"pleural effusion"[MeSH Terms] AND management

ls /home/daytona/workspace/ 2>/dev/null || echo "workspace empty or not found"

mkdir -p /home/daytona/workspace/pleural-flowchart && python3 -c "import matplot…

~/pleural-flowchart/flowchart.py

import matplotlib
matplotlib.use('Agg')
import matplotlib.pyplot as plt
import matplotlib.patches as mpatches
from matplotlib.patches import FancyBboxPatch, FancyArrowPatch

fig, ax = plt.subplots(figsize=(22, 34))
ax.set_xlim(0, 22)
ax.set_ylim(0, 34)
ax.axis('off')

# ── colour palette ──────────────────────────────────────────────────────────
C_START   = '#1A237E'   # deep navy  – start/end
C_STEP    = '#1565C0'   # blue       – process step
C_DIAMOND = '#E65100'   # deep orange– decision
C_TRANS   = '#1B5E20'   # dark green – transudate
C_EXUDATE = '#B71C1C'   # dark red   – exudate
C_CAUSES  = '#4A148C'   # purple     – causes boxes
C_SPEC    = '#00695C'   # teal       – specific tests
C_LIGHT   = '#F57F17'   # amber      – Light's criteria highlight
C_BG      = '#FAFAFA'   # near-white background

fig.patch.set_facecolor('#F0F4F8')
ax.set_facecolor('#F0F4F8')

# ── helper functions ─────────────────────────────────────────────────────────
def box(ax, x, y, w, h, text, fc, tc='white', fs=10, bold=False,
        shape='round,pad=0.1', border='white', lw=1.5, alpha=1.0):
    bp = FancyBboxPatch((x - w/2, y - h/2), w, h,
                        boxstyle=shape, linewidth=lw,
                        edgecolor=border, facecolor=fc, alpha=alpha, zorder=3)
    ax.add_patch(bp)
    weight = 'bold' if bold else 'normal'
    ax.text(x, y, text, ha='center', va='center', fontsize=fs,
            color=tc, fontweight=weight, wrap=True,
            multialignment='center', zorder=4,
            linespacing=1.35)

def diamond(ax, x, y, w, h, text, fc=C_DIAMOND, tc='white', fs=9.5):
    dx, dy = w/2, h/2
    pts = [(x, y+dy), (x+dx, y), (x, y-dy), (x-dx, y)]
    poly = plt.Polygon(pts, closed=True, facecolor=fc, edgecolor='white',
                       linewidth=1.5, zorder=3)
    ax.add_patch(poly)
    ax.text(x, y, text, ha='center', va='center', fontsize=fs,
            color=tc, fontweight='bold', multialignment='center', zorder=4,
            linespacing=1.3)

def arrow(ax, x1, y1, x2, y2, label='', lc='#37474F', lw=2.0,
          label_side='right'):
    ax.annotate('', xy=(x2, y2), xytext=(x1, y1),
                arrowprops=dict(arrowstyle='->', color=lc,
                                lw=lw, mutation_scale=18),
                zorder=2)
    if label:
        mx, my = (x1+x2)/2, (y1+y2)/2
        offset = 0.22 if label_side == 'right' else -0.22
        ax.text(mx + offset, my, label, ha='center', va='center',
                fontsize=8.5, color=lc, fontweight='bold', zorder=5,
                bbox=dict(boxstyle='round,pad=0.15', fc='#ECEFF1',
                          ec=lc, lw=0.8, alpha=0.9))

def h_line(ax, x1, x2, y, lc='#37474F', lw=2.0):
    ax.plot([x1, x2], [y, y], color=lc, lw=lw, zorder=2)

def v_line(ax, x, y1, y2, lc='#37474F', lw=2.0):
    ax.plot([x, x], [y1, y2], color=lc, lw=lw, zorder=2)

# ── TITLE ────────────────────────────────────────────────────────────────────
ax.text(11, 33.3, 'Clinical Decision-Making Flowchart',
        ha='center', va='center', fontsize=20, fontweight='bold',
        color='#1A237E')
ax.text(11, 32.85, 'Diagnosis of Pleural Effusion: Transudate vs. Exudate',
        ha='center', va='center', fontsize=13.5, color='#37474F',
        fontstyle='italic')

