PSM 2 SHORT CASES - Model Answers

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm, mm
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.flowables import HRFlowable

OUTPUT = "/tmp/workspace/psm-revision/PSM_Short_Cases_Revision.pdf"

# ── Colour palette ────────────────────────────────────────────────
C_DEEP_BLUE   = colors.HexColor("#1A3A5C")
C_MID_BLUE    = colors.HexColor("#2563A8")
C_LIGHT_BLUE  = colors.HexColor("#D6E4F0")
C_TEAL        = colors.HexColor("#0B7A75")
C_TEAL_LIGHT  = colors.HexColor("#D0EFED")
C_ORANGE      = colors.HexColor("#E07B39")
C_ORANGE_LIGHT= colors.HexColor("#FDEBD0")
C_GREEN       = colors.HexColor("#1E7A1E")
C_GREEN_LIGHT = colors.HexColor("#D5F0D5")
C_RED         = colors.HexColor("#C0392B")
C_RED_LIGHT   = colors.HexColor("#FADBD8")
C_PURPLE      = colors.HexColor("#6C3483")
C_PURPLE_LIGHT= colors.HexColor("#E8DAEF")
C_YELLOW_LIGHT= colors.HexColor("#FEF9E7")
C_GRAY_LIGHT  = colors.HexColor("#F5F5F5")
C_GRAY_MED    = colors.HexColor("#CCCCCC")
C_BLACK       = colors.black
C_WHITE       = colors.white

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    topMargin=1.8*cm,
    bottomMargin=1.8*cm,
    leftMargin=1.5*cm,
    rightMargin=1.5*cm,
)

W = A4[0] - 3.0*cm   # usable width

styles = getSampleStyleSheet()

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

S_COVER_TITLE = make_style("CoverTitle",
    fontSize=26, fontName="Helvetica-Bold",
    textColor=C_WHITE, alignment=TA_CENTER, spaceAfter=8)
S_COVER_SUB   = make_style("CoverSub",
    fontSize=13, fontName="Helvetica",
    textColor=C_LIGHT_BLUE, alignment=TA_CENTER, spaceAfter=4)
S_CASE_HEADER = make_style("CaseHdr",
    fontSize=13, fontName="Helvetica-Bold",
    textColor=C_WHITE, alignment=TA_LEFT, spaceAfter=0, leading=17)
S_SECTION_HDR = make_style("SecHdr",
    fontSize=10.5, fontName="Helvetica-Bold",
    textColor=C_DEEP_BLUE, spaceBefore=6, spaceAfter=3)
S_BODY        = make_style("Body",
    fontSize=9, fontName="Helvetica",
    textColor=C_BLACK, leading=13, spaceAfter=3)
S_BODY_BOLD   = make_style("BodyBold",
    fontSize=9, fontName="Helvetica-Bold",
    textColor=C_BLACK, leading=13, spaceAfter=3)
S_KEY         = make_style("Key",
    fontSize=8.5, fontName="Helvetica-Bold",
    textColor=C_RED, leading=12)
S_NOTE        = make_style("Note",
    fontSize=8.5, fontName="Helvetica-Oblique",
    textColor=C_TEAL, leading=12, spaceAfter=4)
S_FOOTER      = make_style("Footer",
    fontSize=7.5, fontName="Helvetica",
    textColor=colors.grey, alignment=TA_CENTER)
S_TBL_HDR     = make_style("TblHdr",
    fontSize=8.5, fontName="Helvetica-Bold",
    textColor=C_WHITE, alignment=TA_CENTER, leading=11)
S_TBL_CELL    = make_style("TblCell",
    fontSize=8.3, fontName="Helvetica",
    textColor=C_BLACK, leading=11)
S_TBL_CELL_B  = make_style("TblCellB",
    fontSize=8.3, fontName="Helvetica-Bold",
    textColor=C_BLACK, leading=11)
S_TBL_CELL_RED= make_style("TblCellRed",
    fontSize=8.3, fontName="Helvetica-Bold",
    textColor=C_RED, leading=11)

# ── Helper functions ──────────────────────────────────────────────
def case_banner(num, title, subtitle, bg_color):
    """Returns a Table acting as a coloured case header banner."""
    inner = Table([
        [Paragraph(f"CASE {num}  |  {title}", S_CASE_HEADER)],
        [Paragraph(subtitle, make_style(f"CS{num}",
            fontSize=8.5, fontName="Helvetica-Oblique",
            textColor=C_LIGHT_BLUE, leading=11))],
    ], colWidths=[W])
    inner.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,-1), bg_color),
        ("LEFTPADDING",  (0,0), (-1,-1), 10),
        ("RIGHTPADDING", (0,0), (-1,-1), 6),
        ("TOPPADDING",   (0,0), (0,0),   8),
        ("BOTTOMPADDING",(0,-1),(-1,-1), 8),
        ("ROUNDEDCORNERS", [6]),
    ]))
    return inner

