TIA transient ischemic attack history taking clinical presentation ABCD2 score neurology 2024

TIA differential diagnosis stroke mimics differentiation clinical features 2024 neurology

mkdir -p /home/daytona/workspace/tia-history && ls /home/daytona/workspace/tia-h…

~/tia-history/generate_pdf.py

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

OUTPUT = "/home/daytona/workspace/tia-history/TIA_History_Presentation.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=2*cm, leftMargin=2*cm,
    topMargin=2.2*cm, bottomMargin=2.2*cm,
    title="TIA Patient History Presentation - Shashi Kumar Mahati",
    author="Dhulikhel Hospital Neuro ICU"
)

styles = getSampleStyleSheet()

# ── Custom styles ────────────────────────────────────────────────────
NAVY   = colors.HexColor("#1a3557")
TEAL   = colors.HexColor("#0e7490")
LBLUE  = colors.HexColor("#e8f4f8")
LGREY  = colors.HexColor("#f5f5f5")
RED    = colors.HexColor("#c0392b")
GREEN  = colors.HexColor("#1e7e34")
AMBER  = colors.HexColor("#d97706")
WHITE  = colors.white
BLACK  = colors.black

def S(name, **kw):
    """Quick ParagraphStyle builder."""
    base = styles["Normal"]
    return ParagraphStyle(name, parent=base, **kw)

cover_title    = S("CoverTitle",    fontSize=22, textColor=WHITE,   alignment=TA_CENTER, leading=28, fontName="Helvetica-Bold")
cover_sub      = S("CoverSub",      fontSize=13, textColor=LBLUE,   alignment=TA_CENTER, leading=18, fontName="Helvetica")
cover_detail   = S("CoverDetail",   fontSize=11, textColor=WHITE,   alignment=TA_CENTER, leading=16, fontName="Helvetica")

h1             = S("H1",            fontSize=15, textColor=WHITE,   fontName="Helvetica-Bold",  leading=20, spaceAfter=4, spaceBefore=10)
h2             = S("H2",            fontSize=12, textColor=NAVY,    fontName="Helvetica-Bold",  leading=16, spaceAfter=3, spaceBefore=8)
h3             = S("H3",            fontSize=10, textColor=TEAL,    fontName="Helvetica-Bold",  leading=14, spaceAfter=2, spaceBefore=6)
body           = S("Body",          fontSize=9,  textColor=BLACK,   fontName="Helvetica",       leading=13, spaceAfter=3, alignment=TA_JUSTIFY)
body_sm        = S("BodySm",        fontSize=8,  textColor=BLACK,   fontName="Helvetica",       leading=12, spaceAfter=2)
bold_body      = S("BoldBody",      fontSize=9,  textColor=BLACK,   fontName="Helvetica-Bold",  leading=13, spaceAfter=3)
note           = S("Note",          fontSize=8,  textColor=colors.HexColor("#555555"), fontName="Helvetica-Oblique", leading=11, leftIndent=10)
red_note       = S("RedNote",       fontSize=8,  textColor=RED,     fontName="Helvetica-Bold",  leading=11, leftIndent=8)
green_note     = S("GreenNote",     fontSize=8,  textColor=GREEN,   fontName="Helvetica-Bold",  leading=11, leftIndent=8)
toc_entry      = S("TOCEntry",      fontSize=10, textColor=NAVY,    fontName="Helvetica",       leading=16, leftIndent=12)
section_label  = S("SectionLabel",  fontSize=8,  textColor=WHITE,   fontName="Helvetica-Bold",  leading=10, alignment=TA_CENTER)

def section_header(title, color=NAVY):
    """Full-width coloured section banner."""
    tbl = Table([[Paragraph(title, h1)]], colWidths=[17*cm])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), color),
        ("TOPPADDING",    (0,0), (-1,-1), 6),
        ("BOTTOMPADDING", (0,0), (-1,-1), 6),
        ("LEFTPADDING",   (0,0), (-1,-1), 10),
        ("ROUNDEDCORNERS", [4]),
    ]))
    return tbl

def subsection_header(title):
    return Paragraph(title, h2)

def info_table(rows, col_widths=None):
    """Two-column key-value table."""
    if col_widths is None:
        col_widths = [5.5*cm, 11.5*cm]
    data = []
    for k, v in rows:
        data.append([
            Paragraph(f"<b>{k}</b>", body_sm),
            Paragraph(v, body_sm)
        ])
    tbl = Table(data, colWidths=col_widths)
    tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (0,-1), LBLUE),
        ("BACKGROUND",    (1,0), (1,-1), WHITE),
        ("ROWBACKGROUNDS",(0,0), (-1,-1), [LGREY, WHITE]),
        ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#cccccc")),
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 6),
    ]))
    return tbl

def diff_table(headers, rows, col_widths=None):
    """Multi-column comparison table."""
    if col_widths is None:
        n = len(headers)
        w = 17.0 / n
        col_widths = [w*cm]*n
    header_row = [Paragraph(f"<b>{h}</b>", S("TH", fontSize=8, textColor=WHITE, fontName="Helvetica-Bold", leading=11, alignment=TA_CENTER)) for h in headers]
    data = [header_row]
    for i, row in enumerate(rows):
        data.append([Paragraph(str(cell), body_sm) for cell in row])
    tbl = Table(data, colWidths=col_widths, repeatRows=1)
    tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,0),  NAVY),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [LGREY, WHITE]),
        ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#aaaaaa")),
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("FONTSIZE",      (0,0), (-1,-1), 8),
    ]))
    return tbl

def bp(text):
    return Paragraph(text, body)

def note_box(text, color=LBLUE, border=TEAL, text_style=None):
    ts = text_style or note
    tbl = Table([[Paragraph(text, ts)]], colWidths=[17*cm])
    tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), color),
        ("LEFTPADDING",   (0,0), (-1,-1), 10),
        ("RIGHTPADDING",  (0,0), (-1,-1), 10),
        ("TOPPADDING",    (0,0), (-1,-1), 6),
        ("BOTTOMPADDING", (0,0), (-1,-1), 6),
        ("LINEAFTER",     (0,0), (0,-1),  2, border),
        ("BOX",           (0,0), (-1,-1), 0.5, border),
    ]))
    return tbl

SP = Spacer(1, 0.25*cm)
HR = HRFlowable(width="100%", thickness=0.5, color=colors.HexColor("#cccccc"), spaceAfter=4)

