Metabolic Response to Injury

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (SimpleDocTemplate, Paragraph, Spacer,
                                 Table, TableStyle, PageBreak, HRFlowable)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY

OUTPUT = "/home/daytona/workspace/surgery-study-guide/Surgery_First_Sessional_Study_Guide.pdf"

doc = SimpleDocTemplate(
    OUTPUT, pagesize=A4,
    rightMargin=2*cm, leftMargin=2*cm,
    topMargin=2*cm, bottomMargin=2*cm
)

styles = getSampleStyleSheet()

# Custom styles
title_style = ParagraphStyle('Title', parent=styles['Title'],
    fontSize=22, textColor=colors.HexColor('#1a3a5c'),
    spaceAfter=6, alignment=TA_CENTER)

subtitle_style = ParagraphStyle('Subtitle', parent=styles['Normal'],
    fontSize=12, textColor=colors.HexColor('#2c6e9e'),
    spaceAfter=20, alignment=TA_CENTER)

topic_header_style = ParagraphStyle('TopicHeader', parent=styles['Heading1'],
    fontSize=15, textColor=colors.white,
    backColor=colors.HexColor('#1a3a5c'),
    spaceBefore=14, spaceAfter=8,
    leftIndent=-10, rightIndent=-10,
    borderPad=6)

section_style = ParagraphStyle('Section', parent=styles['Heading2'],
    fontSize=11, textColor=colors.HexColor('#1a3a5c'),
    spaceBefore=10, spaceAfter=4,
    borderPad=2)

body_style = ParagraphStyle('Body', parent=styles['Normal'],
    fontSize=9.5, leading=14,
    spaceAfter=6, alignment=TA_JUSTIFY)

bullet_style = ParagraphStyle('Bullet', parent=styles['Normal'],
    fontSize=9.5, leading=13,
    leftIndent=14, spaceAfter=3,
    bulletIndent=4)

key_style = ParagraphStyle('Key', parent=styles['Normal'],
    fontSize=9, leading=13,
    backColor=colors.HexColor('#eef6ff'),
    leftIndent=8, rightIndent=8,
    borderPad=5, spaceAfter=6)

def topic_title(num, title):
    return [
        Spacer(1, 0.3*cm),
        Paragraph(f"TOPIC {num}: {title}", topic_header_style),
    ]

def section(text):
    return Paragraph(f"<b>{text}</b>", section_style)

def body(text):
    return Paragraph(text, body_style)

def bullet(text):
    return Paragraph(f"• {text}", bullet_style)

def key_box(text):
    return Paragraph(f"<b>KEY POINTS:</b> {text}", key_style)

def make_table(data, col_widths=None):
    if col_widths is None:
        col_widths = [doc.width / len(data[0])] * len(data[0])
    t = Table(data, colWidths=col_widths, repeatRows=1)
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#2c6e9e')),
        ('TEXTCOLOR', (0,0), (-1,0), colors.white),
        ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
        ('FONTSIZE', (0,0), (-1,-1), 8.5),
        ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.white, colors.HexColor('#f0f6ff')]),
        ('GRID', (0,0), (-1,-1), 0.4, colors.HexColor('#ccddee')),
        ('VALIGN', (0,0), (-1,-1), 'TOP'),
        ('TOPPADDING', (0,0), (-1,-1), 4),
        ('BOTTOMPADDING', (0,0), (-1,-1), 4),
        ('LEFTPADDING', (0,0), (-1,-1), 5),
    ]))
    return t

story = []

# ── COVER PAGE ──────────────────────────────────────────────────────────────
story.append(Spacer(1, 3*cm))
story.append(Paragraph("SURGERY FIRST SESSIONAL", title_style))
story.append(Paragraph("COMPREHENSIVE STUDY GUIDE", title_style))
story.append(Spacer(1, 0.5*cm))
story.append(HRFlowable(width="80%", thickness=2, color=colors.HexColor('#2c6e9e'), hAlign='CENTER'))
story.append(Spacer(1, 0.5*cm))
story.append(Paragraph("Based on Bailey & Love's Short Practice of Surgery, 28th Edition", subtitle_style))
story.append(Paragraph("All 28 Exam Topics | High-Yield Notes", subtitle_style))
story.append(Spacer(1, 1*cm))
toc_data = [
    ["#", "Topic"],
    ["1", "Metabolic Response to Injury"],
    ["2", "Shock, Haemorrhage and Transfusion"],
    ["3", "Wound Healing and Tissue Repair"],
    ["4", "Tissue Engineering and Regenerative Therapies"],
    ["5", "Surgical Infection"],
    ["6", "Tropical Infections and Infestations"],
    ["7", "Basic Surgical Skills"],
    ["8", "Diagnostic Imaging"],
    ["9", "Gastrointestinal Endoscopy"],
    ["10", "Principles of Minimal Access Surgery"],
    ["11", "Introduction to Trauma"],
    ["12", "Early Assessment and Management of Severe Trauma"],
    ["13", "Traumatic Brain Injury"],
    ["14", "Torso and Pelvic Trauma"],
    ["15", "The Neck and Spine"],
    ["16", "Maxillofacial Trauma"],
    ["17", "Extremity Trauma"],
    ["18", "Disaster Surgery"],
    ["19", "Conflict Surgery"],
    ["20", "Breast and Endocrine"],
    ["21", "Small and Large Intestine"],
    ["22", "Stomach, Liver, Pancreas, Gall Bladder"],
    ["23", "Peritoneum, Retroperitoneum, Hernia and Abdominal Wall"],
    ["24", "Urology"],
    ["25", "Appendix, Rectum, Anal Canal"],
    ["26", "Ethics and Audit"],
    ["27", "Salivary Glands"],
    ["28", "POVD & Venous Disorders"],
]
story.append(make_table(toc_data, [1.5*cm, 14*cm]))
story.append(PageBreak())

# ── TOPIC 1: METABOLIC RESPONSE TO INJURY ────────────────────────────────────
story += topic_title(1, "METABOLIC RESPONSE TO INJURY")
story.append(section("Definition & Overview"))
story.append(body("The metabolic response to injury is the series of systemic hormonal, inflammatory and neural changes that follow significant tissue injury (surgical or accidental). It affects metabolism, immunity, wound healing and organ function."))
story.append(section("Phases of Response"))
phase_data = [
    ["Phase", "Timing", "Features", "Hormones"],
    ["Ebb (Catabolic)", "0-24/48h post-injury", "Hypovolaemia, ↓BMR, ↓CO, hypothermia, lactic acidosis", "Catecholamines, cortisol, aldosterone"],
    ["Flow (Hypermetabolic)", "After resuscitation", "↑BMR, ↑CO, fever, leukocytosis, oedema, ↑gluconeogenesis", "Cortisol, glucagon; insulin resistance"],
    ["Anabolic", "Days–weeks later", "Wound healing, protein synthesis, weight gain", "GH, IGF-1, insulin"],
]
story.append(make_table(phase_data, [3*cm, 2.5*cm, 6*cm, 5*cm]))
story.append(section("Key Mediators"))
story.append(bullet("<b>DAMPs</b> (Damage-Associated Molecular Patterns): released from injured cells (e.g. HMGB1, heat shock proteins, S100 proteins)"))
story.append(bullet("<b>PRRs</b> (Pattern Recognition Receptors): TLRs and NLRs sense DAMPs → activate inflammasomes → caspases → IL-1, IL-6, TNF-α"))
story.append(bullet("<b>Neuroendocrine axis:</b> Nociception → hypothalamus → pituitary → adrenal → cortisol + catecholamines"))
story.append(bullet("<b>Cytokines:</b> IL-1, IL-6 (key driver of acute phase), TNF-α"))
story.append(section("Metabolic Changes"))
story.append(bullet("<b>Carbohydrate:</b> Hyperglycaemia from ↑gluconeogenesis + insulin resistance (proportional to injury severity)"))
story.append(bullet("<b>Protein:</b> Catabolism, ↑urinary nitrogen, negative nitrogen balance, muscle wasting"))
story.append(bullet("<b>Fat:</b> Lipolysis → free fatty acids as energy substrate"))
story.append(bullet("<b>Acute-phase response:</b> Positive reactants ↑ (CRP, fibrinogen); Negative reactants ↓ (albumin, transferrin)"))
story.append(bullet("<b>Albumin falls</b> due to ↑transcapillary escape (NOT reduced synthesis); TER increases 3-fold"))
story.append(key_box("Graded response: severity of metabolic response correlates with degree of injury. Secondary triggers (sepsis, haemorrhage, acidosis, surgery, crush, ischaemia-reperfusion) amplify and prolong catabolism → MODS."))

