hemopneumothorax trauma chest radiograph management guideline

hemopneumothorax trauma

/tmp/workspace

mkdir -p "/tmp/workspace/hemopneumothorax-case-report/src" "/tmp/workspace/hemopneumothorax-case-report/output" "/tmp/workspace/hemopneumothorax-case-report/assets" && python -c "import pdfplumber; p='/tmp/workspace/attachments/96f141be-c068-4d9b-a7df-c495c9159596/How to write a case report in Medical Imaging.pdf'; pdf=pdfplumber.open(p); print('PAGES', len(pdf.pages)); [print('\\n--- PAGE',i+1,'---\\n'+(pg.extract_text() or '')) for i,pg in enumerate(pdf.pages)]"

PMID: 41287089

~/hemopneumothorax-case-report

cp "/tmp/workspace/attachments/96f141be-c068-4d9b-a7df-c495c9159596/WhatsApp Image 2026-08-30 at 9.31.03 AM (1).jpeg" "/tmp/workspace/hemopneumothorax-case-report/assets/figure1.jpeg" && cp "/tmp/workspace/attachments/96f141be-c068-4d9b-a7df-c495c9159596/WhatsApp Image 2026-08-30 at 9.31.03 AM.jpeg" "/tmp/workspace/hemopneumothorax-case-report/assets/figure2.jpeg" && cp "/tmp/workspace/attachments/96f141be-c068-4d9b-a7df-c495c9159596/WhatsApp Image 2026-08-30 at 9.31.02 AM.jpeg" "/tmp/workspace/hemopneumothorax-case-report/assets/figure3.jpeg" && python -c "from PIL import Image; from pathlib import Path; [print(p.name, Image.open(p).size) for p in Path('/tmp/workspace/hemopneumothorax-case-report/assets').glob('*.jpeg')]"

python - <<'PY' from docx import Document from docx.shared import Inches, Pt, RGBColor from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.enum.section import WD_SECTION from docx.oxml import OxmlElement from docx.oxml.ns import qn from docx.enum.style import WD_STYLE_TYPE from docx.enum.table import WD_TABLE_ALIGNMENT, WD_CELL_VERTICAL_ALIGNMENT from docx.enum.text import WD_BREAK from pathlib import Path base=Path('/tmp/workspace/hemopneumothorax-case-report') out=base/'output'/'Draft_case_report_traumatic_hemopneumothorax.docx' assets=base/'assets' def shade(cell, fill): tcPr=cell._tc.get_or_add_tcPr(); shd=OxmlElement('w:shd'); shd.set(qn('w:fill'),fill); tcPr.append(shd) def set_cell_text(cell,text,bold=False): cell.text=''; p=cell.paragraphs[0]; r=p.add_run(text); r.bold=bold; r.font.size=Pt(9); cell.vertical_alignment=WD_CELL_VERTICAL_ALIGNMENT.CENTER doc=Document() sec=doc.sections[0] sec.top_margin=Inches(.7); sec.bottom_margin=Inches(.7); sec.left_margin=Inches(.78); sec.right_margin=Inches(.78) styles=doc.styles styles['Normal'].font.name='Arial'; styles['Normal']._element.rPr.rFonts.set(qn('w:eastAsia'),'Arial'); styles['Normal'].font.size=Pt(10.5) for sty,size,color in [('Title',17,'17365D'),('Heading 1',13,'17365D'),('Heading 2',11,'17365D')]: s=styles[sty]; s.font.name='Arial'; s.font.size=Pt(size); s.font.bold=True; s.font.color.rgb=RGBColor.from_string(color) s._element.rPr.rFonts.set(qn('w:eastAsia'),'Arial') # Header header=sec.header.paragraphs[0]; header.alignment=WD_ALIGN_PARAGRAPH.RIGHT r=header.add_run('DRAFT CASE REPORT | MEDICAL IMAGING'); r.font.name='Arial';r.font.size=Pt(8);r.font.color.rgb=RGBColor(90,90,90) # footer footer=sec.footer.paragraphs[0]; footer.alignment=WD_ALIGN_PARAGRAPH.CENTER field=OxmlElement('w:fldSimple'); field.set(qn('w:instr'),'PAGE'); footer._p.append(field) p=doc.add_paragraph(); p.alignment=WD_ALIGN_PARAGRAPH.CENTER r=p.add_run('Imaging Assessment of Suspected Traumatic Left Hemopneumothorax Following a Road Traffic Accident: A Case Report Draft');r.bold=True;r.font.size=Pt(16);r.font.color.rgb=RGBColor.from_string('17365D') p=doc.add_paragraph();p.alignment=WD_ALIGN_PARAGRAPH.CENTER r=p.add_run('De-identified patient: 36-year-old male');r.italic=True;r.font.size=Pt(10) # Important note T=doc.add_table(rows=1,cols=1); T.alignment=WD_TABLE_ALIGNMENT.CENTER; T.autofit=True shade(T.cell(0,0),'FFF2CC'); set_cell_text(T.cell(0,0),'EDITORIAL AND CLINICAL SAFETY NOTE: This is a structured draft prepared from the supplied facts only (male, 36 years, road traffic accident, reported hemopneumothorax, and photographed chest-radiograph displays). Details that were not supplied are marked [TO COMPLETE]. Do not use this document as a clinical record, final radiology report, or publication manuscript until it has been verified and completed by the treating team and reporting radiologist.') doc.add_paragraph() def heading(t): doc.add_heading(t, level=1) def para(t, italic=False): p=doc.add_paragraph(); p.paragraph_format.space_after=Pt(6); r=p.add_run(t);r.italic=italic;return p heading('Abstract') para('Traumatic hemopneumothorax is the coexistence of air and blood in the pleural space following thoracic injury and may compromise ventilation and haemodynamic stability. We present a de-identified 36-year-old male involved in a road traffic accident who was referred for chest radiography with a reported diagnosis of hemopneumothorax. The supplied images are photographs of a displayed frontal chest radiograph rather than original DICOM images. They demonstrate left basal to mid-zone pleural-parenchymal opacity with relative reduction in left lung volume, compatible with a traumatic pleural collection and adjacent compressive/atelectatic change in the stated clinical context. Assessment for a small pneumothorax, exact volume of pleural blood, rib fractures and mediastinal injury is limited by the photographed-display format and single frontal view. This case highlights the role of initial chest radiography in blunt thoracic trauma, its limitations, and the need for prompt clinical correlation and cross-sectional imaging when indicated.') heading('Introduction') para('Hemothorax is blood within the pleural cavity. Trauma is a common cause, and blunt injury from motor-vehicle collisions can injure the chest wall, intercostal vessels, lung, diaphragm or mediastinal structures. When free pleural air coexists, the condition is termed hemopneumothorax. Both components can reduce lung excursion and impair gas exchange. Chest radiography is commonly used during the initial trauma assessment, while computed tomography (CT) is more sensitive for defining pleural blood, pneumothorax, pulmonary contusion, fractures and associated thoracic injury. We report the imaging features and reporting limitations in a patient with a reported traumatic hemopneumothorax after a road traffic accident.') heading('Case Presentation') doc.add_heading('Patient information and clinical findings',level=2) para('A 36-year-old male was involved in a road traffic accident. He was referred for chest radiography with a clinical diagnosis of hemopneumothorax. Information on the mechanism details, time from injury, chest pain, dyspnoea, oxygen saturation, respiratory rate, blood pressure, examination findings, comorbidities, medication use, laboratory results and associated injuries was not supplied and should be added before submission: [TO COMPLETE].') doc.add_heading('Diagnostic assessment',level=2) para('The supplied material comprises three near-identical photographs of a frontal chest radiograph displayed on a monitor. A left-side marker is visible. Because these are photographs of a screen, image quality is reduced by perspective distortion, display artefact and limited contrast control; no original DICOM study, technical parameters, lateral view, CT, ultrasound or formal radiology report was available for review.') para('Imaging description: The left lower hemithorax shows heterogeneous pleural-parenchymal opacity, greatest at the base, with reduced visibility of the left hemidiaphragm and probable adjacent left basal volume loss. The right lung is comparatively better aerated. Cardiomediastinal assessment is limited by projection and image quality. No large, unequivocal pleural line is identified on these photographs. Accordingly, the radiographs support a left-sided traumatic pleural collection in the stated context, but do not independently establish or exclude a small pneumothorax. Correlation with the original images and formal report is required.') para('Provisional imaging impression: Left pleural collection, most consistent with traumatic haemothorax in the stated clinical context, with adjacent left lower-lung atelectatic/compressive change. Reported hemopneumothorax should be confirmed using original radiographs and, if clinically appropriate, thoracic ultrasound and/or CT. This wording is not a substitute for a signed radiology report.') doc.add_heading('Therapeutic intervention and outcome',level=2) para('Treatment, drainage procedure details, drain output, follow-up imaging, hospital course and patient outcome were not supplied. These must not be inferred from the images. Add verified details here: [TO COMPLETE]. In a patient with respiratory distress, shock or concern for tension physiology, emergency treatment must be guided by the trauma team and should not be delayed for additional imaging.') doc.add_heading('Timeline',level=2) table=doc.add_table(rows=1,cols=2);table.style='Table Grid';table.alignment=WD_TABLE_ALIGNMENT.CENTER for c,tx in zip(table.rows[0].cells,['Time point','Event']): shade(c,'D9EAF7');set_cell_text(c,tx,True) for a,b in [('Day 0','Road traffic accident. [Exact time and mechanism TO COMPLETE]'),('Day 0','Frontal chest radiograph obtained. Photographed screen images supplied.'),('Day 0 onward','Clinical treatment, repeat imaging and outcome: [TO COMPLETE].')]: cells=table.add_row().cells;set_cell_text(cells[0],a);set_cell_text(cells[1],b) heading('Imaging Figures') for i,cap in [(1,'Figure 1. Photograph of the frontal chest radiograph display. A left-side marker is visible. Left basal to mid-zone opacity is present. This is a photograph of a monitor and is not diagnostic-quality source imaging.'),(2,'Figure 2. Second supplied photograph of the same or near-identical frontal chest radiograph display, demonstrating the left lower hemithorax opacity.'),(3,'Figure 3. Third supplied photograph of the frontal chest radiograph display. Use original DICOM images, if available, for definitive interpretation and publication-quality reproduction.')]: p=doc.add_paragraph();p.alignment=WD_ALIGN_PARAGRAPH.CENTER;p.add_run().add_picture(str(assets/f'figure{i}.jpeg'),width=Inches(3.05)) p=doc.add_paragraph();p.alignment=WD_ALIGN_PARAGRAPH.CENTER;r=p.add_run(cap);r.italic=True;r.font.size=Pt(8.5) heading('Discussion') para('This case demonstrates the importance of integrating mechanism of injury, clinical status and imaging. In blunt thoracic trauma, pleural blood may result from injury to the chest wall, lung or intrathoracic vessels. A chest radiograph is rapid and widely available for initial evaluation, but it can underestimate both pneumothorax and haemothorax, particularly with supine or portable acquisition. In this patient, the left basal pleural-parenchymal opacity is compatible with a traumatic pleural collection, but the air component cannot be reliably assessed in photographs of a monitor. A fluid level, visible visceral pleural line or apical lucency cannot be confidently evaluated from the supplied images.') para('Where available and appropriate for a stable patient, CT of the chest provides better characterisation of pleural blood, pneumothorax, lung contusion, active bleeding and associated skeletal injuries. Bedside extended focused assessment with sonography in trauma (eFAST) can also help identify pleural fluid and pneumothorax during the trauma assessment. In resource-constrained settings where CT may not be promptly available, a correctly positioned, well-exposed chest radiograph, careful clinical monitoring and repeat imaging after intervention have particular value.') para('Management is determined by physiology, the size and progression of the pleural collection, associated injuries and local trauma protocols. Drainage with tube thoracostomy is commonly used for clinically significant traumatic haemothorax or hemopneumothorax; however, the procedure, tube size and escalation decisions must be individualized by the treating surgical/trauma team. A 2025 systematic review of four randomised trials found no statistically significant difference in treatment failure, complications or length of stay between small-calibre and large-bore chest tubes for selected uncomplicated traumatic thoracic injuries, while stressing that evidence remained underpowered. This evidence should not override the need for urgent resuscitation and local protocol-based care in an unstable patient.') heading('Conclusion') para('In a 36-year-old man after a road traffic accident, the supplied frontal chest-radiograph photographs demonstrate a left-sided basal pleural-parenchymal opacity compatible with traumatic pleural fluid and adjacent lung compression/atelectasis. The reported diagnosis of hemopneumothorax cannot be fully confirmed from photographs of a monitor because a small pneumothorax may be occult and image quality is limited. Original radiographs, formal radiologist interpretation, clinical findings and, when indicated, eFAST or CT are necessary for accurate diagnosis and management. Medical-imaging departments should preserve original images and document technical details to support safe reporting, follow-up and publishable case documentation.') heading('Consent for Publication') para('Written informed consent for publication of the case details and accompanying images: [TO COMPLETE BEFORE ANY SHARING OR SUBMISSION]. Permission from the head of the medical facility to access the records and use the radiographic images: [TO COMPLETE]. The patient name has been omitted from this draft to protect confidentiality.') heading('Patient Perspective') para('[TO COMPLETE: Insert the patient’s own verified statement, obtained with consent. Do not fabricate a patient perspective.]',italic=True) heading('References') refs=[ '1. Bwanga O. How to write a case report in Medical Imaging. Presentation, 19 April 2026. Supplied guidance document.', '2. Sun Z. Tips for writing a case report for the novice author. Journal of Medical Radiation Sciences. 2013;60(3):108-113.', '3. Murray & Nadel’s Textbook of Respiratory Medicine. Hemothorax. Elsevier; 2022. (Textbook source consulted for definition, trauma aetiology and imaging overview.)', '4. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. Thoracic trauma. McGraw Hill; 2023. (Textbook source consulted for trauma assessment context.)', '5. Granieri S, Cioffi SPB, Asaro A, et al. Small versus large bore chest tube in traumatic hemothorax, hemopneumothorax, and pneumothorax: a meta-analysis of randomized controlled trials with trial sequential analysis. World Journal of Emergency Surgery. 2025;20:65. doi:10.1186/s13017-025-00655-x. PMID: 41287089.' ] for x in refs: para(x) # final checklist heading('Pre-submission Completion Checklist') for x in ['Replace all [TO COMPLETE] fields with verified chart information or remove them.','Obtain written patient consent and institutional permission before sharing images.','Use de-identified original DICOM images, not photographs of a monitor, where possible.','Have a reporting radiologist and treating clinician verify the final imaging findings, diagnosis, treatment and outcome.','Remove the named patient identifier from every version intended for teaching, publication or circulation.']: p=doc.add_paragraph(style='List Bullet');p.add_run(x) doc.save(out) print(out) PY python - <<'PY' from docx import Document p='/tmp/workspace/hemopneumothorax-case-report/output/Draft_case_report_traumatic_hemopneumothorax.docx' d=Document(p) print('paragraphs',len(d.paragraphs),'tables',len(d.tables),'inline_shapes',len(d.inline_shapes)) print('title',d.paragraphs[1].text[:100]) PY

Which approach should I use for the missing clinical details? · Which details can you provide from the patient record?

CARE case report guideline patient consent de-identification case report

/tmp/workspace

python - <<'PY' from docx import Document p='/tmp/workspace/hemopneumothorax-case-report/output/Draft_case_report_traumatic_hemopneumothorax.docx' d=Document(p) for i,para in enumerate(d.paragraphs): if para.text.strip(): print(i, repr(para.text)) PY

python - <<'PY' from docx import Document from docx.shared import Pt, RGBColor from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.oxml.ns import qn from pathlib import Path src=Path('/tmp/workspace/hemopneumothorax-case-report/output/Draft_case_report_traumatic_hemopneumothorax.docx') out=Path('/tmp/workspace/hemopneumothorax-case-report/output/Frank_Phiri_Hemopneumothorax_Case_Report_Constance_Mtonga.docx') doc=Document(src) def replace_para(p, text, italic=False, bold=False, size=None, color=None, alignment=None): p.clear() if alignment is not None: p.alignment=alignment r=p.add_run(text);r.italic=italic;r.bold=bold;r.font.name='Arial' r._element.rPr.rFonts.set(qn('w:eastAsia'),'Arial') if size:r.font.size=Pt(size) if color:r.font.color.rgb=RGBColor.from_string(color) # title-page metadata replace_para(doc.paragraphs[1], 'Patient: Mr Frank Phiri | Age: 36 years | Sex: Male', italic=True, size=10, alignment=WD_ALIGN_PARAGRAPH.CENTER) owner=doc.paragraphs[2].insert_paragraph_before('Prepared by: Constance Mtonga | Radiology Student Case Report') owner.alignment=WD_ALIGN_PARAGRAPH.CENTER for r in owner.runs: r.font.name='Arial'; r.font.size=Pt(10); r.bold=True; r.font.color.rgb=RGBColor.from_string('17365D') # update factual identifiers exactly in case-report wording replacements={ 'We present a de-identified 36-year-old male involved in a road traffic accident':'We present Mr Frank Phiri, a 36-year-old male involved in a road traffic accident', 'A 36-year-old male was involved in a road traffic accident.':'Mr Frank Phiri, a 36-year-old male, was involved in a road traffic accident.', 'In a 36-year-old man after a road traffic accident,':'In Mr Frank Phiri, a 36-year-old man after a road traffic accident,', 'The patient name has been omitted from this draft to protect confidentiality.':'This student case report identifies the patient at the requester’s instruction. It must not be shared, presented, submitted or otherwise circulated unless written informed consent and institutional permission have been obtained.' } for p in doc.paragraphs: if p.text in replacements: old=p.text; new=replacements[old] # preserve simple body style replace_para(p,new, size=10.5) else: for old,new in replacements.items(): if old in p.text: replace_para(p,p.text.replace(old,new),size=10.5) # change last confidentiality checklist line, preserving safety for p in doc.paragraphs: if p.text == 'Remove the named patient identifier from every version intended for teaching, publication or circulation.': replace_para(p,'Before any teaching, publication or circulation, confirm written patient consent and institutional permission. If these are unavailable, replace the patient name with a de-identified description.',size=10.5) # include a clear details page note next to title note=doc.paragraphs[3].insert_paragraph_before('Academic-use note: The clinical narrative reflects only the supplied case facts. Fields marked [TO COMPLETE] require verification from the patient record or supervising radiographer/radiologist. The three supplied diagnostic chest radiograph photographs are retained as Figures 1-3.') note.alignment=WD_ALIGN_PARAGRAPH.CENTER for r in note.runs: r.italic=True;r.font.name='Arial';r.font.size=Pt(9);r.font.color.rgb=RGBColor(90,90,90) doc.save(out) print(out) PY python - <<'PY' from docx import Document p='/tmp/workspace/hemopneumothorax-case-report/output/Frank_Phiri_Hemopneumothorax_Case_Report_Constance_Mtonga.docx' d=Document(p) print('inline shapes:',len(d.inline_shapes)) for p in d.paragraphs[:8]: if p.text.strip(): print(p.text) print('exists=',__import__('os').path.exists(p)) PY

CARE case report guideline case reports informed consent patient information deidentified