# thin rule under title
ax.plot([1, 21], [32.55, 32.55], color='#90A4AE', lw=1.2)

# ── NODE POSITIONS (top → down) ──────────────────────────────────────────────
# 1. Patient presents
box(ax, 11, 32.1, 7.5, 0.65,
    'Patient presents with suspected Pleural Effusion\n(Dyspnoea · Pleuritic chest pain · Incidental finding)',
    C_START, fs=10, bold=True, shape='round,pad=0.15')

arrow(ax, 11, 31.77, 11, 31.3)

# 2. Clinical assessment
box(ax, 11, 31.0, 8.2, 0.52,
    'History & Physical Examination\n'
    'Percussion dullness · ↓ breath sounds · Absent fremitus · Tracheal shift',
    C_STEP, fs=9.5, bold=False)

arrow(ax, 11, 30.74, 11, 30.25)

# 3. Chest X-ray
box(ax, 11, 29.95, 8.0, 0.52,
    'Chest X-ray  (upright PA + lateral)\n'
    '>250 mL visible · Blunt costophrenic angle · Meniscus sign',
    C_STEP, fs=9.5)

arrow(ax, 11, 29.69, 11, 29.2)

# 4. Confirm with imaging
box(ax, 11, 28.9, 8.5, 0.55,
    'Confirm & Characterise  ─  Ultrasound (≥5–10 mL; guides needle) | CT thorax (loculated? parenchymal Δ?)',
    C_STEP, fs=9.2)

arrow(ax, 11, 28.62, 11, 28.05)

# ── D1: Obvious cause? ───────────────────────────────────────────────────────
diamond(ax, 11, 27.6, 5.6, 0.88,
        'Obvious clinical cause\nof transudate present?\n(CHF / cirrhosis / nephrotic)',
        C_DIAMOND, fs=9.2)

# YES → Treat underlying
arrow(ax, 13.8, 27.6, 16.5, 27.6, label='YES →', lc='#2E7D32')
box(ax, 18.5, 27.6, 3.6, 0.72,
    'Treat underlying cause\n(diuresis, albumin…)\nMonitor response',
    C_TRANS, fs=8.8, bold=False)

# NO ↓
arrow(ax, 11, 27.16, 11, 26.62, label='NO', lc='#C62828')

# ── D2: Thoracentesis ────────────────────────────────────────────────────────
box(ax, 11, 26.3, 7.8, 0.55,
    'Thoracentesis  (diagnostic + therapeutic)\n'
    'Send: Protein · LDH · Glucose · pH · Cell count · Gram stain/Culture · Cytology',
    C_STEP, fs=9.2, bold=True)

arrow(ax, 11, 26.02, 11, 25.45)

# ── LIGHT'S CRITERIA PANEL ───────────────────────────────────────────────────
# background panel
lc_panel = FancyBboxPatch((3.5, 24.35), 15, 1.0,
                           boxstyle='round,pad=0.1', linewidth=2,
                           edgecolor=C_LIGHT, facecolor='#FFF8E1', zorder=2)
ax.add_patch(lc_panel)
ax.text(11, 25.22, "LIGHT'S CRITERIA  (any ONE criterion = Exudate)",
        ha='center', va='center', fontsize=10.5, fontweight='bold',
        color=C_LIGHT, zorder=4)
criteria = (
    '① PF Protein / Serum Protein  > 0.5        '
    '② PF LDH / Serum LDH  > 0.6        '
    '③ PF LDH  > ²⁄₃ × upper limit of normal serum LDH'
)
ax.text(11, 24.73, criteria, ha='center', va='center', fontsize=9,
        color='#4E342E', zorder=4, multialignment='center')

arrow(ax, 11, 24.35, 11, 23.72)

# ── D3: Meets Light's criteria? ─────────────────────────────────────────────
diamond(ax, 11, 23.25, 5.6, 0.88,
        'Meets Light\'s Criteria\n(≥1 criterion positive)?',
        C_DIAMOND, fs=9.5)

# ── LEFT branch = TRANSUDATE ─────────────────────────────────────────────────
arrow(ax, 8.2, 23.25, 4.8, 23.25, label='← NO', lc='#1B5E20')
box(ax, 3.3, 23.25, 3.8, 0.65,
    'TRANSUDATE\n(all 3 criteria negative)',
    C_TRANS, fs=10.5, bold=True)

# edge case note
box(ax, 3.3, 22.3, 4.0, 0.72,
    '⚠ If on diuretics:\ncheck serum-PF albumin gradient\n>1.2 g/dL → transudate',
    '#2E7D32', tc='white', fs=8.3, bold=False, lw=1.2)
arrow(ax, 3.3, 22.93, 3.3, 22.67)

