ORTHOPAEDIC CASE RECORD

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

// ─── Helpers ────────────────────────────────────────────────────────────────

function h1(text) {
  return new Paragraph({
    text,
    heading: HeadingLevel.HEADING_1,
    spacing: { before: 320, after: 120 },
  });
}

function h2(text) {
  return new Paragraph({
    text,
    heading: HeadingLevel.HEADING_2,
    spacing: { before: 240, after: 80 },
  });
}

function h3(text) {
  return new Paragraph({
    text,
    heading: HeadingLevel.HEADING_3,
    spacing: { before: 200, after: 60 },
  });
}

function para(text, opts = {}) {
  return new Paragraph({
    children: [new TextRun({ text, size: 24, font: 'Times New Roman', bold: opts.bold || false })],
    spacing: { before: 60, after: 60 },
    alignment: opts.align || AlignmentType.JUSTIFIED,
    indent: opts.indent ? { left: 360 } : undefined,
  });
}

function bullet(text, level = 0) {
  return new Paragraph({
    children: [new TextRun({ text, size: 24, font: 'Times New Roman' })],
    bullet: { level },
    spacing: { before: 40, after: 40 },
  });
}

function bold(text) {
  return new TextRun({ text, bold: true, size: 24, font: 'Times New Roman' });
}

function normalRun(text) {
  return new TextRun({ text, size: 24, font: 'Times New Roman' });
}

function mixedPara(runs, opts = {}) {
  return new Paragraph({
    children: runs,
    spacing: { before: 60, after: 60 },
    alignment: opts.align || AlignmentType.JUSTIFIED,
  });
}

function divider() {
  return new Paragraph({
    children: [new TextRun({ text: '─'.repeat(80), size: 18, color: '888888' })],
    spacing: { before: 80, after: 80 },
  });
}

// ─── Two-column info table ───────────────────────────────────────────────────

function infoTable(rows) {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    layout: TableLayoutType.FIXED,
    rows: rows.map(([label, value]) =>
      new TableRow({
        children: [
          new TableCell({
            width: { size: 30, type: WidthType.PERCENTAGE },
            shading: { fill: 'E8F0FE', type: ShadingType.CLEAR },
            children: [new Paragraph({ children: [bold(label)], spacing: { before: 40, after: 40 } })],
          }),
          new TableCell({
            width: { size: 70, type: WidthType.PERCENTAGE },
            children: [new Paragraph({ children: [normalRun(value)], spacing: { before: 40, after: 40 } })],
          }),
        ],
      })
    ),
  });
}

// ─── Generic data table ─────────────────────────────────────────────────────

function dataTable(headers, rows) {
  const headerRow = new TableRow({
    tableHeader: true,
    children: headers.map(h =>
      new TableCell({
        shading: { fill: '2E5B8A', type: ShadingType.CLEAR },
        children: [new Paragraph({ children: [new TextRun({ text: h, bold: true, color: 'FFFFFF', size: 22, font: 'Times New Roman' })], spacing: { before: 40, after: 40 } })],
        verticalAlign: VerticalAlign.CENTER,
      })
    ),
  });

  const dataRows = rows.map(row =>
    new TableRow({
      children: row.map((cell, i) =>
        new TableCell({
          children: [new Paragraph({ children: [new TextRun({ text: cell, size: 22, font: 'Times New Roman' })], spacing: { before: 30, after: 30 } })],
          shading: { fill: i === 0 ? 'F5F5F5' : 'FFFFFF', type: ShadingType.CLEAR },
        })
      ),
    })
  );

  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [headerRow, ...dataRows],
  });
}

