STROKE - Comprehensive PG-Level MPT Exam Guide

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.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether, PageBreak
)
from reportlab.platypus.flowables import BalancedColumns
from reportlab.graphics.shapes import Drawing, Rect, String
from reportlab.pdfbase import pdfmetrics
from reportlab.pdfbase.ttfonts import TTFont
import os

OUTPUT = "/home/daytona/workspace/stroke-ref-guide/Stroke_Quick_Reference_Guide.pdf"

# ── Color palette ──────────────────────────────────────────────────────────
C_HEADER   = colors.HexColor("#1a3a5c")   # deep navy
C_ISCHEMIC = colors.HexColor("#1565C0")   # blue
C_HEMOR    = colors.HexColor("#B71C1C")   # red
C_SAH      = colors.HexColor("#6A1B9A")   # purple
C_TIA      = colors.HexColor("#00695C")   # teal
C_ASSESS   = colors.HexColor("#E65100")   # orange
C_REHAB    = colors.HexColor("#2E7D32")   # green
C_GOLD     = colors.HexColor("#F9A825")   # amber accent
C_LIGHT1   = colors.HexColor("#E3F2FD")   # pale blue
C_LIGHT2   = colors.HexColor("#FFEBEE")   # pale red
C_LIGHT3   = colors.HexColor("#F3E5F5")   # pale purple
C_LIGHT4   = colors.HexColor("#E0F2F1")   # pale teal
C_LIGHT5   = colors.HexColor("#FFF8E1")   # pale amber
C_LIGHTG   = colors.HexColor("#E8F5E9")   # pale green
C_ROW_ALT  = colors.HexColor("#F5F5F5")   # light grey
C_WHITE    = colors.white
C_BLACK    = colors.black
C_DARK     = colors.HexColor("#212121")

# ── Document setup ─────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=1.4*cm, leftMargin=1.4*cm,
    topMargin=1.6*cm, bottomMargin=1.4*cm,
    title="Stroke Quick Reference Guide – MPT Exam",
    author="Orris Medical"
)

W, H = A4
CONTENT_W = W - 2.8*cm

styles = getSampleStyleSheet()

def sty(name, **kw):
    return ParagraphStyle(name, **kw)

BASE  = sty("base",  fontName="Helvetica",      fontSize=8,  leading=11, textColor=C_DARK)
BASEB = sty("baseb", fontName="Helvetica-Bold",  fontSize=8,  leading=11, textColor=C_DARK)
SMALL = sty("small", fontName="Helvetica",       fontSize=7,  leading=10, textColor=C_DARK)
SMB   = sty("smb",   fontName="Helvetica-Bold",  fontSize=7,  leading=10, textColor=C_DARK)

def H1(text, bg=C_HEADER):
    return Table(
        [[Paragraph(f"<font color='white'><b>{text}</b></font>",
                    sty("h1p", fontName="Helvetica-Bold", fontSize=13, leading=16,
                        textColor=C_WHITE, alignment=TA_CENTER))]],
        colWidths=[CONTENT_W],
        style=TableStyle([
            ("BACKGROUND", (0,0), (-1,-1), bg),
            ("TOPPADDING",   (0,0), (-1,-1), 7),
            ("BOTTOMPADDING",(0,0), (-1,-1), 7),
            ("LEFTPADDING",  (0,0), (-1,-1), 10),
            ("RIGHTPADDING", (0,0), (-1,-1), 10),
            ("ROUNDEDCORNERS", (0,0), (-1,-1), [4,4,4,4]),
        ])
    )

def H2(text, color=C_HEADER):
    return Table(
        [[Paragraph(f"<font color='white'><b>{text}</b></font>",
                    sty("h2p", fontName="Helvetica-Bold", fontSize=9.5, leading=13,
                        textColor=C_WHITE))]],
        colWidths=[CONTENT_W],
        style=TableStyle([
            ("BACKGROUND", (0,0), (-1,-1), color),
            ("TOPPADDING",   (0,0), (-1,-1), 4),
            ("BOTTOMPADDING",(0,0), (-1,-1), 4),
            ("LEFTPADDING",  (0,0), (-1,-1), 8),
        ])
    )

def H3(text, color=C_HEADER):
    return Paragraph(f"<font color='#{color.hexval()[2:] if hasattr(color,'hexval') else '1a3a5c'}'><b>{text}</b></font>",
                     sty("h3p", fontName="Helvetica-Bold", fontSize=8.5, leading=12))

def colorH3(text, hexcolor):
    return Paragraph(f"<font color='{hexcolor}'><b>{text}</b></font>",
                     sty("ch3", fontName="Helvetica-Bold", fontSize=8.5, leading=12))

def sp(h=4): return Spacer(1, h)
def hr(color=C_HEADER, w=0.5): return HRFlowable(width="100%", thickness=w, color=color, spaceAfter=3, spaceBefore=2)

def plain_table(data, col_widths, bg_header=C_HEADER, row_colors=True, fontsize=7.5):
    """Generic styled table. First row = header."""
    ts = [
        ("BACKGROUND",   (0,0), (-1,0),  bg_header),
        ("TEXTCOLOR",    (0,0), (-1,0),  C_WHITE),
        ("FONTNAME",     (0,0), (-1,0),  "Helvetica-Bold"),
        ("FONTSIZE",     (0,0), (-1,-1), fontsize),
        ("LEADING",      (0,0), (-1,-1), fontsize+2.5),
        ("TOPPADDING",   (0,0), (-1,-1), 3),
        ("BOTTOMPADDING",(0,0), (-1,-1), 3),
        ("LEFTPADDING",  (0,0), (-1,-1), 5),
        ("RIGHTPADDING", (0,0), (-1,-1), 5),
        ("GRID",         (0,0), (-1,-1), 0.4, colors.HexColor("#BDBDBD")),
        ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [C_WHITE, C_ROW_ALT] if row_colors else [C_WHITE]),
        ("FONTNAME",     (0,1), (-1,-1), "Helvetica"),
        ("TEXTCOLOR",    (0,1), (-1,-1), C_DARK),
    ]
    cells = []
    for i, row in enumerate(data):
        cells.append([Paragraph(str(c), sty(f"tc{i}", fontName="Helvetica-Bold" if i==0 else "Helvetica",
                                            fontSize=fontsize, leading=fontsize+2.5,
                                            textColor=C_WHITE if i==0 else C_DARK)) for c in row])
    return Table(cells, colWidths=col_widths, style=TableStyle(ts), repeatRows=1)

