cd /tmp/workspace && python3 << 'EOF' import pdfplumber import os pdf_path = "/tmp/workspace/attachments/55ce74a7-21a0-4f5d-a791-1fe6e5f1e371/9789241504713_eng.pdf" output_dir = "/tmp/workspace/dengue_project" os.makedirs(output_dir, exist_ok=True) with pdfplumber.open(pdf_path) as pdf: print(f"Total pages: {len(pdf.pages)}") # Extract first 5 pages to understand structure for i, page in enumerate(pdf.pages[:5]): print(f"\n=== PAGE {i+1} ===") text = page.extract_text() if text: print(text[:2000]) EOF

python3 << 'EOF' import pdfplumber import os, json pdf_path = "/tmp/workspace/attachments/55ce74a7-21a0-4f5d-a791-1fe6e5f1e371/9789241504713_eng.pdf" output_dir = "/tmp/workspace/dengue_project" os.makedirs(output_dir, exist_ok=True) # Extract all text pages 5-90 (main clinical content) all_text = {} with pdfplumber.open(pdf_path) as pdf: # Extract images info for i, page in enumerate(pdf.pages): text = page.extract_text() if text: all_text[i+1] = text # Save full text with open(f"{output_dir}/who_dengue_full.txt", "w") as f: for pg, txt in all_text.items(): f.write(f"\n\n=== PAGE {pg} ===\n") f.write(txt) print(f"Extracted {len(all_text)} pages of text") print("Done saving to who_dengue_full.txt") EOF

python3 << 'EOF' # Read key sections from WHO PDF with open("/tmp/workspace/dengue_project/who_dengue_full.txt", "r") as f: content = f.read() # Print pages 6-50 (main clinical content) lines = content.split('\n') in_range = False pg_count = 0 output = [] for line in lines: if line.startswith('=== PAGE '): pg_num = int(line.replace('=== PAGE ', '').replace(' ===', '')) in_range = (6 <= pg_num <= 55) if in_range: output.append(line) print('\n'.join(output[:3000])) EOF

python3 << 'EOF' # Read key sections from WHO PDF - pages 63-80 (pediatric section) and complications with open("/tmp/workspace/dengue_project/who_dengue_full.txt", "r") as f: content = f.read() lines = content.split('\n') output = [] for line in lines: if line.startswith('=== PAGE '): pg_num = int(line.replace('=== PAGE ', '').replace(' ===', '')) in_range = (63 <= pg_num <= 82) if in_range: output.append(line) print('\n'.join(output[:3000])) EOF

python3 << 'EOF' # Read key sections from WHO PDF - pages 63-82 (pediatric section) with open("/tmp/workspace/dengue_project/who_dengue_full.txt", "r") as f: content = f.read() lines = content.split('\n') output = [] in_range = False for line in lines: if line.startswith('=== PAGE '): pg_num = int(line.replace('=== PAGE ', '').replace(' ===', '')) in_range = (63 <= pg_num <= 82) if in_range: output.append(line) print('\n'.join(output[:3000])) EOF

python3 << 'EOF' import pdfplumber import os pdf_path = "/tmp/workspace/attachments/55ce74a7-21a0-4f5d-a791-1fe6e5f1e371/9789241504713_eng.pdf" output_dir = "/tmp/workspace/dengue_project/figures" os.makedirs(output_dir, exist_ok=True) # Check image content on key pages with figures from pypdf import PdfReader reader = PdfReader(pdf_path) print(f"Total pages: {len(reader.pages)}") # Pages with key figures: 11 (Fig1 - course), 17 (Fig2 - classification), 34 (Fig4 - algorithm), # 39 (Fig5), 40 (Fig6), 42 (Fig7) figure_pages = [10, 16, 33, 38, 39, 41] # 0-indexed for pg_idx in figure_pages: page = reader.pages[pg_idx] resources = page.get("/Resources") if resources: xobjects = resources.get("/XObject") if xobjects: obj_keys = list(xobjects.keys()) if hasattr(xobjects, 'keys') else [] print(f"Page {pg_idx+1}: {len(obj_keys)} XObjects found: {obj_keys[:5]}") else: print(f"Page {pg_idx+1}: No XObjects") else: print(f"Page {pg_idx+1}: No Resources") EOF