def section_label(text, color=C_DEEP_BLUE):
    bar = Table([[Paragraph(text, make_style("SL",
        fontSize=9.5, fontName="Helvetica-Bold",
        textColor=C_WHITE, leading=12))]],
        colWidths=[W])
    bar.setStyle(TableStyle([
        ("BACKGROUND",   (0,0),(-1,-1), color),
        ("TOPPADDING",   (0,0),(-1,-1), 4),
        ("BOTTOMPADDING",(0,0),(-1,-1), 4),
        ("LEFTPADDING",  (0,0),(-1,-1), 8),
    ]))
    return bar

def make_table(headers, rows, col_widths, hdr_color=C_DEEP_BLUE, alt=True):
    header_row = [Paragraph(h, S_TBL_HDR) for h in headers]
    table_data = [header_row]
    for r in rows:
        table_data.append([Paragraph(str(c), S_TBL_CELL) if not str(c).startswith("**")
                           else Paragraph(str(c)[2:-2], S_TBL_CELL_B) for c in r])
    t = Table(table_data, colWidths=col_widths, repeatRows=1)
    style = [
        ("BACKGROUND",   (0,0), (-1,0),  hdr_color),
        ("TEXTCOLOR",    (0,0), (-1,0),  C_WHITE),
        ("GRID",         (0,0), (-1,-1), 0.4, C_GRAY_MED),
        ("TOPPADDING",   (0,0), (-1,-1), 4),
        ("BOTTOMPADDING",(0,0), (-1,-1), 4),
        ("LEFTPADDING",  (0,0), (-1,-1), 5),
        ("RIGHTPADDING", (0,0), (-1,-1), 5),
        ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    ]
    if alt:
        for i in range(1, len(table_data)):
            if i % 2 == 0:
                style.append(("BACKGROUND", (0,i), (-1,i), C_GRAY_LIGHT))
    t.setStyle(TableStyle(style))
    return t

def highlight_box(text, bg=C_YELLOW_LIGHT, border=C_ORANGE):
    t = Table([[Paragraph(text, S_BODY)]], colWidths=[W])
    t.setStyle(TableStyle([
        ("BACKGROUND",   (0,0),(-1,-1), bg),
        ("BOX",          (0,0),(-1,-1), 1, border),
        ("TOPPADDING",   (0,0),(-1,-1), 6),
        ("BOTTOMPADDING",(0,0),(-1,-1), 6),
        ("LEFTPADDING",  (0,0),(-1,-1), 10),
    ]))
    return t

def mnemonic_box(mnemonic, meaning):
    rows = [[Paragraph(f"<b>{m.strip()}</b>", S_TBL_CELL_B),
             Paragraph(meaning[i].strip(), S_TBL_CELL)]
            for i, m in enumerate(mnemonic)]
    t = Table(rows, colWidths=[1.5*cm, W-1.5*cm])
    t.setStyle(TableStyle([
        ("BACKGROUND",   (0,0),(-1,-1), C_YELLOW_LIGHT),
        ("GRID",         (0,0),(-1,-1), 0.3, C_GRAY_MED),
        ("TOPPADDING",   (0,0),(-1,-1), 3),
        ("BOTTOMPADDING",(0,0),(-1,-1), 3),
        ("LEFTPADDING",  (0,0),(-1,-1), 5),
    ]))
    return t

def sp(n=1): return Spacer(1, n*mm)

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

# ── COVER PAGE ────────────────────────────────────────────────────
cover = Table([[
    Paragraph("PSM SHORT CASES", S_COVER_TITLE),
    Paragraph("Exam-Focused Quick Revision Summary", S_COVER_SUB),
    Paragraph("MBBS Final Year  |  Preventive & Social Medicine", S_COVER_SUB),
    Paragraph("Based on Park's Textbook of PSM (24th Ed.)", make_style("CV3",
        fontSize=10, fontName="Helvetica-Oblique",
        textColor=colors.HexColor("#A9CCE3"), alignment=TA_CENTER)),
    Spacer(1, 6*mm),
    Paragraph("Cases Covered:", make_style("CV4", fontSize=11,
        fontName="Helvetica-Bold", textColor=C_ORANGE, alignment=TA_CENTER)),
    Paragraph(
        "1. Obesity   •   2. Protein-Energy Malnutrition (PEM)"
        "   •   3. Vitamin A Deficiency<br/>"
        "4. Nutritional Anaemia / IDA   •   5. Endemic Fluorosis",
        make_style("CV5", fontSize=10, fontName="Helvetica",
            textColor=C_LIGHT_BLUE, alignment=TA_CENTER, leading=16)),
]], colWidths=[W])
cover.setStyle(TableStyle([
    ("BACKGROUND",   (0,0),(-1,-1), C_DEEP_BLUE),
    ("TOPPADDING",   (0,0),(-1,-1), 28),
    ("BOTTOMPADDING",(0,0),(-1,-1), 28),
    ("LEFTPADDING",  (0,0),(-1,-1), 20),
    ("RIGHTPADDING", (0,0),(-1,-1), 20),
    ("ROUNDEDCORNERS",[8]),
]))
story.append(cover)
story.append(sp(8))
story.append(Paragraph("Quick-Reference Summary  |  MedMayur  |  July 2026",
                        S_FOOTER))
story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════
# CASE 1 — OBESITY
# ══════════════════════════════════════════════════════════════════
story.append(case_banner(1, "OBESITY", "42F, BMI 48, HTN, IFG, knee pain, sleep apnea", C_DEEP_BLUE))
story.append(sp(4))

