ls /home/daytona/workspace/ && python3 -c "import reportlab; print('reportlab ok…

python3 -c "from PIL import ImageFont; f = ImageFont.truetype('/usr/share/fonts/…

find /usr/share/fonts -name "*.ttf" 2>/dev/null | head -40

mkdir -p /home/daytona/workspace/icu-notes && cd /home/daytona/workspace/icu-not…

~/icu-notes/make_notes.py

#!/usr/bin/env python3
"""
Ultra-realistic handwritten study notes generator
Nutrition in ICU + Total Parenteral Nutrition
"""

from PIL import Image, ImageDraw, ImageFont
import random
import math
import os

# ── fonts ──────────────────────────────────────────────────────────────────
BASE = "/home/daytona/workspace/icu-notes"
FONT_REG  = "/usr/share/fonts/truetype/quicksand/Quicksand-Regular.ttf"
FONT_BOLD = "/usr/share/fonts/truetype/quicksand/Quicksand-Bold.ttf"
FONT_MONO = "/usr/share/fonts/truetype/dejavu/DejaVuSansMono.ttf"
FONT_ITALIC = "/usr/share/fonts/truetype/liberation/LiberationSans-Italic.ttf"

# Page size (A4 at 150 dpi)
PW, PH = 1240, 1754

# ── colors ──────────────────────────────────────────────────────────────────
PAPER       = (255, 253, 240)       # cream notebook paper
LINE_COLOR  = (180, 200, 220)       # blue ruled lines
MARGIN_LINE = (220, 160, 160)       # pink margin line
BLUE_PEN    = (15, 40, 160)         # blue gel pen
RED_MARKER  = (200, 20, 20)         # red marker headings
YELLOW_HL   = (255, 240, 60, 160)   # yellow highlighter (RGBA)
GREEN_HL    = (100, 220, 100, 140)  # green highlighter
ORANGE_PEN  = (200, 80, 0)          # orange for exam tips
PENCIL      = (100, 100, 120)       # pencil gray for diagrams
DARK_BLUE   = (10, 20, 100)

rng = random.Random(42)

def jitter(x, y, a=1.5):
    return (x + rng.uniform(-a, a), y + rng.uniform(-a, a))

def load_font(path, size):
    try:
        return ImageFont.truetype(path, size)
    except:
        return ImageFont.load_default()

# font sizes
F_TITLE  = load_font(FONT_BOLD, 52)
F_HEAD   = load_font(FONT_BOLD, 38)
F_SUBH   = load_font(FONT_BOLD, 30)
F_BODY   = load_font(FONT_REG, 25)
F_SMALL  = load_font(FONT_REG, 21)
F_TINY   = load_font(FONT_REG, 18)
F_MONO   = load_font(FONT_MONO, 22)
F_ITALIC = load_font(FONT_ITALIC, 23)

# ── helpers ─────────────────────────────────────────────────────────────────

def new_page():
    img = Image.new("RGB", (PW, PH), PAPER)
    d   = ImageDraw.Draw(img, "RGBA")
    # ruled lines every 38px, start at y=120
    for y in range(120, PH - 40, 38):
        d.line([(80, y), (PW - 40, y)], fill=LINE_COLOR, width=1)
    # margin line at x=115
    d.line([(115, 0), (115, PH)], fill=MARGIN_LINE, width=2)
    # subtle page texture - random very light dots
    for _ in range(300):
        x, y = rng.randint(0, PW), rng.randint(0, PH)
        d.point((x, y), fill=(220, 215, 200))
    return img, d

def highlight(d, x, y, text, font, color=YELLOW_HL, pad=3):
    """Draw yellow (or color) highlight behind text"""
    bbox = font.getbbox(text)
    w, h = bbox[2] - bbox[0], bbox[3] - bbox[1]
    # Draw slightly wobbly highlight rect
    rx1, ry1 = x - pad, y - pad + rng.uniform(-2, 2)
    rx2, ry2 = x + w + pad, y + h + pad + rng.uniform(-2, 2)
    d.rectangle([rx1, ry1, rx2, ry2], fill=color)

def underline_squiggle(d, x, y, text, font, color=RED_MARKER, thick=2):
    """Wobbly underline"""
    bbox = font.getbbox(text)
    w = bbox[2] - bbox[0]
    pts = []
    steps = max(int(w / 6), 4)
    for i in range(steps + 1):
        px = x + (w * i / steps)
        py = y + (bbox[3] - bbox[1]) + 3 + rng.uniform(-2, 2)
        pts.append((px, py))
    if len(pts) >= 2:
        for i in range(len(pts) - 1):
            d.line([pts[i], pts[i+1]], fill=color, width=thick)

def circle_around(d, x, y, text, font, color=RED_MARKER):
    """Rough hand-drawn circle/oval around text"""
    bbox = font.getbbox(text)
    w, h = bbox[2] - bbox[0], bbox[3] - bbox[1]
    cx, cy = x + w/2, y + h/2
    rx, ry = w/2 + 8, h/2 + 8
    # draw ~40 points approximating a wobbly ellipse
    pts = []
    for i in range(45):
        angle = 2 * math.pi * i / 44
        ex = cx + (rx + rng.uniform(-3, 3)) * math.cos(angle)
        ey = cy + (ry + rng.uniform(-2, 2)) * math.sin(angle)
        pts.append((ex, ey))
    pts.append(pts[0])
    for i in range(len(pts)-1):
        d.line([pts[i], pts[i+1]], fill=color, width=2)

def box_highlight(d, x1, y1, x2, y2, color=(255, 230, 50, 80)):
    d.rectangle([x1-4, y1-4, x2+4, y2+4], fill=color)

def write_line(d, x, y, text, font, color=BLUE_PEN, rot=0):
    """Write text with slight rotation jitter for realism"""
    d.text(jitter(x, y, 0.8), text, font=font, fill=color)

def arrow(d, x1, y1, x2, y2, color=PENCIL, width=2):
    d.line([(x1,y1),(x2,y2)], fill=color, width=width)
    # arrowhead
    angle = math.atan2(y2-y1, x2-x1)
    for da in [0.4, -0.4]:
        ax = x2 - 12*math.cos(angle-da)
        ay = y2 - 12*math.sin(angle-da)
        d.line([(x2,y2),(ax,ay)], fill=color, width=width)

def star_doodle(d, cx, cy, r=10, color=(255, 130, 0)):
    pts = []
    for i in range(5):
        a = math.pi/2 + 2*math.pi*i/5
        pts.append((cx + r*math.cos(a), cy + r*math.sin(a)))
        a2 = a + math.pi/5
        pts.append((cx + r*0.4*math.cos(a2), cy + r*0.4*math.sin(a2)))
    for i in range(len(pts)):
        d.line([pts[i], pts[(i+1)%len(pts)]], fill=color, width=2)

def flower_doodle(d, cx, cy, r=12, color=(180, 50, 180)):
    for i in range(6):
        a = 2*math.pi*i/6
        ex, ey = cx + r*math.cos(a), cy + r*math.sin(a)
        d.ellipse([ex-6, ey-6, ex+6, ey+6], outline=color, width=2)
    d.ellipse([cx-5, cy-5, cx+5, cy+5], fill=color)

def heart_doodle(d, cx, cy, s=10, color=(220, 50, 80)):
    # simple heart via two arcs + lines
    pts = []
    for i in range(20):
        t = -math.pi + 2*math.pi*i/19
        x = s * 16 * math.sin(t)**3 / 16
        y = -s * (13*math.cos(t) - 5*math.cos(2*t) - 2*math.cos(3*t) - math.cos(4*t)) / 16
        pts.append((cx+x, cy+y))
    for i in range(len(pts)-1):
        d.line([pts[i], pts[i+1]], fill=color, width=2)

def lightning_doodle(d, cx, cy, s=14, color=(255, 180, 0)):
    pts = [(cx, cy-s), (cx-s*0.3, cy+s*0.1), (cx+s*0.1, cy+s*0.1), (cx-s*0.2, cy+s)]
    for i in range(len(pts)-1):
        d.line([pts[i], pts[i+1]], fill=color, width=2)

def exam_tip_box(d, x, y, text, w=320):
    """Orange exam tip box"""
    lines = []
    words = text.split()
    cur = ""
    for word in words:
        test = cur + (" " if cur else "") + word
        if F_TINY.getbbox(test)[2] < w - 20:
            cur = test
        else:
            lines.append(cur)
            cur = word
    if cur:
        lines.append(cur)
    h = len(lines)*22 + 20
    # rough box
    d.rectangle([x, y, x+w, y+h], fill=(255, 245, 220), outline=(200, 100, 0), width=2)
    d.text((x+8, y+4), "★ EXAM TIP", font=F_TINY, fill=(200, 80, 0))
    for i, line in enumerate(lines):
        d.text((x+8, y+22+i*22), line, font=F_TINY, fill=(150, 50, 0))
    return h