/tmp/workspace

python - <<'PY' from docx import Document from docx.shared import Inches, Pt, RGBColor from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.enum.table import WD_TABLE_ALIGNMENT, WD_CELL_VERTICAL_ALIGNMENT from docx.oxml import OxmlElement from docx.oxml.ns import qn from pathlib import Path base=Path('/tmp/workspace/hemopneumothorax-case-report') out=base/'output'/'SIMULATED_Student_Case_Report_Frank_Phiri_Constance_Mtonga.docx' assets=base/'assets' def shade(cell,fill): tcPr=cell._tc.get_or_add_tcPr(); shd=OxmlElement('w:shd'); shd.set(qn('w:fill'),fill);tcPr.append(shd) def celltext(cell,text,bold=False,size=9): cell.text='';p=cell.paragraphs[0];r=p.add_run(text);r.bold=bold;r.font.name='Arial';r.font.size=Pt(size);cell.vertical_alignment=WD_CELL_VERTICAL_ALIGNMENT.CENTER def setfont(run,size=None,bold=None,italic=None,color=None): run.font.name='Arial';run._element.rPr.rFonts.set(qn('w:eastAsia'),'Arial') if size:run.font.size=Pt(size) if bold is not None:run.bold=bold if italic is not None:run.italic=italic if color:run.font.color.rgb=RGBColor.from_string(color) doc=Document();sec=doc.sections[0] sec.top_margin=Inches(.65);sec.bottom_margin=Inches(.65);sec.left_margin=Inches(.75);sec.right_margin=Inches(.75) for st,size,color in [('Normal',10.5,'000000'),('Title',17,'17365D'),('Heading 1',13,'17365D'),('Heading 2',11,'17365D')]: s=doc.styles[st];s.font.name='Arial';s._element.rPr.rFonts.set(qn('w:eastAsia'),'Arial');s.font.size=Pt(size);s.font.color.rgb=RGBColor.from_string(color) if st!='Normal':s.font.bold=True header=sec.header.paragraphs[0];header.alignment=WD_ALIGN_PARAGRAPH.RIGHT r=header.add_run('SIMULATED STUDENT EXERCISE | NOT A CLINICAL RECORD');setfont(r,8,color='8B0000') footer=sec.footer.paragraphs[0];footer.alignment=WD_ALIGN_PARAGRAPH.CENTER r=footer.add_run('Constance Mtonga | Radiology Student Case Report | ');setfont(r,8,color='666666') f=OxmlElement('w:fldSimple');f.set(qn('w:instr'),'PAGE');footer._p.append(f) p=doc.add_paragraph();p.alignment=WD_ALIGN_PARAGRAPH.CENTER r=p.add_run('Traumatic Left Hemopneumothorax Following a Road Traffic Accident: A Simulated Radiology Student Case Report');setfont(r,16,True,color='17365D') p=doc.add_paragraph();p.alignment=WD_ALIGN_PARAGRAPH.CENTER r=p.add_run('Patient identifier used for classroom exercise: Mr Frank Phiri | 36 years | Male');setfont(r,10,italic=True) p=doc.add_paragraph();p.alignment=WD_ALIGN_PARAGRAPH.CENTER r=p.add_run('Prepared by: Constance Mtonga');setfont(r,10,True,color='17365D') t=doc.add_table(rows=1,cols=1);t.alignment=WD_TABLE_ALIGNMENT.CENTER;shade(t.cell(0,0),'FCE4D6') celltext(t.cell(0,0),'SIMULATION NOTICE: The symptoms, examination findings, vital signs, laboratory results, treatment, timeline, outcome and patient perspective below are invented for radiology-student learning. They are not Mr Frank Phiri’s clinical record and must not be used for patient care, assessment as a real case, publication, or medico-legal documentation. The attached radiograph photographs were supplied by the requester; use of identifiable patient information or images requires appropriate consent and institutional permission.',True,9) def h(text,lvl=1):doc.add_heading(text,level=lvl) def para(text,italic=False): p=doc.add_paragraph();p.paragraph_format.space_after=Pt(5);r=p.add_run(text);setfont(r,10.5,italic=italic);return p h('Abstract') para('Traumatic hemopneumothorax is the accumulation of both air and blood within the pleural cavity after chest injury. This simulated academic case describes Mr Frank Phiri, a 36-year-old male involved in a road traffic accident, who presented with left-sided chest pain and shortness of breath. A frontal chest radiograph, represented by supplied photographs of a monitor display, showed left lower-zone pleural-parenchymal opacity and reduced left lung volume, in keeping with a traumatic pleural collection in the stated setting. The simulated clinical diagnosis was left traumatic hemopneumothorax. The patient was managed with oxygen, analgesia and left tube thoracostomy, followed by serial radiography demonstrating improvement. The case illustrates the role of chest radiography in early assessment of blunt chest trauma, the limitations of a single photographed frontal image, and the importance of correlating imaging with the trauma assessment.') h('Keywords') para('Hemopneumothorax; blunt chest trauma; road traffic accident; chest radiograph; tube thoracostomy; case report.') h('Introduction') para('Hemothorax is the presence of blood in the pleural cavity. When accompanied by pleural air, it is termed hemopneumothorax. Blunt thoracic trauma from road traffic accidents can injure the lung, intercostal vessels, chest wall or diaphragm, causing pleural blood and air. These collections may reduce lung expansion and impair oxygenation. Chest radiography remains a rapid, accessible first-line examination in trauma, while ultrasound and computed tomography (CT) can provide additional information where available. This simulated case report focuses on the radiographic assessment of a left traumatic hemopneumothorax in a young adult following a road traffic accident.') h('Case Presentation') h('Patient information',2) para('SIMULATED DETAILS: Mr Frank Phiri was a 36-year-old man with no reported chronic medical illness, previous thoracic surgery, anticoagulant use or known drug allergy. He was the restrained front-seat passenger in a motor vehicle collision and presented to the emergency department approximately 45 minutes after the incident. His primary concerns were sharp left-sided chest pain, worsened by deep inspiration, and progressive shortness of breath. He denied loss of consciousness, abdominal pain and haemoptysis.') h('Clinical findings',2) para('SIMULATED DETAILS: At presentation he was alert and orientated. Blood pressure was 118/74 mmHg, pulse 108 beats/minute, respiratory rate 28 breaths/minute, temperature 36.8°C and oxygen saturation 92% on room air. He had superficial abrasions over the left lateral chest wall and tenderness over the left lower ribs. Chest expansion was reduced on the left, with decreased breath sounds and dullness to percussion at the left base. No tracheal deviation or clinical features of tension pneumothorax were present. The abdomen was soft and non-tender; no neurological deficit was identified.') h('Diagnostic assessment',2) para('A portable frontal chest radiograph was requested as part of the trauma assessment. The supplied material consists of photographs of a displayed chest radiograph, with a visible left-side marker. The image is limited by being a photograph of a monitor, lack of original DICOM data, projection uncertainty and absence of a lateral view.') para('Radiographic findings: There is left lower hemithorax pleural-parenchymal opacity with blunting/obscuration of the left costophrenic region and reduced aeration of the left base. The left lung appears partially compressed. The right lung is relatively well aerated. No large mediastinal shift is evident on the supplied images. A subtle pneumothorax component cannot be confidently confirmed or quantified from these monitor photographs. In the simulated trauma context, the findings were interpreted as a left traumatic pleural collection, consistent with the clinical diagnosis of hemopneumothorax.') para('SIMULATED ANCILLARY RESULTS: Focused ultrasound of the left chest demonstrated pleural fluid. Haemoglobin was 12.8 g/dL on arrival and 12.3 g/dL on repeat testing four hours later. CT was not performed in this simulation because the patient remained haemodynamically stable and improved after pleural drainage.') h('Radiographic impression',2) para('Left-sided traumatic pleural collection with left basal compressive atelectatic change. In the stated clinical setting, findings are consistent with left haemopneumothorax. No radiographic evidence of tension physiology on the supplied frontal image. Recommend clinical correlation and follow-up chest radiography after intervention.') h('Therapeutic intervention',2) para('SIMULATED DETAILS: The patient received supplemental oxygen by nasal cannula and intravenous analgesia. Following trauma-team assessment, a left intercostal chest drain was inserted under aseptic technique in the safe triangle and connected to an underwater seal drainage system. Approximately 450 mL of blood drained initially. There was no persistent large air leak. The patient was admitted for observation, serial clinical examinations and repeat chest radiography.') h('Follow-up and outcome',2) para('SIMULATED DETAILS: A follow-up chest radiograph at 24 hours showed improved expansion of the left lung and a marked reduction in pleural opacity. Drain output decreased to less than 100 mL over the next 24 hours. The patient’s oxygen saturation improved to 97% on room air, respiratory rate decreased to 18 breaths/minute and pain was controlled with oral analgesia. The drain was removed on day 3 after a satisfactory clinical review and repeat radiograph. He was discharged on day 4 with trauma clinic follow-up and advice to return for worsening dyspnoea, chest pain or fever.') h('Timeline',2) t=doc.add_table(rows=1,cols=2);t.style='Table Grid';t.alignment=WD_TABLE_ALIGNMENT.CENTER for c,txt in zip(t.rows[0].cells,['Time','Simulated event']):shade(c,'D9EAF7');celltext(c,txt,True) for a,b in [('0 minutes','Road traffic accident.'),('45 minutes','Arrival at emergency department with chest pain and dyspnoea.'),('60 minutes','Initial trauma assessment and portable frontal chest radiograph.'),('90 minutes','Left intercostal chest drain inserted; 450 mL blood drained initially.'),('24 hours','Follow-up chest radiograph demonstrated improving left lung expansion.'),('Day 3','Drain removed after clinical and radiographic improvement.'),('Day 4','Discharged in stable condition with outpatient follow-up.')]: cells=t.add_row().cells;celltext(cells[0],a);celltext(cells[1],b) h('Diagnostic Chest Radiograph Images') for i,caption in [(1,'Figure 1. Supplied photograph of the initial frontal chest radiograph display. A left-side marker is visible. Left basal to mid-zone pleural-parenchymal opacity is demonstrated. The image is a monitor photograph and is therefore limited for definitive image interpretation.'),(2,'Figure 2. Second supplied photograph of the frontal chest radiograph display. The left lower hemithorax opacity and reduced left basal aeration are again visible.'),(3,'Figure 3. Third supplied photograph of the frontal chest radiograph display. These figures support the simulated teaching discussion only; original DICOM images should be used for diagnostic reporting and any formal academic submission.')]: p=doc.add_paragraph();p.alignment=WD_ALIGN_PARAGRAPH.CENTER;p.add_run().add_picture(str(assets/f'figure{i}.jpeg'),width=Inches(3.1)) p=doc.add_paragraph();p.alignment=WD_ALIGN_PARAGRAPH.CENTER;r=p.add_run(caption);setfont(r,8.5,italic=True) h('Discussion') para('In this simulated case, the mechanism of injury, respiratory symptoms, physical findings and chest radiograph were integrated to support a diagnosis of left traumatic hemopneumothorax. Blood and air in the pleural space can reduce functional lung volume and cause dyspnoea, hypoxaemia and, if severe, haemodynamic compromise. A portable chest radiograph is useful early in the trauma pathway because it is rapid and widely available. Typical radiographic features of haemothorax include pleural opacity and costophrenic-angle blunting, whereas pneumothorax is identified by a visceral pleural line and absence of peripheral lung markings. However, small pneumothoraces, particularly on supine images, can be difficult to detect.') para('The supplied images have important limitations: they are photographs of a monitor rather than original radiographs, have uncertain projection and exposure parameters, and do not allow manipulation of windowing or magnification. The simulated diagnosis therefore depends on clinical correlation. CT would be more sensitive for identifying the volume of pleural blood and air, lung contusion, rib fractures, active bleeding and other associated injuries. Bedside eFAST may provide rapid evidence of pleural fluid or pneumothorax where CT is unavailable or delayed.') para('In the simulated management pathway, tube thoracostomy was used because the patient was symptomatic and had a clinically significant traumatic pleural collection. Follow-up imaging was important to demonstrate re-expansion of the lung and assess residual collection. The key learning point for radiology students is to provide a structured description of side, location, pleural and lung findings, mediastinal position, image limitations and any urgent communication needed with the trauma team.') h('Conclusion') para('This simulated case demonstrates how chest radiography contributes to the early diagnosis of traumatic hemopneumothorax after a road traffic accident. The supplied images show a left basal pleural-parenchymal opacity compatible with a traumatic pleural collection in the stated scenario. Radiology students should recognise the limitations of a single frontal monitor photograph, correlate radiographic features with trauma findings, and recommend appropriate follow-up imaging or CT when clinically indicated.') h('Patient Perspective') para('SIMULATED PATIENT PERSPECTIVE: “I was frightened because I could not take a full breath after the accident. The treatment team explained why the chest tube was needed and monitored me closely. As my breathing improved, I felt reassured and understood the importance of follow-up.”') h('Consent and Ethical Statement') para('This completed version is a fictional teaching exercise. No statement of real patient consent is made or implied. Before using the patient’s name, real images or any actual clinical information for teaching, assessment, presentation or publication, written informed consent and permission from the relevant health facility must be obtained. The CARE guidance advises de-identification and informed consent before case-report publication.') h('References') for x in [ '1. Bwanga O. How to write a case report in Medical Imaging. Presentation, 19 April 2026. Supplied course guidance document.', '2. Sun Z. Tips for writing a case report for the novice author. Journal of Medical Radiation Sciences. 2013;60(3):108-113.', '3. Gagnier JJ, Kienle G, Altman DG, et al. The CARE guidelines: consensus-based clinical case reporting guideline development. Journal of Clinical Epidemiology. 2014;67(1):46-51.', '4. Murray & Nadel’s Textbook of Respiratory Medicine. Hemothorax. Elsevier; 2022.', '5. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. Thoracic trauma. McGraw Hill; 2023.', '6. Granieri S, Cioffi SPB, Asaro A, et al. Small versus large bore chest tube in traumatic hemothorax, hemopneumothorax, and pneumothorax: a meta-analysis of randomized controlled trials with trial sequential analysis. World Journal of Emergency Surgery. 2025;20:65. doi:10.1186/s13017-025-00655-x. PMID: 41287089.' ]:para(x) doc.save(out) print(out) PY python - <<'PY' from docx import Document from pathlib import Path p=Path('/tmp/workspace/hemopneumothorax-case-report/output/SIMULATED_Student_Case_Report_Frank_Phiri_Constance_Mtonga.docx') d=Document(p) print('exists',p.exists(),'size',p.stat().st_size,'paragraphs',len(d.paragraphs),'tables',len(d.tables),'images',len(d.inline_shapes)) print('title:',d.paragraphs[0].text) print('simulation labels:',sum('SIMULATED' in x.text for x in d.paragraphs)) PY

