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

~/surgery-study-guide/generate_pdf.py

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 import ListFlowable, ListItem

OUTPUT = "/home/daytona/workspace/surgery-study-guide/Surgery_LAQ_Study_Guide.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=1.8*cm,
    leftMargin=1.8*cm,
    topMargin=2*cm,
    bottomMargin=2*cm,
    title="Surgery LAQ Study Guide",
    author="Orris Medical"
)

styles = getSampleStyleSheet()

# Custom styles
DARK_BLUE   = colors.HexColor("#1a3a5c")
MED_BLUE    = colors.HexColor("#1976D2")
LIGHT_BLUE  = colors.HexColor("#E3F2FD")
ACCENT      = colors.HexColor("#0288D1")
GREEN       = colors.HexColor("#2E7D32")
GREEN_BG    = colors.HexColor("#E8F5E9")
ORANGE      = colors.HexColor("#E65100")
ORANGE_BG   = colors.HexColor("#FFF3E0")
GREY_BG     = colors.HexColor("#F5F5F5")
WHITE       = colors.white
RED         = colors.HexColor("#C62828")

cover_title = ParagraphStyle("cover_title", fontSize=28, textColor=WHITE,
    spaceAfter=6, alignment=TA_CENTER, fontName="Helvetica-Bold", leading=34)
cover_sub = ParagraphStyle("cover_sub", fontSize=14, textColor=colors.HexColor("#B3E5FC"),
    spaceAfter=4, alignment=TA_CENTER, fontName="Helvetica")
cover_note = ParagraphStyle("cover_note", fontSize=10, textColor=colors.HexColor("#E1F5FE"),
    spaceAfter=4, alignment=TA_CENTER, fontName="Helvetica-Oblique")

h1 = ParagraphStyle("h1", fontSize=14, textColor=WHITE, spaceAfter=4, spaceBefore=10,
    fontName="Helvetica-Bold", alignment=TA_LEFT, leading=18,
    backColor=DARK_BLUE, borderPadding=(5,8,5,8), leftIndent=0)
h2 = ParagraphStyle("h2", fontSize=11, textColor=DARK_BLUE, spaceAfter=3, spaceBefore=7,
    fontName="Helvetica-Bold", leading=14, borderPadding=(3,6,3,6),
    backColor=LIGHT_BLUE, leftIndent=0)
h3 = ParagraphStyle("h3", fontSize=10, textColor=MED_BLUE, spaceAfter=2, spaceBefore=5,
    fontName="Helvetica-Bold", leading=13)
body = ParagraphStyle("body", fontSize=9, textColor=colors.black, spaceAfter=2,
    fontName="Helvetica", leading=13, alignment=TA_JUSTIFY)
bullet = ParagraphStyle("bullet", fontSize=9, textColor=colors.black, spaceAfter=1,
    fontName="Helvetica", leading=13, leftIndent=14, firstLineIndent=-10)
note_box = ParagraphStyle("note_box", fontSize=8.5, textColor=GREEN, spaceAfter=2,
    fontName="Helvetica-Oblique", leading=12, leftIndent=8,
    backColor=GREEN_BG, borderPadding=(4,6,4,6))
warn_box = ParagraphStyle("warn_box", fontSize=8.5, textColor=ORANGE, spaceAfter=2,
    fontName="Helvetica-Bold", leading=12, leftIndent=8,
    backColor=ORANGE_BG, borderPadding=(4,6,4,6))
footer_style = ParagraphStyle("footer", fontSize=7.5, textColor=colors.grey,
    alignment=TA_CENTER, fontName="Helvetica-Oblique")

def B(text): return f"<b>{text}</b>"
def I(text): return f"<i>{text}</i>"
def C(text, col): return f'<font color="{col}">{text}</font>'

def head1(text):
    return [Paragraph(f"  {text}", h1), Spacer(1, 3)]

def head2(text):
    return [Paragraph(f"  {text}", h2)]

def head3(text):
    return [Paragraph(text, h3)]

def para(text):
    return Paragraph(text, body)

def bp(text):
    return Paragraph(f"• {text}", bullet)

def space(n=4):
    return Spacer(1, n)

def hr():
    return HRFlowable(width="100%", thickness=0.5, color=colors.HexColor("#BBDEFB"), spaceAfter=3)

def make_table(headers, rows, col_widths=None):
    data = [headers] + rows
    if not col_widths:
        n = len(headers)
        w = (A4[0] - 3.6*cm) / n
        col_widths = [w] * n
    tbl = Table(data, colWidths=col_widths, repeatRows=1)
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,0), MED_BLUE),
        ("TEXTCOLOR",  (0,0), (-1,0), WHITE),
        ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",   (0,0), (-1,0), 8.5),
        ("FONTNAME",   (0,1), (-1,-1), "Helvetica"),
        ("FONTSIZE",   (0,1), (-1,-1), 8),
        ("BACKGROUND", (0,1), (-1,-1), GREY_BG),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [WHITE, GREY_BG]),
        ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#B0BEC5")),
        ("VALIGN",     (0,0), (-1,-1), "MIDDLE"),
        ("TOPPADDING", (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING", (0,0), (-1,-1), 5),
        ("RIGHTPADDING", (0,0), (-1,-1), 5),
        ("WORDWRAP",   (0,0), (-1,-1), True),
    ]))
    return tbl

# ─── PAGE HEADER / FOOTER ─────────────────────────────────────────────────────
def on_page(canvas, doc):
    canvas.saveState()
    # header bar
    canvas.setFillColor(DARK_BLUE)
    canvas.rect(0, A4[1]-1.1*cm, A4[0], 1.1*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica-Bold", 9)
    canvas.setFillColor(WHITE)
    canvas.drawString(1.8*cm, A4[1]-0.75*cm, "SURGERY LAQ STUDY GUIDE")
    canvas.drawRightString(A4[0]-1.8*cm, A4[1]-0.75*cm, "Arterial | Lymphatic | Peritoneum | GIT")
    # footer
    canvas.setFillColor(colors.HexColor("#90A4AE"))
    canvas.rect(0, 0, A4[0], 1.0*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica", 7.5)
    canvas.setFillColor(WHITE)
    canvas.drawCentredString(A4[0]/2, 0.35*cm, f"Page {doc.page}  |  For exam preparation only  |  Sources: Bailey & Love, Pye's Surgical Handicraft, Robbins Pathology")
    canvas.restoreState()

def on_first_page(canvas, doc):
    # No header/footer on cover
    pass

# ─── CONTENT ──────────────────────────────────────────────────────────────────
story = []

# ═══════════════════ COVER PAGE ═══════════════════════════════════════════════
cover_bg = ParagraphStyle("cb", fontSize=10, backColor=DARK_BLUE, leading=1)

# Blue cover rectangle using table trick
cover_data = [[""]]
cover_tbl = Table(cover_data, colWidths=[A4[0]-3.6*cm], rowHeights=[4*cm])
cover_tbl.setStyle(TableStyle([
    ("BACKGROUND",(0,0),(-1,-1), DARK_BLUE),
    ("GRID",(0,0),(-1,-1),0,DARK_BLUE),
]))

title_style = ParagraphStyle("ts", fontSize=30, textColor=WHITE, fontName="Helvetica-Bold",
    alignment=TA_CENTER, leading=36, spaceAfter=6)
sub_style = ParagraphStyle("ss", fontSize=14, textColor=colors.HexColor("#B3E5FC"),
    fontName="Helvetica", alignment=TA_CENTER, leading=18, spaceAfter=4)
date_style = ParagraphStyle("ds", fontSize=10, textColor=colors.HexColor("#80DEEA"),
    fontName="Helvetica-Oblique", alignment=TA_CENTER, spaceAfter=2)

story.append(Spacer(1, 2.5*cm))
story.append(Paragraph("SURGERY", title_style))
story.append(Paragraph("LAQ Study Guide", sub_style))
story.append(Spacer(1, 0.4*cm))
story.append(HRFlowable(width="60%", thickness=2, color=ACCENT, spaceAfter=8,
    hAlign="CENTER"))
story.append(Paragraph("Arterial System  •  Lymphatic System", sub_style))
story.append(Paragraph("Peritoneum  •  Stomach  •  Intestines", sub_style))
story.append(Spacer(1, 0.6*cm))
story.append(Paragraph("Exam Preparation Edition  |  July 2026", date_style))
story.append(Spacer(1, 1.0*cm))

toc_box_data = [[
    Paragraph(
        "<b>Topics Covered:</b><br/>"
        "1. Gangrene – Types &amp; Management<br/>"
        "2. Hodgkin's Disease &amp; Non-Hodgkin's Lymphoma<br/>"
        "3. Burkitt's Tumour &amp; Sarcoidosis<br/>"
        "4. Peritonitis<br/>"
        "5. Gastritis<br/>"
        "6. Peptic Ulcer Disease<br/>"
        "7. Gastric Outlet Obstruction<br/>"
        "8. Haematemesis<br/>"
        "9. Gastric Carcinoma<br/>"
        "10. Ulcerative Colitis<br/>"
        "11. Crohn's Disease<br/>"
        "12. Small Intestinal Malignancies<br/>"
        "13. Intestinal Polyposis",
        ParagraphStyle("toc_p", fontSize=9.5, textColor=DARK_BLUE,
            fontName="Helvetica", leading=16))
]]
toc_tbl = Table(toc_box_data, colWidths=[12*cm])
toc_tbl.setStyle(TableStyle([
    ("BACKGROUND",(0,0),(-1,-1), LIGHT_BLUE),
    ("BOX",(0,0),(-1,-1),1.5,MED_BLUE),
    ("LEFTPADDING",(0,0),(-1,-1),12),
    ("RIGHTPADDING",(0,0),(-1,-1),12),
    ("TOPPADDING",(0,0),(-1,-1),12),
    ("BOTTOMPADDING",(0,0),(-1,-1),12),
]))
story.append(toc_tbl)
story.append(Spacer(1, 1*cm))
story.append(Paragraph(I("Compiled from: Bailey & Love's Surgery (28th Ed.), Pye's Surgical Handicraft (22nd Ed.), Robbins Pathology"), footer_style))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
#  Q1 — GANGRENE
# ═══════════════════════════════════════════════════════════════════════════════
story += head1("Q1. GANGRENE – Types & Management")
story += head2("Definition")
story.append(bp("Death of macroscopic tissue with black discoloration due to breakdown of haemoglobin → iron sulphide"))
story.append(bp("Usually affects the most distal part of a limb due to arterial obstruction (thrombosis / embolus / arteritis)"))
story.append(space())

story += head2("Types")
story.append(make_table(
    [B("Feature"), B("Dry Gangrene"), B("Wet Gangrene"), B("Gas Gangrene")],
    [
        ["Cause", "Gradual arterial occlusion (atherosclerosis)", "Infection + putrefaction superimposed", "Gas-forming organisms (Clostridium)"],
        ["Appearance", "Dry, shrivelled, black", "Swollen, moist, foul-smelling", "Crepitus on palpation"],
        ["Demarcation", "Clear, neat", "Poorly defined, proximal", "Spreads rapidly"],
        ["Common in", "Elderly, atherosclerosis", "Diabetic foot", "Diabetic foot, trauma"],
    ],
    col_widths=[3*cm, 4.5*cm, 4.5*cm, 4.5*cm]
))
story.append(space())

story += head2("Management")
story.append(bp(B("Conservative:") + " Clean wound; wait for line of demarcation to form"))
story.append(bp(B("Vascular surgery:") + " Embolectomy / bypass graft to restore blood supply"))
story.append(bp(B("Amputation:") + " Once line of demarcation is clear"))
story.append(bp(B("Antibiotics:") + " Penicillin + Metronidazole for wet/gas gangrene"))
story.append(bp(B("Hyperbaric oxygen:") + " For gas gangrene"))
story.append(bp(B("Debridement:") + " Urgent for gas gangrene (surgical emergency)"))
story.append(bp(B("Diabetic control:") + " Strict blood glucose management"))
story.append(space(8))

