"carpal tunnel syndrome"[MeSH Terms] AND management

ls -la /home/daytona/workspace/ 2>/dev/null && mkdir -p /home/daytona/workspace/…

~/cts-prescription/generate_cts_rx.py

"""
CTS Prescription Template PDF Generator
Uses reportlab for professional clinical layout
"""

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

OUTPUT_PATH = "/home/daytona/workspace/cts-prescription/CTS_Prescription_Template.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
C_DARK_BLUE   = HexColor("#1a3a5c")   # header, section titles
C_MED_BLUE    = HexColor("#2e6da4")   # sub-headers, accents
C_MILD_GREEN  = HexColor("#e8f5e9")   # mild severity bg
C_MOD_YELLOW  = HexColor("#fffde7")   # moderate severity bg
C_SEV_RED     = HexColor("#fce4ec")   # severe severity bg
C_LIGHT_GRAY  = HexColor("#f5f7fa")   # alternating row
C_MID_GRAY    = HexColor("#90a4ae")   # secondary text
C_WHITE       = colors.white
C_BLACK       = colors.black
C_BORDER      = HexColor("#b0bec5")

# ── Build document ───────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT_PATH,
    pagesize=A4,
    rightMargin=18*mm, leftMargin=18*mm,
    topMargin=14*mm, bottomMargin=18*mm,
    title="Carpal Tunnel Syndrome – Prescription Template",
    author="Orris Medical AI"
)

W = A4[0] - 36*mm   # usable width

styles = getSampleStyleSheet()

# Custom paragraph styles
def make_style(name, parent="Normal", **kw):
    return ParagraphStyle(name, parent=styles[parent], **kw)

hdr_title   = make_style("HdrTitle",   fontSize=17, textColor=C_WHITE,
                          fontName="Helvetica-Bold", leading=22, alignment=TA_CENTER)
hdr_sub     = make_style("HdrSub",     fontSize=9,  textColor=HexColor("#cfe4ff"),
                          fontName="Helvetica", leading=13, alignment=TA_CENTER)
sec_title   = make_style("SecTitle",   fontSize=11, textColor=C_WHITE,
                          fontName="Helvetica-Bold", leading=15, alignment=TA_LEFT,
                          leftIndent=4)
sev_label   = make_style("SevLabel",   fontSize=10, textColor=C_DARK_BLUE,
                          fontName="Helvetica-Bold", leading=14)
body        = make_style("Body",       fontSize=8.5, leading=13, textColor=C_BLACK)
body_bold   = make_style("BodyBold",   fontSize=8.5, leading=13,
                          textColor=C_DARK_BLUE, fontName="Helvetica-Bold")
small       = make_style("Small",      fontSize=7.5, leading=11, textColor=HexColor("#546e7a"))
rx_item     = make_style("RxItem",     fontSize=8.5, leading=13,
                          leftIndent=8, firstLineIndent=-8)
note_style  = make_style("Note",       fontSize=7.8, leading=11.5,
                          textColor=HexColor("#37474f"), fontName="Helvetica-Oblique")
footer_s    = make_style("Footer",     fontSize=7,  textColor=C_MID_GRAY,
                          alignment=TA_CENTER)

# ── Helper: coloured section banner ─────────────────────────────────────────
def section_banner(text, bg=C_DARK_BLUE, width=None):
    w = width or W
    return Table(
        [[Paragraph(text, sec_title)]],
        colWidths=[w],
        style=TableStyle([
            ("BACKGROUND", (0,0), (-1,-1), bg),
            ("TOPPADDING",    (0,0), (-1,-1), 5),
            ("BOTTOMPADDING", (0,0), (-1,-1), 5),
            ("LEFTPADDING",   (0,0), (-1,-1), 8),
        ])
    )