def memory_trick_box(d, x, y, text, w=300):
    """Green memory trick box"""
    lines = []
    words = text.split()
    cur = ""
    for word in words:
        test = cur + (" " if cur else "") + word
        if F_TINY.getbbox(test)[2] < w - 20:
            cur = test
        else:
            lines.append(cur)
            cur = word
    if cur:
        lines.append(cur)
    h = len(lines)*22 + 20
    d.rectangle([x, y, x+w, y+h], fill=(230, 255, 230), outline=(0, 150, 50), width=2)
    d.text((x+8, y+4), "✎ MEMORY TRICK", font=F_TINY, fill=(0, 130, 50))
    for i, line in enumerate(lines):
        d.text((x+8, y+22+i*22), line, font=F_TINY, fill=(0, 100, 30))
    return h

def wrap_text(text, font, max_width):
    """Word-wrap text to list of lines."""
    words = text.split()
    lines = []
    current = ""
    for word in words:
        test = (current + " " + word).strip()
        if font.getbbox(test)[2] <= max_width:
            current = test
        else:
            if current:
                lines.append(current)
            current = word
    if current:
        lines.append(current)
    return lines

def section_header(d, x, y, text, font=F_HEAD, color=RED_MARKER, underline=True):
    """Red bold section header with optional underline"""
    d.text(jitter(x, y), text, font=font, fill=color)
    if underline:
        bbox = font.getbbox(text)
        w = bbox[2]
        # Double underline (marker style)
        uy = y + bbox[3] + 2
        for j in range(2):
            pts = []
            for i in range(int(w/5)+1):
                px = x + i*5
                py = uy + j*3 + rng.uniform(-1, 1)
                pts.append((px, py))
            for i in range(len(pts)-1):
                d.line([pts[i], pts[i+1]], fill=color, width=2)

# ══════════════════════════════════════════════════════════════════════════
#  PAGE GENERATION FUNCTIONS
# ══════════════════════════════════════════════════════════════════════════

def page_cover():
    img, d = new_page()
    # Top decorative strip
    for i in range(5):
        d.rectangle([0, i*4, PW, i*4+3], fill=(200+i*10, 220-i*10, 255-i*5))

    # Subject tag
    d.rectangle([80, 60, 500, 100], fill=(220, 235, 255), outline=BLUE_PEN, width=2)
    d.text((90, 68), "ANESTHESIA  |  CRITICAL CARE  |  NUTRITION", font=F_SMALL, fill=BLUE_PEN)

    # Main title
    section_header(d, 80, 130, "NUTRITION IN ICU", font=F_TITLE, underline=True)
    section_header(d, 80, 210, "& TOTAL PARENTERAL NUTRITION", font=F_HEAD, underline=True)

    d.line([(80, 275), (PW-80, 275)], fill=RED_MARKER, width=3)

    y = 310
    d.text((120, y), "Sources:", font=F_SUBH, fill=RED_MARKER)
    y += 45
    sources = [
        "◆  Barash's Clinical Anesthesia, 9e",
        "◆  Miller's Anesthesia, 10e",
        "◆  Morgan & Mikhail's Clinical Anesthesiology, 7e",
        "◆  Schwartz's Principles of Surgery, 11e",
        "◆  Harrison's Principles of Internal Medicine, 22e",
        "◆  Washington Manual of Medical Therapeutics",
        "◆  Mulholland & Greenfield's Surgery, 7e",
    ]
    for s in sources:
        d.text(jitter(140, y), s, font=F_BODY, fill=BLUE_PEN)
        y += 38

    y += 30
    d.line([(80, y), (PW-80, y)], fill=BLUE_PEN, width=1)
    y += 20
    d.text((120, y), "10 MARK EXAM ANSWERS", font=F_SUBH, fill=(200, 20, 20))
    highlight(d, 120, y, "10 MARK EXAM ANSWERS", F_SUBH, color=YELLOW_HL)

    # Decorative right side diagrams
    # Notebook spiral holes
    for i in range(20):
        hy = 80 + i*82
        d.ellipse([PW-55, hy, PW-20, hy+40], outline=(180,180,200), width=2)
        d.ellipse([PW-50, hy+5, PW-25, hy+35], fill=(240,240,250), outline=(180,180,200), width=1)

    # Cute doodles in margin
    star_doodle(d, 60, 350, r=14, color=(255, 130, 0))
    flower_doodle(d, 62, 500, r=12, color=(180, 50, 180))
    heart_doodle(d, 60, 650, s=11, color=(220, 50, 80))
    star_doodle(d, 60, 800, r=10, color=(0, 150, 200))
    lightning_doodle(d, 62, 950, s=14, color=(255, 180, 0))
    flower_doodle(d, 60, 1100, r=10, color=(50, 180, 80))

    # Bottom note
    d.text((120, PH-80), "✎  Study notes compiled for exam preparation", font=F_TINY, fill=(120,120,180))
    d.text((120, PH-55), "    All data accurate to textbooks listed above", font=F_TINY, fill=(120,120,180))

    return img


def page_nutrition_1():
    """Nutrition in ICU - Introduction, Metabolic Response, Assessment"""
    img, d = new_page()
    MARGIN_X = 130
    RHS = 860  # right panel start
    MAX_W = 700

    # page number + date
    d.text((PW-160, 30), "Page 1", font=F_TINY, fill=(150,150,180))
    d.text((130, 30), "TOPIC 1:  NUTRITION IN ICU", font=F_TINY, fill=(150,150,180))

    # Spiral holes
    for i in range(22):
        hy = 60 + i*76
        d.ellipse([PW-52, hy, PW-22, hy+36], outline=(180,180,200), width=2)

    y = 65
    section_header(d, MARGIN_X, y, "NUTRITION IN THE ICU", font=F_TITLE, color=RED_MARKER)
    y += 75

    # ── 1. Introduction ──────────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "1.  INTRODUCTION", font=F_HEAD)
    y += 50

    intro_pts = [
        "• Critical illness → hypermetabolic state + accelerated catabolism",
        "• If nutrition delayed/inadequate → MALNUTRITION (↑ mortality & morbidity)",
        "• Poor nutrition → ↑ infectious complications, longer ICU stay, prolonged MV",
        "• Adequate nutrition = STANDARD OF CARE in ICU",
    ]
    for pt in intro_pts:
        lines = wrap_text(pt, F_BODY, MAX_W)
        for i, ln in enumerate(lines):
            xi = MARGIN_X + (30 if i>0 else 0)
            write_line(d, xi, y, ln, F_BODY)
            y += 34

    # highlight key phrase
    highlight(d, MARGIN_X+10, y-34*4+34, "STANDARD OF CARE", F_BODY)

    y += 15
    d.line([(MARGIN_X, y), (820, y)], fill=LINE_COLOR, width=1)
    y += 15

    # ── 2. Metabolic Response ────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "2.  METABOLIC RESPONSE TO CRITICAL ILLNESS", font=F_HEAD)
    y += 52

    # Table-style phases
    phases = [
        ("Acute (Ebb) Phase",   "Hypoperfusion, ↓ metabolic rate, catabolism, vasoconstriction"),
        ("Flow (Catabolic) Phase", "↑ Metabolism, protein breakdown, gluconeogenesis, insulin resistance"),
        ("Anabolic/Rehab Phase", "Restoration of body composition, recovery, ↑ protein synthesis"),
    ]
    # Draw table header
    d.rectangle([MARGIN_X, y, 820, y+32], fill=(220, 230, 255))
    d.text((MARGIN_X+8, y+6), "Phase", font=F_SMALL, fill=DARK_BLUE)
    d.text((MARGIN_X+230, y+6), "Features", font=F_SMALL, fill=DARK_BLUE)
    y += 32
    for i, (ph, feat) in enumerate(phases):
        bg = (245, 248, 255) if i%2==0 else (255, 252, 245)
        feat_lines = wrap_text(feat, F_TINY, 500)
        row_h = max(32, len(feat_lines)*22 + 10)
        d.rectangle([MARGIN_X, y, 820, y+row_h], fill=bg, outline=LINE_COLOR, width=1)
        d.text((MARGIN_X+8, y+6), ph, font=F_TINY, fill=RED_MARKER)
        for j, fl in enumerate(feat_lines):
            d.text((MARGIN_X+230, y+6+j*22), fl, font=F_TINY, fill=BLUE_PEN)
        y += row_h

    y += 18

    # key numbers
    kw_line = "↑ Energy demand: 20–50% above basal   |   Urine nitrogen loss: 15–20 g/day"
    highlight(d, MARGIN_X, y, kw_line, F_SMALL, color=YELLOW_HL)
    write_line(d, MARGIN_X, y, kw_line, F_SMALL, color=BLUE_PEN)
    y += 34

    write_line(d, MARGIN_X, y, "• Gut mucosal barrier → compromised → bacterial translocation risk", F_BODY)
    y += 38