# ── TOPIC 2: SHOCK, HAEMORRHAGE AND TRANSFUSION ──────────────────────────────
story += topic_title(2, "SHOCK, HAEMORRHAGE AND TRANSFUSION")
story.append(section("Definition of Shock"))
story.append(body("Shock is a state of acute circulatory failure resulting in inadequate tissue perfusion and oxygenation, leading to cellular dysfunction and, if uncorrected, cell death."))
story.append(section("Classification of Shock"))
shock_data = [
    ["Type", "Mechanism", "Example", "CVP", "CO", "SVR"],
    ["Hypovolaemic", "Reduced preload", "Haemorrhage, burns, dehydration", "↓", "↓", "↑"],
    ["Cardiogenic", "Pump failure", "MI, cardiac tamponade, tension pneumothorax", "↑", "↓", "↑"],
    ["Distributive", "Vasodilation", "Sepsis, anaphylaxis, neurogenic", "↓/N", "↑/↓", "↓"],
    ["Obstructive", "Outflow obstruction", "PE, tension pneumothorax", "↑", "↓", "↑"],
    ["Endocrine", "Hormone deficiency", "Addisonian crisis, myxoedema", "Variable", "↓", "↓"],
]
story.append(make_table(shock_data, [2.5*cm, 3*cm, 4.5*cm, 1.5*cm, 1.5*cm, 1.5*cm]))
story.append(section("Haemorrhagic Shock Classes (ATLS)"))
hshock_data = [
    ["Class", "Blood Loss (mL)", "Blood Loss (%)", "HR", "BP", "RR", "Urine (mL/h)"],
    ["I", "<750", "<15%", "<100", "Normal", "14-20", ">30"],
    ["II", "750-1500", "15-30%", "100-120", "Normal/↓", "20-30", "20-30"],
    ["III", "1500-2000", "30-40%", "120-140", "↓", "30-40", "5-15"],
    ["IV", ">2000", ">40%", ">140", "Very ↓", ">35", "<5"],
]
story.append(make_table(hshock_data, [1.5*cm, 2.5*cm, 2.5*cm, 2*cm, 2*cm, 2*cm, 2.5*cm]))
story.append(section("Transfusion"))
story.append(bullet("<b>Massive transfusion:</b> >10 units RBC in 24h (or >1 blood volume)"))
story.append(bullet("<b>Ratio:</b> RBC:FFP:Platelets = 1:1:1 (damage control resuscitation)"))
story.append(bullet("<b>Complications:</b> Hypothermia, acidosis, hypocalcaemia (lethal triad), TRALI, TACO, infection, dilutional coagulopathy"))
story.append(bullet("<b>Cell salvage:</b> Intraoperative autologous blood recovery – preferred to reduce allogeneic transfusion"))
story.append(bullet("<b>Tranexamic acid (TXA):</b> Give within 3 hours of injury – reduces mortality in major haemorrhage"))
story.append(key_box("The 'lethal triad' of trauma: Hypothermia + Acidosis + Coagulopathy. Damage control surgery aims to break this cycle."))

# ── TOPIC 3: WOUND HEALING AND TISSUE REPAIR ─────────────────────────────────
story += topic_title(3, "WOUND HEALING AND TISSUE REPAIR")
story.append(section("Phases of Wound Healing"))
wh_data = [
    ["Phase", "Timing", "Key Events"],
    ["Haemostasis", "0-minutes", "Platelet plug, fibrin clot, vasoconstriction"],
    ["Inflammation", "Days 1-4", "Neutrophils (1-2d), macrophages (2-3d); debridement, growth factor release"],
    ["Proliferation", "Days 4-21", "Fibroblasts, angiogenesis, granulation tissue, collagen III synthesis, epithelialisation"],
    ["Remodelling", "Day 21 – 2 years", "Collagen III → Collagen I; wound contraction; tensile strength ↑ (max 80% of original)"],
]
story.append(make_table(wh_data, [3*cm, 3*cm, 10*cm]))
story.append(section("Types of Healing"))
story.append(bullet("<b>Primary intention:</b> Clean wound edges approximated (e.g. surgical incision) – minimal scarring"))
story.append(bullet("<b>Secondary intention:</b> Wound left open, heals by granulation and contraction – more scarring"))
story.append(bullet("<b>Tertiary (delayed primary):</b> Wound closed after 4-5 days (e.g. contaminated wounds)"))
story.append(section("Factors Affecting Wound Healing"))
story.append(bullet("<b>Local:</b> Infection, ischaemia, foreign body, haematoma, tension, radiation, wound type"))
story.append(bullet("<b>Systemic:</b> Malnutrition (vit C, zinc, protein deficiency), diabetes, steroids, chemotherapy, old age, jaundice, uraemia"))
story.append(section("Abnormal Healing"))
story.append(bullet("<b>Keloid:</b> Scar extends beyond wound margins; does not regress; common in dark skin; treatment: steroids, pressure, excision + radiotherapy"))
story.append(bullet("<b>Hypertrophic scar:</b> Raised but within wound margins; may regress spontaneously"))
story.append(bullet("<b>Wound dehiscence:</b> Disruption of wound closure – 'herald bleed' (serosanguineous discharge) is warning sign"))
story.append(bullet("<b>Incisional hernia:</b> Late complication of abdominal wounds"))
story.append(key_box("Vitamin C is essential for collagen cross-linking (hydroxylation of proline/lysine). Zinc is required for cell proliferation. Protein deficiency impairs every phase."))

# ── TOPIC 4: TISSUE ENGINEERING AND REGENERATIVE THERAPIES ───────────────────
story += topic_title(4, "TISSUE ENGINEERING AND REGENERATIVE THERAPIES")
story.append(section("Key Concepts"))
story.append(body("Tissue engineering combines cells, scaffolds and growth factors to create biological substitutes that restore, maintain or improve tissue function."))
story.append(section("Components of Tissue Engineering"))
story.append(bullet("<b>Cells:</b> Stem cells (embryonic, adult, iPSCs), chondrocytes, keratinocytes, osteoblasts"))
story.append(bullet("<b>Scaffolds:</b> Biodegradable matrices (collagen, fibrin, PLGA) that provide structural support"))
story.append(bullet("<b>Growth factors:</b> PDGF, TGF-β, VEGF, EGF, FGF – signal cell proliferation and differentiation"))
story.append(section("Stem Cell Types"))
stem_data = [
    ["Type", "Source", "Potential", "Issues"],
    ["Embryonic (ESCs)", "Blastocyst inner cell mass", "Totipotent/pluripotent", "Ethical concerns, teratoma risk"],
    ["Adult (ASCs)", "Bone marrow, adipose, gut", "Multipotent", "Limited differentiation"],
    ["iPSCs", "Reprogrammed somatic cells", "Pluripotent", "Tumour risk, costly"],
    ["Mesenchymal (MSCs)", "Bone marrow, fat", "Multipotent", "Best clinical evidence"],
]
story.append(make_table(stem_data, [3*cm, 4*cm, 3*cm, 5*cm]))
story.append(section("Clinical Applications"))
story.append(bullet("<b>Skin substitutes:</b> Apligraf, Integra – for burns and chronic wounds"))
story.append(bullet("<b>Cartilage repair:</b> Autologous chondrocyte implantation (ACI)"))
story.append(bullet("<b>Bone regeneration:</b> BMP-2 (bone morphogenetic protein) + scaffolds"))
story.append(bullet("<b>Vascular grafts:</b> Tissue-engineered blood vessels"))
story.append(bullet("<b>Organ bioprinting:</b> 3D printing of tissue constructs (experimental)"))
story.append(key_box("iPSCs (induced Pluripotent Stem Cells) were discovered by Yamanaka (Nobel Prize 2012) - adult cells reprogrammed to pluripotent state using 4 transcription factors (Oct4, Sox2, Klf4, c-Myc)."))