# ══════════════════════════════════════════════════════════════════════
# BUILD CONTENT
# ══════════════════════════════════════════════════════════════════════
story = []

# ── COVER HEADER ──────────────────────────────────────────────────────
cover = Table(
    [[Paragraph("<font color='white'><b>STROKE</b></font>",
                sty("cov1", fontName="Helvetica-Bold", fontSize=28, leading=32, textColor=C_WHITE, alignment=TA_CENTER)),
      Paragraph("<font color='white'>Quick Reference Guide</font><br/>"
                "<font color='#BBDEFB'>Assessment Scales &amp; Tools for MPT Exam</font>",
                sty("cov2", fontName="Helvetica", fontSize=11, leading=16, textColor=C_WHITE))]],
    colWidths=[4*cm, CONTENT_W - 4*cm],
    style=TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), C_HEADER),
        ("TOPPADDING",    (0,0), (-1,-1), 14),
        ("BOTTOMPADDING", (0,0), (-1,-1), 14),
        ("LEFTPADDING",   (0,0), (0,0),   16),
        ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
        ("LINEBELOW",     (0,0), (-1,-1), 3, C_GOLD),
    ])
)
story.append(cover)
story.append(sp(8))

# ── SECTION 1: STROKE TYPES OVERVIEW ──────────────────────────────────
story.append(H2("1. STROKE CLASSIFICATION AT A GLANCE", C_HEADER))
story.append(sp(4))

type_data = [
    ["TYPE", "SUBTYPE", "% ALL STROKES", "KEY FEATURE", "CT FINDING"],
    ["ISCHEMIC", "Thrombotic (large vessel)", "~50%", "Gradual onset, atherosclerosis RF", "Normal early → hypodensity 24-48h"],
    ["ISCHEMIC", "Embolic (cardioembolic)", "~20%", "Sudden onset, AF/valvular disease", "Territorial infarct, cortical"],
    ["ISCHEMIC", "Lacunar (small vessel)", "~17%", "Pure motor/sensory, no cortical signs", "Small deep lesion; may miss on CT"],
    ["HEMORRHAGIC", "Intracerebral (ICH)", "~10%", "Vomiting, LOC, gradual progression", "Hyperdense lesion 40-100 HU"],
    ["HEMORRHAGIC", "Subarachnoid (SAH)", "~3%", "'Thunderclap headache' worst ever", "Blood in cisterns/sulci"],
    ["TIA", "Any ischemic mechanism", "<1 min-24h", "Full resolution, no infarct on DWI", "CT normal; MRI DWI negative"],
]
col_w = [2.4*cm, 3.8*cm, 2.5*cm, 5.2*cm, 4.6*cm]
t = plain_table(type_data, col_w, bg_header=C_HEADER, fontsize=7)
story.append(t)
story.append(sp(8))

# ── SECTION 2: PREHOSPITAL SCALES ─────────────────────────────────────
story.append(H2("2. PREHOSPITAL STROKE RECOGNITION SCALES", C_ISCHEMIC))
story.append(sp(4))

# 2-col layout: FAST box + CPSS box
fast_rows = [
    [Paragraph("<b>FAST</b>", sty("fs1", fontName="Helvetica-Bold", fontSize=9, textColor=C_ISCHEMIC))],
    [Paragraph("<b>F</b> – Face: Unilateral droop/asymmetry", SMALL)],
    [Paragraph("<b>A</b> – Arm: Unilateral weakness/drift", SMALL)],
    [Paragraph("<b>S</b> – Speech: Slurred/absent/wrong words", SMALL)],
    [Paragraph("<b>T</b> – Time: Call emergency immediately", SMALL)],
    [Paragraph("Sensitivity ~72%  |  Specificity ~83%", sty("fs2", fontName="Helvetica-Oblique", fontSize=7, textColor=colors.grey))],
]
fast_t = Table(fast_rows, colWidths=[CONTENT_W*0.30],
               style=TableStyle([
                   ("BACKGROUND",(0,0),(-1,-1), C_LIGHT1),
                   ("BOX",(0,0),(-1,-1),1,C_ISCHEMIC),
                   ("TOPPADDING",(0,0),(-1,-1),3),
                   ("BOTTOMPADDING",(0,0),(-1,-1),3),
                   ("LEFTPADDING",(0,0),(-1,-1),6),
               ]))

cpss_rows = [
    [Paragraph("<b>CPSS</b> – Cincinnati Prehospital Stroke Scale", sty("cs1", fontName="Helvetica-Bold", fontSize=9, textColor=C_ISCHEMIC))],
    [Paragraph("<b>1.</b> Facial droop: Ask to smile → unilateral droop = abnormal", SMALL)],
    [Paragraph("<b>2.</b> Arm drift: Eyes closed, hold arms 10s → one drifts = abnormal", SMALL)],
    [Paragraph("<b>3.</b> Speech: Repeat 'The sky is blue' → slurred/wrong/none = abnormal", SMALL)],
    [Paragraph("If <b>ANY 1</b> of 3 abnormal → 72% probability of stroke", SMALL)],
    [Paragraph("Sensitivity ~66%  |  Specificity ~87%", sty("cs2", fontName="Helvetica-Oblique", fontSize=7, textColor=colors.grey))],
]
cpss_t = Table(cpss_rows, colWidths=[CONTENT_W*0.46],
               style=TableStyle([
                   ("BACKGROUND",(0,0),(-1,-1), C_LIGHT1),
                   ("BOX",(0,0),(-1,-1),1,C_ISCHEMIC),
                   ("TOPPADDING",(0,0),(-1,-1),3),
                   ("BOTTOMPADDING",(0,0),(-1,-1),3),
                   ("LEFTPADDING",(0,0),(-1,-1),6),
               ]))

