CNS Examination in Detail

#!/usr/bin/env python3
"""
CNS Examination Reference Card - Comprehensive PDF Generator
Based on Adams & Victor's Principles of Neurology 12th Ed and
Bradley & Daroff's Neurology in Clinical Practice
"""

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import mm, cm
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_RIGHT
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether, PageBreak
)
from reportlab.platypus.flowables import Flowable
from reportlab.pdfgen import canvas
from reportlab.lib.colors import HexColor
import os

OUTPUT_PATH = "/home/daytona/workspace/cns-reference-card/CNS_Examination_Reference_Card.pdf"

# ── Colour Palette ──────────────────────────────────────────────────────────
NAVY       = HexColor("#1A2E4A")
TEAL       = HexColor("#1E7B7B")
TEAL_LIGHT = HexColor("#E8F5F5")
BLUE_MID   = HexColor("#2D5F8A")
BLUE_LIGHT = HexColor("#EBF3FA")
AMBER      = HexColor("#D97706")
AMBER_LT   = HexColor("#FFF8E7")
RED_DK     = HexColor("#8B1A1A")
RED_LT     = HexColor("#FDF0F0")
GREEN_DK   = HexColor("#1A5C2E")
GREEN_LT   = HexColor("#EDF7F0")
GREY_BG    = HexColor("#F4F6F9")
GREY_RULE  = HexColor("#C8D4E0")
WHITE      = colors.white
BLACK      = colors.black
TEXT_DARK  = HexColor("#1C2B3A")


# ── Page Number Footer ───────────────────────────────────────────────────────
class NumberedCanvas(canvas.Canvas):
    def __init__(self, *args, **kwargs):
        super().__init__(*args, **kwargs)
        self._saved_page_states = []

    def showPage(self):
        self._saved_page_states.append(dict(self.__dict__))
        self._startPage()

    def save(self):
        num_pages = len(self._saved_page_states)
        for state in self._saved_page_states:
            self.__dict__.update(state)
            self.draw_page_number(num_pages)
            canvas.Canvas.showPage(self)
        canvas.Canvas.save(self)

    def draw_page_number(self, page_count):
        page_num = self._saved_page_states.index(dict(self.__dict__)) + 1
        self.saveState()
        self.setFont("Helvetica", 8)
        self.setFillColor(HexColor("#6B7C8F"))
        w, h = A4
        self.drawCentredString(w / 2, 12 * mm,
                               f"CNS Examination Reference Card  |  Page {page_num} of {page_count}  |  Based on Adams & Victor 12e · Bradley & Daroff")
        # footer rule
        self.setStrokeColor(GREY_RULE)
        self.setLineWidth(0.5)
        self.line(15 * mm, 16 * mm, w - 15 * mm, 16 * mm)
        self.restoreState()


# ── Styles ───────────────────────────────────────────────────────────────────
def make_styles():
    base = getSampleStyleSheet()

    styles = {}

    styles['cover_title'] = ParagraphStyle(
        'cover_title', fontName='Helvetica-Bold', fontSize=26,
        textColor=WHITE, alignment=TA_CENTER, spaceAfter=6, leading=32)

    styles['cover_sub'] = ParagraphStyle(
        'cover_sub', fontName='Helvetica', fontSize=13,
        textColor=HexColor("#B8D4E8"), alignment=TA_CENTER, spaceAfter=4)

    styles['cover_note'] = ParagraphStyle(
        'cover_note', fontName='Helvetica', fontSize=9,
        textColor=HexColor("#8AAFC8"), alignment=TA_CENTER)

    styles['section_header'] = ParagraphStyle(
        'section_header', fontName='Helvetica-Bold', fontSize=13,
        textColor=WHITE, alignment=TA_LEFT, leading=16)

    styles['sub_header'] = ParagraphStyle(
        'sub_header', fontName='Helvetica-Bold', fontSize=10,
        textColor=NAVY, spaceAfter=2, spaceBefore=4, leading=13)

    styles['body'] = ParagraphStyle(
        'body', fontName='Helvetica', fontSize=8.5,
        textColor=TEXT_DARK, spaceAfter=2, leading=12)

    styles['body_bold'] = ParagraphStyle(
        'body_bold', fontName='Helvetica-Bold', fontSize=8.5,
        textColor=TEXT_DARK, spaceAfter=2, leading=12)

    styles['bullet'] = ParagraphStyle(
        'bullet', fontName='Helvetica', fontSize=8.2,
        textColor=TEXT_DARK, leftIndent=10, firstLineIndent=-8,
        spaceAfter=1.5, leading=11.5,
        bulletText='•')

    styles['small'] = ParagraphStyle(
        'small', fontName='Helvetica', fontSize=7.5,
        textColor=HexColor("#4A5568"), leading=10)

    styles['cell_hdr'] = ParagraphStyle(
        'cell_hdr', fontName='Helvetica-Bold', fontSize=8,
        textColor=WHITE, alignment=TA_CENTER, leading=10)

    styles['cell_body'] = ParagraphStyle(
        'cell_body', fontName='Helvetica', fontSize=7.8,
        textColor=TEXT_DARK, alignment=TA_LEFT, leading=10.5)

    styles['cell_center'] = ParagraphStyle(
        'cell_center', fontName='Helvetica', fontSize=7.8,
        textColor=TEXT_DARK, alignment=TA_CENTER, leading=10.5)

    styles['warning'] = ParagraphStyle(
        'warning', fontName='Helvetica-Bold', fontSize=8.5,
        textColor=RED_DK, leading=12)