# ── TOPIC 5: SURGICAL INFECTION ───────────────────────────────────────────────
story += topic_title(5, "SURGICAL INFECTION")
story.append(section("Definitions"))
story.append(bullet("<b>SSI (Surgical Site Infection):</b> Infection within 30 days of surgery (1 year if implant) – most common nosocomial complication"))
story.append(bullet("<b>SIRS:</b> ≥2 of: Temp >38 or <36°C; HR >90; RR >20 or PaCO2 <32; WBC >12 or <4 × 10⁹/L"))
story.append(bullet("<b>Sepsis:</b> Life-threatening organ dysfunction due to dysregulated host response to infection"))
story.append(bullet("<b>Septic shock:</b> Sepsis + vasopressor requirement + lactate >2 mmol/L despite adequate fluid resuscitation"))
story.append(section("SSI Classification"))
story.append(bullet("<b>Superficial incisional:</b> Skin and subcutaneous tissue only"))
story.append(bullet("<b>Deep incisional:</b> Fascia and muscle layers"))
story.append(bullet("<b>Organ/space:</b> Any part of the anatomy opened/manipulated during surgery"))
story.append(section("Common Surgical Pathogens"))
story.append(bullet("<b>Gram positive:</b> S. aureus (MRSA), S. epidermidis, Streptococcus"))
story.append(bullet("<b>Gram negative:</b> E. coli, Pseudomonas, Klebsiella, Proteus"))
story.append(bullet("<b>Anaerobes:</b> Bacteroides fragilis, Clostridium (gas gangrene, tetanus)"))
story.append(section("Antibiotic Prophylaxis"))
story.append(bullet("Given within 60 min before incision (within 30 min for fluoroquinolones)"))
story.append(bullet("Choice based on likely pathogens for that procedure"))
story.append(bullet("Single dose usually sufficient; repeat if surgery >4h or major blood loss"))
story.append(section("Specific Infections"))
story.append(bullet("<b>Necrotising fasciitis:</b> Rapidly spreading infection of fascia; surgical emergency; Strep A or mixed flora; treatment: aggressive debridement + antibiotics"))
story.append(bullet("<b>Gas gangrene:</b> Clostridium perfringens; crepitus, foul smell; hyperbaric O2 + surgery + penicillin"))
story.append(bullet("<b>Tetanus:</b> Clostridium tetani; toxin blocks inhibitory neurotransmitters; treatment: immunoglobulin + wound debridement + diazepam"))
story.append(key_box("Sepsis-3 definition (2016): Sepsis = infection + SOFA score increase ≥2. Quick SOFA (qSOFA) = altered mentation + RR ≥22 + SBP ≤100."))

# ── TOPIC 6: TROPICAL INFECTIONS AND INFESTATIONS ────────────────────────────
story += topic_title(6, "TROPICAL INFECTIONS AND INFESTATIONS")
story.append(section("Important Tropical Surgical Infections"))
trop_data = [
    ["Condition", "Organism", "Surgical Relevance"],
    ["Amoebiasis", "Entamoeba histolytica", "Amoebic liver abscess, colitis, perforations"],
    ["Typhoid", "Salmonella typhi", "Ileal perforation, haemorrhage"],
    ["Tuberculosis", "Mycobacterium tuberculosis", "Peritoneal TB, cold abscess, bowel strictures"],
    ["Hydatid disease", "Echinococcus granulosus", "Liver cysts – PAIR or surgery; anaphylaxis risk"],
    ["Filariasis", "Wuchereria bancrofti", "Lymphoedema, elephantiasis, chylous ascites"],
    ["Schistosomiasis", "Schistosoma mansoni/japonicum", "Portal hypertension, hepatic fibrosis"],
    ["Ascariasis", "Ascaris lumbricoides", "Bowel obstruction, biliary obstruction"],
    ["Amoebic abscess", "E. histolytica", "Right lobe liver; 'anchovy sauce' pus; metronidazole"],
]
story.append(make_table(trop_data, [3.5*cm, 4.5*cm, 8*cm]))
story.append(section("Hydatid Disease - Key Points"))
story.append(bullet("Dog is definitive host; sheep is intermediate host; humans are accidental intermediate host"))
story.append(bullet("Liver (70%) > lung (20%) > other sites"))
story.append(bullet("<b>PAIR:</b> Percutaneous Aspiration, Injection of hypertonic saline, Re-aspiration"))
story.append(bullet("Pre-treatment with albendazole to prevent spread"))
story.append(key_box("Never aspirate a suspected hydatid cyst without cover - spillage causes anaphylaxis and secondary seeding. Casoni test is historical."))

# ── TOPIC 7: BASIC SURGICAL SKILLS ───────────────────────────────────────────
story += topic_title(7, "BASIC SURGICAL SKILLS")
story.append(section("Suture Materials"))
suture_data = [
    ["Type", "Examples", "Properties", "Uses"],
    ["Absorbable (natural)", "Catgut, chromic catgut", "Absorbed by proteolysis in 10-14d", "Bowel anastomosis (historical)"],
    ["Absorbable (synthetic)", "Vicryl (polyglactin), PDS, Monocryl", "Absorbed by hydrolysis; predictable; low reaction", "Deep tissues, fascial closure"],
    ["Non-absorbable (natural)", "Silk, linen", "Tissue reaction; multifilament", "Vascular, ties"],
    ["Non-absorbable (synthetic)", "Nylon, Prolene, Ethibond", "Strong, low reaction; monofilament", "Skin, vascular, hernia"],
]
story.append(make_table(suture_data, [3*cm, 3.5*cm, 4.5*cm, 4.5*cm]))
story.append(section("Knot Types"))
story.append(bullet("<b>Square knot (reef knot):</b> Standard surgical knot; secure for most applications"))
story.append(bullet("<b>Surgeon's knot:</b> First throw doubled; prevents slippage while tying second throw"))
story.append(bullet("<b>Slip knot:</b> For deep cavities where hands cannot reach"))
story.append(section("Anastomosis Principles"))
story.append(bullet("Adequate blood supply, tension-free, no distal obstruction, healthy tissue, good technique"))
story.append(bullet("<b>End-to-end:</b> Best blood supply to cut ends"))
story.append(bullet("<b>End-to-side / Side-to-side:</b> For size discrepancy or bypass"))
story.append(bullet("Stapled vs handsewn – equivalent results in most studies"))
story.append(section("Diathermy"))
story.append(bullet("<b>Monopolar:</b> Current passes through patient to return pad; risk of burns at pad site; not near implants"))
story.append(bullet("<b>Bipolar:</b> Current between two tips; safer; used in neurosurgery, eye surgery, microsurgery"))
story.append(key_box("Absorbable sutures: Vicryl (60-90d), PDS (180d), Monocryl (90-120d). For abdominal fascia closure: mass closure with PDS (loop or single strand) is standard."))

# ── TOPIC 8: DIAGNOSTIC IMAGING ──────────────────────────────────────────────
story += topic_title(8, "DIAGNOSTIC IMAGING")
story.append(section("Modalities Comparison"))
img_data = [
    ["Modality", "Principle", "Key Uses", "Contraindications"],
    ["Plain X-ray", "Ionising radiation", "Chest, bones, abdomen (pneumoperitoneum, obstruction)", "Pregnancy (relative)"],
    ["Ultrasound", "Sound waves (no radiation)", "Abdomen, pelvis, vascular, FAST exam, guided procedures", "Bowel gas, obesity (limited)"],
    ["CT", "X-ray + computer reconstruction", "Trauma, oncology, vascular, chest, head", "Renal failure (contrast), pregnancy"],
    ["MRI", "Magnetic fields + radio waves", "Brain, spine, soft tissue, MSK, liver", "Pacemakers, metallic implants, claustrophobia"],
    ["Nuclear medicine", "Radioactive tracers", "Bone scan, HIDA, VQ scan, sentinel node", "Pregnancy, breastfeeding"],
    ["PET-CT", "FDG uptake in metabolically active cells", "Oncology staging, recurrence", "Poorly controlled diabetes"],
    ["Angiography", "Contrast injection into vessels", "Vascular disease, embolisation, stenting", "Renal failure, contrast allergy"],
]
story.append(make_table(img_data, [2.5*cm, 3.5*cm, 5.5*cm, 4*cm]))
story.append(key_box("In trauma: FAST (Focused Assessment with Sonography for Trauma) – detects free fluid in pericardium, perihepatic, perisplenic and pelvic spaces. Extended FAST (eFAST) adds lung windows for pneumothorax."))

# ── TOPIC 9: GASTROINTESTINAL ENDOSCOPY ──────────────────────────────────────
story += topic_title(9, "GASTROINTESTINAL ENDOSCOPY")
story.append(section("Types of Endoscopy"))
story.append(bullet("<b>OGD (Oesophago-gastro-duodenoscopy):</b> Upper GI – oesophagus to 2nd part duodenum"))
story.append(bullet("<b>Colonoscopy:</b> Entire colon to terminal ileum"))
story.append(bullet("<b>Flexible sigmoidoscopy:</b> Sigmoid and descending colon"))
story.append(bullet("<b>ERCP:</b> Endoscopic Retrograde Cholangiopancreatography – biliary and pancreatic ducts"))
story.append(bullet("<b>EUS:</b> Endoscopic Ultrasound – staging of GI cancers, pancreatic lesions"))
story.append(bullet("<b>Capsule endoscopy:</b> Small bowel visualisation – swallowed camera"))
story.append(bullet("<b>Double balloon enteroscopy:</b> Therapeutic access to small bowel"))
story.append(section("Therapeutic Endoscopy"))
story.append(bullet("Haemostasis: adrenaline injection, thermal coagulation, clips, banding (varices)"))
story.append(bullet("Polypectomy: snare, EMR (endoscopic mucosal resection), ESD (endoscopic submucosal dissection)"))
story.append(bullet("Stenting: oesophageal, biliary, colonic"))
story.append(bullet("PEG: Percutaneous Endoscopic Gastrostomy – enteral feeding access"))
story.append(section("Complications"))
story.append(bullet("<b>OGD:</b> Perforation (0.03%), bleeding, aspiration, cardiorespiratory events"))
story.append(bullet("<b>Colonoscopy:</b> Perforation (0.1-0.3%), bleeding (0.3-1%), post-polypectomy syndrome"))
story.append(bullet("<b>ERCP:</b> Pancreatitis (3-5%), cholangitis, perforation, bleeding"))
story.append(key_box("ERCP is both diagnostic and therapeutic. Complications rate ~10%. Pre-procedural rectal indomethacin reduces post-ERCP pancreatitis risk."))