lapss_rows = [
    [Paragraph("<b>LAPSS</b> – Los Angeles", sty("ls1", fontName="Helvetica-Bold", fontSize=9, textColor=C_ISCHEMIC))],
    [Paragraph("All YES + ≥1 asymmetry →", SMALL)],
    [Paragraph("Sens <b>91%</b>  Spec <b>97%</b>", SMALL)],
    [Paragraph("1. Age >45  2. No seizure hx  3. Ambulatory baseline  4. Glucose 60-400  5. Asymmetry: face/grip/arm", SMALL)],
]
lapss_t = Table(lapss_rows, colWidths=[CONTENT_W*0.20],
                style=TableStyle([
                    ("BACKGROUND",(0,0),(-1,-1), C_LIGHT1),
                    ("BOX",(0,0),(-1,-1),1,C_ISCHEMIC),
                    ("TOPPADDING",(0,0),(-1,-1),3),
                    ("BOTTOMPADDING",(0,0),(-1,-1),3),
                    ("LEFTPADDING",(0,0),(-1,-1),6),
                ]))

pre_row = Table([[fast_t, sp(0), cpss_t, sp(0), lapss_t]],
    colWidths=[CONTENT_W*0.30, 0.4*cm, CONTENT_W*0.46, 0.4*cm, CONTENT_W*0.20],
    style=TableStyle([("VALIGN",(0,0),(-1,-1),"TOP")]))
story.append(pre_row)
story.append(sp(8))

# ── SECTION 3: NIHSS ───────────────────────────────────────────────────
story.append(H2("3. NIH STROKE SCALE (NIHSS)  —  Score 0–42", C_ISCHEMIC))
story.append(sp(4))

nihss_data = [
    ["ITEM", "DOMAIN TESTED", "SCORE RANGE", "KEY NOTE"],
    ["1A", "Level of consciousness (LOC)", "0-3", "0=alert; 3=reflex only/unresponsive"],
    ["1B", "LOC questions (month/age)", "0-2", "0=both correct; 2=both wrong"],
    ["1C", "LOC commands (close eyes/grip)", "0-2", "0=both performed; 2=neither"],
    ["2",  "Horizontal gaze", "0-2", "0=normal; 2=forced deviation"],
    ["3",  "Visual fields", "0-3", "0=no loss; 3=bilateral blindness"],
    ["4",  "Facial palsy", "0-3", "0=normal; 3=complete paralysis"],
    ["5",  "Arm motor (R + L separately)", "0-4 each", "0=no drift; 4=no movement"],
    ["6",  "Leg motor (R + L separately)", "0-4 each", "0=no drift; 4=no movement"],
    ["7",  "Limb ataxia", "0-2", "0=absent; 2=both limbs ataxic"],
    ["8",  "Sensory", "0-2", "0=normal; 2=severe loss"],
    ["9",  "Best language/aphasia", "0-3", "0=no aphasia; 3=mute/global aphasia"],
    ["10", "Dysarthria", "0-2", "0=normal; 2=unintelligible/anarthria"],
    ["11", "Extinction/inattention", "0-2", "0=no abnormality; 2=profound neglect"],
]
nihss_t = plain_table(nihss_data, [1*cm, 4.2*cm, 2.8*cm, CONTENT_W-8*cm], bg_header=C_ISCHEMIC, fontsize=7.2)
story.append(nihss_t)
story.append(sp(4))

# NIHSS severity bands
sev_data = [
    ["NIHSS SCORE", "SEVERITY", "CLINICAL IMPLICATION"],
    ["0",           "Normal",   "No deficit"],
    ["1–4",         "Minor stroke", "tPA eligibility: only if disabling symptoms"],
    ["5–15",        "Moderate stroke", "Standard tPA candidate window"],
    ["16–20",       "Moderate-severe", "High risk; LVO likely"],
    ["21–42",       "Severe stroke",  "Consider thrombectomy; poor prognosis"],
]
sev_t = plain_table(sev_data, [2.6*cm, 3.2*cm, CONTENT_W-5.8*cm], bg_header=C_ISCHEMIC, fontsize=7.5)
story.append(sev_t)
story.append(sp(8))

# ── SECTION 4: ABCD2 SCORE ────────────────────────────────────────────
story.append(H2("4. ABCD² SCORE  —  TIA Risk Stratification", C_TIA))
story.append(sp(4))

abcd2_data = [
    ["PARAMETER", "CRITERIA", "POINTS"],
    ["A – Age",             "≥60 years",                    "1"],
    ["B – Blood Pressure",  "SBP ≥140 or DBP ≥90 mmHg",    "1"],
    ["C – Clinical features","Unilateral weakness",         "2"],
    ["",                    "Speech disturbance only",      "1"],
    ["D – Duration",        "≥60 minutes",                  "2"],
    ["",                    "10–59 minutes",                "1"],
    ["D – Diabetes",        "Diabetes mellitus present",    "1"],
    ["TOTAL RANGE",         "",                             "0–7"],
]
abcd2_t = plain_table(abcd2_data, [3.5*cm, 7.5*cm, 2*cm], bg_header=C_TIA, fontsize=7.5)
story.append(abcd2_t)
story.append(sp(3))
risk_data = [
    ["SCORE", "2-DAY STROKE RISK", "RISK CATEGORY", "ACTION"],
    ["0–3",  "~1%",  "LOW",      "Outpatient workup within 24–48h"],
    ["4–5",  "~4%",  "MODERATE", "Urgent evaluation; admit or expedite"],
    ["6–7",  "~8%",  "HIGH",     "Admit; dual antiplatelet + imaging same day"],
]
risk_t = plain_table(risk_data, [2*cm, 3*cm, 3*cm, CONTENT_W-8*cm], bg_header=C_TIA, fontsize=7.5)
story.append(risk_t)
story.append(sp(8))

# ── SECTION 5: FUGL-MEYER ASSESSMENT ─────────────────────────────────
story.append(H2("5. FUGL-MEYER ASSESSMENT (FMA)", C_REHAB))
story.append(sp(4))

fma_rows = [
    ["DOMAIN",              "MAX SCORE", "CONTENT"],
    ["Upper Extremity",     "66",        "Shoulder, elbow, forearm, wrist, hand, coordination/speed"],
    ["Lower Extremity",     "34",        "Hip, knee, ankle, coordination/speed"],
    ["Balance",             "14",        "Sitting/standing balance in 7 positions"],
    ["Sensation",           "24",        "Light touch, proprioception – 4 limb segments"],
    ["Passive ROM",         "44",        "8 joints tested (pain + ROM)"],
    ["TOTAL",               "226",       "Most common use: UE (66) + LE (34) = Motor domain (100)"],
]
fma_t = plain_table(fma_rows, [3.5*cm, 2.5*cm, CONTENT_W-6*cm], bg_header=C_REHAB, fontsize=7.5)
story.append(fma_t)
story.append(sp(3))