# ═══════════════════════════════════════════════════════════════════
# BUILD STORY
# ═══════════════════════════════════════════════════════════════════
story = []

# ── COVER PAGE ───────────────────────────────────────────────────────
cover_bg = Table(
    [[Paragraph("PATIENT HISTORY PRESENTATION", cover_title)],
     [Spacer(1, 0.3*cm)],
     [Paragraph("Transient Ischemic Attack (TIA)", S("CT2", fontSize=17, textColor=colors.HexColor("#a8d8ea"), alignment=TA_CENTER, fontName="Helvetica-Bold", leading=22))],
     [Spacer(1, 0.4*cm)],
     [Paragraph("Dhulikhel Hospital &bull; Neuro ICU", cover_sub)],
     [Spacer(1, 0.6*cm)],
     [Paragraph("Patient: <b>Mr. Shashi Kumar Mahati</b>", cover_detail)],
     [Paragraph("Age / Sex: 54 Years 4 Months / Male", cover_detail)],
     [Paragraph("IP No.: 69677 &nbsp;&nbsp; Patient No.: 76064207", cover_detail)],
     [Paragraph("Date of Admission: 11 July 2026", cover_detail)],
     [Spacer(1, 0.5*cm)],
     [Paragraph("Final Diagnosis: <b>TIA with Known Case of T2DM with HTN</b>", cover_detail)],
     [Spacer(1, 1.2*cm)],
     [Paragraph("Compiled with references from Harrison's 22E &bull; Adams &amp; Victor's Neurology &bull;<br/>Rosen's Emergency Medicine &bull; Tintinalli's Emergency Medicine", S("CS", fontSize=9, textColor=colors.HexColor("#aaccdd"), alignment=TA_CENTER, leading=13))],
    ],
    colWidths=[17*cm]
)
cover_bg.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), NAVY),
    ("TOPPADDING",    (0,0), (-1,-1), 12),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("LEFTPADDING",   (0,0), (-1,-1), 20),
    ("RIGHTPADDING",  (0,0), (-1,-1), 20),
    ("ROWBACKGROUNDS",(0,0), (-1,-1), [NAVY]*50),
]))
story.append(cover_bg)
story.append(PageBreak())

# ── SECTION 1: DEMOGRAPHICS ──────────────────────────────────────────
story.append(section_header("SECTION 1 — PATIENT DEMOGRAPHICS"))
story.append(SP)
demo_rows = [
    ("Patient Name",        "Mr. Shashi Kumar Mahati"),
    ("Patient No.",         "76064207"),
    ("Inpatient No.",       "69677"),
    ("Age / Sex",           "54 Years 4 Months / Male"),
    ("Date of Birth",       "17 March 1972 (1972/03/17 AD)"),
    ("Address",             "Kavrepalanchowk"),
    ("Date of Admission",   "11 July 2026 (2083/03/27 BS)"),
    ("Date of Discharge",   "11 July 2026 (2083/03/27 BS)"),
    ("Duration of Stay",    "0 Days (Neuro ICU)"),
    ("Department",          "Neurology / Neuro ICU"),
    ("Contact No.",         "9860431793"),
    ("Informant",           "Patient himself (reliable historian)"),
]
story.append(info_table(demo_rows))
story.append(SP)

story.append(section_header("FINAL DIAGNOSIS", TEAL))
story.append(SP)
story.append(note_box(
    "<b>Transient Ischemic Attack (TIA)</b> in a known case of "
    "Type 2 Diabetes Mellitus (T2DM) with Hypertension (HTN)",
    color=colors.HexColor("#e6f4ea"), border=GREEN,
    text_style=S("Dx", fontSize=10, textColor=colors.HexColor("#1e5631"), fontName="Helvetica-Bold", leading=14, leftIndent=8)
))
story.append(SP)

# ── SECTION 2: HISTORY ───────────────────────────────────────────────
story.append(section_header("SECTION 2 — HISTORY OF PRESENT ILLNESS"))
story.append(SP)

story.append(subsection_header("Chief Complaint"))
story.append(info_table([
    ("Complaint",  "Sudden onset slurring of speech (dysarthria)"),
    ("Duration",   "Approximately 8 hours prior to presentation on 11 July 2026"),
    ("Time",       "Onset at 08:00 AM on 11 July 2026"),
]))
story.append(SP)

story.append(subsection_header("History of Present Illness"))
story.append(bp(
    "Mr. Shashi Kumar Mahati, a 54-year-and-4-month-old male from Kavrepalanchowk, a known case of "
    "Type 2 Diabetes Mellitus and Hypertension on regular medication, was apparently well until "
    "<b>8:00 AM on 11 July 2026</b> when he suddenly developed <b>slurring of speech (dysarthria)</b>."
))
story.append(bp(
    "The onset was <b>abrupt</b>, occurring without any preceding prodromal symptoms. The speech slurring "
    "was <b>persistent</b> from its onset and <b>non-progressive</b> in nature (did not worsen over time). "
    "The patient also reported <b>associated dizziness</b> during the same episode. "
    "He presented to the Emergency Department at Dhulikhel Hospital on the same day."
))
story.append(SP)
story.append(subsection_header("Characterization of Chief Complaint"))
story.append(info_table([
    ("Mode of onset",   "Sudden / abrupt"),
    ("Duration",        "Approximately 8 hours before presentation; episode was transient in nature and resolved by examination"),
    ("Character",       "Slurring of speech (dysarthria), non-progressive"),
    ("Associated",      "Dizziness"),
    ("Progression",     "Non-progressive"),
    ("Relieving factors", "None documented"),
    ("Aggravating factors", "None documented"),
]))
story.append(SP)

story.append(subsection_header("Pertinent Positive and Negative History"))
pos_neg = [
    ["Symptom", "Present / Absent", "Clinical Significance"],
    ["Slurring of speech (dysarthria)", "PRESENT", "Focal neurological deficit - hallmark of TIA/stroke"],
    ["Dizziness", "PRESENT", "Posterior circulation involvement possible"],
    ["Loss of consciousness", "ABSENT", "Against hemorrhage / severe ischemia"],
    ["Seizure / abnormal body movements", "ABSENT", "Against Todd's paralysis"],
    ["Vomiting", "ABSENT", "Against hemorrhagic stroke, raised ICP"],
    ["Ear or nose bleeding", "ABSENT", "Against basal skull fracture / trauma"],
    ["Facial deviation (facial palsy)", "ABSENT", "Against significant MCA territory event"],
    ["Headache", "ABSENT", "Against SAH, hypertensive encephalopathy, migraine"],
    ["Blurring of vision / diplopia", "ABSENT", "Against ophthalmic TIA, posterior circulation"],
    ["Limb weakness (hemiparesis)", "ABSENT", "Against large territory ischemia"],
    ["Sensory loss / numbness", "ABSENT", "Against sensory cortex involvement"],
    ["Bowel / bladder incontinence", "ABSENT", "Against significant neurological impairment"],
    ["Recent head trauma", "ABSENT", "Against traumatic cause"],
]
story.append(diff_table(
    pos_neg[0], pos_neg[1:],
    col_widths=[6*cm, 3.5*cm, 7.5*cm]
))
story.append(SP)