def severity_banner(text, bg, text_color=C_DARK_BLUE):
    st = make_style(f"SevBan_{text}", fontSize=11, textColor=text_color,
                    fontName="Helvetica-Bold", leading=16, alignment=TA_LEFT)
    return Table(
        [[Paragraph(text, st)]],
        colWidths=[W],
        style=TableStyle([
            ("BACKGROUND", (0,0), (-1,-1), bg),
            ("TOPPADDING",    (0,0), (-1,-1), 6),
            ("BOTTOMPADDING", (0,0), (-1,-1), 6),
            ("LEFTPADDING",   (0,0), (-1,-1), 10),
            ("BOX", (0,0), (-1,-1), 0.8, C_BORDER),
        ])
    )

def rx_table(rows, col_widths=None):
    """Render a 2-column key/value table for prescriptions."""
    cw = col_widths or [50*mm, W - 50*mm]
    data = []
    for label, val, color in rows:
        data.append([
            Paragraph(f"<b>{label}</b>", body_bold),
            Paragraph(val, body)
        ])
    style = TableStyle([
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 6),
        ("RIGHTPADDING",  (0,0), (-1,-1), 6),
        ("GRID",          (0,0), (-1,-1), 0.4, C_BORDER),
    ])
    # Alternating row backgrounds
    for i, (_, _, c) in enumerate(rows):
        bg = c if c else (C_LIGHT_GRAY if i % 2 == 0 else C_WHITE)
        style.add("BACKGROUND", (0, i), (-1, i), bg)
    return Table(data, colWidths=cw, style=style, hAlign="LEFT")

def drug_box(lines, bg=C_WHITE):
    """A bordered box listing drug entries."""
    rows = [[Paragraph(l, body)] for l in lines]
    t = Table(rows, colWidths=[W],
        style=TableStyle([
            ("BACKGROUND", (0,0), (-1,-1), bg),
            ("BOX",        (0,0), (-1,-1), 0.8, C_MED_BLUE),
            ("INNERGRID",  (0,0), (-1,-1), 0.3, C_BORDER),
            ("TOPPADDING",    (0,0), (-1,-1), 4),
            ("BOTTOMPADDING", (0,0), (-1,-1), 4),
            ("LEFTPADDING",   (0,0), (-1,-1), 10),
        ])
    )
    return t

# ═══════════════════════════════════════════════════════════════════════════════
#  CONTENT
# ═══════════════════════════════════════════════════════════════════════════════
story = []

# ── HEADER ───────────────────────────────────────────────────────────────────
header_data = [[
    Paragraph("CARPAL TUNNEL SYNDROME", hdr_title),
],[
    Paragraph("Clinical Prescription Template · Stratified by Severity Level", hdr_sub),
]]
header = Table(header_data, colWidths=[W],
    style=TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), C_DARK_BLUE),
        ("TOPPADDING",    (0,0), (0,0), 10),
        ("BOTTOMPADDING", (0,1), (0,1), 10),
        ("LEFTPADDING",   (0,0), (-1,-1), 6),
        ("BOX", (0,0), (-1,-1), 1.5, C_MED_BLUE),
    ])
)
story.append(header)
story.append(Spacer(1, 4*mm))

# ── PATIENT DETAILS BOX ──────────────────────────────────────────────────────
story.append(section_banner("▸  PATIENT & CLINICIAN DETAILS"))
story.append(Spacer(1, 1*mm))
pt_fields = [
    ["Patient Name:", "_______________________________", "Date:", "____________"],
    ["Age / Sex:", "____________  /  ____________", "MRN/ID:", "____________"],
    ["Clinician:", "_______________________________", "Signature:", "____________"],
    ["Facility:", "_______________________________", "Stamp:", ""],
]
pt_tbl = Table(pt_fields,
    colWidths=[28*mm, 60*mm, 22*mm, 60*mm],
    style=TableStyle([
        ("FONTNAME",   (0,0), (-1,-1), "Helvetica"),
        ("FONTNAME",   (0,0), (0,-1), "Helvetica-Bold"),  # labels bold
        ("FONTNAME",   (2,0), (2,-1), "Helvetica-Bold"),
        ("FONTSIZE",   (0,0), (-1,-1), 8.5),
        ("TOPPADDING",    (0,0), (-1,-1), 5),
        ("BOTTOMPADDING", (0,0), (-1,-1), 5),
        ("LEFTPADDING",   (0,0), (-1,-1), 4),
        ("GRID",       (0,0), (-1,-1), 0.4, C_BORDER),
        ("BACKGROUND", (0,0), (-1,-1), C_LIGHT_GRAY),
    ])
)
story.append(pt_tbl)
story.append(Spacer(1, 3*mm))