# FMA severity bands
fma_sev = [
    ["UE SCORE (0–66)", "SEVERITY"],
    ["0–22",            "Severe impairment"],
    ["23–42",           "Moderate impairment"],
    ["43–52",           "Mild-moderate impairment"],
    ["53–66",           "Mild / near normal"],
]
fma_sev_t = plain_table(fma_sev, [4*cm, CONTENT_W-4*cm], bg_header=C_REHAB, fontsize=7.5)
story.append(fma_sev_t)
story.append(sp(8))

# ── SECTION 6: BRUNNSTROM STAGES ─────────────────────────────────────
story.append(H2("6. BRUNNSTROM STAGES OF RECOVERY", C_REHAB))
story.append(sp(4))

brunn_data = [
    ["STAGE", "ARM",                    "HAND",                   "LEG",                    "TONE"],
    ["I",  "Flaccidity, no movement",   "No active movement",     "Flaccidity",             "Hypotonia"],
    ["II", "Synergy begins, spasticity appears", "Minimal finger flexion", "Flexor synergy minimal", "Increasing"],
    ["III","Full flexor synergy (voluntary)", "Mass grasp possible", "Full flexor/extensor synergy", "Spasticity peak"],
    ["IV", "Mix of synergy possible",   "Lateral pinch, release", "Knee flex in sitting, ankle DF", "Decreasing"],
    ["V",  "Independent of synergy",    "Palmar pinch, cylindrical grip", "Isolated knee flex/ext", "Minimal"],
    ["VI", "Near normal, isolated",     "All grips, normal speed","Normal gait pattern",    "Normal"],
]
brunn_t = plain_table(brunn_data, [1.2*cm, 4.2*cm, 4*cm, 4*cm, 2.2*cm], bg_header=C_REHAB, fontsize=7)
story.append(brunn_t)
story.append(sp(8))

# ── SECTION 7: MODIFIED ASHWORTH SCALE ───────────────────────────────
story.append(H2("7. MODIFIED ASHWORTH SCALE (MAS) — Spasticity", C_ASSESS))
story.append(sp(4))

mas_data = [
    ["GRADE", "DESCRIPTION", "CLINICAL FINDING"],
    ["0",     "No increase in muscle tone",   "No resistance throughout ROM"],
    ["1",     "Slight increase",              "Catch and release at end of ROM"],
    ["1+",    "Slight increase (>half ROM)",  "Catch followed by slight resistance <half ROM"],
    ["2",     "Marked increase",              "More pronounced but limb easily moved"],
    ["3",     "Considerable increase",        "Passive movement difficult"],
    ["4",     "Rigid in flexion/extension",   "Limb rigid; passive movement impossible"],
]
mas_t = plain_table(mas_data, [1.5*cm, 5*cm, CONTENT_W-6.5*cm], bg_header=C_ASSESS, fontsize=7.5)
story.append(mas_t)
story.append(sp(8))

# ── SECTION 8: BERG BALANCE SCALE ─────────────────────────────────────
story.append(H2("8. BERG BALANCE SCALE (BBS)  —  0–56", C_ASSESS))
story.append(sp(4))

bbs_items = [
    ["ITEM", "TASK", "SCORE (0-4)"],
    ["1",  "Sitting to standing",             "0=needs assist; 4=stands without hands"],
    ["2",  "Standing unsupported",            "0=unable 30s; 4=safe 2 min"],
    ["3",  "Sitting unsupported (feet flat)",  "0=unable 10s; 4=safe 2 min"],
    ["4",  "Standing to sitting",             "0=needs assist; 4=controlled"],
    ["5",  "Transfers (chair to chair)",       "0=needs 2 people; 4=safe with minor hand use"],
    ["6",  "Standing with eyes closed",        "0=needs help; 4=safe 10s"],
    ["7",  "Standing with feet together",      "0=needs help; 4=safe 1 min"],
    ["8",  "Reach forward with arm outstretched","0=loses balance; 4=>25 cm safely"],
    ["9",  "Pick up object from floor",        "0=cannot; 4=easily and safely"],
    ["10", "Turn to look behind",              "0=needs assist; 4=looks behind both sides"],
    ["11", "Turn 360°",                        "0=needs assist; 4=safely <4s"],
    ["12", "Stool tapping (alternating feet)", "0=needs assist; 4=8 taps <20s"],
    ["13", "Tandem standing",                  "0=loses balance; 4=safe 30s"],
    ["14", "One-leg standing",                 "0=cannot; 4=lifts leg independently >10s"],
]
bbs_t = plain_table(bbs_items, [1.2*cm, 5.5*cm, CONTENT_W-6.7*cm], bg_header=C_ASSESS, fontsize=7)
story.append(bbs_t)
story.append(sp(3))
bbs_risk = [
    ["BBS SCORE", "FALL RISK", "CLINICAL NOTE"],
    ["0–20",      "HIGH",      "Wheelchair dependent"],
    ["21–40",     "MODERATE",  "Ambulatory with assistance"],
    ["41–56",     "LOW",       "Functional balance; MCID = 4–6 points"],
]
bbs_risk_t = plain_table(bbs_risk, [2.5*cm, 3*cm, CONTENT_W-5.5*cm], bg_header=C_ASSESS, fontsize=7.5)
story.append(bbs_risk_t)
story.append(sp(8))