# ── PAST HISTORY ─────────────────────────────────────────────────────
story.append(section_header("SECTION 3 — PAST HISTORY"))
story.append(SP)
past_rows = [
    ("Similar illness",     "No history of prior TIA or stroke"),
    ("Diabetes Mellitus",   "Known case of T2DM - on oral hypoglycemic agents (specific drug not documented)"),
    ("Hypertension",        "Known case of HTN - on antihypertensive medication (specific drug not documented)"),
    ("Ischemic Heart Disease", "Not documented - should be elicited"),
    ("Atrial Fibrillation", "Not documented - should be elicited (major cardioembolic cause of TIA)"),
    ("Hyperlipidemia",      "Not documented - should be elicited"),
    ("Other comorbidities", "None known"),
]
story.append(info_table(past_rows))
story.append(SP)
story.append(note_box(
    "PROFESSOR TIP: When presenting, actively document whether atrial fibrillation, prior cardiac history, "
    "dyslipidemia, smoking, and alcohol use are present or absent. These are vascular risk factors directly "
    "relevant to TIA etiology and will almost certainly be asked.",
    color=colors.HexColor("#fff8e1"), border=AMBER,
    text_style=S("AmberNote", fontSize=8, textColor=colors.HexColor("#7c4f00"), fontName="Helvetica-Oblique", leading=12, leftIndent=8)
))
story.append(SP)

# ── PERSONAL / SOCIAL / DRUG HISTORY ─────────────────────────────────
story.append(section_header("SECTION 4 — PERSONAL, SOCIAL & DRUG HISTORY"))
story.append(SP)
story.append(subsection_header("Personal History"))
story.append(info_table([
    ("Bowel habit",    "Normal"),
    ("Bladder habit",  "Normal"),
    ("Smoking",        "Not documented (should be elicited - major vascular risk factor)"),
    ("Alcohol",        "Not documented"),
    ("Diet",           "Not documented"),
    ("Occupation",     "Not documented"),
]))
story.append(SP)
story.append(subsection_header("Drug / Treatment History"))
story.append(info_table([
    ("T2DM medications",        "On oral hypoglycemic agents (specific agent not recorded)"),
    ("HTN medications",         "On antihypertensive medication (specific agent not recorded)"),
    ("Antiplatelet / anticoagulant", "No history of prior use"),
    ("Allergies",               "Not documented"),
]))
story.append(SP)
story.append(subsection_header("Family History"))
story.append(bp("Not documented. Should be elicited: family history of stroke, hypertension, diabetes, ischemic heart disease."))
story.append(SP)

# ── REVIEW OF SYSTEMS ─────────────────────────────────────────────────
story.append(section_header("SECTION 5 — REVIEW OF SYSTEMS"))
story.append(SP)
ros_rows = [
    ("Neurological",       "Dysarthria + dizziness; no limb weakness, no LOC, no visual disturbance, no seizures"),
    ("Cardiovascular",     "No chest pain, no palpitations documented"),
    ("Respiratory",        "No respiratory complaints"),
    ("Gastrointestinal",   "Normal bowel habit; no vomiting"),
    ("Genitourinary",      "Normal bladder habit; no incontinence"),
    ("Musculoskeletal",    "No joint pains; no limb weakness"),
    ("ENT",                "No ear or nose bleeding"),
    ("Psychiatric",        "Not documented"),
]
story.append(info_table(ros_rows))
story.append(SP)

# ── EMERGENCY COURSE ──────────────────────────────────────────────────
story.append(section_header("SECTION 6 — EMERGENCY DEPARTMENT COURSE"))
story.append(SP)
story.append(bp(
    "The patient presented to the Emergency Department of Dhulikhel Hospital where a "
    "<b>primary assessment (ABCDE approach)</b> was performed."
))
story.append(info_table([
    ("Airway",                    "Patent and self-maintained"),
    ("Breathing",                 "Normal, no respiratory distress"),
    ("Circulation",               "Hemodynamically stable"),
    ("Disability (Neuro)",        "GCS 15/15 (E4V5M6); alert, oriented"),
    ("Exposure",                  "No external injuries noted"),
    ("CT Head (Urgent)",          "Unremarkable - no hemorrhage, no early ischemic changes"),
    ("Laboratory investigations", "Obtained (specific results not in available record)"),
    ("Disposition",               "Admitted to Neuro ICU for further evaluation, stroke management, and neurological monitoring"),
]))
story.append(SP)

# ── ON EXAMINATION ────────────────────────────────────────────────────
story.append(section_header("SECTION 7 — ON EXAMINATION"))
story.append(SP)
story.append(subsection_header("General Examination"))
story.append(info_table([
    ("General condition",    "Ill-looking, active"),
    ("Consciousness",        "Conscious and cooperative"),
    ("Orientation",          "Oriented to time, place, and person"),
    ("GCS",                  "E4V5M6 = 15/15 (Full)"),
    ("PILCCOD",              "Pallor: Absent | Icterus: Absent | Lymphadenopathy: Absent | Cyanosis: Absent | Clubbing: Absent | Oedema: Absent | Dehydration: Absent"),
    ("Airway",               "Patent"),
    ("Breathing",            "Normal"),
    ("Circulation",          "Normal"),
]))
story.append(SP)
story.append(subsection_header("Vital Signs (To Be Recorded)"))
story.append(diff_table(
    ["Parameter", "Value", "Clinical Relevance"],
    [
        ["Temperature", "To be recorded", "Fever raises concern for infectious mimic"],
        ["Heart Rate (Pulse)", "To be recorded", "Irregular = possible AF (cardioembolic TIA)"],
        ["Blood Pressure", "To be recorded", "CRITICAL: Component of ABCD2 score; HTN present"],
        ["Respiratory Rate", "To be recorded", "Baseline"],
        ["SpO2", "To be recorded", "Hypoxia can worsen ischemia"],
        ["Capillary Blood Glucose", "To be recorded", "CRITICAL: T2DM - hypoglycemia is TIA mimic"],
        ["Weight / BMI", "To be recorded", "Cardiovascular risk assessment"],
    ],
    col_widths=[4.5*cm, 4.5*cm, 8*cm]
))
story.append(SP)

