const {
  Document, Packer, Paragraph, TextRun, Table, TableRow, TableCell,
  HeadingLevel, AlignmentType, BorderStyle, WidthType, ShadingType,
  VerticalAlign, PageNumber, Header, Footer, UnderlineType,
  TableOfContents, convertInchesToTwip, PageBreak
} = require('docx');
const fs = require('fs');

// ── colour palette ──────────────────────────────────────────────
const BLUE      = '1F4E79';
const BLUE_MID  = '2E75B6';
const BLUE_LITE = 'D6E4F0';
const BLUE_HDR  = 'BDD7EE';
const RED_LITE  = 'FFE0E0';
const GREEN_LITE= 'E2EFDA';
const YELLOW    = 'FFF2CC';
const WHITE     = 'FFFFFF';
const GREY      = 'F2F2F2';
const DARK      = '1A1A2E';

// ── helpers ─────────────────────────────────────────────────────
function bold(text, size=22, color=DARK) {
  return new TextRun({ text, bold: true, size, color });
}
function normal(text, size=20, color=DARK) {
  return new TextRun({ text, size, color });
}
function coloured(text, color, size=20, b=false) {
  return new TextRun({ text, color, size, bold: b });
}

function heading1(text) {
  return new Paragraph({
    children: [new TextRun({ text, bold: true, size: 28, color: WHITE })],
    heading: HeadingLevel.HEADING_1,
    shading: { type: ShadingType.SOLID, color: BLUE },
    spacing: { before: 240, after: 120 },
    indent: { left: 120, right: 120 },
  });
}

function heading2(text) {
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    children: [new TextRun({ text, bold: true, size: 24, color: WHITE })],
    shading: { type: ShadingType.SOLID, color: BLUE_MID },
    spacing: { before: 200, after: 100 },
    indent: { left: 80 },
  });
}

function sectionLabel(text) {
  return new Paragraph({
    children: [new TextRun({ text: text.toUpperCase(), bold: true, size: 20, color: BLUE_MID })],
    spacing: { before: 160, after: 60 },
    border: { bottom: { style: BorderStyle.SINGLE, size: 6, color: BLUE_MID } },
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}

function para(text, size=20, spacing=80) {
  return new Paragraph({
    children: [new TextRun({ text, size, color: DARK })],
    spacing: { before: spacing, after: spacing },
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}

function bullet(text, level=0) {
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    children: [new TextRun({ text, size: 20, color: DARK })],
    bullet: { level },
    spacing: { before: 60, after: 60 },
    indent: { left: convertInchesToTwip(0.25 + level * 0.25) },
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}

function infoBox(lines, bgColor=BLUE_LITE) {
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    children: lines.map((l, i) => new TextRun({
      text: l + (i < lines.length - 1 ? '\n' : ''),
      size: 19,
      color: DARK,
    })),
    shading: { type: ShadingType.SOLID, color: bgColor },
    spacing: { before: 100, after: 100 },
    indent: { left: 180, right: 180 },
    border: {
      left: { style: BorderStyle.THICK, size: 12, color: BLUE_MID },
    },
  });
}

function alertBox(lines, bgColor=YELLOW, borderColor='C9A227') {
  return new Paragraph({
    children: lines.map((l, i) => new TextRun({
      text: l + (i < lines.length - 1 ? '\n' : ''),
      size: 19,
      color: DARK,
    })),
    shading: { type: ShadingType.SOLID, color: bgColor },
    spacing: { before: 100, after: 100 },
    indent: { left: 180, right: 180 },
    border: {
      left: { style: BorderStyle.THICK, size: 12, color: borderColor },
    },
  });
}

function makeTable(headers, rows, headerBg=BLUE_MID) {
  const headerCells = headers.map(h =>
    new TableCell({
      children: [new Paragraph({
        children: [new TextRun({ text: h, bold: true, size: 19, color: WHITE })],
        alignment: AlignmentType.CENTER,
      })],
      shading: { type: ShadingType.SOLID, color: headerBg },
      verticalAlign: VerticalAlign.CENTER,
      margins: { top: 60, bottom: 60, left: 80, right: 80 },
    })
  );