# ── ASSESSMENT SECTION ───────────────────────────────────────────────────────
story.append(section_banner("▸  CLINICAL ASSESSMENT"))
story.append(Spacer(1, 1*mm))

assess_rows = [
    ("Dominant Hand", "Right   /   Left   /   Bilateral", None),
    ("CTS-6 Score", "_______  /26   (≥12 = high probability CTS)", None),
    ("Phalen Test", "Positive   /   Negative   — onset at ______ seconds", None),
    ("Tinel Sign", "Positive   /   Negative", None),
    ("Durkan Test", "Positive   /   Negative", None),
    ("Thenar Atrophy", "None   /   Mild   /   Moderate   /   Severe", None),
    ("2-Point Discrimination", "_____ mm  (>5 mm = abnormal)", None),
    ("Symptom Duration", "_______ months", None),
    ("Symptom Pattern", "Intermittent   /   Constant", None),
    ("NCS / EMG", "Not done   /   Pending   /   Done: DML _____ ms, Sensory latency _____ ms", None),
    ("Ultrasound CSA", "Not done   /   Done: _____ mm² at pisiform level", None),
    ("Underlying Cause", "Idiopathic   /   DM   /   Hypothyroid   /   RA   /   Pregnancy   /   Amyloid   /   CKD   /   Other: _________", None),
]
story.append(rx_table(assess_rows, col_widths=[55*mm, W-55*mm]))
story.append(Spacer(1, 3*mm))

# ── SEVERITY CLASSIFICATION ──────────────────────────────────────────────────
story.append(section_banner("▸  SEVERITY CLASSIFICATION"))
story.append(Spacer(1, 1*mm))

