Acute Abdominal Pain with Vomiting - Clinical Approach & Investigations

ls -la /home/daytona/workspace/ 2>/dev/null || echo "workspace empty or not foun…

mkdir -p /home/daytona/workspace/acute-abdomen-guide && python3 -c "import repor…

~/acute-abdomen-guide/generate_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import mm, cm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether
)
from reportlab.lib.enums import TA_LEFT, TA_CENTER
from reportlab.pdfbase import pdfmetrics
from reportlab.pdfbase.ttfonts import TTFont

OUTPUT = "/home/daytona/workspace/acute-abdomen-guide/Acute_Abdomen_Quick_Reference.pdf"

# ── Colour palette ──────────────────────────────────────────────────
RED      = colors.HexColor("#C0392B")
DARK_RED = colors.HexColor("#922B21")
ORANGE   = colors.HexColor("#E67E22")
BLUE     = colors.HexColor("#1A5276")
LIGHT_BG = colors.HexColor("#EBF5FB")
YELLOW   = colors.HexColor("#FEF9E7")
GREEN_BG = colors.HexColor("#EAFAF1")
RED_BG   = colors.HexColor("#FDEDEC")
GREY_BG  = colors.HexColor("#F2F3F4")
WHITE    = colors.white
TEXT     = colors.HexColor("#17202A")

W, H = A4  # 595 x 842 pt

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=15*mm, rightMargin=15*mm,
    topMargin=18*mm, bottomMargin=15*mm,
    title="Acute Abdominal Pain – Quick Reference Checklist",
    author="Orris Medical Reference"
)

styles = getSampleStyleSheet()

# ── Custom styles ────────────────────────────────────────────────────
def S(name, **kw):
    base = kw.pop("parent", "Normal")
    s = ParagraphStyle(name, parent=styles[base], **kw)
    return s

TITLE_S   = S("Title2",   fontSize=18, textColor=WHITE,      fontName="Helvetica-Bold",
               alignment=TA_CENTER, spaceAfter=2)
SUBTITLE_S= S("Subtitle2",fontSize=9,  textColor=colors.HexColor("#D6EAF8"),
               fontName="Helvetica", alignment=TA_CENTER)
SEC_HEAD  = S("SecHead",  fontSize=10, textColor=WHITE,      fontName="Helvetica-Bold",
               alignment=TA_LEFT, spaceAfter=1, spaceBefore=1, leftIndent=4)
BODY      = S("Body2",    fontSize=8,  textColor=TEXT,       fontName="Helvetica",
               leading=11, spaceAfter=1)
BODY_B    = S("BodyB",    fontSize=8,  textColor=TEXT,       fontName="Helvetica-Bold",
               leading=11)
SMALL     = S("Small",    fontSize=7,  textColor=colors.HexColor("#555555"),
               fontName="Helvetica", leading=9)
FLAG      = S("Flag",     fontSize=8,  textColor=DARK_RED,   fontName="Helvetica-Bold",
               leading=11)
CB        = S("CB",       fontSize=8,  textColor=TEXT,       fontName="Helvetica",
               leading=12, leftIndent=2)

def cb(text, bold=False):
    """Checkbox bullet item."""
    style = BODY_B if bold else BODY
    return Paragraph(f"☐  {text}", style)

def bullet(text, bold=False):
    style = BODY_B if bold else BODY
    return Paragraph(f"• {text}", style)

def flag(text):
    return Paragraph(f"⚠  {text}", FLAG)

def section_header(text, bg=BLUE):
    data = [[Paragraph(text, SEC_HEAD)]]
    t = Table(data, colWidths=[W - 30*mm])
    t.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", (0,0), (-1,-1), [3,3,3,3]),
    ]))
    return t