# ── SECTION 9: MODIFIED RANKIN SCALE ─────────────────────────────────
story.append(H2("9. MODIFIED RANKIN SCALE (mRS)  —  Disability Outcome", C_HEMOR))
story.append(sp(4))

mrs_data = [
    ["SCORE", "DESCRIPTION",            "INDEPENDENCE"],
    ["0",  "No symptoms",               "Fully independent"],
    ["1",  "No significant disability", "Able to carry out usual duties; symptoms present"],
    ["2",  "Slight disability",         "Unable to carry all previous activities; independent in ADLs"],
    ["3",  "Moderate disability",       "Requires some help; walks unassisted"],
    ["4",  "Moderate-severe disability","Unable to walk unassisted; requires help with ADLs"],
    ["5",  "Severe disability",         "Bedridden, incontinent, constant nursing care required"],
    ["6",  "Death",                     "—"],
]
mrs_t = plain_table(mrs_data, [1.5*cm, 5.5*cm, CONTENT_W-7*cm], bg_header=C_HEMOR, fontsize=7.5)
story.append(mrs_t)
story.append(sp(3))
story.append(Paragraph(
    "<b>MCID</b> = 1 point  |  <b>Favourable outcome</b> in trials = mRS ≤2  |  "
    "<b>Used in</b>: thrombectomy trials (DAWN, DEFUSE-3), thrombolysis (NINDS), TIA follow-up",
    sty("mrs_note", fontName="Helvetica", fontSize=7.5, leading=11, textColor=C_DARK)))
story.append(sp(8))

# ── SECTION 10: FUNCTIONAL OUTCOME MEASURES ───────────────────────────
story.append(H2("10. FUNCTIONAL & GAIT OUTCOME MEASURES", C_REHAB))
story.append(sp(4))

func_data = [
    ["SCALE / TEST", "DOMAIN", "DETAILS / NORMS", "MCID"],
    ["Barthel Index (BI)", "ADL",
     "10 items; 0–100; 0=fully dependent, 100=fully independent. Items: feeding, bathing, grooming, dressing, bladder, bowel, toilet, transfers, mobility, stairs",
     "≥10 pts"],
    ["FIM (Functional Independence Measure)", "ADL + Cognition",
     "18 items (motor 13, cognitive 5); 1–7 per item; 18–126; Level 1=total assist; 7=complete independence",
     "22 pts"],
    ["Functional Ambulation Category (FAC)", "Gait",
     "0=non-functional; 1=needs physical support; 2=continuous support; 3=intermittent support; 4=supervision; 5=independent (all surfaces)",
     "1 level"],
    ["10-Metre Walk Test (10MWT)", "Gait speed",
     "Comfortable pace: community ambulation >0.8 m/s; <0.4 m/s = limited household walker",
     "0.10 m/s"],
    ["6-Minute Walk Test (6MWT)", "Endurance",
     "Healthy adults ≈ 400–700m; post-stroke community walkers ≈ 200–400m",
     "34–54 m"],
    ["Timed Up and Go (TUG)", "Mobility/Balance",
     "≤10s = normal; 11–20s = mild impairment; >20s = significant impairment/fall risk",
     "2.9s"],
    ["Trunk Impairment Scale (TIS)", "Trunk control",
     "3 subscales: static sitting (0-7), dynamic sitting (0-10), coordination (0-6); max 23",
     "2 pts"],
    ["Action Research Arm Test (ARAT)", "UL Function",
     "4 subtests: grasp, grip, pinch, gross; 0–57; 0=cannot perform; 3=normal",
     "5.7 pts"],
    ["Stroke-Specific Quality of Life (SS-QOL)", "QOL",
     "12 domains, 49 items; 49–245; higher = better quality of life",
     "1 pts"],
]
func_t = plain_table(func_data, [3.5*cm, 2.5*cm, 9.5*cm, 1.8*cm], bg_header=C_REHAB, fontsize=7)
story.append(func_t)
story.append(sp(8))

# ── SECTION 11: SPASTICITY & TONE ─────────────────────────────────────
story.append(H2("11. SPASTICITY ASSESSMENT — MODIFIED TARDIEU SCALE (MTS)", C_ASSESS))
story.append(sp(4))

tardieu_text = [
    [Paragraph("<b>Components Measured</b>", SMDB := sty("smdb", fontName="Helvetica-Bold", fontSize=7.5, leading=11)),
     Paragraph("<b>Quality of Muscle Reaction (R)</b>", SMDB),
     Paragraph("<b>Angle of Catch (X)</b>", SMDB)],
    [Paragraph("Measured at 2 speeds:<br/>V1 = as slow as possible (no stretch reflex)<br/>V3 = as fast as possible<br/>Angle of catch at V3 minus V1 = Spasticity angle (dynamic component)", SMALL),
     Paragraph("0 = No resistance<br/>1 = Slight resistance, no catch<br/>2 = Clear catch, releases<br/>3 = Fatigable clonus <10s<br/>4 = Non-fatigable clonus ≥10s<br/>5 = Immovable", SMALL),
     Paragraph("R1 = Angle of catch at fast speed<br/>R2 = ROM at slow speed<br/>Spasticity angle = R2 – R1<br/>&gt;10° = significant spasticity<br/>Preferred over MAS for dynamic spasticity", SMALL)],
]
trd_t = Table(tardieu_text,
    colWidths=[CONTENT_W/3, CONTENT_W/3, CONTENT_W/3],
    style=TableStyle([
        ("BACKGROUND",(0,0),(-1,0), C_ASSESS),
        ("BACKGROUND",(0,1),(-1,1), colors.HexColor("#FFF3E0")),
        ("TEXTCOLOR",(0,0),(-1,0), C_WHITE),
        ("GRID",(0,0),(-1,-1),0.4,colors.HexColor("#BDBDBD")),
        ("TOPPADDING",(0,0),(-1,-1),4),
        ("BOTTOMPADDING",(0,0),(-1,-1),4),
        ("LEFTPADDING",(0,0),(-1,-1),6),
        ("VALIGN",(0,0),(-1,-1),"TOP"),
    ]))
story.append(trd_t)
story.append(sp(8))