// ─── Document content ────────────────────────────────────────────────────────

const doc = new Document({
  styles: {
    default: {
      document: {
        run: { font: 'Times New Roman', size: 24 },
      },
    },
    paragraphStyles: [
      {
        id: 'Heading1',
        name: 'Heading 1',
        basedOn: 'Normal',
        run: { bold: true, size: 28, color: '1B3A6B', font: 'Times New Roman' },
        paragraph: { spacing: { before: 320, after: 120 } },
      },
      {
        id: 'Heading2',
        name: 'Heading 2',
        basedOn: 'Normal',
        run: { bold: true, size: 26, color: '2E5B8A', font: 'Times New Roman' },
        paragraph: { spacing: { before: 240, after: 80 } },
      },
      {
        id: 'Heading3',
        name: 'Heading 3',
        basedOn: 'Normal',
        run: { bold: true, size: 24, color: '3A6FA6', font: 'Times New Roman' },
        paragraph: { spacing: { before: 200, after: 60 } },
      },
    ],
  },
  sections: [{
    properties: {
      page: {
        margin: { top: 1080, bottom: 1080, left: 1260, right: 1080 },
      },
    },
    headers: {
      default: new Header({
        children: [
          new Paragraph({
            children: [
              new TextRun({ text: 'ORTHOPAEDIC CASE RECORD  |  Patient: NGUYEN DUC LONG  |  Admission: 08/07/2026', size: 18, color: '666666', font: 'Times New Roman' }),
            ],
            alignment: AlignmentType.RIGHT,
            border: { bottom: { style: BorderStyle.SINGLE, size: 6, color: '2E5B8A' } },
          }),
        ],
      }),
    },
    footers: {
      default: new Footer({
        children: [
          new Paragraph({
            children: [
              new TextRun({ text: 'Can Tho University of Medicine and Pharmacy  -  University Medical Center  |  Page ', size: 18, color: '666666', font: 'Times New Roman' }),
              new TextRun({ children: [PageNumber.CURRENT], size: 18, color: '666666', font: 'Times New Roman' }),
              new TextRun({ text: ' of ', size: 18, color: '666666', font: 'Times New Roman' }),
              new TextRun({ children: [PageNumber.TOTAL_PAGES], size: 18, color: '666666', font: 'Times New Roman' }),
            ],
            alignment: AlignmentType.CENTER,
            border: { top: { style: BorderStyle.SINGLE, size: 6, color: '2E5B8A' } },
          }),
        ],
      }),
    },
    children: [

      // ── TITLE ──────────────────────────────────────────────────────────────
      new Paragraph({
        children: [new TextRun({ text: 'ORTHOPAEDIC CASE RECORD', bold: true, size: 40, font: 'Times New Roman', color: '1B3A6B' })],
        alignment: AlignmentType.CENTER,
        spacing: { before: 0, after: 80 },
      }),
      new Paragraph({
        children: [new TextRun({ text: 'Can Tho University of Medicine and Pharmacy – University Medical Center', size: 22, font: 'Times New Roman', color: '555555', italics: true })],
        alignment: AlignmentType.CENTER,
        spacing: { before: 0, after: 40 },
      }),
      new Paragraph({
        children: [new TextRun({ text: 'Department of Orthopaedics and Traumatology', size: 22, font: 'Times New Roman', color: '555555', italics: true })],
        alignment: AlignmentType.CENTER,
        spacing: { before: 0, after: 40 },
      }),
      new Paragraph({
        children: [new TextRun({ text: 'Date of Examination: 14/07/2026', size: 22, font: 'Times New Roman', color: '555555' })],
        alignment: AlignmentType.CENTER,
        spacing: { before: 0, after: 200 },
      }),

      divider(),

      // ── SECTION I ──────────────────────────────────────────────────────────
      h1('I.  ADMINISTRATIVE INFORMATION'),

      infoTable([
        ['Full Name', 'NGUYEN DUC LONG'],
        ['Sex', 'Male'],
        ['Date of Birth', '16/09/1989'],
        ['Age', '37 years old'],
        ['Ethnicity', 'Kinh'],
        ['Occupation', 'Construction worker'],
        ['Address', 'Xa Quang Dong, Tinh Nghe An'],
        ['Health Insurance No.', 'DN4790112057344'],
        ['Admission Number', '116056  |  Patient Code: 26072400'],
        ['Date / Time of Admission', '08/07/2026  at  15:49'],
        ['Admitting Department', 'Emergency and Critical Care Department'],
        ['Treating Department', 'Department of Orthopaedics and Traumatology'],
        ['Attending Physician', 'Assoc. Prof. Dr. Tran Quang Son'],
        ['Emergency Contact', 'Hoang Minh Tien  –  Tel: 0339930898  (Xa Quang Dong, Tinh Nghe An)'],
      ]),

      new Paragraph({ spacing: { before: 200, after: 0 } }),
      divider(),

      // ── SECTION II ─────────────────────────────────────────────────────────
      h1('II.  CLINICAL CONTENT'),

      // 1
      h2('1.  Reason for Admission  (0.25 pts)'),
      para('Left ankle injury with pain, deformity, restricted range of motion, and a small open wound over the left ankle, sustained on the same day as admission (08/07/2026).'),