# ── Content builder ──────────────────────────────────────────────────
story = []

# ╔══════════════════════════════════════════════════════╗
#  TITLE BANNER
# ╚══════════════════════════════════════════════════════╝
banner_data = [[
    Paragraph("ACUTE ABDOMINAL PAIN", TITLE_S),
    Paragraph("Quick Reference Evaluation Checklist", SUBTITLE_S),
]]
banner = Table(banner_data, colWidths=[W - 30*mm])
banner.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), DARK_RED),
    ("TOPPADDING",    (0,0), (-1,-1), 10),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("LEFTPADDING",   (0,0), (-1,-1), 8),
    ("SPAN",          (0,0), (-1,-1)),
]))
story.append(banner)
story.append(Spacer(1, 4*mm))

# ── STEP 1 : IMMEDIATE ASSESSMENT ──────────────────────────────────
story.append(section_header("STEP 1 — IMMEDIATE STABILISATION"))
story.append(Spacer(1, 1.5*mm))

vitals_items = [
    cb("Assess A-B-C, mental status"),
    cb("Measure HR, BP, RR, SpO2, Temperature"),
    cb("Establish IV access + draw bloods if unstable"),
    cb("Administer IV fluids if haemodynamically compromised"),
    cb("Supplemental O₂ if SpO₂ < 94%"),
    cb("Nil by mouth if surgical condition suspected"),
]
flags_items = [
    flag("BP < 90/60 or HR > 120 → immediate resuscitation + surgical consult"),
    flag("Board-like rigidity / peritonism → urgent surgical review"),
    flag("Pulsatile abdominal mass → AAA until proven otherwise"),
]

col1 = Table([[i] for i in vitals_items], colWidths=[(W-30*mm)*0.52])
col1.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), LIGHT_BG),
    ("TOPPADDING", (0,0), (-1,-1), 1), ("BOTTOMPADDING", (0,0), (-1,-1), 1),
    ("LEFTPADDING", (0,0), (-1,-1), 4), ("RIGHTPADDING", (0,0), (-1,-1), 4),
]))

col2 = Table([[i] for i in flags_items], colWidths=[(W-30*mm)*0.46])
col2.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), RED_BG),
    ("TOPPADDING", (0,0), (-1,-1), 1), ("BOTTOMPADDING", (0,0), (-1,-1), 1),
    ("LEFTPADDING", (0,0), (-1,-1), 4), ("RIGHTPADDING", (0,0), (-1,-1), 4),
]))

two_col = Table([[col1, col2]], colWidths=[(W-30*mm)*0.52, (W-30*mm)*0.48])
two_col.setStyle(TableStyle([("VALIGN", (0,0), (-1,-1), "TOP"),
                              ("LEFTPADDING", (0,0), (-1,-1), 0),
                              ("RIGHTPADDING", (0,0), (-1,-1), 0)]))
story.append(two_col)
story.append(Spacer(1, 3*mm))

# ── STEP 2 : HISTORY ───────────────────────────────────────────────
story.append(section_header("STEP 2 — HISTORY  (SOCRATES + Associated Symptoms)"))
story.append(Spacer(1, 1.5*mm))

history_col1 = [
    Paragraph("<b>Pain Characterisation</b>", BODY_B),
    cb("Site & radiation"),
    cb("Onset – sudden vs gradual"),
    cb("Character – colicky / constant / burning"),
    cb("Severity (1–10)"),
    cb("Timing – duration, progression"),
    cb("Aggravating / relieving factors"),
    Spacer(1, 3),
    Paragraph("<b>Vomiting Assessment</b>", BODY_B),
    cb("Did pain precede vomiting? (surgical clue)"),
    cb("Character – bilious / feculent / coffee-ground"),
    cb("Volume & frequency"),
    cb("Haematemesis?"),
]
history_col2 = [
    Paragraph("<b>Associated Symptoms</b>", BODY_B),
    cb("Fever / chills"),
    cb("Anorexia"),
    cb("Bowel habit change / obstipation"),
    cb("Diarrhoea – bloody?"),
    cb("Dysuria / haematuria"),
    cb("Jaundice"),
    cb("Chest pain / dyspnoea"),
    Spacer(1, 3),
    Paragraph("<b>Past History / Risk Factors</b>", BODY_B),
    cb("Prior similar episodes"),
    cb("Previous abdominal surgery"),
    cb("Medications (NSAIDs, steroids, anticoagulants)"),
    cb("Alcohol / drug use"),
    cb("LMP — ALL females of reproductive age", bold=True),
]