# ── TOPIC 10: MINIMAL ACCESS SURGERY ─────────────────────────────────────────
story += topic_title(10, "PRINCIPLES OF MINIMAL ACCESS SURGERY")
story.append(section("Principles"))
story.append(body("Minimal access (laparoscopic/keyhole) surgery uses small incisions with a camera (laparoscope) and instruments to perform procedures inside body cavities, reducing surgical trauma."))
story.append(section("Pneumoperitoneum"))
story.append(bullet("CO2 insufflation to 12-15 mmHg (standard); Hasson (open) or Veress needle technique"))
story.append(bullet("<b>Physiological effects:</b> ↑intrathoracic pressure, ↓venous return, hypercarbia, hypothermia (gas cooling)"))
story.append(bullet("<b>Contraindications (relative):</b> Severe cardiac/respiratory disease, previous multiple laparotomies, pregnancy (late)"))
story.append(section("Advantages vs Open Surgery"))
story.append(bullet("Reduced postoperative pain, shorter hospital stay, faster return to activity"))
story.append(bullet("Reduced wound infection, hernia, blood loss"))
story.append(bullet("Better cosmesis"))
story.append(section("Specific Procedures"))
story.append(bullet("<b>Cholecystectomy:</b> Most common laparoscopic procedure; bile duct injury 0.3%"))
story.append(bullet("<b>Appendicectomy:</b> Preferred in young women (exclude ovarian pathology)"))
story.append(bullet("<b>Fundoplication:</b> For GORD (Nissen 360° wrap)"))
story.append(bullet("<b>Colectomy, bariatric surgery, hernia repair</b>"))
story.append(bullet("<b>Robotic surgery:</b> Enhanced dexterity, 3D vision, tremor filtration (da Vinci system)"))
story.append(section("Complications"))
story.append(bullet("<b>Entry injuries:</b> Bowel, vessel injury on port insertion"))
story.append(bullet("<b>CO2 embolism:</b> Rare but fatal"))
story.append(bullet("<b>Port site hernia:</b> Especially >10 mm ports"))
story.append(key_box("ERAS (Enhanced Recovery After Surgery): multimodal pathway including carbohydrate loading, regional anaesthesia, early mobilisation, early feeding – reduces LOS and complications."))

# ── TOPIC 11: INTRODUCTION TO TRAUMA ─────────────────────────────────────────
story += topic_title(11, "INTRODUCTION TO TRAUMA")
story.append(section("Epidemiology"))
story.append(bullet("Leading cause of death in people aged 1-40 years"))
story.append(bullet("Trimodal distribution of death: immediate (seconds-minutes), early (minutes-hours), late (days-weeks)"))
story.append(section("Injury Types"))
story.append(bullet("<b>Blunt trauma:</b> MVA, falls, assault – deceleration injuries, crush"))
story.append(bullet("<b>Penetrating trauma:</b> Stab, GSW – trajectory determines injury pattern"))
story.append(bullet("<b>Blast injury:</b> Primary (pressure wave), secondary (fragments), tertiary (displacement), quaternary (burns/crush)"))
story.append(section("Energy Transfer"))
story.append(bullet("KE = ½mv² – velocity is most important determinant of injury severity"))
story.append(bullet("High velocity (military rifle) vs low velocity (handgun)"))
story.append(bullet("<b>Cavitation:</b> Temporary cavity created in tissues by high-velocity projectiles"))
story.append(section("ISS and Scoring"))
story.append(bullet("<b>ISS (Injury Severity Score):</b> Sum of squares of top 3 AIS scores from different body regions; >15 = major trauma"))
story.append(bullet("<b>RTS (Revised Trauma Score):</b> GCS + RR + SBP"))
story.append(bullet("<b>TRISS:</b> Combines ISS + RTS + age to predict survival probability"))
story.append(key_box("Golden hour concept: optimal resuscitation and haemorrhage control within 60 minutes of injury significantly reduces mortality. Damage control resuscitation prioritises haemostasis over definitive repair."))

# ── TOPIC 12: EARLY ASSESSMENT AND MANAGEMENT OF SEVERE TRAUMA ───────────────
story += topic_title(12, "EARLY ASSESSMENT AND MANAGEMENT OF SEVERE TRAUMA")
story.append(section("ATLS Primary Survey: ABCDE"))
atls_data = [
    ["Step", "Assessment", "Action"],
    ["A - Airway + C-spine", "Obstruction? Stridor? Level of consciousness?", "Chin lift, jaw thrust, OPA/NPA, RSI intubation, surgical airway; C-spine immobilisation"],
    ["B - Breathing", "Tracheal deviation, breath sounds, O2 sats, RR", "Seal open wounds; needle/finger decompression; chest drain for haemo/pneumothorax"],
    ["C - Circulation", "HR, BP, capillary refill, bleeding", "Haemorrhage control (direct pressure); 2 large-bore IVs; fluid resuscitation; blood products"],
    ["D - Disability", "GCS, pupils, blood glucose", "Treat hypoglycaemia; head CT if GCS <14"],
    ["E - Exposure", "Full exposure, temperature", "Prevent hypothermia; log-roll; analgesia"],
]
story.append(make_table(atls_data, [3*cm, 5*cm, 7.5*cm]))
story.append(section("Damage Control Resuscitation (DCR)"))
story.append(bullet("Permissive hypotension (SBP 80-90 mmHg until haemorrhage controlled) except TBI"))
story.append(bullet("Haemostatic resuscitation: RBC:FFP:Platelets = 1:1:1"))
story.append(bullet("Tranexamic acid within 3 hours of injury"))
story.append(bullet("Avoid crystalloid excess (worsens coagulopathy and oedema)"))
story.append(section("Secondary Survey"))
story.append(body("Head-to-toe examination after primary survey. Detailed history (AMPLE: Allergies, Medications, Past history, Last meal, Events). Adjuncts: CT trauma scan, FAST/eFAST."))
story.append(key_box("Revised ATLS recommends Haemorrhage be addressed before Airway if there is life-threatening external bleeding (C-ABCDE). Also: 'treat the patient, not the scan'."))

# ── TOPIC 13: TRAUMATIC BRAIN INJURY ─────────────────────────────────────────
story += topic_title(13, "TRAUMATIC BRAIN INJURY")
story.append(section("Classification"))
story.append(bullet("<b>Mild TBI:</b> GCS 13-15; brief LOC or none; most common (80%)"))
story.append(bullet("<b>Moderate TBI:</b> GCS 9-12; LOC minutes to hours"))
story.append(bullet("<b>Severe TBI:</b> GCS ≤8; prolonged LOC; high mortality"))
story.append(section("Primary vs Secondary Injury"))
story.append(bullet("<b>Primary:</b> Direct mechanical injury at time of impact – irreversible"))
story.append(bullet("<b>Secondary:</b> Cascade following primary injury – preventable/treatable"))
story.append(bullet("Secondary injury causes: hypoxia, hypotension (SBP <90 = doubles mortality), hypercapnia, raised ICP, seizures, pyrexia, hyperglycaemia"))
story.append(section("Intracranial Haemorrhage"))
haem_data = [
    ["Type", "Source", "CT Appearance", "Classic Presentation"],
    ["Extradural (EDH)", "Middle meningeal artery", "Biconvex (lens-shaped), hyperdense", "Lucid interval then rapid deterioration"],
    ["Acute subdural (ASDH)", "Bridging veins", "Concave/crescent, hyperdense", "Gradual deterioration; elderly/alcoholics"],
    ["Chronic subdural", "Bridging veins (slow)", "Crescent, hypodense/isodense", "Weeks history; dementia-like; elderly"],
    ["Subarachnoid", "Cortical vessels/aneurysm", "Blood in sulci/cisterns", "Thunderclap headache"],
    ["Intracerebral (ICH)", "Parenchymal vessels", "Hyperdense within parenchyma", "Focal deficits"],
]
story.append(make_table(haem_data, [3*cm, 3.5*cm, 4*cm, 5*cm]))
story.append(section("ICP Management"))
story.append(bullet("Normal ICP: 5-15 mmHg; CPP = MAP - ICP (target CPP 60-70 mmHg)"))
story.append(bullet("Head-up 30°, sedation, analgesia, normocapnia (PaCO2 4.5-5 kPa)"))
story.append(bullet("Mannitol (0.25-1 g/kg) or hypertonic saline for acute ICP spikes"))
story.append(bullet("Surgical: burr holes/craniotomy for EDH; decompressive craniectomy for refractory ICP"))
story.append(key_box("Cushing's triad = Hypertension + Bradycardia + Irregular respirations → sign of imminent brainstem herniation. Immediate action: hyperventilate + mannitol + urgent neurosurgery."))