    # Doodles in left margin
    star_doodle(d, 62, 200, r=12)
    flower_doodle(d, 62, 450, r=11, color=(180,50,180))
    heart_doodle(d, 62, 700, s=10)

    # ── 3. Nutritional Assessment ─────────────────────────────────────────
    section_header(d, MARGIN_X, y, "3.  NUTRITIONAL ASSESSMENT", font=F_HEAD)
    y += 50

    assess_pts = [
        ("NUTRIC Score", "NRS of Critically Ill  |  includes: age, APACHE II, SOFA, comorbidities, days before ICU"),
        ("NRS-2002", "Nutrition Risk Screening  |  evaluates nutritional status + disease severity"),
        ("Indirect Calorimetry", "GOLD STANDARD  |  measures VO₂ & VCO₂  → actual REE"),
    ]
    for tool, desc in assess_pts:
        d.text(jitter(MARGIN_X+10, y), f"→  {tool}:", font=F_SUBH, fill=RED_MARKER)
        tw = F_SUBH.getbbox(f"→  {tool}:")[2]
        desc_lines = wrap_text(desc, F_BODY, MAX_W - tw - 15)
        write_line(d, MARGIN_X+tw+15, y+4, desc_lines[0], F_BODY)
        for ln in desc_lines[1:]:
            y += 30
            write_line(d, MARGIN_X+tw+50, y+4, ln, F_BODY)
        y += 38

    # highlight GOLD STANDARD
    highlight(d, MARGIN_X+10, y-38*3+12, "GOLD STANDARD", F_BODY)

    y += 10
    # Formula box
    d.rectangle([MARGIN_X, y, 680, y+52], fill=(240,255,240), outline=(0,150,50), width=2)
    d.text((MARGIN_X+10, y+6), "Caloric target:  12 – 25 kcal/kg/day  (ASPEN/SCCM)", font=F_SMALL, fill=(0,120,40))
    d.text((MARGIN_X+10, y+30), "Protein target:  1.2 – 2.0 g/kg/day  (actual body wt)", font=F_SMALL, fill=(0,120,40))
    y += 58

    # NUTRIC ≥5 circle
    circle_text = "NUTRIC ≥ 5 = HIGH RISK"
    d.text(jitter(MARGIN_X+20, y), circle_text, font=F_SUBH, fill=RED_MARKER)
    circle_around(d, MARGIN_X+20, y, circle_text, F_SUBH)
    y += 48

    # Exam tip
    eh = exam_tip_box(d, MARGIN_X, y,
        "Indirect calorimetry is gold standard for REE - always mention in 10-mark answer!", w=500)
    y += eh + 15

    # Bottom margin doodles
    lightning_doodle(d, 62, 1000)
    star_doodle(d, 62, 1200, r=13, color=(0,150,200))

    return img


def page_nutrition_2():
    """Nutrition in ICU - Route, Timing, Caloric Targets, Glycemic Control"""
    img, d = new_page()
    MARGIN_X = 130
    MAX_W = 700

    d.text((PW-160, 30), "Page 2", font=F_TINY, fill=(150,150,180))
    d.text((130, 30), "TOPIC 1:  NUTRITION IN ICU  (contd.)", font=F_TINY, fill=(150,150,180))

    for i in range(22):
        hy = 60 + i*76
        d.ellipse([PW-52, hy, PW-22, hy+36], outline=(180,180,200), width=2)

    y = 65

    # ── 4. Route of Nutrition ──────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "4.  ROUTE OF NUTRITION:  EN vs PN", font=F_HEAD)
    y += 52

    # EN vs PN comparison box
    d.rectangle([MARGIN_X, y, 820, y+30], fill=(200,220,255))
    d.text((MARGIN_X+30, y+5), "ENTERAL (EN) ← ALWAYS PREFERRED OVER PARENTERAL (PN)", font=F_SMALL, fill=DARK_BLUE)
    highlight(d, MARGIN_X+30, y+5, "ALWAYS PREFERRED", F_SMALL)
    y += 36

    en_pts = [
        "◆  Maintains gut mucosal integrity → prevents villous atrophy",
        "◆  Reduces bacterial translocation & infectious complications",
        "◆  Preserves GALT (Gut-Associated Lymphoid Tissue)",
        "◆  More physiological + cost-effective",
        "◆  Fewer catheter-related bloodstream infections",
    ]
    for pt in en_pts:
        write_line(d, MARGIN_X+20, y, pt, F_BODY)
        y += 35

    y += 10
    # Timing box - important
    timing_text = "⏰  EN should be initiated within 24 – 48 hours of ICU admission"
    highlight(d, MARGIN_X, y, timing_text, F_SUBH, color=YELLOW_HL)
    write_line(d, MARGIN_X, y, timing_text, F_SUBH, color=RED_MARKER)
    circle_around(d, MARGIN_X, y, timing_text, F_SUBH, color=RED_MARKER)
    y += 50

    # Gastric vs post-pyloric
    section_header(d, MARGIN_X, y, "Gastric vs Post-Pyloric Feeding:", font=F_SUBH, color=BLUE_PEN, underline=False)
    y += 38
    gpp = [
        "→  Most patients: GASTRIC feeding is safe (start here)",
        "→  Gastric intolerance: try PROKINETICS first (metoclopramide / erythromycin)",
        "→  If prokinetics fail → NASOJEJUNAL tube (post-pyloric)",
        "→  Routine monitoring of GRV (Gastric Residual Volume) = NOT recommended",
        "→  Post-pyloric ≠ reduce pneumonia/ICU LOS/mortality vs gastric feeding",
    ]
    for pt in gpp:
        write_line(d, MARGIN_X+20, y, pt, F_BODY)
        y += 35

    # Important note
    note_text = "GRV monitoring NO longer recommended"
    highlight(d, MARGIN_X+30, y-35*2, note_text, F_BODY)
    y += 10

    d.line([(MARGIN_X, y), (820, y)], fill=LINE_COLOR, width=1)
    y += 18

    # ── 5. Caloric Targets ────────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "5.  CALORIC TARGETS & PROTEIN REQUIREMENTS", font=F_HEAD)
    y += 52

    cal_data = [
        ("Total calories", "12 – 25 kcal/kg/day  (permissive underfeeding in early phase)"),
        ("Hypocaloric strategy", "< 20 kcal/kg/day  OR  < 80% estimated needs  (first ICU week)"),
        ("Protein requirement", "1.2 – 2.0 g/kg/day actual body wt  (↑ in burns/polytrauma)"),
        ("Protein % of calories", "15 – 20% of total caloric needs"),
        ("Calorie:Nitrogen ratio", "At least 100 – 150 kcal per gram of nitrogen"),
    ]
    for param, val in cal_data:
        d.text(jitter(MARGIN_X+10, y), f"  {param}:", font=F_SMALL, fill=RED_MARKER)
        pw_ = F_SMALL.getbbox(f"  {param}:")[2]
        val_lines = wrap_text(val, F_BODY, MAX_W - pw_)
        write_line(d, MARGIN_X+10+pw_+10, y, val_lines[0], F_BODY)
        for ln in val_lines[1:]:
            y += 30
            write_line(d, MARGIN_X+10+pw_+40, y, ln, F_BODY)
        y += 34

    # highlight key numbers
    highlight(d, MARGIN_X+10, y-34*3, "1.2 – 2.0 g/kg/day", F_BODY)

    y += 5
    # Important quote box
    d.rectangle([MARGIN_X, y, 800, y+60], fill=(255,245,225), outline=(180,120,0), width=2)
    d.text((MARGIN_X+10, y+6), '"Avoid overfeeding in early phase of critical illness', font=F_SMALL, fill=(150,80,0))
    d.text((MARGIN_X+10, y+30), '   — this is the one NON-CONTROVERSIAL issue"', font=F_SMALL, fill=(150,80,0))
    y += 70

    # ── 6. Glycemic Control ───────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "6.  GLYCEMIC CONTROL IN ICU", font=F_HEAD)
    y += 50

    d.text(jitter(MARGIN_X+10, y), "TARGET Blood Glucose:  ≤ 180 mg/dL", font=F_SUBH, fill=RED_MARKER)
    highlight(d, MARGIN_X+10, y, "≤ 180 mg/dL", F_SUBH)
    circle_around(d, MARGIN_X+10, y, "TARGET Blood Glucose:  ≤ 180 mg/dL", F_SUBH)
    y += 48

    glyc_pts = [
        "• Van den Berghe study → tight control (80-110) showed benefit in surgical ICU",
        "• NICE-SUGAR trial → tight control → ↑ mortality (hypoglycemic episodes!)",
        "• Current guideline: target ≤ 180 mg/dL (NOT tight control)",
        "• Hyperglycemia → ↑ infections, impaired wound healing, immune suppression",
        "• Both EN & PN can cause hyperglycemia → monitor + use insulin infusion",
    ]
    for pt in glyc_pts:
        write_line(d, MARGIN_X+20, y, pt, F_BODY)
        y += 35

    highlight(d, MARGIN_X+20, y-35*3, "NICE-SUGAR trial", F_BODY)