    styles['clinical_pearl'] = ParagraphStyle(
        'clinical_pearl', fontName='Helvetica', fontSize=8.2,
        textColor=GREEN_DK, leading=12, leftIndent=8)

    styles['table_title'] = ParagraphStyle(
        'table_title', fontName='Helvetica-Bold', fontSize=9,
        textColor=NAVY, spaceAfter=2, spaceBefore=6)

    return styles


S = make_styles()
W, H = A4
MARGIN = 15 * mm
CONTENT_W = W - 2 * MARGIN


# ── Helper Flowables ─────────────────────────────────────────────────────────
def section_banner(text, color=NAVY, icon=""):
    """Full-width coloured section banner."""
    label = f"{icon}  {text}" if icon else text
    p = Paragraph(label, S['section_header'])
    t = Table([[p]], colWidths=[CONTENT_W],
              rowHeights=[None])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0, 0), (-1, -1), color),
        ('TOPPADDING',    (0, 0), (-1, -1), 5),
        ('BOTTOMPADDING', (0, 0), (-1, -1), 5),
        ('LEFTPADDING',   (0, 0), (-1, -1), 8),
        ('RIGHTPADDING',  (0, 0), (-1, -1), 8),
        ('ROUNDEDCORNERS', [4, 4, 4, 4]),
    ]))
    return t


def shaded_box(content_flowables, bg=BLUE_LIGHT, border=BLUE_MID, radius=4):
    """Wrap flowables in a shaded rounded box."""
    inner = Table([[f] for f in content_flowables],
                  colWidths=[CONTENT_W - 14])
    t = Table([[inner]], colWidths=[CONTENT_W])
    t.setStyle(TableStyle([
        ('BACKGROUND',   (0, 0), (-1, -1), bg),
        ('BOX',          (0, 0), (-1, -1), 0.8, border),
        ('TOPPADDING',    (0, 0), (-1, -1), 6),
        ('BOTTOMPADDING', (0, 0), (-1, -1), 6),
        ('LEFTPADDING',   (0, 0), (-1, -1), 7),
        ('RIGHTPADDING',  (0, 0), (-1, -1), 7),
    ]))
    return t


def two_col(left_items, right_items, left_w_frac=0.5):
    """Two-column layout. Each arg is a list of flowables."""
    lw = CONTENT_W * left_w_frac - 3 * mm
    rw = CONTENT_W * (1 - left_w_frac) - 3 * mm
    left_col  = Table([[f] for f in left_items],  colWidths=[lw])
    right_col = Table([[f] for f in right_items], colWidths=[rw])
    t = Table([[left_col, right_col]], colWidths=[lw + 3 * mm, rw + 3 * mm])
    t.setStyle(TableStyle([
        ('VALIGN',        (0, 0), (-1, -1), 'TOP'),
        ('LEFTPADDING',   (0, 0), (-1, -1), 0),
        ('RIGHTPADDING',  (0, 0), (-1, -1), 0),
        ('TOPPADDING',    (0, 0), (-1, -1), 0),
        ('BOTTOMPADDING', (0, 0), (-1, -1), 0),
    ]))
    return t


def standard_table(headers, rows, col_widths=None, hdr_color=NAVY):
    """Styled data table with coloured header row."""
    hdr_cells = [Paragraph(h, S['cell_hdr']) for h in headers]
    data = [hdr_cells]
    for r in rows:
        data.append([Paragraph(str(c), S['cell_body']) for c in r])

    if col_widths is None:
        col_widths = [CONTENT_W / len(headers)] * len(headers)

    t = Table(data, colWidths=col_widths, repeatRows=1)
    style = [
        ('BACKGROUND',   (0, 0), (-1, 0),  hdr_color),
        ('TEXTCOLOR',    (0, 0), (-1, 0),  WHITE),
        ('ROWBACKGROUNDS', (0, 1), (-1, -1), [WHITE, GREY_BG]),
        ('GRID',         (0, 0), (-1, -1), 0.4, GREY_RULE),
        ('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'),
    ]
    t.setStyle(TableStyle(style))
    return t


def pearl(text):
    return shaded_box(
        [Paragraph(f"<b>Clinical Pearl:</b> {text}", S['clinical_pearl'])],
        bg=GREEN_LT, border=GREEN_DK)


def alert_box(text):
    return shaded_box(
        [Paragraph(f"<b>Important:</b> {text}", S['warning'])],
        bg=RED_LT, border=RED_DK)


def sp(h=4):
    return Spacer(1, h * mm)


# ── Cover Page ───────────────────────────────────────────────────────────────
class CoverPage(Flowable):
    def __init__(self):
        super().__init__()
        self.width = CONTENT_W
        self.height = H - 2 * MARGIN

    def draw(self):
        c = self.canv
        w, h = self.width, self.height

        # Background gradient-like blocks
        c.setFillColor(NAVY)
        c.roundRect(0, h - 120 * mm, w, 120 * mm, 8, fill=1, stroke=0)

        c.setFillColor(TEAL)
        c.roundRect(0, h - 130 * mm, w, 18 * mm, 4, fill=1, stroke=0)

        # Title
        c.setFillColor(WHITE)
        c.setFont("Helvetica-Bold", 30)
        c.drawCentredString(w / 2, h - 38 * mm, "CNS EXAMINATION")
        c.setFont("Helvetica-Bold", 22)
        c.drawCentredString(w / 2, h - 52 * mm, "REFERENCE CARD")

        c.setFillColor(HexColor("#B8D4E8"))
        c.setFont("Helvetica", 12)
        c.drawCentredString(w / 2, h - 68 * mm, "Comprehensive Neurological Examination Guide")
        c.drawCentredString(w / 2, h - 78 * mm, "for MD Internal Medicine")