story.append(section_label("Q1. Definition of Obesity", C_MID_BLUE))
story.append(sp(2))
story.append(highlight_box(
    "<b>Obesity</b> = Abnormal growth of adipose tissue due to:<br/>"
    "• <b>Hypertrophic obesity</b> – enlargement of fat cell size<br/>"
    "• <b>Hyperplastic obesity</b> – increase in fat cell number<br/>"
    "• <b>Mixed</b> – combination of both<br/><br/>"
    "Expressed as BMI (kg/m²). Overweight = BMI ≥25; Obesity = BMI ≥30."
))
story.append(sp(4))

story.append(section_label("Q2. Epidemiological Determinants of Obesity", C_MID_BLUE))
story.append(sp(2))
story.append(make_table(
    ["Category", "Key Determinants"],
    [
        ["Genetic", "Family history; gene variants (FTO gene); heritable tendency for fat storage"],
        ["Dietary", "High caloric intake, saturated fats, refined sugars, sugar-sweetened beverages"],
        ["Physical activity", "Sedentary occupation (this case), desk jobs, screen time, low leisure activity"],
        ["Socioeconomic", "Higher income in developing countries; urbanization; processed food access"],
        ["Age & Sex", "Increases with age; post-menopausal women (shift in LPL activity)"],
        ["Hormonal", "Hypothyroidism, Cushing's syndrome, PCOS, hyperinsulinism"],
        ["Psychological", "Stress eating, binge eating disorder, night eating syndrome"],
        ["Medications", "Corticosteroids, antipsychotics (olanzapine), insulin, some antidepressants"],
        ["Gut microbiome", "Dysbiosis → increased energy extraction from diet"],
    ],
    [3.2*cm, W-3.2*cm], C_DEEP_BLUE
))
story.append(sp(4))

story.append(section_label("Q3. Obesity Indices & Criteria for Assessment", C_MID_BLUE))
story.append(sp(2))
story.append(make_table(
    ["Index", "Formula", "Threshold"],
    [
        ["**BMI (Quetelet's Index)**", "Weight (kg) / Height² (m²)", "Obesity ≥ 30"],
        ["Ponderal Index", "Height (cm) / ∛Weight (kg)", "Obesity < 12.5 (lower = obese)"],
        ["Brocca Index", "Height (cm) − 100 = ideal weight (kg)", "> 20% above ideal = obese"],
        ["Lorentz formula", "Ht−100−(Ht−150)/4 men; /2 women", "Ideal weight in kg"],
        ["Corpulence Index", "Actual weight / Desirable weight", "> 1.2 = overweight"],
        ["Waist Circumference", "Measured at umbilicus level", "Risk: ♀>88 cm, ♂>102 cm"],
        ["Waist-Hip Ratio (WHR)", "Waist / Hip circumference", "Risk: ♀>0.85, ♂>1.0"],
        ["Skinfold thickness", "Calipers at triceps, subscapular", "Best field estimate of body fat %"],
    ],
    [4.5*cm, 6*cm, W-10.5*cm], C_TEAL
))
story.append(sp(3))

story.append(Paragraph("<b>WHO BMI Classification (Adults):</b>", S_SECTION_HDR))
story.append(make_table(
    ["Classification", "BMI (kg/m²)", "Comorbidity Risk"],
    [
        ["Underweight", "< 18.5", "Low (but other risks ↑)"],
        ["Normal", "18.5 – 24.9", "Average"],
        ["Pre-obese (Overweight)", "25.0 – 29.9", "Increased"],
        ["Obese Class I", "30.0 – 34.9", "Moderate"],
        ["Obese Class II", "35.0 – 39.9", "Severe"],
        ["**Obese Class III (Morbid)**", "**≥ 40.0**", "**Very Severe**"],
    ],
    [5*cm, 4*cm, W-9*cm], C_ORANGE
))
story.append(sp(2))
story.append(Paragraph(
    "★ This patient (BMI 48) = Class III Morbid Obesity → very severe risk",
    S_KEY))
story.append(sp(4))

