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🪨 Renal Calculi (Nephrolithiasis / Urolithiasis) - Complete Exam Guide

1. DEFINITION

Renal calculi = solid crystalline deposits that form within the kidney when the urinary concentration of stone-forming ions exceeds their solubility (supersaturation), leading to nucleation and crystal aggregation in a protein matrix.

Also called: urolithiasis, nephrolithiasis, kidney stones.

2. EPIDEMIOLOGY (High-Yield Numbers)

Fact	Value
Lifetime risk - men	~15%
Lifetime risk - women	~10%
Peak incidence	4th-5th decade
Annual incidence	>1 per 1000 persons
Most common stone	Calcium oxalate (60%)

More common in hot, dry climates (concentrated urine)
More common in whites vs other ethnic groups
Obesity (BMI >30) is a major risk factor

3. STONE TYPES & COMPOSITION

Quick Reference Table

Stone Type	%	Appearance on X-ray	pH	Key Association
Calcium oxalate	60%	Radiopaque	Acidic	Most common overall
Hydroxyapatite (Ca-phosphate)	20%	Radiopaque	Alkaline	Hyperparathyroidism
Struvite (MgNH4PO4)	7%	Radiopaque (staghorn)	Alkaline (>7)	Urease-splitting bacteria
Uric acid	7%	Radiolucent	Acidic (<5.5)	Gout, high-purine diet
Cystine	1-3%	Faintly opaque	Acidic	Cystinuria (genetic)
Drug stones	<1%	Variable	-	Indinavir, triamterene

Exam Mnemonic - Radiopaque stones: "Can Sometimes Be Radiopaque" = Calcium oxalate, Struvite, Brushite, (all calcium-containing). Radiolucent = Uric Acid (and indinavir).

4. PATHOPHYSIOLOGY (Stone Formation Steps)

Normal urine
     ↓
Supersaturation (↑ stone-forming ions OR ↓ urine volume)
     ↓
Nucleation (ions bond → crystal seeds form)
     ↓
Crystal Growth & Aggregation
     ↓
Stone formation

Promoters of stone formation:

Hypercalciuria, hyperoxaluria, hyperuricosuria
Hypocitraturia (citrate is a key INHIBITOR)
Low urine volume (dehydration)
High urine pH (promotes Ca-phosphate, struvite)
Low urine pH (promotes uric acid, Ca-oxalate)

Natural inhibitors (that prevent stones):

Citrate (chelates calcium)
Tamm-Horsfall protein
Osteopontin
Pyrophosphate, nephrocalcin

5. CAUSES & RISK FACTORS

A. Calcium Stones (Hypercalciuria - 3 Types)

┌─────────────────────────────────────────────────────────┐
│              HYPERCALCIURIA TYPES                        │
├────────────────┬────────────────┬────────────────────────┤
│ ABSORPTIVE     │ RENAL          │ RESORPTIVE             │
│ (most common,  │ (Impaired Ca   │ (1° Hyperparathy-      │
│ 20-40%)        │ reabsorption   │ roidism, 3-5%)         │
│ ↑ GI Ca absorb │ in tubules,    │ ↑ PTH → bone           │
│ → ↑ urinary Ca │ 5-8%)          │ resorption             │
└────────────────┴────────────────┴────────────────────────┘

Other causes of calcium stones:

Hyperoxaluria - dietary (spinach, nuts, tea, cocoa), enteric (Crohn's, celiac - malabsorbed fats bind Ca, free oxalate absorbed), primary (genetic - AGXT gene mutation)
Hypocitraturia - RTA (renal tubular acidosis), diarrhea, hypokalemia
Hyperuricosuria - purine-rich diet, gout

B. Struvite Stones (Infection Stones)

Caused by urease-producing bacteria: Proteus mirabilis (#1), Klebsiella, Pseudomonas, Staphylococcus
Urease splits urea → ammonia → alkaline urine (pH >7) → precipitates MgNH4PO4
Forms staghorn calculi (fills entire renal pelvis + calyces)
Almost always associated with recurrent UTIs

C. Uric Acid Stones

Causes: gout, high-purine diet (red meat, organ meats, shellfish), myeloproliferative disorders, tumor lysis syndrome, diabetes/obesity
Acidic urine pH <5.5 promotes uric acid precipitation (uric acid is poorly soluble in acid)
Unique: radiolucent on plain X-ray but visible on CT

D. Cystine Stones

Autosomal recessive defect in cystine-dibasic amino acid transporter (SLC3A1, SLC7A9 genes)
Amino acids affected: Cystine, Ornithine, Lysine, Arginine → "COLA" mnemonic
Cystine is insoluble → forms staghorn-like stones
Appears hexagonal crystals on urine microscopy

6. CLINICAL FEATURES

Classic Presentation

┌──────────────────────────────────────────────────────────┐
│           RENAL COLIC - CLASSIC FEATURES                 │
│                                                          │
│  • Sudden, SEVERE, COLICKY flank pain                    │
│  • Radiates: flank → groin → labia/scrotum              │
│  • "Worst pain of my life" (restless, can't lie still)  │
│  • Nausea & vomiting                                     │
│  • Hematuria (gross or microscopic) - 90%               │
│  • Dysuria/urgency (if stone near UVJ)                  │
│  • NO peritoneal signs (patient constantly moves)        │
└──────────────────────────────────────────────────────────┘

Pain Location by Stone Location

      [Renal pelvis/calyces]
             ↓
      Flank pain / CVA tenderness
             ↓
      [Upper ureter]
             ↓
      Flank → upper abdomen (may mimic appendicitis/cholecystitis)
             ↓
      [Mid-ureter crossing iliac vessels]  ← Common obstruction site
             ↓
      Lower abdomen / pelvis
             ↓
      [Ureterovesical junction (UVJ)]  ← Most common site of obstruction
             ↓
      Urgency, frequency, dysuria, groin pain

3 Points Where Stones Get Stuck (EXAM FAVORITE!)

Ureteropelvic junction (UPJ)
Ureter crossing iliac vessels (pelvic brim)
Ureterovesical junction (UVJ) - narrowest, most common

7. DIAGNOSIS

Step 1 - Urine Tests

Urinalysis: hematuria (90%), crystalluria (RBCs + crystals), pyuria (if infected)
Urine pH: acidic in uric acid stones; alkaline (>7) in struvite; helps narrow stone type
Urine culture: to rule out infection (especially struvite stones)
24-hour urine collection (for recurrent stones): calcium, oxalate, uric acid, citrate, phosphate, sodium, creatinine

Step 2 - Blood Tests

BMP/CMP: serum Ca, uric acid, BUN/Cr (renal function)
PTH: if hypercalcemia present (to exclude hyperparathyroidism)
CBC: leukocytosis if infected stone

Step 3 - Imaging

Gold standard: Non-contrast CT (NCCT) abdomen/pelvis

Non-contrast CT showing an 8mm obstructing calculus at the left ureteropelvic junction (arrow) with surrounding inflammatory changes.