# ── TOPIC 14: TORSO AND PELVIC TRAUMA ────────────────────────────────────────
story += topic_title(14, "TORSO AND PELVIC TRAUMA")
story.append(section("Chest Trauma"))
story.append(bullet("<b>Immediately life-threatening (ATOM FC):</b> Airway obstruction, Tension pneumothorax, Open pneumothorax, Massive haemothorax, Flail chest, Cardiac tamponade"))
story.append(bullet("<b>Tension pneumothorax:</b> Deviated trachea away, absent breath sounds, hypotension; needle decompression 2nd ICS MCL then chest drain 4th/5th ICS"))
story.append(bullet("<b>Massive haemothorax:</b> >1500 mL blood; chest drain + resuscitation; consider thoracotomy if >200 mL/h"))
story.append(bullet("<b>Flail chest:</b> ≥3 adjacent ribs broken in ≥2 places; paradoxical movement; treat with PPV if severe"))
story.append(bullet("<b>Cardiac tamponade:</b> Beck's triad (JVD, muffled heart sounds, hypotension); pericardiocentesis or thoracotomy"))
story.append(section("Abdominal Trauma"))
story.append(bullet("<b>Liver:</b> Most commonly injured solid organ in blunt trauma; Grade I-VI; most managed non-operatively"))
story.append(bullet("<b>Spleen:</b> Most commonly injured organ overall; NOM with angioembolisation or splenectomy; post-splenectomy vaccination (pneumococcal, meningococcal, Hib)"))
story.append(bullet("<b>Hollow viscus:</b> Bowel injury from blunt trauma – lap belt injury; peritonism + pneumoperitoneum on CT"))
story.append(section("Pelvic Trauma"))
story.append(bullet("High energy injury; life-threatening haemorrhage from pelvic venous plexus and iliac vessels"))
story.append(bullet("<b>Pelvic binder:</b> Immediate for open book fractures – reduces pelvic volume and tamponades bleeding"))
story.append(bullet("<b>REBOA:</b> Resuscitative Endovascular Balloon Occlusion of the Aorta – temporising haemostasis"))
story.append(bullet("Angiographic embolisation for arterial bleeding; external fixator for stability"))
story.append(key_box("Indications for emergency laparotomy: haemodynamic instability with positive FAST, peritonitis, evisceration, implement in situ, diaphragmatic injury."))

# ── TOPIC 15: THE NECK AND SPINE ──────────────────────────────────────────────
story += topic_title(15, "THE NECK AND SPINE")
story.append(section("Cervical Spine Injury"))
story.append(bullet("C-spine immobilisation in all blunt trauma until cleared clinically (NEXUS) or radiologically"))
story.append(bullet("<b>NEXUS criteria</b> (no imaging needed if ALL met): no midline tenderness, no focal deficit, normal alertness, no intoxication, no distracting injury"))
story.append(bullet("<b>Canadian C-spine Rule:</b> More specific; safe to clear if low-risk mechanism + able to rotate 45°"))
story.append(bullet("Spinal cord injury: complete vs incomplete; ASIA grading (A-E)"))
story.append(section("Spinal Cord Syndromes"))
spine_data = [
    ["Syndrome", "Mechanism", "Features"],
    ["Central cord", "Hyperextension in elderly", "Arms > legs weakness; bladder dysfunction; most common"],
    ["Anterior cord", "Flexion/compression", "Motor loss + pain/temp loss; preserved proprioception"],
    ["Brown-Sequard", "Hemisection (stab)", "Ipsilateral motor + proprioception loss; contralateral pain/temp loss"],
    ["Cauda equina", "L1-L5 nerve roots", "LMN weakness, saddle anaesthesia, sphincter dysfunction; SURGICAL EMERGENCY"],
]
story.append(make_table(spine_data, [3.5*cm, 4*cm, 8*cm]))
story.append(section("Neck Trauma Zones"))
story.append(bullet("<b>Zone I:</b> Clavicle to cricoid cartilage – great vessels; high mortality"))
story.append(bullet("<b>Zone II:</b> Cricoid to angle of mandible – most accessible; carotid, jugular, trachea, oesophagus"))
story.append(bullet("<b>Zone III:</b> Above angle of mandible – difficult access; angiography first"))
story.append(key_box("Neurogenic shock = hypotension + bradycardia (loss of sympathetic tone from spinal injury). Treat with vasopressors (noradrenaline preferred). Do NOT confuse with haemorrhagic shock."))

# ── TOPIC 16: MAXILLOFACIAL TRAUMA ────────────────────────────────────────────
story += topic_title(16, "MAXILLOFACIAL TRAUMA")
story.append(section("Priorities"))
story.append(body("Airway management is the top priority in maxillofacial trauma. Oropharynx may be compromised by bleeding, swelling, dislodged teeth, or fractured mandible."))
story.append(section("Facial Fractures"))
story.append(bullet("<b>Mandible fracture:</b> Most common; bimanual test (abnormal mobility); panoramic X-ray (OPG)"))
story.append(bullet("<b>Zygomatic fracture:</b> Flattened cheek, trismus, infraorbital nerve paraesthesia"))
story.append(bullet("<b>Orbital blow-out:</b> Inferior wall most common; diplopia (inferior rectus trapping), enophthalmos, infraorbital hypoaesthesia"))
story.append(bullet("<b>Nasal fracture:</b> Most common facial bone fracture; septal haematoma must be drained (avascular necrosis risk)"))
story.append(section("Le Fort Fractures (Midface)"))
le_fort_data = [
    ["Level", "Description", "Landmark"],
    ["Le Fort I", "Horizontal – separates teeth-bearing maxilla from upper face", "Palate moves, nose stable"],
    ["Le Fort II", "Pyramidal – central face disconnected", "Nose + palate moves, orbits stable"],
    ["Le Fort III", "Craniofacial disjunction – face separates from skull", "Entire face moves"],
]
story.append(make_table(le_fort_data, [2.5*cm, 7*cm, 6*cm]))
story.append(key_box("CSF rhinorrhoea (clear fluid from nose) or otorrhoea after facial/head trauma = basal skull fracture until proven otherwise. Do NOT insert NG tube – use orogastric instead."))

# ── TOPIC 17: EXTREMITY TRAUMA ────────────────────────────────────────────────
story += topic_title(17, "EXTREMITY TRAUMA")
story.append(section("Fracture Classification"))
story.append(bullet("<b>Gustilo-Anderson (open fractures):</b> Type I (<1cm, clean), II (1-10cm), IIIA (>10cm, adequate coverage), IIIB (periosteal stripping, requires flap), IIIC (vascular injury requiring repair)"))
story.append(bullet("<b>AO/OTA classification:</b> Bone, region (proximal/shaft/distal), morphology (A/B/C)"))
story.append(section("Compartment Syndrome"))
story.append(bullet("Raised pressure within closed fascial compartment → ischaemia"))
story.append(bullet("<b>Classic 5 Ps:</b> Pain (especially on passive stretch), Pressure, Paresis, Paraesthesia, Pulselessness (late sign)"))
story.append(bullet("Delta P (diastolic BP - compartment pressure) <30 mmHg = fasciotomy indicated"))
story.append(bullet("Treatment: emergency fasciotomy – leave open 48-72h, then closure"))
story.append(section("Vascular Injury"))
story.append(bullet("Hard signs (immediate surgery): pulsatile bleeding, expanding haematoma, bruit/thrill, absent distal pulse, ischaemic limb"))
story.append(bullet("Soft signs (CTA first): small stable haematoma, reduced pulse, proximity to vessel, nerve deficit"))
story.append(bullet("Ankle-Brachial Index (ABI) <0.9 = significant arterial injury"))
story.append(section("Amputation"))
story.append(bullet("MESS Score (Mangled Extremity Severity Score) ≥7 = amputation likely needed"))
story.append(bullet("Replantation criteria: sharp amputation, young patient, viable part, good facilities"))
story.append(key_box("Open fractures: urgent washout within 6 hours. Antibiotic prophylaxis: co-amoxiclav for Gustilo I/II, add gentamicin + metronidazole for Gustilo III."))