  const dataRows = rows.map((row, ri) =>
    new TableRow({
      children: row.map((cell, ci) => {
        const isStatus = typeof cell === 'object';
        const cellText = isStatus ? cell.text : cell;
        const cellBg   = isStatus ? cell.bg : (ri % 2 === 0 ? WHITE : GREY);
        const cellColor= isStatus ? cell.color : DARK;
        const cellBold = isStatus ? (cell.bold || false) : false;
        return new TableCell({
          children: [new Paragraph({
            children: [new TextRun({ text: cellText, size: 19, color: cellColor, bold: cellBold })],
            alignment: ci === 0 ? AlignmentType.LEFT : AlignmentType.CENTER,
          })],
          shading: { type: ShadingType.SOLID, color: cellBg },
          verticalAlign: VerticalAlign.CENTER,
          margins: { top: 60, bottom: 60, left: 80, right: 80 },
        });
      }),
    })
  );

  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [new TableRow({ children: headerCells }), ...dataRows],
    margins: { top: 60, bottom: 60, left: 60, right: 60 },
  });
}

function spacer(pts=120) {
  return new Paragraph({ children: [], spacing: { before: pts, after: 0 } });
}

// ── DOCUMENT BUILD ───────────────────────────────────────────────
const doc = new Document({
  styles: {
    default: {
      document: {
        run: { font: 'Calibri', size: 20, color: DARK },
      },
    },
  },
  sections: [{
    properties: {
      page: {
        margin: { top: 720, bottom: 720, left: 900, right: 900 },
      },
    },
    headers: {
      default: new Header({
        children: [
          new Paragraph({
            children: [
              new TextRun({ text: 'CLINICAL SUMMARY REPORT', bold: true, size: 20, color: WHITE }),
              new TextRun({ text: '     Prepared by Orris AI | Confidential Medical Document', size: 18, color: 'CCDDEE' }),
            ],
            shading: { type: ShadingType.SOLID, color: BLUE },
            alignment: AlignmentType.LEFT,
            indent: { left: 100, right: 100 },
          }),
        ],
      }),
    },
    footers: {
      default: new Footer({
        children: [
          new Paragraph({
            children: [
              new TextRun({ text: 'This document is generated for clinical reference only and must be correlated with physician examination.   |   Page ', size: 17, color: '888888' }),
              new TextRun({ children: [PageNumber.CURRENT], size: 17, color: '888888' }),
            ],
            alignment: AlignmentType.CENTER,
            border: { top: { style: BorderStyle.SINGLE, size: 4, color: 'CCCCCC' } },
          }),
        ],
      }),
    },
    children: [

      // ═══════════════════════════════════════════════
      // COVER BLOCK
      // ═══════════════════════════════════════════════
      new Paragraph({
        children: [new TextRun({ text: 'CLINICAL SUMMARY & EVIDENCE-BASED TREATMENT PLAN', bold: true, size: 36, color: WHITE })],
        shading: { type: ShadingType.SOLID, color: BLUE },
        alignment: AlignmentType.CENTER,
        spacing: { before: 240, after: 60 },
        indent: { left: 100, right: 100 },
      }),
      new Paragraph({
        children: [new TextRun({ text: 'Ejaculatory Duct Obstruction with Subclinical Hypothyroidism', bold: true, size: 24, color: BLUE_LITE })],
        shading: { type: ShadingType.SOLID, color: BLUE },
        alignment: AlignmentType.CENTER,
        spacing: { before: 0, after: 240 },
        indent: { left: 100, right: 100 },
      }),