# ── SECTION 12: HUNT-HESS + FISHER ────────────────────────────────────
story.append(H2("12. SAH GRADING SCALES", C_SAH))
story.append(sp(4))

col_left = CONTENT_W * 0.48
col_right = CONTENT_W * 0.48
gap = CONTENT_W * 0.04

hh_data = [
    ["HUNT-HESS GRADE", "CLINICAL DESCRIPTION", "30-DAY MORTALITY"],
    ["I",   "Asymptomatic or mild headache, slight nuchal rigidity",       "~30%"],
    ["II",  "Moderate-severe HA, nuchal rigidity, no neuro deficit (except CN palsy)", "~40%"],
    ["III", "Drowsiness, confusion, mild focal deficit",                   "~50%"],
    ["IV",  "Stupor, moderate-severe hemiparesis, early decerebrate",      "~80%"],
    ["V",   "Deep coma, decerebrate posturing, moribund",                  "~90%"],
]
hh_t = plain_table(hh_data, [2*cm, col_left-4*cm, 2.8*cm], bg_header=C_SAH, fontsize=7)

fisher_data = [
    ["FISHER GRADE", "CT FINDING", "VASOSPASM RISK"],
    ["1", "No blood detected",                            "Low"],
    ["2", "Diffuse thin SAH (<1mm)",                      "Low"],
    ["3", "Localized clot/thick layer (>1mm)",            "HIGH (most predictive)"],
    ["4", "ICH or IVH with diffuse or no subarachnoid",   "Moderate"],
    ["MODIFIED FISHER", "Grade 3: diffuse thick SAH + IVH = highest vasospasm risk", ""],
]
fish_t = plain_table(fisher_data, [2.5*cm, col_right-5*cm, 2.5*cm], bg_header=C_SAH, fontsize=7)

sah_row = Table([[hh_t, Spacer(gap, 1), fish_t]],
    colWidths=[col_left, gap, col_right],
    style=TableStyle([("VALIGN",(0,0),(-1,-1),"TOP")]))
story.append(sah_row)
story.append(sp(8))

# ── SECTION 13: ICH SCORE ─────────────────────────────────────────────
story.append(H2("13. ICH SCORE — Intracerebral Hemorrhage Severity", C_HEMOR))
story.append(sp(4))

ich_data = [
    ["COMPONENT", "CRITERIA", "POINTS"],
    ["GCS",               "3–4",                     "2"],
    ["",                  "5–12",                    "1"],
    ["",                  "13–15",                   "0"],
    ["ICH Volume",        "≥30 mL",                  "1"],
    ["",                  "<30 mL",                  "0"],
    ["Intraventricular Hemorrhage", "Yes",            "1"],
    ["",                  "No",                      "0"],
    ["Infratentorial origin","Yes",                   "1"],
    ["",                  "No",                      "0"],
    ["Age",               "≥80 years",               "1"],
    ["",                  "<80 years",               "0"],
    ["TOTAL",             "",                        "0–6"],
]
ich_score_t = plain_table(ich_data, [5*cm, 4*cm, 2*cm], bg_header=C_HEMOR, fontsize=7.5)

ich_mort = [
    ["ICH SCORE", "30-DAY MORTALITY"],
    ["0",   "0%"],
    ["1",   "13%"],
    ["2",   "26%"],
    ["3",   "72%"],
    ["4",   "97%"],
    ["5–6", "~100%"],
]
ich_mort_t = plain_table(ich_mort, [3.5*cm, CONTENT_W-11*cm], bg_header=C_HEMOR, fontsize=7.5)

ich_row = Table([[ich_score_t, Spacer(0.4*cm, 1), ich_mort_t]],
    colWidths=[11*cm, 0.4*cm, CONTENT_W-11.4*cm],
    style=TableStyle([("VALIGN",(0,0),(-1,-1),"TOP")]))
story.append(ich_row)
story.append(sp(8))

# ── SECTION 14: COGNITIVE / DEPRESSION ────────────────────────────────
story.append(H2("14. COGNITIVE & DEPRESSION SCREENING", colors.HexColor("#4527A0")))
story.append(sp(4))

cog_data = [
    ["SCALE",  "WHAT IT MEASURES",        "ITEMS/RANGE",       "CUTOFF / NOTES"],
    ["MMSE (Mini-Mental State Exam)",   "Global cognition",  "30 items; 0–30",  "<24 = cognitive impairment; takes ~10 min; insensitive to mild deficits"],
    ["MoCA (Montreal Cognitive Assessment)", "Mild cognitive impairment", "30 items; 0–30", "<26 = MCI; preferred over MMSE in post-stroke; tests executive function"],
    ["PHQ-9 (Patient Health Questionnaire)", "Post-stroke depression", "9 items; 0–27", "0–4 minimal; 5–9 mild; 10–14 moderate; 15+ severe depression"],
    ["HDRS (Hamilton Depression Rating)", "Depression severity", "17 items; 0–52", "<7 normal; 8–13 mild; 14–18 moderate; ≥19 severe"],
    ["MMSE Orientation (post-stroke)", "Orientation to time/place", "10 pts subtest", "Often impaired early; key for legal capacity assessment"],
]
cog_t = plain_table(cog_data, [3.5*cm, 3.5*cm, 3*cm, CONTENT_W-10*cm], bg_header=colors.HexColor("#4527A0"), fontsize=7)
story.append(cog_t)
story.append(sp(8))

# ── SECTION 15: DYSPHAGIA ─────────────────────────────────────────────
story.append(H2("15. DYSPHAGIA ASSESSMENT IN STROKE", C_ASSESS))
story.append(sp(4))

dys_data = [
    ["TOOL",                        "TYPE",               "KEY DETAILS"],
    ["Bedside Swallow Assessment (BSA)", "Screening",     "Water swallow test; 10-20 mL bolus; observe drooling, coughing, voice change"],
    ["MASA (Mann Assessment Swallowing Ability)", "Clinical", "24 items; 0–200; <178 = dysphagia; <170 = aspiration risk"],
    ["FEES (Flexible Endoscopic Evaluation of Swallowing)", "Gold standard", "Direct visualization; identifies silent aspiration; conducted by SLT"],
    ["MBSS/Videofluoroscopy", "Radiological",              "Modified Barium Swallow; evaluates all phases; gold standard for oral/pharyngeal phases"],
    ["Dysphagia Outcome Severity Scale (DOSS)", "Outcome", "7-point scale: 1=nothing by mouth; 7=normal in all situations"],
    ["Functional Oral Intake Scale (FOIS)", "Outcome",    "7 levels: 1=tube feeding only; 7=total oral intake, no restrictions"],
]
dys_t = plain_table(dys_data, [4*cm, 3*cm, CONTENT_W-7*cm], bg_header=C_ASSESS, fontsize=7.2)
story.append(dys_t)
story.append(sp(8))