# Transudate causes
box(ax, 3.3, 21.2, 4.2, 1.6,
    'CAUSES\n'
    '• Heart failure (bilateral; R>L)\n'
    '• Hepatic hydrothorax (cirrhosis)\n'
    '• Nephrotic syndrome\n'
    '• Atelectasis\n'
    '• SVC obstruction\n'
    '• Myxedema\n'
    '• Peritoneal dialysis\n'
    '• Urinothorax',
    C_CAUSES, tc='white', fs=8.3, lw=1.2)
arrow(ax, 3.3, 21.93, 3.3, 22.02)

# Transudate Mx
box(ax, 3.3, 19.85, 4.0, 1.1,
    'MANAGEMENT\n'
    '• Treat underlying disease\n'
    '• Diuretics (CHF/cirrhosis)\n'
    '• Therapeutic thoracentesis\n'
    '  if symptomatic\n'
    '• TIPS (refractory hydrothorax)',
    C_TRANS, tc='white', fs=8.3, lw=1.2)
v_line(ax, 3.3, 20.96, 21.45)
ax.annotate('', xy=(3.3, 21.0), xytext=(3.3, 20.96),
            arrowprops=dict(arrowstyle='->', color='#37474F', lw=2.0), zorder=2)

# ── RIGHT branch = EXUDATE ───────────────────────────────────────────────────
arrow(ax, 13.8, 23.25, 17.2, 23.25, label='YES →', lc='#C62828')
box(ax, 18.7, 23.25, 3.8, 0.65,
    'EXUDATE\n(≥1 criterion positive)',
    C_EXUDATE, fs=10.5, bold=True)

arrow(ax, 18.7, 22.93, 18.7, 22.35)

# ── SPECIFIC TESTS on exudate ────────────────────────────────────────────────
box(ax, 18.7, 22.0, 4.0, 0.62,
    'Additional Specific Tests',
    C_SPEC, fs=9.5, bold=True)

# test-result ladder (right side)
tests = [
    ('pH < 7.2',              'Empyema / Malignancy /\nOesophageal rupture / RA'),
    ('Glucose < 60 mg/dL',    'Infection · RA · TB · Lupus\nOesophageal rupture'),
    ('ADA > 50 U/L',          'TUBERCULOSIS\n(high sensitivity + specificity)'),
    ('Triglycerides >110 mg/dL', 'Chylothorax\n(thoracic duct disruption)'),
    ('Amylase > 200 U/dL',    'Pancreatitis /\nOesophageal rupture / Malignancy'),
    ('RBC > 5000/µL',         'Trauma · Malignancy · PE'),
    ('Cytology / Biopsy (+)', 'MALIGNANCY\n(cytology 60–90% sensitive)'),
    ('RF · ANA · LE cells',   'Collagen vascular disease\n(RA, SLE)'),
]
ty = 21.55
for test, result in tests:
    ax.text(15.1, ty, f'▶  {test}', ha='left', va='center',
            fontsize=7.9, color='#BF360C', fontweight='bold')
    ax.text(15.1, ty - 0.25, f'    → {result}', ha='left', va='center',
            fontsize=7.7, color='#212121')
    ty -= 0.7

# Exudate causes heading
ey = ty - 0.1
box(ax, 18.7, ey, 4.2, 0.48,
    'MAIN EXUDATE CAUSES',
    C_EXUDATE, fs=9, bold=True)

causes_text = (
    '• Parapneumonic effusion / Empyema\n'
    '• Malignancy (lung, breast, lymphoma,\n'
    '  mesothelioma, mets)\n'
    '• Tuberculosis\n'
    '• Pulmonary embolism\n'
    '• RA / SLE / vasculitis\n'
    '• Pancreatitis / subdiaphragmatic abscess\n'
    '• Dressler syndrome\n'
    '• Meigs syndrome\n'
    '• Drug-induced · Sarcoidosis · Radiation'
)
box(ax, 18.7, ey - 1.15, 4.2, 1.78, causes_text,
    C_CAUSES, tc='white', fs=7.9, lw=1.2)