# ── TOPIC 18: DISASTER SURGERY ────────────────────────────────────────────────
story += topic_title(18, "DISASTER SURGERY")
story.append(section("Definition"))
story.append(body("A disaster is an event where the number of casualties overwhelms the capacity of available medical resources. Disaster surgery focuses on doing the most good for the most people."))
story.append(section("Triage Systems"))
triage_data = [
    ["Priority", "Colour", "Description"],
    ["T1 - Immediate", "Red", "Life-threatening but salvageable; needs treatment within 1 hour"],
    ["T2 - Urgent/Delayed", "Yellow", "Serious but can wait 4-6 hours"],
    ["T3 - Minor", "Green", "Walking wounded; can wait"],
    ["T4 - Expectant", "Blue/Black", "Unsurvivable or too resource-intensive given available resources"],
    ["Dead", "Black", "No pulse, no breathing"],
]
story.append(make_table(triage_data, [3*cm, 2*cm, 10.5*cm]))
story.append(bullet("<b>SALT triage:</b> Sort, Assess, Lifesaving interventions, Treatment and transport – used in mass casualty events"))
story.append(bullet("<b>START triage:</b> Simple Triage and Rapid Treatment – RPM (Respirations, Perfusion, Mental status)"))
story.append(section("Damage Control Surgery in Disasters"))
story.append(bullet("Abbreviated surgery to control haemorrhage and contamination; pack and close; ICU stabilisation; definitive repair 24-48h later"))
story.append(bullet("Austere environments: limited anaesthesia, limited blood products, ketamine is key anaesthetic"))
story.append(key_box("MIMMS (Major Incident Medical Management and Support): structured approach to major incident command, safety, communication, assessment, triage, treatment, transport."))

# ── TOPIC 19: CONFLICT SURGERY ────────────────────────────────────────────────
story += topic_title(19, "CONFLICT SURGERY")
story.append(section("Principles"))
story.append(body("Conflict (military/war) surgery differs from civilian trauma: high-energy ballistic and blast injuries, delayed presentation, contamination, and resource constraints."))
story.append(section("Wound Ballistics"))
story.append(bullet("High-velocity rifle rounds: large temporary cavitation, severe tissue destruction"))
story.append(bullet("Fragmentation (IED, artillery): multiple small penetrating injuries, severe contamination"))
story.append(bullet("Blast injury: 4 mechanisms (primary pressure, secondary fragments, tertiary displacement, quaternary burns/crush)"))
story.append(section("Military Wound Management"))
story.append(bullet("<b>No primary closure</b> of war wounds (high contamination risk)"))
story.append(bullet("<b>Serial debridement</b> and delayed primary closure at 4-5 days"))
story.append(bullet("<b>External fixation</b> preferred for fractures in field"))
story.append(bullet("<b>Tourniquet use:</b> Combat Application Tourniquet (CAT) – venous haemorrhage before TXA/resuscitation"))
story.append(bullet("<b>Haemostatic dressings:</b> Celox, QuikClot – for junctional haemorrhage"))
story.append(section("Echelons of Care"))
story.append(bullet("Role 1: Point of injury/first aid"))
story.append(bullet("Role 2: Forward surgical team – damage control"))
story.append(bullet("Role 3: Field hospital – definitive surgery"))
story.append(bullet("Role 4: Tertiary care (home nation)"))
story.append(key_box("Hartford Consensus / THREAT: Threat suppression, Haemorrhage control, Rapid Extrication, Assessment, Transport. Tourniquet application time documented on patient (indelible marker on skin)."))

# ── TOPIC 20: BREAST AND ENDOCRINE ────────────────────────────────────────────
story += topic_title(20, "BREAST AND ENDOCRINE")
story.append(section("Breast: Triple Assessment"))
story.append(bullet("<b>1. Clinical examination:</b> History + examination"))
story.append(bullet("<b>2. Imaging:</b> Mammography (<35y or dense: USS; >35y: mammogram)"))
story.append(bullet("<b>3. Pathology:</b> Core needle biopsy (preferred) or FNA"))
story.append(bullet("All three must agree – discordance requires further investigation"))
story.append(section("Breast Cancer"))
story.append(bullet("<b>Commonest cancer in women;</b> peak age 50-60; BRCA1/2 mutations in hereditary"))
story.append(bullet("<b>Types:</b> IDC (70%), ILC (15%), DCIS, LCIS (risk marker, not cancer)"))
story.append(bullet("<b>Staging:</b> TNM system; sentinel lymph node biopsy (SLNB) for clinically N0"))
story.append(bullet("<b>Surgery:</b> Wide local excision (breast conservation) + RT vs mastectomy ± reconstruction"))
story.append(bullet("<b>Systemic:</b> Hormone receptor +ve → endocrine (tamoxifen/aromatase inhibitors); HER2 +ve → trastuzumab; triple negative → chemotherapy"))
story.append(section("Thyroid"))
story.append(bullet("<b>Goitre assessment:</b> USS + TFTs; FNA for nodule >1 cm or suspicious features"))
story.append(bullet("<b>Thyroid cancer:</b> PTC (80%, best prognosis), FTC, MTC (calcitonin marker), ATC (worst)"))
story.append(bullet("<b>Thyroidectomy complications:</b> Recurrent laryngeal nerve palsy (hoarseness), hypoparathyroidism (hypocalcaemia), thyroid storm"))
story.append(section("Parathyroid"))
story.append(bullet("<b>Primary hyperparathyroidism:</b> ↑Ca, ↑PTH; most common cause = adenoma (85%); treatment: parathyroidectomy"))
story.append(bullet("<b>Symptoms:</b> 'Bones, stones, moans, groans' – bone pain, renal stones, depression, abdominal pain"))
story.append(section("Adrenal"))
story.append(bullet("<b>Cushing's:</b> ↑cortisol; central obesity, striae, DM, HTN; dexamethasone suppression test"))
story.append(bullet("<b>Conn's:</b> ↑aldosterone; HTN + hypokalaemia; adrenal adenoma"))
story.append(bullet("<b>Phaeochromocytoma:</b> Catecholamine-secreting tumour; 24h urinary metanephrines; pre-op alpha-block THEN beta-block"))
story.append(key_box("Phaeochromocytoma: NEVER give beta-blockers first (unopposed alpha causes hypertensive crisis). Alpha-blockade (phenoxybenzamine) first, then beta-blockade."))

# ── TOPIC 21: SMALL AND LARGE INTESTINE ──────────────────────────────────────
story += topic_title(21, "SMALL AND LARGE INTESTINE")
story.append(section("Small Bowel Obstruction (SBO)"))
story.append(bullet("<b>Causes:</b> Adhesions (70%), hernias, Crohn's, intussusception, tumour, volvulus"))
story.append(bullet("<b>Features:</b> Colicky pain, vomiting (early), distension (distal), constipation"))
story.append(bullet("<b>AXR:</b> Central dilated loops >3 cm, valvulae conniventes across full width"))
story.append(bullet("<b>Management:</b> NBM, NG tube, IV fluids; most resolve with conservative treatment; surgery if strangulation/failure to resolve"))
story.append(section("Crohn's Disease vs Ulcerative Colitis"))
ibd_data = [
    ["Feature", "Crohn's Disease", "Ulcerative Colitis"],
    ["Distribution", "Anywhere mouth to anus; skip lesions", "Rectum extending proximally; continuous"],
    ["Depth", "Transmural", "Mucosal only"],
    ["Histology", "Granulomas (non-caseating)", "Crypt abscesses; goblet cell depletion"],
    ["Smoking", "Worsens disease", "Protective"],
    ["Surgery", "Not curative; resection + stricturoplasty", "Curative: proctocolectomy + IPAA"],
    ["Extra-intestinal", "Mouth ulcers, perianal disease", "Primary sclerosing cholangitis"],
]
story.append(make_table(ibd_data, [3*cm, 6.5*cm, 6*cm]))
story.append(section("Colorectal Cancer"))
story.append(bullet("<b>2nd commonest GI cancer;</b> adenocarcinoma; HNPCC and FAP are hereditary syndromes"))
story.append(bullet("<b>Right colon:</b> Iron deficiency anaemia, mass, weight loss (no obstruction)"))
story.append(bullet("<b>Left colon/sigmoid:</b> Change in bowel habit, rectal bleeding, obstruction"))
story.append(bullet("<b>Staging:</b> Dukes (A-D) / TNM; MRI for rectal cancer; CT chest/abdomen/pelvis"))
story.append(bullet("<b>Surgery:</b> Right hemicolectomy, left hemicolectomy, anterior resection, AP resection"))
story.append(bullet("<b>CEA:</b> Not diagnostic; used for surveillance post-resection"))
story.append(key_box("Duke's staging: A = confined to bowel wall; B = through bowel wall; C = lymph node involvement; D = distant metastases. 5-year survival: A~93%, B~77%, C~48%, D~7%."))