# ═══════════════════════════════════════════════════════════════════════════════
#  Q2 — HODGKIN'S & NHL
# ═══════════════════════════════════════════════════════════════════════════════
story += head1("Q2. HODGKIN'S DISEASE & NON-HODGKIN'S LYMPHOMA")

story += head2("Hodgkin's Lymphoma (HL) – Pathology")
story.append(bp("Malignancy of lymphoid tissue; " + B("Reed-Sternberg (RS) cell") + " is hallmark – large binucleated 'owl-eye' cell"))
story.append(bp("4 subtypes: Nodular sclerosis (most common), Mixed cellularity, Lymphocyte-rich, Lymphocyte-depleted"))
story.append(space(3))

story += head3("Clinical Features")
story.append(bp("Painless enlargement of lymph nodes (usually cervical first)"))
story.append(bp(B("B symptoms:") + " Fever, night sweats, weight loss >10%"))
story.append(bp("Pel-Ebstein fever (cyclical fever)"))
story.append(bp("Alcohol-induced pain at nodal sites (characteristic of HL)"))
story.append(bp("Pruritis, splenomegaly, hepatomegaly"))
story.append(space(3))

story += head3("Ann Arbor Staging")
story.append(make_table(
    [B("Stage"), B("Description")],
    [
        ["Stage I", "Single lymph node region"],
        ["Stage II", "Two or more regions, same side of diaphragm"],
        ["Stage III", "Both sides of diaphragm involved"],
        ["Stage IV", "Diffuse: liver, bone marrow involved"],
        ["A/B suffix", "A = no B symptoms;  B = B symptoms present"],
    ],
    col_widths=[3*cm, 13.5*cm]
))
story.append(space(3))

story += head3("Investigations")
story.append(bp("Excisional lymph node biopsy (gold standard)"))
story.append(bp("CBC: anaemia, elevated ESR; LDH, uric acid elevated"))
story.append(bp("CT chest/abdomen/pelvis for staging; PET scan"))
story.append(bp("Bone marrow biopsy in advanced disease"))
story.append(space(3))

story += head3("Treatment")
story.append(bp("Stage I & II: ABVD chemotherapy (Adriamycin, Bleomycin, Vinblastine, Dacarbazine) + Radiotherapy"))
story.append(bp("Stage III & IV: ABVD or BEACOPP"))
story.append(bp("Prognosis: Excellent – >80% 5-year survival"))
story.append(space(5))

story += head2("Non-Hodgkin's Lymphoma (NHL)")
story.append(bp("Heterogeneous group; arise from B cells (85%) or T cells (15%)"))
story.append(bp("NO Reed-Sternberg cells; extra-nodal involvement common"))
story.append(make_table(
    [B("Grade"), B("Type"), B("Example")],
    [
        ["Low-grade (indolent)", "Follicular lymphoma", "Good prognosis, incurable"],
        ["High-grade (aggressive)", "DLBCL", "Most common; potentially curable"],
        ["Very high-grade", "Burkitt's lymphoma", "Extremely aggressive"],
    ],
    col_widths=[5*cm, 5*cm, 6.5*cm]
))
story.append(space(3))
story.append(bp(B("Treatment:") + " Rituximab (anti-CD20) + CHOP chemotherapy (R-CHOP); Stem cell transplant for relapse"))
story.append(space(8))

# ═══════════════════════════════════════════════════════════════════════════════
#  Q3 — BURKITT'S & SARCOIDOSIS
# ═══════════════════════════════════════════════════════════════════════════════
story += head1("Q3. BURKITT'S TUMOUR & SARCOIDOSIS")

story += head2("Burkitt's Lymphoma – Pathology")
story.append(bp("Highly aggressive B-cell NHL; " + B("t(8;14) translocation") + " → c-MYC oncogene overexpression"))
story.append(bp(B("'Starry sky' appearance") + " on histology (macrophages eating apoptotic tumour cells)"))
story.append(bp("Associated with EBV (Epstein-Barr Virus)"))
story.append(space(3))

story += head3("Types & C/F")
story.append(make_table(
    [B("Type"), B("Association"), B("Clinical Features")],
    [
        ["Endemic (African)", "EBV; children", "Jaw / facial bone swelling"],
        ["Sporadic", "No EBV", "Abdominal mass (ileocaecal), ascites"],
        ["Immunodeficiency-related", "HIV", "Any site"],
    ],
    col_widths=[4.5*cm, 4.5*cm, 7.5*cm]
))
story.append(space(3))

story += head3("Investigations & Diagnosis")
story.append(bp("Biopsy: starry sky pattern; Ki-67 nearly 100%"))
story.append(bp("LDH very elevated; FISH for c-MYC rearrangement; CD20+, CD10+"))
story.append(bp(B("Treatment:") + " Intensive chemo (CODOX-M/IVAC) + CNS prophylaxis"))
story.append(space(5))

story += head2("Sarcoidosis")
story.append(bp("Multisystem granulomatous disease of unknown cause"))
story.append(bp(B("Hallmark:") + " Non-caseating granulomas on biopsy"))
story.append(space(3))

story += head3("C/F (Multi-System)")
story.append(make_table(
    [B("System"), B("Manifestation")],
    [
        ["Lungs", "Bilateral hilar lymphadenopathy (BHL), pulmonary infiltrates, dyspnoea"],
        ["Skin", "Erythema nodosum, lupus pernio"],
        ["Eyes", "Anterior uveitis (most common eye manifestation)"],
        ["Joints", "Arthralgia, polyarthritis"],
        ["Nervous", "Facial palsy, peripheral neuropathy"],
        ["Heart", "Arrhythmias, heart block"],
        ["Kidneys", "Hypercalciuria, renal calculi"],
    ],
    col_widths=[4*cm, 12.5*cm]
))
story.append(space(3))

story += head3("Diagnosis")
story.append(bp("CXR: Bilateral hilar lymphadenopathy; Serum ACE elevated (~60%); Serum calcium elevated"))
story.append(bp("BAL: CD4/CD8 ratio >3.5"))
story.append(bp(B("Gold standard:") + " Tissue biopsy showing non-caseating granuloma"))
story.append(bp(B("Löfgren syndrome:") + " BHL + erythema nodosum + arthritis (acute sarcoidosis)"))
story.append(space(3))

story += head3("Treatment")
story.append(bp("Mild: Observation"))
story.append(bp("Symptomatic: Oral corticosteroids (prednisolone) – first line"))
story.append(bp("Steroid-sparing: Methotrexate, Azathioprine"))
story.append(space(8))

# ═══════════════════════════════════════════════════════════════════════════════
#  Q4 — PERITONITIS
# ═══════════════════════════════════════════════════════════════════════════════
story += head1("Q4. PERITONITIS")

story += head2("Types")
story.append(make_table(
    [B("Type"), B("Definition"), B("Organisms")],
    [
        ["Primary (SBP)", "No obvious intra-abdominal source; occurs in cirrhosis/nephrotic syndrome", "E. coli, Klebsiella, Streptococcus"],
        ["Secondary", "Perforation of viscus, trauma, appendicitis, etc.", "Mixed (E. coli, Bacteroides, Enterococcus)"],
        ["Tertiary", "Persistent despite treatment", "Resistant organisms, fungi"],
    ],
    col_widths=[3.5*cm, 8*cm, 5*cm]
))
story.append(space(4))

story += head2("Pathophysiology")
story.append(bp("Bacterial contamination → inflammatory response → fluid exudation → ileus → sepsis → multi-organ failure"))
story.append(space(3))

story += head2("C/F")
story.append(bp("Sudden severe abdominal pain (worse on movement)"))
story.append(bp(B("Rigidity") + " (board-like abdomen) – guarding"))
story.append(bp(B("Rebound tenderness") + " (Blumberg's sign)"))
story.append(bp("Absent bowel sounds (paralytic ileus)"))
story.append(bp("Fever, tachycardia, hypotension (septic shock in late stages)"))
story.append(bp("Shallow breathing (diaphragmatic splinting)"))
story.append(space(3))

story += head2("Investigations + Role of Paracentesis")
story.append(bp("CBC: Leucocytosis; CRP elevated"))
story.append(bp("CXR: " + B("Free gas under diaphragm") + " (perforation)"))
story.append(bp("CT abdomen: Best investigation – identifies cause and extent"))
story.append(bp(B("Paracentesis (Diagnostic):") + " WBC >250 cells/mm³ (PMN) → confirms SBP; Culture & sensitivity; Protein, glucose, LDH"))
story.append(space(3))

story += head2("Indications for Laparotomy")
story.append(bp("Perforated viscus / bowel strangulation"))
story.append(bp("Failure of conservative management / worsening clinical condition"))
story.append(space(3))

story += head2("Complications")
story.append(bp("Septicaemia / septic shock / multi-organ failure"))
story.append(bp("Residual abscess; intestinal adhesions; obstruction"))
story.append(space(3))

story += head2("Treatment")
story.append(bp(B("Conservative:") + " IV fluids, broad-spectrum IV antibiotics, NGT, catheter"))
story.append(bp(B("Surgical:") + " Peritoneal washout + repair/remove source (e.g., Graham's patch for perforation, appendicectomy)"))
story.append(bp(B("SBP:") + " IV Cefotaxime; prophylaxis with oral Norfloxacin"))
story.append(space(8))

# ═══════════════════════════════════════════════════════════════════════════════
#  Q5 — GASTRITIS
# ═══════════════════════════════════════════════════════════════════════════════
story += head1("Q5. GASTRITIS")

story += head2("Classification / Types")
story.append(make_table(
    [B("Type"), B("Cause"), B("Key Features")],
    [
        ["H. pylori (Type B)", "H. pylori infection", "Most common; antrum; peptic ulcer, cancer risk"],
        ["Autoimmune (Type A)", "Anti-parietal cell antibodies", "Body/fundus; achlorhydria; pernicious anaemia"],
        ["Erosive/Stress", "NSAIDs, alcohol, burns, head injury", "Curling's ulcer (burns), Cushing's (head injury)"],
        ["Reflux gastritis", "Bile reflux, post-gastric surgery", "Distinct histology; after gastrectomy"],
        ["Eosinophilic", "Allergic", "Eosinophilic infiltrate on biopsy"],
    ],
    col_widths=[3.5*cm, 6.5*cm, 6.5*cm]
))
story.append(space(3))

story += head2("Role of H. pylori")
story.append(bp("Gram-negative spiral organism; produces " + B("urease") + " → ammonia → damages mucosa"))
story.append(bp("Causes chronic antral gastritis → peptic ulcer → gastric cancer"))
story.append(bp("Dx: Urea breath test, CLO test (rapid urease test on biopsy), stool antigen, serology"))
story.append(space(3))

story += head2("Role of NSAIDs")
story.append(bp("Inhibit COX-1 → ↓ prostaglandins → ↓ mucus & bicarbonate → mucosal damage"))
story.append(space(3))

story += head2("Investigations & Treatment")
story.append(bp("Upper GI Endoscopy + biopsy; CLO test"))
story.append(bp(B("H. pylori eradication:") + " Triple therapy – PPI + Amoxicillin + Clarithromycin (14 days)"))
story.append(bp("NSAIDs-related: Stop NSAID + PPI; Autoimmune: B12 injections IM"))
story.append(space(8))

# ═══════════════════════════════════════════════════════════════════════════════
#  Q6 — PEPTIC ULCER
# ═══════════════════════════════════════════════════════════════════════════════
story += head1("Q6. PEPTIC ULCER DISEASE")

story += head2("Gastric vs Duodenal Ulcer")
story.append(make_table(
    [B("Feature"), B("Gastric Ulcer"), B("Duodenal Ulcer")],
    [
        ["Location", "Lesser curvature of stomach", "1st part of duodenum"],
        ["Pain", "During meals (food-pain)", "2–3 hrs after food; night pain (relieved by food)"],
        ["Acid", "Normal or low", "High"],
        ["H. pylori", "Present", "Very common (~95%)"],
        ["Malignancy", "Yes – must always biopsy", "Very rare"],
        ["Common age", "Older patients", "Younger adults"],
    ],
    col_widths=[3.5*cm, 7*cm, 6*cm]
))
story.append(space(3))

story += head2("Etiological Factors")
story.append(bp(B("Most important:") + " H. pylori, NSAIDs"))
story.append(bp("Smoking, alcohol, stress (ICU ulcers)"))
story.append(bp("Zollinger-Ellison syndrome (gastrinoma – very high acid)"))
story.append(bp("Blood group O – increased risk"))
story.append(space(3))

story += head2("Indications for Surgical Intervention")
story.append(bp("Perforation (emergency – Graham's omental patch)"))
story.append(bp("Haemorrhage not responding to endoscopic treatment"))
story.append(bp("Obstruction (pyloric stenosis)"))
story.append(bp("Suspected malignancy; failure of medical treatment"))
story.append(space(3))

story += head2("Complications")
story.append(bp("Perforation | Haemorrhage | Pyloric stenosis | Penetration (into pancreas) | Malignant change"))
story.append(space(3))

story += head2("Preventive Strategies")
story.append(bp("H. pylori eradication; avoid NSAIDs (use COX-2 inhibitors + PPI if needed)"))
story.append(bp("Stop smoking and alcohol; PPI prophylaxis for high-risk patients"))
story.append(space(3))

story += head2("Treatment")
story.append(bp(B("Medical:") + " PPI (Omeprazole) + H. pylori eradication (triple therapy)"))
story.append(bp(B("Bleeding:") + " Endoscopic adrenaline injection, clips, heater probe; surgery if fails"))
story.append(bp(B("Perforation:") + " Emergency laparotomy + Graham's omental patch closure"))
story.append(space(8))