# ── EXUDATE MANAGEMENT ───────────────────────────────────────────────────────
my = ey - 2.35
box(ax, 18.7, my, 4.2, 0.48,
    'MANAGEMENT PRINCIPLES',
    C_EXUDATE, fs=9, bold=True)

mgmt_text = (
    'Parapneumonic/Empyema:\n'
    '  Simple → Antibiotics alone\n'
    '  Complicated (pH<7.2) → Chest tube\n'
    '  Loculated → Intrapleural fibrinolytics\n'
    '  Non-resolving → VATS / Decortication\n\n'
    'Malignant:\n'
    '  Recurrent → Tunneled pleural catheter\n'
    '  or Talc pleurodesis\n\n'
    'TB → Anti-TB chemotherapy ± steroids\n\n'
    'PE → Anticoagulation\n\n'
    'Chylothorax:\n'
    '  Low-fat diet / TPN; duct ligation'
)
box(ax, 18.7, my - 1.5, 4.2, 2.55, mgmt_text,
    '#7B1FA2', tc='white', fs=7.8, lw=1.2)

# ── CENTRAL BOTTOM: AFTER CLASSIFICATION ─────────────────────────────────────
arrow(ax, 11, 22.81, 11, 21.6)
diamond(ax, 11, 21.15, 5.6, 0.82,
        'Specific diagnosis\nestablished?',
        C_DIAMOND, fs=9.5)

arrow(ax, 11, 20.74, 11, 20.15, label='YES', lc='#2E7D32')
box(ax, 11, 19.85, 6.0, 0.52,
    'Treat specific underlying cause\n(see Transudate / Exudate management branches)',
    '#37474F', fs=9, bold=False)

arrow(ax, 13.8, 21.15, 16.5, 21.15, label='NO →', lc='#C62828')
box(ax, 18.7, 21.15, 3.6, 0.65,
    'Further investigation:\nBiopsy (CT/thoracoscopic)\nPET-CT · Bronchoscopy',
    '#546E7A', fs=8.3, bold=False)

# ── VOLUME LIMIT REMINDER ─────────────────────────────────────────────────────
box(ax, 11, 19.1, 7.5, 0.52,
    '⚠  Drain ≤1.5 L per session to prevent Re-expansion Pulmonary Oedema\n'
    '   Use ultrasound guidance for all thoracentesis procedures',
    '#F57F17', tc='#1A237E', fs=8.5, bold=False,
    shape='round,pad=0.1', border='#F57F17', lw=2.0)

# ── LEGEND ────────────────────────────────────────────────────────────────────
legend_items = [
    (C_START,   'Start / End'),
    (C_STEP,    'Process Step'),
    (C_DIAMOND, 'Decision (diamond)'),
    (C_TRANS,   'Transudate'),
    (C_EXUDATE, 'Exudate'),
    (C_CAUSES,  'Causes'),
    (C_SPEC,    'Specific Tests'),
    (C_LIGHT,   "Light's Criteria"),
]
lx, ly = 1.2, 18.4
ax.text(lx, ly + 0.35, 'LEGEND', fontsize=9, fontweight='bold', color='#37474F')
for i, (col, label) in enumerate(legend_items):
    rx = lx + (i % 4) * 4.0
    ry = ly - (i // 4) * 0.6
    rect = FancyBboxPatch((rx, ry - 0.18), 0.48, 0.36,
                          boxstyle='round,pad=0.04', facecolor=col,
                          edgecolor='white', linewidth=1, zorder=3)
    ax.add_patch(rect)
    ax.text(rx + 0.62, ry, label, fontsize=8, va='center', color='#212121')

# ── FOOTER ────────────────────────────────────────────────────────────────────
ax.plot([1, 21], [17.55, 17.55], color='#90A4AE', lw=1)
ax.text(11, 17.3,
        'Sources: Goldman-Cecil Medicine (26th ed.) · Murray & Nadel Respiratory Medicine · '
        'Light RW criteria (1972) · BTS Guidelines',
        ha='center', va='center', fontsize=7.5, color='#607D8B', fontstyle='italic')
ax.text(11, 17.0,
        'LDH = lactate dehydrogenase · PF = pleural fluid · ADA = adenosine deaminase · '
        'TIPS = transjugular intrahepatic portosystemic shunt · VATS = video-assisted thoracoscopic surgery',
        ha='center', va='center', fontsize=7.2, color='#78909C', fontstyle='italic')

plt.tight_layout(pad=0.3)
plt.savefig('/home/daytona/workspace/pleural-flowchart/pleural_effusion_flowchart.png',
            dpi=180, bbox_inches='tight', facecolor=fig.get_facecolor())
print("Saved successfully")

cd /home/daytona/workspace/pleural-flowchart && python3 flowchart.py 2>&1

ls -lh /home/daytona/workspace/pleural-flowchart/pleural_effusion_flowchart.png …