2025 American Thyroid Association hyperthyroidism guideline thyroid hormone synthesis regulation

hyperthyroidism management guideline

thyroid gland anatomy lobes isthmus trachea diagram

thyroid follicle histology colloid follicular cells diagram

Graves disease thyroid eye disease clinical photograph goiter

mkdir -p "/tmp/workspace/thyroid-resident-presentation/src" "/tmp/workspace/thyroid-resident-presentation/output" "/tmp/workspace/thyroid-resident-presentation/assets" && cat > "/tmp/workspace/thyroid-resident-presentation/src/create_deck.py" <<'PY' from pptx import Presentation from pptx.util import Inches, Pt from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR from pptx.enum.text import PP_ALIGN, MSO_ANCHOR from pptx.dml.color import RGBColor from pptx.enum.dml import MSO_THEME_COLOR from pathlib import Path OUT=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Anatomy_Physiology_and_Hyperthyroidism_Residents.pptx') prs=Presentation(); prs.slide_width=Inches(13.333); prs.slide_height=Inches(7.5) blank=prs.slide_layouts[6] # palette NAVY='123047'; TEAL='007C83'; BLUE='2D6EA3'; SKY='D9ECF5'; PALE='F2F7F9'; INK='19242C'; MUTED='52616B'; GOLD='F2B134'; RED='C84B4B'; GREEN='2F8F6B'; WHITE='FFFFFF'; LILAC='EEE9F6' def rgb(h): return RGBColor.from_string(h) def add_rect(s,x,y,w,h,fill, line=None, radius=False): sh=s.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE if radius else MSO_SHAPE.RECTANGLE, Inches(x), Inches(y), Inches(w), Inches(h)) sh.fill.solid(); sh.fill.fore_color.rgb=rgb(fill) sh.line.color.rgb=rgb(line or fill) return sh def txt(s,x,y,w,h,text,size=18,color=INK,bold=False,align=PP_ALIGN.LEFT,italic=False,margin=.08): box=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h)); tf=box.text_frame;tf.clear();tf.word_wrap=True tf.margin_left=tf.margin_right=Inches(margin);tf.margin_top=tf.margin_bottom=Inches(margin) p=tf.paragraphs[0];p.alignment=align;r=p.add_run();r.text=text;r.font.name='Aptos';r.font.size=Pt(size);r.font.bold=bold;r.font.italic=italic;r.font.color.rgb=rgb(color) return box def bullets(s,x,y,w,h,items,size=16,color=INK,spacing=7): box=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));tf=box.text_frame;tf.clear();tf.word_wrap=True tf.margin_left=Inches(.1);tf.margin_right=Inches(.04);tf.margin_top=Inches(.05) for i,item in enumerate(items): p=tf.paragraphs[0] if i==0 else tf.add_paragraph();p.text=item;p.level=0;p.font.name='Aptos';p.font.size=Pt(size);p.font.color.rgb=rgb(color);p.space_after=Pt(spacing);p.bullet=True return box def line(s,x1,y1,x2,y2,color=TEAL,width=2,arrow=False): ln=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x1),Inches(y1),Inches(x2),Inches(y2));ln.line.color.rgb=rgb(color);ln.line.width=Pt(width) if arrow: ln.line.end_arrowhead=True return ln def title(s,number,heading,sub=''): add_rect(s,0,0,13.333,.36,NAVY);txt(s,.55,.52,11.9,.45,heading,27,NAVY,True) if sub:txt(s,.58,.98,11.8,.26,sub,11,MUTED) txt(s,12.15,.56,.55,.25,f'{number:02d}',11,TEAL,True,PP_ALIGN.RIGHT) def footer(s,label='Endocrinology resident teaching'): line(s,.55,7.12,12.78,7.12,'CBD8DD',.8);txt(s,.58,7.17,7,.18,label,8,MUTED);txt(s,11.3,7.17,1.45,.18,'August 2026',8,MUTED,align=PP_ALIGN.RIGHT) def new(num,heading,sub=''): s=prs.slides.add_slide(blank);add_rect(s,0,0,13.333,7.5,WHITE);title(s,num,heading,sub);footer(s);return s def chip(s,x,y,w,text,fill=SKY,color=NAVY): add_rect(s,x,y,w,.36,fill,fill,True);txt(s,x+.03,y+.04,w-.06,.22,text,10,color,True,PP_ALIGN.CENTER) def circle(s,x,y,d,fill,text='',tcolor=WHITE,sz=18): sh=s.shapes.add_shape(MSO_SHAPE.OVAL,Inches(x),Inches(y),Inches(d),Inches(d));sh.fill.solid();sh.fill.fore_color.rgb=rgb(fill);sh.line.color.rgb=rgb(fill) if text:txt(s,x,y+d*.28,d,d*.35,text,sz,tcolor,True,PP_ALIGN.CENTER) return sh #1 s=prs.slides.add_slide(blank);add_rect(s,0,0,13.333,7.5,NAVY);add_rect(s,0,5.7,13.333,1.8,TEAL) txt(s,.7,.72,10.8,.9,'Thyroid anatomy,\nhormone physiology & hyperthyroidism',32,WHITE,True) txt(s,.74,2.72,8.5,.45,'A practical review for medical residents',18,'DDEEF1') for x,t in [(0.8,'ANATOMY'),(3.05,'SYNTHESIS'),(5.45,'REGULATION'),(8.15,'CLINICAL CARE')]: chip(s,x,4.1,1.9,t,'19465E','DDEEF1') # thyroid silhouette for x in [10.75,11.75]: circle(s,x,1.5,.95,'3CA4A7') add_rect(s,11.45,2.25,.6,.35,'3CA4A7','3CA4A7',True);line(s,11.75,2.6,11.75,4.95,'DDEEF1',8) txt(s,.75,6.35,8,.25,'Resident teaching deck | mechanisms, diagnosis, and treatment selection',12,WHITE) txt(s,.75,6.8,4,.22,'Prepared for clinician education',10,'DDEEF1') #2 objectives s=new(2,'Learning objectives') for i,(head,body,col) in enumerate([('Locate','Relate gross anatomy and vascular anatomy to examination, ultrasound and surgery.',TEAL),('Explain','Map iodide handling to T3/T4 synthesis, transport, activation and feedback.',BLUE),('Diagnose','Use TSH-first testing, TRAb and imaging to determine the cause of thyrotoxicosis.',GOLD),('Treat','Choose symptomatic, antithyroid, radioactive iodine or surgical therapy safely.',GREEN)]): x=.75+(i%2)*6.1;y=1.55+(i//2)*2.25;add_rect(s,x,y,5.5,1.65,PALE,PALE,True);circle(s,x+.3,y+.35,.58,col,str(i+1),WHITE,16);txt(s,x+1.05,y+.3,4.0,.3,head,18,NAVY,True);txt(s,x+1.05,y+.72,3.95,.62,body,12,INK) #3 anatomy s=new(3,'Thyroid anatomy: what matters at the bedside','Butterfly-shaped gland in the central lower neck') # trachea / thyroid add_rect(s,5.98,1.55,1.32,4.55,'DCE5E9','AABBC4',True) for yy in [1.85,2.35,2.85,3.35,3.85,4.35,4.85,5.35]:line(s,6.06,yy,7.22,yy,'AABBC4',1) for x,y,w,h in [(4.25,2.0,1.8,2.55),(7.22,2.0,1.8,2.55)]: sh=add_rect(s,x,y,w,h,'3CA4A7','3CA4A7',True) add_rect(s,5.85,3.05,1.6,.45,'3CA4A7','3CA4A7',True) for x,y,label in [(1.0,1.8,'Lobes: right + left'),(1.0,3.0,'Isthmus: usually over\n2nd-4th tracheal rings'),(9.65,1.85,'Posterior surface:\nparathyroids, RLN'),(9.65,3.5,'Pyramidal lobe: variable'),(9.65,5.05,'Moves with swallowing')]: add_rect(s,x,y,2.6,.65,PALE,PALE,True);txt(s,x+.1,y+.11,2.4,.43,label,12,INK) line(s,3.6,2.15,4.25,2.65,TEAL,2,True);line(s,3.6,3.3,5.85,3.25,TEAL,2,True);line(s,9.6,2.25,8.9,2.5,TEAL,2,True);line(s,9.6,3.85,8.5,3.4,TEAL,2,True) #4 vascular nerve s=new(4,'Surgical anatomy: blood supply and nerves') add_rect(s,.7,1.35,5.85,4.9,PALE,PALE,True);txt(s,.98,1.62,5.2,.28,'Arterial and venous relationships',18,NAVY,True) bullets(s,1.0,2.15,5.1,3.4,['Superior thyroid artery: external carotid branch','Inferior thyroid artery: thyrocervical trunk','Thyroid ima artery: uncommon but relevant in tracheostomy','Superior, middle and inferior thyroid veins drain to internal jugular / brachiocephalic veins'],15) add_rect(s,6.8,1.35,5.85,4.9,'FFF7E5','FFF7E5',True);txt(s,7.1,1.62,5.1,.28,'Nerves at risk during thyroidectomy',18,NAVY,True) bullets(s,7.1,2.15,5.1,3.4,['External branch of superior laryngeal nerve: close to superior pole vessels','Recurrent laryngeal nerve (RLN): usually in tracheo-oesophageal groove; relationship to inferior thyroid artery is variable','Implication: protect voice, airway and parathyroid blood supply'],15) chip(s,.95,6.45,4.8,'Clinical correlate: hoarseness = assess vocal cords', 'FCE4D6','8B2A2A') #5 histology s=new(5,'Microscopic unit: the thyroid follicle') # follicle diagram circle(s,1.2,1.55,3.75,'3CA4A7');circle(s,1.55,1.9,3.05,'F6C76A');circle(s,1.95,2.3,2.25,'FFF4C6');txt(s,2.37,3.2,1.4,.35,'COLLOID\n(THYROGLOBULIN)',12,NAVY,True,PP_ALIGN.CENTER) txt(s,1.45,5.55,3.3,.35,'Follicular cell ring',14,NAVY,True,PP_ALIGN.CENTER) line(s,4.6,2.4,6.0,2.4,TEAL,2,True);txt(s,6.1,2.15,2.1,.28,'Apical surface',15,NAVY,True);txt(s,6.1,2.5,4.9,.55,'TPO catalyses iodination and coupling at the colloid interface.',14,INK) line(s,3.1,5.2,6.0,4.15,TEAL,2,True);txt(s,6.1,3.85,2.1,.28,'Basolateral surface',15,NAVY,True);txt(s,6.1,4.2,5.1,.65,'NIS imports iodide from blood. TSH receptor activation drives synthesis, uptake and secretion.',14,INK) add_rect(s,6.0,5.45,5.8,.65,LILAC,LILAC,True);txt(s,6.2,5.62,5.35,.25,'C cells: parafollicular cells secrete calcitonin; distinct from follicular cells.',12,NAVY) #6 synthesis s=new(6,'Thyroid hormone synthesis: seven linked steps','Target each step clinically or pharmacologically') steps=[('1','Iodide trapping','NIS'),('2','Apical transport','Pendrin'),('3','Oxidation','TPO + H₂O₂'),('4','Organification','MIT / DIT'),('5','Coupling','T3 / T4'),('6','Endocytosis','Proteolysis'),('7','Secretion','T4 >> T3')] for i,(n,a,b) in enumerate(steps): x=.55+i*1.82;circle(s,x,1.55,.52,TEAL,n,WHITE,14);add_rect(s,x-.18,2.22,1.35,1.15,PALE,PALE,True);txt(s,x-.12,2.38,1.23,.3,a,11,NAVY,True,PP_ALIGN.CENTER);txt(s,x-.12,2.82,1.23,.2,b,10,TEAL,False,PP_ALIGN.CENTER) if i<6:line(s,x+.58,1.82,x+1.62,1.82,TEAL,1.5,True) add_rect(s,.85,4.2,11.55,1.65,'F2F7F9','D9ECF5',True);txt(s,1.08,4.45,2.1,.25,'Key stoichiometry',15,NAVY,True);txt(s,1.08,4.85,10.5,.5,'MIT + DIT → T3 | DIT + DIT → T4 | T4 is the principal product released by the thyroid gland',17,INK,True,PP_ALIGN.CENTER) chip(s,2.0,6.25,2.0,'Methimazole: TPO','FCE4D6','8B2A2A');chip(s,4.35,6.25,2.55,'Propylthiouracil: TPO + T4→T3','FCE4D6','8B2A2A');chip(s,7.3,6.25,2.5,'Iodide: transient release block','FFF7E5',NAVY) #7 transport action s=new(7,'Transport, activation and mechanism of action') # blood / liver / tissue for x,y,w,h,hdr,body,col in [(0.8,1.55,3.25,1.5,'Circulation','>99% protein-bound\nTBG > transthyretin > albumin',BLUE),(5.05,1.55,3.25,1.5,'Peripheral conversion','D1/D2: T4 → active T3\nD3: T4 → reverse T3',TEAL),(9.3,1.55,3.25,1.5,'Nuclear action','T3 binds TRα/TRβ\nchanges gene transcription',GOLD)]: add_rect(s,x,y,w,h,PALE,PALE,True);add_rect(s,x,y,w,.36,col,col,True);txt(s,x+.12,y+.07,w-.24,.18,hdr,13,WHITE,True,PP_ALIGN.CENTER);txt(s,x+.22,y+.6,w-.44,.65,body,14,INK,align=PP_ALIGN.CENTER) line(s,4.1,2.3,5.0,2.3,TEAL,2,True);line(s,8.35,2.3,9.25,2.3,TEAL,2,True) for x,head,body in [(1.0,'Physiologic effects','↑ basal metabolic rate, thermogenesis, lipolysis and carbohydrate turnover'),(4.75,'Cardiovascular effects','↑ β-adrenergic responsiveness, heart rate, contractility and cardiac output'),(8.5,'Growth & CNS','Essential for neurodevelopment; permissive for catecholamine effects')]: add_rect(s,x,4.2,3.15,1.45,'F9FBFC','D9ECF5',True);txt(s,x+.15,4.42,2.8,.25,head,14,NAVY,True);txt(s,x+.15,4.78,2.8,.55,body,12,INK) #8 regulation s=new(8,'Hypothalamic-pituitary-thyroid axis','Negative feedback is the core interpretive principle') for x,y,w,h,head,body,col in [(1.0,1.65,2.5,1.2,'Hypothalamus','TRH',TEAL),(5.4,1.65,2.5,1.2,'Anterior pituitary','TSH',BLUE),(9.8,1.65,2.5,1.2,'Thyroid gland','T4 + T3',GOLD)]: add_rect(s,x,y,w,h,PALE,PALE,True);add_rect(s,x,y,w,.34,col,col,True);txt(s,x,y+.08,w,.18,head,13,WHITE,True,PP_ALIGN.CENTER);txt(s,x,y+.55,w,.3,body,18,NAVY,True,PP_ALIGN.CENTER) line(s,3.55,2.25,5.3,2.25,TEAL,3,True);line(s,7.95,2.25,9.7,2.25,TEAL,3,True) # feedback loop line(s,11.05,3.0,11.05,4.4,RED,2,True);line(s,11.05,4.4,2.25,4.4,RED,2,True);line(s,2.25,4.4,2.25,2.98,RED,2,True);txt(s,5.2,4.12,3,.26,'T3/T4 suppress TRH and TSH',13,RED,True,PP_ALIGN.CENTER) add_rect(s,1.1,5.25,11.1,.75,LILAC,LILAC,True);txt(s,1.35,5.45,10.6,.25,'Modifiers: illness, drugs (glucocorticoids, dopamine, amiodarone), iodine exposure, pregnancy and assay interference.',13,NAVY,align=PP_ALIGN.CENTER) #9 labs s=new(9,'Thyroid function tests: pattern recognition') rows=[('Primary hyperthyroidism','↓','↑ FT4 and/or T3','Graves, toxic nodular disease, thyroiditis'),('Central hyperthyroidism','Normal / ↑','↑','TSHoma, thyroid hormone resistance'),('Primary hypothyroidism','↑','↓','Thyroid failure'),('Subclinical hyperthyroidism','↓','Normal','Persistent? assess age, AF, bone risk')] # table x=.75;y=1.4;cols=[3.1,1.35,2.25,5.05] for j,hdr in enumerate(['Pattern','TSH','FT4 / T3','Clinical examples']): xx=x+sum(cols[:j]);add_rect(s,xx,y,cols[j],.5,NAVY,NAVY);txt(s,xx+.05,y+.12,cols[j]-.1,.2,hdr,12,WHITE,True,PP_ALIGN.CENTER) for i,row in enumerate(rows): yy=y+.5+i*.82 for j,val in enumerate(row): xx=x+sum(cols[:j]);add_rect(s,xx,yy,cols[j],.82,PALE if i%2==0 else WHITE,'D9ECF5');txt(s,xx+.1,yy+.16,cols[j]-.2,.42,val,12,INK,j==0,PP_ALIGN.CENTER if j in [1,2] else PP_ALIGN.LEFT) chip(s,.9,5.55,3.3,'Measure FT3 if T3-toxicosis suspected','FFF7E5',NAVY);chip(s,4.55,5.55,3.1,'Biotin can create discordant results','FCE4D6','8B2A2A');chip(s,8.0,5.55,3.8,'Treat the patient, not an isolated result','E4F1EB',GREEN) #10 definition causes s=new(10,'Hyperthyroidism versus thyrotoxicosis','Name the mechanism before choosing therapy') add_rect(s,.8,1.45,5.7,1.25,'E4F1EB','E4F1EB',True);txt(s,1.05,1.7,5.15,.28,'Hyperthyroidism = increased hormone synthesis by the gland',16,GREEN,True,PP_ALIGN.CENTER) add_rect(s,6.82,1.45,5.7,1.25,'FFF7E5','FFF7E5',True);txt(s,7.05,1.7,5.22,.28,'Thyrotoxicosis = clinical state of excess thyroid hormone',16,NAVY,True,PP_ALIGN.CENTER) for x,head,items in [(1.0,'Increased synthesis',['Graves disease','Toxic multinodular goitre','Toxic adenoma','Iodine-induced hyperthyroidism']), (7.05,'Release / exogenous',['Subacute or painless thyroiditis','Postpartum thyroiditis','Factitious thyroid hormone','Struma ovarii (rare)'])]: txt(s,x,3.15,4.5,.28,head,17,NAVY,True);bullets(s,x,3.58,4.9,1.7,items,15) chip(s,2.1,6.0,3.0,'Synthesis ↑ → thionamide may help','E4F1EB',GREEN);chip(s,7.2,6.0,3.6,'Destructive thyroiditis → thionamide will not help','FCE4D6','8B2A2A') #11 Graves s=new(11,'Graves disease: a systemic autoimmune disorder') # 4 boxes for x,y,head,body in [(0.8,1.45,'Pathogenesis','TSH receptor antibodies stimulate synthesis and gland growth.'),(6.85,1.45,'Clinical phenotype','Diffuse goitre, tremor, tachycardia, weight loss, heat intolerance.'),(0.8,4.0,'Extrathyroidal disease','Orbitopathy, pretibial myxoedema and acropachy are immune-mediated.'),(6.85,4.0,'Investigations','TRAb supports diagnosis. Diffuse increased uptake if radionuclide scan is used.')]: add_rect(s,x,y,5.55,1.55,PALE,PALE,True);txt(s,x+.22,y+.22,5.0,.26,head,16,NAVY,True);txt(s,x+.22,y+.62,5.0,.65,body,13,INK) chip(s,2.2,6.35,8.9,'Orbitopathy: smoking cessation, euthyroidism, specialist assessment; avoid RAI alone in active moderate-to-severe disease.', 'FCE4D6','8B2A2A') #12 workup s=new(12,'Etiologic work-up of suppressed TSH') # algorithm for x,y,w,h,label,col in [(5.0,1.25,3.3,.6,'Confirm: repeat TSH + FT4 ± FT3',TEAL),(5.0,2.25,3.3,.6,'History / examination / medication & iodine exposure',BLUE),(5.0,3.25,3.3,.6,'TRAb if Graves suspected',GOLD),(1.0,4.5,3.4,.75,'High diffuse uptake\n→ Graves',GREEN),(4.95,4.5,3.4,.75,'Focal/patchy uptake\n→ toxic nodular disease',GREEN),(8.9,4.5,3.4,.75,'Low uptake\n→ thyroiditis, exogenous hormone, iodine',RED)]: add_rect(s,x,y,w,h,PALE,PALE,True);txt(s,x+.1,y+.13,w-.2,h-.2,label,13,NAVY,True,PP_ALIGN.CENTER) for y1,y2 in [(1.85,2.25),(2.85,3.25),(3.85,4.5)]:line(s,6.65,y1,6.65,y2,TEAL,2,True) line(s,6.65,4.13,2.7,4.48,TEAL,2,True);line(s,6.65,4.13,6.65,4.48,TEAL,2,True);line(s,6.65,4.13,10.6,4.48,TEAL,2,True) chip(s,.9,6.15,11.4,'Pregnancy / lactation: do not use radioactive iodine; use targeted history, TRAb and ultrasound where appropriate.', 'FFF7E5',NAVY) #13 symptom control s=new(13,'Initial management: stabilize, then define the cause') for i,(head,body,col) in enumerate([('Assess severity','Vitals, mental status, heart failure, AF, precipitant, pregnancy status.',RED),('Control adrenergic symptoms','Beta-blocker unless contraindicated. Consider cardioselective agent if reactive airway disease.',TEAL),('Treat cause','Thionamide for increased synthesis. Do not use as definitive therapy for destructive thyroiditis.',BLUE),('Plan definitive therapy','Shared decision: antithyroid drugs, radioactive iodine, or surgery.',GOLD)]): x=.7+(i%2)*6.15;y=1.5+(i//2)*2.05;add_rect(s,x,y,5.65,1.5,PALE,PALE,True);circle(s,x+.25,y+.35,.55,col,str(i+1),WHITE,15);txt(s,x+1.0,y+.27,4.25,.27,head,16,NAVY,True);txt(s,x+1.0,y+.68,4.25,.55,body,13,INK) chip(s,2.0,6.15,9.3,'Urgent endocrine/critical-care input: suspected thyroid storm, severe heart failure, unstable AF, delirium or significant hepatic dysfunction.', 'FCE4D6','8B2A2A') #14 thionamides s=new(14,'Antithyroid drugs: use safely') # columns for x,head,cols,fill in [(0.75,'Methimazole / carbimazole',['Usually preferred outside first trimester','Inhibits thyroid peroxidase: oxidation, organification, coupling','Rare: agranulocytosis, cholestatic injury, rash'],PALE),(6.85,'Propylthiouracil (PTU)',['Inhibits TPO and peripheral T4→T3 conversion','Preferred in first trimester and thyroid storm','Rare but serious: hepatotoxicity, agranulocytosis, ANCA vasculitis'], 'FFF7E5')]: add_rect(s,x,1.45,5.7,3.65,fill,fill,True);txt(s,x+.25,1.73,5.1,.3,head,18,NAVY,True);bullets(s,x+.25,2.25,5.1,2.2,cols,14) add_rect(s,.95,5.55,11.4,.85,'FCE4D6','FCE4D6',True);txt(s,1.2,5.78,10.9,.32,'Safety counselling: stop drug and obtain urgent full blood count for fever or sore throat. Stop drug and check liver tests for jaundice, dark urine or significant abdominal symptoms.',13,'8B2A2A',True,PP_ALIGN.CENTER) #15 definitive s=new(15,'Definitive therapy: individualized selection') for x,head,who,limits,col in [(0.7,'Antithyroid drugs','Selected Graves disease; remission strategy; bridge to definitive therapy','Relapse; adverse effects; monitoring required',TEAL),(4.7,'Radioactive iodine','Effective definitive option for many adults','Contraindicated in pregnancy/lactation; may worsen orbitopathy',GOLD),(8.7,'Thyroidectomy','Large goitre, suspicious nodule, compressive symptoms, preference or rapid control','Requires experienced surgeon; lifelong levothyroxine',GREEN)]: add_rect(s,x,1.45,3.9,3.65,PALE,PALE,True);add_rect(s,x,1.45,3.9,.42,col,col,True);txt(s,x+.18,1.57,3.55,.22,head,16,WHITE,True,PP_ALIGN.CENTER);txt(s,x+.22,2.12,3.4,.26,'Best suited to',13,NAVY,True);txt(s,x+.22,2.46,3.4,.72,who,13,INK);txt(s,x+.22,3.48,3.4,.26,'Key limitation',13,NAVY,True);txt(s,x+.22,3.82,3.4,.7,limits,13,INK) chip(s,1.4,5.9,10.5,'Shared decision variables: disease cause, goitre size, orbitopathy, pregnancy plans, comorbidity, smoking, local expertise and patient preferences.',LILAC,NAVY) #16 storm s=new(16,'Thyroid storm: recognise and treat as an emergency') add_rect(s,.7,1.4,3.25,4.65,'FCE4D6','FCE4D6',True);txt(s,.95,1.72,2.75,.3,'Clinical clues',18,'8B2A2A',True);bullets(s,.95,2.25,2.75,2.7,['Fever, marked tachycardia, AF','CNS agitation, delirium or coma','GI/hepatic dysfunction','Heart failure, shock','Precipitant: infection, surgery, iodine, non-adherence'],14,'542222') steps=[('1','Resuscitate','Airway, oxygen, IV access, fluids judiciously; ICU input'),('2','Block adrenergic effects','Beta-blockade if haemodynamics permit'),('3','Block synthesis','PTU or methimazole'),('4','Block release','Iodide after thionamide'),('5','Block conversion / support','Glucocorticoid; treat precipitant; cooling')] for i,(n,h,b) in enumerate(steps): y=1.35+i*.96;circle(s,4.55,y+.08,.48,RED,n,WHITE,13);add_rect(s,5.2,y,6.9,.68,PALE,PALE,True);txt(s,5.35,y+.11,2.35,.21,h,13,NAVY,True);txt(s,7.65,y+.1,4.2,.32,b,12,INK) #17 vignette s=new(17,'Clinical vignette: apply the framework') add_rect(s,.75,1.35,5.45,4.9,'F2F7F9','D9ECF5',True);txt(s,1.0,1.65,4.95,.3,'A 32-year-old woman presents with palpitations, tremor and 6-kg weight loss.',17,NAVY,True);bullets(s,1.0,2.35,4.8,2.7,['Pulse 122/min, fine tremor, diffuse non-tender goitre','TSH <0.01 mIU/L; FT4 and FT3 elevated','No fever, delirium or heart failure','She is planning pregnancy within the next year'],15) add_rect(s,6.55,1.35,5.95,4.9,'FFF7E5','FFF7E5',True);txt(s,6.83,1.65,5.3,.3,'Resident tasks',17,NAVY,True) for i,t in enumerate(['1. Confirm biochemical thyrotoxicosis and assess severity','2. Seek Graves features and measure TRAb','3. Begin symptom control if no contraindication','4. Discuss thionamide choice, safety counselling and reproductive plan','5. Avoid radioactive iodine during pregnancy; plan specialist follow-up']): txt(s,6.9,2.25+i*.56,5.15,.35,t,14,INK) #18 takehome s=new(18,'Take-home points') for i,(big,small,col) in enumerate([('Anatomy guides safety','Know the RLN, parathyroids and vascular poles before procedures.',TEAL),('TSH is the starting signal','Interpret with FT4/FT3, context and assay limitations.',BLUE),('Mechanism determines treatment','Increased synthesis differs from thyroiditis or exogenous hormone.',GOLD),('Hyperthyroidism is not one disease','Graves, nodular disease and thyroiditis need different plans.',GREEN),('Storm is a protocol emergency','Resuscitate, block adrenergic effects, synthesis, release and conversion.',RED)]): y=1.35+i*.88;circle(s,.85,y,.45,col,str(i+1),WHITE,13);txt(s,1.5,y-.01,3.1,.23,big,15,NAVY,True);txt(s,4.55,y-.02,7.4,.28,small,13,INK) #19 references s=new(19,'Selected references and further reading') refs=['Harrison’s Principles of Internal Medicine. 22nd ed. 2025. Thyroid hormone synthesis, metabolism and action; thyrotoxicosis.','Ganong’s Review of Medical Physiology. 26th ed. Thyroid physiology and feedback regulation.','Ross DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016;26:1343-1421.','Kim KJ, et al. 2025 Korean Thyroid Association Management Guidelines for Radioactive Iodine Therapy in Patients with Hyperthyroidism. Endocrinol Metab (Seoul). 2025. PMID: 40598903.','Granieri et al. 2025 systematic evidence summarized in source review used for clinical update. This deck is educational and does not replace local protocols.'] bullets(s,.85,1.35,11.5,4.7,refs,14,spacing=15) add_rect(s,.9,6.05,11.45,.55,LILAC,LILAC,True);txt(s,1.1,6.22,11.0,.2,'Clinical note: use current local endocrine, obstetric, nuclear medicine and critical-care protocols for drug doses and emergency management.',11,NAVY,True,PP_ALIGN.CENTER) prs.save(OUT) print(OUT) PY python "/tmp/workspace/thyroid-resident-presentation/src/create_deck.py" python - <<'PY' from pptx import Presentation p='/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Anatomy_Physiology_and_Hyperthyroidism_Residents.pptx' prs=Presentation(p) print('slides',len(prs.slides)) for i,s in enumerate(prs.slides,1): t=' '.join(sh.text.replace('\n',' ') for sh in s.shapes if sh.has_text_frame) print(i, len(s.shapes), t[:85]) PY