story.append(subsection_header("Neurological Examination"))
story.append(Paragraph("Higher Mental Functions", h3))
story.append(info_table([
    ("Orientation",     "Intact (GCS V5 - oriented)"),
    ("Memory",          "To be formally tested"),
    ("Speech",          "Dysarthria was presenting complaint - document status at examination (resolved / partially resolved / persisting)"),
    ("Language",        "Comprehension and repetition to be assessed"),
]))
story.append(SP)

story.append(Paragraph("Cranial Nerve Examination", h3))
cn_rows = [
    ["CN", "Nerve", "Examination Finding"],
    ["I",   "Olfactory",            "Not routinely tested"],
    ["II",  "Optic",                "Visual acuity, visual fields by confrontation - document result"],
    ["III/IV/VI", "Oculomotor / Trochlear / Abducens", "Pupillary reactions (PEARL); EOM; no diplopia reported"],
    ["V",   "Trigeminal",           "Facial sensation"],
    ["VII", "Facial",               "Facial symmetry - NO facial deviation documented"],
    ["VIII","Vestibulocochlear",     "Hearing; HINTS exam - important given dizziness"],
    ["IX/X","Glossopharyngeal/Vagus","Palatal movement, gag reflex, swallowing - relevant to dysarthria"],
    ["XI",  "Accessory",            "SCM, trapezius strength"],
    ["XII", "Hypoglossal",          "Tongue movements - relevant to dysarthria"],
]
story.append(diff_table(cn_rows[0], cn_rows[1:], col_widths=[1.5*cm, 5*cm, 10.5*cm]))
story.append(SP)

story.append(Paragraph("Motor, Sensory & Cerebellar Examination", h3))
story.append(info_table([
    ("Tone",        "To be documented in all four limbs"),
    ("Power",       "To be documented (expected 5/5 - no limb weakness mentioned)"),
    ("Reflexes",    "DTRs: biceps, triceps, supinator, knee, ankle; Plantar response"),
    ("Coordination","Heel-shin test, finger-nose test, rapid alternating movements"),
    ("Cerebellar",  "Romberg's test, gait examination, nystagmus - assess given dizziness"),
    ("Sensory",     "Light touch, pinprick, proprioception, vibration - no sensory loss documented"),
    ("Meningeal",   "Neck stiffness: absent; Kernig's: to document; Brudzinski's: to document"),
]))
story.append(SP)

# ── INVESTIGATIONS ────────────────────────────────────────────────────
story.append(section_header("SECTION 8 — INVESTIGATIONS"))
story.append(SP)
story.append(subsection_header("Already Performed"))
story.append(info_table([
    ("CT Head (Non-Contrast)", "UNREMARKABLE - no hemorrhage, no acute infarct visible"),
    ("Laboratory investigations", "Obtained (specific results not available in the record)"),
]))
story.append(SP)
story.append(subsection_header("Required Investigations for Complete TIA Workup"))

story.append(Paragraph("Blood Tests (Urgent)", h3))
story.append(diff_table(
    ["Investigation", "Rationale"],
    [
        ["CBC (Complete Blood Count)", "Rule out polycythemia, thrombocytosis, anemia"],
        ["Blood glucose / HbA1c", "T2DM control assessment; rule out hypoglycemia as TIA mimic"],
        ["Serum electrolytes", "Metabolic cause of neurological symptoms"],
        ["Renal function tests (BUN, Creatinine)", "Baseline; vascular risk assessment"],
        ["Lipid profile (Total chol, LDL, HDL, TG)", "Atherosclerosis risk factor; statin indication"],
        ["Coagulation profile (PT, aPTT, INR)", "Rule out coagulopathy"],
        ["Liver function tests", "Baseline"],
        ["Serum uric acid", "Vascular risk marker"],
    ],
    col_widths=[7*cm, 10*cm]
))
story.append(SP)

story.append(Paragraph("Cardiac Workup", h3))
story.append(diff_table(
    ["Investigation", "Rationale"],
    [
        ["12-lead ECG", "Rule out atrial fibrillation (cardioembolic TIA), ischemic changes"],
        ["2D Echocardiography", "Rule out intracardiac thrombus, valvular disease, PFO"],
        ["Cardiac telemetry / Holter monitoring", "Detect paroxysmal AF (missed on single ECG)"],
        ["Troponin", "Rule out concurrent ACS"],
    ],
    col_widths=[7*cm, 10*cm]
))
story.append(SP)

story.append(Paragraph("Neuroimaging", h3))
story.append(diff_table(
    ["Investigation", "Rationale"],
    [
        ["MRI Brain with DWI (PRIORITY)", "Most sensitive - detects acute ischemic lesions; distinguishes TIA from stroke; CT may be normal in early TIA"],
        ["MRA (Magnetic Resonance Angiography)", "Evaluate intracranial and extracranial vasculature; detect stenosis"],
        ["Carotid Doppler Ultrasound", "Carotid artery stenosis - major treatable cause of TIA"],
    ],
    col_widths=[7*cm, 10*cm]
))
story.append(SP)