python3 << 'EOF' import pdfplumber import os from PIL import Image import io pdf_path = "/tmp/workspace/attachments/55ce74a7-21a0-4f5d-a791-1fe6e5f1e371/9789241504713_eng.pdf" output_dir = "/tmp/workspace/dengue_project/figures" os.makedirs(output_dir, exist_ok=True) # Extract figure pages as images using pdfplumber # Key figure pages (1-indexed): 11 (Fig1 - course), 12 (Fig1 continued), 17 (Fig2 - classification) # 34 (Fig4 - algorithm), 39 (Fig5 - compensated shock adults), 40 (Fig6 - compensated shock children) # 42 (Fig7 - hypotensive shock) fig_pages_info = { 11: "fig1_course_dengue", 17: "fig2_classification", 34: "fig4_management_algorithm", 39: "fig5_compensated_shock_adults", 40: "fig6_compensated_shock_children", 42: "fig7_hypotensive_shock" } with pdfplumber.open(pdf_path) as pdf: for pg_num, name in fig_pages_info.items(): page = pdf.pages[pg_num - 1] # 0-indexed # Convert page to image img = page.to_image(resolution=150) out_path = f"{output_dir}/{name}.png" img.save(out_path) print(f"Saved: {out_path}") print("All figures extracted!") EOF

python3 << 'PYEOF' from docx import Document from docx.shared import Pt, Inches, RGBColor, Cm from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.enum.table import WD_TABLE_ALIGNMENT, WD_ALIGN_VERTICAL from docx.oxml.ns import qn from docx.oxml import OxmlElement import os doc = Document() # ─── PAGE SETUP ───────────────────────────────────────────────────────────── from docx.shared import Mm section = doc.sections[0] section.page_width = Mm(210) section.page_height = Mm(297) section.left_margin = Mm(18) section.right_margin = Mm(18) section.top_margin = Mm(16) section.bottom_margin = Mm(16) # ─── STYLES ───────────────────────────────────────────────────────────────── normal = doc.styles['Normal'] normal.font.name = 'Calibri' normal.font.size = Pt(9.5) def h1(text): p = doc.add_heading(text, level=1) p.runs[0].font.color.rgb = RGBColor(0x1F, 0x49, 0x7D) p.runs[0].font.size = Pt(13) return p def h2(text): p = doc.add_heading(text, level=2) p.runs[0].font.color.rgb = RGBColor(0x2E, 0x74, 0xB5) p.runs[0].font.size = Pt(11) return p def h3(text): p = doc.add_heading(text, level=3) p.runs[0].font.color.rgb = RGBColor(0x5A, 0x96, 0xC8) p.runs[0].font.size = Pt(10) return p def body(text, bold_parts=None, space_after=3): p = doc.add_paragraph() p.paragraph_format.space_after = Pt(space_after) p.paragraph_format.space_before = Pt(0) if bold_parts: for fragment, is_bold in bold_parts: run = p.add_run(fragment) run.bold = is_bold run.font.size = Pt(9.5) else: run = p.add_run(text) run.font.size = Pt(9.5) return p def bullet(text, level=0): p = doc.add_paragraph(style='List Bullet') p.paragraph_format.space_after = Pt(1) p.paragraph_format.space_before = Pt(0) p.paragraph_format.left_indent = Pt(12 + level * 12) run = p.add_run(text) run.font.size = Pt(9.5) return p def add_img(path, width_inches=6.2, caption=None): if os.path.exists(path): doc.add_picture(path, width=Inches(width_inches)) last = doc.paragraphs[-1] last.alignment = WD_ALIGN_PARAGRAPH.CENTER if caption: cp = doc.add_paragraph(caption) cp.alignment = WD_ALIGN_PARAGRAPH.CENTER cp.paragraph_format.space_after = Pt(4) cp.runs[0].font.size = Pt(8.5) cp.runs[0].italic = True def add_table_row(table, cells_text, header=False): row = table.add_row() for i, txt in enumerate(cells_text): cell = row.cells[i] cell.text = txt cell.paragraphs[0].runs[0].font.size = Pt(9) if header: cell.paragraphs[0].runs[0].bold = True shading = OxmlElement("w:shd") shading.set(qn("w:val"), "clear") shading.set(qn("w:color"), "auto") shading.set(qn("w:fill"), "2E74B5") cell._tc.get_or_add_tcPr().append(shading) cell.paragraphs[0].runs[0].font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF) FIGS = "/tmp/workspace/dengue_project/figures" # ════════════════════════════════════════════════════════════════════════════ # TITLE # ════════════════════════════════════════════════════════════════════════════ title = doc.add_paragraph() title.alignment = WD_ALIGN_PARAGRAPH.CENTER r = title.add_run("DENGUE FEVER – Comprehensive Clinical Notes") r.bold = True r.font.size = Pt(15) r.font.color.rgb = RGBColor(0x1F, 0x49, 0x7D) sub = doc.add_paragraph() sub.alignment = WD_ALIGN_PARAGRAPH.CENTER sub.paragraph_format.space_after = Pt(6) rs = sub.add_run("Based on WHO Handbook for Clinical Management of Dengue (2012) & Red Book 2021") rs.font.size = Pt(8.5) rs.italic = True # ════════════════════════════════════════════════════════════════════════════ # 1. ETIOLOGY & PATHOLOGY # ════════════════════════════════════════════════════════════════════════════ h1("1. ETIOLOGY & PATHOLOGY") h2("Etiology") bullet("Dengue virus (DENV) – single-stranded RNA virus, Family Flaviviridae, Genus Flavivirus") bullet("4 serotypes: DENV-1, 2, 3, 4 – antigenically and genetically distinct") bullet("Vector: Aedes aegypti (primary), A. albopictus (secondary)") bullet("Humans are the primary amplifying host; incubation period 4-10 days post-bite") bullet("Secondary infection with a different serotype → markedly increased risk of severe disease (antibody-dependent enhancement)") bullet("Lifetime risk: up to 4 dengue infections (one per serotype)") h2("Pathophysiology") bullet("Vascular endothelium is the main target of dengue-induced injury") bullet("Increased capillary permeability → plasma leakage → haemoconcentration and third-space fluid accumulation") bullet("Thrombocytopenia: bone marrow suppression + peripheral platelet destruction by immune complexes + platelet dysfunction") bullet("Coagulopathy: DIC may supervene in severe/prolonged shock") bullet("Antibody-Dependent Enhancement (ADE): cross-reactive antibodies from prior infection facilitate viral entry into monocytes/macrophages → amplified cytokine storm in secondary infection") bullet("Complement activation, elevated TNF-α, IL-6, IL-10 drive vascular leak and organ damage") bullet("Severe organ involvement: hepatitis (direct viral cytopathy + immune-mediated), encephalitis, myocarditis, nephropathy – can occur with or without shock") # ════════════════════════════════════════════════════════════════════════════ # 2. CLINICAL FEATURES & PHASES # ════════════════════════════════════════════════════════════════════════════ h1("2. CLINICAL FEATURES – THREE PHASES") add_img(f"{FIGS}/fig1_course_dengue.png", width_inches=6.0, caption="Figure 1. The course of dengue illness (WHO, 2012)") h2("Phase 1 – Febrile Phase (Days 1–7)") bullet("Sudden high fever (39-40°C), lasting 2-7 days; often bifasic ('saddle-back' pattern)") bullet("Headache, severe myalgia, arthralgia, retro-orbital pain – 'Breakbone fever'") bullet("Facial flushing, skin erythema, injected pharynx, conjunctival injection") bullet("Anorexia, nausea, vomiting, abdominal pain") bullet("Rash: maculopapular or macular, first trunk then face/extremities") bullet("Mild haemorrhage: petechiae, mucosal bleeding (nose/gums), easy bruising") bullet("Labs: progressive leukopenia, early thrombocytopenia → strong diagnostic clue") bullet("Positive tourniquet test (Rumpel-Leede): ≥20 petechiae/sq inch – increases dengue probability") h2("Phase 2 – Critical Phase (Days 3–7, ~24-48 hrs at defervescence)") body("", bold_parts=[ ("Warning Signs (flag for hospitalization): ", True), ("Abdominal pain/tenderness, persistent vomiting, clinical fluid accumulation (ascites, pleural effusion), mucosal bleeding, lethargy/restlessness, liver enlargement >2 cm, rising HCT + rapid platelet fall.", False) ]) bullet("Plasma