        # Teal stripe text
        c.setFillColor(WHITE)
        c.setFont("Helvetica-Bold", 9)
        c.drawCentredString(w / 2, h - 124 * mm,
            "Adams & Victor 12e  ·  Bradley & Daroff  ·  Harrison's 22e")

        # Section index boxes
        sections = [
            ("I", "Mental Status"),
            ("II", "Cranial Nerves"),
            ("III", "Motor System"),
            ("IV", "Reflexes"),
            ("V", "Sensory"),
            ("VI", "Gait & Station"),
            ("VII", "Special Signs"),
            ("VIII", "Quick Screens"),
        ]
        box_w = (w - 10 * mm) / 4
        box_h = 22 * mm
        start_y = h - 175 * mm
        for i, (num, name) in enumerate(sections):
            col = i % 4
            row = i // 4
            x = col * (box_w + 2 * mm)
            y = start_y - row * (box_h + 3 * mm)
            # box
            c.setFillColor(BLUE_MID if row == 0 else TEAL)
            c.roundRect(x, y, box_w, box_h, 5, fill=1, stroke=0)
            c.setFillColor(WHITE)
            c.setFont("Helvetica-Bold", 16)
            c.drawCentredString(x + box_w / 2, y + 11 * mm, num)
            c.setFont("Helvetica", 8)
            c.drawCentredString(x + box_w / 2, y + 4 * mm, name)

        # Bottom note
        c.setFillColor(GREY_RULE)
        c.setFont("Helvetica", 8)
        c.drawCentredString(w / 2, 8 * mm,
            "For educational and clinical reference. Always apply clinical judgment.")


# ── Content Builders ─────────────────────────────────────────────────────────

def build_mental_status():
    elems = []
    elems.append(section_banner("I. MENTAL STATUS EXAMINATION", NAVY))
    elems.append(sp(3))

    # Consciousness
    elems.append(Paragraph("A. Level of Consciousness", S['sub_header']))
    cons_rows = [
        ["Alert",     "Fully awake, responds normally"],
        ["Drowsy",    "Arousable by verbal stimuli; may drift off"],
        ["Stuporous", "Arousable only by vigorous/painful stimuli; minimal verbal"],
        ["Comatose",  "Unarousable; no purposeful response to stimuli"],
    ]
    elems.append(standard_table(["State", "Description"],
                                cons_rows,
                                [40*mm, CONTENT_W - 40*mm],
                                hdr_color=BLUE_MID))
    elems.append(sp(3))

    # Attention & Orientation
    elems.append(Paragraph("B. Attention Tests", S['sub_header']))
    att_rows = [
        ["Digit Span", "Forward: read digits 1/sec, patient repeats. Normal = 7 ± 2 digits\nBackward: Normal ≥ 5"],
        ["Serial Subtraction", "Subtract 7s from 100 (100, 93, 86…) or 3s from 20"],
        ['"A" Vigilance', "Tap on hearing letter A in random letter sequence read aloud"],
        ["Palm-Side-Fist", "Repeat three-step motor sequence — tests frontal function"],
        ["Spelling Reverse", "Spell WORLD backwards (D-L-R-O-W)"],
    ]
    elems.append(standard_table(["Test", "Method / Normal"],
                                att_rows,
                                [38*mm, CONTENT_W - 38*mm],
                                hdr_color=BLUE_MID))
    elems.append(sp(3))

    # Orientation
    elems.append(Paragraph("C. Orientation (Time · Place · Person)", S['sub_header']))
    elems.append(shaded_box([
        Paragraph("<b>Time:</b> Date (off >3 days = significant), day, month, year, time (off >4 hours = significant)", S['body']),
        Paragraph("<b>Place:</b> Name of hospital/clinic, type of place, city, country", S['body']),
        Paragraph("<b>Person:</b> Own name (lost only in very severe dementia)", S['body']),
    ], bg=BLUE_LIGHT, border=BLUE_MID))
    elems.append(sp(3))

    # Memory
    elems.append(Paragraph("D. Memory", S['sub_header']))
    mem_rows = [
        ["Immediate recall", "Repeat 3 words immediately after hearing them"],
        ["Short-term / Recent", "Recall 3 words after 5 minutes (note number recalled)"],
        ["Remote memory", "Historical facts (PM of India, last Olympics)"],
        ["Episodic memory", "Recall of specific dated personal events"],
        ["Anterograde", "Learning new information after an event"],
        ["Retrograde", "Recall of information before an event"],
    ]
    elems.append(standard_table(["Type", "Test"], mem_rows,
                                [45*mm, CONTENT_W - 45*mm], TEAL))
    elems.append(sp(3))

    # Language
    elems.append(Paragraph("E. Language (test if aphasia suspected)", S['sub_header']))
    lang_rows = [
        ["Spontaneous speech", "Fluency, content, word-finding pauses, paraphrasias"],
        ["Comprehension", "'Point to the window'; execute one/two/three-step commands"],
        ["Repetition", "Repeat 'No ifs, ands, or buts'"],
        ["Naming", "Name objects and parts of objects (pen cap, watch strap)"],
        ["Reading", "Aloud and for comprehension"],
        ["Writing", "Spontaneous sentence and to dictation"],
    ]
    elems.append(standard_table(["Component", "Method"], lang_rows,
                                [42*mm, CONTENT_W - 42*mm], TEAL))
    elems.append(sp(2))
    elems.append(pearl("Distinguish language of confusion (inattentive, intrusions, perseverations) from true aphasia (consistent breakdown in one or more language modalities)."))
    elems.append(sp(3))