h_col1_t = Table([[i] for i in history_col1], colWidths=[(W-30*mm)*0.5])
h_col1_t.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), LIGHT_BG),
    ("TOPPADDING", (0,0), (-1,-1), 1), ("BOTTOMPADDING", (0,0), (-1,-1), 1),
    ("LEFTPADDING", (0,0), (-1,-1), 4), ("RIGHTPADDING", (0,0), (-1,-1), 4),
]))
h_col2_t = Table([[i] for i in history_col2], colWidths=[(W-30*mm)*0.5])
h_col2_t.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), LIGHT_BG),
    ("TOPPADDING", (0,0), (-1,-1), 1), ("BOTTOMPADDING", (0,0), (-1,-1), 1),
    ("LEFTPADDING", (0,0), (-1,-1), 4), ("RIGHTPADDING", (0,0), (-1,-1), 4),
]))

hist_row = Table([[h_col1_t, h_col2_t]], colWidths=[(W-30*mm)*0.5, (W-30*mm)*0.5])
hist_row.setStyle(TableStyle([("VALIGN", (0,0), (-1,-1), "TOP"),
                               ("LEFTPADDING", (0,0), (-1,-1), 0),
                               ("RIGHTPADDING", (0,0), (-1,-1), 0)]))
story.append(hist_row)
story.append(Spacer(1, 3*mm))

# ── STEP 3 : PHYSICAL EXAMINATION ─────────────────────────────────
story.append(section_header("STEP 3 — PHYSICAL EXAMINATION"))
story.append(Spacer(1, 1.5*mm))

exam_data = [
    [Paragraph("<b>Inspect</b>", BODY_B),
     Paragraph("Posture (writhing=colic; still=peritonitis), distension, visible peristalsis, scars, jaundice, pallor", BODY)],
    [Paragraph("<b>Auscultate</b>", BODY_B),
     Paragraph("Bowel sounds: Absent=ileus/peritonitis; Tinkling/high-pitched=obstruction", BODY)],
    [Paragraph("<b>Palpate</b>", BODY_B),
     Paragraph("Tenderness location • Guarding (voluntary) • Rigidity (involuntary – true peritonitis) • Rebound tenderness • Masses", BODY)],
    [Paragraph("<b>Special Signs</b>", BODY_B),
     Paragraph("Murphy's (cholecystitis) • Rovsing's (appendicitis) • Psoas sign (retrocecal appendix) • Obturator sign (pelvic appendix/abscess) • Carnett's (abdominal wall vs visceral)", BODY)],
    [Paragraph("<b>Hernial Orifices</b>", BODY_B),
     Paragraph("Inguinal, femoral, umbilical — strangulated hernia is a common missed cause", BODY)],
    [Paragraph("<b>PR Exam</b>", BODY_B),
     Paragraph("Rectal mass, tenderness, blood, pelvic collection", BODY)],
    [Paragraph("<b>PV Exam</b>", BODY_B),
     Paragraph("(Females) Cervical excitation, adnexal tenderness/mass — exclude ectopic/PID/torsion", BODY)],
    [Paragraph("<b>Chest / CVS</b>", BODY_B),
     Paragraph("Lung bases (pneumonia), arrhythmia (AF → mesenteric ischemia), murmurs", BODY)],
]

exam_t = Table(exam_data, colWidths=[(W-30*mm)*0.18, (W-30*mm)*0.82])
exam_t.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), GREY_BG),
    ("BACKGROUND",    (0,0), (0,-1), colors.HexColor("#D5D8DC")),
    ("TOPPADDING",    (0,0), (-1,-1), 3), ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 5), ("RIGHTPADDING",  (0,0), (-1,-1), 5),
    ("ROWBACKGROUNDS",(0,0), (-1,-1), [GREY_BG, colors.HexColor("#EAF2FF")]),
    ("GRID",          (0,0), (-1,-1), 0.3, colors.HexColor("#BDC3C7")),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
]))
story.append(exam_t)
story.append(Spacer(1, 3*mm))