leakage → rising haematocrit (≥20% above baseline), narrow pulse pressure, shock") bullet("Leukopenia (≤5000/mm³) precedes plasma leakage; platelet <100,000/mm³ typical") bullet("Temperature often subnormal at onset of shock; cold extremities, delayed CRT >2 sec") bullet("Compensated shock: systolic BP maintained but pulse pressure ≤20 mmHg + poor perfusion signs") bullet("Hypotensive (decompensated) shock: both systolic and diastolic collapse simultaneously; imminent cardiorespiratory arrest") h2("Phase 3 – Recovery Phase (Days 7–10)") bullet("Gradual reabsorption of leaked fluid; appetite and well-being return; diuresis ensues") bullet("Rash: confluent erythema with 'isles of white in a sea of red'; generalised pruritus") bullet("Bradycardia, ECG changes common") bullet("HCT drops (haemodilution); WBC rises early; platelet recovery is delayed") bullet("RISK: Fluid overload → pulmonary oedema if IV fluids not reduced promptly") # ════════════════════════════════════════════════════════════════════════════ # 3. CLASSIFICATION # ════════════════════════════════════════════════════════════════════════════ h1("3. CLASSIFICATION (WHO 2009 / Revised)") add_img(f"{FIGS}/fig2_classification.png", width_inches=6.2, caption="Figure 2. Dengue case classification by severity (WHO, 2012)") h2("Dengue without Warning Signs") bullet("Fever + 2 of: nausea/vomiting, rash, aches and pains, leukopenia, positive tourniquet test") h2("Dengue with Warning Signs") bullet("All of above PLUS any of: abdominal pain/tenderness, persistent vomiting, clinical fluid accumulation, mucosal bleed, lethargy/restlessness, liver >2 cm, rising HCT with rapid platelet drop") h2("Severe Dengue (Group C – Emergency)") bullet("Severe plasma leakage → shock (DSS) and/or fluid accumulation with respiratory distress") bullet("Severe haemorrhage as assessed by clinician") bullet("Severe organ impairment: AST/ALT ≥1000 IU/L, impaired consciousness, myocarditis, renal failure") body("", bold_parts=[ ("Classic Criteria (older DHF classification): ", True), ("DHF = Dengue + Thrombocytopenia (≤100,000) + Evidence of plasma leakage (HCT ≥20% rise, pleural effusion, ascites, hypoalbuminaemia) ± Haemorrhage. DSS = DHF + Shock (pulse pressure ≤20 mmHg or undetectable BP/pulse).", False) ]) # ════════════════════════════════════════════════════════════════════════════ # 4. DIAGNOSIS # ════════════════════════════════════════════════════════════════════════════ h1("4. DIAGNOSIS") h2("Clinical Diagnosis") bullet("Tourniquet test: inflate BP cuff to midpoint between systolic and diastolic for 5 min; ≥20 petechiae/sq inch = positive") bullet("Assess all 3 phases; daily FBC from Day 1 when dengue suspected") h2("Laboratory Tests") tbl = doc.add_table(rows=1, cols=3) tbl.style = 'Table Grid' tbl.alignment = WD_TABLE_ALIGNMENT.CENTER add_table_row(tbl, ["Method", "Timing", "Notes"], header=True) rows_data = [ ("Viral isolation / RT-PCR", "Day 1-5 (febrile phase)", "Serotype identification; high sensitivity"), ("NS1 Antigen (ELISA/rapid)", "Day 1-5", "Earliest marker; available at primary care"), ("IgM (MAC-ELISA/rapid)", "After Day 5", "Primary infection: IgM high, IgG low"), ("IgG (ELISA/HIA)", "After Day 5-9", "Secondary infection: IgG high, IgM low"), ("Paired sera (IgM/IgG seroconversion)", "Acute + Day 15-21", "Gold standard confirmation"), ("CBC + HCT (daily)", "From Day 1", "Leukopenia → thrombocytopenia → rising HCT"), ] for r in rows_data: add_table_row(tbl, list(r)) doc.add_paragraph() h2("Key Lab Changes") bullet("WBC: leukopenia is earliest marker; often ≤5000/mm³ before critical phase") bullet("Platelets: fall rapidly around Day 3-5; <20,000 in severe cases; thrombocytopenia