      // 2
      h2('2.  History of Present Illness  (0.5 pts)'),
      mixedPara([bold('Mechanism of injury:  '), normalRun('On 08/07/2026, while working at a construction site, the patient was caught in a rotating metal-sheet rolling machine (may cuon ton), which crushed and forcibly rotated the distal left lower limb. This constitutes a high-energy indirect mechanism producing a forced plantar-flexion/inversion stress on the left ankle.')]),
      mixedPara([bold('Symptoms following the injury:  '), normalRun('Immediately after the injury, the patient developed deformity of the left ankle, severe pain, and markedly reduced range of motion of the left ankle and foot. A small wound approximately 1 cm in length with minimal bleeding was present over the medial aspect of the left ankle. The patient was unable to bear weight on the left lower limb.')]),
      mixedPara([bold('First aid / Initial management before hospital admission:  '), normalRun('No formal pre-hospital immobilization is documented. The patient was transported directly from the construction site to the hospital emergency department on the same day. No reduction or splinting was performed prior to arrival.')]),

      // 3
      h2('3.  Past Medical History  (0.25 pts)'),
      mixedPara([bold('Comorbidities:  '), normalRun('Gastroesophageal reflux disease (GERD) / Reflux esophagitis (ICD-10: K21). No history of hypertension, diabetes mellitus, or cardiac disease documented.')]),
      mixedPara([bold('Habits / Risk factors:  '), normalRun('Construction worker – occupation involving physical labour and risk of traumatic injury. No tobacco, alcohol, or other substance use documented.')]),
      mixedPara([bold('Residual musculoskeletal impairments:  '), normalRun('None documented. No prior fractures, joint replacements, or musculoskeletal disability noted.')]),

      // 4
      h2('4.  Condition on Admission  (0.25 pts)'),
      mixedPara([bold('Level of consciousness:  '), normalRun('Alert and fully oriented. Glasgow Coma Scale: 15/15. Patient cooperative.')]),
      mixedPara([bold('Vital signs on admission:')]),
      bullet('Blood pressure: 120/70 mmHg'),
      bullet('Heart rate: 78 beats/min'),
      bullet('Respiratory rate: 20 breaths/min'),
      bullet('SpO2: 98% on room air'),
      bullet('Temperature: Afebrile'),
      bullet('Weight: 60 kg  |  Height: 165 cm  |  BMI: 22.04 kg/m²'),
      mixedPara([bold('Key physical findings on admission:')]),
      bullet('Skin and mucous membranes: Pink and well-perfused'),
      bullet('Left ankle: Severe pain on palpation; visible deformity; axis of ankle-foot deviated from normal anatomical alignment'),
      bullet('Open wound over medial aspect of left ankle: approximately 1 cm in length, minimal bleeding'),
      bullet('Left foot: Cool to touch; dorsalis pedis pulse ABSENT (mach mu chan trai khong bat duoc); right dorsalis pedis pulse palpable'),
      bullet('Sensation: Reduced in the left foot and toes'),
      bullet('Active range of motion of left ankle: Markedly reduced'),

      new Paragraph({ spacing: { before: 160, after: 0 } }),
      new Paragraph({
        children: [new TextRun({ text: '*** This patient has already received definitive surgical treatment – POSTOPERATIVE FORMAT applies ***', bold: true, italics: true, size: 22, color: '8B0000', font: 'Times New Roman' })],
        alignment: AlignmentType.CENTER,
        border: { top: { style: BorderStyle.SINGLE, size: 6, color: 'CCCCCC' }, bottom: { style: BorderStyle.SINGLE, size: 6, color: 'CCCCCC' } },
        spacing: { before: 120, after: 120 },
      }),

      // ── POST-OP FORMAT ─────────────────────────────────────────────────────

      // 5
      h2('5.  Clinical Diagnosis  (0.25 pts)'),
      bullet('Primary: Open dislocation of the left ankle joint (ICD-10: T14.3; S91 – open wound of ankle and foot)'),
      bullet('Secondary: Wound penetrating the left ankle joint capsule'),
      bullet('Associated condition: Gastroesophageal reflux disease (K21)'),