CT KUB: 8mm obstructing calculus at the left UPJ (arrow) - gold standard imaging. Source: National Kidney Foundation Primer on Kidney Diseases, 8e

Sensitivity & specificity >95% for all stone types (including radiolucent uric acid stones)
Shows hydronephrosis, periureteral stranding, stone size/location
"Low-dose CT protocol" available to reduce radiation

Plain X-ray (KUB - Kidney, Ureter, Bladder):

KUB X-ray showing two calcifications overlying the upper right kidney (arrows) with a percutaneous nephroureterostomy catheter visible.

KUB X-ray: radiopaque calculi in right kidney (arrows). Source: National Kidney Foundation Primer on Kidney Diseases, 8e

Detects radiopaque stones (Ca-oxalate, Ca-phosphate, struvite, cystine)
MISSES radiolucent stones (uric acid, indinavir)
Sensitivity ~60% - less reliable than CT

Ultrasound:

Renal ultrasound: hyperechoic stone with acoustic shadow (arrow). Source: National Kidney Foundation Primer on Kidney Diseases, 8e

First-line in: pregnant patients, children, recurrent disease (no radiation)
Detects hydronephrosis and larger stones >5mm
Less sensitive than CT for small/ureteral stones
Finding: hyperechoic focus + posterior acoustic shadowing

Imaging Summary Table

Modality	Sensitivity	Best For	Misses
NCCT	>95%	Gold standard, all stones	Radiation
KUB X-ray	~60%	Follow-up of radiopaque stones	Uric acid stones
Ultrasound	~45-78%	Pregnancy, kids, hydronephrosis	Small/ureteral stones
IVP/IVU	Good	Anatomy, radiolucent stones	Largely replaced by CT
MRI	Poor	Not standard for stones	Most calculi (no MR signal)

8. TREATMENT

Algorithm Based on Stone Size

Stone Detected
     │
     ├─── ≤4 mm ──→ 95% pass spontaneously
     │              Medical expulsive therapy (MET)
     │              Hydration, pain control
     │
     ├─── 4-6 mm ──→ ~50% pass spontaneously
     │               MET + α-blocker (tamsulosin)
     │               Wait up to 4 weeks
     │
     ├─── 6-10 mm ──→ Unlikely to pass spontaneously
     │                Consider procedural intervention
     │
     └─── >10 mm ──→ Intervention needed
                     Choose based on location/type

A. Conservative/Medical Management (Acute Colic)

Treatment	Purpose
IV/oral hydration	Dilute urine, encourage stone passage
NSAIDs (ketorolac, ibuprofen)	First-line pain control (better than opioids)
Opioids (morphine)	Rescue analgesia
α-blockers (tamsulosin 0.4 mg)	Relax ureteral smooth muscle → ↑ passage rate
Anti-emetics (ondansetron)	Nausea/vomiting

B. Interventional Procedures

Procedure	Best For	Mechanism
ESWL (Extracorporeal Shock Wave Lithotripsy)	Stones <2 cm, renal pelvis, upper ureter	External shock waves fragment stone
URS (Ureteroscopy + laser lithotripsy)	Ureteral stones, any size	Endoscope + holmium laser
PCNL (Percutaneous Nephrolithotomy)	Large stones >2 cm, staghorn calculi	Nephroscope through flank
Open/laparoscopic surgery	Complex/rare cases	Rarely needed

C. Emergency Indications (IMMEDIATE intervention)

Infected obstructing stone (urosepsis) - most urgent
Bilateral obstruction or solitary kidney
Refractory pain/vomiting
Worsening renal function

9. STONE-SPECIFIC MEDICAL PREVENTION

Stone Type	Prevention Strategy
Calcium oxalate	↑ fluids (>2-2.5 L/day), low-oxalate diet, normal (not low) Ca intake, thiazide diuretics (for hypercalciuria), potassium citrate (for hypocitraturia)
Calcium phosphate	Thiazide diuretics, potassium citrate
Uric acid	Alkalinize urine (potassium citrate → pH 6-7), allopurinol (for hyperuricosuria), low-purine diet
Struvite	Antibiotics (treat underlying infection), acetohydroxamic acid (urease inhibitor), surgical removal
Cystine	High fluid intake (>3 L/day), alkalinize urine, D-penicillamine or tiopronin (chelates cystine)

10. COMPLICATIONS

Complication	Key Point
Urinary obstruction	→ Hydronephrosis → obstructive nephropathy
Pyelonephritis/urosepsis	Infected obstructing stone = surgical emergency
CKD/renal failure	Recurrent stones → progressive nephron loss
Recurrence	~50% within 5-10 years if no prevention
Ureteral stricture	From repeated stone passage

11. HIGH-YIELD EXAM FAST FACTS

Fact	Answer
Most common stone	Calcium oxalate
Only radiolucent stone	Uric acid (also indinavir)
Stone in alkaline urine	Struvite, Calcium phosphate
Stone in acidic urine	Uric acid, Calcium oxalate
Staghorn calculus =	Struvite (or rarely cystine)
"COLA" amino acids lost in cystinuria	Cystine, Ornithine, Lysine, Arginine
Crystal shape: uric acid	Rhomboid/needle shaped
Crystal shape: cystine	Hexagonal (pathognomonic)
Crystal shape: Ca-oxalate dihydrate	Envelope/bipyramid
Crystal shape: struvite	Coffin-lid shaped
Gold standard imaging	Non-contrast CT
First-line imaging in pregnancy	Ultrasound
Most common site of obstruction	Ureterovesical junction (UVJ)
Inhibitor of stone formation	Citrate
Bacteria causing struvite	Proteus mirabilis (#1)
MET agent	Tamsulosin (α-blocker)
Large stone (>2cm) treatment	PCNL