# ── STEP 4 : BEDSIDE TESTS ──────────────────────────────────────────
story.append(section_header("STEP 4 — BEDSIDE & IMMEDIATE TESTS"))
story.append(Spacer(1, 1.5*mm))

bedside = [
    cb("⚡ β-hCG (urine/serum) — ALL females of reproductive age", bold=True),
    cb("12-lead ECG — exclude inferior MI / PE"),
    cb("Urine dipstick — haematuria (calculi), nitrites (UTI), ketones (DKA)"),
    cb("Capillary blood glucose — DKA / hypoglycaemia"),
    cb("Temperature (core)"),
]
bedside_t = Table([[i] for i in bedside], colWidths=[W-30*mm])
bedside_t.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), YELLOW),
    ("TOPPADDING", (0,0), (-1,-1), 2), ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING", (0,0), (-1,-1), 6),
    ("GRID", (0,0), (-1,-1), 0.3, colors.HexColor("#F0B27A")),
]))
story.append(bedside_t)
story.append(Spacer(1, 3*mm))

# ── STEP 5 : BLOOD TESTS ───────────────────────────────────────────
story.append(section_header("STEP 5 — BLOOD INVESTIGATIONS"))
story.append(Spacer(1, 1.5*mm))

blood_headers = [
    Paragraph("<b>Test</b>", BODY_B),
    Paragraph("<b>Purpose / Key Finding</b>", BODY_B)
]
blood_rows = [
    ["FBC / CBC",             "Leucocytosis = infection/inflammation; Anaemia = haemorrhage"],
    ["CRP / ESR",             "Inflammatory marker; markedly elevated in peritonitis/sepsis"],
    ["Amylase / Lipase",      "Acute pancreatitis (lipase more sensitive & specific)"],
    ["LFTs",                  "Bilirubin ↑, ALP ↑ = biliary; AST/ALT ↑ = hepatitis"],
    ["Serum Lactate",         "⚠ Elevated (>2 mmol/L) = mesenteric ischaemia / sepsis / shock"],
    ["U&E / Creatinine",      "Dehydration, renal disease, electrolyte disturbance"],
    ["Serum Calcium",         "Cause of pancreatitis; hypercalcaemia-related pain"],
    ["Coagulation (INR/PT)",  "Hepatic disease, pre-operative assessment"],
    ["Group & Save / X-match","Suspected haemorrhage (AAA, ectopic, upper GI bleed)"],
    ["Blood Cultures (x2)",   "If fever ≥38°C or signs of systemic sepsis"],
]

blood_table_data = [blood_headers] + [
    [Paragraph(r[0], BODY_B), Paragraph(r[1], BODY)] for r in blood_rows
]
blood_t = Table(blood_table_data, colWidths=[(W-30*mm)*0.28, (W-30*mm)*0.72])
blood_t.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), BLUE),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, colors.HexColor("#EBF5FB")]),
    ("GRID",          (0,0), (-1,-1), 0.3, colors.HexColor("#AED6F1")),
    ("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"),
    # Highlight lactate row
    ("BACKGROUND",    (0,5), (-1,5), colors.HexColor("#FDE8E8")),
]))
story.append(blood_t)
story.append(Spacer(1, 3*mm))

# ── STEP 6 : IMAGING ───────────────────────────────────────────────
story.append(section_header("STEP 6 — IMAGING"))
story.append(Spacer(1, 1.5*mm))