# ── SECTION 16: SHOULDER PAIN / UPPER LIMB ───────────────────────────
story.append(H2("16. UPPER LIMB & SHOULDER SPECIFIC TOOLS", C_REHAB))
story.append(sp(4))

ul_data = [
    ["TOOL", "MEASURES", "RANGE / CUTOFF"],
    ["Box & Block Test (BBT)",               "Manual dexterity, unilateral gross motor",     "Count blocks transferred in 60s; norm >50; MCID = 5.5 blocks"],
    ["Grip Strength (Dynamometer)",          "Hand grip force",                              "% difference unaffected vs. affected; MCID = 2.9 kg"],
    ["Chedoke McMaster Stroke Assessment",   "Motor recovery (impairment + activity)",       "7-point scale per stage; 6 sections; correlates with Brunnstrom"],
    ["Shoulder Pain and Disability Index (SPADI)", "Shoulder pain + disability",            "0–100; 0=no disability; MCID = 13 pts; VAS + 13 items"],
    ["Visual Analogue Scale (VAS)",          "Pain intensity",                              "0–10 cm line; MCID = 1.5 cm; simple, widely used"],
    ["Numeric Rating Scale (NRS)",           "Pain intensity",                              "0–10; 0=no pain; 10=worst imaginable; MCID = 2 pts"],
    ["Wolf Motor Function Test (WMFT)",      "UL function speed + quality (post-CIMT)",     "17 timed tasks; functional ability scale 0-5 per task"],
]
ul_t = plain_table(ul_data, [4*cm, 4*cm, CONTENT_W-8*cm], bg_header=C_REHAB, fontsize=7.2)
story.append(ul_t)
story.append(sp(8))

# ── SECTION 17: IMAGING QUICK REF ─────────────────────────────────────
story.append(H2("17. NEUROIMAGING QUICK REFERENCE", C_HEADER))
story.append(sp(4))

img_data = [
    ["MODALITY", "FINDING IN STROKE", "USE / TIMING"],
    ["Non-contrast CT (NCCT)", "Ischemic: normal <6h; hypodensity 24-48h; hyperdense artery sign. ICH: hyperdense 40-100HU. SAH: blood in cisterns", "First-line; excludes hemorrhage; done within 25 min of arrival"],
    ["CT Angiography (CTA)",   "LVO identification; aneurysm; dissection; stenosis", "Immediate if LVO suspected; guides thrombectomy decision"],
    ["CT Perfusion (CTP)",     "Core (CBF<30%) vs. penumbra (Tmax>6s) mismatch",   "Extends thrombectomy window to 24h (DAWN/DEFUSE-3)"],
    ["MRI DWI",                "Bright on DWI + dark on ADC = acute ischemia (within minutes)", "Most sensitive for early ischemia; gold standard"],
    ["MRI FLAIR",              "Bright lesion = infarct older than 4.5h (DWI+/FLAIR- = wake-up stroke)", "FLAIR-DWI mismatch guides late-window tPA"],
    ["MRA",                    "Non-invasive vessel imaging; stenosis, aneurysm, dissection", "Pre-discharge in TIA; planning revascularization"],
    ["ASPECTS Score",          "10-point CT scoring of MCA territory; ≤6 = large infarct", "Thrombectomy: ASPECTS ≥6 favored; some trials accept ≥3"],
    ["DSA (angiography)",      "Gold standard for aneurysm, AVM, vasculitis",              "Pre-clipping/coiling for SAH; definitivevessel imaging"],
]
img_t = plain_table(img_data, [3.2*cm, 6.5*cm, CONTENT_W-9.7*cm], bg_header=C_HEADER, fontsize=7)
story.append(img_t)
story.append(sp(8))

# ── SECTION 18: THROMBOLYSIS ELIGIBILITY ─────────────────────────────
story.append(H2("18. IV tPA (ALTEPLASE) — ELIGIBILITY CHECKLIST", C_ISCHEMIC))
story.append(sp(4))

incl_rows = [
    ["INCLUSION CRITERIA", "EXCLUSION CRITERIA (ABSOLUTE)"],
    ["Ischemic stroke with measurable neurological deficit",
     "Any prior intracranial hemorrhage"],
    ["Onset of symptoms ≤4.5 hours (tissue damage threshold)",
     "CT showing multilobar infarction (hypodensity >1/3 MCA territory)"],
    ["Age ≥18 years",
     "Active internal bleeding (excluding menses)"],
    ["BP <185/110 after treatment (if needed)",
     "SBP >185 or DBP >110 (refractory to treatment)"],
    ["Blood glucose 50–400 mg/dL",
     "Platelets <100,000; INR >1.7; aPTT >40s; PT >15s"],
    ["Disabling neurological deficit",
     "Major surgery or serious trauma within 14 days"],
    ["",
     "Recent intracranial/spinal surgery, head trauma (<3 months)"],
    ["DOSE: Alteplase 0.9 mg/kg (max 90mg)", "10% IV bolus + 90% over 60 min"],
]

