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const fs = require('fs');

// ─── Helper functions ────────────────────────────────────────────
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// ─── DOCUMENT CONTENT ────────────────────────────────────────────

const children = [

  // ===== TITLE PAGE =====
  new Paragraph({
    children: [new TextRun({ text: "GPSC INTERVIEW PREPARATION", bold: true, size: 52, color: "1F3864" })],
    alignment: AlignmentType.CENTER,
    spacing: { before: 600, after: 120 }
  }),
  new Paragraph({
    children: [new TextRun({ text: "Emergency Medicine & Clinical Case Guide", bold: true, size: 36, color: "2E74B5" })],
    alignment: AlignmentType.CENTER,
    spacing: { after: 80 }
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  new Paragraph({
    children: [new TextRun({ text: "Based on 2025 AHA/WHO/India National Guidelines", italics: true, size: 24, color: "595959" })],
    alignment: AlignmentType.CENTER,
    spacing: { after: 600 }
  }),

  page_break(),

  // ===========================
  // SECTION 1: CARDIAC EMERGENCY
  // ===========================
  h1("SECTION 1: CARDIAC EMERGENCIES"),

  h2("1.1 CARDIAC ARREST – BLS / ACLS (AHA 2025 Guidelines)"),
  h3("Emergency Case Scenario"),
  para("A 58-year-old male collapses at home. Unresponsive, no breathing, no pulse detected."),

  h3("Immediate Management – Chain of Survival (2025 AHA: Unified 6-link)"),
  bold_bullet("1. Safety & Recognition: ", "Check scene safety. Confirm unresponsiveness, no normal breathing within 10 sec."),
  bold_bullet("2. Activate EMS: ", "Call 108 (India). Send for AED."),
  bold_bullet("3. High-Quality CPR: ", "Rate 100-120/min, depth 5-6 cm (adult), full recoil, minimize interruptions (<10 sec pause). Compression:Ventilation = 30:2."),
  bold_bullet("4. Defibrillation: ", "Shock ASAP for shockable rhythms (VF/pulseless VT). 1st shock within 3 min for in-hospital arrest."),
  bold_bullet("5. Advanced Life Support: ","Airway (ETT/LMA), IV/IO access, drugs."),
  bold_bullet("6. Post-Resuscitation Care: ", "Targeted Temperature Management, PCI if indicated."),

  h3("ACLS Drug Protocol"),
  two_col_table([
    ["Drug", "Dose / Route"],
    ["Epinephrine (adrenaline)", "1 mg IV/IO every 3-5 min (give early in non-shockable)"],
    ["Amiodarone (VF/pulseless VT)", "1st dose 300 mg IV/IO; 2nd dose 150 mg"],
    ["Lidocaine (alt to amiodarone)", "1-1.5 mg/kg IV/IO; 0.5-0.75 mg/kg for repeat"],
    ["Sodium Bicarbonate", "1 mEq/kg IV in hyperkalemia / TCA overdose"],
    ["Calcium Chloride 10%", "500-1000 mg IV in hyperkalemia / CCB toxicity"],
    ["Magnesium Sulfate", "1-2 g IV for Torsades de Pointes"],
    ["Atropine", "NOT recommended for PEA/asystole; 0.5 mg IV for symptomatic bradycardia"],
  ]),

  h3("Key 2025 AHA Updates"),
  bullet("Unified single 6-link Chain of Survival (replaced separate adult/child chains)"),
  bullet("Mechanical CPR devices (AutoPulse/LUCAS) - NO survival benefit; hand CPR preferred"),
  bullet("Epinephrine: give as soon as possible for non-shockable rhythms"),
  bullet("Double sequential defibrillation (DSD): considered for refractory VF"),
  bullet("Amiodarone vs Lidocaine: both acceptable; no clear superiority"),
  bullet("Post-ROSC: Targeted Temperature Management (TTM) 32-36°C for 24h; avoid fever"),

  h3("Reversible Causes - 5H5T Rule"),
  bold_bullet("5H: ", "Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia"),
  bold_bullet("5T: ", "Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary)"),

  new Paragraph({ spacing: { after: 120 } }),
  h2("1.2 ACUTE MI (STEMI) - Emergency Management"),
  h3("Emergency Case Scenario"),
  para("A 55-year-old male presents with crushing chest pain radiating to left arm for 2 hours. Diaphoretic, BP 90/60, ECG: ST elevation in V1-V4."),

  h3("Immediate Management - TIME IS MUSCLE"),
  bold_bullet("MONA protocol (initial): ", "Morphine 2-4 mg IV (cautious), Oxygen if SpO2 <90%, Nitrate (SL nitro - avoid if BP low/RV infarct), Aspirin 325 mg stat."),
  bold_bullet("ECG within 10 min. ",""),
  bold_bullet("Dual Antiplatelet: ","Aspirin 300 mg + Clopidogrel 300-600 mg (or Ticagrelor 180 mg / Prasugrel 60 mg)."),
  bold_bullet("Anticoagulation: ","Heparin UFH 60 U/kg IV (max 4000 U) or Enoxaparin 30 mg IV then 1 mg/kg SC."),
  bold_bullet("Reperfusion (PRIORITY):",""),
  sub_bullet("Primary PCI: GOLD STANDARD. Door-to-balloon <90 min (onset-to-balloon <12 h)."),
  sub_bullet("Thrombolysis: If PCI not available within 120 min. Streptokinase 1.5 MU over 60 min or Tenecteplase weight-based IV bolus."),
  sub_bullet("Thrombolysis contraindications: Previous hemorrhagic stroke, active bleeding, recent surgery/trauma, severe HTN >180/110."),

  h3("STEMI Management Table"),
  two_col_table([
    ["Phase", "Key Action"],
    ["0-10 min", "12-lead ECG, IV access, O2, aspirin, monitor"],
    ["10-30 min", "Dual antiplatelet, anticoagulant, decision on reperfusion"],
    ["<90 min", "Primary PCI if available (Door-to-balloon)"],
    ["<30 min from arrival", "Thrombolysis if PCI unavailable (Door-to-needle)"],
    ["After reperfusion", "Beta-blocker, ACEI, statin, monitor for complications"],
  ]),

  h3("Complications of MI"),
  bullet("Arrhythmias: VF, complete heart block (inferior MI), AF"),
  bullet("Cardiogenic shock: SBP <90, cold clammy, urine <20 mL/hr - vasopressors + urgent PCI"),
  bullet("Acute LVF / pulmonary edema: diuretics, CPAP, vasodilators"),
  bullet("Free wall rupture: Day 3-5 - fatal unless emergency surgery"),
  bullet("VSD: new harsh systolic murmur - surgical repair"),
  bullet("Dressler syndrome: 2-6 weeks post-MI - pericarditis - NSAIDs/steroids"),

  new Paragraph({ spacing: { after: 120 } }),
  h2("1.3 ACUTE HEART FAILURE WITH PULMONARY EDEMA"),
  h3("Emergency Case"),
  para("A 65-year-old with known IHD presents with sudden breathlessness, pink frothy sputum, BP 180/110, RR 32, SpO2 82% on air."),
  h3("Management"),
  bold_bullet("Position: ", "Sit upright, legs down."),
  bold_bullet("O2/NIV: ", "High-flow O2; CPAP/BiPAP first choice over intubation."),
  bold_bullet("Furosemide: ", "40-80 mg IV stat (up to 200 mg if refractory)."),
  bold_bullet("Nitrates: ", "GTN infusion 10-200 mcg/min IV (if BP adequate); lowers preload/afterload."),
  bold_bullet("Morphine: ", "2-4 mg IV for anxiety/vasodilation (use cautiously; may increase mortality)."),
  bold_bullet("Avoid: ", "Beta-blockers acutely (negative inotrope)."),
  bold_bullet("If cardiogenic shock: ", "Dobutamine 2-20 mcg/kg/min + Dopamine/Noradrenaline."),