# ═══════════════════════════════════════════════════════════════════════════════
#  Q7 — GASTRIC OUTLET OBSTRUCTION
# ═══════════════════════════════════════════════════════════════════════════════
story += head1("Q7. GASTRIC OUTLET OBSTRUCTION (GOO)")

story += head2("Common Causes")
story.append(bp(B("Benign:") + " PUD with pyloric scarring (most common), hypertrophic pyloric stenosis (infants), Crohn's disease"))
story.append(bp(B("Malignant:") + " Carcinoma of stomach antrum, carcinoma of head of pancreas, duodenal carcinoma"))
story.append(space(3))

story += head2("C/F")
story.append(bp(B("Projectile vomiting") + " – non-bilious; contains old food eaten days ago"))
story.append(bp("Epigastric fullness, distension, weight loss, dehydration"))
story.append(bp(B("Succussion splash") + " (fluid sloshing on shaking patient's abdomen)"))
story.append(bp("Visible gastric peristalsis; " + B("Metabolic alkalosis") + " (hypochloraemic, hypokalaemic)"))
story.append(space(3))

story += head2("Benign vs Malignant GOO")
story.append(make_table(
    [B("Feature"), B("Benign"), B("Malignant")],
    [
        ["History", "Long history of PUD symptoms", "Short history, rapid progression"],
        ["Weight loss", "Less prominent", "Significant"],
        ["Endoscopy", "Smooth narrowing, adjacent ulcer", "Irregular, friable mass"],
        ["Biopsy", "Negative for malignancy", "Positive for carcinoma"],
    ],
    col_widths=[3.5*cm, 7*cm, 6*cm]
))
story.append(space(3))

story += head2("Surgical Options")
story.append(bp(B("Benign:") + " Endoscopic balloon dilatation OR Gastrojejunostomy / Antrectomy + vagotomy"))
story.append(bp(B("Malignant:") + " Gastrectomy (curative) OR Gastrojejunostomy (palliative bypass)"))
story.append(space(3))

story += head2("Conservative / Home Treatment")
story.append(bp("NG tube decompression; IV fluids + electrolyte correction (replace Cl⁻ and K⁺)"))
story.append(bp("PPI, H. pylori eradication; nutritional support; endoscopic dilatation for benign stricture"))
story.append(space(8))

# ═══════════════════════════════════════════════════════════════════════════════
#  Q8 — HAEMATEMESIS
# ═══════════════════════════════════════════════════════════════════════════════
story += head1("Q8. HAEMATEMESIS (Upper GI Bleeding)")

story += head2("Common Causes")
story.append(make_table(
    [B("Cause"), B("Notes")],
    [
        ["Peptic ulcer disease", "Most common (~50%); duodenal > gastric"],
        ["Oesophageal varices", "Portal hypertension; liver cirrhosis; massive bleed"],
        ["Mallory-Weiss tear", "Forceful vomiting; mucosal tear at GOJ"],
        ["Erosive gastritis", "NSAIDs, alcohol, stress"],
        ["Gastric carcinoma", "Often with weight loss, chronic symptoms"],
        ["Dieulafoy's lesion", "Abnormal submucosal artery; massive bleed"],
    ],
    col_widths=[5.5*cm, 11*cm]
))
story.append(space(3))

story += head2("Management – ABCDE Resuscitation First")
story.append(bp("Airway, Breathing, Circulation; 2 large-bore IV cannulas"))
story.append(bp("IV fluids (crystalloids) → blood transfusion; cross-match; CBC, LFT, coagulation"))
story.append(bp("Foley catheter (monitor urine output); NGT (assess bleed)"))
story.append(space(3))

story += head2("Endoscopic Techniques for Haemorrhage Control")
story.append(bp("Endoscopic injection: Adrenaline (1:10,000) + sclerosant"))
story.append(bp("Haemoclips; heater probe / electrocautery (thermal therapy)"))
story.append(bp("Band ligation for varices"))
story.append(bp("TIPSS (Transjugular Intrahepatic Portosystemic Shunt) – refractory variceal bleed"))
story.append(space(3))

story += head2("Pharmacological (Home) Therapy")
story.append(bp("PPI IV infusion (Pantoprazole / Omeprazole)"))
story.append(bp("Octreotide / Somatostatin – variceal bleed"))
story.append(bp("Antibiotics (Norfloxacin) – variceal bleed in cirrhosis"))
story.append(bp("H. pylori eradication if PUD confirmed"))
story.append(space(8))

# ═══════════════════════════════════════════════════════════════════════════════
#  Q9 — GASTRIC CARCINOMA
# ═══════════════════════════════════════════════════════════════════════════════
story += head1("Q9. GASTRIC CARCINOMA")

story += head2("Epidemiology & Risk Factors")
story.append(bp("5th most common cancer worldwide; high incidence in Japan, East Asia, Eastern Europe"))
story.append(bp("Male > Female (2:1); peak age 50–70 years"))
story.append(bp(B("RF:") + " H. pylori (most important), high salt/smoked food diet, smoking, atrophic gastritis, pernicious anaemia, family history, blood group A, prior gastric surgery"))
story.append(space(3))

story += head2("Types")
story.append(make_table(
    [B("Type"), B("Features"), B("Prognosis")],
    [
        ["Intestinal type", "Well-differentiated; expanding pattern; distal stomach", "Better"],
        ["Diffuse type", "Poorly differentiated; infiltrates wall; Linitis plastica (leather bottle stomach)", "Worse"],
    ],
    col_widths=[4*cm, 9*cm, 3.5*cm]
))
story.append(space(3))

story += head2("C/F – Metastatic Signs (Imp!)")
story.append(bp(B("Virchow's node") + " – left supraclavicular lymph node (Troisier's sign)"))
story.append(bp(B("Sister Mary Joseph's nodule") + " – umbilical metastasis"))
story.append(bp(B("Blumer's shelf") + " – rectal shelf on PR examination"))
story.append(bp(B("Krukenberg tumour") + " – ovarian metastasis"))
story.append(space(3))

story += head2("Diagnosis & TNM Staging")
story.append(bp("Upper GI Endoscopy + biopsy (gold standard); CT CAP; EUS for T-staging; PET scan"))
story.append(make_table(
    [B("TNM"), B("Description")],
    [
        ["T1", "Mucosa / submucosa (early gastric cancer)"],
        ["T2", "Muscularis propria"],
        ["T3", "Subserosal/serosa"],
        ["T4", "Adjacent organs"],
        ["N0/N1/N2/N3", "0 / 1–2 / 3–6 / 7+ regional nodes"],
        ["M0/M1", "No / distant metastasis"],
    ],
    col_widths=[3.5*cm, 13*cm]
))
story.append(space(3))

story += head2("Treatment")
story.append(bp(B("Curative:") + " Total/subtotal gastrectomy + D2 lymphadenectomy"))
story.append(bp(B("Perioperative chemo:") + " FLOT regimen (preferred); ECF (Epirubicin, Cisplatin, 5-FU)"))
story.append(bp(B("Targeted:") + " Trastuzumab for HER2-positive gastric cancer"))
story.append(bp(B("Palliative:") + " Gastrojejunostomy, stenting, palliative chemo/RT"))
story.append(space(8))

# ═══════════════════════════════════════════════════════════════════════════════
#  Q10 — ULCERATIVE COLITIS
# ═══════════════════════════════════════════════════════════════════════════════
story += head1("Q10. ULCERATIVE COLITIS (UC)")

story += head2("UC vs Crohn's Disease – Key Differences")
story.append(make_table(
    [B("Feature"), B("Ulcerative Colitis"), B("Crohn's Disease")],
    [
        ["Location", "Colon + rectum only", "Any part of GIT (mouth to anus)"],
        ["Depth", "Mucosal only", "Transmural (full thickness)"],
        ["Pattern", "Continuous from rectum", "Skip lesions"],
        ["Rectal involvement", "Always present", "Rectal sparing common"],
        ["Fistulae/abscesses", "Rare", "Common"],
        ["Granulomas", "Absent", "Non-caseating granulomas"],
        ["Malignancy risk", "High (UC)", "Lower (CD)"],
        ["Surgery", "Curative (proctocolectomy)", "Palliative (recurrence)"],
    ],
    col_widths=[4*cm, 6.5*cm, 6*cm]
))
story.append(space(3))

story += head2("Pathology & C/F")
story.append(bp("Mucosal oedema, ulceration, friable mucosa; inflammatory pseudopolyps"))
story.append(bp(B("Main symptom:") + " Bloody diarrhoea with mucus; abdominal cramps; tenesmus"))
story.append(bp("Weight loss, anaemia, fever"))
story.append(space(3))

story += head2("Extra-Intestinal Manifestations")
story.append(make_table(
    [B("System"), B("Manifestation")],
    [
        ["Joints", "Peripheral arthropathy, ankylosing spondylitis"],
        ["Eyes", "Uveitis, episcleritis"],
        ["Skin", "Erythema nodosum, pyoderma gangrenosum"],
        ["Liver", "Primary Sclerosing Cholangitis (PSC) – most specific for UC"],
    ],
    col_widths=[4*cm, 12.5*cm]
))
story.append(space(3))

story += head2("Complications")
story.append(bp(B("Toxic megacolon") + " – colon dilates >6 cm; life-threatening; emergency colectomy"))
story.append(bp("Perforation; massive haemorrhage; " + B("colorectal carcinoma") + " (~20% risk after 10 years)"))
story.append(space(3))

story += head2("Diagnosis")
story.append(bp("Colonoscopy + biopsy: crypt abscesses, goblet cell depletion"))
story.append(bp("Barium enema: loss of haustra, " + B("'lead-pipe' colon")))
story.append(bp("AXR: rule out toxic megacolon; CRP, ESR, CBC"))
story.append(space(3))

story += head2("Medical Treatment")
story.append(bp(B("Mild-moderate:") + " 5-ASA (Mesalazine, Sulphasalazine) – oral + enema"))
story.append(bp(B("Moderate-severe:") + " Systemic corticosteroids (prednisolone)"))
story.append(bp(B("Maintenance:") + " Azathioprine / 6-Mercaptopurine"))
story.append(bp(B("Biologics:") + " Infliximab (anti-TNF), Vedolizumab"))
story.append(bp(B("Surgery (curative):") + " Total proctocolectomy + ileal pouch-anal anastomosis (IPAA)"))
story.append(space(8))

# ═══════════════════════════════════════════════════════════════════════════════
#  Q11 — CROHN'S DISEASE
# ═══════════════════════════════════════════════════════════════════════════════
story += head1("Q11. CROHN'S DISEASE")

story += head2("Epidemiology & R/F")
story.append(bp("Bimodal peak: 15–30 and 55–70 years; more common in developed countries"))
story.append(bp(B("Smoking increases risk") + " (opposite to UC where smoking is protective!)"))
story.append(bp("Genetic: NOD2 mutation, HLA associations; Jewish populations higher risk"))
story.append(space(3))

story += head2("Pathophysiology")
story.append(bp("Transmural inflammation → fissures → fistulae and strictures"))
story.append(bp("Skip lesions; " + B("non-caseating granulomas") + " (hallmark histology)"))
story.append(bp("Terminal ileum most commonly affected site"))
story.append(space(3))

story += head2("C/F & Extra-Intestinal Manifestations")
story.append(bp("Chronic diarrhoea (may not be bloody); RIF pain; weight loss; fever"))
story.append(bp("Perianal disease: fistulae, abscesses, skin tags"))
story.append(bp("Same EIM as UC + extra: gallstones, renal oxalate calculi"))
story.append(space(3))

story += head2("Diagnosis")
story.append(bp("Colonoscopy + ileoscopy + biopsy (transmural granulomas)"))
story.append(bp(B("Kantor's string sign") + " on barium: terminal ileal stricture"))
story.append(bp("MRI enterography; ASCA positive; calprotectin elevated"))
story.append(space(3))

story += head2("CD vs Other Causes of Chronic Diarrhoea")
story.append(make_table(
    [B("Condition"), B("Differentiating Feature")],
    [
        ["Intestinal TB", "Caseating granulomas; AFB positive; CBNAAT positive"],
        ["IBS", "No inflammation; normal colonoscopy; young female"],
        ["Coeliac disease", "Anti-TTG antibody; villous atrophy; proximal small bowel"],
        ["Infective", "Acute onset; stool culture positive"],
    ],
    col_widths=[5*cm, 11.5*cm]
))
story.append(space(3))

story += head2("Complications")
story.append(bp("Fistulae (entero-enteral, enterocutaneous, enterovesical)"))
story.append(bp("Strictures → bowel obstruction; intra-abdominal abscesses"))
story.append(bp("Malabsorption; B12 deficiency; anaemia; short bowel syndrome"))
story.append(space(3))

story += head2("Treatment")
story.append(bp(B("Induction:") + " Corticosteroids (prednisolone) or Budesonide"))
story.append(bp(B("Maintenance:") + " Azathioprine / Methotrexate"))
story.append(bp(B("Biologics:") + " Infliximab, Adalimumab (anti-TNF) for moderate-severe disease"))
story.append(bp(B("Perianal disease:") + " Metronidazole + Ciprofloxacin"))
story.append(bp(B("Surgery:") + " Resection of affected segment (not curative – disease recurs)"))
story.append(space(8))