    # Higher cortical
    elems.append(Paragraph("F. Higher Cortical Functions", S['sub_header']))

    left = [
        Paragraph("<b>Praxis</b>", S['body_bold']),
        Paragraph("• Hammer a nail (ideomotor)", S['bullet']),
        Paragraph("• Blow out a candle", S['bullet']),
        Paragraph("• Fist-edge-palm sequence (Luria)", S['bullet']),
        Paragraph("• Dressing apraxia (observe while dressing)", S['bullet']),
        sp(3),
        Paragraph("<b>Executive / Frontal</b>", S['body_bold']),
        Paragraph("• Abstract reasoning: interpret proverbs", S['bullet']),
        Paragraph("• Similarities: apple vs orange", S['bullet']),
        Paragraph("• Go/No-Go task", S['bullet']),
        Paragraph("• Alternate sequence drawing", S['bullet']),
        Paragraph("• Insight and judgment", S['bullet']),
    ]
    right = [
        Paragraph("<b>Visuospatial / Gnosis</b>", S['body_bold']),
        Paragraph("• Clock drawing (set to 10 past 11)", S['bullet']),
        Paragraph("• Line bisection (neglect = off-centre)", S['bullet']),
        Paragraph("• Copy intersecting pentagons, cube", S['bullet']),
        Paragraph("• Stereognosis: identify object by touch", S['bullet']),
        Paragraph("• Graphesthesia: number written on palm", S['bullet']),
        Paragraph("• Two-point discrimination (fingertip: 2–5 mm)", S['bullet']),
        sp(3),
        Paragraph("<b>Primitive Reflexes (frontal release)</b>", S['body_bold']),
        Paragraph("• Grasp reflex (frontal lesion)", S['bullet']),
        Paragraph("• Palmomental (scratch thenar → ipsilateral chin)", S['bullet']),
        Paragraph("• Snout reflex (bilateral frontal disease)", S['bullet']),
        Paragraph("• Glabellar tap: no habituation = Parkinson's", S['bullet']),
    ]
    elems.append(two_col(left, right))
    elems.append(sp(2))
    return elems


def build_cranial_nerves():
    elems = []
    elems.append(section_banner("II. CRANIAL NERVE EXAMINATION", TEAL))
    elems.append(sp(3))

    cn_rows = [
        ["CN I\nOlfactory",
         "Each nostril separately with familiar odors (coffee, vanilla, clove)",
         "Anosmia → frontal mass, Parkinson's, head trauma",
         "Test when: head trauma, suspected PD, anosmia"],
        ["CN II\nOptic",
         "Visual acuity (Snellen/Rosenbaum); confrontation fields; fundoscopy; colour vision (Ishihara)",
         "Reduced acuity → lens, optic nerve; Field defects → chiasm/tract/cortex",
         "RAPD = optic nerve or severe retinal disease"],
        ["CN III\nOculomotor",
         "Pupil size, shape, direct + consensual light reflex; near reflex; eyelid position",
         "Complete CN III palsy: ptosis + dilated pupil + eye 'down and out'",
         "Pupil-involving = surgical CN III until proven otherwise"],
        ["CN III, IV, VI\nEye Movements",
         "H-pattern pursuit; saccades; VOR (doll's head); nystagmus direction",
         "Diplopia on gaze → specific nerve palsy; INO → MLF lesion",
         "Fast phase of nystagmus defines direction"],
        ["CN V\nTrigeminal",
         "Pinprick + light touch: V1/V2/V3 bilaterally; corneal reflex; jaw strength + jaw jerk",
         "Reduced corneal reflex: CN V1 or VII; Jaw deviates to weak side",
         "Jaw jerk brisk = UMN above pons"],
        ["CN VII\nFacial",
         "Raise brows, close eyes tight, smile to command, puff cheeks, show teeth",
         "UMN: forehead spared (bilateral cortical supply); LMN: entire hemiface",
         "Hyperacusis = stapedius branch involvement"],
        ["CN VIII\nVestibulocochlear",
         "Whisper test; Rinne (512 Hz fork): AC vs BC; Weber (midline forehead)",
         "Rinne −ve = conductive; Weber → worse ear (conductive) / better ear (SNHL)",
         "Romberg test; Dix-Hallpike for BPPV"],
        ["CN IX, X\nGlossopharyngeal\nVagus",
         "'Aah' — palate elevation + symmetry; gag reflex; swallowing; voice quality",
         "Palate deviates to normal side (unilateral X palsy)",
         "Hoarse/bovine cough = recurrent laryngeal n."],
        ["CN XI\nAccessory",
         "SCM: head turn against resistance; Trapezius: shoulder shrug against resistance",
         "Ipsilateral weakness; SCM turns head to opposite side",
         ""],
        ["CN XII\nHypoglossal",
         "Tongue at rest (fasciculations, atrophy); protrusion; rapid movements 'La-la-la'",
         "LMN: deviates to side of lesion; UMN: deviates away",
         "Fasciculations + wasting = LMN / MND"],
    ]