  new Paragraph({ spacing: { after: 120 } }),
  h2("1.4 HYPERTENSIVE EMERGENCY"),
  h3("Definition"),
  para("SBP >180/120 mmHg WITH end-organ damage (brain, heart, kidneys, eyes). Distinguished from Hypertensive Urgency (no organ damage)."),
  h3("Emergency Case"),
  para("Patient presents with BP 220/130, severe headache, altered consciousness, fundus: papilledema. Urine protein 3+."),
  h3("Management"),
  bold_bullet("Target: ", "Reduce MAP by max 25% in first hour (NOT to normal - risk of ischemia)."),
  bold_bullet("IV Labetalol: ", "20 mg IV bolus, then 40-80 mg q10min (max 300 mg) OR infusion 2 mg/min."),
  bold_bullet("IV Nicardipine: ", "5-15 mg/hr infusion (preferred in neurological emergencies)."),
  bold_bullet("IV Sodium Nitroprusside: ", "0.3-10 mcg/kg/min (powerful; risk of cyanide toxicity >72 hr)."),
  bold_bullet("Hydralazine: ", "10-20 mg IV (used in pregnancy/eclampsia)."),
  bold_bullet("Specific contexts: ",""),
  sub_bullet("Aortic Dissection: IV Labetalol / Esmolol - HR <60, SBP <120 urgently."),
  sub_bullet("Hypertensive Encephalopathy: Labetalol or Nicardipine."),
  sub_bullet("Eclampsia: MgSO4 4g IV loading + antihypertensives (Hydralazine/Labetalol)."),
  sub_bullet("Phaeochromocytoma: Phentolamine IV (alpha-blocker first, THEN beta-blocker)."),

  page_break(),

  // ===========================
  // SECTION 2: RESPIRATORY EMERGENCY
  // ===========================
  h1("SECTION 2: RESPIRATORY EMERGENCIES"),

  h2("2.1 ACUTE SEVERE ASTHMA"),
  h3("Emergency Case"),
  para("A 28-year-old presents with severe breathlessness, unable to complete sentences, RR 32, SpO2 88%, peak flow <33% predicted, widespread wheeze."),
  h3("Features of Life-Threatening Asthma"),
  bullet("PEF <33% predicted or best"),
  bullet("SpO2 <92%, PaO2 <8 kPa"),
  bullet("PaCO2 normal (4.6-6 kPa) - indicates fatigue, impending respiratory failure"),
  bullet("Silent chest, cyanosis, feeble respiratory effort"),
  bullet("Bradycardia, arrhythmia, hypotension"),
  bullet("Altered consciousness"),

  h3("Management (BTS/SIGN Guidelines)"),
  bold_bullet("O2: ", "High-flow O2 to maintain SpO2 94-98%."),
  bold_bullet("Salbutamol: ", "5 mg nebulized back-to-back x3, then q20min. IV Salbutamol 5 mcg/min if no response."),
  bold_bullet("Ipratropium bromide: ", "0.5 mg nebulized with salbutamol in severe/life-threatening."),
  bold_bullet("Steroids: ", "Prednisolone 40-50 mg PO or Hydrocortisone 200 mg IV stat."),
  bold_bullet("MgSO4: ", "1.2-2 g IV over 20 min in life-threatening or no response to bronchodilators."),
  bold_bullet("Heliox: ", "Consider in near-fatal asthma to reduce airway resistance."),
  bold_bullet("Intubation: ", "Last resort - RSI, avoid air trapping; use low RR, high inspiratory flow."),

  new Paragraph({ spacing: { after: 120 } }),
  h2("2.2 COPD EXACERBATION"),
  h3("Emergency Case"),
  para("A 68-year-old smoker presents with worsening dyspnea, increased purulent sputum, RR 28, SpO2 84%, using accessory muscles."),
  h3("Management (GOLD Guidelines)"),
  bold_bullet("O2: ", "CONTROLLED O2 - target SpO2 88-92% (avoid hypercapnic drive suppression). Use Venturi mask."),
  bold_bullet("Short-acting bronchodilators: ", "Salbutamol 2.5-5 mg + Ipratropium 0.5 mg neb q20-30 min."),
  bold_bullet("Steroids: ", "Prednisolone 40 mg PO x5 days (preferred) or Hydrocortisone 100 mg IV q6h."),
  bold_bullet("Antibiotics: ", "Amoxicillin/Doxycycline/Azithromycin if purulent sputum / suspected infection."),
  bold_bullet("NIV (BiPAP): ", "FIRST-LINE for type 2 (hypercapnic) respiratory failure - reduces intubation need by 50%."),
  bold_bullet("Indications for NIV: ", "pH <7.35 + PaCO2 >6 kPa + RR >23."),
  bold_bullet("Theophylline IV: ", "Consider if poor response to bronchodilators."),
  note("NIV is contraindicated in: facial trauma, vomiting, GCS <8, hemodynamic instability, unable to protect airway."),

  new Paragraph({ spacing: { after: 120 } }),
  h2("2.3 PNEUMOTHORAX"),
  h3("Emergency Case - Tension Pneumothorax"),
  para("A 25-year-old trauma patient: sudden deterioration, trachea deviated right, absent left breath sounds, distended neck veins, hypotension, HR 130."),
  h3("Management"),
  bold_bullet("Tension PTX: CLINICAL DIAGNOSIS - DO NOT wait for X-ray.",""),
  bold_bullet("Immediate needle decompression: ", "14G cannula in 2nd ICS midclavicular line on affected side."),
  bold_bullet("Then chest drain: ", "5th ICS anterior axillary line (ATLS)."),
  bold_bullet("Simple PTX <2 cm, no symptoms: ", "Observation or needle aspiration."),
  bold_bullet("Simple PTX >2 cm / symptomatic: ", "Intercostal chest drain (ICD)."),

  new Paragraph({ spacing: { after: 120 } }),
  h2("2.4 PULMONARY EMBOLISM (PE)"),
  h3("Emergency Case"),
  para("A 45-year-old post-op patient with sudden pleuritic chest pain, dyspnea, tachycardia HR 115, SpO2 91%. Recent knee surgery."),
  h3("Wells Score (PE)"),
  two_col_table([
    ["Criteria", "Score"],
    ["Clinical signs of DVT", "+3"],
    ["PE most likely diagnosis", "+3"],
    ["HR >100/min", "+1.5"],
    ["Immobilization / Surgery <4 weeks", "+1.5"],
    ["Previous DVT/PE", "+1.5"],
    ["Haemoptysis", "+1"],
    ["Malignancy", "+1"],
    ["Score >4: HIGH probability; <4: LOW probability", ""],
  ]),
  h3("Management"),
  bold_bullet("Anticoagulation: ", "LMWH (Enoxaparin 1 mg/kg SC BD) or Fondaparinux or DOAC (Rivaroxaban 15 mg BD x21d then 20 mg OD)."),
  bold_bullet("Massive PE (hemodynamically unstable): ", "Systemic thrombolysis - Alteplase 100 mg IV over 2 hr."),
  bold_bullet("Absolute contraindication to thrombolysis: ", "Recent stroke (<3 months), active bleeding, intracranial tumor."),
  bold_bullet("Surgical embolectomy / catheter-directed thrombolysis: ", "If thrombolysis fails or contraindicated."),

  page_break(),

  // ===========================
  // SECTION 3: POISONING EMERGENCIES
  // ===========================
  h1("SECTION 3: POISONING EMERGENCIES"),