story.append(section_label("Q4. Prevention of Obesity", C_MID_BLUE))
story.append(sp(2))
story.append(make_table(
    ["Level", "Intervention"],
    [
        ["**Primary Prevention**",
         "Dietary modification (↓ saturated fat, ↓ refined sugars, ↑ fiber); "
         "≥30 min moderate activity most days; health education; school-based programs; "
         "restriction of junk food advertising; workplace wellness"],
        ["**Secondary Prevention**",
         "Regular BMI & waist circumference screening; target 5-10% weight loss initially; "
         "behavioural therapy / CBT; pharmacotherapy (orlistat for BMI >30 with comorbidities)"],
        ["**Tertiary Prevention**",
         "Bariatric surgery for BMI ≥40 or ≥35 with serious comorbidities; "
         "management of HTN, T2DM, sleep apnoea, osteoarthritis"],
    ],
    [3.5*cm, W-3.5*cm], C_GREEN
))
story.append(sp(2))
story.append(Paragraph(
    "WHO Goal: Maintain BMI 18.5–24.9 throughout adulthood; prevent weight gain >5 kg in all adults.",
    S_NOTE))

story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════
# CASE 2 — PEM
# ══════════════════════════════════════════════════════════════════
story.append(case_banner(2, "PROTEIN-ENERGY MALNUTRITION (PEM)",
    "2-year-old child, wasting + bilateral pedal edema, recurrent diarrhea",
    colors.HexColor("#5D4037")))
story.append(sp(4))

story.append(section_label("Q1. Diagnosis", colors.HexColor("#5D4037")))
story.append(sp(2))
story.append(highlight_box(
    "<b>KWASHIORKOR</b> — Severe form of PEM<br/><br/>"
    "Key diagnostic features: <b>Bilateral pedal edema</b> (hallmark) + <b>generalized wasting</b> + "
    "lethargy + low albumin + inadequate protein intake + recurrent diarrhea + age 1–3 years.",
    bg=C_RED_LIGHT, border=C_RED
))
story.append(sp(4))

story.append(section_label("Q2. Classification of PEM & Differentiation", colors.HexColor("#5D4037")))
story.append(sp(2))

story.append(Paragraph("<b>Wellcome Classification:</b>", S_SECTION_HDR))
story.append(make_table(
    ["Type", "% Standard Weight", "Edema"],
    [
        ["Underweight", "60–80%", "Absent"],
        ["**Kwashiorkor**", "**60–80%**", "**Present**"],
        ["Marasmus", "< 60%", "Absent"],
        ["Marasmic-Kwashiorkor", "< 60%", "Present"],
    ],
    [4.5*cm, 4*cm, W-8.5*cm], colors.HexColor("#5D4037")
))
story.append(sp(3))

story.append(Paragraph("<b>Gomez Classification (Weight-for-Age):</b>", S_SECTION_HDR))
story.append(make_table(
    ["Grade", "Weight for Age", "Severity"],
    [
        ["Grade I", "75–90% of standard", "Mild"],
        ["Grade II", "60–74% of standard", "Moderate"],
        ["Grade III", "< 60% of standard", "Severe"],
    ],
    [2.5*cm, 5*cm, W-7.5*cm], colors.HexColor("#795548")
))
story.append(sp(3))

story.append(Paragraph("<b>Kwashiorkor vs. Marasmus — High-Yield Differentiation:</b>", S_SECTION_HDR))
story.append(make_table(
    ["Feature", "Kwashiorkor", "Marasmus"],
    [
        ["Cause", "Protein deficiency (low P:E ratio)", "Deficiency of protein + calories"],
        ["Age", "1–3 years (weaning age)", "< 1 year (infancy)"],
        ["**Edema**", "**Present (HALLMARK)**", "**Absent**"],
        ["Wasting", "Present but masked by edema", "Severe, very marked"],
        ["Subcutaneous fat", "Relatively preserved", "Markedly reduced ('skin & bones')"],
        ["Face", "Moon face", "Monkey/old man face"],
        ["Skin", "Flaky paint dermatosis, pigmentation", "Loose, wrinkled, dry"],
        ["Hair", "Depigmented, Flag sign, easily plucked", "Sparse, thin"],
        ["Liver", "Enlarged (fatty liver)", "Normal or small"],
        ["Appetite", "Poor, irritable", "Hungry, alert"],
        ["Serum albumin", "Markedly low", "Less markedly reduced"],
        ["Mood", "Apathetic, irritable", "Alert but miserable"],
    ],
    [3.5*cm, 5.5*cm, W-9*cm], colors.HexColor("#5D4037")
))
story.append(sp(2))
story.append(Paragraph(
    "★ Mnemonic for Kwashiorkor: EDEMA-MHFL = Edema, Depigmentation, "
    "Enlarged liver, Moon face, Apathy, Muscle wasting (hidden), Hair changes, Fatty liver, Low albumin",
    S_NOTE))
story.append(sp(4))