precedes shock") bullet("HCT: rising HCT ≥20% above baseline = plasma leakage; falling HCT in setting of shock = haemorrhage") bullet("Liver enzymes: mild-to-moderate elevation common; AST/ALT ≥1000 = severe organ involvement") # ════════════════════════════════════════════════════════════════════════════ # 5. MANAGEMENT # ════════════════════════════════════════════════════════════════════════════ h1("5. MANAGEMENT – STEPWISE APPROACH") add_img(f"{FIGS}/fig4_management_algorithm.png", width_inches=6.2, caption="Figure 4. Dengue case management algorithm – Groups A, B, C (WHO, 2012)") h2("Group A – Outpatient (No Warning Signs, Able to Tolerate Oral Fluids)") bullet("Bed rest, adequate oral fluids (ORS, fruit juices, coconut water, rice water)") bullet("Paracetamol: 10 mg/kg/dose in children, max 3-4 doses/day; max 3 g/day in adults") bullet("AVOID: aspirin, ibuprofen, NSAIDs, IM injections (risk of haemorrhage/gastritis)") bullet("Daily review: WBC, platelets, HCT; return immediately if any warning sign appears") bullet("Urine frequency ≥4-6 times/day = adequate oral hydration") h2("Group B – Inpatient (Warning Signs OR Co-morbidities)") bullet("Obtain baseline HCT before starting IV fluids") bullet("Isotonic crystalloid: 0.9% saline or Ringer's Lactate (RL) – START at 5-7 ml/kg/hr for 1-2 hrs") bullet("Reassess: if improving → reduce to 3-5 ml/kg/hr for 2-4 hrs → then 2-3 ml/kg/hr") bullet("If vital signs worsen + HCT rising → increase to 5-10 ml/kg/hr for 1-2 hrs") bullet("Total IV fluid duration usually 24-48 hrs; reduce when plasma leak resolves") bullet("Monitor: vitals + perfusion 1-4 hourly, urine output 4-6 hourly, HCT 6-12 hourly, blood glucose") h2("Group C – Emergency (Severe Dengue / Shock)") h3("Compensated Shock (systolic maintained, pulse pressure ≤20 mmHg)") body("Start isotonic crystalloid: Adults 5-10 ml/kg/hr × 1 hr; Children/Infants 10-20 ml/kg/hr × 1 hr") add_img(f"{FIGS}/fig5_compensated_shock_adults.png", width_inches=5.5, caption="Figure 5. Fluid management – Compensated Shock in Adults (WHO, 2012)") add_img(f"{FIGS}/fig6_compensated_shock_children.png", width_inches=5.5, caption="Figure 6. Fluid management – Compensated Shock in Children (WHO, 2012)") h3("Hypotensive / Profound Shock (undetectable BP/pulse)") body("All patients: crystalloid OR colloid 20 ml/kg bolus over 15-30 min; colloid preferred if pulse pressure <10 mmHg") add_img(f"{FIGS}/fig7_hypotensive_shock.png", width_inches=5.5, caption="Figure 7. Fluid management – Hypotensive Shock (WHO, 2012)") h3("Decision Tree After First Bolus") bullet("If HCT ↑ or still high: repeat crystalloid/colloid 10-20 ml/kg/hr × 1 hr; if improves → taper") bullet("If HCT ↓ + unstable: suspect haemorrhage → cross-match; transfuse fresh whole blood 10-20 ml/kg OR packed RBCs 5-10 ml/kg") bullet("Stop IV fluids at 48 hrs; signs of cessation of leak = stable vitals, HCT declining, good urine output, afebrile >24 hrs") h2("Platelet Transfusion") bullet("NO prophylactic platelet transfusion in haemodynamically stable patients – no evidence of benefit, risk of fluid overload") bullet("Consider only in: surgery/delivery with severe thrombocytopenia, or massive uncontrolled haemorrhage") h2("Haemorrhagic Complications") bullet("Minor mucosal bleeding: manage conservatively; improves in recovery phase") bullet("Severe GI bleed: fresh packed RBCs 5-10 ml/kg or FWB 10-20 ml/kg; H2 antagonist / PPI") bullet("FFP/platelet concentrates NOT recommended routinely – exacerbate fluid overload") bullet("No evidence for DIC regime in dengue-related coagulopathy") # ════════════════════════════════════════════════════════════════════════════ # 6. COMPLICATIONS # ════════════════════════════════════════════════════════════════════════════ h1("6. COMPLICATIONS") tbl2 = doc.add_table(rows=1, cols=2) tbl2.style = 'Table Grid' tbl2.alignment = WD_TABLE_ALIGNMENT.CENTER add_table_row(tbl2, ["Complication", "Notes"], header=True) comp_data = [ ("Dengue Shock Syndrome (DSS)", "Hypovolaemic shock from plasma leak; pulse pressure ≤20 mmHg; mortality high if prolonged"), ("Severe Haemorrhage", "GI bleed, haematemesis, melaena, hypermenorrhoea; risk ↑ with NSAIDs, peptic ulcer, prolonged shock"), ("Fluid Overload / Pulmonary Oedema", "From excessive/prolonged IV fluids; 'bat-wing' X-ray, Kerley B lines, frothy sputum"), ("Acute Hepatitis / Liver Failure", "ALT/AST >1000 IU/L; fulminant hepatic failure rare; hypoglycaemia risk"), ("Encephalopathy / Encephalitis", "Altered consciousness, seizures; direct viral neurotropism or metabolic (hypoglycaemia, hyponatraemia)"), ("Myocarditis", "ECG changes, arrhythmia, cardiogenic shock; monitor cardiac enzymes"), ("Acute Kidney Injury", "Renal hypoperfusion in shock; haemoglobinuria worsens it; dialysis in refractory cases"), ("ARDS", "Noncardiogenic pulmonary oedema; complication of fluid overload or severe systemic disease"), ("Haemophagocytic Syndrome", "Rare; persistent fever, cytopenias, hyperferritinaemia; bone marrow biopsy confirms"), ("DIC", "Severe coagulopathy in prolonged/profound shock; prolonged PT/PTT, low fibrinogen"), ("Febrile Seizures", "Especially in infants/young children; manage fever aggressively"), ("Multi-organ Failure", "End-stage of prolonged profound shock; liver + kidney + CNS + heart involvement"), ] for r in comp_data: add_table_row(tbl2, list(r)) doc.add_paragraph() # ════════════════════════════════════════════════════════════════════════════ # 7. DENGUE IN INFANTS # ════════════════════════════════════════════════════════════════════════════ h1("7. DENGUE IN INFANTS (Special Note)") h2("Epidemiology & Risk") bullet("~5% of all severe dengue cases occur in infants; peak burden ages 4-9 months") bullet("Most are primary infections; vertical transmission from dengue-infected mother is recognized") bullet("Maternal dengue IgG antibodies cross placenta and can cause ADE → severe disease in newborn") bullet("Mortality rate higher in infants than older children despite lower overall incidence") h2("Distinctive Clinical Features") bullet("High fever lasting 2-7 days (same as older children) but URTI symptoms more prominent: cough, nasal congestion, rhinorrhoea") bullet("GI symptoms (vomiting, diarrhoea) and febrile convulsions more frequent") bullet("Skin bleeding: petechiae, mucosal bleeding around defervescence (Day 3-6)") bullet("Hepatomegaly very common; splenomegaly ~10% (7x more frequent than older children)") bullet("Baseline HCT lower in infants (28-42%); HCT of 40% may represent significant haemoconcentration if baseline was 30%") bullet("Differentiation from bacterial sepsis, pneumonia, HFMD, meningitis often impossible at febrile stage") bullet("Warning signs same as adults; a positive tourniquet test, early petechiae, low platelets in a febrile infant → think dengue") h2("Management of Dengue Infants") body("", bold_parts=[("Without warning signs: ", True), ("Supportive – oral fluids (ORS + breastfeeding/formula), paracetamol, fever sponging; advise parents on warning signs", False)]) body("", bold_parts=[("With warning signs: ", True), ("Admit. IV isotonic crystalloid (RL/NS) at 5-7 ml/kg/hr for 1-2 hrs, then adjust. Mean volume needed: ~102 ml/kg over ~26 hrs. Higher proportion of infants (79.6%) require IV therapy than older children (25-33%).", False)]) body("", bold_parts=[("Severe dengue/shock: ", True), ("Same