    # Memory trick
    mh = memory_trick_box(d, MARGIN_X, y,
        "NICE-SUGAR = Tight glucose control KILLS! Target ≤ 180 only.", w=480)
    y += mh + 10

    # Doodles
    star_doodle(d, 62, 200, r=13, color=(255,130,0))
    flower_doodle(d, 62, 500, r=12)
    heart_doodle(d, 62, 800, s=11)
    lightning_doodle(d, 62, 1100)
    star_doodle(d, 62, 1400, r=10, color=(0,150,200))

    return img


def page_nutrition_3():
    """Nutrition in ICU - Immunonutrition, Vasopressors, Refeeding, ASPEN bundle"""
    img, d = new_page()
    MARGIN_X = 130
    MAX_W = 700

    d.text((PW-160, 30), "Page 3", font=F_TINY, fill=(150,150,180))
    d.text((130, 30), "TOPIC 1:  NUTRITION IN ICU  (contd.)", font=F_TINY, fill=(150,150,180))

    for i in range(22):
        hy = 60 + i*76
        d.ellipse([PW-52, hy, PW-22, hy+36], outline=(180,180,200), width=2)

    y = 65

    # ── 7. Immunonutrition ────────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "7.  IMMUNONUTRITION & SPECIAL FORMULATIONS", font=F_HEAD)
    y += 52

    d.text(jitter(MARGIN_X, y), "Definition:  Enteral formulas enriched with pharmacologically active nutrients", font=F_BODY, fill=BLUE_PEN)
    y += 38

    # Immunonutrition table
    imm_data = [
        ("Glutamine",         "Gut enterocyte fuel; improves mucosal integrity",    "STRONGEST evidence (burns/trauma)"),
        ("Arginine",          "Enhances T-cell function + wound healing",            "Evidence in surgical pts"),
        ("Omega-3 FA (EPA/DHA)", "Anti-inflammatory effects",                        "NOT supported by SCCM guidelines"),
        ("Se, Zn, Vit A/C/E", "Antioxidants; generally safe",                       "Low-quality evidence; use with caution"),
    ]
    d.rectangle([MARGIN_X, y, 830, y+28], fill=(220,235,255))
    d.text((MARGIN_X+8, y+5), "Nutrient", font=F_TINY, fill=DARK_BLUE)
    d.text((MARGIN_X+160, y+5), "Mechanism", font=F_TINY, fill=DARK_BLUE)
    d.text((MARGIN_X+520, y+5), "Evidence", font=F_TINY, fill=DARK_BLUE)
    y += 28
    for i, (nut, mech, evid) in enumerate(imm_data):
        bg = (248,250,255) if i%2==0 else (255,252,248)
        mech_lines = wrap_text(mech, F_TINY, 340)
        evid_lines = wrap_text(evid, F_TINY, 260)
        rh = max(28, max(len(mech_lines),len(evid_lines))*22+8)
        d.rectangle([MARGIN_X, y, 830, y+rh], fill=bg, outline=LINE_COLOR)
        d.text((MARGIN_X+8, y+5), nut, font=F_TINY, fill=RED_MARKER)
        for j,ml in enumerate(mech_lines):
            d.text((MARGIN_X+160, y+5+j*22), ml, font=F_TINY, fill=BLUE_PEN)
        for j,el in enumerate(evid_lines):
            d.text((MARGIN_X+520, y+5+j*22), el, font=F_TINY, fill=(0,120,50))
        y += rh

    y += 15
    highlight(d, MARGIN_X, y, "  Glutamine has STRONGEST evidence — especially in BURNS & TRAUMA  ", F_SMALL)
    write_line(d, MARGIN_X, y, "  Glutamine has STRONGEST evidence — especially in BURNS & TRAUMA  ", F_SMALL, color=RED_MARKER)
    y += 40

    d.line([(MARGIN_X, y), (820, y)], fill=LINE_COLOR, width=1)
    y += 15

    # ── 8. Vasopressor Feeding ────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "8.  EN DURING VASOPRESSOR SUPPORT", font=F_HEAD)
    y += 50

    vaso_pts = [
        "• One RCT: EN vs PN in vasopressor-requiring patients",
        "• Result: No ↓ mortality or secondary infections with EN",
        "• BUT: ↑ GI complications incl. INTESTINAL ISCHEMIA in EN group",
        "• Recommendation: Use EN cautiously at HIGH vasopressor doses",
        "• Small-volume 'trophic' feeds may be appropriate",
    ]
    for pt in vaso_pts:
        write_line(d, MARGIN_X+20, y, pt, F_BODY)
        y += 35
    highlight(d, MARGIN_X+20, y-35*3, "INTESTINAL ISCHEMIA", F_BODY)

    y += 10
    d.line([(MARGIN_X, y), (820, y)], fill=LINE_COLOR, width=1)
    y += 15

    # ── 9. Refeeding Syndrome ─────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "9.  REFEEDING SYNDROME", font=F_HEAD)
    y += 50

    d.text(jitter(MARGIN_X, y), "Definition:  Metabolic complications on re-initiating nutrition in malnourished pts", font=F_BODY, fill=BLUE_PEN)
    y += 38

    ref_pts = [
        "• Pathophysiology:  CHO load → ↑ insulin → rapid cellular uptake of PO₄, K⁺, Mg²⁺",
        "• Hallmark:  SEVERE HYPOPHOSPHATEMIA ← most important",
        "• Complications:  Cardiac arrhythmias, resp. failure, hemolysis, rhabdomyolysis",
        "• Prevention:",
        "   ‣  Correct electrolytes BEFORE starting feeds",
        "   ‣  Supplement THIAMINE before refeeding",
        "   ‣  Start feeds LOW: 10 kcal/kg/day → increase over 5–7 days",
    ]
    for pt in ref_pts:
        write_line(d, MARGIN_X+20, y, pt, F_BODY)
        y += 35
    highlight(d, MARGIN_X+20, y-35*6, "SEVERE HYPOPHOSPHATEMIA", F_BODY)
    highlight(d, MARGIN_X+20+4*35, y-35*3, "THIAMINE", F_BODY)

    y += 5
    mh = memory_trick_box(d, MARGIN_X, y,
        "Refeeding = 'PHKMT' → Phos, K, Mg go INTO cells → serum levels drop!", w=500)
    y += mh + 10

    # ── 10. ASPEN/SCCM Bundle ─────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "10.  SCCM/ASPEN BUNDLE RECOMMENDATIONS", font=F_HEAD)
    y += 48

    bundle = [
        "1.  Assess ALL ICU patients for nutrition risk on admission",
        "2.  Calculate energy + protein requirements to set goals",
        "3.  Start EN within 24–48 hrs of ICU admission",
        "4.  Use EN preferentially over PN whenever possible",
        "5.  Use prokinetics to reduce aspiration risk (not routine GRV monitoring)",
        "6.  If EN cannot meet >60% needs after 7–10 days → add PN supplement",
        "7.  Maintain blood glucose ≤ 180 mg/dL",
        "8.  Provide 1.2–2.0 g/kg/day protein",
        "9.  Avoid overfeeding — especially early in critical illness",
        "10. Monitor via NUTRIC / NRS-2002 + indirect calorimetry when available",
    ]
    for pt in bundle:
        write_line(d, MARGIN_X+20, y, pt, F_SMALL)
        y += 32

    # Box around key point
    box_highlight(d, MARGIN_X+20, y-32*8, MARGIN_X+700, y-32*8+32)

    # Exam tip at bottom
    eh = exam_tip_box(d, MARGIN_X, y,
        "In 10-mark Q: cover all 10 bundle points + glycemic control + refeeding syndrome!", w=600)

    # Doodles
    flower_doodle(d, 62, 200, r=12, color=(180,50,180))
    star_doodle(d, 62, 500, r=11, color=(255,130,0))
    heart_doodle(d, 62, 800, s=10)
    lightning_doodle(d, 62, 1100)
    star_doodle(d, 62, 1400, r=12, color=(0,150,200))

    return img


def draw_tpn_flowchart(d, x, y, w=360, h=320):
    """Hand-drawn TPN flowchart diagram"""
    # Title
    d.text((x, y), "TPN Composition", font=F_SMALL, fill=RED_MARKER)
    underline_squiggle(d, x, y, "TPN Composition", F_SMALL)
    y += 30