img_headers = [
    Paragraph("<b>Modality</b>", BODY_B),
    Paragraph("<b>When to Use</b>", BODY_B),
    Paragraph("<b>Key Findings</b>", BODY_B),
]
img_rows = [
    ["Erect CXR\n(FIRST-LINE)",
     "All acute abdominal presentations",
     "Free air under diaphragm = perforation"],
    ["AXR",
     "Suspected obstruction / volvulus",
     "Dilated bowel loops, air-fluid levels, 'coffee bean' (volvulus)"],
    ["USS Abdomen/Pelvis",
     "RUQ pain (biliary), RLQ (appendix), females, child",
     "Gallstones, cholecystitis, appendix, ovarian pathology, free fluid, AAA"],
    ["CT Abdomen/Pelvis\n(IV contrast)",
     "Diagnosis unclear after USS; severe/complex presentations",
     "Gold standard – appendicitis, diverticulitis, pancreatitis staging, SBO, ischaemia, AAA"],
    ["MRI / MRCP",
     "Pregnancy, biliary pathology, soft tissue",
     "Biliary stones, choledocholithiasis – preferred when radiation contraindicated"],
]
img_table_data = [img_headers] + [
    [Paragraph(r[0], BODY_B), Paragraph(r[1], BODY), Paragraph(r[2], BODY)] for r in img_rows
]
img_t = Table(img_table_data, colWidths=[(W-30*mm)*0.20, (W-30*mm)*0.33, (W-30*mm)*0.47])
img_t.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), colors.HexColor("#1F618D")),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, GREEN_BG]),
    ("GRID",          (0,0), (-1,-1), 0.3, colors.HexColor("#A9CCE3")),
    ("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"),
    ("BACKGROUND",    (0,3), (-1,3), colors.HexColor("#D6EAF8")),  # CT row highlight
]))
story.append(img_t)
story.append(Spacer(1, 3*mm))

# ── STEP 7 : DIFFERENTIAL DIAGNOSIS ───────────────────────────────
story.append(section_header("STEP 7 — DIFFERENTIAL DIAGNOSIS BY LOCATION"))
story.append(Spacer(1, 1.5*mm))

dd_headers = [
    Paragraph("<b>Region</b>", BODY_B),
    Paragraph("<b>Key Diagnoses</b>", BODY_B),
]
dd_rows = [
    ["Epigastric",   "PUD, gastritis, acute pancreatitis, GERD, MI (atypical)"],
    ["RUQ",          "Acute cholecystitis, biliary colic, cholangitis, hepatitis, hepatic abscess"],
    ["LUQ",          "Splenic infarct/rupture, gastric volvulus, splenic flexure colitis"],
    ["Periumbilical","Early appendicitis, small bowel obstruction, mesenteric ischaemia"],
    ["RLQ",          "Appendicitis, Meckel's diverticulitis, Crohn's, ovarian torsion, ectopic pregnancy"],
    ["LLQ",          "Diverticulitis, sigmoid volvulus, IBD, ovarian/tubal pathology"],
    ["Loin / Flank", "Renal colic (ureteric stone), pyelonephritis, renal infarct"],
    ["Diffuse",      "Peritonitis, gastroenteritis, mesenteric ischaemia, bowel obstruction"],
    ["Extra-abdominal","Inferior MI, pneumonia (lower lobe), PE, DKA, sickle cell crisis, herpes zoster"],
]
dd_data = [dd_headers] + [
    [Paragraph(r[0], BODY_B), Paragraph(r[1], BODY)] for r in dd_rows
]
dd_t = Table(dd_data, colWidths=[(W-30*mm)*0.22, (W-30*mm)*0.78])
dd_t.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), colors.HexColor("#117A65")),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, GREEN_BG]),
    ("GRID",          (0,0), (-1,-1), 0.3, colors.HexColor("#A9DFBF")),
    ("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"),
    ("BACKGROUND",    (0,9), (-1,9), colors.HexColor("#FDFEFE")),
]))
story.append(dd_t)
story.append(Spacer(1, 3*mm))