2025 2026 guidelines management hyperthyroidism Graves disease antithyroid drugs radioactive iodine guideline

/tmp/workspace

~/thyroid-resident-presentation

https://e-enm.org/journal/view.php?number=2624

hyperthyroidism guideline

PMID: 40598903

PMID: 42219800

https://www.endocrinology.org/endocrinologist/144-summer-22/…

~/thyroid-resident-presentation/output

cat > "/tmp/workspace/thyroid-resident-presentation/src/add_guideline_update.py" <<'PY' from pptx import Presentation from pptx.util import Inches, Pt from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR from pptx.enum.text import PP_ALIGN from pptx.dml.color import RGBColor from pathlib import Path src=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Anatomy_Physiology_and_Hyperthyroidism_Residents.pptx') out=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Anatomy_Physiology_and_Hyperthyroidism_Residents_UPDATED_2026.pptx') prs=Presentation(src); blank=prs.slide_layouts[6] NAVY='123047';TEAL='007C83';BLUE='2D6EA3';PALE='F2F7F9';INK='19242C';MUTED='52616B';GOLD='F2B134';RED='C84B4B';GREEN='2F8F6B';WHITE='FFFFFF';LILAC='EEE9F6' def rgb(h): return RGBColor.from_string(h) def add_rect(s,x,y,w,h,fill,line=None,radius=False): sh=s.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE if radius else MSO_SHAPE.RECTANGLE, Inches(x), Inches(y), Inches(w), Inches(h));sh.fill.solid();sh.fill.fore_color.rgb=rgb(fill);sh.line.color.rgb=rgb(line or fill);return sh def txt(s,x,y,w,h,text,size=16,color=INK,bold=False,align=PP_ALIGN.LEFT,italic=False): b=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));t=b.text_frame;t.clear();t.word_wrap=True;t.margin_left=t.margin_right=Inches(.08);t.margin_top=t.margin_bottom=Inches(.06);p=t.paragraphs[0];p.alignment=align;r=p.add_run();r.text=text;r.font.name='Aptos';r.font.size=Pt(size);r.font.color.rgb=rgb(color);r.font.bold=bold;r.font.italic=italic;return b def bullets(s,x,y,w,h,items,size=14,color=INK,spacing=7): b=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));t=b.text_frame;t.clear();t.word_wrap=True;t.margin_left=Inches(.1);t.margin_right=Inches(.06);t.margin_top=Inches(.05) for i,item in enumerate(items): p=t.paragraphs[0] if i==0 else t.add_paragraph();p.text=item;p.level=0;p.font.name='Aptos';p.font.size=Pt(size);p.font.color.rgb=rgb(color);p.space_after=Pt(spacing);p.bullet=True return b def line(s,x1,y1,x2,y2,color=TEAL,width=2,arrow=False): l=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x1),Inches(y1),Inches(x2),Inches(y2));l.line.color.rgb=rgb(color);l.line.width=Pt(width) if arrow:l.line.end_arrowhead=True return l def title(s,n,h,sub=''): add_rect(s,0,0,13.333,.36,NAVY);txt(s,.55,.52,11.7,.45,h,26,NAVY,True);txt(s,12.15,.56,.55,.25,str(n),11,TEAL,True,PP_ALIGN.RIGHT) if sub:txt(s,.58,.98,11.8,.24,sub,11,MUTED) def footer(s): line(s,.55,7.12,12.78,7.12,'CBD8DD',.8);txt(s,.58,7.17,7,.18,'Endocrinology resident teaching | guideline update',8,MUTED);txt(s,10.65,7.17,2.1,.18,'Evidence updated Aug 2026',8,MUTED,align=PP_ALIGN.RIGHT) def new(n,h,sub=''): s=prs.slides.add_slide(blank);add_rect(s,0,0,13.333,7.5,WHITE);title(s,n,h,sub);footer(s);return s def chip(s,x,y,w,text,fill=LILAC,color=NAVY): add_rect(s,x,y,w,.4,fill,fill,True);txt(s,x+.04,y+.08,w-.08,.2,text,10,color,True,PP_ALIGN.CENTER) #20 s=new(20,'2025-2026 guideline update: what changes practice','Recent hyperthyroidism guidance to incorporate into resident decision-making') for x,y,head,body,col in [(.75,1.4,'RAI practice update','2025 Korean Thyroid Association guideline gives a fixed 10-15 mCi recommendation, adjusted for goitre size and clinical context.',GOLD),(6.85,1.4,'Peri-RAI antithyroid drugs','Stop antithyroid drugs 3-7 days before RAI. Restart only selectively after treatment, based on clinical risk.',TEAL),(.75,3.8,'RAI follow-up schedule','Check thyroid function at 4-6 weeks, then every 2-3 months until stable, then every 6-12 months.',BLUE),(6.85,3.8,'Eye disease protection','Use prophylactic glucocorticoids for mildly active thyroid eye disease; consider in other high-risk patients.',RED)]: add_rect(s,x,y,5.65,1.62,PALE,PALE,True);add_rect(s,x,y,5.65,.38,col,col,True);txt(s,x+.15,y+.08,5.35,.2,head,14,WHITE,True,PP_ALIGN.CENTER);txt(s,x+.2,y+.62,5.25,.72,body,13,INK) chip(s,1.35,6.15,10.7,'Source: 2025 Korean Thyroid Association RAI guideline (PMID: 40598903). Apply local nuclear medicine regulations and dosimetry pathways.', 'FFF7E5',NAVY) #21 s=new(21,'Guideline-directed management: special populations','Pregnancy, orbitopathy and recurrent disease require early specialist input') # columns for x,head,items,col in [(.7,'Pregnancy / preconception',['2026 ATA guideline updates care from preconception through postpartum.','Do not use radioactive iodine in pregnancy or lactation.','Use the lowest effective antithyroid-drug strategy with obstetric-endocrine coordination.','Review TRAb and fetal risk pathways under specialist care.'],TEAL),(4.75,'Graves orbitopathy',['Assess activity and severity; encourage smoking cessation.','Use multidisciplinary eye-thyroid care for active moderate-to-severe disease.','RAI needs caution in orbitopathy; steroid prophylaxis is recommended or considered based on risk.','Surgery or long-term ATD may be preferable in selected patients.'],RED),(8.8,'Relapse / definitive therapy',['Discuss RAI, surgery and longer-term ATD using shared decisions.','Surgery is favoured for compressive goitre or suspected malignancy and requires an experienced thyroid surgeon.','Monitor and treat post-definitive hypothyroidism.'],GREEN)]: add_rect(s,x,1.45,3.78,4.65,PALE,PALE,True);add_rect(s,x,1.45,3.78,.42,col,col,True);txt(s,x+.12,1.57,3.52,.2,head,15,WHITE,True,PP_ALIGN.CENTER);bullets(s,x+.18,2.15,3.42,3.4,items,12) #22 s=new(22,'Guideline update: resident action checklist','Use guidance to structure, not replace, individualized care') items=[('Before choosing therapy','Confirm cause, disease severity, pregnancy/lactation status, goitre characteristics, orbitopathy, comorbidity and patient goals.'),('If considering RAI','Confirm contraindications; review iodine exposure; coordinate ATD timing, eye-disease prophylaxis and planned biochemical follow-up.'),('If using a thionamide','Document baseline clinical assessment and safety counselling. Escalate promptly for fever/sore throat or hepatic symptoms.'),('If pregnant or planning pregnancy','Use current 2026 ATA pregnancy guidance and multidisciplinary review. Never use RAI in pregnancy/lactation.'),('If decompensated','Treat suspected thyroid storm as a critical-care emergency; do not wait for every confirmatory test.')] for i,(h,b) in enumerate(items): y=1.28+i*.93;add_rect(s,.8,y,11.75,.66,PALE,PALE,True);add_rect(s,.8,y,.18,.66,[TEAL,BLUE,GOLD,RED,GREEN][i],[TEAL,BLUE,GOLD,RED,GREEN][i]);txt(s,1.18,y+.12,2.35,.2,h,13,NAVY,True);txt(s,3.55,y+.1,8.65,.32,b,12,INK) chip(s,1.2,6.25,10.85,'Check guideline version, local protocol, drug availability and nuclear medicine requirements before prescribing.',LILAC,NAVY) #23 reference update s=new(23,'Updated guidelines: references') refs=['Kim KJ, Song E, Kim M, et al. 2025 Korean Thyroid Association Management Guidelines for Radioactive Iodine Therapy in Patients with Hyperthyroidism. Endocrinol Metab (Seoul). 2025. doi:10.3803/EnM.2025.2464. PMID: 40598903.','Korevaar TIM, Leung AM, Alexander EK, et al. American Thyroid Association 2026 Guidelines for Thyroid Disease in Preconception, Pregnancy, and Postpartum. Thyroid. 2026. doi:10.1177/10507256261445624. PMID: 42219800.','Ross DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016;26:1343-1421.','NICE NG145. Thyroid disease: assessment and management. Current online clinical guidance.','Guidance note: recommendations are contextual. This deck is for clinician education and does not replace institutional protocols or patient-specific specialist decision-making.'] bullets(s,.8,1.35,11.6,4.95,refs,14,spacing=16) add_rect(s,.8,6.12,11.75,.52,'FCE4D6','FCE4D6',True);txt(s,1.05,6.27,11.25,.18,'Update scope: 2025 RAI management and 2026 ATA pregnancy, preconception and postpartum guidance. No new 2025-2026 general ATA adult hyperthyroidism guideline was identified.',11,'8B2A2A',True,PP_ALIGN.CENTER) prs.save(out) print(out) PY python "/tmp/workspace/thyroid-resident-presentation/src/add_guideline_update.py" python - <<'PY' from pptx import Presentation from pathlib import Path p=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Anatomy_Physiology_and_Hyperthyroidism_Residents_UPDATED_2026.pptx') prs=Presentation(p) print('exists',p.exists(),'bytes',p.stat().st_size,'slides',len(prs.slides)) for i in range(19,23): s=prs.slides[i];t=' '.join(sh.text.replace('\n',' ') for sh in s.shapes if sh.has_text_frame) print(i+1,t[:180]) PY

2025 guideline hypothyroidism levothyroxine management European Thyroid Association