# ── ABCD2 SCORE ───────────────────────────────────────────────────────
story.append(section_header("SECTION 9 — ABCD2 RISK STRATIFICATION"))
story.append(SP)
story.append(bp("The ABCD2 score stratifies patients presenting with TIA by risk of stroke within 48 hours, 7 days, and 90 days. (Source: Harrison's 22E Table 438-5; Rosen's EM Table 87.6)"))
story.append(SP)
story.append(diff_table(
    ["Parameter", "Criterion", "Score for This Patient"],
    [
        ["A - Age", "Age >= 60 years = 1 point", "Age 54 years = 0"],
        ["B - Blood Pressure", "SBP >140 or DBP >90 = 1 point", "Not documented - PENDING (likely 1 given HTN)"],
        ["C - Clinical Features", "Unilateral weakness = 2; Speech disturbance without weakness = 1", "Dysarthria without weakness = 1"],
        ["D - Duration", ">60 min = 2; 10-59 min = 1; <10 min = 0", "Duration not precisely quantified - PENDING"],
        ["D - Diabetes", "History of diabetes = 1 point", "T2DM confirmed = 1"],
        ["MINIMUM SCORE", "0-3 = Low; 4-5 = Moderate; 6-7 = High", "Minimum 2+; rises to 3-4 with BP + duration"],
    ],
    col_widths=[4*cm, 7*cm, 6*cm]
))
story.append(SP)
story.append(diff_table(
    ["ABCD2 Score", "2-Day Stroke Risk", "7-Day Stroke Risk", "90-Day Stroke Risk", "Recommendation"],
    [
        ["0-3 (Low)",    "1.0%",  "1.2%",  "3.1%",  "Outpatient management possible"],
        ["4-5 (Moderate)","4.1%", "5.9%",  "9.8%",  "Hospitalization recommended"],
        [">=6 (High)",   "8.1%", "11.7%", "17.8%",  "Hospitalization mandatory"],
    ],
    col_widths=[3.5*cm, 3.5*cm, 3.5*cm, 3.5*cm, 3*cm]
))
story.append(SP)

# ── MANAGEMENT PLAN ───────────────────────────────────────────────────
story.append(section_header("SECTION 10 — MANAGEMENT PLAN"))
story.append(SP)
story.append(subsection_header("Acute Management (Already Initiated)"))
story.append(info_table([
    ("1", "Admission to Neuro ICU for monitoring"),
    ("2", "ABCDE stabilization - patient hemodynamically stable"),
    ("3", "Urgent CT head - unremarkable"),
    ("4", "Laboratory investigations - obtained"),
    ("5", "Continuous neurological observation"),
]))
story.append(SP)
story.append(subsection_header("Antiplatelet Therapy (Secondary Prevention)"))
story.append(note_box(
    "DUAL ANTIPLATELET THERAPY: Aspirin (75-100 mg/day) + Clopidogrel (75 mg/day) for 21 days, "
    "then aspirin monotherapy long-term. Based on POINT and CHANCE trials. "
    "Alternative: Ticagrelor 180 mg loading then 90 mg BD + aspirin (Harrison's 22E). "
    "NOTE: CYP2C19 polymorphism (common in Asians) may reduce clopidogrel efficacy.",
    color=colors.HexColor("#e8f4f8"), border=TEAL,
    text_style=S("MgmtNote", fontSize=8.5, textColor=NAVY, fontName="Helvetica", leading=13, leftIndent=8)
))
story.append(SP)
story.append(subsection_header("Risk Factor Management"))
story.append(diff_table(
    ["Target", "Goal", "Intervention"],
    [
        ["Blood Pressure", "<130/80 mmHg", "Optimize existing antihypertensive regimen"],
        ["Glycemic Control", "HbA1c <7%", "Review and optimize oral hypoglycemic agents"],
        ["Lipids (LDL)", "<70 mg/dL", "High-intensity statin: Atorvastatin 40-80 mg/day"],
        ["Lifestyle", "Comprehensive modification", "Smoking cessation, diet, exercise, weight management"],
    ],
    col_widths=[4*cm, 4*cm, 9*cm]
))
story.append(SP)

story.append(subsection_header("Patient and Family Education"))
story.append(info_table([
    ("TIA as warning sign", "Educate that TIA is a medical emergency and a strong warning sign of impending stroke"),
    ("FAST acronym",         "Face drooping, Arm weakness, Speech difficulty, Time to call emergency"),
    ("Medication compliance","Critical importance of taking all medications regularly"),
    ("Follow-up",            "Strict outpatient follow-up with neurology"),
]))
story.append(SP)

# ═══════════════════════════════════════════════════════════════════
# SECTION 11: DIFFERENTIAL DIAGNOSIS
# ═══════════════════════════════════════════════════════════════════
story.append(PageBreak())
story.append(section_header("SECTION 11 — DIFFERENTIAL DIAGNOSES & DIFFERENTIATION FROM TIA", RED))
story.append(SP)
story.append(note_box(
    "The following differentials are presented with a detailed comparison for each, followed by a "
    "summary master table and a stepwise bedside approach to differentiation.",
    color=colors.HexColor("#fef3c7"), border=AMBER,
    text_style=S("IntroNote", fontSize=9, textColor=BLACK, fontName="Helvetica", leading=13, leftIndent=8)
))
story.append(SP)

# --- Diff 1: Ischemic Stroke
story.append(subsection_header("1. Ischemic Stroke (Minor Stroke) — Closest Differential"))
story.append(bp("This is the most important differential. TIA and minor ischemic stroke exist on a clinical continuum and are distinguished by MRI DWI."))
story.append(diff_table(
    ["Feature", "TIA", "Ischemic Stroke"],
    [
        ["Definition", "Focal neurological deficit with NO infarction on imaging (tissue-based)", "Focal neurological deficit WITH infarction on imaging"],
        ["CT Head", "Normal (as in this patient)", "May show early hypodense area - often normal in first 24h"],
        ["MRI DWI", "NORMAL - no diffusion restriction", "POSITIVE DWI signal - restricted diffusion confirms infarct"],
        ["Duration of symptoms", "Typically fully resolves", "Deficit persists or partially resolved"],
        ["Clinical on exam", "Complete resolution", "Residual deficit on examination"],
        ["Thrombolysis", "CONTRAINDICATED (no infarct)", "Indicated if within window period"],
    ],
    col_widths=[4.5*cm, 6.25*cm, 6.25*cm]
))
story.append(SP)
story.append(note_box("KEY: MRI Brain with DWI is MANDATORY. If DWI shows restricted diffusion, the diagnosis is minor ischemic stroke, not TIA. This distinction changes management (thrombolysis eligibility).", color=colors.HexColor("#e8f4f8"), border=TEAL))
story.append(SP)