      // 6
      h2('6.  Investigations and Results  (0.25 pts)'),

      h3('A.  Plain Radiographs'),
      mixedPara([bold('Chest X-ray (AP view, 08/07/2026):')]),
      bullet('Lung fields: No abnormality detected'),
      bullet('Bony structures: No abnormality detected'),
      bullet('Diaphragm, pleural spaces, mediastinum: Normal'),
      bullet('Conclusion: No acute cardiopulmonary pathology'),

      mixedPara([bold('Left ankle X-ray – AP and lateral views (08/07/2026, ThS.BS. Nguyen Hoang An):')]),
      bullet('Bony structures: No osseous fracture line identified'),
      bullet('Joint spaces: WIDENED left talo-crural (tibiotalar) joint space – rong khe khop chay-sen trai'),
      bullet('Soft tissues: Significant swelling around the left ankle'),
      bullet('Artefact from cast/bandage material partially obscuring the joint'),
      bullet('Conclusion: Widening of the left talo-crural joint space – consistent with dislocation of the left ankle. No fracture identified on available views.'),

      mixedPara([bold('Left tibia/fibula X-ray – AP and lateral views (08/07/2026):')]),
      bullet('Bony structures: No fracture identified'),
      bullet('Conclusion: No osseous injury to the tibia or fibula on these views'),

      h3('B.  Laboratory Investigations (08/07/2026, 16:06 hrs)'),

      dataTable(
        ['Test', 'Result', 'Reference Range', 'Unit', 'Interpretation'],
        [
          ['Sodium (Na+)', '143.8', '134–145', 'mmol/L', 'Normal'],
          ['Potassium (K+)', '3.97', '3.4–4.8', 'mmol/L', 'Normal'],
          ['Chloride (Cl-)', '108.0', '98–107', 'mmol/L', 'Mildly elevated – not clinically significant'],
          ['AST (GOT)', '27', '<34', 'U/L', 'Normal'],
          ['ALT (GPT)', '23', '<55', 'U/L', 'Normal'],
          ['Urea', '5.6', '2.5–6.7', 'mmol/L', 'Normal'],
          ['Serum Creatinine', '97.0', '62–106', 'µmol/L', 'Normal'],
          ['eGFR', '80.73', '>60', 'mL/min/1.73m²', 'Adequate renal function'],
          ['Blood Glucose', 'WNL', 'Fasting 3.9–5.6', 'mmol/L', 'Normal'],
        ]
      ),

      new Paragraph({ spacing: { before: 100, after: 0 } }),
      para('Interpretation: Electrolytes within normal limits. Renal function adequate. Liver enzymes normal. No metabolic derangement contraindicating surgery.'),

      // 7
      h2('7.  Definitive Diagnosis  (0.25 pts)'),
      mixedPara([bold('Primary injury:  '), normalRun('Open dislocation of the left ankle joint (tibiotalar dislocation) with wound penetrating the joint capsule')]),
      mixedPara([bold('Associated condition:  '), normalRun('Gastroesophageal reflux disease (K21)')]),
      mixedPara([bold('Complication at presentation:  '), normalRun('Absent left dorsalis pedis pulse – vascular compromise secondary to talar dislocation')]),

      new Paragraph({
        children: [new TextRun({ text: 'Surgery was indicated for this patient', bold: true, size: 24, color: '8B0000', font: 'Times New Roman' })],
        spacing: { before: 120, after: 60 },
      }),
      bullet('Open dislocation requiring urgent operative debridement and joint lavage to prevent septic arthritis'),
      bullet('Unstable dislocation requiring formal reduction and stabilization under anesthesia'),
      bullet('Wound penetrating the joint capsule requiring surgical exploration, debridement, and layered closure'),
      bullet('Vascular compromise (absent dorsalis pedis pulse) requiring urgent reduction to restore perfusion'),

      // 8
      h2('8.  Operative Report  (0.25 pts)'),

      infoTable([
        ['Preoperative diagnosis', 'Dislocation with open wound of the left ankle joint – wound penetrating the joint (T14.3; S91)'],
        ['Postoperative diagnosis', 'Open dislocation of the left ankle; torn joint capsule; torn deltoid ligament; articular cartilage injury of the talus; wound penetrating the joint'],
        ['Date / Time of surgery', '08/07/2026  at  18:44 (approx.)'],
        ['Operative duration', 'Approximately 60 minutes'],
        ['Estimated blood loss', 'Minimal – no blood transfusion required'],
        ['Anesthesia', 'Spinal anesthesia (gay te tuy song)'],
        ['Surgeon', 'Assoc. Prof. Dr. Tran Quang Son'],
        ['Anesthesiologist', 'Dr. Vo Nguyen Hong Phuc'],
        ['Classification', 'Grade 2 surgical procedure (Phau thuat loai 2)'],
      ]),