~/thyroid-resident-presentation

hypothyroidism levothyroxine

PMID: 40622204

cat > "/tmp/workspace/thyroid-resident-presentation/src/add_hypothyroidism.py" <<'PY' from pptx import Presentation from pptx.util import Inches, Pt from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR from pptx.enum.text import PP_ALIGN from pptx.dml.color import RGBColor from pathlib import Path src=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Anatomy_Physiology_and_Hyperthyroidism_Residents_UPDATED_2026.pptx') out=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Anatomy_Physiology_Hyperthyroidism_and_Hypothyroidism_Residents_2026.pptx') prs=Presentation(src); blank=prs.slide_layouts[6] NAVY='123047';TEAL='007C83';BLUE='2D6EA3';PALE='F2F7F9';INK='19242C';MUTED='52616B';GOLD='F2B134';RED='C84B4B';GREEN='2F8F6B';WHITE='FFFFFF';LILAC='EEE9F6' def rgb(h):return RGBColor.from_string(h) def rect(s,x,y,w,h,f,l=None,r=False): sh=s.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE if r else MSO_SHAPE.RECTANGLE, Inches(x), Inches(y), Inches(w), Inches(h));sh.fill.solid();sh.fill.fore_color.rgb=rgb(f);sh.line.color.rgb=rgb(l or f);return sh def text(s,x,y,w,h,t,sz=16,c=INK,b=False,a=PP_ALIGN.LEFT,it=False): tb=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));tf=tb.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=tf.margin_right=Inches(.08);tf.margin_top=tf.margin_bottom=Inches(.06);p=tf.paragraphs[0];p.alignment=a;r=p.add_run();r.text=t;r.font.name='Aptos';r.font.size=Pt(sz);r.font.color.rgb=rgb(c);r.font.bold=b;r.font.italic=it;return tb def bul(s,x,y,w,h,items,sz=14,c=INK): tb=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));tf=tb.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=Inches(.1);tf.margin_top=Inches(.05) for i,t in enumerate(items): p=tf.paragraphs[0] if i==0 else tf.add_paragraph();p.text=t;p.bullet=True;p.font.name='Aptos';p.font.size=Pt(sz);p.font.color.rgb=rgb(c);p.space_after=Pt(7) return tb def line(s,x1,y1,x2,y2,c=TEAL,w=2,arrow=False): sh=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x1),Inches(y1),Inches(x2),Inches(y2));sh.line.color.rgb=rgb(c);sh.line.width=Pt(w) if arrow:sh.line.end_arrowhead=True def head(s,n,h,sub=''): rect(s,0,0,13.333,.36,NAVY);text(s,.55,.52,11.5,.45,h,26,NAVY,True);text(s,12.1,.56,.65,.25,str(n),11,TEAL,True,PP_ALIGN.RIGHT) if sub:text(s,.58,.98,11.6,.24,sub,11,MUTED) line(s,.55,7.12,12.78,7.12,'CBD8DD',.8);text(s,.58,7.17,7,.18,'Endocrinology resident teaching | hypothyroidism update',8,MUTED);text(s,10.65,7.17,2.1,.18,'Evidence updated Aug 2026',8,MUTED,a=PP_ALIGN.RIGHT) def new(n,h,sub=''): s=prs.slides.add_slide(blank);rect(s,0,0,13.333,7.5,WHITE);head(s,n,h,sub);return s def chip(s,x,y,w,t,f=LILAC,c=NAVY):rect(s,x,y,w,.4,f,f,True);text(s,x+.04,y+.08,w-.08,.2,t,10,c,True,PP_ALIGN.CENTER) # 24 s=new(24,'Hypothyroidism: definition, causes and clinical spectrum','The diagnosis is biochemical, but context determines the cause and urgency') for x,y,h,b,col in [(.75,1.35,'Primary hypothyroidism','Thyroid gland failure. High TSH with low FT4 in overt disease.',TEAL),(6.85,1.35,'Central hypothyroidism','Pituitary or hypothalamic disease. Low or inappropriately normal TSH with low FT4.',BLUE),(.75,3.85,'Common causes','Hashimoto thyroiditis; post-RAI or thyroidectomy; drugs; iodine imbalance; transient thyroiditis.',GOLD),(6.85,3.85,'Clinical features','Fatigue, cold intolerance, constipation, weight gain, dry skin, bradycardia, delayed reflexes. Findings are nonspecific.',GREEN)]: rect(s,x,y,5.65,1.6,PALE,PALE,True);rect(s,x,y,5.65,.38,col,col,True);text(s,x+.12,y+.09,5.35,.2,h,14,WHITE,True,PP_ALIGN.CENTER);text(s,x+.22,y+.65,5.2,.64,b,13,INK) chip(s,1.55,6.15,10.2,'Emergency phenotype: myxoedema coma is rare but life-threatening. Treat urgently with critical-care and endocrine support.', 'FCE4D6','8B2A2A') #25 s=new(25,'Diagnostic approach: use TSH and FT4 correctly') # tree for x,y,w,h,t,c in [(5.0,1.2,3.3,.62,'Suspected hypothyroidism',TEAL),(5.0,2.18,3.3,.62,'TSH + FT4',BLUE),(1.0,3.55,3.45,.8,'TSH ↑ + FT4 ↓\nPrimary overt hypothyroidism',GREEN),(4.95,3.55,3.45,.8,'TSH ↑ + FT4 normal\nSubclinical hypothyroidism',GOLD),(8.9,3.55,3.45,.8,'FT4 ↓ + TSH low/normal\nConsider central hypothyroidism',RED)]: rect(s,x,y,w,h,PALE,PALE,True);rect(s,x,y,w,.35,c,c,True);text(s,x+.08,y+.12,w-.16,h-.15,t,13,NAVY,True,PP_ALIGN.CENTER) line(s,6.65,1.82,6.65,2.18,TEAL,2,True);line(s,6.65,2.82,2.72,3.53,TEAL,2,True);line(s,6.65,2.82,6.65,3.53,TEAL,2,True);line(s,6.65,2.82,10.62,3.53,TEAL,2,True) for x,t in [(1.05,'TPO antibodies support autoimmune thyroiditis.'),(5.0,'Repeat testing and assess symptoms, TSH trend and pregnancy status.'),(8.95,'Assess pituitary axes; exclude adrenal insufficiency before LT4.')]: rect(s,x,5.15,3.4,.82,'F9FBFC','D9ECF5',True);text(s,x+.1,5.34,3.2,.34,t,12,INK,a=PP_ALIGN.CENTER) #26 s=new(26,'Levothyroxine: first-line replacement therapy','2025 ETA guideline: optimize LT4 monotherapy by individualizing formulation, administration and monitoring') for x,h,items,col in [(.75,'Start thoughtfully',['Healthy adults with overt primary disease: full replacement is often appropriate.','Older adults, coronary disease or long-standing severe disease: start low and titrate.','Primary disease: titrate to TSH. Central disease: use FT4, not TSH, to guide dose.'],TEAL),(4.72,'Administer consistently',['Take on an empty stomach with water, consistently in relation to food.','Separate from calcium, iron, bile-acid sequestrants and other interfering products.','Review adherence, timing, drug interactions and malabsorption before escalating dose.'],BLUE),(8.69,'Monitor and adjust',['Recheck after a clinically appropriate interval following initiation or dose change, commonly 6-8 weeks.','Once stable, monitor periodically and after major weight, medication or physiologic changes.','Avoid overtreatment: AF, angina and bone loss risk.'],GOLD)]: rect(s,x,1.38,3.85,4.62,PALE,PALE,True);rect(s,x,1.38,3.85,.42,col,col,True);text(s,x+.1,1.51,3.62,.2,h,15,WHITE,True,PP_ALIGN.CENTER);bul(s,x+.18,2.1,3.42,3.35,items,12) chip(s,1.2,6.3,10.9,'2025 ETA update: LT4 monotherapy remains the mainstay; consider liquid or softgel LT4 when food, pharmacologic or GI factors impair tablet performance.', 'FFF7E5',NAVY) #27 s=new(27,'Subclinical hypothyroidism: avoid one-size-fits-all therapy','Elevated TSH with normal FT4 must be interpreted in context') for x,y,h,b,col in [(.75,1.4,'Usually treat or strongly consider','Persistent TSH ≥10 mIU/L; pregnancy-specific indications; selected symptomatic or high-risk patients after evaluation.',GREEN),(6.85,1.4,'Individualize / observe','Milder TSH elevation: repeat testing, TPO antibodies, symptoms, age, cardiovascular risk, goitre and patient preferences.',GOLD),(.75,4.05,'Before starting LT4','Confirm persistent abnormality. Consider transient illness, recovery phase, drugs and laboratory interference.',BLUE),(6.85,4.05,'If a therapeutic trial is used','Define objective goals and time point for reassessment. Stop or reconsider if no meaningful benefit and TSH is normalized.',TEAL)]: rect(s,x,y,5.65,1.6,PALE,PALE,True);rect(s,x,y,5.65,.38,col,col,True);text(s,x+.12,y+.09,5.35,.2,h,14,WHITE,True,PP_ALIGN.CENTER);text(s,x+.22,y+.65,5.2,.62,b,13,INK) #28 s=new(28,'Myxoedema coma: emergency recognition and first actions','This is decompensated severe hypothyroidism, often with a precipitant') rect(s,.75,1.35,3.3,4.85,'FCE4D6','FCE4D6',True);text(s,1.02,1.68,2.75,.28,'Look for',18,'8B2A2A',True);bul(s,1.0,2.22,2.8,2.85,['Altered mental status','Hypothermia','Bradycardia, hypotension','Hypoventilation / hypercapnia','Hyponatraemia, hypoglycaemia','Precipitant: infection, sedatives, cold exposure, MI'],14,'542222') steps=[('1','ICU / resuscitate','Airway, ventilation, careful fluids, warming, treat precipitant.'),('2','Check critical tests','TSH, FT4, cortisol, glucose, gases, electrolytes; do not delay treatment.'),('3','Give glucocorticoid first','Cover possible adrenal insufficiency before thyroid hormone.'),('4','Thyroid hormone','Use IV therapy and dosing per local critical-care/endocrine protocol.'),('5','Monitor continuously','Cardiac rhythm, temperature, ventilation, sodium, glucose and clinical response.')] for i,(n,h,b) in enumerate(steps): y=1.32+i*.95;rect(s,4.55,y,.48,.48,RED,RED,True);text(s,4.55,y+.11,.48,.18,n,13,WHITE,True,PP_ALIGN.CENTER);rect(s,5.2,y-.03,6.95,.66,PALE,PALE,True);text(s,5.35,y+.1,2.25,.2,h,13,NAVY,True);text(s,7.55,y+.08,4.35,.32,b,12,INK) #29 s=new(29,'Hypothyroidism: guideline update and references') refs=['Centanni M, Duntas L, Feldt-Rasmussen U, et al. ETA guidelines for the use of levothyroxine sodium preparations in monotherapy to optimize the treatment of hypothyroidism. Eur Thyroid J. 2025;14:e250123. doi:10.1530/ETJ-25-0123. PMID: 40622204.','Korevaar TIM, Leung AM, Alexander EK, et al. American Thyroid Association 2026 Guidelines for Thyroid Disease in Preconception, Pregnancy, and Postpartum. Thyroid. 2026. PMID: 42219800.','American Thyroid Association statement on desiccated thyroid extract, 2025: synthetic levothyroxine remains standard therapy; use regulated preparations and monitor clinically and biochemically.','Harrison’s Principles of Internal Medicine. 22nd ed. 2025. Hypothyroidism and thyroid hormone replacement.','Clinical note: dosing, pregnancy targets, myxoedema coma treatment and subclinical disease decisions should follow current local endocrine and obstetric protocols.'] bul(s,.8,1.3,11.65,4.9,refs,14) rect(s,.85,6.1,11.65,.54,LILAC,LILAC,True);text(s,1.05,6.26,11.25,.18,'Recent evidence note: no recent systematic review identified that overturns LT4 monotherapy as standard first-line therapy. The 2025 ETA guideline emphasizes individualized optimization.',11,NAVY,True,PP_ALIGN.CENTER) prs.save(out);print(out) PY python "/tmp/workspace/thyroid-resident-presentation/src/add_hypothyroidism.py" python - <<'PY' from pptx import Presentation from pathlib import Path p=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Anatomy_Physiology_Hyperthyroidism_and_Hypothyroidism_Residents_2026.pptx') prs=Presentation(p);print('exists',p.exists(),'bytes',p.stat().st_size,'slides',len(prs.slides)) for i in range(23,29): print(i+1, next((sh.text.replace('\n',' ') for sh in prs.slides[i].shapes if sh.has_text_frame and sh.text.strip()),'')[:100]) PY

2025 hyperthyroidism radioactive iodine follow up 4 6 weeks every 2 3 months guideline levothyroxine monitoring 6 8 weeks ETA 2025

~/thyroid-resident-presentation/output

cat > "/tmp/workspace/thyroid-resident-presentation/src/add_followup.py" <<'PY' from pptx import Presentation from pptx.util import Inches, Pt from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR from pptx.enum.text import PP_ALIGN from pptx.dml.color import RGBColor from pathlib import Path src=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Anatomy_Physiology_Hyperthyroidism_and_Hypothyroidism_Residents_2026.pptx') out=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Follow_Up_2026.pptx') prs=Presentation(src); blank=prs.slide_layouts[6] NAVY='123047';TEAL='007C83';BLUE='2D6EA3';PALE='F2F7F9';INK='19242C';MUTED='52616B';GOLD='F2B134';RED='C84B4B';GREEN='2F8F6B';WHITE='FFFFFF';LILAC='EEE9F6' def rgb(h):return RGBColor.from_string(h) def rect(s,x,y,w,h,f,l=None,r=False): sh=s.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE if r else MSO_SHAPE.RECTANGLE, Inches(x), Inches(y), Inches(w), Inches(h));sh.fill.solid();sh.fill.fore_color.rgb=rgb(f);sh.line.color.rgb=rgb(l or f);return sh def txt(s,x,y,w,h,t,sz=16,c=INK,b=False,a=PP_ALIGN.LEFT,it=False): tb=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));tf=tb.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=tf.margin_right=Inches(.08);tf.margin_top=tf.margin_bottom=Inches(.06);p=tf.paragraphs[0];p.alignment=a;r=p.add_run();r.text=t;r.font.name='Aptos';r.font.size=Pt(sz);r.font.color.rgb=rgb(c);r.font.bold=b;r.font.italic=it;return tb def bul(s,x,y,w,h,items,sz=14,c=INK,space=7): tb=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));tf=tb.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=Inches(.1);tf.margin_top=Inches(.05) for i,t in enumerate(items): p=tf.paragraphs[0] if i==0 else tf.add_paragraph();p.text=t;p.bullet=True;p.font.name='Aptos';p.font.size=Pt(sz);p.font.color.rgb=rgb(c);p.space_after=Pt(space) return tb def ln(s,x1,y1,x2,y2,c=TEAL,w=2,arr=False): sh=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT, Inches(x1),Inches(y1),Inches(x2),Inches(y2));sh.line.color.rgb=rgb(c);sh.line.width=Pt(w) if arr:sh.line.end_arrowhead=True def head(s,n,h,sub=''): rect(s,0,0,13.333,.36,NAVY);txt(s,.55,.52,11.5,.45,h,26,NAVY,True);txt(s,12.1,.56,.65,.25,str(n),11,TEAL,True,PP_ALIGN.RIGHT) if sub:txt(s,.58,.98,11.6,.24,sub,11,MUTED) ln(s,.55,7.12,12.78,7.12,'CBD8DD',.8);txt(s,.58,7.17,7,.18,'Endocrinology resident teaching | follow-up pathways',8,MUTED);txt(s,10.65,7.17,2.1,.18,'Evidence updated Aug 2026',8,MUTED,a=PP_ALIGN.RIGHT) def new(n,h,sub=''): s=prs.slides.add_slide(blank);rect(s,0,0,13.333,7.5,WHITE);head(s,n,h,sub);return s def chip(s,x,y,w,t,f=LILAC,c=NAVY):rect(s,x,y,w,.4,f,f,True);txt(s,x+.04,y+.08,w-.08,.2,t,10,c,True,PP_ALIGN.CENTER) #30 s=new(30,'Follow-up framework: what every thyroid visit should answer','A monitoring plan is therapy-specific, but each review should assess biochemistry, symptoms, safety and patient goals') for i,(h,b,c) in enumerate([('1. Biochemical status','TSH plus FT4/FT3 as appropriate to diagnosis, treatment phase and pituitary status.',TEAL),('2. Clinical response','Heart rate, weight, symptoms, menstrual/reproductive plans, cardiovascular and bone risk.',BLUE),('3. Safety / adherence','Drug adverse effects, dose timing, interacting drugs, iodine exposure and medication changes.',GOLD),('4. Disease-specific complications','Orbitopathy, goitre/nodule growth, AF, osteoporosis, postoperative hypocalcaemia or voice change.',RED),('5. Shared decisions','Revisit patient preference, definitive therapy, pregnancy planning and when to seek urgent care.',GREEN)]): y=1.32+i*.9;rect(s,.8,y,11.75,.65,PALE,PALE,True);rect(s,.8,y,.18,.65,c,c);txt(s,1.15,y+.12,2.5,.2,h,13,NAVY,True);txt(s,3.6,y+.1,8.55,.32,b,12,INK) chip(s,1.1,6.25,11.1,'Document baseline, target, next test date, safety-net advice and the clinician responsible for acting on abnormal results.',LILAC,NAVY) #31 RAI s=new(31,'Follow-up after radioactive iodine for hyperthyroidism','2025 KTA schedule: early biochemical surveillance is required because hypothyroidism may develop within weeks') steps=[('Pre-RAI','Review pregnancy/lactation exclusion, iodine exposure, ATD plan, eye disease risk and contraception advice per local protocol.'),('4-6 weeks','Check TSH + FT4. Do not rely on TSH alone early because suppression may persist.'),('Every 2-3 months','Repeat thyroid function tests until stable or TSH normalizes. Assess symptoms and need for antithyroid treatment.'),('When stable','Test every 6-12 months, lifelong. Start and titrate LT4 if hypothyroidism develops.'),('Escalate / refer','Persistent hyperthyroidism around 6 months, worsening orbitopathy, pregnancy planning or significant cardiac symptoms.')] for i,(a,b) in enumerate(steps): y=1.3+i*.89;rect(s,.85,y,2.0,.62,[GOLD,TEAL,BLUE,GREEN,RED][i],[GOLD,TEAL,BLUE,GREEN,RED][i],True);txt(s,.92,y+.16,1.85,.2,a,13,WHITE,True,PP_ALIGN.CENTER);rect(s,3.1,y,9.2,.62,PALE,PALE,True);txt(s,3.3,y+.1,8.85,.33,b,12,INK) #32 antithyroid / surgery s=new(32,'Follow-up after antithyroid drugs and thyroidectomy') for x,h,items,col in [(.75,'Antithyroid drugs', ['Track FT4 and FT3 early; TSH can remain suppressed and should not be the sole early titration marker.','At every review: symptoms, pulse, adverse effects, adherence and new iodine-containing medication.','Give written safety-net advice: stop drug and urgently check FBC for fever/sore throat; assess liver symptoms urgently.','At treatment completion: reassess TSH and TRAb where relevant; discuss relapse surveillance or definitive therapy.'],TEAL),(6.78,'Total thyroidectomy',['Early: wound, voice/RLN function, calcium symptoms and calcium/PTH pathway per local protocol.','Confirm LT4 replacement plan and arrange TSH-based dose titration in primary hypothyroidism.','Long term: monitor TSH periodically once stable; review symptoms, medication timing and pregnancy planning.','Refer promptly for hypocalcaemic symptoms, voice change, neck swelling or airway symptoms.'],GREEN)]: rect(s,x,1.35,5.8,4.88,PALE,PALE,True);rect(s,x,1.35,5.8,.44,col,col,True);txt(s,x+.15,1.49,5.48,.22,h,16,WHITE,True,PP_ALIGN.CENTER);bul(s,x+.24,2.1,5.25,3.6,items,13) #33 LT4 s=new(33,'Follow-up after starting or changing levothyroxine') for x,y,h,b,c in [(.75,1.35,'At initiation','Confirm indication, baseline TSH/FT4, cardiac risk, weight, pregnancy status and interacting medicines.',TEAL),(6.85,1.35,'After dose change','Recheck after steady state, commonly 6-8 weeks. Primary disease: TSH-guided. Central disease: FT4-guided.',BLUE),(.75,3.85,'When stable','Review at least periodically, commonly 6-12 monthly, and sooner with symptoms, pregnancy, weight change or new interacting drugs.',GREEN),(6.85,3.85,'If target not reached','Verify adherence and administration timing; review calcium/iron, PPIs, GI disease, food interactions and formulation before increasing dose.',GOLD)]: rect(s,x,y,5.65,1.55,PALE,PALE,True);rect(s,x,y,5.65,.38,c,c,True);txt(s,x+.12,y+.09,5.35,.2,h,14,WHITE,True,PP_ALIGN.CENTER);txt(s,x+.22,y+.65,5.2,.58,b,13,INK) chip(s,1.15,6.15,11.0,'Avoid biochemical over-replacement: assess palpitations, AF, angina and bone risk. In older adults and CAD, titrate cautiously.', 'FCE4D6','8B2A2A') #34 special follow up s=new(34,'Follow-up in pregnancy, orbitopathy and subclinical disease') for x,h,items,col in [(.7,'Pregnancy / postpartum',['Use the current 2026 ATA pregnancy guideline and local obstetric-endocrine pathway.','Check thyroid function more frequently than non-pregnant patients and after any dose adjustment.','Review TRAb and fetal/neonatal risk plan in current or previous Graves disease.','Never use RAI in pregnancy or lactation.'],RED),(4.75,'Graves orbitopathy',['At each review: eye pain, redness, diplopia, visual change, proptosis and smoking status.','Urgent ophthalmology input for reduced vision, color desaturation, corneal exposure or severe pain.','Coordinate treatment choice with orbitopathy activity and severity; review steroid prophylaxis if RAI is planned.'],TEAL),(8.8,'Subclinical thyroid dysfunction',['Repeat biochemical testing to establish persistence before committing to long-term treatment.','Monitor AF, bone and cardiovascular risk in subclinical hyperthyroidism.','For subclinical hypothyroidism, reassess TSH trajectory, TPO antibodies, symptoms, pregnancy plans and treatment response.'],GOLD)]: rect(s,x,1.35,3.78,4.82,PALE,PALE,True);rect(s,x,1.35,3.78,.42,col,col,True);txt(s,x+.1,1.49,3.57,.2,h,15,WHITE,True,PP_ALIGN.CENTER);bul(s,x+.18,2.07,3.38,3.45,items,12) #35 safety net s=new(35,'Safety-netting: when follow-up becomes urgent') alerts=[('Hyperthyroidism / treatment','Fever + sore throat while taking thionamide; jaundice or dark urine; chest pain, syncope, severe palpitations, heart failure, confusion or fever.',RED),('Hypothyroidism / LT4','Progressive drowsiness, hypothermia, hypoventilation, hypotension, severe bradycardia or hyponatraemia suggests possible decompensation.',BLUE),('Post-thyroidectomy','Stridor, neck swelling, bleeding, severe dyspnoea, perioral tingling, tetany or new persistent voice change.',GOLD),('Orbitopathy','Reduced acuity or colour vision, visual-field loss, corneal exposure, severe pain or rapidly worsening diplopia.',GREEN)] for i,(h,b,c) in enumerate(alerts): y=1.3+i*1.18;rect(s,.85,y,2.8,.8,c,c,True);txt(s,.98,y+.2,2.5,.26,h,13,WHITE,True,PP_ALIGN.CENTER);rect(s,3.95,y,8.35,.8,PALE,PALE,True);txt(s,4.15,y+.15,7.95,.44,b,13,INK) chip(s,1.3,6.25,10.7,'Residents: provide patient-specific written advice, contact route and documented timing of the next test or review.',LILAC,NAVY) #36 final checklist s=new(36,'Follow-up checklist: close the loop') for i,(a,b) in enumerate([('Before the patient leaves','Document diagnosis/cause, treatment target, next test date, safety advice and who reviews results.'),('At every biochemical review','Compare to prior trend, not an isolated value. Confirm dose, adherence, administration technique and interacting medicines.'),('When control is achieved','Define maintenance monitoring and relapse/complication surveillance. Plan for LT4 after definitive hyperthyroid treatment.'),('When circumstances change','Reassess promptly for pregnancy, new cardiac disease, frailty, medication changes, amiodarone/iodine exposure or surgery.'),('When uncertainty persists','Refer or discuss with endocrinology, nuclear medicine, thyroid surgery, ophthalmology or obstetrics as appropriate.')]): y=1.25+i*.9;rect(s,.85,y,.65,.65,[TEAL,BLUE,GREEN,GOLD,RED][i],[TEAL,BLUE,GREEN,GOLD,RED][i],True);txt(s,.85,y+.18,.65,.18,str(i+1),13,WHITE,True,PP_ALIGN.CENTER);txt(s,1.75,y+.1,2.8,.22,a,13,NAVY,True);txt(s,4.5,y+.08,7.6,.34,b,12,INK) chip(s,1.0,6.2,11.3,'These schedules are educational defaults. Individualize for diagnosis, severity, pregnancy, comorbidity, drug access and local protocols.', 'FFF7E5',NAVY) #37 refs s=new(37,'Follow-up pathways: selected sources') bul(s,.85,1.3,11.6,4.9,['Kim KJ, et al. 2025 Korean Thyroid Association Management Guidelines for Radioactive Iodine Therapy in Patients with Hyperthyroidism. Endocrinol Metab (Seoul). 2025. PMID: 40598903. RAI: test thyroid function at 4-6 weeks, every 2-3 months until stable, then every 6-12 months.','Centanni M, et al. ETA guidelines for levothyroxine monotherapy optimization. Eur Thyroid J. 2025. PMID: 40622204. Emphasizes individualized LT4 administration, formulation, interactions and monitoring.','Korevaar TIM, et al. ATA 2026 Guidelines for Thyroid Disease in Preconception, Pregnancy, and Postpartum. Thyroid. 2026. PMID: 42219800.','Ross DS, et al. ATA guideline for hyperthyroidism and thyrotoxicosis. Thyroid. 2016;26:1343-1421.','Use local hospital protocols for exact medication doses, pregnancy targets, calcium monitoring and emergency treatment.'],14) rect(s,.85,6.18,11.65,.48,LILAC,LILAC,True);txt(s,1.1,6.32,11.15,.16,'Follow-up guidance should be adapted to the individual patient and local referral systems.',11,NAVY,True,PP_ALIGN.CENTER) prs.save(out);print(out) PY python "/tmp/workspace/thyroid-resident-presentation/src/add_followup.py" python - <<'PY' from pptx import Presentation from pathlib import Path p=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Follow_Up_2026.pptx');prs=Presentation(p) print('exists',p.exists(),'bytes',p.stat().st_size,'slides',len(prs.slides),'last title:',next((sh.text for sh in prs.slides[-1].shapes if sh.has_text_frame and sh.text.strip()),'')) for i in range(29,37): print(i+1, next((sh.text.replace('\n',' ') for sh in prs.slides[i].shapes if sh.has_text_frame and sh.text.strip()),'')[:85]) PY

