTIGATION RESULTS"),
  p([I("Results from 22/06/2026. Only abnormal findings are reported.")]),
  sp(),
  p([BU("A. Abnormal Biochemistry Findings")]),
  tbl([
    new TableRow({ children: [hc("Test", 2600), hc("Result", 2200), hc("Reference Range", 2300), hc("Flag", 2260)] }),
    new TableRow({ children: [rc("HbA1c","FFE0E0",true), rc("12.6%","FFE0E0",true), rc("<7%","FFE0E0"), rc("\u2191\u2191 Critically High","FFE0E0",true)] }),
    new TableRow({ children: [rc("Fasting Blood Glucose","FFE0E0",true), rc("251 mg/dL (13.9 mmol/L)","FFE0E0",true), rc("80\u2013130 mg/dL","FFE0E0"), rc("\u2191\u2191 Critically High","FFE0E0",true)] }),
  ]),
  sp(),
  p([BU("B. Abnormal Thyroid Function")]),
  tbl([
    new TableRow({ children: [hc("Test", 2600), hc("Result", 2200), hc("Reference Range", 2300), hc("Flag", 2260)] }),
    new TableRow({ children: [rc("TSH","FFF2CC",true), rc("0.0027 uIU/mL","FFF2CC",true), rc("0.35\u20134.94","FFF2CC"), rc("\u2193\u2193 Suppressed \u2014 Active Hyperthyroidism","FFF2CC",true)] }),
  ]),
  sp(),
  p([BU("C. Abnormal Urinalysis")]),
  tbl([
    new TableRow({ children: [hc("Parameter", 2600), hc("Result", 2200), hc("Reference", 2300), hc("Flag", 2260)] }),
    new TableRow({ children: [rc("Glucose","FFE0E0",true), rc("111 mmol/L","FFE0E0",true), rc("Negative","FFE0E0"), rc("\u2191\u2191 Glycosuria","FFE0E0",true)] }),
    new TableRow({ children: [rc("Specific Gravity","FFF2CC",false), rc("1.032","FFF2CC",false), rc("1.005\u20131.030","FFF2CC"), rc("\u2191 Elevated \u2014 dehydration/concentration","FFF2CC",false)] }),
  ]),
  sp(),
  p([I("Full Blood Count, electrolytes, renal function, liver enzymes, and abdominal ultrasound were all within normal limits.")]),
  sp(),

  // VIII. DEFINITIVE DIAGNOSIS
  secHead("VIII. CURRENT / DEFINITIVE DIAGNOSIS"),
  p([BU("Lab Findings Supporting Diagnoses:")]),
  sp(),
  p([B("1. HbA1c 12.6% and Fasting Blood Glucose 251 mg/dL: "), N("Confirm critically uncontrolled Type 2 Diabetes Mellitus. Reflects chronic hyperglycaemia over the preceding 2\u20133 months. Insulin initiation is indicated.")]),
  p([B("2. TSH 0.0027 uIU/mL (suppressed): "), N("Confirms active hyperthyroidism. Excess thyroid hormone increases hepatic glucose production and peripheral insulin resistance, directly worsening diabetic control. Must be treated in parallel.")]),
  p([B("3. Glycosuria 111 mmol/L: "), N("Consistent with glucose threshold overflow from sustained hyperglycaemia.")]),
  p([B("4. Urine specific gravity 1.032: "), N("Consistent with dehydration and urinary concentration from osmotic diuresis.")]),
  sp(),
  p([BU("Current Diagnoses:")]),
  bullet("1. Type 2 Diabetes Mellitus, uncontrolled \u2014 HbA1c 12.6%, fasting glucose 251 mg/dL, glycosuria."),
  bullet("2. Hyperthyroidism (Toxic Thyroid Disease) \u2014 TSH suppressed 0.0027 uIU/mL; active disease compounding glycaemic failure."),
  bullet("3. Hypertension \u2014 known, on ARB; BP 130/60 mmHg on admission."),
  bullet("4. Peripheral Diabetic Neuropathy \u2014 symptomatic distal symmetric polyneuropathy (bilateral plantar numbness stocking distribution, balance loss, hypoglycaemia unawareness)."),
  sp(),

  // IX. TREATMENT PLAN
  secHead("IX. TREATMENT PLAN"),
  p([BU("Pharmacological Treatment")]),
  sp(),