12. QUICK MEMORY DIAGRAM - Stone Types at a Glance

                    KIDNEY STONES
                        │
        ┌───────────────┼────────────────┐
        │               │                │
   CALCIUM (80%)    URIC ACID (7%)   STRUVITE (7%)
   ├─ Oxalate 60%   Radiolucent      Urease bacteria
   ├─ Phosphate 20%  pH <5.5         pH >7 (alkaline)
   └─ Brushite 2%   Gout/obesity    Staghorn calculi
        
   CYSTINE (1-3%)        DRUG STONES (<1%)
   Genetic/AR            Indinavir,
   Hexagonal crystals    Triamterene
   COLA amino acids

Sources: Goldman-Cecil Medicine, 26e | Campbell-Walsh-Wein Urology | National Kidney Foundation Primer on Kidney Diseases, 8e | Robbins Pathologic Basis of Disease

Generate a PDF quick reference card summarizing stone classifications, diagnostic criteria, and treatment protocols

Reading File

Running Command

mkdir -p /tmp/workspace/renal-calculi && ls /tmp/workspace/

Writing File

~/renal-calculi/generate_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import cm, mm
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Table, TableStyle, Spacer,
    HRFlowable, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_RIGHT
from reportlab.pdfgen import canvas
from reportlab.platypus import BaseDocTemplate, Frame, PageTemplate

OUTPUT = "/tmp/workspace/renal-calculi/Renal_Calculi_Quick_Reference.pdf"

# ── Colour palette ────────────────────────────────────────────────────────────
NAVY       = colors.HexColor("#1B3A6B")
STEEL      = colors.HexColor("#2E6DA4")
LIGHT_BLUE = colors.HexColor("#D6E8F7")
TEAL       = colors.HexColor("#1A7A7A")
LIGHT_TEAL = colors.HexColor("#D0EFEF")
ORANGE     = colors.HexColor("#C0540A")
ORANGE_LT  = colors.HexColor("#FDE8D8")
RED        = colors.HexColor("#B22222")
RED_LT     = colors.HexColor("#FAE0E0")
GREEN      = colors.HexColor("#1B6B2F")
GREEN_LT   = colors.HexColor("#D8F0DE")
PURPLE     = colors.HexColor("#5B2C8D")
PURPLE_LT  = colors.HexColor("#EAD8F8")
GOLD       = colors.HexColor("#B8860B")
GOLD_LT    = colors.HexColor("#FFF8DC")
GREY_DARK  = colors.HexColor("#333333")
GREY_MID   = colors.HexColor("#666666")
GREY_LIGHT = colors.HexColor("#F4F6FA")
WHITE      = colors.white

# ── Page dimensions ───────────────────────────────────────────────────────────
W, H = A4   # 595.27 x 841.89 pts
MARGIN = 1.5 * cm

# ── Styles ────────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

def style(name, **kw):
    s = ParagraphStyle(name, **kw)
    return s

HDR1 = style("HDR1", fontSize=18, fontName="Helvetica-Bold",
             textColor=WHITE, alignment=TA_CENTER, leading=22)
HDR2 = style("HDR2", fontSize=11, fontName="Helvetica-Bold",
             textColor=WHITE, alignment=TA_LEFT, leading=14)
HDR3 = style("HDR3", fontSize=9.5, fontName="Helvetica-Bold",
             textColor=NAVY, alignment=TA_LEFT, leading=12)
BODY = style("BODY", fontSize=8.2, fontName="Helvetica",
             textColor=GREY_DARK, leading=11)
BODY_B = style("BODY_B", fontSize=8.2, fontName="Helvetica-Bold",
               textColor=GREY_DARK, leading=11)
SMALL = style("SMALL", fontSize=7.5, fontName="Helvetica",
              textColor=GREY_MID, leading=10)
SMALL_B = style("SMALL_B", fontSize=7.5, fontName="Helvetica-Bold",
                textColor=GREY_DARK, leading=10)
CELL  = style("CELL",  fontSize=7.8, fontName="Helvetica",
              textColor=GREY_DARK, leading=10, alignment=TA_LEFT)
CELL_B = style("CELL_B", fontSize=7.8, fontName="Helvetica-Bold",
               textColor=GREY_DARK, leading=10)
CELL_W = style("CELL_W", fontSize=8, fontName="Helvetica-Bold",
               textColor=WHITE, leading=10, alignment=TA_LEFT)
ALERT = style("ALERT", fontSize=8, fontName="Helvetica-Bold",
              textColor=RED, leading=10)
MNEM  = style("MNEM", fontSize=8, fontName="Helvetica-BoldOblique",
              textColor=PURPLE, leading=10)

usable_w = W - 2 * MARGIN   # ≈ 165 mm

# ── Helper: section header bar ────────────────────────────────────────────────
def section_header(text, bg=NAVY, fg=WHITE):
    tbl = Table([[Paragraph(text, style("_sh", fontSize=10,
                                        fontName="Helvetica-Bold",
                                        textColor=fg, leading=13))]],
                colWidths=[usable_w])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg),
        ("TOPPADDING",  (0,0), (-1,-1), 4),
        ("BOTTOMPADDING",(0,0), (-1,-1), 4),
        ("LEFTPADDING", (0,0), (-1,-1), 6),
        ("RIGHTPADDING",(0,0), (-1,-1), 6),
        ("ROUNDEDCORNERS", [4, 4, 4, 4]),
    ]))
    return tbl