# ── TOPIC 22: STOMACH, LIVER, PANCREAS, GALL BLADDER ─────────────────────────
story += topic_title(22, "STOMACH, LIVER, PANCREAS, GALL BLADDER")
story.append(section("Peptic Ulcer Disease"))
story.append(bullet("<b>H. pylori</b> (80% DU, 60% GU) and NSAIDs are main causes"))
story.append(bullet("Complications: perforation (peritonitis; air under diaphragm on erect CXR), haemorrhage (Rockall score), obstruction"))
story.append(bullet("Treatment: H. pylori eradication (triple therapy: PPI + amoxicillin + clarithromycin × 7-14d)"))
story.append(bullet("Perforated DU: Graham patch repair or omentoplasty"))
story.append(section("Gastric Cancer"))
story.append(bullet("Adenocarcinoma >90%; H. pylori major risk factor"))
story.append(bullet("Virchow's node (left supraclavicular); Krukenberg tumour (ovarian metastasis); Sister Mary Joseph nodule (umbilical)"))
story.append(bullet("Treatment: gastrectomy ± D2 lymphadenectomy; perioperative chemotherapy (FLOT)"))
story.append(section("Liver"))
story.append(bullet("<b>Hepatocellular carcinoma (HCC):</b> Cirrhosis + HBV/HCV; AFP marker; BCLC staging; resection or transplant"))
story.append(bullet("<b>Colorectal liver metastases:</b> Synchronous or metachronous; resectable in ~20%; potentially curative"))
story.append(bullet("<b>Child-Pugh score:</b> Bilirubin, albumin, INR, ascites, encephalopathy – assesses liver reserve"))
story.append(section("Pancreas"))
story.append(bullet("<b>Acute pancreatitis:</b> Gallstones (40%) + alcohol (40%); Ranson/Glasgow criteria for severity; CT for necrotising pancreatitis; ERCP if CBD stone"))
story.append(bullet("<b>Chronic pancreatitis:</b> Calcification on AXR; malabsorption, DM, pain; ERCP/surgery for complications"))
story.append(bullet("<b>Pancreatic carcinoma:</b> 5% 5yr survival; Whipple's (pancreaticoduodenectomy); CA 19-9 marker"))
story.append(section("Gall Bladder"))
story.append(bullet("<b>Cholelithiasis → cholecystitis → cholangitis → pancreatitis:</b> Charcot's triad (fever, jaundice, RUQ pain) = cholangitis; Reynolds' pentad = Charcot's + confusion + shock"))
story.append(bullet("<b>Mirizzi syndrome:</b> Stone in Hartmann's pouch compressing CHD"))
story.append(bullet("<b>Cholecystectomy:</b> Gold standard; beware bile duct injury (Strasberg classification)"))
story.append(key_box("Modified Glasgow criteria for pancreatitis severity (≥3 = severe): PaO2 <8, Age >55, Neutrophils >15, Ca <2, Renal function (urea >16), Enzymes (LDH >600, AST >200), Albumin <32, Sugar (glucose >10) — mnemonic PANCREAS."))

# ── TOPIC 23: PERITONEUM, RETROPERITONEUM, HERNIA ────────────────────────────
story += topic_title(23, "PERITONEUM, RETROPERITONEUM, HERNIA & ABDOMINAL WALL")
story.append(section("Peritonitis"))
story.append(bullet("<b>Primary:</b> Spontaneous bacterial peritonitis (SBP) – cirrhosis; E. coli; ascitic tap PMN >250; treat with cefotaxime"))
story.append(bullet("<b>Secondary:</b> Perforated viscus, ruptured appendix, ischaemic bowel – requires surgery"))
story.append(bullet("<b>Tertiary:</b> Persistent infection post-surgery; Candida, Enterococcus; very poor prognosis"))
story.append(section("Hernia"))
hernia_data = [
    ["Type", "Location", "Risk of Strangulation", "Key Points"],
    ["Inguinal (indirect)", "Lateral to inferior epigastric, through deep ring", "Moderate", "Most common; M>F; young; deep ring controlled"],
    ["Inguinal (direct)", "Medial to inferior epigastric, through posterior wall", "Low", "Elderly males; weakness of transversalis fascia"],
    ["Femoral", "Femoral canal, below inguinal ligament", "HIGH", "F>M; emergency often; Lockwood, Lotheissen, McEvedy repairs"],
    ["Umbilical", "Umbilicus", "Low", "Adults: acquired; common in obese, multiparous women"],
    ["Paraumbilical", "Near umbilicus", "Moderate", "True fascial defect; repair recommended"],
    ["Incisional", "Through previous scar", "Variable", "Mesh repair; high recurrence without mesh"],
]
story.append(make_table(hernia_data, [2.5*cm, 4*cm, 2.5*cm, 6.5*cm]))
story.append(section("Complications of Hernia"))
story.append(bullet("<b>Reducible:</b> Contents return to abdominal cavity"))
story.append(bullet("<b>Irreducible:</b> Contents cannot be reduced (incarcerated)"))
story.append(bullet("<b>Obstructed:</b> Bowel contents cannot pass – bowel obstruction present"))
story.append(bullet("<b>Strangulated:</b> Blood supply compromised → ischaemia/gangrene → emergency surgery"))
story.append(key_box("Femoral hernia: highest risk of strangulation of all hernias (higher than inguinal). Any femoral hernia should be repaired electively. If strangulated, McEvedy or Lotheissen approach."))

# ── TOPIC 24: UROLOGY ─────────────────────────────────────────────────────────
story += topic_title(24, "UROLOGY")
story.append(section("Urological Cancers"))
uro_data = [
    ["Cancer", "Type", "Marker", "Key Treatment"],
    ["Renal cell carcinoma", "Clear cell (80%)", "None specific; haematuria", "Radical nephrectomy; sunitinib for metastatic"],
    ["Transitional cell (urothelial)", "Urothelium of bladder/ureter", "Haematuria", "TURBT; BCG instillation; cystectomy"],
    ["Prostate", "Adenocarcinoma", "PSA; Gleason score", "Active surveillance, prostatectomy, RT, ADT"],
    ["Testicular", "Seminoma/NSGCT", "AFP, β-HCG, LDH", "Orchidectomy via inguinal approach; BEP chemo"],
]
story.append(make_table(uro_data, [3.5*cm, 3.5*cm, 3.5*cm, 5*cm]))
story.append(section("Urolithiasis"))
story.append(bullet("Calcium oxalate most common (70%); urate, struvite, cystine"))
story.append(bullet("Staghorn calculi = struvite; associated with Proteus (urease-producing)"))
story.append(bullet("Treatment: <5mm pass spontaneously; ESWL for <2cm kidney; URS/PCNL for larger"))
story.append(bullet("Emergency: urosepsis with obstruction = urgent nephrostomy or stent"))
story.append(section("BPH and Acute Urinary Retention"))
story.append(bullet("<b>AUR:</b> Painful inability to void; painful tender bladder; catheterise immediately"))
story.append(bullet("After TWOC failure or recurrent AUR: TURP (gold standard) or alpha-blockers (tamsulosin)"))
story.append(section("Testicular Torsion"))
story.append(bullet("Surgical emergency; highest risk age 12-18; sudden onset severe pain + high-riding testis"))
story.append(bullet("Explore within 4-6 hours (salvage rate >90%); bilateral orchidopexy even if one side viable"))
story.append(key_box("Haematuria = bladder cancer until proven otherwise. Any painless macroscopic haematuria in adults needs cystoscopy + upper tract imaging. Never attribute to UTI without investigation."))

# ── TOPIC 25: APPENDIX, RECTUM, ANAL CANAL ───────────────────────────────────
story += topic_title(25, "APPENDIX, RECTUM, ANAL CANAL")
story.append(section("Acute Appendicitis"))
story.append(bullet("<b>Alvarado Score (MANTRELS):</b> Migration of pain, Anorexia, Nausea, Tenderness RIF, Rebound, Elevated temp, Leukocytosis, Shift to left → Score ≥7 = appendicitis likely"))
story.append(bullet("Rovsing's sign: RIF pain on palpating LIF; Psoas sign; Obturator sign"))
story.append(bullet("Treatment: laparoscopic appendicectomy (preferred); antibiotic-only for uncomplicated (controversial)"))
story.append(bullet("Complications: perforation → peritonitis or appendix mass (conservative initially → interval appendicectomy)"))
story.append(section("Rectal Cancer"))
story.append(bullet("MRI is gold standard for local staging; assess CRM (circumferential resection margin)"))
story.append(bullet("Neoadjuvant long-course chemoRT if T3/T4 or N+ or threatened CRM"))
story.append(bullet("Surgery: anterior resection (sphincter-preserving) vs APER (abdominoperineal excision of rectum)"))
story.append(bullet("TME (Total Mesorectal Excision) is essential to reduce local recurrence"))
story.append(section("Anal Canal Conditions"))
story.append(bullet("<b>Haemorrhoids:</b> Dilated vascular cushions; classified I-IV; treatment: dietary → banding → haemorrhoidectomy"))
story.append(bullet("<b>Anal fissure:</b> Posterior midline (90%); spasm of internal sphincter; GTN cream/botox/lateral sphincterotomy"))
story.append(bullet("<b>Anorectal abscess:</b> Perianal, ischiorectal, intersphincteric, supralevator; incise and drain"))
story.append(bullet("<b>Fistula-in-ano:</b> Park's classification; Goodsall's rule; MRI for complex fistulas; seton for sphincter-involved"))
story.append(bullet("<b>Anal cancer:</b> SCC; HPV-16/18; treated with Nigro protocol (5-FU + mitomycin + RT) – not surgery"))
story.append(key_box("Goodsall's rule: fistulas with external opening anterior to transverse anal line open directly into anal canal; those posterior to this line follow a curved tract to posterior midline."))