story.append(section_label("Q3. Epidemiology of PEM", colors.HexColor("#5D4037")))
story.append(sp(2))
story.append(make_table(
    ["Key Fact", "Data"],
    [
        ["Child mortality", "Underlying cause in ~30% of under-5 deaths"],
        ["Stunting (low HFA)", "~27% of children in low-income countries"],
        ["Wasting (low WFH)", "~17% of children globally"],
        ["Mortality risk", "Severely wasted children 9× more likely to die"],
        ["High-risk age", "6 months – 3 years (weaning period)"],
        ["Key risk factors", "Poverty, low literacy, large family, diarrhea, measles, poor weaning foods"],
        ["India: high burden states", "UP, Bihar, Jharkhand, Rajasthan, MP"],
    ],
    [5*cm, W-5*cm], colors.HexColor("#795548")
))
story.append(sp(4))

story.append(section_label("Q4. Prevention & Control of PEM", colors.HexColor("#5D4037")))
story.append(sp(2))
story.append(make_table(
    ["Strategy", "Measures"],
    [
        ["Health Promotion",
         "Exclusive breastfeeding ×6 months; low-cost weaning foods; "
         "nutrition education; birth spacing; maternal supplementation; home economics"],
        ["Specific Protection",
         "Protein & energy-rich diet (milk, eggs, fruits); immunization (measles); "
         "food fortification"],
        ["Early Detection",
         "Growth monitoring charts (weight-for-age); MUAC < 12.5 cm = severe malnutrition; "
         "12.5–13.5 cm = mild-moderate"],
        ["Government Programs",
         "ICDS (supplementary nutrition); Mid-Day Meal; Poshan Abhiyaan; "
         "SAM management via NRCs (Nutrition Rehabilitation Centres)"],
    ],
    [3.8*cm, W-3.8*cm], colors.HexColor("#5D4037")
))

story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════
# CASE 3 — VITAMIN A DEFICIENCY
# ══════════════════════════════════════════════════════════════════
story.append(case_banner(3, "VITAMIN A DEFICIENCY (XEROPHTHALMIA)",
    "3-year-old, night blindness + Bitot's spots, no Vit.A supplementation",
    C_TEAL))
story.append(sp(4))

story.append(section_label("Q1. Diagnosis", C_TEAL))
story.append(sp(2))
story.append(highlight_box(
    "<b>XEROPHTHALMIA</b> due to Vitamin A Deficiency<br/><br/>"
    "Stage: <b>XN (Night blindness) + X1B (Bitot's spots)</b><br/><br/>"
    "Basis: Night blindness + bilateral foamy Bitot's spots + prolonged exclusive cereal weaning "
    "(no Vit.A) + drought area (food scarcity) + age 3 years (highest risk: 6 months–6 years).",
    bg=C_TEAL_LIGHT, border=C_TEAL
))
story.append(sp(4))

story.append(section_label("Q2. Clinical Features", C_TEAL))
story.append(sp(2))
story.append(Paragraph("<b>WHO Xerophthalmia Classification:</b>", S_SECTION_HDR))
story.append(make_table(
    ["Stage", "Code", "Feature"],
    [
        ["Night blindness", "XN", "Earliest symptom; child cannot see in dim light"],
        ["Conjunctival xerosis", "X1A", "Dry, hazy, lusterless conjunctiva"],
        ["**Bitot's spots**", "**X1B**", "**Foamy, cheesy triangular white deposits on temporal conjunctiva**"],
        ["Corneal xerosis", "X2", "Dull, hazy cornea"],
        ["Corneal ulcer / keratomalacia (<1/3)", "X3A", "Partial corneal melt"],
        ["Corneal ulcer / keratomalacia (≥1/3)", "X3B", "Major corneal melt — emergency"],
        ["Corneal scar", "XS", "After healing — permanent"],
        ["Xerophthalmic fundus", "XF", "Rare fundus changes"],
    ],
    [4.5*cm, 1.5*cm, W-6*cm], C_TEAL
))
story.append(sp(3))
story.append(Paragraph("<b>Systemic features:</b>", S_SECTION_HDR))
story.append(make_table(
    ["System", "Manifestation"],
    [
        ["Skin", "Follicular hyperkeratosis (Phrynoderma / 'toad skin') — dry, rough, follicular plugging"],
        ["Immunity", "↑ susceptibility to respiratory & GI infections; 20% of VAD children at ↑ mortality risk"],
        ["Growth", "Growth retardation"],
        ["Blood", "Anaemia (often co-exists)"],
        ["Reproduction", "Reproductive failure in severe, prolonged deficiency"],
    ],
    [3*cm, W-3*cm], C_TEAL
))
story.append(sp(4))