  h2("3.1 GENERAL APPROACH TO POISONING - AEIOU"),
  bold_bullet("A - Airway/Antidote: ", "Secure airway, identify antidote early."),
  bold_bullet("E - Eliminate: ", "Decontamination: activated charcoal, gastric lavage, skin washing."),
  bold_bullet("I - Intensive care: ", "Monitor vitals, ECG, RFT, LFT, glucose."),
  bold_bullet("O - Organ support: ", "IV fluids, vasopressors, dialysis if needed."),
  bold_bullet("U - Undress: ", "Remove contaminated clothing."),

  new Paragraph({ spacing: { after: 120 } }),
  h2("3.2 ORGANOPHOSPHATE POISONING (OP) - Most common in India"),
  h3("Emergency Case"),
  para("A 35-year-old farmer brought unconscious after consuming pesticide. Pin-point pupils, excessive secretions, bradycardia HR 45, muscle fasciculations, convulsions, defecation."),
  h3("Toxidrome - SLUDGE + Nicotinic"),
  bold_bullet("SLUDGE (Muscarinic): ", "Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis."),
  bold_bullet("Nicotinic: ", "Muscle fasciculations, weakness, paralysis (respiratory failure)."),
  bold_bullet("CNS: ", "Anxiety, seizures, coma."),
  h3("Management"),
  bold_bullet("Atropine: ", "FIRST AND MOST IMPORTANT. 2-4 mg IV every 5-10 min until atropinization (dry secretions, HR>80, pupils dilated). May need 100s of mg. No dose ceiling."),
  bold_bullet("Pralidoxime (PAM): ", "1-2 g IV over 15-30 min, then 200-400 mg/hr infusion. Must give WITHIN 24-48 hrs (before aging of AChE). Reverses nicotinic effects."),
  bold_bullet("Benzodiazepines: ", "Diazepam 5-10 mg IV for seizures."),
  bold_bullet("Airway: ", "Suction secretions, early intubation if GCS low or respiratory failure."),
  bold_bullet("Avoid: ", "Succinylcholine (prolonged paralysis), morphine, atracurium."),
  note("Atropine treats muscarinic symptoms ONLY. PAM treats both nicotinic + muscarinic if given early."),

  new Paragraph({ spacing: { after: 120 } }),
  h2("3.3 PARACETAMOL (ACETAMINOPHEN) OVERDOSE"),
  h3("Emergency Case"),
  para("A 22-year-old presents 6 hrs after ingesting 20g paracetamol. Mildly nauseated. LFTs normal at this point."),
  h3("Stages of Toxicity"),
  bold_bullet("Phase 1 (0-24 hr): ", "Nausea, vomiting, malaise. LFTs may be normal."),
  bold_bullet("Phase 2 (24-72 hr): ", "RUQ pain, LFTs rising, renal impairment."),
  bold_bullet("Phase 3 (72-96 hr): ", "Peak hepatotoxicity, ALT >1000, jaundice, coagulopathy, encephalopathy."),
  bold_bullet("Phase 4 (>96 hr): ", "Recovery or fulminant hepatic failure."),
  h3("Management"),
  bold_bullet("N-Acetylcysteine (NAC): ", "Antidote. Give if serum paracetamol level above treatment line (Rumack-Matthew nomogram). IV: 150 mg/kg over 60 min, then 50 mg/kg over 4 hr, then 100 mg/kg over 16 hr."),
  bold_bullet("Charcoal: ", "Activated charcoal 50 g if within 1 hour of ingestion."),
  bold_bullet("Liver transplant: ", "If King's College Criteria met (pH <7.3 OR PT >100s + Cr >300 + Grade 3-4 encephalopathy)."),

  new Paragraph({ spacing: { after: 120 } }),
  h2("3.4 BENZODIAZEPINE OVERDOSE"),
  h3("Features: ",""),
  bullet("CNS depression, drowsiness, slurred speech, ataxia"),
  bullet("Respiratory depression (mild), rarely fatal alone"),
  h3("Management"),
  bold_bullet("Flumazenil: ", "Antidote. 0.2 mg IV over 30 sec, repeat 0.1 mg q60 sec (max 1 mg). Short-acting; may need re-dosing. CAUTION: can precipitate seizures in BZD-dependent patients."),
  bold_bullet("Supportive care: ", "Airway, O2, IV fluids."),

  new Paragraph({ spacing: { after: 120 } }),
  h2("3.5 OPIOID OVERDOSE"),
  h3("Toxidrome: ",""),
  bullet("Miosis (pin-point pupils), respiratory depression, unconsciousness - TRIAD"),
  h3("Management"),
  bold_bullet("Naloxone: ", "Antidote. 0.4-2 mg IV/IM/IN, repeat q2-3 min (max 10 mg). Infusion if long-acting opioid (morphine, methadone)."),

  new Paragraph({ spacing: { after: 120 } }),
  h2("3.6 TRICYCLIC ANTIDEPRESSANT (TCA) OVERDOSE"),
  h3("Features: ",""),
  bullet("Anticholinergic: dry mouth, urinary retention, dilated pupils, tachycardia"),
  bullet("Cardiac: QRS >100 ms (arrhythmia risk), QTc prolongation, hypotension"),
  bullet("CNS: seizures, coma"),
  h3("Management"),
  bold_bullet("Sodium Bicarbonate: ", "1-2 mEq/kg IV bolus. KEY treatment. Alkalinize urine + serum (target pH 7.45-7.55). Reverses Na-channel blockade."),
  bold_bullet("Avoid: ", "Flumazenil (seizures), physostigmine, Class 1A antiarrhythmics."),
  bold_bullet("Intubation: ", "If GCS <8 or severe respiratory depression."),

  page_break(),

  // ===========================
  // SECTION 4: HTN
  // ===========================
  h1("SECTION 4: HYPERTENSION (HTN)"),
  h2("4.1 Classification (JNC 8 / ACC/AHA 2017)"),
  two_col_table([
    ["Category", "BP (mmHg)"],
    ["Normal", "<120/<80"],
    ["Elevated", "120-129 / <80"],
    ["Stage 1 HTN", "130-139 / 80-89"],
    ["Stage 2 HTN", ">=140 / >=90"],
    ["Hypertensive Urgency", ">180/120, NO organ damage"],
    ["Hypertensive Emergency", ">180/120 WITH organ damage"],
  ]),
  h2("4.2 Treatment Goals"),
  bold_bullet("General: ", "<130/80 mmHg (AHA 2017). JNC 8: <150/90 if age >=60."),
  bold_bullet("Diabetes/CKD: ", "<130/80."),
  bold_bullet("High CVD risk: ", "<120 systolic if tolerated."),
  h2("4.3 Drug Treatment (Step Therapy)"),
  two_col_table([
    ["Indication / Type", "First-Line Drugs"],
    ["Uncomplicated HTN", "Thiazide diuretic (Hydrochlorothiazide / Chlorthalidone), ACEi, ARB, CCB"],
    ["HTN + CKD / Proteinuria", "ACEi (Ramipril) or ARB (Losartan)"],
    ["HTN + Heart failure (HFrEF)", "ACEi + Beta-blocker + Spironolactone"],
    ["HTN + Post-MI", "Beta-blocker + ACEi"],
    ["HTN + Angina", "Beta-blocker or Amlodipine"],
    ["HTN + Pregnancy", "Methyldopa, Labetalol, Nifedipine (NOT ACEi/ARB)"],
    ["HTN + DM", "ACEi/ARB preferred"],
    ["Resistant HTN (4th agent)", "Spironolactone 25-50 mg OD"],
    ["Black patients", "Thiazide + CCB (ACEi less effective alone)"],
  ]),
  h2("4.4 Key Drug Contraindications"),
  two_col_table([
    ["Drug", "Avoid In"],
    ["ACEi/ARB", "Pregnancy, bilateral renal artery stenosis, hyperkalemia"],
    ["Beta-blockers", "Asthma, COPD, complete heart block"],
    ["Thiazides", "Gout, hyponatremia"],
    ["Spironolactone", "Hyperkalemia, renal failure"],
    ["CCB (Diltiazem/Verapamil)", "Heart failure (HFrEF), AV block"],
  ]),
  note("JNC 8 India: Start drug at Stage 1 if 10-yr ASCVD risk >=10% or age >65 or known CVD/DM/CKD."),