# ═══════════════════════════════════════════════════════════════════════════════
#  Q12 — SMALL INTESTINAL MALIGNANCIES
# ═══════════════════════════════════════════════════════════════════════════════
story += head1("Q12. SMALL INTESTINAL MALIGNANCIES")

story += head2("Epidemiology & R/F")
story.append(bp("Rare (2–3% of all GI malignancies); more common in males, age >60"))
story.append(bp(B("RF:") + " Crohn's disease, coeliac disease, FAP, Lynch syndrome, Peutz-Jeghers syndrome"))
story.append(space(3))

story += head2("Types")
story.append(make_table(
    [B("Type"), B("Location"), B("Key Feature")],
    [
        ["Adenocarcinoma (most common, ~40%)", "Duodenum / proximal jejunum", "Adenoma-carcinoma sequence"],
        ["Carcinoid / NETs", "Ileum (most common)", "Serotonin excess → carcinoid syndrome"],
        ["GIST", "Anywhere in GIT", "c-KIT mutation; CD117+"],
        ["Lymphoma", "Ileum / jejunum", "Associated with Crohn's, coeliac disease"],
    ],
    col_widths=[5.5*cm, 4.5*cm, 6.5*cm]
))
story.append(space(3))

story += head2("Carcinoid Syndrome")
story.append(bp("Flushing, watery diarrhoea, bronchospasm, right-sided valvular disease"))
story.append(bp("Diagnosed by: " + B("24-hr urine 5-HIAA") + ", serum Chromogranin A, Octreotide scan"))
story.append(space(3))

story += head2("Diagnosis & Treatment")
story.append(bp("CT enterography; capsule endoscopy; double-balloon enteroscopy; biopsy"))
story.append(bp(B("Adenocarcinoma:") + " Wide local resection + lymph node dissection + FOLFOX chemotherapy"))
story.append(bp(B("Carcinoid/NETs:") + " Resection + Octreotide/Lanreotide + PRRT"))
story.append(bp(B("GIST:") + " Resection + Imatinib (KIT inhibitor – targeted therapy)"))
story.append(bp(B("Lymphoma:") + " Chemotherapy (CHOP regimen)"))
story.append(space(8))

# ═══════════════════════════════════════════════════════════════════════════════
#  Q13 — INTESTINAL POLYPOSIS
# ═══════════════════════════════════════════════════════════════════════════════
story += head1("Q13. INTESTINAL POLYPOSIS")

story += head2("Types of Intestinal Polyps")
story.append(make_table(
    [B("Type"), B("Nature"), B("Malignant Potential")],
    [
        ["Hyperplastic", "Non-neoplastic", "Nil"],
        ["Tubular adenoma", "Neoplastic", "Low (~5%)"],
        ["Tubulovillous adenoma", "Neoplastic", "Moderate (~22%)"],
        ["Villous adenoma", "Neoplastic", "High (~40%)"],
        ["Inflammatory pseudopolyp", "Non-neoplastic", "Nil"],
        ["Hamartomatous", "Non-neoplastic", "Low"],
    ],
    col_widths=[5.5*cm, 4.5*cm, 6.5*cm]
))
story.append(space(3))

story += head2("Polyposis Syndromes")
story.append(make_table(
    [B("Syndrome"), B("Gene"), B("Key Feature"), B("Treatment")],
    [
        ["FAP", "APC (chr 5q21); AD", ">100 adenomas; 100% malignant transformation; osteomas, CHRPE (Gardner's)", "Prophylactic colectomy by age 20–25"],
        ["Peutz-Jeghers", "STK11/LKB1; AD", "Hamartomatous polyps; mucocutaneous pigmentation (lips, fingers)", "Surveillance + polypectomy"],
        ["Juvenile Polyposis", "SMAD4/BMPR1A", "Hamartomas; rectal bleeding in children", "Surveillance + colectomy"],
        ["MAP", "MUTYH; AR", "10–100 adenomas; CRC risk", "Surveillance"],
    ],
    col_widths=[3*cm, 3.5*cm, 6.5*cm, 3.5*cm]
))
story.append(space(3))

story += head2("C/F")
story.append(bp("Often asymptomatic (found on screening)"))
story.append(bp("Rectal bleeding; change in bowel habits"))
story.append(bp("Mucus diarrhoea with hypokalaemia (villous adenoma – 'Secretary polyp')"))
story.append(bp("Large polyps: obstruction, intussusception"))
story.append(space(3))

story += head2("Diagnosis")
story.append(bp(B("Colonoscopy (gold standard)") + " – visualize and biopsy"))
story.append(bp("CT colonoscopy (virtual colonoscopy); faecal occult blood test (screening)"))
story.append(bp("Genetic testing: APC gene for FAP"))
story.append(space(3))

story += head2("Management & Treatment")
story.append(bp(B("Single polyp:") + " Endoscopic polypectomy (snare excision)"))
story.append(bp(B("FAP:") + " Total proctocolectomy with IPAA (curative)"))
story.append(bp(B("Chemopreventive:") + " Sulindac / COX-2 inhibitors reduce polyp burden in FAP"))
story.append(bp(B("Surveillance:") + " Regular colonoscopy; genetic counselling for familial syndromes"))
story.append(space(3))

story += head2("Complications")
story.append(bp("Malignant transformation (adenoma-carcinoma sequence)"))
story.append(bp("Bleeding; obstruction; intussusception; electrolyte imbalance"))
story.append(space(12))

# ─── Last page note ────────────────────────────────────────────────────────────
story.append(HRFlowable(width="100%", thickness=1, color=MED_BLUE, spaceAfter=6))
story.append(Paragraph(
    B("Sources: ") + "Bailey &amp; Love's Short Practice of Surgery (28th Ed.) | Pye's Surgical Handicraft (22nd Ed.) | "
    "Robbins Pathologic Basis of Disease | Sleisenger &amp; Fordtran's GI &amp; Liver Disease",
    ParagraphStyle("src", fontSize=8, textColor=colors.grey, fontName="Helvetica-Oblique",
        alignment=TA_CENTER, leading=12)
))
story.append(Spacer(1, 4))
story.append(Paragraph(
    "Good luck on your exam! You've got this.",
    ParagraphStyle("gl", fontSize=11, textColor=MED_BLUE, fontName="Helvetica-Bold",
        alignment=TA_CENTER)
))

# ─── BUILD ─────────────────────────────────────────────────────────────────────
doc.build(story, onFirstPage=on_first_page, onLaterPages=on_page)
print(f"PDF created: {OUTPUT}")

cd /home/daytona/workspace/surgery-study-guide && python generate_pdf.py 2>&1

ls -lh /home/daytona/workspace/surgery-study-guide/Surgery_LAQ_Study_Guide.pdf

~/surgery-study-guide/generate_pdf2.py

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

OUTPUT = "/home/daytona/workspace/surgery-study-guide/Surgery_LAQ_Study_Guide_Part2.pdf"

doc = SimpleDocTemplate(
    OUTPUT, pagesize=A4,
    rightMargin=1.8*cm, leftMargin=1.8*cm,
    topMargin=2.2*cm, bottomMargin=2*cm,
    title="Surgery LAQ Study Guide Part 2",
    author="Orris Medical"
)

# ── Colours ──────────────────────────────────────────────────────────────────
DARK_BLUE  = colors.HexColor("#1a3a5c")
MED_BLUE   = colors.HexColor("#1976D2")
LIGHT_BLUE = colors.HexColor("#E3F2FD")
ACCENT     = colors.HexColor("#0288D1")
GREEN      = colors.HexColor("#2E7D32")
GREEN_BG   = colors.HexColor("#E8F5E9")
ORANGE     = colors.HexColor("#E65100")
ORANGE_BG  = colors.HexColor("#FFF3E0")
GREY_BG    = colors.HexColor("#F5F5F5")
WHITE      = colors.white
RED        = colors.HexColor("#C62828")
PURPLE     = colors.HexColor("#6A1B9A")
PURPLE_BG  = colors.HexColor("#F3E5F5")
TEAL       = colors.HexColor("#00695C")
TEAL_BG    = colors.HexColor("#E0F2F1")

# ── Styles ────────────────────────────────────────────────────────────────────
h1 = ParagraphStyle("h1", fontSize=13, textColor=WHITE, spaceAfter=4, spaceBefore=10,
    fontName="Helvetica-Bold", backColor=DARK_BLUE, borderPadding=(5,8,5,8), leading=17)
h2 = ParagraphStyle("h2", fontSize=10.5, textColor=DARK_BLUE, spaceAfter=3, spaceBefore=6,
    fontName="Helvetica-Bold", backColor=LIGHT_BLUE, borderPadding=(3,6,3,6), leading=14)
h3 = ParagraphStyle("h3", fontSize=9.5, textColor=MED_BLUE, spaceAfter=2, spaceBefore=4,
    fontName="Helvetica-Bold", leading=13)
body = ParagraphStyle("body", fontSize=8.5, textColor=colors.black, spaceAfter=1,
    fontName="Helvetica", leading=12, alignment=TA_JUSTIFY)
bullet = ParagraphStyle("bullet", fontSize=8.5, textColor=colors.black, spaceAfter=1,
    fontName="Helvetica", leading=12, leftIndent=13, firstLineIndent=-10)
bullet2 = ParagraphStyle("bullet2", fontSize=8, textColor=colors.HexColor("#333333"), spaceAfter=1,
    fontName="Helvetica", leading=11, leftIndent=24, firstLineIndent=-10)
note = ParagraphStyle("note", fontSize=8, textColor=GREEN, spaceAfter=2, fontName="Helvetica-Oblique",
    leading=11, leftIndent=6, backColor=GREEN_BG, borderPadding=(3,5,3,5))
warn = ParagraphStyle("warn", fontSize=8, textColor=ORANGE, spaceAfter=2, fontName="Helvetica-Bold",
    leading=11, leftIndent=6, backColor=ORANGE_BG, borderPadding=(3,5,3,5))
imp  = ParagraphStyle("imp", fontSize=8, textColor=RED, spaceAfter=2, fontName="Helvetica-Bold",
    leading=11, leftIndent=6, backColor=colors.HexColor("#FFEBEE"), borderPadding=(3,5,3,5))
footer_style = ParagraphStyle("footer", fontSize=7, textColor=colors.grey,
    alignment=TA_CENTER, fontName="Helvetica-Oblique")

def B(t): return f"<b>{t}</b>"
def I(t): return f"<i>{t}</i>"

def H1(text):
    return [Paragraph(f"  {text}", h1), Spacer(1,3)]

def H2(text):
    return [Paragraph(f"  {text}", h2)]

def H3(text):
    return [Paragraph(text, h3)]

def bp(text):
    return Paragraph(f"• {text}", bullet)

def bp2(text):
    return Paragraph(f"  – {text}", bullet2)

def sp(n=4):
    return Spacer(1, n)

def hr():
    return HRFlowable(width="100%", thickness=0.4, color=colors.HexColor("#BBDEFB"), spaceAfter=2)

def tbl(headers, rows, col_widths=None):
    data = [headers] + rows
    if not col_widths:
        n = len(headers); w = (A4[0]-3.6*cm)/n
        col_widths = [w]*n
    t = Table(data, colWidths=col_widths, repeatRows=1)
    t.setStyle(TableStyle([
        ("BACKGROUND",(0,0),(-1,0), MED_BLUE),
        ("TEXTCOLOR",(0,0),(-1,0), WHITE),
        ("FONTNAME",(0,0),(-1,0),"Helvetica-Bold"),
        ("FONTSIZE",(0,0),(-1,0),8),
        ("FONTNAME",(0,1),(-1,-1),"Helvetica"),
        ("FONTSIZE",(0,1),(-1,-1),7.5),
        ("ROWBACKGROUNDS",(0,1),(-1,-1),[WHITE, GREY_BG]),
        ("GRID",(0,0),(-1,-1),0.4,colors.HexColor("#B0BEC5")),
        ("VALIGN",(0,0),(-1,-1),"MIDDLE"),
        ("TOPPADDING",(0,0),(-1,-1),3),
        ("BOTTOMPADDING",(0,0),(-1,-1),3),
        ("LEFTPADDING",(0,0),(-1,-1),4),
        ("RIGHTPADDING",(0,0),(-1,-1),4),
        ("WORDWRAP",(0,0),(-1,-1),True),
    ]))
    return t