sev_data = [
    [Paragraph("<b>Severity</b>", body_bold),
     Paragraph("<b>Clinical Features</b>", body_bold),
     Paragraph("<b>NCS Findings</b>", body_bold),
     Paragraph("<b>Circled Level</b>", body_bold)],
    [Paragraph("<b>MILD</b>", make_style("M", fontSize=8.5, textColor=HexColor("#2e7d32"), fontName="Helvetica-Bold")),
     Paragraph("Intermittent paresthesia, no atrophy, nocturnal symptoms only, normal grip strength", body),
     Paragraph("Mildly prolonged sensory latency; normal or borderline motor latency", body),
     Paragraph("MILD", make_style("M2", fontSize=9, alignment=TA_CENTER, fontName="Helvetica-Bold", textColor=HexColor("#2e7d32")))],
    [Paragraph("<b>MODERATE</b>", make_style("Mo", fontSize=8.5, textColor=HexColor("#e65100"), fontName="Helvetica-Bold")),
     Paragraph("Frequent paresthesia, daytime symptoms, mild thenar weakness, positive Phalen <30 s", body),
     Paragraph("Prolonged DML (>4.5 ms) and/or sensory latency (>3.5 ms)", body),
     Paragraph("MODERATE", make_style("Mo2", fontSize=9, alignment=TA_CENTER, fontName="Helvetica-Bold", textColor=HexColor("#e65100")))],
    [Paragraph("<b>SEVERE</b>", make_style("S", fontSize=8.5, textColor=HexColor("#b71c1c"), fontName="Helvetica-Bold")),
     Paragraph("Constant paresthesia, thenar atrophy, objective sensory loss, grip weakness, symptoms >10 months", body),
     Paragraph("Markedly prolonged latencies; fibrillations / positive waves in APB on EMG", body),
     Paragraph("SEVERE", make_style("S2", fontSize=9, alignment=TA_CENTER, fontName="Helvetica-Bold", textColor=HexColor("#b71c1c")))],
]
sev_tbl = Table(sev_data, colWidths=[24*mm, 70*mm, 54*mm, 22*mm],
    style=TableStyle([
        ("BACKGROUND", (0,0), (-1,0), C_DARK_BLUE),
        ("TEXTCOLOR",  (0,0), (-1,0), C_WHITE),
        ("BACKGROUND", (0,1), (-1,1), C_MILD_GREEN),
        ("BACKGROUND", (0,2), (-1,2), C_MOD_YELLOW),
        ("BACKGROUND", (0,3), (-1,3), C_SEV_RED),
        ("GRID",       (0,0), (-1,-1), 0.5, C_BORDER),
        ("VALIGN",     (0,0), (-1,-1), "MIDDLE"),
        ("TOPPADDING",    (0,0), (-1,-1), 5),
        ("BOTTOMPADDING", (0,0), (-1,-1), 5),
        ("LEFTPADDING",   (0,0), (-1,-1), 6),
        ("ALIGN",      (3,0), (3,-1), "CENTER"),
        ("BOX",        (3,1), (3,1), 1.5, HexColor("#2e7d32")),
        ("BOX",        (3,2), (3,2), 1.5, HexColor("#e65100")),
        ("BOX",        (3,3), (3,3), 1.5, HexColor("#b71c1c")),
    ])
)
story.append(sev_tbl)
story.append(Spacer(1, 4*mm))

# ══════════════════════════════════════════════════════════════════════════════
#  PAGE 2 START — Prescription by severity
# ══════════════════════════════════════════════════════════════════════════════
story.append(PageBreak())

# ── PAGE 2 MINI HEADER ───────────────────────────────────────────────────────
mini_hdr = Table([[Paragraph("CTS PRESCRIPTION — BY SEVERITY LEVEL", 
    make_style("MH", fontSize=12, fontName="Helvetica-Bold", textColor=C_WHITE, alignment=TA_CENTER))]],
    colWidths=[W],
    style=TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), C_DARK_BLUE),
        ("TOPPADDING",    (0,0), (-1,-1), 7),
        ("BOTTOMPADDING", (0,0), (-1,-1), 7),
    ])
)
story.append(mini_hdr)
story.append(Spacer(1, 3*mm))

# ────────────────────────────────────────────────────────────────────────────
#  MILD CTS
# ────────────────────────────────────────────────────────────────────────────
story.append(KeepTogether([
    severity_banner("🟢  MILD CTS  —  Intermittent symptoms, no motor deficit", C_MILD_GREEN),
    Spacer(1, 2*mm),
    section_banner("Non-Pharmacological", bg=HexColor("#43a047"), width=W),
]))
story.append(Spacer(1, 1*mm))

mild_nonpharm = [
    ("<b>1.</b> Neutral wrist splint",
     "Wear nightly (6–8 h). May also wear during provoking activities. "
     "Splint should hold wrist at 0° (neutral), not extended or flexed.", None),
    ("<b>2.</b> Activity modification",
     "Avoid sustained wrist flexion/extension. Ergonomic review of keyboard/workstation. "
     "Wrist rests during typing. Reduce vibratory tool use.", None),
    ("<b>3.</b> Nerve gliding exercises",
     "Daily programme × 10 repetitions each. Refer to hand therapist if available. "
     "Tendon gliding + median nerve mobilisation sequence.", None),
]
story.append(rx_table(mild_nonpharm, col_widths=[40*mm, W-40*mm]))
story.append(Spacer(1, 2*mm))

story.append(section_banner("Pharmacological", bg=HexColor("#43a047"), width=W))
story.append(Spacer(1, 1*mm))