  page_break(),

  // ===========================
  // SECTION 5: DIABETES MELLITUS
  // ===========================
  h1("SECTION 5: DIABETES MELLITUS (DM)"),
  h2("5.1 Classification & Diagnosis"),
  two_col_table([
    ["Test", "Diagnostic Threshold"],
    ["FPG (Fasting Plasma Glucose)", ">=126 mg/dL (7.0 mmol/L)"],
    ["2-hr OGTT", ">=200 mg/dL (11.1 mmol/L)"],
    ["HbA1c", ">=6.5% (48 mmol/mol)"],
    ["Random PG + symptoms", ">=200 mg/dL"],
    ["Pre-DM: FPG", "100-125 mg/dL"],
    ["Pre-DM: HbA1c", "5.7-6.4%"],
  ]),
  h2("5.2 DM Emergencies"),
  h3("Diabetic Ketoacidosis (DKA) - Mostly T1DM"),
  bold_bullet("Triad: ", "Hyperglycemia (>250 mg/dL), Metabolic acidosis (pH <7.3, bicarb <18), Ketonemia/ketonuria."),
  bold_bullet("Precipitants: ", "Infection (50%), missed insulin, new-onset T1DM."),
  para("Management (ADA / ISPAD Protocol):"),
  bold_bullet("1. Fluids: ", "Normal saline 0.9% NS - 1L first hour, then 500 mL/hr x2 hr, then 250 mL/hr. Switch to 0.45% NS when glucose <250."),
  bold_bullet("2. Insulin: ", "Regular insulin IV infusion 0.1 U/kg/hr. Start ONLY after K+ >3.5. Switch to SC when pH >7.3, bicarb >15, anion gap closed, patient eating."),
  bold_bullet("3. Potassium: ", "Replace K+ aggressively. Target 4-5 mEq/L. Give K+ if <5.5. If <3.5 - hold insulin, give K+ urgently."),
  bold_bullet("4. Bicarb: ", "Only if pH <6.9. Avoid routine use."),
  bold_bullet("5. Monitor: ", "Glucose q1h, electrolytes q2-4h, VBG q2h, urine output."),

  h3("Hyperglycemic Hyperosmolar State (HHS) - T2DM"),
  bold_bullet("Features: ", "Glucose >600 mg/dL, Osmolality >320, NO acidosis, NO ketones, severe dehydration, neurological signs."),
  bold_bullet("Management: ", "Slow rehydration (water deficit may be 10-20L), gentle insulin (0.05 U/kg/hr), prevent cerebral edema."),

  h3("Hypoglycemia - Emergency"),
  bold_bullet("Symptoms: ", "Sweating, palpitations, tremor (adrenergic); confusion, seizure, coma (neuroglycopenic). BG <70 mg/dL (<3.9 mmol/L)."),
  bold_bullet("Conscious patient: ", "15g fast-acting carb (4 glucose tabs / 150 mL fruit juice). Recheck in 15 min."),
  bold_bullet("Unconscious: ", "50 mL 50% dextrose IV OR Glucagon 1 mg IM/SC. Start 10% dextrose infusion."),

  h2("5.3 T2DM Drug Algorithm (ADA 2025)"),
  two_col_table([
    ["Step", "Drug"],
    ["All T2DM: Start", "Metformin (if eGFR >=30, no contraindication)"],
    ["+ CVD / high CV risk", "SGLT2i (Empagliflozin) or GLP-1 RA (Semaglutide)"],
    ["+ CKD / proteinuria", "SGLT2i (Empagliflozin, Dapagliflozin)"],
    ["+ Heart failure (HFrEF)", "SGLT2i (Empagliflozin/Dapagliflozin)"],
    ["+ Obesity/weight loss need", "GLP-1 RA (Semaglutide, Liraglutide)"],
    ["Hypoglycemia risk concern", "DPP-4i (Sitagliptin) - weight neutral, low hypo risk"],
    ["Triple therapy", "Metformin + SGLT2i + GLP-1 RA OR insulin"],
  ]),
  bold_bullet("HbA1c target: ", "<7% (ADA standard), <6.5% if young/no CVD, <8% if elderly/frail."),

  page_break(),

  // ===========================
  // SECTION 6: TUBERCULOSIS
  // ===========================
  h1("SECTION 6: TUBERCULOSIS (TB)"),
  h2("6.1 Classification"),
  bullet("Pulmonary TB (PTB) - most common"),
  bullet("Extrapulmonary TB: pleural, lymph node, CNS (TBM), bone/joint, genitourinary, abdominal, miliary"),
  bullet("Drug-sensitive TB (DS-TB)"),
  bullet("Drug-resistant TB: MDR-TB (resistant to INH + Rifampicin), XDR-TB (MDR + FQ + injectable)"),

  h2("6.2 Diagnosis"),
  bold_bullet("Sputum AFB smear: ", "Fast, cheap, but low sensitivity (50-60%)."),
  bold_bullet("Sputum Culture (LJ/MGIT): ", "Gold standard. 4-8 weeks (MGIT faster 1-3 wk)."),
  bold_bullet("CBNAAT/GeneXpert MTB/RIF: ", "Rapid (2 hr), detects MTB and rifampicin resistance. FIRST-LINE in India (NTEP)."),
  bold_bullet("X-ray: ", "Upper lobe cavitation, fibrosis, hilar adenopathy."),
  bold_bullet("IGRA/TST: ", "IGRA (QuantiFERON-TB Gold) preferred in BCG-vaccinated populations. TST >10 mm positive."),
  bold_bullet("Mantoux test: ", ">10 mm positive in immunocompetent; >5 mm in HIV/immunosuppressed."),

  h2("6.3 Treatment (NTEP/WHO 2023 Guidelines)"),
  h3("DS-TB (Drug-Sensitive)"),
  two_col_table([
    ["Phase", "Drugs (RHEZ)"],
    ["Intensive Phase (2 months)", "Rifampicin (R) + Isoniazid (H) + Ethambutol (E) + Pyrazinamide (Z) - 2RHEZ"],
    ["Continuation Phase (4 months)", "Rifampicin (R) + Isoniazid (H) - 4RH"],
    ["Total Duration", "6 months for pulmonary TB"],
    ["TBM / Bone TB", "9-12 months (2RHEZ + 7RH)"],
    ["DOT", "Directly Observed Treatment - core of NTEP"],
  ]),
  h3("MDR-TB (WHO 2022 BPaL Regimen - Shorter Regimen)"),
  bullet("Bedaquiline (B) + Pretomanid (Pa) + Linezolid (L) - 6 months (BPaL) - PREFERRED shorter regimen"),
  bullet("Older longer regimen: 18-24 months with multiple drugs"),
  bullet("Never add single drug to failing regimen (resistance amplification)"),