# ── Header / Footer ───────────────────────────────────────────────────────────
def on_page(canvas, doc):
    canvas.saveState()
    canvas.setFillColor(DARK_BLUE)
    canvas.rect(0, A4[1]-1.1*cm, A4[0], 1.1*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica-Bold", 8.5)
    canvas.setFillColor(WHITE)
    canvas.drawString(1.8*cm, A4[1]-0.75*cm, "SURGERY LAQ STUDY GUIDE – PART 2")
    canvas.drawRightString(A4[0]-1.8*cm, A4[1]-0.75*cm, "Q13–Q28 | Intestine · Liver · Pancreas · Pleura")
    canvas.setFillColor(colors.HexColor("#90A4AE"))
    canvas.rect(0, 0, A4[0], 1.0*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica", 7)
    canvas.setFillColor(WHITE)
    canvas.drawCentredString(A4[0]/2, 0.35*cm,
        f"Page {doc.page}  |  For exam preparation only  |  Sources: Bailey & Love, Harrison's, Schwartz's Surgery, Robbins Pathology")
    canvas.restoreState()

def on_first_page(canvas, doc):
    pass

# ── STORY ─────────────────────────────────────────────────────────────────────
story = []

# ═══ COVER ════════════════════════════════════════════════════════════════════
title_s  = ParagraphStyle("ts",fontSize=28,textColor=WHITE,fontName="Helvetica-Bold",
    alignment=TA_CENTER,leading=34,spaceAfter=4)
sub_s    = ParagraphStyle("ss",fontSize=13,textColor=colors.HexColor("#B3E5FC"),
    fontName="Helvetica",alignment=TA_CENTER,leading=17,spaceAfter=3)
date_s   = ParagraphStyle("ds",fontSize=9.5,textColor=colors.HexColor("#80DEEA"),
    fontName="Helvetica-Oblique",alignment=TA_CENTER,spaceAfter=2)

story.append(Spacer(1,2.5*cm))
story.append(Paragraph("SURGERY", title_s))
story.append(Paragraph("LAQ Study Guide – Part 2", sub_s))
story.append(Spacer(1,0.3*cm))
story.append(HRFlowable(width="55%",thickness=2,color=ACCENT,spaceAfter=8,hAlign="CENTER"))
story.append(Paragraph("Large Intestine  •  Liver  •  Biliary  •  Spleen", sub_s))
story.append(Paragraph("Pancreas  •  Anorectal  •  Pleura", sub_s))
story.append(Spacer(1,0.5*cm))
story.append(Paragraph("Exam Preparation Edition  |  July 2026", date_s))
story.append(Spacer(1,0.8*cm))

toc_data = [[Paragraph(
    "<b>Topics:</b><br/>"
    "13. Large Intestinal Malignancy &amp; Intestinal Diverticula<br/>"
    "14. Intestinal Obstruction<br/>"
    "15. Appendicitis<br/>"
    "16 &amp; 17. Ano-Rectal Diseases – Fissure in Ano<br/>"
    "18. Acute &amp; Chronic Liver Insufficiency<br/>"
    "19. Portal HTN &amp; Oesophageal Varices<br/>"
    "20. Benign Liver Tumours<br/>"
    "21. Hepatocellular Carcinoma<br/>"
    "22. Surgical Jaundice (Courvoisier's Law)<br/>"
    "23. Carcinoma of Gall Bladder<br/>"
    "24. Splenomegaly<br/>"
    "25. Acute Pancreatitis<br/>"
    "26. Chronic Pancreatitis<br/>"
    "27. Carcinoma of Pancreas<br/>"
    "28. Pleural Effusion &amp; Pleural Tapping",
    ParagraphStyle("tp",fontSize=9,textColor=DARK_BLUE,fontName="Helvetica",leading=15))
]]
toc_t = Table(toc_data, colWidths=[12*cm])
toc_t.setStyle(TableStyle([
    ("BACKGROUND",(0,0),(-1,-1),LIGHT_BLUE),
    ("BOX",(0,0),(-1,-1),1.5,MED_BLUE),
    ("LEFTPADDING",(0,0),(-1,-1),12),("RIGHTPADDING",(0,0),(-1,-1),12),
    ("TOPPADDING",(0,0),(-1,-1),10),("BOTTOMPADDING",(0,0),(-1,-1),10),
]))
story.append(toc_t)
story.append(Spacer(1,0.8*cm))
story.append(Paragraph(I("Sources: Bailey &amp; Love's Surgery (28th Ed.) · Harrison's Medicine · Schwartz's Surgery · Robbins Pathology"), footer_style))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# Q13 – LARGE INTESTINAL MALIGNANCY
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q13. LARGE INTESTINAL MALIGNANCY (Colorectal Carcinoma)")
story += H2("Epidemiology & Risk Factors")
story.append(bp("3rd most common cancer worldwide; peak age >50; Male = Female"))
story.append(bp(B("RF:") + " High-fat/low-fibre diet, obesity, smoking, alcohol, family history, IBD, FAP, Lynch syndrome (HNPCC), previous polyps"))
story.append(sp(3))

story += H2("Pathology")
story.append(bp("95% Adenocarcinomas; arise via adenoma-carcinoma sequence (polyp → cancer over 10-15 years)"))
story.append(bp(B("APC gene mutation") + " → uncontrolled cell growth"))
story.append(bp("Macroscopic: Polypoid (right colon) / Annular/Apple-core (left colon) / Ulcerating"))
story.append(sp(3))

story += H2("C/F by Location")
story.append(tbl(
    [B("Location"), B("Clinical Features")],
    [
        ["Right colon", "Anaemia, fatigue, occult bleeding, palpable mass (wide lumen = late obstruction)"],
        ["Left colon", "Change in bowel habits, fresh rectal bleeding, pencil-thin stools, obstruction"],
        ["Rectum", "Tenesmus, rectal bleeding, mucus PR, feeling of incomplete evacuation"],
    ],
    col_widths=[3.5*cm, 13*cm]
))
story.append(sp(3))

story += H2("Diagnosis")
story.append(bp("Colonoscopy + biopsy (gold standard); CT colonoscopy; CT CAP for staging"))
story.append(bp("CEA (tumour marker for monitoring); FBC: anaemia; Faecal occult blood (screening)"))
story.append(sp(3))

story += H2("Dukes / TNM Staging")
story.append(tbl(
    [B("Dukes"), B("Stage"), B("Description")],
    [
        ["A", "T1/T2 N0 M0", "Confined to bowel wall"],
        ["B", "T3/T4 N0 M0", "Through bowel wall, no nodes"],
        ["C", "Any T N+ M0", "Lymph node involvement"],
        ["D", "Any T Any N M1", "Distant metastasis (liver most common)"],
    ],
    col_widths=[2.5*cm, 4.5*cm, 9.5*cm]
))
story.append(sp(3))

story += H2("Treatment")
story.append(bp(B("Surgery (curative):") + " Right hemicolectomy / Left hemicolectomy / Anterior resection (upper rectum) / APR (lower rectum)"))
story.append(bp(B("Adjuvant chemo:") + " FOLFOX (Oxaliplatin + 5-FU) for Stage III/IV"))
story.append(bp(B("Targeted:") + " Bevacizumab (anti-VEGF), Cetuximab (anti-EGFR) for metastatic disease"))
story.append(bp(B("Rectal cancer:") + " Neoadjuvant chemoradiotherapy to downstage before surgery"))
story.append(sp(3))

story += H2("Preventive Measures")
story.append(bp("High-fibre diet; avoid red/processed meat; regular colonoscopy from age 50 (40 if FH)"))
story.append(bp("Aspirin reduces risk; early removal of polyps"))
story.append(sp(3))

story += H2("Intestinal Diverticula")
story.append(bp(B("Meckel's Diverticulum – Rule of 2s:") + " 2% population, 2 feet from ileocaecal valve, 2 inches long, 2 years peak age, 2x in males; remnant of vitello-intestinal duct"))
story.append(bp("Colonic diverticulosis: Sigmoid most common; increased intraluminal pressure + muscle weakness"))
story.append(bp(B("Complicated diverticulitis:") + " Abscess, perforation, fistula (colovesical → pneumaturia), obstruction, bleeding"))
story.append(bp(B("Treatment:") + " Acute: NPO + IV antibiotics (Metronidazole + Ciprofloxacin); Elective surgery: Hartmann's procedure for recurrent attacks"))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q14 – INTESTINAL OBSTRUCTION
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q14. INTESTINAL OBSTRUCTION")
story += H2("Classification & Common Causes")
story.append(tbl(
    [B("Type"), B("Subtype"), B("Common Examples")],
    [
        ["Mechanical", "Intraluminal", "Foreign body, faecalith, gallstone ileus"],
        ["Mechanical", "Intramural", "Stricture (Crohn's/TB/cancer), intussusception"],
        ["Mechanical", "Extraluminal", "Adhesions (MOST COMMON), hernias, volvulus"],
        ["Functional", "Paralytic ileus", "Post-surgery, peritonitis, electrolyte imbalance"],
    ],
    col_widths=[3.5*cm, 4*cm, 9*cm]
))
story.append(sp(3))

story += H2("Pathophysiology")
story.append(bp("Obstruction → distension → ↑ secretion → fluid/electrolyte loss → dehydration → ischaemia → perforation → sepsis"))
story.append(sp(3))

story += H2("C/F – 4 Cardinal Features")
story.append(Paragraph("  1. " + B("Colicky abdominal pain") + "   2. " + B("Vomiting") + "   3. " + B("Distension") + "   4. " + B("Absolute constipation"), body))
story.append(sp(2))
story.append(tbl(
    [B("Feature"), B("Small Bowel"), B("Large Bowel")],
    [
        ["Vomiting", "Early, bilious/faeculent", "Late, faeculent"],
        ["Distension", "Mild, central", "Marked, peripheral"],
        ["Pain", "Periumbilical, frequent", "Lower abdominal, less frequent"],
    ],
    col_widths=[4*cm, 6*cm, 6.5*cm]
))
story.append(sp(3))

story.append(Paragraph(B("⚠ Signs of STRANGULATION (= SURGICAL EMERGENCY):"), warn))
story.append(bp("Continuous severe pain (no relief between episodes)"))
story.append(bp("Fever, tachycardia, signs of sepsis / peritonism"))
story.append(bp("Localised tenderness + rigidity; raised WBC + lactate"))
story.append(Paragraph(B("Strangulation window = 6 hours; after 6 hrs bowel becomes gangrenous → mortality rises sharply"), imp))
story.append(sp(3))

story += H2("Diagnosis")
story.append(bp("AXR: Dilated loops + air-fluid levels (mechanical); gas throughout (paralytic ileus)"))
story.append(bp(B("CT abdomen/pelvis (gold standard):") + " Identifies level, cause, strangulation signs"))
story.append(bp("Gastrografin follow-through: Small bowel (also therapeutic); Contrast enema: Large bowel"))
story.append(sp(3))

story += H2("Initial Management (Drip & Suck)")
story.append(bp("IV fluids + NG tube decompression; Nil by mouth; Catheterize; Correct electrolytes; Analgesia; Antibiotics if strangulation suspected"))
story.append(sp(3))

story += H2("Surgical Intervention")
story.append(bp("Adhesions: Adhesiolysis | Hernia: Repair + bowel resection if strangulated"))
story.append(bp("Volvulus: Endoscopic decompression first; surgery if fails | Cancer: Resection / Hartmann's"))
story.append(bp("Intussusception (child): Pneumatic/hydrostatic reduction; surgery if fails"))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q15 – APPENDICITIS
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q15. APPENDICITIS")
story += H2("Epidemiology & Etiology")
story.append(bp("Most common acute surgical emergency; Peak age 10-30 yrs; Male > Female; Lifetime risk 7-8%"))
story.append(bp("Obstruction of lumen → stasis → bacterial overgrowth → inflammation → perforation"))
story.append(bp(B("Causes of obstruction:") + " Faecoliths (most common), lymphoid hyperplasia, parasites, tumours"))
story.append(sp(3))

story += H2("Pathology (Progression)")
story.append(bp("Simple/Catarrhal → Suppurative → Gangrenous → Perforated"))
story.append(bp("If walled off = Appendix mass/abscess; If not = Generalised peritonitis"))
story.append(sp(3))

story += H2("C/F")
story.append(bp(B("Classic:") + " Periumbilical pain migrating to Right Iliac Fossa (McBurney's point)"))
story.append(bp("Nausea, vomiting; " + B("Anorexia (very characteristic)") + "; Low-grade fever"))
story.append(sp(3))