# ── Helper: two-col layout ────────────────────────────────────────────────────
def two_col(left_items, right_items, ratio=(1, 1)):
    total = sum(ratio)
    lw = usable_w * ratio[0] / total - 3
    rw = usable_w * ratio[1] / total - 3
    rows = max(len(left_items), len(right_items))
    data = []
    for i in range(rows):
        l = left_items[i]  if i < len(left_items)  else ""
        r = right_items[i] if i < len(right_items) else ""
        data.append([l, r])
    tbl = Table(data, colWidths=[lw, rw], hAlign="LEFT")
    tbl.setStyle(TableStyle([
        ("VALIGN", (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING", (0,0), (-1,-1), 0),
        ("RIGHTPADDING",(0,0), (-1,-1), 4),
        ("TOPPADDING",  (0,0), (-1,-1), 0),
        ("BOTTOMPADDING",(0,0), (-1,-1), 0),
    ]))
    return tbl

# ══════════════════════════════════════════════════════════════════════════════
# Build story
# ══════════════════════════════════════════════════════════════════════════════
story = []

# ── TITLE BANNER ──────────────────────────────────────────────────────────────
title_data = [[
    Paragraph("🪨  RENAL CALCULI", style("T1", fontSize=20,
              fontName="Helvetica-Bold", textColor=WHITE, leading=24)),
    Paragraph("Quick Reference Card", style("T2", fontSize=11,
              fontName="Helvetica-BoldOblique", textColor=LIGHT_BLUE,
              alignment=TA_RIGHT, leading=14)),
]]
title_tbl = Table(title_data, colWidths=[usable_w * 0.6, usable_w * 0.4])
title_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), NAVY),
    ("TOPPADDING",  (0,0), (-1,-1), 10),
    ("BOTTOMPADDING",(0,0), (-1,-1), 10),
    ("LEFTPADDING", (0,0), (-1,-1), 10),
    ("RIGHTPADDING",(0,0), (-1,-1), 10),
    ("VALIGN",      (0,0), (-1,-1), "MIDDLE"),
]))
story.append(title_tbl)

sub_data = [[
    Paragraph("Nephrolithiasis / Urolithiasis", style("S1", fontSize=9,
              fontName="Helvetica", textColor=WHITE, leading=11)),
    Paragraph("Classification · Diagnosis · Treatment · Prevention",
              style("S2", fontSize=8, fontName="Helvetica-Oblique",
                    textColor=LIGHT_BLUE, alignment=TA_RIGHT, leading=11)),
]]
sub_tbl = Table(sub_data, colWidths=[usable_w * 0.55, usable_w * 0.45])
sub_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), STEEL),
    ("TOPPADDING",  (0,0), (-1,-1), 4),
    ("BOTTOMPADDING",(0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 10),
    ("RIGHTPADDING",(0,0), (-1,-1), 10),
    ("VALIGN",      (0,0), (-1,-1), "MIDDLE"),
]))
story.append(sub_tbl)
story.append(Spacer(1, 6))

# ══════════════════════════════════════════════════════════════════════════════
# SECTION 1 – DEFINITION & EPIDEMIOLOGY
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("1. DEFINITION & EPIDEMIOLOGY", NAVY))
story.append(Spacer(1, 4))

def_items = [
    Paragraph("<b>Definition:</b> Crystalline deposits formed in the kidney when urine becomes "
              "supersaturated with stone-forming ions, exceeding their solubility "
              "→ nucleation → crystal growth → stone.", BODY),
    Spacer(1, 4),
    Paragraph("<b>Mechanism:</b> Supersaturation → Nucleation (homo/heterogeneous) → "
              "Aggregation → Stone (inhibitors: citrate, Tamm-Horsfall protein, osteopontin)", BODY),
]

epi_rows = [
    [Paragraph("Fact", CELL_W), Paragraph("Value", CELL_W)],
    [Paragraph("Lifetime risk – Men", CELL_B), Paragraph("~15%", CELL)],
    [Paragraph("Lifetime risk – Women", CELL_B), Paragraph("~10%", CELL)],
    [Paragraph("Peak incidence", CELL_B), Paragraph("4th–5th decade", CELL)],
    [Paragraph("Annual incidence", CELL_B), Paragraph(">1 per 1,000 persons", CELL)],
    [Paragraph("Most common stone", CELL_B), Paragraph("Calcium oxalate (60%)", CELL)],
    [Paragraph("Key risk factors", CELL_B), Paragraph("Obesity, hot climate, low fluid intake, family Hx", CELL)],
]
epi_tbl = Table(epi_rows, colWidths=[usable_w*0.42, usable_w*0.58])
epi_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), STEEL),
    ("BACKGROUND", (0,1), (-1,1), LIGHT_BLUE),
    ("BACKGROUND", (0,2), (-1,2), WHITE),
    ("BACKGROUND", (0,3), (-1,3), LIGHT_BLUE),
    ("BACKGROUND", (0,4), (-1,4), WHITE),
    ("BACKGROUND", (0,5), (-1,5), LIGHT_BLUE),
    ("BACKGROUND", (0,6), (-1,6), WHITE),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#BBCDE0")),
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ("RIGHTPADDING",  (0,0), (-1,-1), 5),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))

story.append(two_col(def_items, [epi_tbl], ratio=(55, 45)))
story.append(Spacer(1, 7))

# ══════════════════════════════════════════════════════════════════════════════
# SECTION 2 – STONE CLASSIFICATION
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("2. STONE CLASSIFICATION (Composition & Key Features)", TEAL))
story.append(Spacer(1, 4))