    elems.append(Paragraph("Summary Table", S['table_title']))
    t = Table(
        [[Paragraph(h, S['cell_hdr']) for h in ["Nerve", "Test Method", "Key Finding / Localisation", "Notes"]]]+
        [[Paragraph(str(r[i]), S['cell_body']) for i in range(4)] for r in cn_rows],
        colWidths=[28*mm, 54*mm, 60*mm, 38*mm],
        repeatRows=1
    )
    t.setStyle(TableStyle([
        ('BACKGROUND',    (0, 0), (-1, 0),  TEAL),
        ('TEXTCOLOR',     (0, 0), (-1, 0),  WHITE),
        ('ROWBACKGROUNDS',(0, 1), (-1, -1), [WHITE, TEAL_LIGHT]),
        ('GRID',          (0, 0), (-1, -1), 0.4, GREY_RULE),
        ('TOPPADDING',     (0, 0), (-1, -1), 3),
        ('BOTTOMPADDING',  (0, 0), (-1, -1), 3),
        ('LEFTPADDING',    (0, 0), (-1, -1), 4),
        ('RIGHTPADDING',   (0, 0), (-1, -1), 4),
        ('VALIGN',        (0, 0), (-1, -1), 'TOP'),
    ]))
    elems.append(t)
    elems.append(sp(3))

    elems.append(Paragraph("Swinging Flashlight Test (RAPD)", S['sub_header']))
    elems.append(shaded_box([
        Paragraph("Alternate the light between eyes every 3 seconds. Normally both pupils constrict equally.", S['body']),
        Paragraph("RAPD (+): When light swings to affected eye → that pupil dilates (paradoxical dilatation) = afferent defect (optic nerve disease or severe retinal lesion).", S['body']),
    ], bg=AMBER_LT, border=AMBER))
    elems.append(sp(3))

    elems.append(Paragraph("Rinne and Weber Test Interpretation", S['sub_header']))
    rw_rows = [
        ["Normal", "AC > BC (Rinne +ve)", "No lateralisation"],
        ["Conductive loss", "BC > AC (Rinne −ve) ipsilateral ear", "Lateralises to WORSE (deaf) ear"],
        ["Sensorineural loss (SNHL)", "AC > BC (Rinne +ve, but both reduced)", "Lateralises to BETTER ear"],
    ]
    elems.append(standard_table(
        ["Condition", "Rinne Result", "Weber Result"],
        rw_rows,
        [48*mm, 65*mm, 67*mm],
        TEAL
    ))
    elems.append(sp(2))
    return elems


def build_motor():
    elems = []
    elems.append(section_banner("III. MOTOR SYSTEM EXAMINATION", BLUE_MID))
    elems.append(sp(3))

    # Inspection & Tone side by side
    left = [
        Paragraph("A. Inspection", S['sub_header']),
        Paragraph("• Muscle bulk: wasting (LMN/disuse/myopathy), hypertrophy", S['bullet']),
        Paragraph("• Fasciculations: spontaneous twitching at rest (LMN/AHC)", S['bullet']),
        Paragraph("• Abnormal movements: tremor, chorea, dystonia, myoclonus, tics", S['bullet']),
        Paragraph("• Posture: external hip rotation (UMN), hemiplegic posture", S['bullet']),
        Paragraph("• Atrophy pattern: global vs focal vs dermatomal", S['bullet']),
    ]
    right = [
        Paragraph("B. Tone (passive movement)", S['sub_header']),
        Paragraph("• <b>Hypotonia:</b> LMN, cerebellar, acute shock, chorea", S['bullet']),
        Paragraph("• <b>Spasticity:</b> velocity-dependent (UMN); clasp-knife; flexors > extensors in arms", S['bullet']),
        Paragraph("• <b>Rigidity:</b> lead-pipe (extrapyramidal); cogwheel (PD — enhanced by Froment's)", S['bullet']),
        Paragraph("• <b>Gegenhalten:</b> mirrors examiner's pressure (frontal lobe)", S['bullet']),
        Paragraph("• <b>Clonus:</b> >5 beats = pathological (brisk at ankle); UMN lesion", S['bullet']),
    ]
    elems.append(two_col(left, right))
    elems.append(sp(3))

    # MRC scale
    elems.append(Paragraph("C. MRC Power Grading Scale", S['sub_header']))
    mrc_rows = [
        ["0", "No contraction visible or palpable"],
        ["1", "Flicker/trace of contraction; no joint movement"],
        ["2", "Full range of movement with gravity eliminated (horizontal plane)"],
        ["3", "Movement against gravity but not against examiner's resistance"],
        ["4−/4/4+", "Movement against mild / moderate / strong resistance"],
        ["5", "Normal power against full resistance"],
    ]
    elems.append(standard_table(["Grade", "Description"], mrc_rows,
                                [20*mm, CONTENT_W - 20*mm], BLUE_MID))
    elems.append(sp(3))