      // patient card
      makeTable(
        ['PATIENT DETAILS', ''],
        [
          ['Patient Name', 'Mr. Imtiaz'],
          ['Age / Sex', '28-29 Years / Male'],
          ['Report Date', 'July 11-12, 2026'],
          ['Referring Concern', 'Lower abdominal pain (episodic) + Infertility (7-8 years)'],
          ['Prepared By', 'Orris AI Clinical Assistant | July 13, 2026'],
        ],
        BLUE
      ),

      spacer(200),

      // ═══════════════════════════════════════════════
      // SECTION 1 — PRESENTING COMPLAINTS
      // ═══════════════════════════════════════════════
      heading1('1.  PRESENTING COMPLAINTS'),
      spacer(80),

      makeTable(
        ['Symptom', 'Description', 'Duration'],
        [
          ['Lower abdominal pain', 'Localized, high-intensity, crampy — resolves spontaneously', '15-30 minutes per episode'],
          ['Pattern', 'Episodic; pain is post-orgasmic/post-ejaculatory in nature', '7-8 years ongoing'],
          ['Ejaculate appearance', 'Very watery / thin — no visible sperm output', '7-8 years ongoing'],
          ['Semen volume', 'Severely reduced (0.5 mL; normal >1.5 mL)', 'Consistent finding'],
          ['Erectile function', 'Normal', 'No complaints'],
          ['Ejaculation', 'Present (not anejaculation)', 'Orgasm sensation intact'],
        ]
      ),

      spacer(160),

      // ═══════════════════════════════════════════════
      // SECTION 2 — INVESTIGATIONS SUMMARY
      // ═══════════════════════════════════════════════
      heading1('2.  INVESTIGATIONS SUMMARY'),
      spacer(80),

      sectionLabel('2a. Hormonal Profile (Serum — July 11, 2026)'),
      spacer(60),

      makeTable(
        ['Test', 'Result', 'Reference Range', 'Interpretation'],
        [
          ['Testosterone (Total)', '510 ng/dL', '164-753 ng/dL (<50 yr)', { text: 'NORMAL', bg: GREEN_LITE, color: '375623', bold: true }],
          ['TSH (Ultrasensitive)', '5.119 µIU/mL', '0.55-4.78 µIU/mL', { text: 'ELEVATED ⚠', bg: YELLOW, color: '7F5600', bold: true }],
          ['T3 (Total)', '1.47 ng/mL', '0.60-1.81 ng/mL', { text: 'NORMAL', bg: GREEN_LITE, color: '375623', bold: true }],
          ['T4 (Total)', '10.70 µg/dL', '3.2-12.6 µg/dL', { text: 'NORMAL', bg: GREEN_LITE, color: '375623', bold: true }],
          ['LH', '4.26 mIU/mL', '1.5-9.3 mIU/mL', { text: 'NORMAL', bg: GREEN_LITE, color: '375623', bold: true }],
          ['FSH', '3.41 mIU/mL', '1.4-18.1 mIU/mL', { text: 'NORMAL', bg: GREEN_LITE, color: '375623', bold: true }],
          ['Prolactin', '12.45 ng/mL', '2.1-17.7 ng/mL', { text: 'NORMAL', bg: GREEN_LITE, color: '375623', bold: true }],
        ]
      ),

      spacer(160),
      sectionLabel('2b. Semen Analysis (July 10, 2026)'),
      spacer(60),

      makeTable(
        ['Parameter', 'Result', 'Reference (WHO)', 'Status'],
        [
          ['Volume', '0.5 mL', '>1.5 mL', { text: 'CRITICALLY LOW ✗', bg: RED_LITE, color: '9C0006', bold: true }],
          ['Sperm Count', 'AZOOSPERMIA', '>16 million/mL', { text: 'ABSENT ✗', bg: RED_LITE, color: '9C0006', bold: true }],
          ['Liquefaction', '30 minutes', 'Complete in 30 min', { text: 'BORDERLINE', bg: YELLOW, color: '7F5600', bold: true }],
          ['pH', '8.0', '>7.2', { text: 'NORMAL', bg: GREEN_LITE, color: '375623', bold: true }],
          ['Colour', 'Whitish', 'Whitish/grey', { text: 'NORMAL', bg: GREEN_LITE, color: '375623', bold: true }],
        ]
      ),