story.append(section_label("Q3. Methods to Prevent Vitamin A Deficiency", C_TEAL))
story.append(sp(2))
story.append(make_table(
    ["Approach", "Measures"],
    [
        ["**Massive Dose Supplementation\n(Short-term — most impactful)**",
         "• 9 months: 1,00,000 IU (with measles vaccine)\n"
         "• Every 6 months up to age 5: 2,00,000 IU\n"
         "• Xerophthalmia: treat at facility\n"
         "• Measles cases: 1 dose Vit.A (if not received in past 1 month)\n"
         "• SAM cases: 1 additional dose"],
        ["Food Fortification\n(Medium-term)",
         "Edible oil / vanaspati with Vit.A (mandatory in India); "
         "sugar (Central America model); milk (Vit.A+D)"],
        ["Dietary Diversification\n(Long-term)",
         "Dark green leafy vegetables, yellow/orange fruits & veg, liver, eggs, milk, fish; "
         "promote breastfeeding"],
        ["Infection Control",
         "Immunization against measles; control diarrhea (safe water, sanitation); "
         "treat infections promptly"],
    ],
    [4.5*cm, W-4.5*cm], C_TEAL
))
story.append(sp(4))

story.append(section_label("Q4. Food Fortification", C_TEAL))
story.append(sp(2))
story.append(highlight_box(
    "<b>Food Fortification</b> = Addition of one or more essential nutrients to a food "
    "(whether or not normally present) to prevent/correct demonstrated deficiency in the population."
))
story.append(sp(2))
story.append(make_table(
    ["Type", "Definition", "Example"],
    [
        ["Mass fortification", "Nutrients added to staple foods for general population",
         "Iodized salt, Vitamin A in oil"],
        ["Targeted fortification", "For specific at-risk groups",
         "Infant formula, complementary foods"],
        ["Market-driven", "Voluntary by food industry", "Fortified breakfast cereals"],
    ],
    [3.5*cm, 5.5*cm, W-9*cm], C_TEAL
))
story.append(sp(2))
story.append(Paragraph("<b>Advantages:</b> No change in food habits needed | Reaches large populations "
    "via existing distribution | Cost-effective | Sustainable | No medical infrastructure required<br/>"
    "<b>FSSAI '+F' program</b>: Mandates fortification of oil (Vit A+D), flour (Fe+FA+B12), "
    "milk, rice, and double-fortified salt.", S_BODY))

story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════
# CASE 4 — NUTRITIONAL ANAEMIA / IDA
# ══════════════════════════════════════════════════════════════════
story.append(case_banner(4, "IRON DEFICIENCY ANAEMIA (NUTRITIONAL ANAEMIA)",
    "32F, menorrhagia, red-meat deficient diet, microcytic hypochromic, low ferritin",
    C_RED))
story.append(sp(4))

story.append(section_label("Q1. Diagnosis", C_RED))
story.append(sp(2))
story.append(highlight_box(
    "<b>Iron Deficiency Anaemia (IDA)</b> — most common nutritional anaemia<br/><br/>"
    "WHO Definition: 'A condition where Hb is lower than normal due to deficiency of ≥1 essential "
    "nutrients, regardless of cause.' (WHO)<br/><br/>"
    "Key findings: Premenopausal + menorrhagia (↑ Fe loss) + diet lacking red meat (↓ Fe intake) "
    "+ fatigue + pallor + <b>pagophagia (pica for ice)</b> + microcytic hypochromic + low serum ferritin.",
    bg=C_RED_LIGHT, border=C_RED
))
story.append(sp(3))
story.append(Paragraph("<b>WHO Haemoglobin Cut-offs for Anaemia:</b>", S_SECTION_HDR))
story.append(make_table(
    ["Group", "Hb Cut-off (g/dL)"],
    [
        ["Adult men", "< 13.0"],
        ["**Non-pregnant women**", "**< 12.0**"],
        ["Pregnant women", "< 11.0"],
        ["Children 6–59 months", "< 11.0"],
        ["Children 5–11 years", "< 11.5"],
        ["Children 12–14 years", "< 12.0"],
    ],
    [6*cm, W-6*cm], C_RED
))
story.append(sp(2))
story.append(Paragraph("<b>Severity Classification (India, National Programme):</b>", S_SECTION_HDR))
story.append(make_table(
    ["Grade", "Hb (g/dL)", "Management"],
    [
        ["Mild", "10.0 – 10.9", "IFA tablets at health facility"],
        ["Moderate", "7.0 – 9.9", "Refer to PHC"],
        ["Severe", "< 7.0", "Refer to hospital"],
        ["Very severe", "< 4.0", "Emergency referral"],
    ],
    [2.5*cm, 4*cm, W-6.5*cm], colors.HexColor("#922B21")
))
story.append(sp(4))