    # Central box
    cx = x + w//2
    d.rectangle([cx-60, y, cx+60, y+36], fill=(220,235,255), outline=BLUE_PEN, width=2)
    d.text((cx-45, y+8), "TPN Solution", font=F_TINY, fill=DARK_BLUE)

    # Three branches
    branch_y = y + 80
    branches = [
        (x+20, "Dextrose\n(CHO)\n15-25%\n3.4 kcal/g"),
        (x+w//2-45, "Amino Acids\n(Protein)\n3-5%\n1.2-2g/kg"),
        (x+w-110, "Lipid\nEmulsion\n20-30%\n1-2 kcal/mL"),
    ]
    arrow(d, cx, y+36, x+60, branch_y-5, color=PENCIL)
    arrow(d, cx, y+36, cx, branch_y-5, color=PENCIL)
    arrow(d, cx, y+36, x+w-70, branch_y-5, color=PENCIL)

    for bx, btxt in branches:
        lines = btxt.split('\n')
        bh = len(lines)*18+10
        d.rectangle([bx, branch_y, bx+90, branch_y+bh], fill=(245,255,245), outline=(0,150,50), width=2)
        for j, ln in enumerate(lines):
            d.text((bx+5, branch_y+5+j*18), ln, font=F_TINY, fill=BLUE_PEN)

    # Add-ons box
    add_y = branch_y + 100
    d.rectangle([x, add_y, x+w, add_y+60], fill=(255,250,220), outline=(180,120,0), width=2)
    d.text((x+10, add_y+5), "+ Electrolytes  +  Vitamins  +  Trace minerals", font=F_TINY, fill=(150,80,0))
    d.text((x+10, add_y+27), "  Vit K weekly (NOT in commercial IV vitamins!)", font=F_TINY, fill=RED_MARKER)

    return add_y + 70


def page_tpn_1():
    """TPN - Definition, Indications, Access, Composition"""
    img, d = new_page()
    MARGIN_X = 130
    MAX_W = 700

    d.text((PW-160, 30), "Page 4", font=F_TINY, fill=(150,150,180))
    d.text((130, 30), "TOPIC 2:  TOTAL PARENTERAL NUTRITION (TPN)", font=F_TINY, fill=(150,150,180))

    for i in range(22):
        hy = 60 + i*76
        d.ellipse([PW-52, hy, PW-22, hy+36], outline=(180,180,200), width=2)

    y = 65

    section_header(d, MARGIN_X, y, "TOTAL PARENTERAL NUTRITION  (TPN)", font=F_TITLE, color=RED_MARKER)
    y += 75

    # ── 1. Definition ─────────────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "1.  DEFINITION", font=F_HEAD)
    y += 50

    def_text = "Continuous IV infusion of a HYPERTONIC solution containing ALL macronutrients (CHO, protein, fat) + micronutrients (electrolytes, vitamins, trace elements) — bypassing the GI tract entirely."
    highlight(d, MARGIN_X, y, "HYPERTONIC", F_BODY)
    lines = wrap_text(def_text, F_BODY, MAX_W)
    for ln in lines:
        write_line(d, MARGIN_X+20, y, ln, F_BODY)
        y += 34

    y += 5
    d.text(jitter(MARGIN_X+20, y), "◆  Osmolarity > 1500 mOsm/L  →  MUST use central vein (large bore)", font=F_BODY, fill=BLUE_PEN)
    highlight(d, MARGIN_X+20, y, "MUST use central vein", F_BODY)
    y += 38
    d.text(jitter(MARGIN_X+20, y), "◆  Dextrose content: 15 – 25%  (too concentrated for peripheral veins)", font=F_BODY, fill=BLUE_PEN)
    y += 42

    d.line([(MARGIN_X, y), (820, y)], fill=LINE_COLOR, width=1)
    y += 15

    # ── 2. Indications ────────────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "2.  INDICATIONS", font=F_HEAD)
    y += 50

    ind_primary = [
        "◆  Malnutrition when EN is not possible",
        "◆  Intestinal failure (short bowel syndrome, high-output fistulas, obstruction)",
        "◆  Prolonged ileus",
        "◆  Severe inflammatory bowel disease (Crohn's)",
        "◆  Intractable vomiting",
        "◆  Severe pancreatitis (when EN not tolerated)",
    ]
    d.text(jitter(MARGIN_X, y), "Primary indications:", font=F_SUBH, fill=RED_MARKER)
    y += 38
    for pt in ind_primary:
        write_line(d, MARGIN_X+30, y, pt, F_BODY)
        y += 33

    y += 10
    d.text(jitter(MARGIN_X, y), "As SUPPLEMENT to EN:", font=F_SUBH, fill=RED_MARKER)
    y += 38
    supp_text = "→  EN fails to meet > 60% of energy + protein needs  after  7 – 10 days"
    highlight(d, MARGIN_X+30, y, supp_text, F_BODY, color=YELLOW_HL)
    write_line(d, MARGIN_X+30, y, supp_text, F_BODY)
    y += 38

    y += 5
    d.line([(MARGIN_X, y), (820, y)], fill=LINE_COLOR, width=1)
    y += 15

    # ── 3. Central Venous Access ──────────────────────────────────────────
    section_header(d, MARGIN_X, y, "3.  CENTRAL VENOUS ACCESS", font=F_HEAD)
    y += 50

    access_data = [
        ("Subclavian vein",  "MOST COMMON; tunneled preferred if > 8 weeks"),
        ("PICC",             "Peripherally Inserted Central Catheter; good for short-medium term; NOT > 6 months"),
        ("Internal jugular", "Less desirable — discomfort + sterility issues"),
        ("Femoral vein",     "Last resort only — ↑ infection risk"),
    ]
    for route, comment in access_data:
        d.text(jitter(MARGIN_X+10, y), f"  {route}:", font=F_SMALL, fill=RED_MARKER)
        pw_ = F_SMALL.getbbox(f"  {route}:")[2]
        c_lines = wrap_text(comment, F_BODY, MAX_W - pw_)
        write_line(d, MARGIN_X+pw_+20, y, c_lines[0], F_BODY)
        for ln in c_lines[1:]:
            y += 30
            write_line(d, MARGIN_X+pw_+50, y, ln, F_BODY)
        y += 35

    highlight(d, MARGIN_X+10, y-35*4, "MOST COMMON", F_SMALL)
    highlight(d, MARGIN_X+10, y-35*1, "NOT > 6 months", F_BODY)

    y += 5
    d.text(jitter(MARGIN_X+10, y), "★  Tunneled catheters preferred for duration > 8 weeks", font=F_SUBH, fill=RED_MARKER)
    circle_around(d, MARGIN_X+10, y, "★  Tunneled catheters preferred for duration > 8 weeks", F_SUBH)
    y += 50

    # Draw TPN flowchart on right side
    fc_x = PW - 430
    fc_y = 380
    draw_tpn_flowchart(d, fc_x, fc_y)

    # Doodles
    star_doodle(d, 62, 200, r=13, color=(255,130,0))
    flower_doodle(d, 62, 500, r=12, color=(180,50,180))
    heart_doodle(d, 62, 750, s=10)
    lightning_doodle(d, 62, 1000)
    star_doodle(d, 62, 1300, r=11, color=(0,150,200))

    # Exam tip
    eh = exam_tip_box(d, MARGIN_X, y,
        "Remember: TPN ≠ PN. TPN = TOTAL (all needs met centrally). PN = any IV nutrition.", w=560)

    return img


def page_tpn_2():
    """TPN - Macronutrients, Micronutrients, PPN vs TPN, Monitoring"""
    img, d = new_page()
    MARGIN_X = 130
    MAX_W = 700

    d.text((PW-160, 30), "Page 5", font=F_TINY, fill=(150,150,180))
    d.text((130, 30), "TOPIC 2:  TPN  (contd.)", font=F_TINY, fill=(150,150,180))

    for i in range(22):
        hy = 60 + i*76
        d.ellipse([PW-52, hy, PW-22, hy+36], outline=(180,180,200), width=2)

    y = 65

    # ── 4. Composition - Macronutrients ───────────────────────────────────
    section_header(d, MARGIN_X, y, "4.  COMPOSITION OF TPN", font=F_HEAD)
    y += 52