      spacer(160),
      sectionLabel('2c. Uroflowmetry'),
      spacer(60),

      makeTable(
        ['Parameter', 'Result', 'Normal', 'Status'],
        [
          ['Maximum Flow Rate (Qmax)', '21 mL/sec', '>15 mL/sec', { text: 'NORMAL', bg: GREEN_LITE, color: '375623', bold: true }],
          ['Voided Volume', '177 mL', 'Adequate', { text: 'NORMAL', bg: GREEN_LITE, color: '375623', bold: true }],
          ['Average Flow Rate', '3.0 mL/sec', 'Varies', { text: 'NOTE: Low average vs. Qmax', bg: YELLOW, color: '7F5600', bold: true }],
        ]
      ),

      spacer(160),
      sectionLabel('2d. Ultrasound Abdomen & Pelvis'),
      spacer(60),

      makeTable(
        ['Organ', 'Finding'],
        [
          ['Liver', 'Enlarged with bright echopattern — Grade 2 Fatty Liver (NAFLD)'],
          ['Gall Bladder / CBD', 'Not significantly abnormal'],
          ['Pancreas / Spleen', 'Normal'],
          ['Kidneys', 'Reported (details partially legible on scan)'],
          ['Urinary Bladder', 'Normal outline, wall thickness normal'],
          ['Prostate', 'Measured (dimensions partially legible) — further correlation needed'],
        ]
      ),

      spacer(200),

      // ═══════════════════════════════════════════════
      // SECTION 3 — DIAGNOSIS
      // ═══════════════════════════════════════════════
      heading1('3.  DIAGNOSIS'),
      spacer(80),

      heading2('Primary Diagnosis'),
      spacer(60),

      new Paragraph({
        children: [
          new TextRun({ text: 'Ejaculatory Duct Obstruction (EDO)', bold: true, size: 26, color: BLUE }),
          new TextRun({ text: '  —  Obstructive Azoospermia', size: 22, color: BLUE_MID }),
        ],
        spacing: { before: 100, after: 100 },
        indent: { left: 100 },
      }),

      infoBox([
        'Clinical basis:  Azoospermia + severely low semen volume (0.5 mL) + normal LH/FSH/Testosterone + episodic',
        'post-orgasmic lower abdominal pain lasting 15-30 minutes = CLASSIC triad of Ejaculatory Duct Obstruction.',
        '',
        'Seminal vesicles contribute ~80% of semen volume. In EDO, this fructose-rich fluid cannot exit, producing a',
        'thin, watery, low-volume azoospermic ejaculate. Pressure build-up causes post-ejaculatory pelvic/abdominal pain.',
        '',
        'Normal gonadotropins (LH/FSH) and testosterone confirm intact testicular function — the obstruction is',
        'mechanical/structural, NOT hormonal or testicular in origin.',
      ]),

      spacer(120),
      sectionLabel('Pathophysiology'),
      spacer(80),

      makeTable(
        ['Finding', 'Explanation', 'Significance'],
        [
          ['Low semen volume (0.5 mL)', 'Seminal vesicle secretions blocked by obstruction', 'Pathognomonic of EDO'],
          ['Azoospermia', 'Sperm trapped proximal to obstruction', 'Obstructive — testes produce sperm normally'],
          ['Normal LH/FSH', 'Pituitary-gonadal axis intact', 'Rules out hypogonadism/primary testicular failure'],
          ['Post-orgasmic abdominal pain', 'Seminal vesicle contraction against blocked duct → pressure', 'Confirms functional obstruction'],
          ['7-8 year duration', 'Structural/anatomical cause (congenital cyst, calculus, scar)', 'Not an acute/infective cause'],
          ['Normal erections', 'Erectile function independent of ejaculatory ducts', 'Consistent with pure obstruction'],
        ]
      ),