story += H2("Clinical Signs (Important!)")
story.append(tbl(
    [B("Sign"), B("Description")],
    [
        ["McBurney's tenderness", "Max tenderness at 1/3 between ASIS and umbilicus"],
        ["Rovsing's sign", "LIF palpation causes pain in RIF"],
        ["Psoas sign", "Pain on extending right hip (retrocaecal appendix)"],
        ["Obturator sign", "Pain on internal rotation of flexed right hip (pelvic appendix)"],
        ["Rebound tenderness", "Suggests peritonism / perforation"],
    ],
    col_widths=[5*cm, 11.5*cm]
))
story.append(sp(3))

story += H2("Investigations & Diagnosis")
story.append(bp("FBC: Leucocytosis; CRP elevated; USS: appendix >6mm, non-compressible"))
story.append(bp(B("CT abdomen/pelvis (gold standard):") + " Thickened appendix + periappendiceal fat stranding"))
story.append(bp(B("Alvarado score ≥7:") + " High probability → operate"))
story.append(sp(3))

story += H2("Differential Diagnosis")
story.append(bp("Mesenteric adenitis (children) | Meckel's diverticulitis | Ovarian cyst/ectopic/PID (females)"))
story.append(bp("UTI / ureteric colic | Crohn's disease | Caecal carcinoma (elderly) | Psoas abscess"))
story.append(sp(3))

story += H2("Treatment")
story.append(bp(B("Surgical:") + " Laparoscopic appendicectomy (preferred) or Open (grid-iron incision)"))
story.append(bp(B("Conservative (uncomplicated):") + " IV antibiotics (Co-amoxiclav + Metronidazole) – some centres"))
story.append(bp(B("Perforated:") + " Laparoscopic washout + appendicectomy + antibiotics"))
story.append(sp(3))

story += H2("Complications")
story.append(bp("Perforation → peritonitis | Appendix abscess | Adhesions → bowel obstruction later | Portal pyaemia (rare)"))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q16/17 – FISSURE IN ANO
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q16 & Q17. ANO-RECTAL DISEASES – FISSURE IN ANO")
story += H2("Definition & Etiopathogenesis")
story.append(bp("Longitudinal tear/ulcer in the anal canal below the dentate line"))
story.append(bp("Hard stool → tear → internal sphincter spasm → ↓ blood supply → poor healing → chronic fissure"))
story.append(bp(B("Posterior midline") + " (90%) due to poor vascularity; Anterior – more in females"))
story.append(bp(B("Multiple/lateral fissures:") + " Suspect Crohn's, TB, syphilis, HIV"))
story.append(sp(3))

story += H2("Types")
story.append(tbl(
    [B("Type"), B("Duration"), B("Features")],
    [
        ["Acute", "<6 weeks", "Fresh tear, bleeds, no fibrous induration"],
        ["Chronic", ">6 weeks", "Sentinel pile (external skin tag), hypertrophied anal papilla, exposed internal sphincter at base"],
    ],
    col_widths=[3*cm, 3.5*cm, 10*cm]
))
story.append(sp(3))

story += H2("C/F")
story.append(bp("Severe anal pain during and after defaecation (knife-cutting/tearing)"))
story.append(bp("Bright red rectal bleeding on paper/pan; Constipation (avoids defaecation due to pain)"))
story.append(bp("Visible sentinel pile (skin tag at anal margin)"))
story.append(sp(3))

story += H2("Non-Surgical Treatment")
story.append(bp(B("Stool softeners:") + " Lactulose, ispaghula, high-fibre diet, warm sitz baths"))
story.append(bp(B("GTN 0.2% ointment:") + " Chemical sphincterotomy; relaxes internal sphincter; SE = headache"))
story.append(bp(B("Diltiazem 2% cream:") + " Calcium channel blocker; fewer headaches than GTN"))
story.append(bp(B("Botulinum toxin injection:") + " Into internal sphincter; relaxes spasm; good for chronic fissure"))
story.append(sp(3))

story += H2("Surgical Treatment")
story.append(Paragraph(B("Lateral Internal Sphincterotomy (LIS) = Gold Standard Surgery"), imp))
story.append(bp("Cut lateral portion of internal anal sphincter → relieves spasm permanently"))
story.append(bp("Risk: Minor faecal incontinence"))
story.append(bp("Lord's procedure (anal dilation) – no longer recommended; high incontinence risk"))
story.append(sp(3))

story += H2("Other Ano-Rectal Diseases – Home Therapies")
story.append(bp(B("Haemorrhoids:") + " High-fibre diet, sitz baths, stool softeners, topical steroid cream (Proctosedyl) → Band ligation / Sclerotherapy / Haemorrhoidectomy"))
story.append(bp(B("Perianal Abscess:") + " I&D (Incision & Drainage) – " + B("cannot be treated with antibiotics alone")))
story.append(bp(B("Fistula in Ano:") + " Fistulotomy / Fistulectomy / Seton placement"))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q18 – ACUTE & CHRONIC LIVER INSUFFICIENCY
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q18. ACUTE & CHRONIC LIVER INSUFFICIENCY")
story += H2("Acute vs Chronic – Key Differences")
story.append(tbl(
    [B("Feature"), B("Acute Liver Failure"), B("Chronic Liver Failure")],
    [
        ["Onset", "Days to weeks", "Months to years"],
        ["Cause", "Paracetamol OD, viral hepatitis A/E, drugs", "Cirrhosis (alcohol, HBV, HCV, NAFLD)"],
        ["Liver size", "Normal or enlarged", "Small, nodular, shrunken"],
        ["Portal HTN", "Absent", "Present (varices, ascites)"],
        ["Encephalopathy", "Early, prominent", "Late stage"],
        ["Prognosis", "Can recover if cause removed", "Progressive, irreversible"],
    ],
    col_widths=[4*cm, 6.5*cm, 6*cm]
))
story.append(sp(3))

story += H2("Pathophysiology")
story.append(bp("Hepatocyte destruction → loss of: Protein synthesis (albumin, clotting factors) / Detoxification (↑ ammonia → encephalopathy) / Bile production (jaundice) / Glycogen storage (hypoglycaemia)"))
story.append(bp("Portal hypertension → ascites, varices, splenomegaly"))
story.append(sp(3))

story += H2("Diagnostic Tests")
story.append(bp("LFT: ↑ bilirubin, ALT, AST; ↓ albumin | PT/INR: ↑ (clotting factor synthesis ↓)"))
story.append(bp("Blood ammonia ↑ (encephalopathy) | USS: liver size, ascites | Viral markers: HBsAg, Anti-HCV, Anti-HAV IgM"))
story.append(bp("Paracetamol level (if OD) | Liver biopsy if needed | EEG for encephalopathy grading"))
story.append(sp(3))

story += H2("Complications")
story.append(bp(B("Acute:") + " Cerebral oedema (leading cause of death), coagulopathy, hypoglycaemia, renal failure, sepsis, MOF"))
story.append(bp(B("Chronic:") + " Ascites, SBP, hepatic encephalopathy, variceal bleeding, hepatorenal syndrome, HCC, coagulopathy"))
story.append(sp(3))

story += H2("Home (Medical) Therapies")
story.append(bp(B("Acute:") + " N-acetylcysteine (paracetamol OD); Entecavir (HBV); IV glucose; FFP + Vit K; Lactulose; ICU; Liver transplant (King's College Criteria)"))
story.append(bp(B("Chronic:") + " Treat cause (stop alcohol, antivirals) | Ascites: Salt restriction + Spironolactone ± Furosemide | Encephalopathy: Lactulose + Rifaximin | SBP prophylaxis: Norfloxacin | Liver transplant"))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q19 – PORTAL HTN & OESOPHAGEAL VARICES
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q19. PORTAL HYPERTENSION & OESOPHAGEAL VARICES")
story += H2("Etiology")
story.append(tbl(
    [B("Type"), B("Causes")],
    [
        ["Pre-hepatic", "Portal vein thrombosis, splenic vein thrombosis"],
        ["Hepatic (MOST COMMON)", "Cirrhosis (alcohol, viral hepatitis, NASH), schistosomiasis"],
        ["Post-hepatic", "Budd-Chiari syndrome, constrictive pericarditis, right heart failure"],
    ],
    col_widths=[4.5*cm, 12*cm]
))
story.append(sp(3))

story += H2("How Portal HTN Leads to Oesophageal Varices")
story.append(bp("Normal portal pressure = 5-10 mmHg; Portal HTN = >12 mmHg"))
story.append(bp("Cirrhosis → scarring → ↑ intrahepatic resistance → ↑ portal pressure → blood seeks alternative collateral routes"))
story.append(bp("Portal vein → left gastric (coronary) vein → " + B("oesophageal submucosal veins dilate = VARICES")))
story.append(bp("Varices = thin-walled, high-pressure veins → rupture → massive haematemesis"))
story.append(bp(B("Other collaterals:") + " Rectal varices, caput medusae (umbilicus), haemorrhoids"))
story.append(sp(3))

story += H2("Clinical Signs / Symptoms")
story.append(bp("Jaundice, spider naevi, palmar erythema, gynaecomastia"))
story.append(bp("Ascites, splenomegaly, caput medusae (dilated veins around umbilicus)"))
story.append(bp("Haematemesis (variceal bleed), hepatic encephalopathy, peripheral oedema"))
story.append(sp(3))

story += H2("Diagnosis")
story.append(bp("OGD: See + grade varices (I-IV) | USS Doppler: Portal vein >13mm, reversed flow"))
story.append(bp("CT/MRI angiography; Liver biopsy; HVPG >10mmHg = clinically significant portal HTN"))
story.append(sp(3))

story += H2("Management of Variceal Bleeding")
story.append(Paragraph(B("Step 1 – Immediate Resuscitation:"), h3))
story.append(bp("ABC; IV access; Blood transfusion (target Hb 7-8 g/dL – " + B("do NOT over-transfuse") + ")"))
story.append(bp(B("Terlipressin IV") + " ASAP – reduces portal pressure | " + B("IV Ceftriaxone") + " (mandatory antibiotics in cirrhosis)"))
story.append(bp("Correct coagulopathy: FFP + Vitamin K"))
story.append(sp(2))
story.append(Paragraph(B("Step 2 – Endoscopy within 12 hours:"), h3))
story.append(bp(B("Band ligation (EVL)") + " = gold standard | Sclerotherapy if band ligation unavailable"))
story.append(sp(2))
story.append(Paragraph(B("Step 3 – Rescue (if above fails):"), h3))
story.append(bp(B("Sengstaken-Blakemore tube:") + " Balloon tamponade (temporary, max 24 hrs)"))
story.append(bp(B("TIPSS") + " (Transjugular Intrahepatic Portosystemic Shunt): Creates portal-hepatic vein shunt; risk = encephalopathy"))
story.append(sp(2))
story.append(Paragraph(B("Secondary Prevention:"), h3))
story.append(bp("Beta-blockers (Propranolol/Carvedilol) + repeat band ligation every 2-4 weeks until varices obliterated"))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q20 – BENIGN LIVER TUMOURS
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q20. BENIGN LIVER TUMOURS")
story += H2("Classification & C/F")
story.append(tbl(
    [B("Type"), B("Key Feature"), B("Diagnosis"), B("Treatment")],
    [
        ["Haemangioma\n(most common)", "Blood-filled spaces; asymptomatic", "MRI: Peripheral nodular enhancement (\"stop sign\")", "Observe; resect if symptomatic"],
        ["Hepatic Adenoma", "OCP use; risk of rupture & malignancy", "CT/MRI: fat content", "Stop OCP; resect"],
        ["Focal Nodular\nHyperplasia (FNH)", "\"Central scar\" on MRI; no malignant potential", "MRI: Central scar with spoke-wheel pattern", "Observe (no treatment needed)"],
        ["Simple Hepatic Cyst", "Congenital, fluid-filled", "USS: anechoic", "Observe; aspirate if large"],
        ["Hydatid Cyst", "Echinococcus; dog-acquired; daughter cysts", "USS: snowstorm; ELISA positive", "PAIR procedure + Albendazole; surgery"],
    ],
    col_widths=[3.5*cm, 4*cm, 4.5*cm, 4.5*cm]
))
story.append(sp(3))
story.append(Paragraph(B("Most benign liver tumours are asymptomatic – found incidentally on imaging."), note))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q21 – HEPATOCELLULAR CARCINOMA
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q21. HEPATOCELLULAR CARCINOMA (HCC)")
story += H2("Risk Factors")
story.append(bp("Chronic HBV (most common worldwide) | Chronic HCV | Liver cirrhosis (any cause)"))
story.append(bp("Alcohol | NAFLD/NASH | " + B("Aflatoxin B1") + " (contaminated groundnuts – Aspergillus)"))
story.append(bp("Haemochromatosis, Wilson's disease | Male > Female; Age >50"))
story.append(sp(3))