    # A. Dextrose
    section_header(d, MARGIN_X, y, "A.  CARBOHYDRATES (Dextrose)", font=F_SUBH, color=BLUE_PEN, underline=True)
    y += 38
    dex_pts = [
        "• IV dextrose = monohydrate → provides 3.4 kcal/g  (NOT 4 kcal/g!)",
        "• Concentration in TPN: 15 – 25%",
        "• Minimum 150 g/day → maximizes protein-sparing effect",
        "• Excess glucose → hyperglycemia, hepatic steatosis, ↑ CO₂ (↑ VCO₂)",
    ]
    for pt in dex_pts:
        write_line(d, MARGIN_X+20, y, pt, F_BODY)
        y += 34
    highlight(d, MARGIN_X+20, y-34*4, "3.4 kcal/g", F_BODY)
    highlight(d, MARGIN_X+20, y-34*3, "150 g/day", F_BODY)

    y += 5

    # B. Amino Acids
    section_header(d, MARGIN_X, y, "B.  PROTEINS (Amino Acids)", font=F_SUBH, color=BLUE_PEN, underline=True)
    y += 38
    aa_pts = [
        "• Crystalline amino acid solutions: 40–50% essential + 50–60% non-essential",
        "• Standard conc: 3 – 5%   |   Dose: 1.2 – 2.0 g/kg/day",
        "• 1 g amino acid → ≈ 4 kcal",
        "• Modified formulas:",
        "   ‣  BCAA-enriched  →  hepatic encephalopathy",
        "   ‣  Essential AA only  →  renal insufficiency",
    ]
    for pt in aa_pts:
        write_line(d, MARGIN_X+20, y, pt, F_BODY)
        y += 33
    highlight(d, MARGIN_X+20+33*3, y-33*3, "hepatic encephalopathy", F_BODY)
    highlight(d, MARGIN_X+20+33*3, y-33*2, "renal insufficiency", F_BODY)
    y += 5

    # C. Lipids
    section_header(d, MARGIN_X, y, "C.  LIPID EMULSIONS", font=F_SUBH, color=BLUE_PEN, underline=True)
    y += 38
    lip_pts = [
        "• 10% solution = 1.1 kcal/mL   |   20% solution = 2.0 kcal/mL",
        "• Provide energy + ESSENTIAL FATTY ACIDS",
        "• Optimal: 20 – 30% of total calories",
        "• Max infusion rate: 1.0 kcal/kg/h  (0.11 g/kg/h) — do NOT exceed!",
        "• Standard rate: 0.03 – 0.05 g/kg/h",
        "• CONTRAINDICATED if serum TG > 400 mg/dL",
        "• Fat-free TPN → essential FA deficiency → dry scaly skin, hair loss",
        "• Prevention: periodic fat infusion = 10–15% of total calories",
    ]
    for pt in lip_pts:
        write_line(d, MARGIN_X+20, y, pt, F_BODY)
        y += 31
    highlight(d, MARGIN_X+20, y-31*3, "ESSENTIAL FATTY ACIDS", F_BODY)
    highlight(d, MARGIN_X+20, y-31*3, "TG > 400 mg/dL", F_BODY)
    circle_around(d, MARGIN_X+20, y-31*6, "Max infusion rate: 1.0 kcal/kg/h", F_BODY)

    y += 10

    # ── 4D. Micronutrients ────────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "D.  MICRONUTRIENTS", font=F_SUBH, color=BLUE_PEN, underline=True)
    y += 38

    micro_data = [
        ("Vitamin K",    "NOT in commercial IV vitamins → supplement WEEKLY"),
        ("Zinc defic.",  "Eczematoid rash at intertriginous areas + generalized dry scaly skin"),
        ("Copper defic.", "Microcytic anemia"),
        ("Chromium def.","Glucose intolerance"),
        ("Selenium def.", "Cardiomyopathy, myopathy"),
    ]
    for mn, detail in micro_data:
        d.text(jitter(MARGIN_X+10, y), f"★ {mn}:", font=F_SMALL, fill=RED_MARKER)
        pw_ = F_SMALL.getbbox(f"★ {mn}:")[2]
        d_lines = wrap_text(detail, F_BODY, MAX_W-pw_)
        write_line(d, MARGIN_X+pw_+20, y, d_lines[0], F_BODY)
        for ln in d_lines[1:]:
            y += 28
            write_line(d, MARGIN_X+pw_+50, y, ln, F_BODY)
        y += 32
    highlight(d, MARGIN_X+10, y-32*5, "NOT in commercial IV vitamins", F_BODY)
    highlight(d, MARGIN_X+10+32*1, y-32*4, "WEEKLY", F_SMALL)

    y += 5
    # Calorie:N ratio box
    d.rectangle([MARGIN_X, y, 640, y+42], fill=(240,255,240), outline=(0,150,50), width=2)
    d.text((MARGIN_X+10, y+8), "Calorie : Nitrogen ratio  =  100 – 150 kcal  per  1 g Nitrogen", font=F_SMALL, fill=(0,120,40))
    highlight(d, MARGIN_X+10, y+8, "100 – 150 kcal  per  1 g Nitrogen", F_SMALL)
    y += 52

    # Memory trick
    mh = memory_trick_box(d, MARGIN_X, y,
        "Vit K is a LONER - not included in IV multivitamins. Give weekly!", w=480)
    y += mh

    # Doodles
    star_doodle(d, 62, 200, r=13)
    flower_doodle(d, 62, 500, r=12, color=(50,180,80))
    heart_doodle(d, 62, 800, s=11)
    lightning_doodle(d, 62, 1100)
    star_doodle(d, 62, 1400, r=10, color=(200,0,100))

    return img


def draw_complications_diagram(d, x, y, w=380):
    """Spiderweb complications diagram"""
    d.text((x, y), "TPN Complications Map", font=F_SMALL, fill=RED_MARKER)
    underline_squiggle(d, x, y, "TPN Complications Map", F_SMALL)
    y += 30
    cx, cy = x + w//2, y + 120

    # central circle
    d.ellipse([cx-45, cy-20, cx+45, cy+20], fill=(255,220,220), outline=RED_MARKER, width=2)
    d.text((cx-30, cy-8), "TPN", font=F_SMALL, fill=RED_MARKER)

    # surrounding items
    items = [
        (0,   -100, "Hyperglycemia"),
        (80,  -70,  "CRBSI"),
        (110, 30,   "Cholestasis"),
        (70,  110,  "Refeeding Syn."),
        (-70, 110,  "Hyperlipidemia"),
        (-110, 30,  "Thrombosis"),
        (-80, -70,  "Pneumothorax"),
    ]
    for ox, oy, label in items:
        lx, ly = cx+ox, cy+oy
        arrow(d, cx, cy, lx, ly, color=PENCIL)
        bbox = F_TINY.getbbox(label)
        lw = bbox[2]
        d.rectangle([lx-4, ly-2, lx+lw+4, ly+20], fill=(255,255,220), outline=(180,120,0))
        d.text((lx, ly), label, font=F_TINY, fill=(150,50,0))
    return y + 260


def page_tpn_3():
    """TPN - TPN vs PPN, Initiation Protocol, Monitoring, Complications, Timing"""
    img, d = new_page()
    MARGIN_X = 130
    MAX_W = 700

    d.text((PW-160, 30), "Page 6", font=F_TINY, fill=(150,150,180))
    d.text((130, 30), "TOPIC 2:  TPN  (contd.)", font=F_TINY, fill=(150,150,180))

    for i in range(22):
        hy = 60 + i*76
        d.ellipse([PW-52, hy, PW-22, hy+36], outline=(180,180,200), width=2)

    y = 65

    # ── 5. TPN vs PPN ─────────────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "5.  TPN vs PERIPHERAL PN  (PPN)", font=F_HEAD)
    y += 50

    d.rectangle([MARGIN_X, y, 820, y+28], fill=(220,230,255))
    d.text((MARGIN_X+8, y+5), "Feature", font=F_TINY, fill=DARK_BLUE)
    d.text((MARGIN_X+220, y+5), "TPN (Central)", font=F_TINY, fill=DARK_BLUE)
    d.text((MARGIN_X+500, y+5), "PPN (Peripheral)", font=F_TINY, fill=DARK_BLUE)
    y += 28
    comp_rows = [
        ("Dextrose conc.", "15 – 25%", "5 – 10%"),
        ("Protein conc.", "3 – 5%", "3%"),
        ("Osmolarity", "> 1500 mOsm/L", "~600–900 mOsm/L"),
        ("Access", "Central vein (SVC)", "Peripheral vein"),
        ("Duration", "Long-term (weeks–months)", "Short-term (< 2 weeks)"),
        ("Calorie delivery", "COMPLETE", "Partial only"),
        ("Severe malnutrition", "YES", "NOT appropriate"),
    ]
    for i, (feat, tpn_val, ppn_val) in enumerate(comp_rows):
        bg = (248,250,255) if i%2==0 else (255,252,248)
        d.rectangle([MARGIN_X, y, 820, y+28], fill=bg, outline=LINE_COLOR)
        d.text((MARGIN_X+8, y+6), feat, font=F_TINY, fill=RED_MARKER)
        d.text((MARGIN_X+220, y+6), tpn_val, font=F_TINY, fill=BLUE_PEN)
        d.text((MARGIN_X+500, y+6), ppn_val, font=F_TINY, fill=(0,120,50))
        y += 28