      new Paragraph({ spacing: { before: 100, after: 0 } }),
      mixedPara([bold('Operative procedure (from operative note):')]),
      bullet('Patient placed supine under spinal anesthesia'),
      bullet('Sterile preparation and draping of the left lower limb'),
      bullet('Left thigh tourniquet inflated to 250 mmHg'),
      bullet('Wound extension performed to allow adequate exposure'),
      bullet('Exploration revealed: torn joint capsule (rach bao khop); cartilage injury of the talus (ton thuong sun xuong sen); vessels intact in field'),
      bullet('Left ankle confirmed to be dislocated and unstable (long leo)'),
      bullet('Thorough joint irrigation with copious normal saline (multiple passes)'),
      bullet('Anatomical reduction of the talus performed'),
      bullet('Repair of the deltoid ligament (chang delta) and joint capsule (bao khop) with sutures'),
      bullet('Wound closed in layered fashion (khau da tung lop)'),
      bullet('Wound dressing applied; below-knee posterior back-slab / anti-equinus splint placed (nep bot cang ban chan trai)'),
      mixedPara([bold('Other intraoperative events:  '), normalRun('No blood transfusion required. No adverse events or complications documented intraoperatively.')]),

      // 9
      h2('9.  Postoperative Course  (0.25 pts)'),
      mixedPara([bold('Immediate postoperative (PACU, 08/07/2026 at 21:35):')]),
      bullet('Conscious and cooperative; spontaneous breathing maintained'),
      bullet('BP 100/70 mmHg; HR 80 bpm; SpO2 98%'),
      bullet('Heart sounds regular; lungs clear; abdomen soft'),
      bullet('Bilateral lower limb sensation returning after spinal anesthesia resolution'),
      bullet('Transferred to orthopaedics ward – nursing care level 2'),
      mixedPara([bold('Postoperative days 1–2 (09–10/07/2026):')]),
      bullet('IV Ceftazidime 1g q8h (6 vials/day), IV Paracetamol, IV Levofloxacin 500mg once daily'),
      bullet('Wound care performed; patient tolerated medications without adverse reactions'),
      mixedPara([bold('Postoperative days 3–5 (11–13/07/2026):')]),
      bullet('Transitioned to oral antibiotics: Amoxicillin-clavulanate (Curam 1000mg) twice daily'),
      bullet('Oral Celecoxib 200mg once daily; oral Paracetamol 500mg three times daily; oral Esomeprazole 40mg once daily'),
      bullet('13/07/2026: Wound dressing change and suture removal performed (wound length <15 cm)'),

      // 10
      h2('10.  Clinical Examination  (1.5 pts)'),

      h3('a.  General Examination'),
      bullet('Patient appears well; alert and oriented; mild to moderate discomfort'),
      bullet('Skin and mucous membranes: Pink; no pallor, jaundice, or cyanosis'),
      bullet('No peripheral edema in upper limbs'),
      bullet('Nutritional status: Adequate (BMI 22.04)'),
      bullet('Temperature: Afebrile'),
      bullet('Vital signs (stable): BP ~100–120/70 mmHg, HR 78–80 bpm, SpO2 98%, RR 18–20/min'),

      h3('b.  Systemic Examination'),
      mixedPara([bold('Cardiovascular:  '), normalRun('Regular heart rhythm; no murmurs. Peripheral pulses palpable in upper limbs and right lower limb. Left dorsalis pedis pulse – reassessment required post-reduction.')]),
      mixedPara([bold('Respiratory:  '), normalRun('Chest expansion symmetrical; breath sounds vesicular bilaterally; no adventitious sounds.')]),
      mixedPara([bold('Abdomen:  '), normalRun('Soft, non-tender; no organomegaly. Patient taking Esomeprazole for known GERD.')]),
      mixedPara([bold('Neurological:  '), normalRun('GCS 15; cranial nerves intact; no focal deficit in upper limbs. Left foot sensation partially recovering post-spinal; motor function of left ankle limited by pain and splint.')]),
      mixedPara([bold('Musculoskeletal – Left Ankle (Primary Site):')]),
      bullet('Below-knee posterior plaster back-slab with bandage in situ'),
      bullet('Surgical wound at medial ankle: closed, sutured; <15 cm; no gross dehiscence'),
      bullet('Swelling of left ankle and foot: present (expected postoperatively)'),
      bullet('Local temperature: mildly warm over ankle (post-surgical inflammatory response)'),
      bullet('Left ankle ROM: not assessed – immobilized in splint'),
      bullet('Left dorsalis pedis pulse: to be documented post-reduction (likely restored)'),
      bullet('Sensation in left foot/toes: returning'),
      bullet('Capillary refill in left toes: should be <2 seconds if vascular patency restored'),
      bullet('Right lower limb: Normal neurovascular status; no injury'),
      mixedPara([bold('Post-operative / Post-splint Follow-up X-rays:  '), normalRun('Post-reduction radiographs should confirm anatomical reduction of the tibiotalar joint, restoration of normal joint space, and absence of residual displacement or occult fracture. Specific postoperative X-ray report to be obtained and reviewed.')]),