story += H2("C/F")
story.append(bp(B("Early:") + " Asymptomatic; detected on surveillance USS"))
story.append(bp(B("Late:") + " RUQ pain/fullness, weight loss, worsening liver failure (jaundice, ascites, encephalopathy), haemoperitoneum if rupture"))
story.append(bp(B("Paraneoplastic:") + " Hypoglycaemia, polycythaemia, hypercalcaemia"))
story.append(sp(3))

story += H2("Diagnosis")
story.append(bp(B("AFP >400 ng/mL:") + " Highly suggestive (not always elevated)"))
story.append(bp("USS every 6 months: Surveillance in cirrhotics"))
story.append(bp(B("CT triphasic:") + " Arterial enhancement + venous washout = " + B("hallmark of HCC (no biopsy needed if CT/MRI diagnostic)")))
story.append(bp("MRI with contrast (more sensitive); Biopsy if imaging inconclusive"))
story.append(bp(B("Milan Criteria (for transplant):") + " Single nodule ≤5cm OR up to 3 nodules each ≤3cm; no vascular invasion; no metastasis"))
story.append(sp(3))

story += H2("Treatment")
story.append(tbl(
    [B("Stage"), B("Treatment")],
    [
        ["Early (resectable)", "Surgical resection OR Liver transplant (if within Milan criteria)"],
        ["Very early / small", "Radiofrequency ablation (RFA)"],
        ["Intermediate", "TACE (Transarterial Chemoembolisation)"],
        ["Advanced/metastatic", "Sorafenib (targeted) OR Atezolizumab + Bevacizumab (now 1st line)"],
    ],
    col_widths=[5*cm, 11.5*cm]
))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q22 – SURGICAL JAUNDICE
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q22. SURGICAL JAUNDICE (Obstructive Jaundice)")
story += H2("Causes")
story.append(tbl(
    [B("Level"), B("Causes")],
    [
        ["Intraluminal (inside duct)", "Gallstones (MOST COMMON), parasites (Ascaris)"],
        ["Intramural (wall of duct)", "Cholangiocarcinoma, stricture (post-traumatic), PSC"],
        ["Extramural (outside duct)", "CA head of pancreas (PAINLESS jaundice), enlarged nodes, Mirizzi's syndrome, chronic pancreatitis"],
    ],
    col_widths=[5*cm, 11.5*cm]
))
story.append(sp(3))

story += H2("Pathophysiology")
story.append(bp("Bile duct obstruction → conjugated bilirubin backs up → jaundice + dark urine + pale stools"))
story.append(bp("Bile salts in skin → intense pruritus | No bile in gut → fat malabsorption + steatorrhoea + Vit K deficiency"))
story.append(sp(3))

story += H2("C/F")
story.append(bp("Deep jaundice; pruritus; dark urine (Coca-Cola); pale/clay stools"))
story.append(bp("Colicky pain = gallstones; " + B("Painless progressive jaundice = MALIGNANCY until proven otherwise")))
story.append(bp(B("Charcot's triad:") + " Jaundice + Fever + RUQ pain = Cholangitis (emergency)"))
story.append(sp(3))

story.append(Paragraph(B("★ COURVOISIER'S LAW (Very Important Exam Fact!):"), imp))
story.append(Paragraph(
    I('"If the gallbladder is palpable AND the patient is jaundiced, the cause is UNLIKELY to be gallstones"'),
    ParagraphStyle("q", fontSize=9, textColor=DARK_BLUE, fontName="Helvetica-Oblique",
        leading=13, leftIndent=10, backColor=LIGHT_BLUE, borderPadding=(4,6,4,6), spaceAfter=3)
))
story.append(bp("Gallstones → GB is fibrotic/shrunken (cannot distend)"))
story.append(bp("Cancer (head of pancreas) → GB was previously healthy → distends (Courvoisier's sign +ve = malignant obstruction)"))
story.append(sp(3))

story += H2("Diagnosis")
story.append(bp("LFT: ↑ direct bilirubin, ALP, GGT | USS: First investigation – dilated ducts, stones, mass"))
story.append(bp(B("MRCP:") + " Best non-invasive biliary imaging | CT abdomen: Mass lesion, staging"))
story.append(bp(B("ERCP:") + " Diagnostic + therapeutic (stent, stone removal) | PTC if ERCP fails"))
story.append(sp(3))

story += H2("Complications")
story.append(bp("Cholangitis → septic shock | Biliary cirrhosis | Acute pancreatitis | Renal failure | Coagulopathy (Vit K malabsorption)"))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q23 – CA OF GALL BLADDER
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q23. CARCINOMA OF GALL BLADDER")
story += H2("Risk Factors & Pathophysiology")
story.append(bp(B("Gallstones (most important;") + " >90% have gallstones) | Chronic cholecystitis | Choledochal cysts"))
story.append(bp("Female > Male (3:1); Age >60 | Obesity | Salmonella typhi chronic carriers"))
story.append(bp("Chronic stone irritation → mucosal dysplasia → Adenocarcinoma (~95%) | Dense fibrous stroma"))
story.append(sp(3))

story += H2("C/F")
story.append(bp(B("Early:") + " Asymptomatic; found incidentally at cholecystectomy (incidental gallbladder cancer)"))
story.append(bp(B("Late:") + " RUQ pain (dull, persistent), jaundice (CBD compression), weight loss, palpable RUQ mass, Courvoisier's +ve"))
story.append(sp(3))

story += H2("Diagnosis")
story.append(bp("USS: GB wall thickening >3mm, polyps >1cm, loss of GB wall planes | CT CAP for staging"))
story.append(bp("CA 19-9, CEA (tumour markers) | MRCP/ERCP if biliary obstruction | PET for occult mets"))
story.append(sp(3))

story += H2("TNM Staging")
story.append(tbl(
    [B("Stage"), B("Description")],
    [
        ["T1a/T1b", "Confined to mucosa (T1a) or muscle layer (T1b)"],
        ["T2", "Perimuscular connective tissue – peritoneal side (T2a) or hepatic side (T2b)"],
        ["T3", "Perforates serosa / invades liver / 1 adjacent organ"],
        ["T4", "Main portal vein/hepatic artery or ≥2 adjacent organs"],
        ["N+", "Regional lymph node metastasis"],
        ["M1", "Distant metastasis"],
    ],
    col_widths=[3*cm, 13.5*cm]
))
story.append(sp(3))

story += H2("Treatment")
story.append(bp(B("T1a:") + " Simple cholecystectomy (curative)"))
story.append(bp(B("T1b/T2:") + " Extended cholecystectomy (GB + 2cm liver margin + lymph node dissection)"))
story.append(bp(B("T3/T4 (advanced):") + " Palliative surgery / biliary stenting + Gemcitabine + Cisplatin"))
story.append(bp(B("Adjuvant:") + " Capecitabine for resected disease"))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q24 – SPLENOMEGALY
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q24. SPLENOMEGALY")
story += H2("Causes (MIAMI Mnemonic)")
story.append(tbl(
    [B("Letter"), B("Category"), B("Examples")],
    [
        ["M", "Myeloproliferative", "CML, polycythaemia vera, myelofibrosis"],
        ["I", "Infection", "Malaria (worldwide #1), EBV (mono), typhoid, TB, leishmaniasis"],
        ["A", "Autoimmune", "SLE, Felty's syndrome (RA), haemolytic anaemia"],
        ["M", "Metabolic/Storage", "Gaucher's, Niemann-Pick, amyloidosis"],
        ["I", "Infiltrative/Haematological", "Lymphoma (most common in West), leukaemia, myeloma"],
        ["+", "Portal HTN", "Cirrhosis, portal vein thrombosis (congestive splenomegaly)"],
    ],
    col_widths=[1.5*cm, 5*cm, 10*cm]
))
story.append(sp(3))

story += H2("C/F")
story.append(bp("Left abdominal fullness / heaviness; early satiety; left shoulder tip pain (diaphragm irritation)"))
story.append(bp(B("Hypersplenism:") + " Anaemia, thrombocytopenia, leucopenia"))
story.append(bp(B("Massive splenomegaly (below umbilicus):") + " Malaria, leishmaniasis, CML, myelofibrosis"))
story.append(sp(3))

story += H2("Examination")
story.append(bp("Enlarges towards right iliac fossa; moves with respiration; cannot get above it; notch on medial border"))
story.append(sp(3))

story += H2("Initial Diagnostic Workup")
story.append(bp("FBC: Anaemia, thrombocytopenia; Peripheral blood smear: Malaria parasites, blast cells"))
story.append(bp("LFT: Liver disease | USS abdomen: Confirm splenomegaly + liver + portal vein | Malaria RDT / thick film"))
story.append(sp(3))

story += H2("Advanced Diagnostic Tools")
story.append(bp("CT abdomen: Size, texture, lymph nodes | Bone marrow biopsy: Haematological malignancy"))
story.append(bp("Flow cytometry: Leukaemia/lymphoma phenotyping | PET scan: Lymphoma staging"))
story.append(sp(3))

story += H2("Therapies")
story.append(bp("Treat underlying cause (antimalarials, chemo, antivirals, etc.)"))
story.append(bp(B("Splenectomy indications:") + " Hypersplenism, hereditary spherocytosis, ITP, trauma, lymphoma"))
story.append(bp(B("Post-splenectomy:") + " Vaccines (Pneumococcus, Meningococcus, HiB) + " + B("lifelong Penicillin V") + " prophylaxis"))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q25 – ACUTE PANCREATITIS
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q25. ACUTE PANCREATITIS")
story += H2("Etiology (GET SMASHED)")
story.append(tbl(
    [B("Letter"), B("Cause")],
    [
        ["G", "Gallstones (most common, ~40%)"],
        ["E", "Ethanol/Alcohol (~35%)"],
        ["T", "Trauma"],
        ["S", "Steroids"],
        ["M", "Mumps / Infections"],
        ["A", "Autoimmune"],
        ["S", "Scorpion sting (rare)"],
        ["H", "Hyperlipidaemia / Hypercalcaemia"],
        ["E", "ERCP (post-procedure)"],
        ["D", "Drugs (azathioprine, thiazides, NSAIDs)"],
    ],
    col_widths=[2*cm, 14.5*cm]
))
story.append(sp(3))

story += H2("Pathophysiology")
story.append(bp("Premature activation of trypsinogen → trypsin → activates other pancreatic enzymes → " + B("autodigestion of pancreas")))
story.append(bp("Release of cytokines → systemic inflammatory response → ARDS, renal failure, shock"))
story.append(sp(3))

story += H2("C/F")
story.append(bp("Sudden severe " + B("epigastric pain radiating to the back") + " (belt-like)"))
story.append(bp("Nausea, vomiting; fever, tachycardia; reduced bowel sounds"))
story.append(bp(B("Cullen's sign:") + " Periumbilical bruising | " + B("Grey Turner's sign:") + " Flank bruising (both = severe necrotising pancreatitis)"))
story.append(sp(3))

story += H2("Investigations")
story.append(bp(B("Serum lipase (preferred):") + " More sensitive and specific; stays elevated longer"))
story.append(bp(B("Serum amylase:") + " >3x normal (diagnostic if >1000 IU/L); falls after 3 days"))
story.append(bp("FBC: Leucocytosis; ↑ haematocrit | LFT: ↑ ALP/bilirubin (gallstone cause) | ↓ Ca (saponification) | ↑ glucose"))
story.append(bp(B("CT abdomen (contrast-enhanced):") + " Best for complications; shows necrosis – done if Ranson ≥3"))
story.append(sp(3))

story += H2("Severity Scoring (Ranson's Criteria)")
story.append(tbl(
    [B("At Admission"), B("At 48 Hours")],
    [
        ["Age >55", "BUN rise >5"],
        ["WBC >16,000", "PaO2 <60 mmHg"],
        ["Glucose >11 mmol/L", "Ca <2 mmol/L"],
        ["LDH >350 IU/L", "Haematocrit fall >10%"],
        ["AST >250 IU/L", "Base deficit >4; Fluid >6L"],
    ],
    col_widths=[8*cm, 8.5*cm]
))
story.append(Paragraph("Score ≥3 = " + B("SEVERE pancreatitis"), imp))
story.append(sp(3))

story += H2("Complications")
story.append(bp(B("Local:") + " Pancreatic necrosis (sterile/infected), pseudocyst, abscess, walled-off necrosis"))
story.append(bp(B("Systemic:") + " ARDS, AKI, DIC, septic shock, multi-organ failure"))
story.append(sp(3))

story += H2("Indications for Surgical Intervention")
story.append(bp(B("Infected pancreatic necrosis:") + " Step-up approach: Antibiotics (Meropenem) → Percutaneous drainage → VARD → Open necrosectomy"))
story.append(bp(B("Gallstone pancreatitis:") + " Cholecystectomy after recovery (same admission or within 2 weeks)"))
story.append(bp(B("Persistent pseudocyst >6 weeks:") + " Endoscopic/surgical cystgastrostomy | Abdominal compartment syndrome: Decompressive laparotomy"))
story.append(sp(3))