  // 1. Diabetes
  subHead("1. Diabetes Mellitus \u2014 Glycaemic Management"),
  tbl([
    new TableRow({ children: [hc("Drug",3000), hc("Dose",1200), hc("Route",800), hc("Timing",2400), hc("Duration",1960)] }),
    new TableRow({ children: [tc("Mixtard 30 (Biphasic Human Insulin 30/70, rDNA)",{bold:true}), tc("16 IU",{bold:true}), tc("SC"), tc("Morning + Evening, 30 min before meals"), tc("Ongoing; titrate by 2 IU every 3 days to fasting target 80\u2013130 mg/dL")] }),
    new TableRow({ children: [tc("Metformin XR (Glucophage XR) 750 mg",{bold:true}), tc("750 mg"), tc("PO"), tc("Evening with meal"), tc("Long-term; continue indefinitely (eGFR 94 \u2014 safe)")] }),
    new TableRow({ children: [tc("Sitagliptin (Mebista) 50 mg",{bold:true}), tc("50 mg"), tc("PO"), tc("Morning"), tc("Long-term; adds incremental HbA1c reduction with low hypoglycaemia risk")] }),
  ]),
  sp(),
  p([I("After stabilisation, add: Semaglutide 0.5 mg SC once weekly (uptitrate to 1 mg after 4 weeks) \u2014 provides cardiovascular benefit and supports weight management. Also consider Empagliflozin 10 mg PO once daily morning post-discharge (eGFR 94 \u2014 eligible) for additional cardiovascular and renal protection.")]),
  sp(),

  // 2. Hypertension
  subHead("2. Hypertension"),
  tbl([
    new TableRow({ children: [hc("Drug",3000), hc("Dose",1200), hc("Route",800), hc("Timing",2400), hc("Duration",1960)] }),
    new TableRow({ children: [tc("Irbesartan (Ibartain MR) 150 mg",{bold:true}), tc("150 mg"), tc("PO"), tc("Morning"), tc("Long-term; review at each visit")] }),
  ]),
  p([I("ARB preferred in diabetic hypertension for renal protection. Target BP <130/80 mmHg. Monitor diastolic (current 60 mmHg) \u2014 avoid over-treatment.")]),
  sp(),

  // 3. Hyperthyroidism
  subHead("3. Hyperthyroidism"),
  tbl([
    new TableRow({ children: [hc("Drug",3000), hc("Dose",1200), hc("Route",800), hc("Timing",2400), hc("Duration",1960)] }),
    new TableRow({ children: [tc("Thiamazole (Thyrozol) 5 mg",{bold:true}), tc("10 mg (2 tabs)"), tc("PO"), tc("Morning"), tc("28 days; recheck TSH + Free T4 in 6\u20138 weeks; adjust dose accordingly")] }),
  ]),
  p([I("Suppressed TSH (0.0027 uIU/mL) indicates active hyperthyroidism directly worsening glycaemic control. Thiamazole blocks thyroid hormone synthesis. Endocrinology referral recommended for long-term management.")]),
  sp(),

  // 4. Neuropathy
  subHead("4. Peripheral Diabetic Neuropathy"),
  tbl([
    new TableRow({ children: [hc("Drug",3000), hc("Dose",1200), hc("Route",800), hc("Timing",2400), hc("Duration",1960)] }),
    new TableRow({ children: [tc("Pregabalin 75 mg",{bold:true}), tc("75 mg"), tc("PO"), tc("Twice daily (morning and evening)"), tc("Start 75 mg BD; uptitrate to 150 mg BD after 1 week based on response; long-term")] }),
  ]),
  p([I("Pregabalin is a first-line agent for painful diabetic peripheral neuropathy. Glycaemic optimisation remains the primary strategy to halt neuropathy progression \u2014 pregabalin addresses symptomatic relief in parallel.")]),
  sp(),

  // 5. Rehydration
  subHead("5. Rehydration (Admission Day Only)"),
  tbl([
    new TableRow({ children: [hc("Fluid",3600), hc("Volume",2880), hc("Route",1400), hc("Duration",1480)] }),
    new TableRow({ children: [tc("Ringer Lactate"), tc("500 mL"), tc("IV infusion"), tc("Admission day only")] }),
  ]),
  sp(),