story.append(section_label("Q2. Community Interventions to Control Nutritional Anaemia", C_RED))
story.append(sp(2))
story.append(make_table(
    ["Strategy", "Details"],
    [
        ["**1. IFA Supplementation\n(Most immediate)**",
         "• Pregnant/Lactating: 100 mg elemental Fe + 0.5 mg FA/day\n"
         "• Children 6–60 months: 20 mg Fe + 0.1 mg FA (liquid) × 100 days\n"
         "• Children 6–10 yrs: 30 mg Fe + 250 mcg FA × 100 days\n"
         "• Adolescents: same as adults"],
        ["**2. Iron Fortification\n(Medium-term)**",
         "Double Fortified Salt (DFS) with Fe + Iodine — universally consumed, no special delivery; "
         "ferric ortho-phosphate in salt proven by NIN Hyderabad; "
         "FSSAI mandates Fe-fortified wheat flour"],
        ["**3. Dietary Diversification\n(Long-term)**",
         "↑ iron-rich foods (green leafy veg, meat, pulses, jaggery); "
         "↑ Vitamin C (enhances Fe absorption); "
         "avoid tea/coffee with meals (inhibit non-heme Fe absorption); "
         "use iron cooking pots"],
        ["4. Parasite & Infection Control",
         "Deworming (hookworm major cause of Fe loss); treatment of malaria; sanitation"],
        ["5. Other measures",
         "Delayed cord clamping (retains 40–60 mL iron-rich blood); "
         "nutrition education; health awareness"],
    ],
    [3.8*cm, W-3.8*cm], C_RED
))
story.append(sp(4))

story.append(section_label("Q3. Anaemia Mukt Bharat (AMB)", C_RED))
story.append(sp(2))
story.append(make_table(
    ["Item", "Detail"],
    [
        ["Full name", "Anaemia Mukt Bharat (AMB)"],
        ["Launched", "2018, Ministry of Health & Family Welfare"],
        ["Parent program", "POSHAN Abhiyaan + Intensified National Iron Plus Initiative (I-NIPI)"],
        ["Target", "Reduce anaemia by 3 percentage points per year across life cycle"],
        ["Framework", "6 × 6 × 6 Strategy"],
    ],
    [4*cm, W-4*cm], colors.HexColor("#922B21")
))
story.append(sp(3))
story.append(Paragraph("<b>6 × 6 × 6 Strategy:</b>", S_SECTION_HDR))
story.append(make_table(
    ["6 Target Groups", "6 Interventions", "6 Delivery Platforms"],
    [
        ["Children 6–59 months", "IFA supplementation", "ICDS / Anganwadi"],
        ["Children 5–9 years", "Deworming (Albendazole)", "School Health Programme"],
        ["Adolescent girls & boys", "Point-of-care Hb testing", "RBSK"],
        ["WRA 20–49 years", "Behaviour Change Communication", "RMNCHA+"],
        ["Pregnant women", "Delayed cord clamping", "RKSK (Adolescent Health)"],
        ["Lactating mothers", "Fortified rice via PDS/MDM/ICDS", "HWCs / Primary Healthcare"],
    ],
    [(W/3), (W/3), (W/3)], C_RED
))
story.append(sp(2))
story.append(Paragraph(
    "★ National Deworming Day: February 10 and August 10 annually | "
    "AMB Tracker App for real-time monitoring",
    S_NOTE))

story.append(PageBreak())

# ══════════════════════════════════════════════════════════════════
# CASE 5 — ENDEMIC FLUOROSIS
# ══════════════════════════════════════════════════════════════════
story.append(case_banner(5, "ENDEMIC FLUOROSIS",
    "50M, Rajasthan, borewell water, mottled teeth + spinal stiffness × 5 years",
    C_PURPLE))
story.append(sp(4))

story.append(section_label("Q1. Diagnosis", C_PURPLE))
story.append(sp(2))
story.append(highlight_box(
    "<b>Endemic Fluorosis</b> (Dental + Skeletal)<br/><br/>"
    "• <b>Dental fluorosis</b>: brownish-yellow mottling and pitting of permanent teeth "
    "(fluoride > 1.5 mg/L during tooth calcification)<br/>"
    "• <b>Skeletal fluorosis</b>: progressive low back pain, morning spinal stiffness, "
    "difficulty climbing stairs (fluoride 3–6 mg/L lifetime intake)<br/><br/>"
    "Clue: Deep borewell water in fluoride-endemic Rajasthan + unaffected adult children who migrated "
    "= environmental/water-borne, NOT genetic.",
    bg=C_PURPLE_LIGHT, border=C_PURPLE
))
story.append(sp(2))
story.append(make_table(
    ["Fluoride Level", "Clinical Effect"],
    [
        ["< 0.5 mg/L", "Dental caries (no protective effect)"],
        ["0.5–0.8 mg/L", "Safe; WHO/BIS permissible (optimal for caries prevention)"],
        ["1.5 mg/L", "Threshold for dental fluorosis (enamel mottling)"],
        ["3.0–6.0 mg/L", "Skeletal fluorosis (lifetime daily intake)"],
        ["> 10 mg/L", "Crippling fluorosis"],
    ],
    [4*cm, W-4*cm], C_PURPLE
))
story.append(sp(4))