mild_pharm_lines = [
    "💊  <b>Rx 1 — Corticosteroid Injection</b> (first-line if splinting fails at 4–6 weeks)",
    "     Drug: Methylprednisolone acetate 40 mg (1 mL) + 1% Lidocaine HCl 1 mL",
    "     Route: Intracarpal (palmar approach, ulnar to palmaris longus tendon)",
    "     Technique: Ultrasound-guided preferred; needle directed distally at 30–45° angle",
    "     Frequency: Single injection; may repeat once after 4–6 weeks if partial response",
    "     Max: 2–3 total injections — do NOT inject directly into the median nerve",
    "",
    "💊  <b>Rx 2 — Oral Prednisolone</b> (if injection declined or for acute flare)",
    "     Prednisolone 20 mg orally once daily × 10–14 days (taper not required for short course)",
    "     Take with food to reduce GI irritation",
    "",
    "⚠️  <b>NSAIDs:</b>  Not recommended — evidence shows no benefit over placebo for CTS symptoms",
    "     (May be used adjunctively for coexisting tenosynovitis at clinician's discretion)",
]
story.append(drug_box(mild_pharm_lines, bg=HexColor("#f1f8e9")))
story.append(Spacer(1, 2*mm))

story.append(section_banner("Investigations / Workup for Underlying Cause", bg=HexColor("#43a047"), width=W))
story.append(Spacer(1, 1*mm))
mild_ix_lines = [
    "□  TSH (hypothyroidism)           □  Fasting glucose + HbA1c (diabetes)",
    "□  Renal function / eGFR (CKD)   □  RF / anti-CCP (rheumatoid arthritis)",
    "□  Pregnancy test (if applicable) □  Consider ESR, CRP, ANA if autoimmune suspected",
]
story.append(drug_box(mild_ix_lines, bg=HexColor("#f1f8e9")))
story.append(Spacer(1, 2*mm))

story.append(Paragraph(
    "📅  <b>Follow-up:</b> Review at 4–6 weeks. If no improvement with splint + injection → upgrade to moderate protocol.",
    note_style))
story.append(Spacer(1, 4*mm))

# ────────────────────────────────────────────────────────────────────────────
#  MODERATE CTS
# ────────────────────────────────────────────────────────────────────────────
story.append(KeepTogether([
    severity_banner("🟡  MODERATE CTS  —  Frequent symptoms, mild motor signs", C_MOD_YELLOW),
    Spacer(1, 2*mm),
    section_banner("Non-Pharmacological", bg=HexColor("#f9a825"), width=W),
]))
story.append(Spacer(1, 1*mm))

mod_nonpharm = [
    ("<b>1.</b> Neutral wrist splint",
     "Full-time splinting for 4–6 weeks (day + night), then reassess. "
     "Removable thermoplastic splint preferred.", None),
    ("<b>2.</b> Workplace ergonomics",
     "Formal occupational therapy referral. Workstation redesign, modified duties if required.", None),
    ("<b>3.</b> Nerve gliding exercises",
     "Twice daily. Include tendon gliding, nerve mobilisation, and opposition strengthening.", None),
    ("<b>4.</b> Treat underlying cause",
     "Optimise thyroid replacement, glycaemic control, RA disease-modifying therapy, "
     "or diuresis (pregnancy/renal).", None),
]
story.append(rx_table(mod_nonpharm, col_widths=[40*mm, W-40*mm]))
story.append(Spacer(1, 2*mm))

story.append(section_banner("Pharmacological", bg=HexColor("#f9a825"), width=W))
story.append(Spacer(1, 1*mm))