# ── RED FLAGS ──────────────────────────────────────────────────────
story.append(section_header("⚠  RED FLAGS — REQUIRE URGENT SURGICAL / SPECIALIST REVIEW", bg=DARK_RED))
story.append(Spacer(1, 1.5*mm))

rf_items = [
    "Haemodynamic instability (HR >120 or SBP <90)",
    "Board-like rigidity / rebound tenderness (peritonitis)",
    "Free air under diaphragm on CXR (perforation)",
    "Pulsatile abdominal mass (AAA)",
    "Positive β-hCG + acute pain (ectopic until excluded)",
    "Vomiting + obstipation + distension (bowel obstruction / strangulation)",
    "Serum lactate >2 mmol/L (ischaemia / sepsis)",
    "Coffee-ground vomit / haematemesis (upper GI bleed)",
    "Severe epigastric pain radiating to back (pancreatitis / AAA)",
    "Elderly / immunocompromised with ANY abdominal pain — higher threshold for workup",
]

rf_col1 = rf_items[:5]
rf_col2 = rf_items[5:]

rf1_t = Table([[flag(i)] for i in rf_col1], colWidths=[(W-30*mm)*0.50])
rf1_t.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), RED_BG),
    ("TOPPADDING", (0,0), (-1,-1), 2), ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING", (0,0), (-1,-1), 4),
]))
rf2_t = Table([[flag(i)] for i in rf_col2], colWidths=[(W-30*mm)*0.50])
rf2_t.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), RED_BG),
    ("TOPPADDING", (0,0), (-1,-1), 2), ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING", (0,0), (-1,-1), 4),
]))

rf_row = Table([[rf1_t, rf2_t]], colWidths=[(W-30*mm)*0.50, (W-30*mm)*0.50])
rf_row.setStyle(TableStyle([("VALIGN", (0,0), (-1,-1), "TOP"),
                             ("LEFTPADDING", (0,0), (-1,-1), 0),
                             ("RIGHTPADDING", (0,0), (-1,-1), 0)]))
story.append(rf_row)
story.append(Spacer(1, 3*mm))

# ── VOMITING CLUES QUICK BOX ───────────────────────────────────────
story.append(section_header("VOMITING PATTERN — DIAGNOSTIC CLUES", bg=ORANGE))
story.append(Spacer(1, 1.5*mm))

vom_data = [
    [Paragraph("<b>Vomiting Pattern</b>", BODY_B), Paragraph("<b>Suggests</b>", BODY_B)],
    [Paragraph("Pain THEN vomiting", BODY),      Paragraph("Surgical condition", BODY)],
    [Paragraph("Vomiting THEN pain", BODY),      Paragraph("Medical/non-surgical (gastroenteritis)", BODY)],
    [Paragraph("Bilious vomiting", BODY),         Paragraph("Obstruction distal to duodenum", BODY)],
    [Paragraph("Feculent vomiting", BODY),        Paragraph("Distal SBO with bacterial proliferation", BODY)],
    [Paragraph("Large-volume non-bilious", BODY), Paragraph("Gastric outlet obstruction", BODY)],
    [Paragraph("Coffee-ground / haematemesis", BODY), Paragraph("Upper GI bleed (PUD, erosive gastritis)", BODY)],
    [Paragraph("Self-limited with diarrhoea", BODY),  Paragraph("Gastroenteritis / food-borne illness", BODY)],
]
vom_t = Table(vom_data, colWidths=[(W-30*mm)*0.38, (W-30*mm)*0.62])
vom_t.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), ORANGE),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, YELLOW]),
    ("GRID",          (0,0), (-1,-1), 0.3, colors.HexColor("#F0B27A")),
    ("TOPPADDING",    (0,0), (-1,-1), 3), ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING",   (0,0), (-1,-1), 5), ("RIGHTPADDING",  (0,0), (-1,-1), 5),
]))
story.append(vom_t)
story.append(Spacer(1, 4*mm))

# ── FOOTER ──────────────────────────────────────────────────────────
story.append(HRFlowable(width="100%", thickness=0.5, color=colors.HexColor("#AEB6BF")))
story.append(Spacer(1, 1.5*mm))
footer_text = (
    "Sources: Yamada's Textbook of Gastroenterology 7e • Bailey & Love's Short Practice of Surgery 28e • "
    "Pye's Surgical Handicraft 22e  |  For clinical decision-making, always apply local protocols and senior review."
)
story.append(Paragraph(footer_text, SMALL))

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

cd /home/daytona/workspace/acute-abdomen-guide && python3 generate_pdf.py 2>&1

ls -lh /home/daytona/workspace/acute-abdomen-guide/