      spacer(140),
      sectionLabel('Possible Aetiology of EDO'),
      spacer(80),

      makeTable(
        ['Cause', 'Likelihood', 'Notes'],
        [
          ['Mullerian duct cyst / midline prostatic cyst', { text: 'HIGH', bg: RED_LITE, color: '9C0006', bold: true }, 'Congenital; most common cause; seen on TRUS as midline cyst'],
          ['Ejaculatory duct calculus', { text: 'MODERATE', bg: YELLOW, color: '7F5600', bold: true }, 'Can cause intermittent obstruction and pain'],
          ['Seminal vesicle cyst', { text: 'MODERATE', bg: YELLOW, color: '7F5600', bold: true }, 'Causes pain + low volume; detectable on TRUS/MRI'],
          ['Post-infective scarring (Chlamydia, Gonorrhoea, TB)', { text: 'MODERATE', bg: YELLOW, color: '7F5600', bold: true }, '7-8 year history; prior STI cannot be excluded'],
          ['Wolffian duct anomaly (congenital)', { text: 'POSSIBLE', bg: GREY, color: DARK, bold: false }, 'If bilateral vas absent on examination'],
        ]
      ),

      spacer(160),
      heading2('Secondary / Contributing Diagnosis'),
      spacer(60),

      new Paragraph({
        children: [
          new TextRun({ text: 'Subclinical Hypothyroidism', bold: true, size: 22, color: BLUE_MID }),
          new TextRun({ text: '  (TSH 5.119 µIU/mL — above range of 0.55-4.78)', size: 20, color: DARK }),
        ],
        spacing: { before: 80, after: 80 },
        indent: { left: 100 },
      }),

      alertBox([
        'TSH is elevated while T3 and T4 remain within normal limits = Subclinical Hypothyroidism.',
        'Thyroid dysfunction is a recognised cause of impaired spermatogenesis even at subclinical levels.',
        'Smith & Tanagho General Urology: "Thyroid abnormalities impact spermatogenesis at the level of both',
        'the pituitary and testis. Euthyroidism is important for normal hypothalamic-pituitary-gonadal function."',
        'This requires treatment independently of the EDO.',
      ], YELLOW, 'C9A227'),

      spacer(160),
      heading2('Incidental Finding'),
      spacer(60),

      new Paragraph({
        children: [
          new TextRun({ text: 'Hepatic Steatosis — Grade 2 (Non-Alcoholic Fatty Liver Disease)', bold: true, size: 22, color: BLUE_MID }),
        ],
        spacing: { before: 80, after: 80 },
        indent: { left: 100 },
      }),
      para('Detected on ultrasound. Clinically relevant as it may impair hepatic testosterone metabolism. Requires dietary intervention and metabolic review.', 19, 60),

      spacer(160),
      sectionLabel('Differential Diagnoses Considered & Excluded'),
      spacer(80),

      makeTable(
        ['Diagnosis', 'For', 'Against', 'Verdict'],
        [
          ['Ejaculatory Duct Obstruction', 'Entire symptom triad', '—', { text: 'PRIMARY DX', bg: BLUE_LITE, color: BLUE, bold: true }],
          ['Non-obstructive azoospermia', 'Azoospermia', 'Normal FSH/LH/testosterone; normal semen pH', { text: 'EXCLUDED', bg: RED_LITE, color: '9C0006', bold: true }],
          ['Bilateral vas deferens absence', 'Low volume azoospermia', 'Normal volume semen in CBAVD; no examination finding mentioned', { text: 'UNLIKELY', bg: YELLOW, color: '7F5600', bold: true }],
          ['Retrograde ejaculation', 'Azoospermia', 'Volume is 0.5 mL (not zero); normal uroflow', { text: 'UNLIKELY', bg: YELLOW, color: '7F5600', bold: true }],
          ['Primary hypogonadism', 'Infertility', 'FSH/LH normal; testosterone normal', { text: 'EXCLUDED', bg: RED_LITE, color: '9C0006', bold: true }],
          ['Idiopathic male infertility', 'Azoospermia', 'Structural signs (low volume, pain) present', { text: 'EXCLUDED', bg: RED_LITE, color: '9C0006', bold: true }],
        ]
      ),