    # Muscle testing
    elems.append(Paragraph("D. Key Muscle Testing (Root & Nerve)", S['sub_header']))

    ul_rows = [
        ["Shoulder abduction",    "C5",   "Deltoid",          "Axillary nerve"],
        ["Elbow flexion",         "C5-6", "Biceps",           "Musculocutaneous"],
        ["Elbow extension",       "C7",   "Triceps",          "Radial nerve"],
        ["Wrist extension",       "C6-7", "Ext. carpi rad.",  "Radial nerve"],
        ["Wrist flexion",         "C6-7", "Flex. carpi rad.", "Median nerve"],
        ["Finger extension",      "C7",   "Ext. digitorum",   "Posterior interosseous"],
        ["Finger flexion (DIP)",  "C8",   "FDP",              "Median/Ulnar"],
        ["Finger abduction",      "T1",   "Dorsal interossei","Ulnar nerve"],
        ["Thumb opposition",      "C8-T1","Abductor poll. br.","Median nerve (recurrent br.)"],
    ]
    ll_rows = [
        ["Hip flexion",           "L1-2", "Iliopsoas",        "Femoral/lumbar plexus"],
        ["Hip extension",         "L5-S1","Glut. maximus",    "Inferior gluteal"],
        ["Hip abduction",         "L4-5", "Glut. medius",     "Superior gluteal"],
        ["Knee extension",        "L3-4", "Quadriceps",       "Femoral nerve"],
        ["Knee flexion",          "L5-S1","Hamstrings",       "Sciatic nerve"],
        ["Ankle dorsiflexion",    "L4-5", "Tibialis anterior","Deep peroneal"],
        ["Ankle plantarflexion",  "S1-2", "Gastrocnemius",    "Tibial nerve"],
        ["Hallux extension",      "L5",   "EHL",              "Deep peroneal"],
        ["Toe flexion",           "S1-2", "FHL/FDL",          "Tibial nerve"],
    ]

    col_w = [(CONTENT_W - 4*mm) / 2 - 1*mm] * 2

    ul_t = Table(
        [[Paragraph(h, S['cell_hdr']) for h in ["Movement", "Root", "Muscle", "Nerve"]]]+
        [[Paragraph(r[i], S['cell_body']) for i in range(4)] for r in ul_rows],
        colWidths=[40*mm, 12*mm, 35*mm, 40*mm],
        repeatRows=1
    )
    ul_t.setStyle(TableStyle([
        ('BACKGROUND',    (0,0),(-1,0), BLUE_MID),
        ('TEXTCOLOR',     (0,0),(-1,0), WHITE),
        ('ROWBACKGROUNDS',(0,1),(-1,-1),[WHITE, BLUE_LIGHT]),
        ('GRID',          (0,0),(-1,-1), 0.4, GREY_RULE),
        ('TOPPADDING',    (0,0),(-1,-1), 2), ('BOTTOMPADDING',(0,0),(-1,-1),2),
        ('LEFTPADDING',   (0,0),(-1,-1), 3), ('RIGHTPADDING', (0,0),(-1,-1),3),
        ('FONTSIZE',      (0,1),(-1,-1), 7.5),
    ]))

    ll_t = Table(
        [[Paragraph(h, S['cell_hdr']) for h in ["Movement", "Root", "Muscle", "Nerve"]]]+
        [[Paragraph(r[i], S['cell_body']) for i in range(4)] for r in ll_rows],
        colWidths=[40*mm, 12*mm, 35*mm, 40*mm],
        repeatRows=1
    )
    ll_t.setStyle(TableStyle([
        ('BACKGROUND',    (0,0),(-1,0), TEAL),
        ('TEXTCOLOR',     (0,0),(-1,0), WHITE),
        ('ROWBACKGROUNDS',(0,1),(-1,-1),[WHITE, TEAL_LIGHT]),
        ('GRID',          (0,0),(-1,-1), 0.4, GREY_RULE),
        ('TOPPADDING',    (0,0),(-1,-1), 2), ('BOTTOMPADDING',(0,0),(-1,-1),2),
        ('LEFTPADDING',   (0,0),(-1,-1), 3), ('RIGHTPADDING', (0,0),(-1,-1),3),
        ('FONTSIZE',      (0,1),(-1,-1), 7.5),
    ]))

    elems.append(Paragraph("Upper Limb", S['body_bold']))
    elems.append(ul_t)
    elems.append(sp(2))
    elems.append(Paragraph("Lower Limb", S['body_bold']))
    elems.append(ll_t)
    elems.append(sp(3))

    # Screening manoeuvres
    elems.append(Paragraph("E. Quick Screening Manoeuvres", S['sub_header']))
    sm_rows = [
        ["Pronator Drift", "Arms outstretched, palms up, eyes closed ×10 sec; pronation/downward drift = UMN; upward drift = sensory ataxia"],
        ["Barre's Sign (legs)", "Patient prone, knees flexed 90°; weak leg drifts down = UMN"],
        ["Heel-walking", "Tests L4-5 (tibialis anterior); foot drop = cannot heel-walk"],
        ["Toe-walking", "Tests S1 (gastrocnemius); S1 lesion = cannot toe-walk"],
        ["Rise from floor", "Without hand support; tests proximal muscle power (hip extensors, quadriceps)"],
        ["Arm 'orbiting'", "Asymmetric orbiting of one forearm around the other = subtle contralateral UMN weakness"],
    ]
    elems.append(standard_table(["Manoeuvre", "Interpretation"], sm_rows,
                                [40*mm, CONTENT_W - 40*mm], BLUE_MID))
    elems.append(sp(3))

    # Coordination
    elems.append(Paragraph("F. Coordination (Cerebellar Function)", S['sub_header']))
    coord_left = [
        Paragraph("<b>Upper Limb Tests</b>", S['body_bold']),
        Paragraph("• Finger-nose-finger: intention tremor, dysmetria, past-pointing", S['bullet']),
        Paragraph("• Rapid alternating movements (dysdiadochokinesia): alternating pronation/supination", S['bullet']),
        Paragraph("• Rapid finger-thumb tapping", S['bullet']),
        Paragraph("• Rebound test: delayed check / overshoot on sudden release", S['bullet']),
    ]
    coord_right = [
        Paragraph("<b>Lower Limb + Truncal</b>", S['body_bold']),
        Paragraph("• Heel-shin test: run heel down front of shin smoothly", S['bullet']),
        Paragraph("• Foot tapping on examiner's hand", S['bullet']),
        Paragraph("• Truncal ataxia: inability to sit upright unsupported (vermis lesion)", S['bullet']),
        Paragraph("• Romberg — eyes open sway = cerebellar (not Romberg positive)", S['bullet']),
    ]
    elems.append(two_col(coord_left, coord_right))
    elems.append(sp(2))
    elems.append(pearl("DANISH mnemonic for cerebellar signs: Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Scanning speech, Hypotonia/Heel-shin impairment"))
    elems.append(sp(2))
    return elems


def build_reflexes():
    elems = []
    elems.append(section_banner("IV. REFLEXES", NAVY))
    elems.append(sp(3))