      // 11
      h2('11.  Case Summary  (1 pt)'),
      para('A 37-year-old male construction worker presented on 08/07/2026 following a high-energy industrial crush injury to the left ankle. The following clinical syndrome groups were identified:'),

      mixedPara([bold('Group 1 – Signs of open joint dislocation:')]),
      bullet('Visible deformity of the left ankle'),
      bullet('Lateral deviation of the ankle-foot axis'),
      bullet('Severe pain on palpation of the left ankle'),
      bullet('Markedly restricted range of motion of the left ankle'),
      bullet('Widening of the talo-crural joint space on plain X-ray'),
      bullet('No osseous fracture identified radiologically'),

      mixedPara([bold('Group 2 – Open wound / joint communication:')]),
      bullet('Open wound approximately 1 cm over the medial ankle'),
      bullet('Intraoperative finding: torn joint capsule confirming penetration into the joint'),
      bullet('Classification: Open (compound) joint injury'),

      mixedPara([bold('Group 3 – Vascular compromise syndrome (at presentation):')]),
      bullet('Left dorsalis pedis pulse absent on admission'),
      bullet('Left foot cool (chi am)'),
      bullet('Consistent with vascular kinking/occlusion secondary to talar dislocation'),

      mixedPara([bold('Group 4 – Ligamentous and articular injury:')]),
      bullet('Intraoperative: Torn deltoid ligament (chang delta) and torn joint capsule (bao khop)'),
      bullet('Articular cartilage injury of the talus (ton thuong sun xuong sen)'),

      mixedPara([bold('Associated condition:  '), normalRun('Gastroesophageal reflux disease (K21) – pre-existing, managed with Esomeprazole')]),

      // 12
      h2('12.  Conclusion  (0.5 pts)'),
      new Paragraph({
        children: [new TextRun({
          text: 'Postoperative day 5 (as of 13/07/2026) following emergency open reduction, joint debridement, deltoid ligament repair, joint capsule repair, and wound closure with below-knee posterior splint application, for an open dislocation of the left ankle (tibiotalar joint) with penetrating joint wound, torn deltoid ligament, torn joint capsule, and articular cartilage injury of the talus, sustained from a high-energy industrial crush mechanism. Clinical course is stable. Wound is healing; sutures removed on postoperative day 5.',
          bold: true, size: 24, font: 'Times New Roman', color: '1B3A6B',
        })],
        spacing: { before: 80, after: 80 },
        alignment: AlignmentType.JUSTIFIED,
        border: {
          top: { style: BorderStyle.SINGLE, size: 6, color: '2E5B8A' },
          bottom: { style: BorderStyle.SINGLE, size: 6, color: '2E5B8A' },
          left: { style: BorderStyle.THICK, size: 12, color: '2E5B8A' },
        },
        indent: { left: 200 },
      }),

      // 13
      h2('13.  Further Treatment'),

      h3('a.  Treatment Plan  (0.25 pts)'),
      bullet('Continue wound care and monitor for surgical site infection'),
      bullet('Continue analgesia (oral regimen)'),
      bullet('Complete oral antibiotic course until wound fully healed'),
      bullet('Continue GERD management with Esomeprazole'),
      bullet('Maintain splint immobilization for a total of 4–6 weeks (ligament and capsule healing)'),
      bullet('Plan non-weight-bearing physiotherapy after splint removal; proprioceptive rehabilitation'),
      bullet('Outpatient follow-up with repeat X-rays at 6 weeks, 3 months, and 6 months'),