  h3("Key Drug Side Effects"),
  two_col_table([
    ["Drug", "Key Side Effect"],
    ["Isoniazid (H)", "Peripheral neuropathy (give B6/pyridoxine), hepatitis"],
    ["Rifampicin (R)", "Orange-red urine/tears, hepatitis, CYP450 inducer (drug interactions)"],
    ["Pyrazinamide (Z)", "Hyperuricemia/gout, hepatotoxicity"],
    ["Ethambutol (E)", "Optic neuritis (check visual acuity/color monthly)"],
    ["Streptomycin", "Ototoxicity, nephrotoxicity"],
    ["Bedaquiline", "QTc prolongation, hepatotoxicity"],
    ["Linezolid", "Myelosuppression, peripheral neuropathy, serotonin syndrome"],
  ]),

  h2("6.4 HIV-TB Coinfection"),
  bullet("Start ART within 2 weeks of starting TB treatment (CD4 <50) or within 8 weeks (CD4 >=50)."),
  bullet("Exception: TB meningitis - delay ART 4-8 weeks (immune reconstitution risk)."),
  bullet("Rifampicin interacts with most ART drugs - prefer Efavirenz-based regimen."),

  page_break(),

  // ===========================
  // SECTION 7: ABDOMINAL EMERGENCY
  // ===========================
  h1("SECTION 7: ABDOMINAL EMERGENCIES"),
  h2("7.1 ACUTE ABDOMEN - Systematic Approach"),
  bold_bullet("History: ","SOCRATES (Site, Onset, Character, Radiation, Associations, Time, Exacerbating/Relieving, Severity)"),
  bold_bullet("Examination: ","Inspection, Auscultation, Percussion, Palpation - check for guarding, rigidity, rebound tenderness."),
  bold_bullet("Investigations: ","CBC, BMP, LFT, Amylase/Lipase, Urine R/M, Pregnancy test (females), ECG, CXR, USG, CT abdomen."),

  h2("7.2 ACUTE APPENDICITIS"),
  h3("Emergency Case"),
  para("18-year-old with periumbilical pain migrating to RIF, fever 38.5°C, nausea, vomiting, Rovsing sign +ve, guarding RIF."),
  bold_bullet("Alvarado Score: ","Migratory pain (1) + Anorexia (1) + Nausea/vomiting (1) + RIF tenderness (2) + Rebound (1) + Temp >37.3 (1) + Leukocytosis (2) + Shift left (1). Score 7-10 = surgical."),
  bold_bullet("Management: ", "IV fluids, analgesics, IV antibiotics (Cefuroxime + Metronidazole), emergency appendicectomy (laparoscopic preferred)."),

  h2("7.3 ACUTE PANCREATITIS"),
  h3("Emergency Case"),
  para("40-year-old heavy drinker: sudden severe epigastric pain radiating to back, vomiting, Serum Amylase 1200 U/L."),
  bold_bullet("Severity (Ranson / BISAP / APACHE II): ",""),
  sub_bullet("Ranson on admission: Age >55, WBC >16,000, Glucose >200, LDH >350, AST >250"),
  sub_bullet("Ranson at 48 hr: Hematocrit fall >10%, BUN rise >5, Calcium <8, Base deficit >4, Fluid sequestration >6L"),
  sub_bullet("Score >=3 = severe pancreatitis"),
  bold_bullet("CT Severity Index (CTSI - Balthazar): ","Grade A-E. Grade D/E = severe, necrosis >50% = high morbidity."),
  bold_bullet("Management: ", "NPO, aggressive IV fluids (Ringer lactate preferred, 250-500 mL/hr), analgesia (morphine/NSAIDs), early enteral nutrition (NGT/jejunal) - do NOT fast for >48-72 hr."),
  bold_bullet("Antibiotics: ","Only if infected necrosis (fever >38.5 persisting >7 days + CT showing gas in necrosis). Use Imipenem or Meropenem."),
  bold_bullet("ERCP: ","If gallstone pancreatitis + choledocholithiasis / cholangitis within 24-72 hr."),
  bold_bullet("Cholecystectomy: ","Same admission for mild gallstone pancreatitis."),

  h2("7.4 GASTROINTESTINAL BLEEDING"),
  h3("Upper GI Bleed (UGIB)"),
  bold_bullet("Causes: ", "Peptic ulcer (most common, 50%), esophageal varices, Mallory-Weiss tear, gastric erosions."),
  bold_bullet("Glasgow-Blatchford Score: ", "Predicts need for intervention. Urea, Hb, SBP, HR, melena, syncope, liver disease."),
  bold_bullet("Management: ", "IV PPI (omeprazole/pantoprazole 80 mg bolus then 8 mg/hr infusion), IV octreotide if variceal, Terlipressin for varices, NGT, blood transfusion (Hb target 7-8 g/dL; avoid overtransfusion in varices), urgent OGD within 24 hr."),
  bold_bullet("Varices: ", "Octreotide/Terlipressin + endoscopic band ligation (EBL) + prophylactic antibiotics (Ceftriaxone 1g BD)."),
  h3("Lower GI Bleed (LGIB)"),
  bold_bullet("Causes: ", "Diverticulosis (most common), angiodysplasia, colorectal cancer, IBD, hemorrhoids."),
  bold_bullet("Management: ", "Colonoscopy after preparation, CT angiography if massive bleeding, mesenteric angiography + embolization."),

  page_break(),

  // ===========================
  // SECTION 8: DIARRHEA & VOMITING
  // ===========================
  h1("SECTION 8: DIARRHEA & VOMITING"),
  h2("8.1 ACUTE DIARRHEA"),
  h3("Classification & Common Causes"),
  two_col_table([
    ["Type", "Features / Causes"],
    ["Secretory diarrhea", "Large vol, watery, no WBC in stool. Vibrio cholerae, ETEC, rotavirus"],
    ["Invasive/Inflammatory", "Bloody diarrhea, fever, WBC in stool. Shigella, Salmonella, Campylobacter, C. difficile"],
    ["Osmotic diarrhea", "Stops with fasting. Lactose intolerance, malabsorption"],
    ["Motility disorder", "IBS, diabetic autonomic neuropathy"],
  ]),
  h3("Assessment - Dehydration"),
  two_col_table([
    ["Severity", "Features"],
    ["No dehydration", "Normal, alert, drinks normally"],
    ["Some dehydration", "Restless, sunken eyes, dry mouth, skin pinch slow (<=2 sec), drinks eagerly - Plan B ORS"],
    ["Severe dehydration", "Lethargic, very sunken eyes, skin pinch very slow (>2 sec), not drinking - Plan C IV fluids"],
  ]),
  h3("Management (WHO Diarrhea Treatment Guidelines)"),
  bold_bullet("ORS: ", "Gold standard. WHO low-osmolarity ORS (245 mOsm/L): NaCl 2.6g + KCl 1.5g + Na Citrate 2.9g + Glucose 13.5g per Liter."),
  bold_bullet("Plan A: ", "Home ORS. 200-400 mL after each loose stool (adult)."),
  bold_bullet("Plan B: ", "ORS 75 mL/kg over 4 hr for some dehydration."),
  bold_bullet("Plan C (Severe dehydration): ", "Ringer Lactate 100 mL/kg IV (children: 30 mL/kg in 30 min, then 70 mL/kg in 2.5 hr; adults: faster)."),
  bold_bullet("Zinc supplementation: ", "20 mg/day x 10-14 days in children (10 mg/day <6 months). Reduces severity/duration."),
  bold_bullet("Antibiotics: ","ONLY for cholera (Azithromycin/Doxycycline/Tetracycline), Shigella (Ciprofloxacin 500 mg BD x3d), C. difficile (Metronidazole/Vancomycin PO)."),
  bold_bullet("Antidiarrheals: ","Loperamide in adults if no blood/fever. AVOID in children, bloody/febrile diarrhea."),
  note("Do NOT withhold food. Continue age-appropriate feeding. Banana, rice, apple, toast (BRAT diet)."),