algorithm as children (Figs. 6 & 7). CAUTION: infants have relatively higher total body water, more permeable capillaries, and less intracellular fluid reserve – fluid overload risk is high. Total IV duration: 24-48 hrs maximum.", False)]) bullet("Blood transfusion only for severe overt bleeding") bullet("Monitor glucose carefully – hypoglycaemia risk is higher in infants") bullet("Stop IV fluids promptly when clinically stable; watch for fluid overload in recovery phase") h2("Neonatal / Vertical Transmission Dengue") bullet("Incidence of vertical transmission ~12-64% in peripartum maternal dengue") bullet("Neonatal presentation: fever + petechiae, thrombocytopenia, hepatomegaly, or fulminant sepsis-like picture with shock, intracranial haemorrhage, death") bullet("Fever onset in neonate: 1-11 days after birth (median Day 4); maternal fever onset → neonatal fever interval 5-13 days") bullet("Manage with supportive/symptomatic treatment under close hospital monitoring") # ════════════════════════════════════════════════════════════════════════════ # 8. SEVERE DENGUE / DHF / DSS – INTEGRATED APPROACH # ════════════════════════════════════════════════════════════════════════════ h1("8. APPROACH TO A CHILD WITH SEVERE DENGUE / DHF / DSS") h2("Clinical Scenario: Child with Fever, Petechial Rash, Haematemesis, Shock, Low TLC & Platelets") body("", bold_parts=[("Immediate impression: ", True), ("Dengue Shock Syndrome (DSS) with haemorrhagic manifestations – this is a Group C medical emergency.", False)]) h2("Immediate Assessment (ABC)") bullet("Airway/Breathing: assess for respiratory distress, Kussmaul's breathing (metabolic acidosis), pleural effusion") bullet("Circulation: cold extremities, CRT >2 sec, weak/thready pulse, narrow pulse pressure ≤20 mmHg, tachycardia") bullet("Mental state: restlessness → confusion → stupor = cortical hypoperfusion (ominous sign in infants: failure to make eye contact)") bullet("Check: temperature (often subnormal in DSS), urine output (last void time)") h2("Immediate Investigations") bullet("CBC + HCT (urgent) – establish baseline; thrombocytopenia + leukopenia + rising HCT = dengue") bullet("Blood glucose, electrolytes (Na+, K+, Ca²+), renal function, LFTs") bullet("PT, PTT, INR, fibrinogen (if DIC suspected)") bullet("Blood gas + lactate (venous/capillary) – assess metabolic acidosis severity") bullet("CXR: small cardiac shadow (intravascular depletion) vs. 'bat-wings' (fluid overload)") bullet("Dengue serology/NS1 antigen (confirms diagnosis; does NOT delay treatment)") bullet("Blood group and cross-match (for potential transfusion)") h2("Management of DSS") body("COMPENSATED SHOCK: IV isotonic crystalloid (RL or 0.9% NaCl) 10-20 ml/kg over 1 hr → reassess vitals, HCT, CRT every 30 min") body("HYPOTENSIVE SHOCK: Crystalloid OR colloid 20 ml/kg bolus over 15-30 min; if no response → check HCT:") bullet("HCT high/rising: repeat colloid 10-20 ml/kg/hr over 1 hr") bullet("HCT low/falling: haemorrhage → urgent cross-match → fresh whole blood 10-20 ml/kg or packed RBCs 5-10 ml/kg") body("", bold_parts=[("Goal of resuscitation: ", True), ("decreasing tachycardia, improving BP and pulse volume, warm pink extremities, CRT <2 sec, urine ≥0.5 ml/kg/hr, resolving acidosis.", False)]) body("", bold_parts=[("STOP IV fluids at 48 hrs ", True), ("or when: stable BP/pulse, HCT declining with good pulse, afebrile >24 hrs without antipyretics, good urine output.", False)]) h2("For Haematemesis / Active GI Bleeding") bullet("Fresh packed RBCs 5-10 ml/kg OR fresh whole blood 10-20 ml/kg – give early when severe overt bleeding suspected") bullet("PPI/H2 antagonist for gastric protection") bullet("Orogastric tube