mod_pharm_lines = [
    "💊  <b>Rx 1 — Corticosteroid Injection (First-line)</b>",
    "     Methylprednisolone acetate 40 mg + 1% Lidocaine 1 mL — intracarpal, as above",
    "     If 90% improvement → continues conservative; if partial → plan surgical referral",
    "",
    "💊  <b>Rx 2 — Oral Prednisolone (bridge or injection not feasible)</b>",
    "     Prednisolone 25 mg once daily × 14 days; reduce to 12.5 mg × 7 days, then stop",
    "",
    "💊  <b>Rx 3 — Treat underlying metabolic disease (examples):</b>",
    "     Hypothyroidism: Levothyroxine — start 25–50 mcg/day; titrate to TSH 0.5–2.0 mIU/L",
    "     Diabetes mellitus: Optimise HbA1c to <7%; add or adjust antidiabetic agent",
    "     Rheumatoid arthritis: Continue/escalate DMARDs per rheumatology; consider MTX ± biologic",
    "     Pregnancy: Neutral splint + single injection safe; most cases resolve post-partum",
    "     CKD / dialysis: Optimise dialysis adequacy; early surgical referral (amyloid-related CTS)",
    "",
    "💊  <b>Neuropathic pain adjunct</b> (if burning/dysaesthetic component prominent):",
    "     Gabapentin 100–300 mg at night; titrate cautiously. Or Amitriptyline 10 mg nocte.",
    "     Use with caution in elderly; monitor for sedation.",
]
story.append(drug_box(mod_pharm_lines, bg=HexColor("#fffde7")))
story.append(Spacer(1, 2*mm))

story.append(section_banner("Investigations", bg=HexColor("#f9a825"), width=W))
story.append(Spacer(1, 1*mm))
mod_ix_lines = [
    "□  NCS / EMG — mandatory before surgical referral  (DML, sensory latency, APB EMG)",
    "□  Wrist ultrasound — median nerve CSA (cutoff >10 mm² at pisiform)",
    "□  Blood: TSH, HbA1c, RF/anti-CCP, renal panel, FBC, SPEP if amyloid suspected",
    "□  Wrist X-ray — if post-traumatic or arthropathy suspected",
]
story.append(drug_box(mod_ix_lines, bg=HexColor("#fffde7")))
story.append(Spacer(1, 2*mm))

story.append(Paragraph(
    "📅  <b>Follow-up:</b> 4–6 weeks. If ≥3 failure predictors present (age >50, duration >10 months, "
    "constant paresthesia, stenosing tenosynovitis, Phalen <30 s) → refer for surgery.",
    note_style))
story.append(Spacer(1, 4*mm))

# ────────────────────────────────────────────────────────────────────────────
#  SEVERE CTS  (page 3)
# ────────────────────────────────────────────────────────────────────────────
story.append(PageBreak())

# Mini repeat header
story.append(mini_hdr)
story.append(Spacer(1, 3*mm))

story.append(KeepTogether([
    severity_banner("🔴  SEVERE CTS  —  Constant symptoms, thenar atrophy, motor deficit", C_SEV_RED),
    Spacer(1, 2*mm),
    section_banner("Immediate Management", bg=HexColor("#c62828"), width=W),
]))
story.append(Spacer(1, 1*mm))

sev_immediate = [
    ("<b>URGENT surgical referral</b>",
     "Refer to hand surgery / orthopaedic surgery for carpal tunnel release (CTR). "
     "Thenar atrophy and motor weakness indicate irreversible nerve damage risk.", None),
    ("<b>Cease provoking activities</b>",
     "Modified duties or temporary work cessation if occupation involves repetitive wrist use.", None),
    ("<b>Full-time neutral wrist splint</b>",
     "Continue while awaiting surgery to limit further compression.", None),
    ("<b>Corticosteroid injection</b>",
     "May provide temporary relief and confirms diagnosis (90% who respond will benefit from surgery). "
     "Do NOT delay surgical referral awaiting injection response.", None),
]
story.append(rx_table(sev_immediate, col_widths=[45*mm, W-45*mm]))
story.append(Spacer(1, 2*mm))

story.append(section_banner("Surgical Options", bg=HexColor("#c62828"), width=W))
story.append(Spacer(1, 1*mm))