# --- Diff 2: Hemorrhagic Stroke
story.append(subsection_header("2. Hemorrhagic Stroke (ICH / SAH)"))
story.append(diff_table(
    ["Feature", "TIA", "Hemorrhagic Stroke"],
    [
        ["Headache", "ABSENT", "SEVERE ('thunderclap') - hallmark of SAH"],
        ["Vomiting", "ABSENT", "COMMON"],
        ["Loss of consciousness", "ABSENT", "Common in SAH / large ICH"],
        ["CT Head", "Normal", "HYPERDENSE (white) blood - visible IMMEDIATELY on CT"],
        ["Neck stiffness", "Absent", "Present in SAH (meningism)"],
        ["Progression", "Non-progressive, resolving", "Progressive worsening"],
        ["GCS", "Normal (15/15)", "Reduced in significant hemorrhage"],
        ["This patient", "No headache, no vomiting, no LOC, CT unremarkable", "EXCLUDED by CT findings in this patient"],
    ],
    col_widths=[4.5*cm, 6.25*cm, 6.25*cm]
))
story.append(SP)

# --- Diff 3: Todd's Paralysis
story.append(subsection_header("3. Focal Seizure with Todd's Paralysis (Post-ictal Deficit)"))
story.append(diff_table(
    ["Feature", "TIA", "Todd's Paralysis"],
    [
        ["Onset of deficit", "Abrupt NEGATIVE symptoms (loss of function)", "POSITIVE symptoms first (jerking/twitching) then weakness"],
        ["Seizure activity", "ABSENT", "HISTORY of tonic-clonic or focal jerking immediately before"],
        ["Loss of consciousness", "ABSENT", "May be present during ictus"],
        ["Post-ictal confusion", "ABSENT", "PRESENT - key distinguishing feature"],
        ["Tongue biting / incontinence", "ABSENT", "May be present"],
        ["Duration", "Minutes to hours", "Minutes to few hours, then resolves"],
        ["EEG", "Normal", "Epileptiform discharges or postictal slowing"],
        ["This patient", "No abnormal movements, no LOC, no post-ictal confusion", "Seizure UNLIKELY - all distinguishing features absent"],
    ],
    col_widths=[4.5*cm, 6.25*cm, 6.25*cm]
))
story.append(SP)
story.append(note_box("Adams & Victor's: 'Abrupt onset and absence of positive (muscle-activating) motor symptoms argue in favor of TIA over seizure.'"))
story.append(SP)

# --- Diff 4: Migraine
story.append(subsection_header("4. Hemiplegic / Acephalgic Migraine (Complex Migraine)"))
story.append(diff_table(
    ["Feature", "TIA", "Migraine with Aura / Hemiplegic Migraine"],
    [
        ["Age / Sex", "Older (>50), male, vascular risk factors", "Often younger, female predominance"],
        ["Onset of deficit", "ABRUPT (seconds)", "GRADUAL 'march' over minutes"],
        ["Spread pattern", "Stays within a vascular territory", "CROSSES vascular boundaries"],
        ["Headache", "ABSENT", "Usually present after aura; absent in acephalgic migraine"],
        ["Visual symptoms", "Amaurosis fugax (monocular)", "Scintillating scotoma, fortification spectra (binocular)"],
        ["Prior migraine history", "Not relevant", "Typically present (but not always)"],
        ["Vascular risk factors", "Present (HTN, DM)", "Usually absent"],
        ["MRI", "Normal or DWI bright", "Normal; no vascular occlusion; may cross territories"],
        ["This patient", "54M, HTN, DM2, abrupt onset, no headache, no migraine history", "UNLIKELY - vascular profile and abrupt onset favor TIA"],
    ],
    col_widths=[4.5*cm, 6.25*cm, 6.25*cm]
))
story.append(SP)
story.append(note_box("Harrison's 22E: 'A sensory disturbance tends to migrate slowly across a limb, over minutes rather than seconds as with stroke. The diagnosis of migraine becomes more secure if the cortical disturbance crosses vascular boundaries.'"))
story.append(SP)

# --- Diff 5: Hypoglycemia
story.append(subsection_header("5. Hypoglycemia — MUST NOT MISS (especially in T2DM patient)"))
story.append(diff_table(
    ["Feature", "TIA", "Hypoglycemia"],
    [
        ["Blood glucose", "Normal", "LOW (<70 mg/dL; often <50 mg/dL for focal symptoms)"],
        ["Onset", "Abrupt focal neurological deficit", "May be gradual; often associated with autonomic features"],
        ["Autonomic features", "ABSENT", "Sweating, palpitations, hunger, tremor, anxiety"],
        ["CT / MRI", "Normal or infarct", "NORMAL (metabolic, not structural)"],
        ["Response to glucose", "No change", "RAPID RESOLUTION with IV/oral glucose"],
        ["Diabetic status", "Not required", "Almost always diabetic on insulin or sulfonylureas"],
        ["This patient", "T2DM on medication - CBG MUST be checked immediately", "Rule out with immediate bedside glucose"],
    ],
    col_widths=[4.5*cm, 6.25*cm, 6.25*cm]
))
story.append(SP)
story.append(note_box("Tintinalli's EM: 'Both hypoglycemia AND hyperglycemia are important stroke mimics.' Rosen's EM: 'Hypoglycemia is a common cause of sustained focal neurologic symptoms that can persist for several days.'", color=colors.HexColor("#fff0f0"), border=RED, text_style=S("WarnNote", fontSize=8, textColor=RED, fontName="Helvetica-Bold", leading=12, leftIndent=8)))
story.append(SP)

# --- Diff 6: Vestibular
story.append(subsection_header("6. Peripheral Vestibular Disorders (BPPV / Labyrinthitis / Vestibular Neuritis / Meniere's)"))
story.append(bp("Relevant because this patient had dizziness as an associated symptom."))
story.append(diff_table(
    ["Feature", "Posterior Circulation TIA", "Peripheral Vestibular Disorder"],
    [
        ["Focal neurological deficits", "YES - dysarthria, dysphagia, diplopia, ataxia, facial numbness", "NO - isolated dizziness/vertigo ONLY"],
        ["Nystagmus type", "Direction-changing, vertical, or torsional (CENTRAL pattern)", "Horizontal, unidirectional, fatigable (PERIPHERAL pattern)"],
        ["Hearing loss / tinnitus", "Absent (unless AICA territory)", "PRESENT in Meniere's, labyrinthitis"],
        ["HINTS exam", "HINTS negative = central lesion (DANGEROUS)", "HINTS positive = peripheral (reassuring)"],
        ["Response to position (Dix-Hallpike)", "No change", "WORSENED by position change in BPPV"],
        ["Vascular risk factors", "Present", "Absent or less relevant"],
        ["This patient", "DYSARTHRIA alongside dizziness = central cause", "Peripheral vestibular EXCLUDED by presence of dysarthria"],
    ],
    col_widths=[4.5*cm, 6.25*cm, 6.25*cm]
))
story.append(SP)
story.append(note_box("Rosen's EM: 'Meniere disease - dizziness, vertigo, hearing loss, and tinnitus are common; difficulties with vision or speech (focal symptoms) are less common.' Presence of dysarthria in this patient points to a central cause."))
story.append(SP)