    # DTRs
    elems.append(Paragraph("A. Deep Tendon Reflexes (Muscle Stretch Reflexes)", S['sub_header']))
    dtr_rows = [
        ["Biceps",         "Biceps tendon (antecubital fossa)",    "C5–C6", "Elbow flexion"],
        ["Supinator (BR)", "Radial styloid process",               "C5–C6", "Forearm supination + flexion"],
        ["Triceps",        "Triceps tendon (above olecranon)",      "C7–C8", "Elbow extension"],
        ["Finger flexion", "Examiner's fingers over patient's DIP", "C8–T1","Finger flexion (Hoffman equivalent)"],
        ["Patellar",       "Patellar tendon (just below patella)",  "L3–L4", "Knee extension"],
        ["Achilles",       "Achilles tendon",                       "S1–S2", "Plantarflexion"],
    ]
    elems.append(standard_table(
        ["Reflex", "Stimulus Site", "Root", "Response"],
        dtr_rows,
        [32*mm, 55*mm, 18*mm, CONTENT_W - 105*mm], NAVY))
    elems.append(sp(3))

    # Grading
    elems.append(Paragraph("B. DTR Grading", S['sub_header']))
    grade_rows = [
        ["0",   "Absent (even with reinforcement)"],
        ["1+",  "Present only with Jendrassik reinforcement; hypoactive"],
        ["2+",  "Normal"],
        ["3+",  "Brisk; may spread to adjacent muscles; may be normal in anxious patient"],
        ["4+",  "Very brisk; clonus present; pathological — UMN lesion"],
    ]
    elems.append(standard_table(["Grade", "Description"], grade_rows,
                                [20*mm, CONTENT_W - 20*mm], BLUE_MID))
    elems.append(sp(2))
    elems.append(shaded_box([
        Paragraph("<b>Jendrassik Manoeuvre:</b> Patient hooks interlocked fingers and pulls outward simultaneously as examiner taps lower limb reflexes. Reinforces barely obtainable reflexes by increasing gamma motor neuron activity.", S['body']),
    ], bg=AMBER_LT, border=AMBER))
    elems.append(sp(3))

    # Plantar response
    elems.append(Paragraph("C. Plantar Response (Babinski Sign)", S['sub_header']))
    elems.append(shaded_box([
        Paragraph("<b>Technique:</b> Stroke the lateral sole firmly from heel toward the ball and across to the base of the big toe using a blunt instrument (orange stick).", S['body']),
        Paragraph("<b>Flexor response (Normal):</b> Plantarflexion of all toes.", S['body']),
        Paragraph("<b>Extensor response (Babinski +ve):</b> Dorsiflexion of big toe ± fanning of other toes = corticospinal tract damage (UMN).", S['warning']),
        Paragraph("<b>Withdrawal:</b> Quick whole-foot withdrawal — not Babinski; no pathological significance.", S['body']),
        Paragraph("<b>Triple flexion:</b> Hip + knee flexion + foot dorsiflexion — same significance as Babinski; severe spinal lesion.", S['body']),
    ], bg=RED_LT, border=RED_DK))
    elems.append(sp(3))

    # Equivalent signs
    elems.append(Paragraph("D. Babinski Equivalent Signs", S['sub_header']))
    bab_rows = [
        ["Oppenheim",  "Knuckle pressed firmly down shin", "Extensor toe response"],
        ["Gordon",     "Squeeze the calf muscle",          "Extensor toe response"],
        ["Chaddock",   "Stroke lateral dorsum of foot from lateral malleolus forward", "Extensor toe response"],
        ["Bing",       "Prick dorsum of foot with pin",    "Extensor toe response"],
        ["Gonda",      "Flick or extend fourth toe down then release", "Extensor toe response"],
    ]
    elems.append(standard_table(
        ["Sign", "Technique", "Response"],
        bab_rows,
        [28*mm, 95*mm, CONTENT_W - 123*mm], TEAL))
    elems.append(sp(3))

    # Superficial reflexes
    elems.append(Paragraph("E. Superficial Reflexes", S['sub_header']))
    sup_rows = [
        ["Abdominal", "Stroke skin lateral → midline in each quadrant", "T7-12",
         "Absent ipsilateral to pyramidal lesion; absent bilaterally (obese, multiparous)"],
        ["Cremasteric", "Stroke inner thigh", "L1-2",
         "Loss: UMN lesion, ipsilateral cord/root lesion"],
        ["Anal", "Perianal skin scratch", "S3-5",
         "Sphincter contracts; Loss = sacral/conus/LMN"],
        ["Bulbocavernosus", "Squeeze glans penis / tap pubic symphysis", "S3-4",
         "Bulbocavernosus contraction; Loss = sacral cord/conus"],
    ]
    elems.append(standard_table(
        ["Reflex", "Stimulus", "Segment", "Significance"],
        sup_rows,
        [30*mm, 45*mm, 22*mm, CONTENT_W - 97*mm], NAVY))
    elems.append(sp(2))
    return elems


def build_sensory():
    elems = []
    elems.append(section_banner("V. SENSORY EXAMINATION", TEAL))
    elems.append(sp(3))

    elems.append(shaded_box([
        Paragraph("Require full patient cooperation. Test one side against the other. Move from area of reduced sensation outward to normal. Start distally for vibration and JPS.", S['body']),
    ], bg=AMBER_LT, border=AMBER))
    elems.append(sp(3))