story.append(section_label("Q2. Sources of Fluoride", C_PURPLE))
story.append(sp(2))
story.append(make_table(
    ["Source Type", "Examples"],
    [
        ["**Groundwater (MOST IMPORTANT)**",
         "Deep borewells — fluoride leaches from fluorapatite/fluoride-containing rocks; "
         "higher in groundwater than surface water"],
        ["Soil & Rocks", "Fluorapatite, cryolite, fluorite deposits in soil"],
        ["Food", "Tea leaves (very high), seafood, marine fish, some vegetables from fluoride-rich soil"],
        ["Industrial emissions", "Aluminium smelting, phosphate fertilizer plants, brick kilns, coal combustion"],
        ["Pesticides", "Some fluoride-containing agricultural chemicals"],
        ["Dental products", "Fluoride toothpaste/gels (NOT relevant in endemic areas; AVOID in children < 6 yrs)"],
        ["Intentional fluoridation", "Added at 0.7–1.0 mg/L for caries prevention in some developed countries"],
        ["Diet-related",
         "Sorghum (jowar)-based diet promotes HIGHER fluoride retention compared to rice-based diet "
         "(relevant in AP & TN genu valgum fluorosis)"],
    ],
    [4.5*cm, W-4.5*cm], C_PURPLE
))
story.append(sp(2))
story.append(Paragraph(
    "★ Endemic areas in India: Andhra Pradesh (Nellore, Nalgonda, Prakasam), "
    "Punjab, Haryana, Karnataka, Kerala, Tamil Nadu, Rajasthan",
    S_NOTE))
story.append(sp(4))

story.append(section_label("Q3. Clinical Features of Fluorosis", C_PURPLE))
story.append(sp(2))
story.append(Paragraph("<b>A. Dental Fluorosis (Threshold: > 1.5 mg/L; during first 7 years of life):</b>",
    S_SECTION_HDR))
story.append(make_table(
    ["Stage", "Features"],
    [
        ["Early", "Loss of shiny enamel; chalk-white patches (upper incisors most affected)"],
        ["Progressive", "White patches → yellow → brown → black"],
        ["Severe", "Pitting, corroded appearance, loss of enamel"],
        ["Key points",
         "Confined to PERMANENT teeth | develops only during calcification period | "
         "Dean's Index grades severity | mottling best on upper incisors"],
    ],
    [3*cm, W-3*cm], C_PURPLE
))
story.append(sp(3))

story.append(Paragraph("<b>B. Skeletal Fluorosis (Threshold: 3–6 mg/L; lifetime exposure):</b>",
    S_SECTION_HDR))
story.append(make_table(
    ["Stage", "Features"],
    [
        ["Pre-skeletal",
         "Backache, joint pains, muscle weakness (fatigue, burning, tingling sensations)"],
        ["Stage 1",
         "Sporadic joint pain; slight stiffness; osteosclerosis on X-ray"],
        ["Stage 2",
         "Chronic joint pain, arthritis; calcification of ligaments & tendons; "
         "especially spinal (this patient's presentation)"],
        ["Stage 3 — Crippling\n(> 10 mg/L)",
         "Permanent disability; kyphosis; flexion deformities; neurological compression"],
        ["X-ray findings",
         "Osteosclerosis ('chalky white bones'); calcified interosseous membranes; "
         "bamboo spine appearance"],
    ],
    [3.5*cm, W-3.5*cm], C_PURPLE
))
story.append(sp(3))

story.append(Paragraph("<b>C. Genu Valgum Fluorosis (South India — AP, TN):</b>", S_SECTION_HDR))
story.append(highlight_box(
    "Knock-knee deformity (genu valgum) + osteoporosis of lower limbs<br/>"
    "Associated with <b>sorghum (jowar)</b>-based diet → promotes ↑ fluoride retention vs rice diet",
    bg=C_PURPLE_LIGHT, border=C_PURPLE
))
story.append(sp(3))

story.append(section_label("Intervention / Control of Fluorosis", C_PURPLE))
story.append(sp(2))
story.append(make_table(
    ["Method", "Details"],
    [
        ["Change water source", "Switch to surface water (< 0.8 mg/L); running surface water has less fluoride than deep wells"],
        ["**Nalgonda Technique**",
         "Defluoridation: Add lime + alum in sequence → flocculation → sedimentation → filtration; "
         "developed by NEERI Nagpur; moderately expensive"],
        ["Avoid fluoride products", "No fluoride toothpaste for children < 6 yrs in endemic areas; "
         "no fluoride supplements for children drinking fluoridated water"],
        ["NPPCF", "National Programme for Prevention and Control of Fluorosis — MoHFW"],
    ],
    [4*cm, W-4*cm], C_PURPLE
))

story.append(sp(5))
story.append(HRFlowable(W, thickness=1, color=C_GRAY_MED))
story.append(sp(3))
story.append(Paragraph(
    "Summary prepared by MedMayur  |  Based on Park's Textbook of PSM, 24th Ed.  |  July 2026",
    S_FOOTER))

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