insertion (lubricated) with great care – can precipitate haemorrhage") bullet("Do NOT transfuse platelet concentrates or FFP routinely – risk of fluid overload, no proven benefit") bullet("Blood transfusion ≠ haematocrit trigger of <30% (unlike sepsis); recognise severe bleeding on clinical grounds") h2("Complications to Watch in DSS") bullet("Fluid overload: reduce/stop fluids; furosemide 0.1-0.5 mg/kg/dose after plasma leakage resolves") bullet("Metabolic acidosis: correct shock → corrects acidosis; sodium bicarbonate only if pH <7.1") bullet("Hypoglycaemia: 0.1-0.5 g/kg dextrose bolus; then glucose-isotonic infusion maintenance") bullet("Hyponatraemia: use isotonic crystalloids; avoid hypotonic solutions") bullet("Multi-organ failure (liver, kidney, CNS): ICU, organ support, dialysis if needed") bullet("Mechanical ventilation: for ARDS, severe metabolic acidosis unresponsive to fluids, profound shock Scenario 2") # ════════════════════════════════════════════════════════════════════════════ # 9. MONITORING CHART REFERENCE # ════════════════════════════════════════════════════════════════════════════ h1("9. KEY MONITORING PARAMETERS") tbl3 = doc.add_table(rows=1, cols=3) tbl3.style = 'Table Grid' tbl3.alignment = WD_TABLE_ALIGNMENT.CENTER add_table_row(tbl3, ["Parameter", "Frequency (Shock)", "Frequency (Group B)"], header=True) mon_data = [ ("Vitals + peripheral perfusion", "Every 15-30 min until out of shock, then 1-2 hourly", "1-4 hourly"), ("Urine output", "Hourly (bladder catheter)", "4-6 hourly"), ("Haematocrit", "Before + after each bolus; then 4-6 hourly", "6-12 hourly"), ("Blood glucose", "Before resuscitation; repeat as needed", "Daily or as indicated"), ("Electrolytes / RFT / LFT", "Before resuscitation; repeat in severe cases", "As indicated"), ("CBC + platelets", "6-12 hourly in ICU", "Daily"), ("Blood gas + lactate", "Every 30-60 min in severe acidosis", "Not routine"), ] for r in mon_data: add_table_row(tbl3, list(r)) doc.add_paragraph() # ════════════════════════════════════════════════════════════════════════════ # REFERENCE / DISCHARGE # ════════════════════════════════════════════════════════════════════════════ h1("10. DISCHARGE CRITERIA") bullet("Afebrile for ≥48 hours (without antipyretics)") bullet("Improvement in clinical picture (appetite, activity, well-being)") bullet("Stable HCT without IV fluids") bullet("Platelet count trending upward (usually recovering by Day 7-9)") bullet("No respiratory distress; no fluid accumulation signs") bullet("Adequate urine output") p_ref = doc.add_paragraph() p_ref.paragraph_format.space_before = Pt(8) r = p_ref.add_run("Reference: ") r.bold = True r.font.size = Pt(8.5) r2 = p_ref.add_run("WHO. Handbook for Clinical Management of Dengue. WHO/NTD/TDR, 2012 (ISBN 978 92 4 150471 3) | Kimberlin et al. Red Book 2021 (Dengue, pp 520-529)") r2.font.size = Pt(8.5) r2.italic = True # ─── SAVE ──────────────────────────────────────────────────────────────────── out_dir = "/tmp/workspace/dengue_project" out_path = f"{out_dir}/Dengue_Fever_Clinical_Notes.docx" doc.save(out_path) print(f"Saved: {out_path}") import os size_kb = os.path.getsize(out_path) // 1024 print(f"File size: {size_kb} KB") PYEOF

python3 -c " from docx import Document doc = Document('/tmp/workspace/dengue_project/Dengue_Fever_Clinical_Notes.docx') headings = [(p.style.name, p.text) for p in doc.paragraphs if 'Heading' in p.style.name and p.text.strip()] for h in headings: print(h) print(f'\nTotal paragraphs: {len(doc.paragraphs)}') print(f'Total tables: {len(doc.tables)}') # Count inline images from docx.oxml.ns import qn img_count = len(doc.inline_shapes) print(f'Inline images/shapes: {img_count}') "