hdr = [Paragraph(h, CELL_W) for h in
       ["Stone Type", "% of All", "X-Ray", "Urine pH", "Crystal Shape", "Key Association"]]
stone_rows = [
    hdr,
    [Paragraph("Calcium Oxalate", CELL_B),
     Paragraph("60%", CELL),
     Paragraph("Radiopaque", CELL),
     Paragraph("Acidic", CELL),
     Paragraph("Envelope/bipyramid (dihydrate)\nDumbbell (monohydrate)", SMALL),
     Paragraph("Hypercalciuria, hyperoxaluria, hypocitraturia", CELL)],
    [Paragraph("Calcium Phosphate\n(Hydroxyapatite)", CELL_B),
     Paragraph("20%", CELL),
     Paragraph("Radiopaque", CELL),
     Paragraph("Alkaline", CELL),
     Paragraph("Amorphous / needle", SMALL),
     Paragraph("Hyperparathyroidism, RTA type 1", CELL)],
    [Paragraph("Struvite\n(MgNH₄PO₄)", CELL_B),
     Paragraph("7%", CELL),
     Paragraph("Radiopaque", CELL),
     Paragraph("Alkaline >7", CELL),
     Paragraph("Coffin-lid", SMALL),
     Paragraph("Urease bacteria (Proteus #1)\nStaghorn calculi, recurrent UTIs", CELL)],
    [Paragraph("Uric Acid", CELL_B),
     Paragraph("7%", CELL),
     Paragraph("Radiolucent ★", CELL),
     Paragraph("Acidic <5.5", CELL),
     Paragraph("Rhomboid/needle", SMALL),
     Paragraph("Gout, obesity, high-purine diet,\ntumor lysis, diabetes", CELL)],
    [Paragraph("Cystine", CELL_B),
     Paragraph("1–3%", CELL),
     Paragraph("Faint opaque", CELL),
     Paragraph("Acidic", CELL),
     Paragraph("Hexagonal ★★", SMALL),
     Paragraph("Cystinuria (AR) – COLA: Cystine,\nOrnithine, Lysine, Arginine", CELL)],
    [Paragraph("Drug Stones", CELL_B),
     Paragraph("<1%", CELL),
     Paragraph("Radiolucent\n(indinavir)", CELL),
     Paragraph("Variable", CELL),
     Paragraph("Variable", SMALL),
     Paragraph("Indinavir, triamterene, ephedrine,\nsilica", CELL)],
]
stone_tbl = Table(stone_rows, colWidths=[
    usable_w*0.16, usable_w*0.07, usable_w*0.10,
    usable_w*0.10, usable_w*0.17, usable_w*0.40
])
stone_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), TEAL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_TEAL, WHITE]),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#A0C8C8")),
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("FONTNAME",   (0,1), (-1,-1), "Helvetica"),
    ("FONTSIZE",   (0,1), (-1,-1), 7.8),
]))
story.append(stone_tbl)
story.append(Paragraph(
    "★ Uric acid stones are the ONLY radiolucent stones on plain X-ray but are visible on CT  "
    "★★ Hexagonal crystals on urine microscopy are pathognomonic for cystinuria",
    style("fn", fontSize=7, fontName="Helvetica-Oblique",
          textColor=GREY_MID, leading=9)))
story.append(Spacer(1, 7))

# ══════════════════════════════════════════════════════════════════════════════
# SECTION 3 – CAUSES / RISK FACTORS
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("3. CAUSES & RISK FACTORS", ORANGE))
story.append(Spacer(1, 4))

# Hypercalciuria box
hyper_rows = [
    [Paragraph("HYPERCALCIURIA (3 types)", CELL_W), Paragraph("Prevalence", CELL_W), Paragraph("Mechanism", CELL_W)],
    [Paragraph("Absorptive (most common)", CELL_B), Paragraph("20–40%", CELL), Paragraph("↑ GI Ca absorption → ↑ urinary Ca", CELL)],
    [Paragraph("Renal", CELL_B), Paragraph("5–8%", CELL), Paragraph("Impaired tubular Ca reabsorption", CELL)],
    [Paragraph("Resorptive (1° HPT)", CELL_B), Paragraph("3–5%", CELL), Paragraph("↑ PTH → bone Ca release → ↑ urine Ca", CELL)],
]
hyper_tbl = Table(hyper_rows, colWidths=[usable_w*0.35, usable_w*0.15, usable_w*0.50])
hyper_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), ORANGE),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [ORANGE_LT, WHITE]),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#E0A080")),
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))

# Other causes
other_rows = [
    [Paragraph("Condition", CELL_W), Paragraph("Mechanism / Association", CELL_W)],
    [Paragraph("Hyperoxaluria", CELL_B),
     Paragraph("Dietary (spinach, nuts, tea) | Enteric (Crohn's, celiac – malabsorbed fat binds Ca, free oxalate absorbed) | Primary (AGXT gene defect)", CELL)],
    [Paragraph("Hypocitraturia", CELL_B),
     Paragraph("RTA type 1, chronic diarrhea, hypokalemia – citrate is key stone INHIBITOR", CELL)],
    [Paragraph("Hyperuricosuria", CELL_B),
     Paragraph("High purine diet, gout, myeloproliferative disease – promotes Ca-oxalate & uric acid stones", CELL)],
    [Paragraph("Dehydration / Low UO", CELL_B),
     Paragraph("Hot climate, occupation, exercise → concentrated urine → supersaturation", CELL)],
    [Paragraph("Urease bacteria", CELL_B),
     Paragraph("Proteus mirabilis, Klebsiella, Pseudomonas → alkaline pH → struvite", CELL)],
    [Paragraph("Cystinuria (AR)", CELL_B),
     Paragraph("SLC3A1 / SLC7A9 mutations → defective COLA transport → cystine in urine", CELL)],
]
other_tbl = Table(other_rows, colWidths=[usable_w*0.22, usable_w*0.78])
other_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#7A3A0A")),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [ORANGE_LT, WHITE]),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#E0A080")),
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))

story.append(hyper_tbl)
story.append(Spacer(1, 4))
story.append(other_tbl)
story.append(Spacer(1, 7))

# ══════════════════════════════════════════════════════════════════════════════
# SECTION 4 – CLINICAL FEATURES
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("4. CLINICAL FEATURES", RED))
story.append(Spacer(1, 4))

# Symptoms column
sx_items = [
    Paragraph("<b>Classic Renal Colic:</b>", BODY_B),
    Paragraph("• Sudden, severe, colicky flank pain", BODY),
    Paragraph("• Radiates: flank → groin → labia/scrotum", BODY),
    Paragraph("• Restless (can't get comfortable)", BODY),
    Paragraph("• Nausea & vomiting", BODY),
    Paragraph("• Haematuria (90% – gross or micro)", BODY),
    Paragraph("• Dysuria/urgency (stone near UVJ)", BODY),
    Spacer(1, 4),
    Paragraph("<b>No peritoneal signs</b> (patient constantly moves)", ALERT),
]