  h3("Cholera - Special Notes"),
  bullet("Causative agent: Vibrio cholerae O1 / O139"),
  bullet("Rice water stools, no odor, severe dehydration, muscle cramps"),
  bullet("Treatment: ORS/IV fluids + single dose Azithromycin 1g (DOC) or Doxycycline 300 mg single dose"),

  h2("8.2 VOMITING - Causes & Management"),
  h3("Classification of Vomiting Causes"),
  two_col_table([
    ["Category", "Examples"],
    ["GI causes", "Gastroenteritis, GERD, peptic ulcer, gastroparesis, intestinal obstruction, pancreatitis"],
    ["CNS causes", "Raised ICP (projectile), meningitis, migraine, vestibular disorders"],
    ["Metabolic", "DKA, Addisonian crisis, uraemia, hypercalcemia"],
    ["Drugs", "Chemotherapy, opioids, digoxin, antibiotics, NSAIDs"],
    ["Pregnancy", "Hyperemesis gravidarum (first trimester)"],
    ["Psychogenic", "Bulimia, anxiety"],
  ]),
  h3("Antiemetic Drugs"),
  two_col_table([
    ["Drug (Class)", "Use"],
    ["Ondansetron (5-HT3 antagonist)", "First-line, post-chemo, post-op N&V, pregnancy"],
    ["Metoclopramide (D2 antagonist)", "Gastroparesis, GERD, migraine-associated N&V"],
    ["Domperidone (D2 antagonist)", "Gastroparesis, does not cross BBB"],
    ["Prochlorperazine (Phenothiazine)", "Vestibular, migraine-associated"],
    ["Cyclizine (Antihistamine)", "Motion sickness, vestibular"],
    ["Dexamethasone", "Chemo-induced N&V (combined regimen)"],
    ["Hyoscine (Anticholinergic)", "Motion sickness (transdermal patch)"],
  ]),
  bold_bullet("Hyperemesis Gravidarum: ","IV fluids (NS/Hartmanns), Pyridoxine (B6) 25 mg TDS + Doxylamine (first-line in pregnancy), then Ondansetron/Metoclopramide, Thiamine 100 mg IV (prevent Wernicke encephalopathy)."),

  page_break(),

  // ===========================
  // SECTION 9: FEVER
  // ===========================
  h1("SECTION 9: FEVER - CAUSES, TYPES & PATTERNS"),
  h2("9.1 Definition"),
  bold_bullet("Fever: ","Core temperature >37.8°C (oral) or >38°C (rectal) / tympanic. Clinically significant: >38.3°C."),
  bold_bullet("Hyperpyrexia: ", ">41°C. Medical emergency."),
  bold_bullet("Hypothermia: ", "<35°C."),

  h2("9.2 Causes of Fever - Differential Diagnosis"),
  two_col_table([
    ["Category", "Examples"],
    ["Infections (most common)", "Bacterial, viral, fungal, parasitic - see below"],
    ["Malignancy", "Hodgkin lymphoma (Pel-Ebstein fever), leukemia, solid tumors"],
    ["Autoimmune/Rheumatologic", "SLE, rheumatoid arthritis, polyarteritis nodosa, Adult-onset Still's disease"],
    ["Drug fever", "Antibiotics (penicillin, sulfa), phenytoin, allopurinol, heparin, methyldopa"],
    ["Factitious fever", "Self-induced (thermometer manipulation)"],
    ["Endocrine", "Thyroid storm, phaeochromocytoma"],
    ["Thromboembolic", "DVT, PE (low-grade fever)"],
    ["Tissue injury", "MI, pulmonary infarction, haematoma"],
    ["CNS disorder", "Hypothalamic damage (central fever, no diurnal variation)"],
  ]),

  h2("9.3 FEVER OF UNKNOWN ORIGIN (FUO)"),
  bold_bullet("Classic FUO definition: ","Fever >38.3°C on >=3 occasions; duration >3 weeks; no diagnosis after 3 outpatient visits or 3 days inpatient."),
  bold_bullet("Causes: ","Infections (35%), Neoplasms (20%), Autoimmune (15%), Miscellaneous (15%), Undiagnosed (15%)."),
  bold_bullet("Workup: ","CBC, ESR, CRP, LFT, RFT, Urine C/S, Blood culture x3, CXR, USG abdomen, ANA, RF, ANCA, CT chest/abdomen/pelvis, bone marrow biopsy, PET scan."),

  h2("9.4 FEVER PATTERNS - KEY FOR CLINICAL RECOGNITION"),
  two_col_table([
    ["Pattern", "Description", ],
    ["Continued/Sustained", "Temp >38°C, variation <1°C, no normal. Lobar pneumonia, typhoid (relative bradycardia), UTI"],
    ["Remittent", "Temp >38°C but falls, variation >1°C but never reaches normal. Infective endocarditis, viral infections, TB"],
    ["Intermittent (Quotidian)", "Spikes then returns to normal. Sepsis, malaria, pyaemia, kala-azar"],
    ["Hectic/Septic (Swinging)", "Wide variation >2°C, chills/rigors with spikes. Pyaemia, abscess, brucellosis"],
    ["Tertian", "Every 48 hr (every 3rd day). P. vivax / P. ovale malaria"],
    ["Quartan", "Every 72 hr (every 4th day). P. malariae"],
    ["Pel-Ebstein", "Cyclic: fever weeks, afebrile weeks. Hodgkin lymphoma (classic but uncommon)"],
    ["Double quotidian", "Two fever spikes in 24 hr. Adult Still's disease, gonococcal endocarditis, malaria"],
    ["Saddle-back / Biphasic", "Fever-afebrile-fever pattern. Dengue (classic), leptospirosis"],
    ["Inverse (PM>AM)", "Temperature higher in evening than morning. TB (characteristic pattern)"],
    ["Relapsing fever", "Borrelia (tick/louse-borne): 3-7 days fever, 3-7 days apyrexia, cycles"],
  ]),

  h3("How to Recognize Fever Pattern - Key Points"),
  bold_bullet("Temperature chart: ","Plot temperature 4-6 hourly for at least 5-7 days. Look for spikes, periodicity, pulse-temperature dissociation."),
  bold_bullet("Relative bradycardia: ","Pulse rise expected 10 beats per 1°F fever. If pulse does NOT rise appropriately = Faget sign. Seen in: typhoid, leptospirosis, brucellosis, dengue, yellow fever, Legionella."),
  bold_bullet("Rigor/chills: ","Suggest bacteremia/septicemia (malaria, abscess, pyelonephritis)."),
  bold_bullet("Drenching night sweats: ","TB, lymphoma, brucellosis, HIV."),
  bold_bullet("Rash with fever: ", "Morbilliform = viral; Petechiae = meningococcemia, dengue, rickettsial; Eschar = scrub typhus; Rose spots = typhoid; Malar rash = SLE."),

  page_break(),

  // ===========================
  // SECTION 10: DENGUE
  // ===========================
  h1("SECTION 10: DENGUE FEVER"),
  h2("10.1 Etiology & Epidemiology"),
  bullet("Causative agent: Dengue virus (DENV 1-4) - Flavivirus"),
  bullet("Vector: Aedes aegypti (primary), Aedes albopictus"),
  bullet("Day-biting mosquito, breeds in clean stagnant water"),
  bullet("Secondary infection with different serotype = severe dengue risk (ADE - antibody-dependent enhancement)"),