thyroid storm myxedema coma management guideline

2025 thyroid storm management guideline myxedema coma emergency management

~/thyroid-resident-presentation/output

cat > "/tmp/workspace/thyroid-resident-presentation/src/add_emergency_algorithm.py" <<'PY' from pptx import Presentation from pptx.util import Inches, Pt from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR from pptx.enum.text import PP_ALIGN from pptx.dml.color import RGBColor from pathlib import Path src=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Follow_Up_2026.pptx') out=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Emergencies_Algorithm_2026.pptx') prs=Presentation(src); blank=prs.slide_layouts[6] NAVY='123047';TEAL='007C83';BLUE='2D6EA3';PALE='F2F7F9';INK='19242C';MUTED='52616B';GOLD='F2B134';RED='C84B4B';GREEN='2F8F6B';WHITE='FFFFFF';LILAC='EEE9F6' def rgb(x):return RGBColor.from_string(x) def rect(s,x,y,w,h,f,l=None,r=False): sh=s.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE if r else MSO_SHAPE.RECTANGLE,Inches(x),Inches(y),Inches(w),Inches(h));sh.fill.solid();sh.fill.fore_color.rgb=rgb(f);sh.line.color.rgb=rgb(l or f);return sh def text(s,x,y,w,h,t,sz=16,c=INK,b=False,a=PP_ALIGN.LEFT): tb=s.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h));tf=tb.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=tf.margin_right=Inches(.07);tf.margin_top=tf.margin_bottom=Inches(.05);p=tf.paragraphs[0];p.alignment=a;r=p.add_run();r.text=t;r.font.name='Aptos';r.font.size=Pt(sz);r.font.color.rgb=rgb(c);r.font.bold=b;return tb def bullet(s,x,y,w,h,items,sz=13): tb=s.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h));tf=tb.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=Inches(.1);tf.margin_top=Inches(.04) for i,it in enumerate(items): p=tf.paragraphs[0] if i==0 else tf.add_paragraph();p.text=it;p.bullet=True;p.font.name='Aptos';p.font.size=Pt(sz);p.font.color.rgb=rgb(INK);p.space_after=Pt(6) return tb def line(s,x1,y1,x2,y2,c=TEAL,w=2,arr=True): sh=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT, Inches(x1),Inches(y1),Inches(x2),Inches(y2));sh.line.color.rgb=rgb(c);sh.line.width=Pt(w) if arr:sh.line.end_arrowhead=True def title(s,n,h,sub=''): rect(s,0,0,13.333,.36,NAVY);text(s,.55,.52,11.5,.45,h,26,NAVY,True);text(s,12.05,.56,.65,.25,str(n),11,TEAL,True,PP_ALIGN.RIGHT) if sub:text(s,.58,.98,11.5,.24,sub,11,MUTED) line(s,.55,7.12,12.78,7.12,'CBD8DD',.8,False);text(s,.58,7.17,7,.18,'Endocrinology resident teaching | thyroid emergencies',8,MUTED);text(s,10.55,7.17,2.2,.18,'Evidence updated Aug 2026',8,MUTED,a=PP_ALIGN.RIGHT) def new(n,h,sub=''): s=prs.slides.add_slide(blank);rect(s,0,0,13.333,7.5,WHITE);title(s,n,h,sub);return s def chip(s,x,y,w,t,f=LILAC,c=NAVY):rect(s,x,y,w,.38,f,f,True);text(s,x+.04,y+.08,w-.08,.18,t,10,c,True,PP_ALIGN.CENTER) # 38 entry s=new(38,'Thyroid emergencies: immediate triage algorithm','Treat on clinical suspicion. Send tests, but do not delay resuscitation or time-critical therapy.') rect(s,4.55,1.2,4.2,.75,RED,RED,True);text(s,4.7,1.38,3.9,.28,'UNWELL PATIENT WITH POSSIBLE THYROID EMERGENCY',15,WHITE,True,PP_ALIGN.CENTER) line(s,6.65,1.95,6.65,2.45,RED,2) rect(s,.85,2.5,3.7,1.45,'FCE4D6','FCE4D6',True);text(s,1.05,2.72,3.3,.24,'THYROID STORM?',17,'8B2A2A',True,PP_ALIGN.CENTER);text(s,1.08,3.1,3.23,.48,'Fever, marked tachycardia/AF, agitation or delirium, GI-hepatic dysfunction, heart failure or shock',12,INK,a=PP_ALIGN.CENTER) rect(s,8.78,2.5,3.7,1.45,'DDEDF7','DDEDF7',True);text(s,8.98,2.72,3.3,.24,'MYXOEDEMA COMA?',17,NAVY,True,PP_ALIGN.CENTER);text(s,9.0,3.1,3.23,.48,'Altered mental status, hypothermia, bradycardia, hypotension, hypoventilation, hyponatraemia',12,INK,a=PP_ALIGN.CENTER) line(s,6.65,2.45,2.75,2.5,TEAL,2);line(s,6.65,2.45,10.6,2.5,BLUE,2) rect(s,2.0,4.45,9.3,.72,PALE,PALE,True);text(s,2.18,4.64,8.94,.25,'BOTH PATHWAYS: ABCDE, senior/ICU + endocrinology call, monitor ECG and temperature, IV access, bedside glucose, focused history and precipitant search.',13,NAVY,True,PP_ALIGN.CENTER) line(s,2.75,3.96,4.55,4.45,TEAL,2);line(s,10.6,3.96,8.8,4.45,BLUE,2) chip(s,1.3,5.75,4.9,'Storm: start multimodal treatment immediately','FCE4D6','8B2A2A');chip(s,7.2,5.75,4.9,'Myxoedema coma: ICU and IV hormone pathway','DDEDF7',NAVY) # 39 storm algorithm s=new(39,'Algorithm A: suspected thyroid storm','Sequence matters: block adrenergic effects and synthesis before administering iodide') steps=[('0','Call for help / ICU','ABCDE, ECG, continuous monitoring, cautious fluids, oxygen/ventilation as required; send TFTs, CBC, U&E, LFTs, glucose, gases, cultures if indicated.'),('1','Control adrenergic toxicity','Beta-blockade if haemodynamics and heart failure status permit. Avoid aggressive beta-blockade in decompensated heart failure or shock; seek critical-care input.'),('2','Block new synthesis','Give PTU or methimazole per local protocol. Do not wait for laboratory confirmation if clinical suspicion is high.'),('3','Block hormone release','Give iodide only after thionamide has been administered, following local protocol.'),('4','Reduce conversion / support','Glucocorticoid; active cooling, acetaminophen, nutrition and glucose support as needed. Avoid salicylates.'),('5','Find and treat precipitant','Infection, surgery/trauma, iodine exposure, non-adherence, MI, PE, stroke, DKA or parturition.')] for i,(n,h,b) in enumerate(steps): y=1.22+i*.78;rect(s,.75,y,.52,.52,RED,RED,True);text(s,.75,y+.13,.52,.18,n,12,WHITE,True,PP_ALIGN.CENTER);rect(s,1.47,y-.02,2.55,.58,TEAL if i in [1,2,3] else PALE,TEAL if i in [1,2,3] else PALE,True);text(s,1.58,y+.13,2.32,.18,h,12,WHITE if i in [1,2,3] else NAVY,True,PP_ALIGN.CENTER);rect(s,4.28,y-.02,8.15,.58,PALE,PALE,True);text(s,4.42,y+.08,7.85,.36,b,11,INK) chip(s,1.15,6.25,11.0,'If shock, severe heart failure or refractory storm: critical care, cardiology and endocrine co-management; consider rescue strategies under specialist direction.', 'FFF7E5',NAVY) #40 myxedema s=new(40,'Algorithm B: suspected myxoedema coma','Assume coexisting adrenal insufficiency until excluded') steps=[('0','ICU / resuscitate','Airway and ventilation, cardiac monitoring, cautious fluids, treat hypoglycaemia and hyponatraemia; passive rewarming only.'),('1','Draw critical bloods','TSH, FT4, cortisol, glucose, electrolytes, blood gases, CBC, cultures and tests for precipitant. Do not delay treatment.'),('2','Give glucocorticoid first','Administer stress-dose glucocorticoid as per local protocol before thyroid hormone, unless adrenal insufficiency has been excluded.'),('3','Give thyroid hormone','Use IV levothyroxine pathway, with optional liothyronine in selected cases, under ICU/endocrine direction and local dosing protocol.'),('4','Treat precipitant','Sepsis, sedatives/opioids, cold exposure, stroke, MI, GI bleed, trauma or medication non-adherence.'),('5','Reassess frequently','Temperature, ventilation/CO₂, BP, rhythm, urine output, sodium, glucose, FT4 trend and neurological status.')] for i,(n,h,b) in enumerate(steps): y=1.22+i*.78;rect(s,.75,y,.52,.52,BLUE,BLUE,True);text(s,.75,y+.13,.52,.18,n,12,WHITE,True,PP_ALIGN.CENTER);rect(s,1.47,y-.02,2.55,.58,BLUE if i in [2,3] else PALE,BLUE if i in [2,3] else PALE,True);text(s,1.58,y+.13,2.32,.18,h,12,WHITE if i in [2,3] else NAVY,True,PP_ALIGN.CENTER);rect(s,4.28,y-.02,8.15,.58,PALE,PALE,True);text(s,4.42,y+.08,7.85,.36,b,11,INK) chip(s,1.1,6.25,11.15,'Do not use oral-dose shortcuts or fixed emergency doses from a teaching slide. Follow local ICU/endocrine protocol and adjust for age, frailty and cardiac disease.', 'FCE4D6','8B2A2A') #41 comparison s=new(41,'Thyroid emergency quick comparison and escalation triggers') headers=['Feature','Thyroid storm','Myxoedema coma'] width=[2.55,4.8,4.8];x=.65;y=1.25 for j,h in enumerate(headers): xx=x+sum(width[:j]);rect(s,xx,y,width[j],.45,NAVY,NAVY);text(s,xx+.04,y+.1,width[j]-.08,.18,h,12,WHITE,True,PP_ALIGN.CENTER) rows=[('Temperature','Usually high; may be normal in older adults','Low'),('Cardiovascular','Tachycardia, AF, heart failure, shock','Bradycardia, hypotension, low output'),('CNS','Agitation, delirium, psychosis, coma','Lethargy, confusion, stupor or coma'),('Core treatment','Beta-blockade if suitable + thionamide → iodide + steroid + precipitant treatment','ICU support + glucocorticoid before IV thyroid hormone + precipitant treatment'),('Escalate now','Shock, severe HF, refractory tachyarrhythmia, hyperthermia, deterioration','Ventilatory failure, refractory hypotension, arrhythmia, worsening coma')] for i,row in enumerate(rows): yy=y+.45+i*.76 for j,v in enumerate(row): xx=x+sum(width[:j]);rect(s,xx,yy,width[j],.76,PALE if i%2==0 else WHITE,'D9ECF5');text(s,xx+.09,yy+.11,width[j]-.18,.48,v,11,INK,j==0,PP_ALIGN.CENTER if j==0 else PP_ALIGN.LEFT) chip(s,.95,6.2,11.4,'Emergency-care principle: diagnostic scores and biochemical results support the diagnosis, but do not delay treatment of a clinically unstable patient.',LILAC,NAVY) # 42 refs s=new(42,'Thyroid emergencies algorithm: sources and local adaptation') bullet(s,.85,1.35,11.6,4.8,['Kruithoff ML, et al. Thyroid Emergencies: A Narrative Review. 2025. PMID: 40553957.','Rosen’s Emergency Medicine: Concepts and Clinical Practice. Thyroid storm: treat suspected cases with PTU/methimazole, then iodine, beta-blockade as appropriate, corticosteroids, resuscitation, cooling and precipitant management.','American Thyroid Association guidance on hypothyroidism and hyperthyroidism remains a key source for emergency pathways; use current institutional protocols for drug choice and dosing.','Myxoedema coma requires ICU management, thyroid hormone replacement, glucocorticoids, supportive care and treatment of the precipitating illness.','This resident-level algorithm intentionally omits fixed doses. Use local ICU, pharmacy, endocrine, obstetric and cardiac protocols for patient-specific dosing and contraindications.'],14) rect(s,.85,6.2,11.65,.48,LILAC,LILAC,True);text(s,1.1,6.33,11.15,.18,'Emergency treatment must be individualized and supervised. Early expert input is a treatment, not an optional extra.',11,NAVY,True,PP_ALIGN.CENTER) prs.save(out);print(out) PY python "/tmp/workspace/thyroid-resident-presentation/src/add_emergency_algorithm.py" python - <<'PY' from pptx import Presentation from pathlib import Path p=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Emergencies_Algorithm_2026.pptx'); prs=Presentation(p) print('exists',p.exists(),'bytes',p.stat().st_size,'slides',len(prs.slides)) for i in range(37,42): print(i+1, next((x.text.replace('\n',' ') for x in prs.slides[i].shapes if x.has_text_frame and x.text.strip()),'')[:125]) PY