# 3 points of obstruction
obs_data = [
    [Paragraph("Site", CELL_W), Paragraph("Location / Pain", CELL_W)],
    [Paragraph("① UPJ", CELL_B), Paragraph("Ureteropelvic junction → flank pain", CELL)],
    [Paragraph("② Iliac brim", CELL_B), Paragraph("Ureter crosses iliac vessels → lower abdomen", CELL)],
    [Paragraph("③ UVJ ★", CELL_B), Paragraph("Ureterovesical junction (narrowest) → urgency, groin pain – MOST COMMON OBSTRUCTION SITE", CELL)],
]
obs_tbl = Table(obs_data, colWidths=[usable_w*0.20, usable_w*0.80])
obs_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), RED),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [RED_LT, WHITE]),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#D08080")),
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))

obs_block = [
    Paragraph("<b>3 Sites of Stone Impaction (Exam Favourite)</b>", BODY_B),
    Spacer(1, 3),
    obs_tbl,
]

story.append(two_col(sx_items, obs_block, ratio=(45, 55)))
story.append(Spacer(1, 7))

# ══════════════════════════════════════════════════════════════════════════════
# SECTION 5 – DIAGNOSTIC CRITERIA
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("5. DIAGNOSTIC CRITERIA & INVESTIGATIONS", PURPLE))
story.append(Spacer(1, 4))

diag_rows = [
    [Paragraph("Investigation", CELL_W), Paragraph("Findings / Purpose", CELL_W), Paragraph("Notes", CELL_W)],
    [Paragraph("Urinalysis", CELL_B),
     Paragraph("Haematuria (90%), crystalluria, pyuria (if infected), urine pH", CELL),
     Paragraph("Essential first step", CELL)],
    [Paragraph("Urine culture", CELL_B),
     Paragraph("Rule out/confirm infection, especially struvite", CELL),
     Paragraph("Alkaline pH + bacteriuria = struvite until proven otherwise", CELL)],
    [Paragraph("24-hr urine (recurrent stones)", CELL_B),
     Paragraph("Calcium, oxalate, uric acid, citrate, phosphate, Na, Cr", CELL),
     Paragraph("Guides prevention therapy", CELL)],
    [Paragraph("Serum BMP/Ca/Uric acid", CELL_B),
     Paragraph("Renal function, hypercalcaemia, hyperuricaemia", CELL),
     Paragraph("Check Cr before contrast", CELL)],
    [Paragraph("PTH", CELL_B),
     Paragraph("If serum Ca elevated → exclude 1° hyperparathyroidism", CELL),
     Paragraph("Resorptive hypercalciuria", CELL)],
    [Paragraph("★ NCCT (Non-contrast CT) KUB", CELL_B),
     Paragraph("GOLD STANDARD – >95% sensitivity & specificity. Detects all stone types, hydronephrosis, ureteral stranding", CELL),
     Paragraph("Preferred in ED. Visible: ALL stones incl. uric acid", CELL)],
    [Paragraph("KUB X-ray (Plain)", CELL_B),
     Paragraph("Radiopaque stones only (~60% sensitive). Useful for follow-up of known radiopaque stones", CELL),
     Paragraph("MISSES uric acid/indinavir stones", CELL)],
    [Paragraph("Ultrasound", CELL_B),
     Paragraph("Detects hydronephrosis, larger stones >5 mm. Hyperechoic + posterior acoustic shadowing", CELL),
     Paragraph("1st line in PREGNANCY & CHILDREN (no radiation)", CELL)],
    [Paragraph("IVP/IVU", CELL_B),
     Paragraph("Anatomic detail, radiolucent stones visible as filling defects", CELL),
     Paragraph("Largely replaced by NCCT", CELL)],
    [Paragraph("MRI", CELL_B),
     Paragraph("Poor sensitivity for calculi (no MR signal from most stones)", CELL),
     Paragraph("Not standard", CELL)],
]
diag_tbl = Table(diag_rows, colWidths=[usable_w*0.22, usable_w*0.46, usable_w*0.32])
diag_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), PURPLE),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [PURPLE_LT, WHITE]),
    # Highlight CT row
    ("BACKGROUND", (0,6), (-1,6), colors.HexColor("#D0B8F5")),
    ("FONTNAME", (0,6), (0,6), "Helvetica-Bold"),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#C0A0E0")),
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))
story.append(diag_tbl)
story.append(Spacer(1, 7))

# ══════════════════════════════════════════════════════════════════════════════
# SECTION 6 – TREATMENT PROTOCOLS
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("6. TREATMENT PROTOCOLS", GREEN))
story.append(Spacer(1, 4))

# Treatment algorithm as a highlighted box
algo_data = [
    [Paragraph("SIZE", CELL_W),
     Paragraph("SPONTANEOUS PASSAGE", CELL_W),
     Paragraph("FIRST-LINE APPROACH", CELL_W)],
    [Paragraph("≤ 4 mm", CELL_B),
     Paragraph("~95% pass", CELL),
     Paragraph("Conservative: hydration + NSAIDs + tamsulosin. Wait up to 4 weeks", CELL)],
    [Paragraph("4–6 mm", CELL_B),
     Paragraph("~50% pass", CELL),
     Paragraph("MET with α-blocker (tamsulosin 0.4 mg). Monitor 4 weeks", CELL)],
    [Paragraph("6–10 mm", CELL_B),
     Paragraph("Unlikely", CELL),
     Paragraph("Plan intervention. MET while waiting; consider ESWL or URS", CELL)],
    [Paragraph("> 10 mm", CELL_B),
     Paragraph("Will not pass", CELL),
     Paragraph("Intervention required (see procedural table)", CELL)],
]
algo_tbl = Table(algo_data, colWidths=[usable_w*0.12, usable_w*0.20, usable_w*0.68])
algo_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), GREEN),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [GREEN_LT, WHITE]),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#80C090")),
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))
story.append(algo_tbl)
story.append(Spacer(1, 4))