  // Non-Pharm
  p([BU("Non-Pharmacological Treatment")]),
  sp(),
  subHead("1. Medical Nutrition Therapy (MNT):"),
  bullet("Hospital diet: DD01-Com (diabetic rice diet)."),
  bullet("Limit rice to 1/2\u20133/4 cup per cooked serving; distribute evenly across 3 meals."),
  bullet("Avoid excess sweet potato and refined starches."),
  bullet("Increase non-starchy vegetables at each meal; lean protein (fish is appropriate)."),
  bullet("Limit sodium to <2,300 mg/day; eliminate all added sugars and sugar-sweetened beverages."),
  bullet("Maintain fluid intake of approximately 2 litres per day."),
  bullet("Never skip meals \u2014 patient has documented hypoglycaemic episodes on missed meals; carry 15 g fast-acting glucose at all times (15-15 rule: 15 g glucose, recheck in 15 minutes)."),
  sp(),
  subHead("2. Physical Activity:"),
  bullet("Target: minimum 150 minutes per week of moderate-intensity aerobic activity."),
  bullet("Begin with daily 30-minute low-impact walks on flat surfaces (given leg pain and neuropathy)."),
  bullet("Resistance/strength training 2\u20133 times per week when tolerated."),
  bullet("Check blood glucose before and after exercise; treat hypoglycaemia promptly."),
  bullet("Avoid prolonged sedentary periods; break sitting with brief activity every 30 minutes."),
  bullet("Supervise exercise given balance impairment from neuropathy \u2014 fall risk."),
  sp(),
  subHead("3. Diabetes Self-Management Education (DSMES):"),
  bullet("SMBG: fasting target 80\u2013130 mg/dL; 2-hour post-meal target <180 mg/dL. CGM recommended for patients on insulin."),
  bullet("Insulin injection technique: correct angle, site rotation (abdomen > thigh > arm), storage (refrigerator; discard open pen after 28 days at room temperature)."),
  bullet("Hypoglycaemia recognition: symptoms = sweating, shakiness, confusion; treat with 15 g glucose immediately."),
  bullet("Sick-day rules: never stop insulin when unwell; increase monitoring; contact physician if glucose >300 mg/dL or unable to eat."),
  bullet("Foot care: daily foot inspection, appropriate closed-toe footwear, no barefoot walking, report any wound or colour change immediately."),
  bullet("Medication adherence: importance of consistent thiamazole use to improve thyroid control and thereby improve glucose levels."),
  bullet("All GDSK nurse educator documentation completed: diet, exercise, medication, warning signs, safety."),
  sp(),
  subHead("4. Foot Care and Fall Prevention:"),
  bullet("Formal 10-g monofilament examination and vibration assessment at each clinic visit."),
  bullet("Podiatry referral for diabetic footwear prescription."),
  bullet("Fall prevention: non-slip footwear, remove floor hazards at home, use handrail on stairs."),
  bullet("Physiotherapy referral for balance and gait training given neuropathic balance impairment."),
  sp(),

  // X. MONITORING
  secHead("X. MONITORING AND FOLLOW-UP"),
  tbl([
    new TableRow({ children: [hc("Parameter",4680), hc("Frequency",4680)] }),
    new TableRow({ children: [tc("HbA1c"), tc("Every 3 months until HbA1c <7%, then 6-monthly")] }),
    new TableRow({ children: [tc("Fasting and post-meal blood glucose"), tc("Daily SMBG; CGM recommended (on insulin)")] }),
    new TableRow({ children: [tc("TSH and Free T4"), tc("Every 6\u20138 weeks until euthyroid; then every 3\u20136 months")] }),
    new TableRow({ children: [tc("Urine Albumin-to-Creatinine Ratio (ACR)"), tc("Order at first outpatient follow-up (not done this admission)")] }),
    new TableRow({ children: [tc("Renal function (Creatinine, eGFR)"), tc("Annually")] }),
    new TableRow({ children: [tc("Lipid panel"), tc("Annually; 3-monthly if treatment adjusted")] }),
    new TableRow({ children: [tc("Dilated fundoscopy (retinopathy screening)"), tc("Annually")] }),
    new TableRow({ children: [tc("Comprehensive foot exam (monofilament)"), tc("Every clinic visit; annual formal assessment")] }),
    new TableRow({ children: [tc("Blood pressure"), tc("Every clinic visit; target <130/80 mmHg")] }),
    new TableRow({ children: [tc("Body weight and BMI"), tc("Every visit")] }),
    new TableRow({ children: [tc("Vaccinations"), tc("Influenza annually; Pneumococcal (once); COVID booster per local guidelines")] }),
    new TableRow({ children: [tc("Endocrinology review"), tc("2 weeks post-discharge; then as directed by specialist")] }),
  ]),
  sp(),
  sp(),

  // SIGNATURE
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  new Paragraph({ children: [I("Khoa Noi Tiet - Tong Hop, Trung Vuong Hospital, Ho Chi Minh City", 20)], alignment: AlignmentType.RIGHT, spacing: { after: 80 } }),
  new Paragraph({ children: [N("Date: 22\u201323 June 2026", 20)], alignment: AlignmentType.RIGHT, spacing: { after: 200 } }),
];

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