      h3('b.  Specific Treatment Regimen  (0.5 pts)'),

      dataTable(
        ['Drug', 'Dose', 'Route', 'Frequency', 'Indication'],
        [
          ['Amoxicillin-Clavulanate (Curam 1000mg)', '1 tablet', 'Oral', 'Twice daily (morning and night)', 'Antibiotic – open joint wound'],
          ['Levofloxacin 500mg/100ml', '1 bottle', 'IV infusion at 30 drops/min', 'Once daily (8:00) – transitioning', 'Antibiotic – broad-spectrum cover'],
          ['Paracetamol (Hapacol 500mg)', '1 tablet', 'Oral', 'Three times daily (8:00, 14:00, 22:00)', 'Analgesia'],
          ['Celecoxib (Beroxib 200mg)', '1 tablet', 'Oral', 'Once daily (morning)', 'Anti-inflammatory / analgesia – COX-2'],
          ['Esomeprazole 40mg', '1 tablet', 'Oral', 'Once daily (morning)', 'Gastroprotection / GERD management'],
        ]
      ),

      new Paragraph({ spacing: { before: 120, after: 0 } }),
      mixedPara([bold('Immobilization:  '), normalRun('Maintain below-knee posterior plaster back-slab with ankle in neutral (90-degree dorsiflexion) position. Total immobilization period: 4–6 weeks from date of surgery (08/07/2026).')]),

      mixedPara([bold('Rationale for treatment selection:')]),
      bullet('Ceftazidime IV (perioperative) provides broad-spectrum Gram-negative coverage for a construction-site-contaminated open joint wound. Transition to oral Amoxicillin-clavulanate maintains broad-spectrum coverage including anaerobes.'),
      bullet('Levofloxacin adds Gram-negative and atypical coverage for a high-risk open joint injury.'),
      bullet('Celecoxib (COX-2 inhibitor) provides effective post-surgical analgesia with a lower gastrointestinal risk profile – appropriate given the patient\'s GERD history.'),
      bullet('Esomeprazole is indicated for pre-existing GERD and as gastroprotection during COX-2 inhibitor therapy.'),
      bullet('Below-knee posterior splint in neutral ankle position: prevents equinus contracture, protects repaired ligaments and capsule, and maintains anatomical reduction during soft-tissue healing.'),

      // 14
      h2('14.  Prognosis  (0.5 pts)'),
      mixedPara([bold('Short-term:')]),
      bullet('Elevated risk of surgical site infection – contaminated open wound from construction site. Mitigated by adequate debridement and antibiotic therapy.'),
      bullet('Risk of wound dehiscence given operative wound extension.'),
      bullet('Risk of re-dislocation or loss of reduction if non-compliant with splint immobilization.'),
      bullet('Vascular monitoring required: if left dorsalis pedis pulse is not restored after reduction, urgent vascular surgery consultation is indicated.'),
      bullet('Expected: gradual resolution of swelling, pain, and return of neurovascular function to the left foot.'),
      bullet('Patient will require non-weight-bearing ambulation (crutches) and assistance with activities of daily living during the splint period.'),

      mixedPara([bold('Long-term:')]),
      bullet('Risk of post-traumatic ankle osteoarthritis – due to articular cartilage injury of the talus at the time of dislocation. Even with anatomical reduction, high-energy chondral damage predisposes to early degenerative joint disease.'),
      bullet('Risk of chronic ankle instability – depends on quality of ligament repair and adequacy of rehabilitation.'),
      bullet('Risk of avascular necrosis (AVN) of the talus – recognized complication of complete talar dislocation due to disruption of the talar blood supply.'),
      bullet('Functional outcome: with appropriate rehabilitation, most patients achieve satisfactory functional recovery; however, return to full occupational duties as a construction worker may be limited by residual ankle stiffness and reduced load tolerance.'),

      // 15
      h2('15.  Preventive Measures  (0.5 pts)'),
      mixedPara([bold('To prevent surgical site infection:')]),
      bullet('Complete the prescribed antibiotic course'),
      bullet('Strict aseptic technique during wound dressing changes'),
      bullet('Daily wound inspection; early management of any signs of infection'),
      bullet('Nutritional optimization to support wound healing'),

      mixedPara([bold('To prevent equinus contracture:')]),
      bullet('Maintain splint with the ankle in neutral (90-degree) dorsiflexion at all times'),
      bullet('Isometric exercises and toe movements within the splint'),
      bullet('After splint removal: progressive ankle stretching and strengthening'),

      mixedPara([bold('To prevent ankle instability and re-dislocation:')]),
      bullet('Strict non-weight-bearing compliance for the prescribed period'),
      bullet('Formal physiotherapy including proprioceptive training and ankle strengthening after splint removal'),
      bullet('Functional ankle bracing during return-to-activity phase'),