# Acute management + Procedural
acute_rows = [
    [Paragraph("Acute Pain Management", CELL_W), Paragraph("", CELL_W)],
    [Paragraph("NSAIDs (ketorolac/ibuprofen)", CELL_B), Paragraph("First-line analgesia (↓ ureteral spasm, superior to opioids)", CELL)],
    [Paragraph("Opioids (morphine)", CELL_B), Paragraph("Rescue analgesia when NSAIDs insufficient", CELL)],
    [Paragraph("Tamsulosin (α-blocker)", CELL_B), Paragraph("Medical expulsive therapy – relaxes ureteral smooth muscle", CELL)],
    [Paragraph("Anti-emetics (ondansetron)", CELL_B), Paragraph("For nausea/vomiting", CELL)],
    [Paragraph("IV hydration", CELL_B), Paragraph("Dilute urine, encourage passage", CELL)],
]
acute_tbl = Table(acute_rows, colWidths=[usable_w*0.38, usable_w*0.62])
acute_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), GREEN),
    ("SPAN",       (0,0), (-1,0)),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [GREEN_LT, WHITE]),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#80C090")),
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))

proc_rows = [
    [Paragraph("Procedure", CELL_W), Paragraph("Indication", CELL_W), Paragraph("Mechanism", CELL_W)],
    [Paragraph("ESWL", CELL_B),
     Paragraph("Stones <2 cm, renal pelvis, upper ureter", CELL),
     Paragraph("External shock waves fragment stone", CELL)],
    [Paragraph("URS + Laser", CELL_B),
     Paragraph("Ureteral stones (any size), failed ESWL", CELL),
     Paragraph("Endoscope + holmium laser lithotripsy", CELL)],
    [Paragraph("PCNL", CELL_B),
     Paragraph("Large stones >2 cm, staghorn calculi", CELL),
     Paragraph("Nephroscope via percutaneous flank access", CELL)],
    [Paragraph("Open/Laparoscopic", CELL_B),
     Paragraph("Complex/rare cases only", CELL),
     Paragraph("Rarely needed today", CELL)],
]
proc_tbl = Table(proc_rows, colWidths=[usable_w*0.15, usable_w*0.45, usable_w*0.40])
proc_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#1B5C30")),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [GREEN_LT, WHITE]),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#80C090")),
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))

story.append(two_col(
    [Paragraph("<b>Acute / Medical Management</b>", BODY_B), Spacer(1,3), acute_tbl],
    [Paragraph("<b>Interventional Procedures</b>", BODY_B), Spacer(1,3), proc_tbl],
    ratio=(45, 55)
))
story.append(Spacer(1, 4))

# Emergency box
emerg_data = [[
    Paragraph("⚠ EMERGENCY INDICATIONS (Immediate Intervention Required):", ALERT),
    Paragraph("• Infected obstructing stone / Urosepsis (most urgent)   "
              "• Bilateral obstruction   "
              "• Solitary kidney obstruction   "
              "• Refractory pain/vomiting   "
              "• Deteriorating renal function",
              style("em2", fontSize=7.8, fontName="Helvetica", textColor=GREY_DARK, leading=11))
]]
emerg_tbl = Table(emerg_data, colWidths=[usable_w])
emerg_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), RED_LT),
    ("BOX",        (0,0), (-1,-1), 1.2, RED),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING",   (0,0), (-1,-1), 6),
    ("RIGHTPADDING",  (0,0), (-1,-1), 6),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))
story.append(emerg_tbl)
story.append(Spacer(1, 7))

# ══════════════════════════════════════════════════════════════════════════════
# SECTION 7 – PREVENTION (Stone-specific)
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("7. STONE-SPECIFIC PREVENTION", GOLD))
story.append(Spacer(1, 4))

prev_rows = [
    [Paragraph("Stone Type", CELL_W),
     Paragraph("Dietary Measures", CELL_W),
     Paragraph("Medical Therapy", CELL_W)],
    [Paragraph("Calcium Oxalate", CELL_B),
     Paragraph("↑ fluids >2.5 L/day; normal (not low) Ca diet; low oxalate, low Na, low protein", CELL),
     Paragraph("Thiazide diuretics (hypercalciuria); Potassium citrate (hypocitraturia); Pyridoxine (hyperoxaluria)", CELL)],
    [Paragraph("Calcium Phosphate", CELL_B),
     Paragraph("↑ fluids; low Na", CELL),
     Paragraph("Thiazide diuretics; Potassium citrate", CELL)],
    [Paragraph("Uric Acid", CELL_B),
     Paragraph("Low-purine diet (avoid red meat, organ meats, shellfish); ↑ fluids", CELL),
     Paragraph("Potassium citrate (alkalinise urine pH 6–7); Allopurinol (hyperuricosuria)", CELL)],
    [Paragraph("Struvite", CELL_B),
     Paragraph("Adequate hydration; treat UTIs promptly", CELL),
     Paragraph("Antibiotics; Acetohydroxamic acid (urease inhibitor); Surgical stone removal", CELL)],
    [Paragraph("Cystine", CELL_B),
     Paragraph("High fluid intake >3 L/day (most important!); limit Na & protein", CELL),
     Paragraph("Alkalinise urine; D-penicillamine or Tiopronin (chelates cystine)", CELL)],
]
prev_tbl = Table(prev_rows, colWidths=[usable_w*0.17, usable_w*0.42, usable_w*0.41])
prev_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), GOLD),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [GOLD_LT, WHITE]),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#D0B000")),
    ("TOPPADDING",    (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))
story.append(prev_tbl)
story.append(Spacer(1, 7))