# ── TOPIC 26: ETHICS AND AUDIT ────────────────────────────────────────────────
story += topic_title(26, "ETHICS AND AUDIT")
story.append(section("Four Principles of Medical Ethics (Beauchamp & Childress)"))
story.append(bullet("<b>Autonomy:</b> Respect patient's right to make informed decisions"))
story.append(bullet("<b>Beneficence:</b> Act in the patient's best interest"))
story.append(bullet("<b>Non-maleficence:</b> Do no harm ('primum non nocere')"))
story.append(bullet("<b>Justice:</b> Fair distribution of resources and equitable care"))
story.append(section("Informed Consent"))
story.append(bullet("Must be voluntary, informed and by a competent patient"))
story.append(bullet("Patient must understand: procedure, purpose, risks, alternatives, what happens if they decline"))
story.append(bullet("<b>Montgomery ruling (2015):</b> All material risks (those the patient would consider significant) must be disclosed"))
story.append(bullet("Incapacity: Mental Capacity Act (2005 UK) – best interests decision; Lasting Power of Attorney"))
story.append(section("Clinical Audit"))
story.append(bullet("<b>Audit cycle:</b> Set standards → collect data → compare to standards → implement change → re-audit"))
story.append(bullet("<b>Audit vs Research:</b> Audit measures current practice against standards; research generates new knowledge"))
story.append(bullet("Types: Criterion-based, re-audit, national audit (NCEPOD, NBOCAP, NBCA)"))
story.append(section("Clinical Governance"))
story.append(bullet("Framework through which NHS organisations are accountable for improving quality"))
story.append(bullet("Seven pillars: Clinical audit, Risk management, Education and training, Clinical effectiveness, Patient and public involvement, Staffing, Information management"))
story.append(key_box("NCEPOD (National Confidential Enquiry into Patient Outcome and Death) - key UK body for audit of surgical/anaesthetic mortality. Graded reports identify areas for improvement."))

# ── TOPIC 27: SALIVARY GLANDS ─────────────────────────────────────────────────
story += topic_title(27, "SALIVARY GLANDS")
story.append(section("Anatomy"))
story.append(bullet("<b>Parotid:</b> Largest; serous; Stensen's duct opens opposite upper 2nd molar; facial nerve runs through it"))
story.append(bullet("<b>Submandibular:</b> Mixed serous/mucous; Wharton's duct opens at sublingual papilla; lingual nerve + submandibular ganglion closely related"))
story.append(bullet("<b>Sublingual:</b> Smallest major gland; predominantly mucous; multiple ducts (ducts of Rivinus)"))
story.append(section("Salivary Gland Disorders"))
sg_data = [
    ["Condition", "Gland", "Features", "Treatment"],
    ["Sialolithiasis", "Submandibular (80%)", "Pain + swelling at meal times; palpable stone", "Conservative, duct dilatation, lithotripsy, excision"],
    ["Sialadenitis", "Parotid (post-op)", "Swelling, pain, trismus; dehydrated elderly post-op patients", "Hydration, antibiotics (flucloxacillin), massage"],
    ["Mumps", "Parotid", "Bilateral painful swelling; teenage/young adults", "Supportive; MMR vaccination"],
    ["Pleomorphic adenoma", "Parotid (85%)", "Slow-growing firm lump; commonest parotid tumour", "Superficial parotidectomy; risk of recurrence if ruptured"],
    ["Warthin's tumour", "Parotid", "Bilateral in 10%; smokers; 'hot' on Tc scan", "Excision"],
    ["Mucoepidermoid Ca", "Parotid", "Most common malignant parotid tumour", "Total parotidectomy + RT"],
]
story.append(make_table(sg_data, [3.5*cm, 2.5*cm, 5*cm, 4.5*cm]))
story.append(key_box("Pleomorphic adenoma = most common salivary gland tumour overall. Parotidectomy: superficial (lobe superficial to facial nerve) is standard; facial nerve monitoring used intraoperatively. FNAC before surgery."))

# ── TOPIC 28: POVD AND VENOUS DISORDERS ──────────────────────────────────────
story += topic_title(28, "POVD & VENOUS DISORDERS")
story.append(section("Peripheral Occlusive Vascular Disease (POVD) – Arterial"))
story.append(bullet("<b>Risk factors:</b> Smoking (strongest), DM, hypertension, hyperlipidaemia, age, male"))
story.append(bullet("<b>Fontaine classification:</b> I = asymptomatic; II = intermittent claudication; III = rest pain; IV = tissue loss (ulcer/gangrene)"))
story.append(bullet("<b>Investigations:</b> ABPI (ABI): normal ≥1.0, claudication 0.5-0.9, critical ischaemia <0.5, non-compressible >1.3 (calcified); Duplex USS; CT angiography"))
story.append(bullet("<b>Treatment:</b> Risk factor modification + antiplatelet (aspirin/clopidogrel) + statin + exercise; angioplasty/stenting; bypass surgery; amputation"))
story.append(section("Acute Limb Ischaemia"))
story.append(bullet("<b>6 Ps:</b> Pain, Pallor, Pulselessness, Paraesthesia, Paralysis (late), Perishing cold"))
story.append(bullet("Embolic (AF most common source) vs thrombotic (on background PVD)"))
story.append(bullet("Treatment: Embolectomy (Fogarty catheter); Thrombolysis (catheter-directed); Bypass; Amputation"))
story.append(bullet("Reperfusion injury: release of myoglobin → rhabdomyolysis → AKI; treat with aggressive hydration"))
story.append(section("Varicose Veins"))
story.append(bullet("Dilated, tortuous superficial veins; caused by incompetent venous valves (SFJ, SPJ)"))
story.append(bullet("Complications: varicose eczema, lipodermatosclerosis, venous ulcer, superficial thrombophlebitis, haemorrhage"))
story.append(bullet("Trendelenburg test: tourniquet at SFJ level – controls filling = SFJ incompetence"))
story.append(bullet("Treatment: EVLA (endovenous laser ablation), RFA, foam sclerotherapy, surgery (Trendelenburg + stripping)"))
story.append(section("Deep Vein Thrombosis (DVT) & Pulmonary Embolism (PE)"))
story.append(bullet("<b>Virchow's triad:</b> Stasis, Endothelial damage, Hypercoagulability"))
story.append(bullet("<b>Wells score:</b> Pre-test probability; <2 = low probability (D-dimer); ≥2 = USS"))
story.append(bullet("<b>Treatment:</b> LMWH → DOAC (rivaroxaban/apixaban preferred); 3 months for provoked, 6+ for unprovoked"))
story.append(bullet("<b>Massive PE:</b> Haemodynamic instability; thrombolysis (alteplase) if not contraindicated; embolectomy"))
story.append(section("Venous Ulcers"))
ulcer_comp = [
    ["Feature", "Venous", "Arterial", "Diabetic (neuropathic)"],
    ["Location", "Gaiter area (medial malleolus)", "Pressure points, toes, heel", "Pressure points, plantar"],
    ["Wound edge", "Sloping/irregular", "Punched out", "Punched out"],
    ["Pain", "Minimal (unless infected)", "Severe; worse at night/elevation", "Painless"],
    ["Skin", "Lipodermatosclerosis, eczema", "Pale, hairless, shiny, cold", "Warm, neuropathy signs"],
    ["ABPI", ">0.8", "<0.5", "May be >1.3 (calcified)"],
    ["Treatment", "Compression bandaging", "Revascularisation", "Offloading, debridement"],
]
story.append(make_table(ulcer_comp, [2.5*cm, 3.5*cm, 3.5*cm, 4*cm]))
story.append(key_box("Compression bandaging is CONTRAINDICATED if ABPI <0.8 (significant arterial disease). Always check ABPI before applying compression in venous ulcers."))

# ── FINAL PAGE ────────────────────────────────────────────────────────────────
story.append(PageBreak())
story.append(Spacer(1, 3*cm))
story.append(Paragraph("END OF STUDY GUIDE", title_style))
story.append(Spacer(1, 0.5*cm))
story.append(HRFlowable(width="60%", thickness=2, color=colors.HexColor('#2c6e9e'), hAlign='CENTER'))
story.append(Spacer(1, 1*cm))
story.append(Paragraph("All 28 topics covered | Bailey & Love's Short Practice of Surgery, 28th Edition", subtitle_style))
story.append(Paragraph("Good luck with your Surgery First Sessional Exam!", subtitle_style))

doc.build(story)
print(f"PDF generated: {OUTPUT}")