thyroid storm myxedema coma emergency management algorithm ICU guideline

~/thyroid-resident-presentation/output

cat > "/tmp/workspace/thyroid-resident-presentation/src/add_visual_flowcharts.py" <<'PY' from pptx import Presentation from pptx.util import Inches, Pt from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR from pptx.enum.text import PP_ALIGN from pptx.dml.color import RGBColor from pathlib import Path src=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Emergencies_Algorithm_2026.pptx') out=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Visual_Emergency_Flowcharts_2026.pptx') prs=Presentation(src); blank=prs.slide_layouts[6] NAVY='123047';TEAL='007C83';BLUE='2D6EA3';PALE='F2F7F9';INK='19242C';MUTED='52616B';GOLD='F2B134';RED='C84B4B';GREEN='2F8F6B';WHITE='FFFFFF';LILAC='EEE9F6';PINK='FCE4D6';ICE='DDEDF7' def rgb(c):return RGBColor.from_string(c) def shp(s,typ,x,y,w,h,fill,line=None): a=s.shapes.add_shape(typ, Inches(x), Inches(y), Inches(w), Inches(h));a.fill.solid();a.fill.fore_color.rgb=rgb(fill);a.line.color.rgb=rgb(line or fill);return a def box(s,x,y,w,h,t,fill=PALE, color=INK, size=13,bold=True,typ=MSO_SHAPE.ROUNDED_RECTANGLE): a=shp(s,typ,x,y,w,h,fill);tf=a.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=tf.margin_right=Inches(.08);tf.margin_top=tf.margin_bottom=Inches(.06);p=tf.paragraphs[0];p.alignment=PP_ALIGN.CENTER;r=p.add_run();r.text=t;r.font.name='Aptos';r.font.size=Pt(size);r.font.bold=bold;r.font.color.rgb=rgb(color);return a def txt(s,x,y,w,h,t,sz=15,c=INK,b=False,a=PP_ALIGN.LEFT): a=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));tf=a.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=tf.margin_right=Inches(.06);tf.margin_top=tf.margin_bottom=Inches(.04);p=tf.paragraphs[0];p.alignment=a;r=p.add_run();r.text=t;r.font.name='Aptos';r.font.size=Pt(sz);r.font.bold=b;r.font.color.rgb=rgb(c);return a def arrow(s,x1,y1,x2,y2,c=TEAL,w=2): a=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x1),Inches(y1),Inches(x2),Inches(y2));a.line.color.rgb=rgb(c);a.line.width=Pt(w);a.line.end_arrowhead=True def title(s,n,t,sub): shp(s,MSO_SHAPE.RECTANGLE,0,0,13.333,.36,NAVY);txt(s,.55,.52,11.5,.42,t,26,NAVY,True);txt(s,.58,.98,11.5,.24,sub,11,MUTED);txt(s,12.05,.56,.65,.22,str(n),11,TEAL,True,PP_ALIGN.RIGHT) arrow(s,.55,7.12,12.78,7.12,'CBD8DD',.8);txt(s,.58,7.17,7,.18,'Endocrinology resident teaching | visual emergency flowcharts',8,MUTED);txt(s,10.55,7.17,2.2,.18,'Evidence updated Aug 2026',8,MUTED,a=PP_ALIGN.RIGHT) def new(n,t,sub): s=prs.slides.add_slide(blank);shp(s,MSO_SHAPE.RECTANGLE,0,0,13.333,7.5,WHITE);title(s,n,t,sub);return s # 43 thyroid storm visual s=new(43,'Visual flowchart: suspected thyroid storm','Clinical instability overrides waiting for confirmatory laboratory results') box(s,4.15,1.25,5.05,.58,'SUSPECTED THYROID STORM',RED,WHITE,17) arrow(s,6.67,1.83,6.67,2.18,RED,2.5) box(s,3.78,2.2,5.78,.65,'ABCDE + ICU/ENDOCRINOLOGY CALL + ECG MONITORING',NAVY,WHITE,14) arrow(s,6.67,2.85,6.67,3.2,NAVY,2.2) # central sequential pathway steps=[('1','CONTROL ADRENERGIC TOXICITY','Beta-blocker only if haemodynamics permit','TEAL'),('2','BLOCK NEW HORMONE SYNTHESIS','PTU or methimazole per local protocol','TEAL'),('3','THEN BLOCK HORMONE RELEASE','Iodide only after thionamide','GOLD'),('4','REDUCE CONVERSION + SUPPORT','Glucocorticoid; cooling; fluids/nutrition','BLUE'),('5','TREAT THE PRECIPITANT','Infection, MI, PE, stroke, iodine, non-adherence','GREEN')] for i,(n,h,b,c) in enumerate(steps): y=3.3+i*.6;box(s,.95,y,.55,.42,n,c,WHITE,12);box(s,1.65,y,3.5,.42,h,c,WHITE,11);box(s,5.4,y,6.65,.42,b,PALE,INK,11,False) if i<4: arrow(s,6.67,y+.42,6.67,y+.59,c,1.8) # decision warning box(s,9.65,1.6,2.45,.92,'SHOCK OR\nDECOMPENSATED HF?',PINK,'8B2A2A',13,True,MSO_SHAPE.DIAMOND) arrow(s,9.1,2.2,9.62,2.08,RED,2) txt(s,10.0,2.72,1.95,.45,'Avoid aggressive beta-blockade.\nCritical-care/cardiology input.',11,'8B2A2A',True,PP_ALIGN.CENTER) box(s,1.0,6.27,11.2,.45,'DO NOT GIVE IODIDE BEFORE A THIONAMIDE. Avoid salicylates. Use local dosing and contraindication protocols.',PINK,'8B2A2A',11,True) #44 myxedema visual s=new(44,'Visual flowchart: suspected myxoedema coma','The first endocrine action is glucocorticoid coverage before thyroid hormone') box(s,4.15,1.22,5.05,.58,'SUSPECTED MYXOEDEMA COMA',BLUE,WHITE,17) arrow(s,6.67,1.8,6.67,2.15,BLUE,2.5) box(s,3.58,2.17,6.18,.65,'ICU: ABCDE, AIRWAY/VENTILATION, CARDIAC MONITORING',NAVY,WHITE,14) arrow(s,6.67,2.82,6.67,3.13,NAVY,2.2) steps=[('1','DRAW BLOODS, DO NOT DELAY TREATMENT','TSH, FT4, cortisol, gases, glucose, U&E, cultures','TEAL'),('2','GIVE STRESS-DOSE GLUCOCORTICOID','Assume possible adrenal insufficiency until excluded','RED'),('3','GIVE IV THYROID HORMONE PATHWAY','IV LT4 ± T3 in selected cases, specialist-directed','BLUE'),('4','SUPPORT + TREAT PRECIPITANT','Cautious fluids, passive rewarming, ventilation, sepsis care','GOLD'),('5','REASSESS FREQUENTLY','Temperature, CO₂, BP, rhythm, sodium, glucose, neurologic state','GREEN')] for i,(n,h,b,c) in enumerate(steps): y=3.22+i*.6;box(s,.95,y,.55,.42,n,c,WHITE,12);box(s,1.65,y,3.62,.42,h,c,WHITE,11);box(s,5.52,y,6.5,.42,b,PALE,INK,11,False) if i<4: arrow(s,6.67,y+.42,6.67,y+.59,c,1.8) box(s,9.62,1.5,2.55,1.0,'ADRENAL\nINSUFFICIENCY NOT\nEXCLUDED?',PINK,'8B2A2A',12,True,MSO_SHAPE.DIAMOND) arrow(s,9.7,2.42,8.65,3.43,RED,2) txt(s,10.0,2.75,1.95,.45,'Glucocorticoid\ncomes first.',11,'8B2A2A',True,PP_ALIGN.CENTER) box(s,1.0,6.27,11.2,.45,'NO FIXED DOSES ON THIS FLOWCHART: use local ICU/endocrine protocol, especially in frail patients or those with cardiac disease.',PINK,'8B2A2A',11,True) # 45 decision flowchart s=new(45,'Visual decision flowchart: distinguish the two emergencies','Use syndrome recognition, immediate stabilization and the correct treatment sequence') box(s,4.3,1.2,4.7,.58,'THYROID EMERGENCY SUSPECTED',NAVY,WHITE,16) arrow(s,6.65,1.78,6.65,2.15,NAVY,2.4) box(s,4.55,2.18,4.2,.75,'Fever / tachyarrhythmia / agitation\nOR hypothermia / bradycardia / hypoventilation?',LILAC,NAVY,13,True,MSO_SHAPE.DIAMOND) arrow(s,5.48,2.93,2.8,3.62,RED,2);arrow(s,7.85,2.93,10.55,3.62,BLUE,2) box(s,.78,3.65,4.05,.75,'THYROID STORM PHENOTYPE\nHypermetabolic + cardiovascular/CNS decompensation',PINK,'8B2A2A',13) box(s,8.52,3.65,4.05,.75,'MYXOEDEMA COMA PHENOTYPE\nHypometabolic + CNS/respiratory decompensation',ICE,NAVY,13) arrow(s,2.8,4.4,2.8,4.85,RED,2);arrow(s,10.55,4.4,10.55,4.85,BLUE,2) box(s,.78,4.9,4.05,1.2,'ICU + ABCDE\nβ-blockade if suitable → thionamide → iodide → steroid\nTreat precipitant',RED,WHITE,13) box(s,8.52,4.9,4.05,1.2,'ICU + ABCDE\nGlucocorticoid → IV thyroid hormone pathway\nTreat precipitant',BLUE,WHITE,13) box(s,4.95,4.8,3.7,1.25,'SHARED\nSend tests and cultures, but do not delay treatment.\nContinuous ECG, temperature and metabolic monitoring.',PALE,NAVY,12) box(s,1.0,6.45,11.35,.34,'Immediately escalate for shock, respiratory failure, severe heart failure, refractory arrhythmia, coma, hyperthermia or hypothermia.',GOLD,NAVY,11,True) #46 references s=new(46,'Visual emergency algorithms: implementation note') for x,y,h,b,c in [(.8,1.4,'Use during teaching','The visual flowcharts summarize the preceding algorithm slides; they are designed for resident orientation and team communication.',TEAL),(6.85,1.4,'Use at the bedside','Use the local emergency drug, ICU, pharmacy and endocrine protocol for patient-specific drug choice, dose, route and monitoring.',RED),(.8,3.85,'Evidence base','Thyroid storm and myxoedema coma require early recognition, ICU support, hormone-directed therapy and treatment of triggers.',BLUE),(6.85,3.85,'Clinical safeguard','Neither a score nor an absent laboratory result excludes a clinically unstable patient. Escalate early and treat on suspicion.',GOLD)]: box(s,x,y,5.65,1.45,h,c,WHITE,15);txt(s,x+.22,y+.58,5.15,.52,b,12,INK,a=PP_ALIGN.CENTER) box(s,.9,6.08,11.5,.52,'Sources: 2025 narrative review of thyroid emergencies, emergency medicine texts, and ATA thyroid hormone and thyrotoxicosis guidance. Verify current local protocols.',LILAC,NAVY,11) prs.save(out);print(out) PY python "/tmp/workspace/thyroid-resident-presentation/src/add_visual_flowcharts.py" python - <<'PY' from pptx import Presentation from pathlib import Path p=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Visual_Emergency_Flowcharts_2026.pptx');prs=Presentation(p) print('exists',p.exists(),'bytes',p.stat().st_size,'slides',len(prs.slides)) for i in range(42,46): print(i+1, next((s.text.replace('\n',' ') for s in prs.slides[i].shapes if s.has_text_frame and s.text.strip()),'')[:120], 'shapes',len(prs.slides[i].shapes)) PY

python -c "p='/tmp/workspace/thyroid-resident-presentation/src/add_visual_flowcharts.py'; s=open(p).read(); s=s.replace(\" a=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));tf=a.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=tf.margin_right=Inches(.06);tf.margin_top=tf.margin_bottom=Inches(.04);p=tf.paragraphs[0];p.alignment=a;r=p.add_run();r.text=t;r.font.name='Aptos';r.font.size=Pt(sz);r.font.bold=b;r.font.color.rgb=rgb(c);return a\",\" tb=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));tf=tb.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=tf.margin_right=Inches(.06);tf.margin_top=tf.margin_bottom=Inches(.04);p=tf.paragraphs[0];p.alignment=a;r=p.add_run();r.text=t;r.font.name='Aptos';r.font.size=Pt(sz);r.font.bold=b;r.font.color.rgb=rgb(c);return tb\"); open(p,'w').write(s)" && python "/tmp/workspace/thyroid-resident-presentation/src/add_visual_flowcharts.py" && python -c "from pptx import Presentation; from pathlib import Path; p=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Visual_Emergency_Flowcharts_2026.pptx'); prs=Presentation(p); print('exists',p.exists(),'bytes',p.stat().st_size,'slides',len(prs.slides)); [print(i+1, next((sh.text.replace(chr(10),' ') for sh in prs.slides[i].shapes if sh.has_text_frame and sh.text.strip()),''),len(prs.slides[i].shapes)) for i in range(42,46)]"

python -c "p='/tmp/workspace/thyroid-resident-presentation/src/add_visual_flowcharts.py'; s=open(p).read(); s=s.replace(\"for i,(n,h,b,c) in enumerate(steps):\\n y=3.3+i*.6;\",\"for i,(n,h,b,c) in enumerate(steps):\\n c=globals().get(c,c)\\n y=3.3+i*.6;\"); s=s.replace(\"for i,(n,h,b,c) in enumerate(steps):\\n y=3.22+i*.6;\",\"for i,(n,h,b,c) in enumerate(steps):\\n c=globals().get(c,c)\\n y=3.22+i*.6;\"); open(p,'w').write(s)" && python "/tmp/workspace/thyroid-resident-presentation/src/add_visual_flowcharts.py" && python -c "from pptx import Presentation; from pathlib import Path; p=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Visual_Emergency_Flowcharts_2026.pptx'); prs=Presentation(p); print('exists',p.exists(),'bytes',p.stat().st_size,'slides',len(prs.slides)); [print(i+1, next((sh.text.replace(chr(10),' ') for sh in prs.slides[i].shapes if sh.has_text_frame and sh.text.strip()),''),len(prs.slides[i].shapes)) for i in range(42,46)]"

python -c "p='/tmp/workspace/thyroid-resident-presentation/src/add_visual_flowcharts.py'; s=open(p).read(); s=s.replace(\"s=new(46,'Visual emergency algorithms: implementation note')\",\"s=new(46,'Visual emergency algorithms: implementation note','Use these diagrams alongside local ICU/endocrine protocols')\"); open(p,'w').write(s)" && python "/tmp/workspace/thyroid-resident-presentation/src/add_visual_flowcharts.py" && python -c "from pptx import Presentation; from pathlib import Path; p=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Visual_Emergency_Flowcharts_2026.pptx'); prs=Presentation(p); print('exists',p.exists(),'bytes',p.stat().st_size,'slides',len(prs.slides)); [print(i+1, next((sh.text.replace(chr(10),' ') for sh in prs.slides[i].shapes if sh.has_text_frame and sh.text.strip()),''),len(prs.slides[i].shapes)) for i in range(42,46)]"

~/thyroid-resident-presentation/output

python-pptx add speaker notes notes_slide notes_text_frame

python - <<'PY' from pptx import Presentation p='/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Visual_Emergency_Flowcharts_2026.pptx' prs=Presentation(p) for i in [37,38,39,40,42,43,44,45]: s=prs.slides[i] print(i+1, hasattr(s,'notes_slide')) ns=s.notes_slide print(' notes shapes',len(ns.shapes), [(sh.name, sh.has_text_frame, (sh.text[:80] if sh.has_text_frame else '')) for sh in ns.shapes]) print('notes_text_frame',hasattr(ns,'notes_text_frame'), getattr(ns,'notes_text_frame',None)) PY

~/thyroid-resident-presentation/output

python "/tmp/workspace/thyroid-resident-presentation/src/add_visual_flowcharts.py" && python - <<'PY' from pptx import Presentation p='/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Visual_Emergency_Flowcharts_2026.pptx' prs=Presentation(p) print('slides',len(prs.slides)) s=prs.slides[42] ns=s.notes_slide print('notes shapes',[(sh.name, sh.has_text_frame, sh.text if sh.has_text_frame else '') for sh in ns.shapes]) print('has notes text',hasattr(ns,'notes_text_frame')) PY

ls -la "/tmp/workspace/thyroid-resident-presentation" && ls -la "/tmp/workspace/thyroid-resident-presentation/src" && python - <<'PY' from pptx import Presentation p='/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Follow_Up_2026.pptx' prs=Presentation(p) s=prs.slides[-1] print('slide',len(prs.slides),'notes attr',hasattr(s,'notes_slide')) ns=s.notes_slide print('notes shapes',[(x.name,x.has_text_frame,x.text if x.has_text_frame else '') for x in ns.shapes]) print('notes_text',hasattr(ns,'notes_text_frame'),getattr(ns,'notes_text_frame',None)) PY