      spacer(200),

      // ═══════════════════════════════════════════════
      // SECTION 4 — INVESTIGATIONS REQUIRED
      // ═══════════════════════════════════════════════
      heading1('4.  INVESTIGATIONS REQUIRED (In Order of Priority)'),
      spacer(80),

      makeTable(
        ['Priority', 'Investigation', 'Purpose', 'Expected Finding in EDO'],
        [
          [{ text: '1 — URGENT', bg: RED_LITE, color: '9C0006', bold: true }, 'Transrectal Ultrasound (TRUS)', 'First-line structural imaging for EDO', 'Dilated seminal vesicles (>1.5 cm), midline prostatic cyst, duct calculi'],
          [{ text: '2 — URGENT', bg: RED_LITE, color: '9C0006', bold: true }, 'Post-ejaculate Urinalysis', 'Rule out retrograde ejaculation', 'No sperm in urine confirms antegrade obstruction'],
          [{ text: '3 — HIGH', bg: YELLOW, color: '7F5600', bold: true }, 'Semen Fructose Level', 'Confirm seminal vesicle secretion blockage', 'Absent or very low fructose = confirms EDO'],
          [{ text: '4 — HIGH', bg: YELLOW, color: '7F5600', bold: true }, 'MRI Pelvis (endorectal coil)', 'Detailed anatomy if TRUS inconclusive', 'Dilated SV, prostatic cyst, duct anatomy'],
          [{ text: '5 — HIGH', bg: YELLOW, color: '7F5600', bold: true }, 'Thyroid review / Endocrinology referral', 'Manage subclinical hypothyroidism', 'Confirm need for levothyroxine'],
          [{ text: '6 — ROUTINE', bg: GREEN_LITE, color: '375623', bold: true }, 'Testicular Biopsy (if TRUS confirms obstruction)', 'Confirm spermatogenesis is normal', 'Normal spermatogenesis = correctable surgically'],
          [{ text: '7 — ROUTINE', bg: GREEN_LITE, color: '375623', bold: true }, 'Physical Examination — Vas Deferens & Testes', 'Rule out CBAVD; assess testicular size', 'Palpable vas; normal testicular volume'],
          [{ text: '8 — ROUTINE', bg: GREEN_LITE, color: '375623', bold: true }, 'Liver Function Tests + Lipid Profile', 'Assess severity of NAFLD', 'Elevated ALT/AST; dyslipidaemia'],
        ]
      ),

      spacer(200),

      // ═══════════════════════════════════════════════
      // SECTION 5 — TREATMENT PLAN
      // ═══════════════════════════════════════════════
      heading1('5.  EVIDENCE-BASED TREATMENT PLAN'),
      spacer(80),

      heading2('5a. Definitive Treatment — Ejaculatory Duct Obstruction'),
      spacer(80),

      sectionLabel('Step 1: Confirm Obstruction (TRUS / MRI)'),
      spacer(60),
      para('Before any intervention, transrectal ultrasound must confirm the presence and level of obstruction. TRUS is the standard first-line imaging modality as per Campbell Walsh Wein Urology. If inconclusive, MRI pelvis with endorectal coil provides superior anatomical resolution.', 19),

      spacer(120),
      sectionLabel('Step 2: Transurethral Resection of Ejaculatory Ducts (TURED)'),
      spacer(60),

      infoBox([
        'TURED is the standard surgical treatment for confirmed ejaculatory duct obstruction.',
        '',
        'Procedure: A cystoscope with resecting loop removes the verumontanum and unroofs any obstructing',
        'cyst compressing the ejaculatory ducts. Real-time TRUS guidance improves accuracy.',
        '',
        'Evidence (Smith & Tanagho General Urology, 19th Ed):',
        '  • 65-70% of men show significant improvement in semen quality post-TURED',
        '  • 30% natural pregnancy rate expected',
        '  • Minimally invasive, cystoscopic procedure',
        '',
        'Complications (~20%, mostly self-limited): hematospermia, hematuria, UTI, epididymitis.',
        'Rare: retrograde ejaculation, rectal perforation, urinary incontinence.',
      ]),