sev_surg_lines = [
    "🔪  <b>Option 1 — Open Carpal Tunnel Release (standard / mini-palm)</b>",
    "     Longitudinal incision distal to wrist crease, ulnar to ring finger midline (~2–3 cm)",
    "     Division of flexor retinaculum (TCL) under direct vision; nerve safety confirmed before release",
    "     Preferred when anatomy uncertain, revision case, or concurrent tenosynovectomy needed",
    "",
    "🔪  <b>Option 2 — Endoscopic CTR (ECTR)</b>",
    "     1–2 portal technique; faster return to function, less pillar pain",
    "     Equivalent long-term outcomes to open CTR (meta-analysis 2024, PMID 38768022)",
    "     Generally preferred when straightforward anatomy",
    "",
    "⚕️  <b>Special surgical considerations by underlying cause:</b>",
    "     RA / tenosynovitis: CTR + concurrent tenosynovectomy; if thenar atrophy + poor opposition",
    "       → Camitz palmaris longus opponensplasty (especially in elderly patients)",
    "     Post-Colles fracture: Loosen cast → change wrist to neutral; if persists → urgent CTR",
    "     Dialysis amyloid: Bilateral staged CTR; do not delay — amyloid does not respond conservatively",
    "     Age >70 / advanced compression: Counsel that thenar atrophy may not fully resolve post-CTR",
]
story.append(drug_box(sev_surg_lines, bg=HexColor("#ffebee")))
story.append(Spacer(1, 2*mm))

story.append(section_banner("Pre-operative Investigations", bg=HexColor("#c62828"), width=W))
story.append(Spacer(1, 1*mm))
sev_ix_lines = [
    "□  NCS / EMG — mandatory (DML >4.5 ms, sensory latency >3.5 ms; fibrillations in APB on EMG)",
    "□  Wrist ultrasound (median nerve CSA) if NCS equivocal",
    "□  FBC, coagulation (INR/APTT), renal/liver function, blood glucose",
    "□  Wrist X-ray (PA + lateral) — assess carpal anatomy, osteophytes, fracture deformity",
    "□  MRI — only if space-occupying lesion (ganglion, lipoma, tumour) suspected",
    "□  Anaesthetic review if indicated (comorbidities)",
]
story.append(drug_box(sev_ix_lines, bg=HexColor("#ffebee")))
story.append(Spacer(1, 2*mm))

story.append(Paragraph(
    "📅  <b>Post-operative follow-up:</b> Wound review at 10–14 days. Maximum improvement expected within "
    "first 6 months post-CTR. Sensory recovery precedes motor recovery. Physiotherapy for grip strengthening "
    "and scar management. Thenar atrophy resolves slowly and may be incomplete.",
    note_style))
story.append(Spacer(1, 4*mm))

# ────────────────────────────────────────────────────────────────────────────
#  UNDERLYING CAUSE TREATMENT QUICK REFERENCE
# ────────────────────────────────────────────────────────────────────────────
story.append(section_banner("▸  TREATMENT OF UNDERLYING CAUSE — QUICK REFERENCE"))
story.append(Spacer(1, 1*mm))