# ══════════════════════════════════════════════════════════════════════════════
# SECTION 8 – HIGH-YIELD EXAM FACTS
# ══════════════════════════════════════════════════════════════════════════════
story.append(section_header("8. HIGH-YIELD EXAM FACTS & MNEMONICS", NAVY))
story.append(Spacer(1, 4))

hyfacts_l = [
    [Paragraph("Q", CELL_W), Paragraph("A", CELL_W)],
    [Paragraph("Most common stone?", CELL_B), Paragraph("Calcium oxalate (60%)", CELL)],
    [Paragraph("Only radiolucent stone?", CELL_B), Paragraph("Uric acid (+ indinavir)", CELL)],
    [Paragraph("Staghorn calculus =?", CELL_B), Paragraph("Struvite (infection stone)", CELL)],
    [Paragraph("Stone in alkaline urine?", CELL_B), Paragraph("Struvite, Ca-phosphate", CELL)],
    [Paragraph("Stone in acidic urine?", CELL_B), Paragraph("Uric acid, Ca-oxalate", CELL)],
    [Paragraph("Gold standard imaging?", CELL_B), Paragraph("Non-contrast CT (NCCT)", CELL)],
    [Paragraph("Imaging in pregnancy?", CELL_B), Paragraph("Ultrasound", CELL)],
    [Paragraph("Most common obstruction site?", CELL_B), Paragraph("Ureterovesical junction (UVJ)", CELL)],
    [Paragraph("Key stone inhibitor?", CELL_B), Paragraph("Citrate", CELL)],
    [Paragraph("Urease bacteria #1?", CELL_B), Paragraph("Proteus mirabilis", CELL)],
    [Paragraph("Medical expulsive therapy?", CELL_B), Paragraph("Tamsulosin (α-blocker)", CELL)],
    [Paragraph("Large stone >2 cm treatment?", CELL_B), Paragraph("PCNL", CELL)],
]
hyfacts_tbl_l = Table(hyfacts_l, colWidths=[usable_w*0.32, usable_w*0.28])
hyfacts_tbl_l.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), NAVY),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_BLUE, WHITE]),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#BBCDE0")),
    ("TOPPADDING",    (0,0), (-1,-1), 2.5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 2.5),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
]))

# Mnemonics box
mnem_items = [
    Paragraph("<b>MNEMONICS</b>", BODY_B),
    Spacer(1, 4),
    Paragraph("<b>COLA</b> (Cystinuria – amino acids lost)", MNEM),
    Paragraph("Cystine · Ornithine · Lysine · Arginine", SMALL),
    Spacer(1, 4),
    Paragraph("<b>Radiolucent = U</b>nidentified on X-ray = <b>U</b>ric Acid", MNEM),
    Spacer(1, 4),
    Paragraph("<b>STRUVITE</b> bugs = Urease-splitting", MNEM),
    Paragraph("Proteus, Klebsiella, Pseudomonas, Staph saprophyticus", SMALL),
    Spacer(1, 4),
    Paragraph("<b>Crystal shapes (exam key):</b>", BODY_B),
    Paragraph("• Hexagonal → Cystine", SMALL_B),
    Paragraph("• Coffin-lid → Struvite", SMALL),
    Paragraph("• Envelope/bipyramid → CaOx dihydrate", SMALL),
    Paragraph("• Rhomboid/needle → Uric acid", SMALL),
    Spacer(1, 4),
    Paragraph("<b>Complications:</b>", BODY_B),
    Paragraph("Obstruction → Hydronephrosis → Obstructive nephropathy → CKD", SMALL),
    Paragraph("Infected stone + obstruction = UROSEPSIS (surgical emergency)", ALERT),
    Spacer(1, 4),
    Paragraph("<b>Recurrence rate:</b> ~50% within 5–10 yrs without prevention", SMALL),
]

story.append(two_col([hyfacts_tbl_l], mnem_items, ratio=(60, 40)))
story.append(Spacer(1, 8))

# ── FOOTER ────────────────────────────────────────────────────────────────────
story.append(HRFlowable(width=usable_w, thickness=0.8, color=NAVY))
story.append(Spacer(1, 3))
footer_data = [[
    Paragraph("Sources: Goldman-Cecil Medicine 26e | Campbell-Walsh-Wein Urology | "
              "NKF Primer on Kidney Diseases 8e | Robbins Pathologic Basis of Disease",
              style("ft", fontSize=6.8, fontName="Helvetica-Oblique",
                    textColor=GREY_MID, leading=9)),
    Paragraph("Renal Calculi Quick Reference · Orris",
              style("ft2", fontSize=6.8, fontName="Helvetica-Bold",
                    textColor=GREY_MID, alignment=TA_RIGHT, leading=9)),
]]
footer_tbl = Table(footer_data, colWidths=[usable_w*0.72, usable_w*0.28])
footer_tbl.setStyle(TableStyle([
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    ("LEFTPADDING",  (0,0), (-1,-1), 0),
    ("RIGHTPADDING", (0,0), (-1,-1), 0),
    ("TOPPADDING",   (0,0), (-1,-1), 0),
    ("BOTTOMPADDING",(0,0), (-1,-1), 0),
]))
story.append(footer_tbl)

# ── Build PDF ─────────────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=MARGIN,
    rightMargin=MARGIN,
    topMargin=MARGIN,
    bottomMargin=MARGIN,
    title="Renal Calculi Quick Reference Card",
    author="Orris",
    subject="Nephrolithiasis – Classification, Diagnosis, Treatment",
)
doc.build(story)
print(f"PDF saved to: {OUTPUT}")

Running Command

cd /tmp/workspace/renal-calculi && python generate_pdf.py 2>&1

Running Command

ls -lh /tmp/workspace/renal-calculi/Renal_Calculi_Quick_Reference.pdf

Your PDF quick reference card is ready!

Renal Calculi Quick Reference

PDF Document · PDF

Here's what's packed into the single A4 card:

Section	Content
1. Definition & Epidemiology	Mechanism of stone formation, lifetime risk, peak age, key risk factors table
2. Stone Classification	All 6 stone types - % occurrence, X-ray opacity, urine pH, crystal shape, key associations in a colour-coded table
3. Causes & Risk Factors	3 types of hypercalciuria (absorptive/renal/resorptive) with prevalence, plus hyperoxaluria, hypocitraturia, cystinuria
4. Clinical Features	Classic renal colic symptoms + the 3 sites of stone impaction (UPJ, iliac brim, UVJ)
5. Diagnostic Criteria	All imaging modalities (CT, KUB, US, IVP, MRI) with sensitivity, uses, and limitations; lab investigations
6. Treatment Protocols	Size-based treatment algorithm (≤4mm to >10mm), acute medical management, procedural options (ESWL/URS/PCNL), emergency indications box
7. Stone-specific Prevention	Dietary + medical prevention for each stone type
8. High-yield Exam Facts	Q&A rapid-fire table + mnemonics (COLA, crystal shapes, complication chain)

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