# --- Diff 7: Hypertensive Encephalopathy / PRES
story.append(subsection_header("7. Hypertensive Encephalopathy / PRES"))
story.append(diff_table(
    ["Feature", "TIA", "Hypertensive Encephalopathy / PRES"],
    [
        ["Blood pressure", "May be elevated", "SEVERELY elevated (SBP >180-200 mmHg)"],
        ["Headache", "ABSENT", "SEVERE headache - hallmark feature"],
        ["Vomiting", "ABSENT", "COMMON"],
        ["LOC / Confusion", "ABSENT", "ALTERED consciousness - common"],
        ["Seizures", "ABSENT", "COMMON - may be the presenting feature"],
        ["MRI", "Normal or focal infarct", "Posterior white matter T2/FLAIR hyperintensity (parieto-occipital)"],
        ["Focal deficit", "Specific vascular territory", "Generalized rather than focal"],
        ["This patient", "No headache, no vomiting, no LOC, no seizures", "UNLIKELY given absence of encephalopathy features"],
    ],
    col_widths=[4.5*cm, 6.25*cm, 6.25*cm]
))
story.append(SP)

# --- Diff 8: Brain Tumor
story.append(subsection_header("8. Intracranial Mass Lesion (Brain Tumor)"))
story.append(diff_table(
    ["Feature", "TIA", "Brain Tumor"],
    [
        ["Onset", "ABRUPT (seconds to minutes)", "Gradual, progressive (days to weeks)"],
        ["Progression", "Non-progressive, resolving", "PROGRESSIVE worsening"],
        ["Headache", "Absent", "Progressive headache, worse in morning"],
        ["Papilledema", "Absent", "May be present (raised ICP)"],
        ["CT Head", "Normal", "Mass lesion, ring-enhancing lesion, midline shift"],
        ["This patient", "Abrupt onset, transient, unremarkable CT - tumor UNLIKELY", "Excluded by CT findings and clinical course"],
    ],
    col_widths=[4.5*cm, 6.25*cm, 6.25*cm]
))
story.append(SP)

# --- Diff 9: Bell's Palsy
story.append(subsection_header("9. Bell's Palsy vs. Central Facial Weakness (for Facial Examination)"))
story.append(diff_table(
    ["Feature", "Central Facial Weakness (TIA/Stroke - UMN)", "Bell's Palsy (LMN - Peripheral)"],
    [
        ["Forehead involvement", "SPARED (bilateral cortical representation)", "INVOLVED - cannot wrinkle forehead"],
        ["Eye closure", "Normal", "IMPAIRED - Bell's phenomenon visible"],
        ["Associated features", "Limb weakness, dysarthria possible", "Taste disturbance, hyperacusis"],
        ["This patient", "NO facial deviation documented", "Not the primary differential here"],
    ],
    col_widths=[4.5*cm, 6.25*cm, 6.25*cm]
))
story.append(SP)

# --- Diff 10: MS
story.append(subsection_header("10. Multiple Sclerosis (Demyelinating Disease)"))
story.append(diff_table(
    ["Feature", "TIA", "Multiple Sclerosis"],
    [
        ["Age / Sex", "Older, male predominance, vascular RF", "Younger, female predominance"],
        ["Onset", "ABRUPT (seconds)", "Subacute (hours to days)"],
        ["Prior episodes", "First episode", "Relapsing-remitting history"],
        ["Vascular risk factors", "Present", "Absent"],
        ["MRI Brain", "Infarct in vascular distribution", "Periventricular / juxtacortical white matter plaques (Dawson's fingers)"],
        ["CSF", "Normal", "Oligoclonal bands, elevated IgG index"],
        ["This patient", "Age 54, male, HTN, DM - classic vascular profile", "UNLIKELY - age, sex, vascular risk factors favor TIA"],
    ],
    col_widths=[4.5*cm, 6.25*cm, 6.25*cm]
))
story.append(SP)

# ── MASTER SUMMARY TABLE ──────────────────────────────────────────────
story.append(PageBreak())
story.append(section_header("SECTION 12 — MASTER DIFFERENTIAL DIAGNOSIS SUMMARY TABLE", colors.HexColor("#2d4a7a")))
story.append(SP)
master = [
    ["Feature", "TIA", "Isch. Stroke", "ICH/SAH", "Todd's", "Migraine", "Hypoglycemia", "Vestibular", "PRES"],
    ["Onset", "Abrupt", "Abrupt", "Abrupt", "Post-seizure", "Gradual march", "Variable", "Sudden vertigo", "Gradual"],
    ["Headache", "Absent", "Absent", "SEVERE", "Absent", "Present", "Absent", "Absent", "SEVERE"],
    ["LOC", "Absent", "Rare", "COMMON", "Present", "Absent", "May occur", "Absent", "COMMON"],
    ["Seizure", "Absent", "Rare", "Rare", "YES (precedes)", "Rare", "Absent", "Absent", "COMMON"],
    ["Vomiting", "Absent", "Rare", "COMMON", "Absent", "May occur", "Absent", "May occur", "COMMON"],
    ["CT Head", "Normal", "Normal/low density", "HYPERDENSE", "Normal", "Normal", "Normal", "Normal", "May be abnormal"],
    ["MRI DWI", "NORMAL", "BRIGHT (infarct)", "Confirms blood", "Normal", "Normal", "Normal", "Normal", "Posterior T2 signal"],
    ["Blood glucose", "Normal", "Normal", "Normal", "Normal", "Normal", "LOW", "Normal", "Normal"],
    ["Resolution", "Complete", "Incomplete", "Incomplete", "Complete", "Complete", "With glucose", "Complete", "With BP control"],
]
tbl = Table(master, colWidths=[3.2*cm, 1.9*cm, 2.0*cm, 1.9*cm, 1.7*cm, 1.9*cm, 2.3*cm, 2.1*cm, 1.9*cm], repeatRows=1)
tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0),  NAVY),
    ("TEXTCOLOR",     (0,0), (-1,0),  WHITE),
    ("FONTNAME",      (0,0), (-1,0),  "Helvetica-Bold"),
    ("FONTSIZE",      (0,0), (-1,-1), 7),
    ("BACKGROUND",    (0,1), (0,-1),  LBLUE),
    ("FONTNAME",      (0,1), (0,-1),  "Helvetica-Bold"),
    ("ROWBACKGROUNDS",(1,1), (-1,-1), [LGREY, WHITE]),
    ("GRID",          (0,0), (-1,-1), 0.3, colors.HexColor("#999999")),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
]))
story.append(tbl)
story.append(SP)