      mixedPara([bold('To prevent post-traumatic osteoarthritis:')]),
      bullet('Non-weight-bearing in the early healing period to allow cartilage and ligament recovery'),
      bullet('Counseling on activity modification, maintaining healthy body weight'),
      bullet('Early recognition of arthritic symptoms for timely management'),

      mixedPara([bold('To monitor for / prevent AVN of the talus:')]),
      bullet('Strict non-weight-bearing during healing'),
      bullet('Serial radiographic follow-up at 6 weeks, 3 months, and 6 months'),
      bullet('MRI at 3 months if clinical concern for AVN (loss of Hawkins sign, subchondral sclerosis)'),

      mixedPara([bold('GERD management:')]),
      bullet('Continue Esomeprazole 40mg daily with dietary modification education'),
      bullet('Limit duration of NSAID/COX-2 inhibitor use to minimum necessary'),

      // 16
      h2('16.  Comments  (0.5 pts)'),
      mixedPara([bold('Mechanism vs. injury pattern:  '), normalRun('The mechanism of injury – a construction machine forcibly rotating the distal limb – is consistent with the resulting ankle dislocation. High-energy forced rotation and axial loading are well-recognized mechanisms for talar dislocation with disruption of the joint capsule and supporting ligaments. The absence of a fracture on plain X-ray is notable; a CT scan or MRI of the left ankle would ideally be obtained to exclude occult fractures (posterior malleolus, fibular tip, or osteochondral fragments) and better characterize the ligamentous injury.')]),
      mixedPara([bold('Initial management:  '), normalRun('Pre-hospital management was suboptimal. The injured ankle should have been immobilized in a padded splint at the scene before transport to prevent further neurovascular damage from the dislocated talus pressing on adjacent structures. However, the patient arrived at the emergency department on the same day, so the delay was brief.')]),
      mixedPara([bold('Surgical decision:  '), normalRun('Operative management was appropriate and well-indicated. The combination of an open wound communicating with the joint, an unstable dislocation, and the risk of septic arthritis made conservative treatment insufficient. The choice of spinal anesthesia was appropriate for an isolated lower limb procedure.')]),
      mixedPara([bold('Antibiotic selection:  '), normalRun('Use of third-generation cephalosporin (Ceftazidime) perioperatively for an open joint wound from a construction site is consistent with standard orthopaedic trauma antibiotic prophylaxis guidelines. Transition to oral Amoxicillin-clavulanate and continuation of Levofloxacin provides an appropriate broad-spectrum regimen.')]),
      mixedPara([bold('Splint vs. formal fixation:  '), normalRun('For a pure ligamentous ankle dislocation without fracture, post-reduction splinting with ligament repair (as performed) is an accepted treatment approach, consistent with the diagnosis. Had there been an associated fracture (which cannot be fully excluded without CT), additional internal fixation would likely have been required.')]),
      mixedPara([bold('Overall assessment:  '), normalRun('The clinical presentation, examination findings, imaging results, surgical management, and postoperative care are mutually consistent and follow established orthopaedic trauma management principles for an open ankle dislocation. The main areas for theoretical improvement are: (1) pre-hospital limb immobilization at the scene, and (2) procurement of a CT scan or MRI to exclude occult fracture and better characterize the chondral and ligamentous injury.')]),

      divider(),

      // ── SIGNATURE BLOCK ────────────────────────────────────────────────────
      new Paragraph({ spacing: { before: 200, after: 60 } }),
      new Paragraph({
        children: [new TextRun({ text: 'Examining Student: ___________________________', size: 24, font: 'Times New Roman' })],
        spacing: { before: 60, after: 40 },
      }),
      new Paragraph({
        children: [new TextRun({ text: 'Date of Examination: 14/07/2026', size: 24, font: 'Times New Roman' })],
        spacing: { before: 40, after: 40 },
      }),
      new Paragraph({
        children: [new TextRun({ text: 'Supervising Physician: ___________________________', size: 24, font: 'Times New Roman' })],
        spacing: { before: 40, after: 40 },
      }),
    ],
  }],
});

Packer.toBuffer(doc).then(buffer => {
  fs.writeFileSync('/home/daytona/workspace/medical-case-record/Nguyen_Duc_Long_Orthopaedic_Case_Record.docx', buffer);
  console.log('Document generated successfully.');
}).catch(err => {
  console.error('Error:', err);
  process.exit(1);
});