      spacer(140),
      sectionLabel('Step 3: If TURED Fails or is Not Suitable'),
      spacer(60),

      makeTable(
        ['Option', 'Description', 'Indication'],
        [
          ['Surgical Sperm Aspiration (PESA/TESA)', 'Percutaneous or testicular sperm extraction', 'If TURED fails; sperm obtained for ART'],
          ['ICSI (Intracytoplasmic Sperm Injection)', 'Single sperm injected directly into oocyte', 'Used with extracted sperm when natural conception not possible'],
          ['IVF + ICSI', 'Full IVF cycle with surgically retrieved sperm', 'If female partner also has fertility factors'],
        ]
      ),

      spacer(160),
      heading2('5b. Subclinical Hypothyroidism Treatment'),
      spacer(80),

      makeTable(
        ['Aspect', 'Recommendation'],
        [
          ['Drug', 'Levothyroxine (L-T4)'],
          ['Starting dose', '25-50 mcg once daily (morning, fasting)'],
          ['Target TSH', '0.5-2.5 µIU/mL (optimise for fertility)'],
          ['Follow-up', 'Repeat TSH in 6-8 weeks; adjust dose accordingly'],
          ['Rationale', 'Euthyroidism required for normal spermatogenesis (Campbell Walsh Wein Urology)'],
          ['Specialist', 'Endocrinology referral recommended'],
        ]
      ),

      spacer(160),
      heading2('5c. Current Prescription — Spercus (L-Carnitine + CoQ10 + Lycopene + Zinc)'),
      spacer(80),

      alertBox([
        '⚠  IMPORTANT ASSESSMENT OF CURRENT PRESCRIPTION',
        '',
        'Spercus is a nutraceutical antioxidant supplement. It is NOT a treatment for obstructive azoospermia.',
        '',
        'Evidence (Cochrane Review 2022, PMID 35506389 — 90 RCTs, 10,303 men):',
        'Antioxidants may improve sperm motility and morphology in men with EXISTING sperm (idiopathic subfertility).',
        'When high-bias studies are removed, live birth benefit is NOT statistically significant.',
        '',
        'Evidence (Meta-Analysis 2020, PMID 35128424 — L-Carnitine):',
        'L-Carnitine improves sperm motility and morphology but shows no effect on sperm CONCENTRATION',
        'and no demonstrable improvement in clinical pregnancy rates.',
        '',
        'CLINICAL CONCLUSION:',
        'In this patient, azoospermia is OBSTRUCTIVE — there are no sperm in the ejaculate to improve.',
        'Spercus cannot dissolve a mechanical block. It WILL NOT resolve the underlying cause.',
        'Spercus is safe and may be continued alongside definitive treatment but SHOULD NOT REPLACE surgery.',
        '',
        'ACTION REQUIRED: Request TRUS from urologist before concluding medical management alone is sufficient.',
      ], YELLOW, 'C9A227'),

      spacer(160),
      heading2('5d. Fatty Liver (NAFLD Grade 2) Management'),
      spacer(80),

      makeTable(
        ['Intervention', 'Details'],
        [
          ['Dietary modification', 'Reduce refined carbohydrates, sugar, saturated fats; Mediterranean diet'],
          ['Exercise', 'Aerobic exercise 150 min/week; reduces hepatic fat'],
          ['Weight management', 'Target BMI <25; even 5-10% weight loss reduces liver fat significantly'],
          ['Alcohol', 'Complete avoidance'],
          ['LFT + Lipid panel', 'Baseline and 3-monthly monitoring'],
          ['Gastroenterology referral', 'If ALT persistently elevated or Grade 3 on follow-up USG'],
        ]
      ),