# ── STEPWISE APPROACH TO DIFFERENTIATION ─────────────────────────────
story.append(section_header("SECTION 13 — STEPWISE BEDSIDE APPROACH TO DIFFERENTIATION"))
story.append(SP)
story.append(diff_table(
    ["Step", "Action", "Differentials Excluded"],
    [
        ["Step 1 - Immediate", "Bedside blood glucose (CBG/RBS)", "Hypoglycemia - MUST check first in any T2DM patient"],
        ["Step 2 - Immediate", "Non-contrast CT Head (already done)", "Hemorrhagic stroke (ICH/SAH) - EXCLUDED if normal CT"],
        ["Step 3 - Immediate", "12-lead ECG", "Atrial fibrillation (cardioembolic source), ACS"],
        ["Step 4 - History", "Was there jerking/convulsive activity before deficit?", "Seizure / Todd's paralysis if NO"],
        ["Step 5 - History", "Was there severe headache at onset?", "ICH / SAH / Migraine if NO"],
        ["Step 6 - History", "Did symptoms gradually spread over minutes?", "Migraine if NO (TIA is abrupt)"],
        ["Step 7 - Examination", "HINTS exam (Head Impulse, Nystagmus, Skew deviation)", "Peripheral vestibular disorder if positive HINTS"],
        ["Step 8 - Gold Standard", "MRI Brain with DWI", "TIA (normal DWI) vs. ischemic stroke (bright DWI); also identifies MS, tumor, PRES"],
        ["Step 9 - Vascular", "MRA + Carotid Doppler", "Identifies underlying etiology, guides secondary prevention"],
    ],
    col_widths=[3*cm, 7*cm, 7*cm]
))
story.append(SP)

# ── PROGNOSIS ─────────────────────────────────────────────────────────
story.append(section_header("SECTION 14 — PROGNOSIS"))
story.append(SP)
story.append(info_table([
    ("Short-term stroke risk", "Per Adams & Victor's: ~6% of strokes following TIA occur within 1 month; another ~6% in the following year. Highest risk is in the first 48-72 hours."),
    ("Modifiable risk factors", "T2DM and HTN - both present and treatable. Optimal control significantly reduces future vascular events."),
    ("Favorable indicators", "Hemodynamically stable, GCS 15/15, early presentation, unremarkable CT head, full symptom resolution."),
    ("With optimal treatment", "Early dual antiplatelet therapy + statin + BP control + glycemic control can reduce 90-day stroke risk by up to 80% (AAFP evidence)."),
]))
story.append(SP)

# ── VERBAL SUMMARY ────────────────────────────────────────────────────
story.append(section_header("SECTION 15 — VERBAL SUMMARY FOR PRESENTATION"))
story.append(SP)
story.append(note_box(
    "\"Mr. Shashi Kumar Mahati, a 54-year-old male from Kavrepalanchowk, a known case of T2DM and HTN on "
    "regular medication, presented to the Emergency Department of Dhulikhel Hospital on 11 July 2026 with "
    "a chief complaint of sudden onset slurring of speech (dysarthria) since 8:00 AM of the same day - "
    "approximately 8 hours prior to presentation. The onset was abrupt, the symptom was persistent and "
    "non-progressive, and was associated with dizziness. There was no loss of consciousness, seizure "
    "activity, vomiting, headache, visual disturbance, facial deviation, limb weakness, sensory loss, or "
    "bowel-bladder incontinence. This was his first such episode. On examination, GCS was E4V5M6 (15/15), "
    "he appeared ill-looking but active, PILCCOD was nil, and airway-breathing-circulation were all normal. "
    "Urgent CT Head was unremarkable. Based on the acute onset focal neurological deficit (dysarthria and "
    "dizziness) in a patient with vascular risk factors, with complete/near-complete resolution and a normal "
    "CT head, a diagnosis of Transient Ischemic Attack was made. He was admitted for MRI Brain, MRA, "
    "cardiac workup, and initiation of dual antiplatelet and vascular risk modification therapy.\"",
    color=colors.HexColor("#f0f7ff"), border=NAVY,
    text_style=S("Summary", fontSize=9, textColor=NAVY, fontName="Helvetica", leading=14, leftIndent=8)
))
story.append(SP)

# ── REFERENCES ────────────────────────────────────────────────────────
story.append(HRFlowable(width="100%", thickness=1, color=NAVY, spaceAfter=6))
story.append(Paragraph("References", h2))
refs = [
    "Harrison's Principles of Internal Medicine, 22nd Edition (2025) — Cerebrovascular Disease (Chapter 437-438), Table 438-5 ABCD2 Score",
    "Adams and Victor's Principles of Neurology, 12th Edition — Chapter 33 (TIA)",
    "Rosen's Emergency Medicine: Concepts and Clinical Practice — Chapter 87 (Stroke, TIA, Table 87.6)",
    "Tintinalli's Emergency Medicine: A Comprehensive Study Guide — Chapter 167 (Stroke Diagnosis, Stroke Mimics)",
    "Bradley and Daroff's Neurology in Clinical Practice — TIA and Differential Diagnosis",
    "AAFP: Transient Ischemic Attack: Part I. Diagnosis and Evaluation. Am Fam Physician 2012;86(6):521-526",
    "Patient Record: Dhulikhel Hospital, Inpatient No. 69677, Patient: Shashi Kumar Mahati, Admitted 11 July 2026",
]
for r in refs:
    story.append(Paragraph(f"• {r}", body_sm))
story.append(SP)

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

cd /home/daytona/workspace/tia-history && python generate_pdf.py 2>&1

ls -lh /home/daytona/workspace/tia-history/TIA_History_Presentation.pdf