story += H2("Home (Medical) Treatment")
story.append(bp(B("Aggressive IV fluids (Ringer's Lactate) = most important treatment")))
story.append(bp("Analgesia (IV Morphine/Pethidine); Nil by mouth; Monitor + correct electrolytes"))
story.append(bp(B("Early enteral nutrition") + " via nasojejunal tube (better than TPN – prevents bacterial translocation)"))
story.append(bp("Antibiotics: ONLY if infected necrosis (NOT prophylactic); PPI"))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q26 – CHRONIC PANCREATITIS
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q26. CHRONIC PANCREATITIS")
story += H2("Etiology / Risk Factors")
story.append(bp(B("Most common:") + " Chronic alcohol abuse (70-80%)"))
story.append(bp("Tropical pancreatitis (cassava toxin – young patients in developing countries)"))
story.append(bp("Hereditary (PRSS1, SPINK1 mutations) | Autoimmune (IgG4-related) | Idiopathic"))
story.append(bp("Hyperlipidaemia, hypercalcaemia, obstructive, smoking (independent RF)"))
story.append(sp(3))

story += H2("Pathophysiology")
story.append(bp("Repeated inflammation → irreversible fibrosis → destruction of exocrine and endocrine tissue"))
story.append(bp("Exocrine loss → malabsorption, steatorrhoea | Endocrine loss → diabetes mellitus"))
story.append(bp("Duct obstruction → ductal hypertension → " + B("chronic pain")))
story.append(sp(3))

story += H2("C/F")
story.append(bp(B("Chronic upper abdominal pain") + " radiating to back – worse after meals and alcohol"))
story.append(bp(B("Steatorrhoea") + " (fatty, foul-smelling, floating stools)"))
story.append(bp(B("Diabetes mellitus") + " (fragile/brittle – occurs late)"))
story.append(bp("Weight loss, malnutrition; jaundice if bile duct strictured"))
story.append(sp(3))

story += H2("Investigations")
story.append(bp("USS: Calcifications, dilated duct, pseudocysts"))
story.append(bp(B("CT abdomen:") + " Pancreatic calcifications (pathognomonic!), atrophy, ductal dilation"))
story.append(bp(B("MRCP/ERCP:") + " 'Chain of lakes' (dilated + strictured duct alternating)"))
story.append(bp("Faecal elastase: Low (<100 µg/g = severe exocrine insufficiency) | IgG4: Autoimmune"))
story.append(sp(3))

story += H2("Complications")
story.append(bp("Pseudocyst (most common) | Pancreatic ascites | Splenic vein thrombosis → segmental portal HTN"))
story.append(bp("Bile duct stricture | Duodenal obstruction | Narcotic addiction | Pancreatic cancer (rare)"))
story.append(sp(3))

story += H2("Surgical Intervention – Indications")
story.append(bp("Intractable pain unresponsive to medical management"))
story.append(bp("Dilated pancreatic duct >6mm | Complications (pseudocyst, biliary/duodenal obstruction) | Suspected malignancy"))
story.append(tbl(
    [B("Operation"), B("Indication")],
    [
        ["Lateral pancreaticojejunostomy (Puestow procedure)", "Dilated duct disease (most common)"],
        ["Whipple's procedure (Pancreaticoduodenectomy)", "Head disease / mass"],
        ["Frey's procedure", "Local head resection + lateral pancreaticojejunostomy"],
        ["Total pancreatectomy + islet autotransplant", "Last resort"],
    ],
    col_widths=[8.5*cm, 8*cm]
))
story.append(sp(3))

story += H2("Home (Medical) Treatment")
story.append(bp(B("Pain:") + " NSAIDs → weak opioids → strong opioids; Pregabalin; Coeliac plexus block"))
story.append(bp(B("Steatorrhoea:") + " Pancreatic enzyme replacement (Creon) with every meal"))
story.append(bp(B("Diabetes:") + " Insulin (fragile; monitor closely)"))
story.append(bp(B("Lifestyle:") + " " + B("Stop alcohol + smoking (most important!)") + "; small frequent meals; low-fat diet"))
story.append(bp("Fat-soluble vitamin supplementation (A, D, E, K)"))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q27 – CA OF PANCREAS
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q27. CARCINOMA OF PANCREAS")
story += H2("Epidemiology & Risk Factors")
story.append(bp("4th most common cause of cancer death; 5-year survival <10% (worst prognosis)"))
story.append(bp("90% are ductal adenocarcinomas; 70% in head; peak age 60-80 years; Male > Female"))
story.append(bp(B("RF:") + " Smoking (most important modifiable RF), chronic pancreatitis, diabetes, obesity, family history, BRCA2 mutation, Lynch syndrome"))
story.append(sp(3))

story += H2("Pathology")
story.append(bp("Dense desmoplastic stroma (makes chemotherapy hard to penetrate)"))
story.append(bp("Perineural invasion common (cause of severe back pain)"))
story.append(bp(B("K-RAS mutation") + " present in >90% | IPMN (Intraductal Papillary Mucinous Neoplasm) = precursor lesion"))
story.append(sp(3))

story += H2("C/F by Location")
story.append(tbl(
    [B("Location (70%)"), B("Head of Pancreas"), B("Body/Tail (30%)")],
    [
        ["Pain", "Less prominent", "Severe back/epigastric pain (late, often unresectable)"],
        ["Jaundice", "Painless progressive jaundice (classic)", "Absent (late or never)"],
        ["Signs", "Courvoisier's +ve, pale stools, dark urine, pruritus", "Weight loss, palpable mass"],
    ],
    col_widths=[3.5*cm, 7*cm, 6*cm]
))
story.append(bp("New-onset diabetes; Trousseau's sign (migratory thrombophlebitis); depression (paraneoplastic)"))
story.append(sp(3))

story += H2("Investigations")
story.append(bp("USS: First; dilated ducts, mass"))
story.append(bp(B("CT pancreas protocol (triple phase) = gold standard:") + " 'Double-duct sign' (dilated pancreatic duct + CBD); assess resectability"))
story.append(bp(B("EUS + FNA:") + " Best for small tumours and tissue sampling | MRCP/ERCP: Biliary anatomy + stenting"))
story.append(bp("CA 19-9: Tumour marker (monitoring) | PET scan: Metastases | Diagnostic laparoscopy: Before laparotomy"))
story.append(sp(3))

story += H2("TNM Staging")
story.append(tbl(
    [B("Stage"), B("Description")],
    [
        ["IA", "T1 N0 M0 – ≤2cm confined to pancreas"],
        ["IB", "T2 N0 M0 – >2cm confined to pancreas"],
        ["IIA", "T3 N0 M0 – beyond pancreas, no vessel involvement"],
        ["IIB", "T1-3 N1 M0 – regional nodes positive"],
        ["III", "T4 Any N M0 – major vessel invasion (UNRESECTABLE)"],
        ["IV", "Any T Any N M1 – distant metastasis"],
    ],
    col_widths=[2.5*cm, 14*cm]
))
story.append(sp(3))

story += H2("Surgical Intervention")
story.append(Paragraph(B("Whipple's Procedure (Pancreaticoduodenectomy) = Gold Standard for Resectable Head Tumours"), imp))
story.append(bp("Removes: Head of pancreas + duodenum + CBD + gallbladder + distal stomach"))
story.append(bp("5-year survival after resection ~20%"))
story.append(bp(B("Distal pancreatectomy + splenectomy:") + " For body/tail tumours"))
story.append(bp(B("Palliative bypass:") + " Choledochojejunostomy + Gastrojejunostomy (for unresectable – relieves jaundice + prevents GOO)"))
story.append(sp(3))

story += H2("Home (Medical) Therapies")
story.append(bp(B("Chemotherapy:") + " Gemcitabine + Abraxane (nab-paclitaxel); FOLFIRINOX (fit patients)"))
story.append(bp("Biliary stenting (ERCP) for palliation | Pancreatic enzyme replacement (Creon) | Coeliac plexus block for pain"))
story.append(bp("Nutritional support; Insulin for diabetes"))
story.append(sp(8))

# ═══════════════════════════════════════════════════════════════════════════════
# Q28 – PLEURAL EFFUSION & PLEURAL TAPPING
# ═══════════════════════════════════════════════════════════════════════════════
story += H1("Q28. PLEURAL EFFUSION & PLEURAL TAPPING")
story += H2("Causes of Pleural Effusion")
story.append(tbl(
    [B("Type"), B("Mechanism"), B("Common Causes")],
    [
        ["Transudate\n(Protein <25 g/L)", "Hydrostatic pressure ↑ or oncotic pressure ↓", "Heart failure (most common), liver cirrhosis, nephrotic syndrome, hypothyroidism"],
        ["Exudate\n(Protein >35 g/L)", "Inflammation / increased capillary permeability", "Pneumonia, malignancy (lung/breast/mesothelioma), TB, PE, RA/SLE, pancreatitis (left-sided)"],
    ],
    col_widths=[3.5*cm, 5*cm, 8*cm]
))
story.append(sp(2))
story.append(Paragraph(B("Light's Criteria (Exudate if ANY one met):"), h3))
story.append(bp("Pleural protein / serum protein >0.5"))
story.append(bp("Pleural LDH / serum LDH >0.6"))
story.append(bp("Pleural LDH >2/3 upper limit of normal serum LDH"))
story.append(sp(3))

story += H2("Indications for Pleural Tapping (Thoracentesis)")
story.append(bp(B("Diagnostic:") + " All undiagnosed effusions needing fluid analysis"))
story.append(bp(B("Therapeutic:") + " Large effusion causing dyspnoea/respiratory compromise"))
story.append(bp("Empyema (infected pleural fluid); Haemothorax; Malignant effusion symptom relief"))
story.append(sp(3))

story += H2("Contraindications")
story.append(bp("Uncooperative patient | Coagulopathy (INR >2 or platelets <50,000) – relative"))
story.append(bp("Skin infection at puncture site | Effusion <1cm on USS | On mechanical ventilation (relative)"))
story.append(sp(3))

story += H2("Complications of Pleural Tapping")
story.append(bp(B("Pneumothorax (most common)") + " | Haemothorax (intercostal vessel laceration)"))
story.append(bp(B("Re-expansion pulmonary oedema") + " (if >1.5L drained too rapidly – most dangerous)"))
story.append(bp("Infection / empyema | Organ perforation (liver, spleen) | Air embolism (rare) | Dry tap"))
story.append(sp(3))

story += H2("Technique")
story.append(bp(B("Site:") + " Triangle of safety (anterior axillary line, posterior axillary line, 5th-6th ICS)"))
story.append(bp(B("Needle ABOVE the rib") + " (to avoid neurovascular bundle running under each rib)"))
story.append(bp("USS guidance mandatory (reduces complications by >50%)"))
story.append(bp(B("Drain maximum 1–1.5 L per session") + " to prevent re-expansion pulmonary oedema"))
story.append(sp(3))

story += H2("Home (Medical) Treatment")
story.append(bp(B("Transudate:") + " Diuretics (heart failure), treat liver/renal disease, albumin replacement"))
story.append(bp(B("Exudate/Infection:") + " Antibiotics + chest drain"))
story.append(bp(B("TB:") + " ATT (anti-TB treatment) + steroids for large effusion"))
story.append(bp(B("Malignant:") + " Repeated tapping OR " + B("pleurodesis") + " (talc/tetracycline) to seal pleural space"))
story.append(bp(B("Empyema:") + " Chest drain + IV antibiotics; VATS (Video-Assisted Thoracoscopic Surgery) if loculated"))
story.append(sp(10))

# ── Final line ─────────────────────────────────────────────────────────────────
story.append(HRFlowable(width="100%", thickness=1, color=MED_BLUE, spaceAfter=6))
story.append(Paragraph(
    B("Sources: ") + "Bailey &amp; Love's Surgery (28th Ed.) | Harrison's Principles of Internal Medicine | "
    "Schwartz's Surgery | Robbins Pathology",
    ParagraphStyle("src", fontSize=7.5, textColor=colors.grey, fontName="Helvetica-Oblique",
        alignment=TA_CENTER, leading=11)
))
story.append(Spacer(1,4))
story.append(Paragraph(
    "Best of luck for your exam tomorrow! You've prepared well.",
    ParagraphStyle("gl", fontSize=11, textColor=MED_BLUE, fontName="Helvetica-Bold", alignment=TA_CENTER)
))

# ── BUILD ──────────────────────────────────────────────────────────────────────
doc.build(story, onFirstPage=on_first_page, onLaterPages=on_page)
print(f"PDF created: {OUTPUT}")