      spacer(200),

      // ═══════════════════════════════════════════════
      // SECTION 6 — FOLLOW-UP PLAN
      // ═══════════════════════════════════════════════
      heading1('6.  FOLLOW-UP PLAN'),
      spacer(80),

      makeTable(
        ['Timeline', 'Action'],
        [
          ['IMMEDIATELY', 'TRUS pelvis — confirm/exclude ejaculatory duct obstruction'],
          ['IMMEDIATELY', 'Post-ejaculate urinalysis — rule out retrograde ejaculation'],
          ['IMMEDIATELY', 'Semen fructose — confirm absence of seminal vesicle contribution'],
          ['Within 2 weeks', 'Endocrinology referral — commence levothyroxine for subclinical hypothyroidism'],
          ['Within 4 weeks', 'Urology review with TRUS results — plan TURED if confirmed'],
          ['3 months post-TURED', 'Repeat semen analysis — assess surgical outcome'],
          ['6 months', 'Repeat TSH — confirm euthyroidism; reassess fertility status'],
          ['Ongoing', 'Liver function monitoring; dietary compliance review'],
        ]
      ),

      spacer(200),

      // ═══════════════════════════════════════════════
      // SECTION 7 — SUMMARY
      // ═══════════════════════════════════════════════
      heading1('7.  CLINICAL SUMMARY'),
      spacer(80),

      infoBox([
        'Mr. Imtiaz, 28-year-old male, presents with a 7-8 year history of:',
        '  (1) Episodic, high-intensity lower abdominal pain lasting 15-30 minutes (post-ejaculatory in nature)',
        '  (2) Azoospermia with severely reduced semen volume (0.5 mL)',
        '  (3) Watery/thin ejaculate with no visible sperm',
        '  (4) Normal erectile function and orgasm',
        '',
        'Laboratory findings confirm:',
        '  • Azoospermia with low semen volume — obstructive pattern',
        '  • Normal testosterone, LH, FSH, prolactin — ruling out hormonal/testicular failure',
        '  • Elevated TSH (5.119 µIU/mL) — subclinical hypothyroidism',
        '  • Grade 2 fatty liver on ultrasound',
        '',
        'PRIMARY DIAGNOSIS:  Ejaculatory Duct Obstruction (EDO) — Obstructive Azoospermia',
        'SECONDARY:          Subclinical Hypothyroidism',
        'INCIDENTAL:         Non-Alcoholic Fatty Liver Disease (NAFLD), Grade 2',
        '',
        'IMMEDIATE PRIORITY: TRUS pelvis to confirm EDO → TURED if confirmed.',
        'Levothyroxine for TSH normalisation. Current prescription (Spercus) is insufficient as sole treatment.',
      ], BLUE_LITE),

      spacer(200),

      // ═══════════════════════════════════════════════
      // SECTION 8 — REFERENCES
      // ═══════════════════════════════════════════════
      heading1('8.  EVIDENCE REFERENCES'),
      spacer(80),

      bullet('Campbell Walsh Wein Urology, 3-Volume Set — Ejaculatory Duct Obstruction, Chapter 66'),
      bullet('Smith and Tanagho\'s General Urology, 19th Edition — Ejaculatory Duct Obstruction & TURED'),
      bullet('Smith and Tanagho\'s General Urology — Thyroid Abnormalities in Male Infertility (0.5% of cases)'),
      bullet('de Ligny W, et al. Antioxidants for male subfertility. Cochrane Database Syst Rev. 2022 (PMID: 35506389)'),
      bullet('Khaw SC, et al. L-carnitine and L-acetylcarnitine supplementation for idiopathic male infertility. Reprod Fertil. 2020 (PMID: 35128424)'),
      bullet('WHO Laboratory Manual for Examination and Processing of Human Semen, 6th Edition — Reference values'),
      bullet('American Thyroid Association Guidelines — Subclinical Hypothyroidism Management'),

      spacer(200),

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