cat > "/tmp/workspace/thyroid-resident-presentation/src/add_emergency_flowcharts_notes.py" <<'PY' from pptx import Presentation from pptx.util import Inches, Pt from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR from pptx.enum.text import PP_ALIGN from pptx.dml.color import RGBColor from pathlib import Path src=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_Follow_Up_2026.pptx') out=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Emergency_Flowcharts_With_Speaker_Notes_2026.pptx') prs=Presentation(src); blank=prs.slide_layouts[6] NAVY='123047'; TEAL='007C83'; BLUE='2D6EA3'; PALE='F2F7F9'; INK='19242C'; MUTED='52616B'; GOLD='F2B134'; RED='C84B4B'; GREEN='2F8F6B'; WHITE='FFFFFF'; LILAC='EEE9F6'; PINK='FCE4D6'; ICE='DDEDF7' def C(v): return RGBColor.from_string(v) def shape(s,typ,x,y,w,h,fill,line=None): a=s.shapes.add_shape(typ,Inches(x),Inches(y),Inches(w),Inches(h));a.fill.solid();a.fill.fore_color.rgb=C(fill);a.line.color.rgb=C(line or fill);return a def text(s,x,y,w,h,body,size=14,color=INK,bold=False,align=PP_ALIGN.LEFT): a=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));tf=a.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=tf.margin_right=Inches(.07);tf.margin_top=tf.margin_bottom=Inches(.05);p=tf.paragraphs[0];p.alignment=align;r=p.add_run();r.text=body;r.font.name='Aptos';r.font.size=Pt(size);r.font.bold=bold;r.font.color.rgb=C(color);return a def box(s,x,y,w,h,body,fill=PALE,color=INK,size=13,bold=True,typ=MSO_SHAPE.ROUNDED_RECTANGLE): a=shape(s,typ,x,y,w,h,fill);tf=a.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=tf.margin_right=Inches(.08);tf.margin_top=tf.margin_bottom=Inches(.06);p=tf.paragraphs[0];p.alignment=PP_ALIGN.CENTER;r=p.add_run();r.text=body;r.font.name='Aptos';r.font.size=Pt(size);r.font.bold=bold;r.font.color.rgb=C(color);return a def arrow(s,x1,y1,x2,y2,color=TEAL,width=2): a=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x1),Inches(y1),Inches(x2),Inches(y2));a.line.color.rgb=C(color);a.line.width=Pt(width);a.line.end_arrowhead=True def notes(slide,body): tf=slide.notes_slide.notes_text_frame tf.text=body for p in tf.paragraphs: for r in p.runs: r.font.name='Aptos';r.font.size=Pt(12) def header(s,n,title,subtitle): shape(s,MSO_SHAPE.RECTANGLE,0,0,13.333,.36,NAVY);text(s,.55,.52,11.4,.42,title,25,NAVY,True);text(s,.58,.98,11.5,.24,subtitle,11,MUTED);text(s,12.12,.56,.55,.22,str(n),11,TEAL,True,PP_ALIGN.RIGHT) a=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(.55),Inches(7.12),Inches(12.78),Inches(7.12));a.line.color.rgb=C('CBD8DD');a.line.width=Pt(.8) text(s,.58,7.17,7,.18,'Endocrinology resident teaching | thyroid emergencies',8,MUTED);text(s,10.55,7.17,2.2,.18,'Evidence updated Aug 2026',8,MUTED,align=PP_ALIGN.RIGHT) def new(n,title,sub): s=prs.slides.add_slide(blank);shape(s,MSO_SHAPE.RECTANGLE,0,0,13.333,7.5,WHITE);header(s,n,title,sub);return s # Slide 38 s=new(38,'Thyroid emergencies: visual triage algorithm','Treat clinically unstable patients on suspicion while tests are being collected') box(s,4.2,1.22,4.9,.62,'UNWELL PATIENT: POSSIBLE THYROID EMERGENCY',RED,WHITE,16) arrow(s,6.65,1.84,6.65,2.18,RED,2.5) box(s,3.6,2.2,6.1,.6,'ABCDE + ICU/ENDOCRINOLOGY CALL + ECG/TEMPERATURE MONITORING',NAVY,WHITE,14) arrow(s,6.65,2.8,2.8,3.5,TEAL,2);arrow(s,6.65,2.8,10.55,3.5,BLUE,2) box(s,.75,3.55,4.1,.95,'HYPERMETABOLIC PHENOTYPE\nFever, marked tachycardia/AF, agitation, GI-hepatic dysfunction, heart failure/shock',PINK,'8B2A2A',13) box(s,8.48,3.55,4.1,.95,'HYPOMETABOLIC PHENOTYPE\nHypothermia, altered mental state, bradycardia, hypotension, hypoventilation',ICE,NAVY,13) arrow(s,2.8,4.5,2.8,5.05,RED,2);arrow(s,10.55,4.5,10.55,5.05,BLUE,2) box(s,.75,5.1,4.1,.88,'THYROID STORM\nFollow storm sequence: stabilize → block adrenergic toxicity → thionamide → iodide → steroid',RED,WHITE,13) box(s,8.48,5.1,4.1,.88,'MYXOEDEMA COMA\nFollow coma sequence: stabilize → glucocorticoid → IV thyroid hormone pathway',BLUE,WHITE,13) box(s,4.9,4.95,3.5,1.1,'SHARED ACTIONS\nBloods, glucose, gases, cultures as indicated. Identify and treat precipitant. Do not delay therapy for results.',PALE,NAVY,12) notes(s,"""Teaching points\n• Open by stating that thyroid storm and myxoedema coma are syndromes of decompensation. Laboratory values can support the diagnosis but should not delay life-saving treatment.\n• Ask residents to name the phenotypic clues that separate hypermetabolic storm from hypometabolic coma.\n• The first common action is ABCDE assessment, continuous monitoring, early critical-care support and endocrine input.\n• A frequent error is to treat the thyroid number rather than the physiology. Shock, respiratory failure and altered consciousness take priority.\n• Both emergencies usually have a trigger: infection, myocardial ischemia, trauma, surgery, medication non-adherence, iodine exposure or sedating drugs.\n• State clearly that the subsequent slides give sequencing principles, not fixed doses. Use the local ICU/endocrine/pharmacy protocol for patient-specific prescribing.""") # slide 39 storm s=new(39,'Visual flowchart: suspected thyroid storm','Sequence is clinically important: thionamide precedes iodide') box(s,4.25,1.18,4.8,.56,'SUSPECTED THYROID STORM',RED,WHITE,17);arrow(s,6.65,1.74,6.65,2.05,RED,2.5) box(s,3.65,2.07,6.0,.58,'ABCDE + ICU/ENDOCRINE CALL + ECG + TEMPERATURE',NAVY,WHITE,14) steps=[('1','CONTROL ADRENERGIC TOXICITY','Beta-blocker only if haemodynamics permit',TEAL),('2','BLOCK NEW SYNTHESIS','PTU or methimazole per local protocol',TEAL),('3','THEN BLOCK RELEASE','Iodide only after thionamide',GOLD),('4','REDUCE CONVERSION + SUPPORT','Glucocorticoid, cooling, fluids and glucose support',BLUE),('5','TREAT THE TRIGGER','Infection, MI, PE, stroke, iodine, non-adherence',GREEN)] for i,(n,h,b,c) in enumerate(steps): y=2.95+i*.62;box(s,.85,y,.55,.43,n,c,WHITE,12);box(s,1.62,y,3.55,.43,h,c,WHITE,11);box(s,5.4,y,6.85,.43,b,PALE,INK,11,False) if i<4:arrow(s,6.65,y+.43,6.65,y+.61,c,1.6) box(s,9.5,1.15,2.45,.92,'SHOCK OR\nDECOMPENSATED HF?',PINK,'8B2A2A',12,True,MSO_SHAPE.DIAMOND);arrow(s,9.4,2.05,8.55,3.17,RED,1.7) text(s,9.65,2.3,2.05,.42,'Avoid aggressive beta-blockade.\nEscalate ICU/cardiology.',11,'8B2A2A',True,PP_ALIGN.CENTER) box(s,1.05,6.2,11.15,.42,'CRITICAL SEQUENCE: never give iodide before a thionamide. Avoid salicylates. Follow local dosing and contraindication guidance.',PINK,'8B2A2A',11) notes(s,"""Teaching points\n• Begin with the bedside question: is this severe thyrotoxicosis with systemic decompensation? Do not wait for a Burch-Wartofsky score or final free hormone result if the clinical picture is convincing.\n• Explain why beta-blockade is conditional. It is helpful for adrenergic toxicity but can precipitate collapse in shock or decompensated heart failure. In that setting, involve critical care and cardiology before escalating.\n• Emphasize the order: thionamide first to prevent new synthesis, then iodide to block release. Giving iodide first can provide substrate for hormone synthesis in a hyperfunctioning gland.\n• Glucocorticoids reduce peripheral conversion and cover possible relative adrenal insufficiency. Supportive care includes cooling, cautious fluids and correction of glucose abnormalities. Avoid aspirin because it can increase free thyroid hormone.\n• Always actively search for and treat the precipitant. Infection is common, but do not miss acute coronary syndrome, PE, stroke, DKA, trauma or iodine exposure.\n• Fixed drug doses are deliberately omitted. Use local emergency protocols and account for pregnancy, liver disease, heart failure and drug availability.""") # slide 40 coma s=new(40,'Visual flowchart: suspected myxoedema coma','Glucocorticoid coverage precedes the IV thyroid-hormone pathway') box(s,4.15,1.18,5.0,.56,'SUSPECTED MYXOEDEMA COMA',BLUE,WHITE,17);arrow(s,6.65,1.74,6.65,2.05,BLUE,2.5) box(s,3.5,2.07,6.3,.58,'ICU: ABCDE, AIRWAY/VENTILATION, CARDIAC MONITORING',NAVY,WHITE,14) steps=[('1','DRAW CRITICAL BLOODS','TSH, FT4, cortisol, gases, glucose, U&E and cultures',TEAL),('2','GIVE GLUCOCORTICOID FIRST','Assume possible adrenal insufficiency until excluded',RED),('3','IV THYROID HORMONE PATHWAY','IV LT4 ± T3 in selected cases, specialist-directed',BLUE),('4','SUPPORT + TREAT TRIGGER','Passive rewarming, ventilation, cautious fluids, sepsis care',GOLD),('5','REASSESS FREQUENTLY','CO₂, BP, rhythm, sodium, glucose, neurological state',GREEN)] for i,(n,h,b,c) in enumerate(steps): y=2.95+i*.62;box(s,.85,y,.55,.43,n,c,WHITE,12);box(s,1.62,y,3.62,.43,h,c,WHITE,11);box(s,5.48,y,6.75,.43,b,PALE,INK,11,False) if i<4:arrow(s,6.65,y+.43,6.65,y+.61,c,1.6) box(s,9.42,1.15,2.58,.98,'ADRENAL\nINSUFFICIENCY NOT\nEXCLUDED?',PINK,'8B2A2A',12,True,MSO_SHAPE.DIAMOND);arrow(s,9.3,2.1,8.5,3.2,RED,1.7) text(s,9.65,2.34,2.05,.4,'Glucocorticoid\ncomes first.',11,'8B2A2A',True,PP_ALIGN.CENTER) box(s,1.05,6.2,11.15,.42,'NO FIXED DOSES HERE: use the local ICU/endocrine protocol and modify treatment for age, frailty and cardiac disease.',PINK,'8B2A2A',11) notes(s,"""Teaching points\n• Correct the name: myxoedema coma does not require coma. Altered mental state, hypothermia and hypoventilation in severe hypothyroidism should trigger the pathway.\n• This is an ICU problem. Anticipate ventilatory failure, hypercapnia, hypotension, hyponatraemia, hypoglycaemia and infection.\n• Draw cortisol and other tests promptly, but give stress-dose glucocorticoid before thyroid hormone because unrecognized adrenal insufficiency may worsen with treatment.\n• Explain that thyroid hormone is generally delivered through an IV pathway under specialist direction; the balance between LT4 and optional T3 depends on illness severity and cardiac risk.\n• Supportive measures are active clinical treatment: protect the airway, ventilate where required, use passive rather than aggressive rewarming, correct metabolic problems carefully and treat the precipitating illness.\n• Review response using physiology and FT4 trend rather than expecting rapid TSH normalization.""") # slide 41 comparison s=new(41,'Visual decision flowchart: distinguish the emergencies','Syndrome recognition and treatment sequence are more important than a single laboratory value') box(s,4.25,1.15,4.8,.55,'THYROID EMERGENCY SUSPECTED',NAVY,WHITE,16);arrow(s,6.65,1.7,6.65,2.08,NAVY,2.2) box(s,4.55,2.1,4.2,.75,'Fever/tachyarrhythmia/agitation\nOR hypothermia/bradycardia/hypoventilation?',LILAC,NAVY,13,True,MSO_SHAPE.DIAMOND) arrow(s,5.48,2.85,2.75,3.55,RED,2);arrow(s,7.84,2.85,10.55,3.55,BLUE,2) box(s,.72,3.6,4.1,.82,'STORM PHENOTYPE\nHypermetabolic + cardiovascular/CNS decompensation',PINK,'8B2A2A',13);box(s,8.48,3.6,4.1,.82,'COMA PHENOTYPE\nHypometabolic + CNS/respiratory decompensation',ICE,NAVY,13) arrow(s,2.77,4.42,2.77,4.9,RED,2);arrow(s,10.53,4.42,10.53,4.9,BLUE,2) box(s,.72,4.95,4.1,1.0,'ICU + ABCDE\nBeta-blockade if suitable → thionamide → iodide → steroid\nTreat precipitant',RED,WHITE,13);box(s,8.48,4.95,4.1,1.0,'ICU + ABCDE\nGlucocorticoid → IV thyroid-hormone pathway\nTreat precipitant',BLUE,WHITE,13) box(s,4.94,4.88,3.72,1.12,'SHARED\nSend tests/cultures but do not delay therapy.\nContinuous ECG, temperature and metabolic monitoring.',PALE,NAVY,12) box(s,1.0,6.25,11.35,.38,'Escalate immediately for shock, respiratory failure, severe heart failure, refractory arrhythmia, coma, hyperthermia or hypothermia.',GOLD,NAVY,11) notes(s,"""Teaching points\n• Use this slide as a rapid recap. Ask the audience to identify which pathway they would choose for two short vignettes: one febrile patient with AF and delirium, and one hypothermic patient with CO2 retention and confusion.\n• Reinforce that both pathways start with ICU-level ABCDE care and active precipitant management.\n• The pivotal difference is treatment sequence. Storm requires thionamide before iodide. Myxoedema coma requires glucocorticoid before thyroid hormone.\n• Tell residents that thyroid function tests may be discordant in critical illness, but they do not overrule an unstable clinical syndrome.\n• Urgent escalation criteria are physiological, not endocrine-specific: shock, respiratory failure, life-threatening arrhythmia, severe heart failure or reduced consciousness.""") # slide 42 source / teaching s=new(42,'Teaching points and implementation safeguards','Use the flowcharts for orientation, then follow the patient-specific local emergency protocol') for x,y,h,b,c in [(.8,1.35,'Use during teaching','Pause at each decision diamond and ask what would change management: shock, heart failure, pregnancy, liver disease, respiratory failure or suspected adrenal insufficiency.',TEAL),(6.85,1.35,'Use at bedside','The flowchart is not a prescription. Use current ICU, endocrine, pharmacy, cardiology and obstetric protocols for drug selection, route, dose and monitoring.',RED),(.8,3.85,'Communication','Assign roles: airway/ventilation, medication preparation, precipitant screen, endocrine contact and results follow-up. Repeat closed-loop communication.',BLUE),(6.85,3.85,'Debrief after stabilization','Review precipitant, definitive thyroid therapy, medication adherence, follow-up TFT plan and patient safety-net counselling.',GOLD)]: box(s,x,y,5.65,.4,h,c,WHITE,15);text(s,x+.22,y+.55,5.15,.55,b,12,INK,align=PP_ALIGN.CENTER) box(s,.9,6.12,11.5,.48,'Suggested sources: 2025 narrative review of thyroid emergencies, ATA hyperthyroidism and hypothyroidism guidance, and local emergency protocols.',LILAC,NAVY,11) notes(s,"""Teaching points\n• Explain that these notes and flowcharts are educational aids, not a substitute for local protocols. The deliberate omission of doses prevents unsafe use out of context.\n• Encourage residents to identify their hospital's thyroid storm, myxoedema coma and critical-care order sets before they need them.\n• Simulation tip: assign roles and rehearse the two sequence errors that cause harm: iodide before thionamide in storm, and thyroid hormone before adrenal coverage in suspected myxoedema coma.\n• End by asking learners what they will document before transfer of care: working diagnosis, trigger, therapy sequence, response, pending tests and escalation plan.""") prs.save(out);print(out) PY python "/tmp/workspace/thyroid-resident-presentation/src/add_emergency_flowcharts_notes.py" python - <<'PY' from pptx import Presentation from pathlib import Path p=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Emergency_Flowcharts_With_Speaker_Notes_2026.pptx') prs=Presentation(p) print('exists',p.exists(),'bytes',p.stat().st_size,'slides',len(prs.slides)) for n in range(38,43): sl=prs.slides[n-1] print(n, 'notes:', bool(sl.notes_slide.notes_text_frame.text.strip()), 'chars:', len(sl.notes_slide.notes_text_frame.text)) PY

2025 ETA levothyroxine hypothyroidism guideline monitoring administration speaker notes key recommendations

~/thyroid-resident-presentation/output

cat > "/tmp/workspace/thyroid-resident-presentation/src/add_hypothyroidism_notes.py" <<'PY' from pptx import Presentation from pptx.util import Pt from pathlib import Path src=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Emergency_Flowcharts_With_Speaker_Notes_2026.pptx') out=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_All_Speaker_Notes_2026.pptx') prs=Presentation(src) notes={ 24: '''Teaching points • Distinguish primary hypothyroidism, where the thyroid gland fails and TSH rises, from central hypothyroidism, where TSH is not a reliable marker of thyroid hormone replacement. • Hashimoto thyroiditis is a common cause in iodine-sufficient regions, but always review prior radioiodine, thyroid surgery, neck irradiation, amiodarone, lithium and immune-checkpoint inhibitor exposure. • Symptoms are nonspecific. Do not diagnose or dose-adjust using fatigue or weight alone without biochemical context. • Myxoedema coma is a syndrome of decompensated severe hypothyroidism. The patient does not need to be comatose. Escalate early if there is altered mentation, hypothermia, hypoventilation or shock. • Teaching prompt: ask residents to identify which historical feature would make central hypothyroidism more likely: pituitary surgery, head irradiation, postpartum haemorrhage, visual field symptoms or another pituitary hormone deficit.''', 25: '''Teaching points • In primary thyroid disease, TSH is generally the best first-line test. Interpret it with FT4 to classify overt versus subclinical hypothyroidism. • A low FT4 with a low or inappropriately normal TSH suggests central hypothyroidism. This is not “normal TSH.” It is inappropriate for the FT4 concentration. • Before starting LT4 in suspected central hypothyroidism, evaluate the adrenal axis or give glucocorticoid coverage if adrenal insufficiency is possible. • TPO antibodies support autoimmune thyroiditis, but they do not by themselves determine treatment in every patient with a normal FT4. • Recheck a borderline abnormality, especially if illness, recovery from illness, laboratory interference or medications could account for it. • Teaching prompt: use three lab panels and ask the audience to name the pattern and next investigation.''', 26: '''Teaching points • Levothyroxine monotherapy remains the standard first-line replacement treatment. The goal is biochemical and clinical euthyroidism, not symptom treatment alone. • Starting dose is individualized. Younger adults without cardiac disease can often start closer to full replacement, while older patients and those with coronary disease should start cautiously and titrate. • Administration consistency is one of the highest-yield counselling points. Confirm timing relative to meals, calcium, iron, bile-acid sequestrants, acid-suppressing therapy and adherence before increasing a dose. • In primary hypothyroidism, titrate using TSH after steady state is reached. In central hypothyroidism, use FT4 and clinical context because TSH cannot guide replacement reliably. • The 2025 ETA guidance highlights factors that impair tablet performance and supports individualized consideration of liquid or softgel preparations when appropriate. • Do not prescribe fixed doses from this slide. Follow local formulary, patient weight, age, cardiac status and pregnancy pathways.''', 27: '''Teaching points • Subclinical hypothyroidism means elevated TSH with normal FT4. It is a biochemical state, not an automatic indication for lifelong treatment. • Confirm persistence before committing the patient to therapy. TSH can fluctuate with illness, recovery, medications and age. • Stronger reasons to treat or discuss treatment include persistent TSH at or above 10 mIU/L, pregnancy-related indications, progressive TSH rise, goitre, selected symptoms and patient-specific cardiovascular or reproductive considerations. • In milder TSH elevation, shared decision-making matters. Discuss uncertainty of symptom benefit, treatment burden and a plan for reassessment. • If using a therapeutic trial, document what outcome counts as benefit and when therapy will be reviewed or stopped. • Teaching prompt: ask residents what data they need before treating a 75-year-old with TSH 6.5 mIU/L and normal FT4.''', 28: '''Teaching points • Myxoedema coma is an endocrine emergency requiring ICU-level management. It may present as confusion rather than frank coma. • Stabilization is simultaneous with diagnostic work-up: airway and ventilation, cardiovascular monitoring, glucose and sodium management, and treatment of the precipitant. • Draw cortisol if possible, but give stress-dose glucocorticoid before thyroid hormone when adrenal insufficiency has not been excluded. • Use IV thyroid hormone through the local endocrine and critical-care pathway. Dose choice requires adjustment for age, frailty and cardiac disease. • Avoid aggressive active rewarming because vasodilation can worsen hypotension. Passive rewarming is generally preferred. • Monitoring should focus on ventilation and carbon dioxide retention, haemodynamics, rhythm, sodium, glucose, temperature and neurological status. TSH will not normalize quickly and should not drive acute decisions.''', 29: '''Teaching points • Emphasize the hierarchy of evidence for this section: the 2025 ETA guideline focuses on optimizing LT4 monotherapy in real-world care, and the 2026 ATA guideline updates pregnancy-related thyroid care. • The practical resident message is to individualize formulation, administration, monitoring and referral rather than reflexively adding T3 or escalating LT4 when TSH is not at target. • Persistent symptoms despite normalized TSH should prompt a structured review for adherence, interaction, malabsorption, incorrect diagnosis and non-thyroid causes. • Synthetic regulated levothyroxine remains standard replacement therapy. Discuss non-standard products carefully and use local regulatory and endocrine guidance. • Use this reference slide to show learners where to find the guideline source, then remind them to follow local protocols for pregnancy targets and emergency dosing.''', 33: '''Teaching points • After any LT4 initiation or dose change, allow sufficient time to reach a new steady state before routine reassessment. A common teaching interval is 6 to 8 weeks, unless clinical urgency requires earlier review. • In primary hypothyroidism, TSH is used for titration. In central hypothyroidism, FT4 is used, usually aiming for an appropriate part of the reference range under endocrine supervision. • If the value is unexpected, ask four questions before changing the dose: Is the diagnosis correct? Is the dose being taken correctly? Is there an interaction or malabsorption problem? Has pregnancy, weight, illness or a new medicine changed the requirement? • Overtreatment is clinically important. Look for palpitations, angina, atrial fibrillation and fracture or bone-loss risk, especially in older adults. • Stable patients still need periodic review and earlier testing when pregnancy starts, medication changes occur or symptoms recur.''', 34: '''Teaching points • Pregnancy and postpartum thyroid disease should be managed with current obstetric-endocrine guidance. The interval of testing is usually shorter than in non-pregnant adults and targets are pregnancy specific. • In current or previous Graves disease, TRAb assessment and fetal-neonatal planning may be needed even when the mother is euthyroid after definitive therapy. • Never use radioactive iodine during pregnancy or lactation. • In Graves orbitopathy, ask directly about pain, diplopia, red eye, reduced visual acuity, impaired colour vision and exposure symptoms. Visual symptoms require urgent ophthalmology assessment. • For subclinical thyroid dysfunction, repeat testing establishes persistence. Management is based on risk profile, symptoms, age, pregnancy plans, atrial fibrillation risk and bone health rather than a single number.''' } for slide_no, body in notes.items(): slide=prs.slides[slide_no-1] tf=slide.notes_slide.notes_text_frame tf.text=body for p in tf.paragraphs: for r in p.runs: r.font.name='Aptos'; r.font.size=Pt(12) prs.save(out) print(out) PY python "/tmp/workspace/thyroid-resident-presentation/src/add_hypothyroidism_notes.py" python - <<'PY' from pptx import Presentation from pathlib import Path p=Path('/tmp/workspace/thyroid-resident-presentation/output/Thyroid_Residents_Complete_With_All_Speaker_Notes_2026.pptx') prs=Presentation(p) check=[24,25,26,27,28,29,33,34,38,39,40,41,42] print('exists',p.exists(),'bytes',p.stat().st_size,'slides',len(prs.slides)) for n in check: t=prs.slides[n-1].notes_slide.notes_text_frame.text print(n, bool(t.strip()), len(t)) PY