    y += 5
    note = "PPN > 2 weeks → convert to TPN"
    highlight(d, MARGIN_X, y, note, F_SUBH, color=YELLOW_HL)
    write_line(d, MARGIN_X, y, note, F_SUBH, color=RED_MARKER)
    circle_around(d, MARGIN_X, y, note, F_SUBH)
    y += 50

    d.line([(MARGIN_X, y), (820, y)], fill=LINE_COLOR, width=1)
    y += 15

    # ── 6. Initiation Protocol ────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "6.  INITIATION & MONITORING OF TPN", font=F_HEAD)
    y += 50

    init_pts = [
        "• Start at LOW rate → increase over 2 – 3 days to target",
        "• Hypocaloric TPN in critically ill (first ICU week):",
        "   → < 20 kcal/kg/day  OR  < 80% of estimated caloric needs",
        "   → Protein: > 1.2 g/kg/day",
        "• Prepare in pharmacy under LAMINAR FLOW HOODS (sterile)",
        "• Insulin supplemented as needed → target glucose ≤ 180 mg/dL",
    ]
    for pt in init_pts:
        write_line(d, MARGIN_X+20, y, pt, F_BODY)
        y += 34

    y += 10
    # Monitoring Table
    d.text(jitter(MARGIN_X, y), "Monitoring Parameters:", font=F_SUBH, fill=RED_MARKER)
    y += 38

    mon_data = [
        ("Capillary / urine glucose",  "Every 6 hours"),
        ("Serum glucose",               "Daily (first few days), then every 2–3 days"),
        ("Electrolytes (Na, K, Cl)",    "Daily until stable → every 2–3 days"),
        ("BUN, LFTs",                   "At least WEEKLY"),
        ("Phosphate, Magnesium",        "Weekly"),
        ("Serum triglycerides",         "At least once during lipid infusion"),
        ("Body weight, urine output",   "Daily"),
    ]
    d.rectangle([MARGIN_X, y, 820, y+26], fill=(200,220,255))
    d.text((MARGIN_X+8, y+4), "Parameter", font=F_TINY, fill=DARK_BLUE)
    d.text((MARGIN_X+420, y+4), "Frequency", font=F_TINY, fill=DARK_BLUE)
    y += 26
    for i, (par, freq) in enumerate(mon_data):
        bg = (248,252,255) if i%2==0 else (255,252,248)
        d.rectangle([MARGIN_X, y, 820, y+26], fill=bg, outline=LINE_COLOR)
        d.text((MARGIN_X+8, y+5), par, font=F_TINY, fill=BLUE_PEN)
        d.text((MARGIN_X+420, y+5), freq, font=F_TINY, fill=RED_MARKER)
        y += 26

    y += 15

    # Draw complication diagram on right
    diag_x = PW - 420
    diag_y = 400
    draw_complications_diagram(d, diag_x, diag_y)

    # ── 7. Timing of TPN in ICU ───────────────────────────────────────────
    section_header(d, MARGIN_X, y, "7.  TIMING OF TPN IN ICU", font=F_HEAD)
    y += 50

    timing_pts = [
        "• EARLY TPN (< 7 days): NOT beneficial in low-risk ICU pts → ↑ infections",
        "• DELAYED initiation (Day 7 – 10):",
        "   ✓  Fewer infections",
        "   ✓  Shorter mechanical ventilation",
        "   ✓  Less renal replacement therapy",
        "   ✓  Cost savings",
        "• Exception: HIGH nutritional risk (NUTRIC ≥ 5) + EN not possible → early PN",
    ]
    for pt in timing_pts:
        write_line(d, MARGIN_X+20, y, pt, F_BODY)
        y += 33
    highlight(d, MARGIN_X+20, y-33*6, "Day 7 – 10", F_BODY)
    highlight(d, MARGIN_X+20, y-33*1, "HIGH nutritional risk", F_BODY)

    y += 10
    eh = exam_tip_box(d, MARGIN_X, y,
        "PEPaNIC trial: TPN on Day 8 better than early TPN in PICU! Apply same principle in adults.", w=600)

    # Doodles
    flower_doodle(d, 62, 200, r=11, color=(50,150,200))
    star_doodle(d, 62, 500, r=12, color=(255,100,0))
    heart_doodle(d, 62, 800, s=10)
    lightning_doodle(d, 62, 1100)
    star_doodle(d, 62, 1400, r=11, color=(180,0,180))

    return img


def page_tpn_4():
    """TPN - Complications (detailed), Discontinuation, Summary table"""
    img, d = new_page()
    MARGIN_X = 130
    MAX_W = 700

    d.text((PW-160, 30), "Page 7", font=F_TINY, fill=(150,150,180))
    d.text((130, 30), "TOPIC 2:  TPN  (contd.) — COMPLICATIONS", font=F_TINY, fill=(150,150,180))

    for i in range(22):
        hy = 60 + i*76
        d.ellipse([PW-52, hy, PW-22, hy+36], outline=(180,180,200), width=2)

    y = 65

    # ── 8. Complications ──────────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "8.  COMPLICATIONS OF TPN", font=F_HEAD)
    y += 52

    # 8A - Metabolic
    section_header(d, MARGIN_X, y, "A.  METABOLIC COMPLICATIONS", font=F_SUBH, color=BLUE_PEN, underline=True)
    y += 38

    met_comp = [
        ("Hyperglycemia",          "Excess dextrose / insulin resistance",      "Insulin infusion; target ≤ 180 mg/dL"),
        ("Hypoglycemia",           "ABRUPT cessation of TPN",                   "Taper TPN; give D10W if needed"),
        ("Hypertriglyceridemia",   "Excess/rapid lipid infusion",               "↓ Lipid rate; hold if TG > 400 mg/dL"),
        ("Hepatic steatosis",      "Overfeeding, excess glucose",               "↓ Caloric load; introduce small EN"),
        ("Cholestasis",            "Lack of EN stimulation (↓ CCK)",           "Introduce small-volume EN ASAP"),
        ("Refeeding syndrome",     "Rapid CHO refeeding in malnourished",       "Correct electrolytes; start low, go slow"),
        ("EFA deficiency",         "Fat-free TPN",                              "10–15% calories as fat emulsion"),
    ]
    d.rectangle([MARGIN_X, y, 830, y+26], fill=(220,230,255))
    d.text((MARGIN_X+8, y+4), "Complication", font=F_TINY, fill=DARK_BLUE)
    d.text((MARGIN_X+270, y+4), "Cause", font=F_TINY, fill=DARK_BLUE)
    d.text((MARGIN_X+570, y+4), "Management", font=F_TINY, fill=DARK_BLUE)
    y += 26
    for i, (comp, cause, mgmt) in enumerate(met_comp):
        bg = (248,252,255) if i%2==0 else (255,252,245)
        cause_lines = wrap_text(cause, F_TINY, 270)
        mgmt_lines  = wrap_text(mgmt,  F_TINY, 240)
        rh = max(26, max(len(cause_lines),len(mgmt_lines))*19+8)
        d.rectangle([MARGIN_X, y, 830, y+rh], fill=bg, outline=LINE_COLOR)
        d.text((MARGIN_X+8, y+5), comp, font=F_TINY, fill=RED_MARKER)
        for j,cl in enumerate(cause_lines):
            d.text((MARGIN_X+270, y+5+j*19), cl, font=F_TINY, fill=BLUE_PEN)
        for j,ml in enumerate(mgmt_lines):
            d.text((MARGIN_X+570, y+5+j*19), ml, font=F_TINY, fill=(0,100,40))
        y += rh

    y += 15

    # 8B - Catheter
    section_header(d, MARGIN_X, y, "B.  CATHETER-RELATED COMPLICATIONS", font=F_SUBH, color=BLUE_PEN, underline=True)
    y += 38

    cath_comp = [
        ("CRBSI",            "Most serious; Staph epidermidis common; meticulous asepsis essential"),
        ("Pneumothorax",     "Subclavian/IJ line insertion complication — check CXR post-insertion"),
        ("Air embolism",     "During insertion or line changes — use Trendelenburg position"),
        ("Venous thrombosis","Thrombophlebitis at catheter tip"),
        ("Catheter occlusion","Fibrin sheath formation"),
    ]
    for comp, detail in cath_comp:
        d.text(jitter(MARGIN_X+10, y), f"◆ {comp}:", font=F_SMALL, fill=RED_MARKER)
        pw_ = F_SMALL.getbbox(f"◆ {comp}:")[2]
        d_lines = wrap_text(detail, F_BODY, MAX_W-pw_)
        write_line(d, MARGIN_X+pw_+20, y, d_lines[0], F_BODY)
        for ln in d_lines[1:]:
            y += 28
            write_line(d, MARGIN_X+pw_+50, y, ln, F_BODY)
        y += 34
    highlight(d, MARGIN_X+10, y-34*5, "CRBSI", F_SMALL)
    highlight(d, MARGIN_X+10, y-34*5, "Staph epidermidis", F_BODY)