incl_t = Table(
    [[Paragraph(row[0], sty(f"il{i}0", fontName="Helvetica" if i>0 else "Helvetica-Bold",
                            fontSize=7.5, leading=11,
                            textColor=C_WHITE if i==0 else (colors.HexColor("#1A237E") if row[0] else C_DARK)))
      for j, cell in enumerate(row)
      for row in [row]] for i, row in enumerate(incl_rows)],
    colWidths=[CONTENT_W/2 - 0.2*cm, CONTENT_W/2 - 0.2*cm],
    style=TableStyle([
        ("BACKGROUND",(0,0),(-1,0), C_ISCHEMIC),
        ("TEXTCOLOR",(0,0),(-1,0), C_WHITE),
        ("FONTNAME",(0,0),(-1,0),"Helvetica-Bold"),
        ("FONTSIZE",(0,0),(-1,-1),7.5),
        ("LEADING",(0,0),(-1,-1),11),
        ("GRID",(0,0),(-1,-1),0.4,colors.HexColor("#BDBDBD")),
        ("VALIGN",(0,0),(-1,-1),"TOP"),
        ("TOPPADDING",(0,0),(-1,-1),3),
        ("BOTTOMPADDING",(0,0),(-1,-1),3),
        ("LEFTPADDING",(0,0),(-1,-1),5),
        ("BACKGROUND",(0,-1),(-1,-1), C_LIGHT1),
        ("FONTNAME",(0,-1),(-1,-1),"Helvetica-Bold"),
        ("ROWBACKGROUNDS",(0,1),(-1,-2),[C_WHITE, C_ROW_ALT]),
    ])
)
# Rebuild as simpler table
rows_incl = []
for i, row in enumerate(incl_rows):
    c1 = Paragraph(row[0], sty(f"i1{i}", fontName="Helvetica-Bold" if i==0 or i==len(incl_rows)-1 else "Helvetica",
                                fontSize=7.5, leading=11, textColor=C_WHITE if i==0 else C_DARK))
    c2 = Paragraph(row[1], sty(f"i2{i}", fontName="Helvetica-Bold" if i==0 else "Helvetica",
                                fontSize=7.5, leading=11, textColor=C_WHITE if i==0 else C_DARK))
    rows_incl.append([c1, c2])
incl_final = Table(rows_incl,
    colWidths=[CONTENT_W/2 - 0.1*cm, CONTENT_W/2 - 0.1*cm],
    style=TableStyle([
        ("BACKGROUND",(0,0),(-1,0), C_ISCHEMIC),
        ("BACKGROUND",(0,-1),(-1,-1), C_LIGHT1),
        ("GRID",(0,0),(-1,-1),0.4,colors.HexColor("#BDBDBD")),
        ("VALIGN",(0,0),(-1,-1),"TOP"),
        ("TOPPADDING",(0,0),(-1,-1),3),
        ("BOTTOMPADDING",(0,0),(-1,-1),3),
        ("LEFTPADDING",(0,0),(-1,-1),5),
        ("ROWBACKGROUNDS",(0,1),(-1,-2),[C_WHITE, C_ROW_ALT]),
        ("FONTNAME",(0,-1),(-1,-1),"Helvetica-Bold"),
        ("TEXTCOLOR",(0,-1),(-1,-1), C_ISCHEMIC),
    ]))
story.append(incl_final)
story.append(sp(8))

# ── SECTION 19: RECENT ADVANCES BOX ───────────────────────────────────
story.append(H2("19. RECENT ADVANCES IN STROKE REHABILITATION (2023–2026)", C_REHAB))
story.append(sp(4))

adv_data = [
    ["ADVANCE", "EVIDENCE / KEY POINTS"],
    ["Robot-Assisted Therapy (RAT)",
     "Cochrane SR 2025 (PMID 39932103): RAT improves UL function + gait vs. conventional therapy. High-intensity repetitive training drives neuroplasticity. Devices: Lokomat (gait), Armeo/Myomo (UL)."],
    ["Virtual Reality (VR)",
     "Cochrane SR 2025 (PMID 40537150): VR improves arm function, balance & gait in chronic stroke. Clinically meaningful gains on FMA. Enhanced engagement via immersive feedback. Best combined with RAT."],
    ["Non-Invasive Brain Stimulation (NIBS)",
     "rTMS (high-frequency ipsilesional M1 or inhibitory contralesional M1) + tDCS (anodal over ipsilesional motor cortex). Meta-analysis 2023 (PMID 38082316): tDCS improves post-stroke dysphagia."],
    ["Tenecteplase (TNK)",
     "Single IV bolus thrombolytic; non-inferior to alteplase in multiple trials. Simpler logistics; longer half-life. Now endorsed in AHA guidelines as acceptable alternative."],
    ["Extended Thrombectomy Window (up to 24h)",
     "DAWN trial (6–24h, clinical-imaging mismatch) + DEFUSE-3 (6–16h, perfusion mismatch): thrombectomy beneficial well beyond 6h in selected patients. CT perfusion guides selection."],
    ["Remote Ischemic Conditioning (RIC)",
     "SR 2024 (PMID 38457772): limb ischemia/reperfusion cycles (4×5 min cuff inflation) reduce infarct size. Benefit greatest when combined with reperfusion therapy."],
    ["Brain-Computer Interface (BCI)",
     "EEG motor imagery → robotic hand movement feedback → reinforces neuroplasticity. FDA-cleared devices emerging (e.g. IpsiHand). Motor intention training without physical movement."],
    ["Functional Electrical Stimulation (FES)",
     "Stimulates peripheral nerves to produce functional movement. Bioness H200 (hand opening), L300 (foot drop correction). Can be EMG-triggered (neuroprosthetic approach)."],
    ["AI-Assisted Imaging",
     "Automated ASPECTS scoring, LVO detection on CTA, perfusion analysis (RapidAI). Reduces door-to-needle time. Identifies mismatch for extended window thrombectomy."],
    ["2025 ESO BP Guidelines (PMID 42095756)",
     "Updated ESO 2026 targets: acute ischemic stroke pre-thrombolysis <185/110; ICH with SBP 150–220 → target 140 mmHg; avoidance of aggressive lowering in non-thrombolysis candidates."],
]
adv_t = plain_table(adv_data, [4*cm, CONTENT_W-4*cm], bg_header=C_REHAB, fontsize=7.2)
story.append(adv_t)
story.append(sp(8))

# ── FOOTER NOTE ───────────────────────────────────────────────────────
footer_style = sty("footer", fontName="Helvetica-Oblique", fontSize=6.5, leading=9,
                   textColor=colors.grey, alignment=TA_CENTER)
story.append(HRFlowable(width="100%", thickness=0.5, color=C_HEADER))
story.append(sp(3))
story.append(Paragraph(
    "Sources: Bradley & Daroff's Neurology in Clinical Practice | Tintinalli's Emergency Medicine | "
    "ROSEN's Emergency Medicine | Frameworks for Internal Medicine | "
    "Cochrane Database Syst Rev 2025 (PMID 39932103, 40537150) | "
    "ESO Guidelines 2026 (PMID 42095756) | Remote Ischemic Conditioning SR 2024 (PMID 38457772)",
    footer_style
))
story.append(sp(2))
story.append(Paragraph(
    "Orris Medical — Stroke Quick Reference Guide | MPT Exam Preparation | June 2026",
    footer_style
))

# ── BUILD PDF ─────────────────────────────────────────────────────────
doc.build(story)
print(f"PDF created: {OUTPUT}")

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