  h2("10.2 Clinical Phases"),
  two_col_table([
    ["Phase", "Duration", ],
    ["Febrile Phase", "Day 1-3: High fever (39-40°C), headache, retro-orbital pain, myalgia, arthralgia ('breakbone fever'), flushed face"],
    ["Critical Phase", "Day 3-7: Fever defervescence, plasma leakage (ascites, pleural effusion), thrombocytopenia, hemorrhagic manifestations - DANGER ZONE"],
    ["Recovery Phase", "Day 7-10: Fluid reabsorption, bradycardia, confluent erythematous rash with islands of sparing"],
  ]),

  h2("10.3 WHO 2009 Classification"),
  bold_bullet("Dengue without warning signs: ","Fever + 2 criteria (nausea, rash, aches, leucopenia, positive tourniquet test)."),
  bold_bullet("Dengue with warning signs (admit): ","Abdominal pain, persistent vomiting, rapid breathing, bleeding, fatigue/restlessness, liver >2 cm, rising HCT with falling platelets."),
  bold_bullet("Severe dengue: ","Severe plasma leakage (dengue shock syndrome / DSS), severe bleeding, severe organ impairment."),

  h2("10.4 Diagnosis"),
  two_col_table([
    ["Test", "When Positive"],
    ["NS1 antigen", "Day 1-5 (early febrile phase)"],
    ["IgM ELISA", "Day 5+ (primary infection)"],
    ["IgG ELISA", "Secondary infection (rises faster)"],
    ["RT-PCR", "Day 1-5, most accurate but expensive"],
    ["CBC", "Leucopenia, thrombocytopenia (platelet <100,000 = warning), rising HCT"],
    ["Tourniquet test +ve", ">=20 petechiae in 2.5 cm square"],
  ]),

  h2("10.5 Management (WHO Dengue Guidelines 2012 / Updated 2024)"),
  h3("Group A (Home Care)"),
  bullet("Adequate oral fluids (ORS/coconut water/fruit juice)"),
  bullet("Paracetamol for fever (NOT aspirin/NSAIDs - platelet dysfunction + GI bleed risk)"),
  bullet("Rest"),
  bullet("Return immediately if warning signs develop"),

  h3("Group B (Hospital - Warning Signs)"),
  bold_bullet("IV Fluids: ","Isotonic crystalloid (NS/RL). Start 5-7 mL/kg/hr x1-2 hr, then reduce stepwise (5, 3, then 1.5 mL/kg/hr) guided by clinical response."),
  bold_bullet("Monitor: ","Urine output >0.5 mL/kg/hr, vitals q1-4h, HCT q4-6h, platelets daily."),

  h3("Group C (Severe Dengue - ICU)"),
  bold_bullet("Dengue Shock Syndrome: ","Bolus isotonic crystalloid 10-20 mL/kg over 15 min. Repeat up to 3x. If still in shock: colloid (gelatin/starch). Blood transfusion if HCT falling with shock."),
  bold_bullet("Platelet transfusion: ","Threshold: <10,000 with active bleeding, OR <20,000 if high bleeding risk. NOT routinely for platelet <50,000."),
  bold_bullet("AVOID: ","Aspirin, NSAIDs, corticosteroids (not proven), antibiotics (unless secondary infection)."),
  note("Rise in HCT 20% above baseline = significant plasma leakage. Fall in HCT with hemodynamic compromise = internal hemorrhage."),

  page_break(),

  // ===========================
  // SECTION 11: TYPHOID
  // ===========================
  h1("SECTION 11: TYPHOID FEVER (ENTERIC FEVER)"),
  h2("11.1 Etiology"),
  bullet("Salmonella typhi (typhoid) and S. paratyphi A, B, C (paratyphoid)"),
  bullet("Feco-oral route, contaminated water/food"),
  bullet("Incubation: 7-14 days (range 3-30 days)"),

  h2("11.2 Clinical Features by Week"),
  two_col_table([
    ["Week", "Features"],
    ["Week 1", "Stepladder fever (progressive rise: 37-38-39-40°C), malaise, headache, relative bradycardia, constipation in adults"],
    ["Week 2", "High sustained fever, splenomegaly, Rose spots (2-4 mm salmon-pink macules on abdomen/trunk, fades on pressure), hepatomegaly, diarrhea pea-soup"],
    ["Week 3", "Complications: intestinal perforation, hemorrhage, toxic myocarditis, encephalopathy"],
    ["Week 4", "Defervescence / recovery or complications"],
  ]),
  h2("11.3 Diagnosis"),
  two_col_table([
    ["Test", "Comments"],
    ["Blood culture", "Gold standard. Positive in 70-80% in week 1-2. Send BEFORE antibiotics."],
    ["Widal test", "O antigen >1:160, H antigen >1:160 suggests active infection. False positives: endemic area, cross-reactions. Not reliable alone."],
    ["Stool/urine culture", "Positive later in disease (week 3-4)"],
    ["CBC", "Leucopenia (relative), anemia, thrombocytopenia"],
    ["IGRA/PCR", "Typhidot, TUBEX - rapid serological tests (moderate sensitivity)"],
    ["Bone marrow culture", "Most sensitive (90%+) even after antibiotics"],
  ]),
  h2("11.4 Treatment (WHO / India NTEP)"),
  two_col_table([
    ["Drug", "Dose / Duration", ],
    ["Azithromycin (DOC - uncomplicated)", "1g OD (or 500 mg OD) x 7 days (PO)"],
    ["Ceftriaxone (severe/complicated)", "60-75 mg/kg/day IV (max 4g) x 10-14 days"],
    ["Cefixime (oral alternative)", "20 mg/kg/day x 7-14 days"],
    ["Ciprofloxacin", "500 mg BD x 10-14 days (resistance increasing, avoid if QRDR)"],
    ["Chloramphenicol / Cotrimoxazole / Ampicillin", "Only for sensitive strains (resistance common in India now)"],
  ]),
  bold_bullet("MDR Typhoid: ","Resistant to Ampicillin + Chloramphenicol + Cotrimoxazole. Treat with Azithromycin or Ceftriaxone."),
  bold_bullet("XDR Typhoid (Pakistan 2019 outbreak): ","Resistant to all first-line + FQ + 3rd gen cephalosporins. Only Azithromycin or Carbapenems."),
  h3("Complications"),
  bullet("Intestinal perforation (Week 3-4): sudden abdominal pain, rigidity, free air on X-ray - emergency surgery"),
  bullet("GI hemorrhage: malaena, fresh rectal bleed"),
  bullet("Typhoid hepatitis"),
  bullet("Myocarditis, encephalopathy, DIC"),
  bullet("Carrier state: >1 year excretion; treat with high-dose ciprofloxacin + cholecystectomy if gallstones"),

  page_break(),

  // ===========================
  // SECTION 12: MALARIA
  // ===========================
  h1("SECTION 12: MALARIA"),
  h2("12.1 Etiology & Characteristics"),
  two_col_table([
    ["Species", "Key Features"],
    ["P. falciparum", "Most dangerous. No dormant hypnozoites. Knobs, rosetting, cytoadherence (causes severe malaria). Irregular/continuous fever. INDIA - dominant in tribal areas."],
    ["P. vivax", "Most common in India overall. Dormant hypnozoites (relapse). Benign tertian (48 hr cycle). Can cause severe malaria."],
    ["P. malariae", "Quartan (72 hr cycle). Can cause nephrotic syndrome. Recrudescence (not relapse)."],
    ["P. ovale", "Dormant hypnozoites like vivax. Rare in India."],
    ["P. knowlesi", "Zoonosis (macaques), Southeast Asia, daily quotidian fever."],
  ]),

  h2("12.2 Clinical Features"),
  bold_bullet("Classic malarial paroxysm: ", "Cold stage (chills/rigor) - Hot stage (high fever, headache) - Sweating stage (drenching sweats, temperature falls)."),
  bold_bullet("Splenomegaly: ","Characteristic of chronic malaria."),
  bold_bullet("Anemia: ","Hemolytic."),