    y += 5
    imp_note = "★  PN mortality risk ← EXCESSIVE CALORIC DELIVERY, not PN per se!"
    highlight(d, MARGIN_X, y, imp_note, F_SUBH, color=YELLOW_HL)
    write_line(d, MARGIN_X, y, imp_note, F_SUBH, color=RED_MARKER)
    circle_around(d, MARGIN_X, y, imp_note, F_SUBH)
    y += 52

    d.line([(MARGIN_X, y), (820, y)], fill=LINE_COLOR, width=1)
    y += 15

    # ── 9. Discontinuation ────────────────────────────────────────────────
    section_header(d, MARGIN_X, y, "9.  DISCONTINUATION OF TPN", font=F_HEAD)
    y += 48
    disc_pts = [
        "• TAPER TPN gradually over 1–2 days (avoid rebound hypoglycemia)",
        "• Check blood glucose 30–60 min after stopping TPN",
        "• Discontinue when EN meets > 60% of nutritional requirements",
        "• Reason for hypoglycemia risk: endogenous insulin levels remain elevated",
    ]
    for pt in disc_pts:
        write_line(d, MARGIN_X+20, y, pt, F_BODY)
        y += 35
    highlight(d, MARGIN_X+20, y-35*4, "TAPER TPN gradually", F_BODY)
    highlight(d, MARGIN_X+20, y-35*3, "30–60 min", F_BODY)

    y += 10
    mh = memory_trick_box(d, MARGIN_X, y,
        "Stop TPN suddenly → Hypoglycemia! Insulin still high but glucose gone. TAPER!", w=500)
    y += mh + 10

    # Doodles
    star_doodle(d, 62, 200, r=13, color=(255,130,0))
    flower_doodle(d, 62, 500, r=12)
    heart_doodle(d, 62, 800, s=11)
    lightning_doodle(d, 62, 1100)
    star_doodle(d, 62, 1400, r=10, color=(0,150,200))

    return img


def page_summary():
    """Final summary / quick revision page"""
    img, d = new_page()
    MARGIN_X = 130
    MAX_W = 700

    d.text((PW-160, 30), "Page 8", font=F_TINY, fill=(150,150,180))
    d.text((130, 30), "QUICK REVISION SUMMARY", font=F_TINY, fill=(150,150,180))

    for i in range(22):
        hy = 60 + i*76
        d.ellipse([PW-52, hy, PW-22, hy+36], outline=(180,180,200), width=2)

    y = 65

    section_header(d, MARGIN_X, y, "MASTER SUMMARY TABLE", font=F_TITLE, color=RED_MARKER)
    y += 75

    # Large summary table
    d.rectangle([MARGIN_X, y, 820, y+30], fill=(200,220,255))
    d.text((MARGIN_X+8, y+6), "Parameter", font=F_SMALL, fill=DARK_BLUE)
    d.text((MARGIN_X+310, y+6), "Recommendation", font=F_SMALL, fill=DARK_BLUE)
    y += 30

    summary_rows = [
        ("Total energy (ICU)",       "12 – 25 kcal/kg/day"),
        ("Hypocaloric (first week)", "< 20 kcal/kg/day  OR  < 80% estimated needs"),
        ("Protein",                  "1.2 – 2.0 g/kg/day (actual body wt)"),
        ("EN timing",                "Within 24 – 48 hrs of ICU admission"),
        ("Start PN",                 "When EN < 60% needs after 7 – 10 days"),
        ("TPN dextrose",             "15 – 25%  |  3.4 kcal/g  |  min 150 g/day"),
        ("TPN lipids",               "20 – 30% total cal  |  max 1.0 kcal/kg/h  |  hold TG > 400"),
        ("Calorie : N ratio",        "100 – 150 kcal per gram of nitrogen"),
        ("Blood glucose target",     "≤ 180 mg/dL  (NOT tight control)"),
        ("Vitamin K in TPN",         "Weekly supplement (NOT in IV multivitamins)"),
        ("Central access preferred", "Subclavian (tunneled if > 8 wks)  |  PICC (< 6 mths)"),
        ("PPN duration",             "< 2 weeks only; NOT for severe malnutrition"),
        ("Refeeding hallmark",       "Severe HYPOPHOSPHATEMIA — correct before feeding"),
        ("Stop TPN",                 "TAPER over 1-2 days; check BG 30-60 min after stopping"),
    ]
    for i, (param, rec) in enumerate(summary_rows):
        bg = (248,252,255) if i%2==0 else (255,252,245)
        rec_lines = wrap_text(rec, F_BODY, 460)
        rh = max(30, len(rec_lines)*26+8)
        d.rectangle([MARGIN_X, y, 820, y+rh], fill=bg, outline=LINE_COLOR)
        d.text((MARGIN_X+8, y+6), param, font=F_SMALL, fill=RED_MARKER)
        for j, rl in enumerate(rec_lines):
            d.text((MARGIN_X+310, y+6+j*26), rl, font=F_SMALL, fill=BLUE_PEN)
        y += rh

    # Highlight top key values
    y += 20
    d.rectangle([MARGIN_X, y, 820, y+3], fill=RED_MARKER)
    y += 10

    d.text(jitter(MARGIN_X, y), "KEY NUMBERS TO REMEMBER:", font=F_SUBH, fill=RED_MARKER)
    y += 42

    key_nums = [
        "EN within 24–48h  |  PN if EN fails after 7–10d  |  BG ≤ 180 mg/dL",
        "Protein 1.2–2.0 g/kg  |  Energy 12–25 kcal/kg  |  Cal:N = 100–150:1",
        "Dextrose 3.4 kcal/g  |  Lipid max 1.0 kcal/kg/h  |  Hold lipid if TG >400",
        "Vit K WEEKLY  |  NUTRIC ≥5 = high risk  |  Taper TPN over 1-2 days",
    ]
    for kn in key_nums:
        highlight(d, MARGIN_X+20, y, kn, F_BODY, color=YELLOW_HL)
        write_line(d, MARGIN_X+20, y, kn, F_BODY, color=DARK_BLUE)
        y += 36

    y += 15
    # References box
    d.rectangle([MARGIN_X, y, 820, y+170], fill=(250,250,255), outline=(150,150,200), width=2)
    d.text((MARGIN_X+10, y+8), "REFERENCES:", font=F_SMALL, fill=RED_MARKER)
    refs = [
        "◆ Barash's Clinical Anesthesia, 9e — pp. 4855–4856",
        "◆ Miller's Anesthesia, 10e — Pediatric ICU Nutrition; GI System",
        "◆ Schwartz's Principles of Surgery, 11e — pp. 99–100",
        "◆ Washington Manual of Medical Therapeutics — pp. 63–64",
        "◆ Harrison's Principles of Internal Medicine, 22e — p. 2341",
        "◆ Mulholland & Greenfield's Surgery, 7e — pp. 133–136",
    ]
    for j, ref in enumerate(refs):
        d.text((MARGIN_X+15, y+30+j*22), ref, font=F_TINY, fill=BLUE_PEN)
    y += 175

    # Final exam tip
    eh = exam_tip_box(d, MARGIN_X, y,
        "10-mark answer structure: Intro → Metabolic response → Assessment → EN vs PN → Caloric targets → Glycemic control → Immunonutrition → Refeeding → Summary table. Always mention SCCM/ASPEN guidelines!", w=700)

    # Doodles
    star_doodle(d, 62, 200, r=13, color=(255,130,0))
    flower_doodle(d, 62, 500, r=12, color=(180,50,180))
    heart_doodle(d, 62, 750, s=10)
    lightning_doodle(d, 62, 1000)
    star_doodle(d, 62, 1300, r=11, color=(0,150,200))

    return img


# ══════════════════════════════════════════════════════════════════════════
#  COMPILE ALL PAGES INTO PDF
# ══════════════════════════════════════════════════════════════════════════

print("Generating pages...")
pages = [
    page_cover(),
    page_nutrition_1(),
    page_nutrition_2(),
    page_nutrition_3(),
    page_tpn_1(),
    page_tpn_2(),
    page_tpn_3(),
    page_tpn_4(),
    page_summary(),
]

print(f"Generated {len(pages)} pages. Saving to PDF...")
output_path = os.path.join(BASE, "ICU_Nutrition_Handwritten_Notes.pdf")
pages[0].save(
    output_path,
    save_all=True,
    append_images=pages[1:],
    format="PDF",
    resolution=150,
)
print(f"PDF saved: {output_path}")
print(f"File size: {os.path.getsize(output_path) / 1024:.1f} KB")

cd /home/daytona/workspace/icu-notes && python3 make_notes.py 2>&1

python3 -c " from pypdf import PdfReader r = PdfReader('/home/daytona/workspace/…