cause_data = [
    [Paragraph("<b>Condition</b>", body_bold),
     Paragraph("<b>Target / Goal</b>", body_bold),
     Paragraph("<b>First-line Treatment</b>", body_bold),
     Paragraph("<b>Notes</b>", body_bold)],
    [Paragraph("Hypothyroidism", body),
     Paragraph("TSH 0.5–2.0 mIU/L", body),
     Paragraph("Levothyroxine 25–100 mcg/day PO", body),
     Paragraph("CTS may resolve with euthyroid state alone", small)],
    [Paragraph("Diabetes mellitus", body),
     Paragraph("HbA1c <7%", body),
     Paragraph("Optimise antidiabetic regimen per guidelines", body),
     Paragraph("NCS may underestimate severity; surgical outcome still favourable", small)],
    [Paragraph("Rheumatoid arthritis", body),
     Paragraph("DAS28 remission", body),
     Paragraph("Methotrexate ± biologic DMARD", body),
     Paragraph("Concurrent tenosynovectomy at CTR", small)],
    [Paragraph("Pregnancy", body),
     Paragraph("Symptom control", body),
     Paragraph("Neutral splint; single intracarpal steroid injection if needed", body),
     Paragraph("Usually resolves post-partum; avoid surgery unless severe", small)],
    [Paragraph("CKD / Dialysis amyloid", body),
     Paragraph("Symptom control; prevent progression", body),
     Paragraph("Optimise dialysis; early CTR referral", body),
     Paragraph("Amyloid infiltration of TCL does not respond to conservative care", small)],
    [Paragraph("Acromegaly", body),
     Paragraph("Normalise IGF-1 / GH", body),
     Paragraph("Somatostatin analogue (octreotide) or surgery", body),
     Paragraph("CTS from bony tunnel narrowing; CTR often required regardless", small)],
    [Paragraph("Obesity", body),
     Paragraph("BMI <30", body),
     Paragraph("Lifestyle modification; bariatric referral if BMI >40", body),
     Paragraph("Weight loss may reduce tunnel pressure and fluid retention", small)],
]
cause_tbl = Table(cause_data, colWidths=[28*mm, 28*mm, 62*mm, 52*mm],
    style=TableStyle([
        ("BACKGROUND", (0,0), (-1,0), C_DARK_BLUE),
        ("TEXTCOLOR",  (0,0), (-1,0), C_WHITE),
        ("GRID",       (0,0), (-1,-1), 0.4, C_BORDER),
        ("VALIGN",     (0,0), (-1,-1), "TOP"),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [C_WHITE, C_LIGHT_GRAY]),
    ])
)
story.append(cause_tbl)
story.append(Spacer(1, 4*mm))

# ────────────────────────────────────────────────────────────────────────────
#  CLINICIAN NOTES BOX
# ────────────────────────────────────────────────────────────────────────────
story.append(section_banner("▸  CLINICIAN NOTES"))
story.append(Spacer(1, 1*mm))
notes_lines = ["" for _ in range(5)]
notes_data = [[Paragraph("____________________________________________________________________________________"
                          "____________________________________________________________________________________",
                          small)] for _ in range(5)]
notes_tbl = Table(notes_data, colWidths=[W],
    style=TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), C_LIGHT_GRAY),
        ("BOX",        (0,0), (-1,-1), 0.8, C_BORDER),
        ("TOPPADDING",    (0,0), (-1,-1), 6),
        ("BOTTOMPADDING", (0,0), (-1,-1), 2),
        ("LEFTPADDING",   (0,0), (-1,-1), 8),
    ])
)
story.append(notes_tbl)
story.append(Spacer(1, 4*mm))

# ── FOOTER ───────────────────────────────────────────────────────────────────
story.append(HRFlowable(width=W, thickness=0.5, color=C_BORDER))
story.append(Spacer(1, 2*mm))
story.append(Paragraph(
    "Sources: Campbell's Operative Orthopaedics 15e | Goldman-Cecil Medicine | Bradley and Daroff's Neurology | "
    "Textbook of Family Medicine 9e | Tintinalli's Emergency Medicine · Generated by Orris Medical AI · May 2026",
    footer_s
))
story.append(Paragraph(
    "⚠ This template is a clinical aide-memoire. All prescriptions must be verified by a licensed clinician. "
    "Doses should be adjusted for individual patient factors including renal/hepatic function, age, weight and comorbidities.",
    make_style("Disclaimer", fontSize=7, textColor=HexColor("#b71c1c"), alignment=TA_CENTER, leading=10)
))

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

cd /home/daytona/workspace/cts-prescription && python generate_cts_rx.py

ls -lh /home/daytona/workspace/cts-prescription/CTS_Prescription_Template.pdf