  h2("12.3 Severe Malaria (P. falciparum, occasionally P. vivax) - WHO Criteria"),
  bold_bullet("Cerebral malaria: ","Unarousable coma (GCS <11), no other cause."),
  bold_bullet("Severe anemia: ","Hb <7 g/dL (adults) / <5 g/dL (children)."),
  bold_bullet("Respiratory distress: ","ARDS / metabolic acidosis."),
  bold_bullet("Hypoglycemia: ","BG <2.2 mmol/L."),
  bold_bullet("Acute renal failure: ","Cr >265 umol/L."),
  bold_bullet("Hyperparasitemia: ",">5% RBCs parasitized (or >100,000/uL)."),
  bold_bullet("Blackwater fever: ","Massive intravascular hemolysis, hemoglobinuria, renal failure."),
  bold_bullet("Algid malaria: ","Septicemic shock."),
  bold_bullet("Bleeding / DIC / pulmonary edema.",""),

  h2("12.4 Diagnosis"),
  bold_bullet("Peripheral blood smear (thick + thin): ","Gold standard. Identify species, parasitemia. Ring forms / banana-shaped gametocytes (falciparum)."),
  bold_bullet("RDT (Rapid Diagnostic Test): ","HRP-2 (falciparum-specific), pLDH (all species). Fast but misses low parasitemia. Quality varies."),
  bold_bullet("PCR: ","Most sensitive. Used for low parasitemia, mixed infections, species identification."),

  h2("12.5 Treatment (WHO Malaria Guidelines 2015 / Updated 2023; India NVBDCP)"),
  h3("Uncomplicated P. falciparum Malaria"),
  two_col_table([
    ["Drug", "Dose"],
    ["Artemether-Lumefantrine (AL) - First-line India", "80/480 mg twice daily x 3 days (weight-based)"],
    ["Artesunate-Mefloquine (ASAQ)", "Alternative"],
    ["Artesunate-Sulfadoxine-Pyrimethamine (AS+SP)", "Artesunate 4 mg/kg/day x3d + SP single dose"],
    ["Do NOT use chloroquine alone for Pf", "Global resistance >90%"],
    ["Primaquine single dose", "0.75 mg/kg (25 mg adult) day 1 - kills gametocytes, prevents transmission (G6PD screen first)"],
  ]),
  h3("Uncomplicated P. vivax Malaria"),
  two_col_table([
    ["Drug", "Dose"],
    ["Chloroquine (CQ)", "600 mg base (day 1-2), 300 mg base (day 3) = 25 mg/kg total over 3 days"],
    ["PLUS Primaquine (radical cure)", "0.25 mg/kg/day x 14 days (kills hypnozoites, prevents relapse)"],
    ["G6PD deficiency", "If G6PD deficient: Primaquine 0.75 mg/kg once weekly x 8 weeks"],
    ["Chloroquine-resistant vivax (CRVv) areas", "Artemether-Lumefantrine + Primaquine"],
  ]),
  h3("Severe / Complicated Malaria"),
  two_col_table([
    ["Drug", "Dose"],
    ["Artesunate IV (First-line - WHO)", "2.4 mg/kg IV at 0, 12, 24 hr, then daily until PO tolerated"],
    ["Artemether IM (if IV unavailable)", "3.2 mg/kg IM loading, then 1.6 mg/kg/day"],
    ["Quinine IV + Doxycycline (alternative)", "20 mg/kg loading over 4 hr, then 10 mg/kg q8hr"],
    ["Switch to oral AL when tolerated", "Complete full course"],
  ]),
  bold_bullet("Supportive care: ","IV fluids (cautious - avoid overhydration, risk of pulmonary edema), antipyretics, anticonvulsants for seizures, blood transfusion for severe anemia, dialysis for AKI."),
  bold_bullet("Contraindicated: ","IV fluids if pulmonary edema risk; steroids (worsen outcome in cerebral malaria); heparin; adrenaline."),

  h3("Special Considerations"),
  bold_bullet("Pregnancy: ","Artesunate-based ACT (second/third trimester); Quinine + Clindamycin (first trimester). AVOID Primaquine in pregnancy."),
  bold_bullet("G6PD deficiency: ","Test before primaquine. If deficient - modified weekly regimen."),
  bold_bullet("Mixed infection Pf + Pv: ","Treat as falciparum (ACT) + add Primaquine for vivax radical cure."),

  page_break(),

  // ===========================
  // QUICK REFERENCE CARD
  // ===========================
  h1("QUICK REFERENCE CARD - ANTIDOTES & KEY DRUGS"),
  two_col_table([
    ["Poison/Condition", "Antidote/Key Drug"],
    ["OP poisoning", "Atropine (no ceiling) + Pralidoxime (PAM)"],
    ["Opioid overdose", "Naloxone 0.4-2 mg IV/IM"],
    ["Benzodiazepine overdose", "Flumazenil 0.2 mg IV"],
    ["Paracetamol overdose", "N-Acetylcysteine (NAC) - start within 8 hr"],
    ["TCA overdose", "Sodium Bicarbonate IV (target pH 7.45-7.55)"],
    ["Warfarin overdose", "Vitamin K + FFP (for emergency)"],
    ["Heparin overdose", "Protamine Sulfate 1 mg per 100 U heparin"],
    ["Beta-blocker overdose", "Glucagon IV (+ Calcium, Insulin-glucose therapy)"],
    ["CCB overdose", "Calcium Gluconate + Insulin-glucose (HIE) + Noradrenaline"],
    ["Cyanide poisoning", "Hydroxocobalamin 5g IV OR Sodium thiosulfate"],
    ["CO poisoning", "100% O2 / Hyperbaric O2"],
    ["Iron overdose", "Desferrioxamine IV"],
    ["Lead poisoning (acute)", "DMSA (succimer) PO or EDTA IV"],
    ["Methanol/Ethylene glycol", "Fomepizole (4-methylpyrazole) IV or Ethanol"],
    ["Digoxin toxicity", "Digoxin-specific Fab antibodies (DigiFab)"],
    ["Heparin-induced thrombocytopenia (HIT)", "Argatroban or Danaparoid (NOT heparin/LMWH)"],
  ]),

  new Paragraph({ spacing: { after: 200 } }),
  h1("KEY MNEMONICS FOR GPSC INTERVIEW"),
  bold_bullet("5H5T (cardiac arrest reversible causes): ","Hypovolemia, Hypoxia, H+ (acidosis), Hypo/Hyperkalemia, Hypothermia + Tension PTX, Tamponade, Toxins, Thrombosis-PE, Thrombosis-MI"),
  bold_bullet("SLUDGE (OP poisoning): ","Salivation, Lacrimation, Urination, Defecation, GI cramps, Emesis"),
  bold_bullet("MONA (chest pain): ","Morphine, Oxygen, Nitrates, Aspirin"),
  bold_bullet("RIPA (Relative bradycardia causes): ","Rickettsia/Typhoid, Infection-leptospirosis/brucellosis, Paratyphoid, Arboviral-dengue/yellow fever"),
  bold_bullet("TORCH: ","Toxoplasma, Other (syphilis/zika), Rubella, CMV, Herpes"),
  bold_bullet("AEIOU (poisoning approach): ","Antidote/Airway, Eliminate, Intensive care, Organ support, Undress"),
  bold_bullet("CHAP (DKA management): ","Crystalloids (fluids), Hold insulin till K>3.5, Add potassium, PO bicarb only if pH<6.9"),
  bold_bullet("RHEZ (anti-TB): ","Rifampicin, Isoniazid, Ethambutol, Pyrazinamide"),

  new Paragraph({ spacing: { after: 200 } }),
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