    # Primary modalities
    elems.append(Paragraph("A. Primary Sensory Modalities", S['sub_header']))
    prim_rows = [
        ["Pain (nociception)", "Spinothalamic tract (contralateral)",
         "Fresh disposable pin; sharp vs dull; compare both sides",
         "Use fresh pin; do not draw blood"],
        ["Temperature", "Spinothalamic tract (contralateral)",
         "Cold metal tuning fork or cold/warm test tubes",
         "Cold: 5°C; Warm: 40°C"],
        ["Vibration", "Posterior column (ipsilateral)",
         "128 Hz tuning fork on bony prominences: toes → medial malleolus → tibial crest → ASIS → fingers → wrist → elbow",
         "Ask: 'Is it buzzing or still?'; move proximally until felt"],
        ["Joint Position Sense (JPS)", "Posterior column (ipsilateral)",
         "Hold distal phalanx laterally; move up/down; patient says 'up' or 'down'; start distally",
         "Normal: detect 1–2° movements of DIP/MTP"],
        ["Light touch", "Post. column + spinothalamic",
         "Wisp of cotton wool; compare both sides symmetrically",
         "Not dermatomal 'dragging'"],
    ]
    elems.append(standard_table(
        ["Modality", "Pathway", "Test Method", "Notes"],
        prim_rows,
        [32*mm, 40*mm, 65*mm, CONTENT_W - 137*mm], TEAL))
    elems.append(sp(3))

    # Cortical sensory
    elems.append(Paragraph("B. Cortical Sensory Modalities (require intact primary sensation)", S['sub_header']))
    cort_rows = [
        ["Stereognosis", "Identify common objects (key, coin, pen) placed in hand without looking", "Parietal lobe"],
        ["Graphesthesia", "Identify numbers / letters written on palm", "Parietal lobe"],
        ["Two-point discrimination", "Min. distance for 2 distinct stimuli; fingertip normal = 2–5 mm", "Parietal lobe"],
        ["Sensory extinction", "Touch both sides simultaneously; patient reports only one side = extinction/neglect", "Contralateral parietal (often non-dominant)"],
        ["Point localisation", "Patient points (eyes closed) to where examiner touched", "Parietal lobe"],
    ]
    elems.append(standard_table(
        ["Test", "Method", "Lesion Site"],
        cort_rows,
        [38*mm, 100*mm, CONTENT_W - 138*mm], BLUE_MID))
    elems.append(sp(3))

    # Patterns
    elems.append(Paragraph("C. Patterns of Sensory Loss — Localisation", S['sub_header']))
    pat_rows = [
        ["Glove-and-stocking", "Peripheral neuropathy (length-dependent / dying-back)",
         "Pain + vibration + JPS; starts distally"],
        ["Dermatomal", "Single nerve root (radiculopathy)",
         "Follows dermatome; associated radicular pain"],
        ["Single peripheral nerve", "Mononeuropathy (trauma, entrapment)",
         "Distribution of specific nerve territory"],
        ["Dissociated loss\n(pain/temp ↓, vibration/JPS intact)", "Spinothalamic only\n(hemisection: Brown-Séquard, syringomyelia)",
         "Crossed: lesion side loses vibration; opposite side loses pain/temp"],
        ["Contralateral hemibody (all modalities)", "Internal capsule or thalamus (VPL nucleus)",
         "Sudden onset → vascular; deep thalamic lesion"],
        ["Ipsilateral body + contralateral face", "Lateral medullary syndrome (Wallenberg)",
         "PICA territory infarct"],
        ["Saddle (perineal) distribution", "Cauda equina or conus medullaris",
         "S3–S5; bladder/bowel involved"],
        ["Cortical sensory loss only\n(primary sensation intact)", "Parietal cortex lesion",
         "Astereognosis, agraphesthesia, extinction, reduced 2-PD"],
    ]
    elems.append(standard_table(
        ["Pattern", "Lesion", "Key Features"],
        pat_rows,
        [45*mm, 65*mm, CONTENT_W - 110*mm], TEAL))
    elems.append(sp(2))
    return elems


def build_gait():
    elems = []
    elems.append(section_banner("VI. GAIT AND STATION", BLUE_MID))
    elems.append(sp(3))

    gait_rows = [
        ["Hemiplegic", "Arm flexed/adducted, leg circumducts (swings out in arc)",
         "Contralateral corticospinal tract lesion", "UMN signs on affected side"],
        ["Spastic-Bilateral (Scissors)", "Both legs stiff, adducted, crossing each other; small steps",
         "Bilateral corticospinal (cervical myelopathy, CP)", "Bilateral UMN signs"],
        ["Steppage (Foot Drop)", "Exaggerated hip/knee flexion to clear dropped foot; foot slap",
         "L4-5; common peroneal nerve; deep peroneal", "Cannot heel-walk on affected side"],
        ["Trendelenburg (Waddling)", "Pelvis dips to opposite side on weight-bearing step",
         "Hip abductors (L4-5, S1); bilateral = waddling gait",
         "Proximal myopathy / muscular dystrophy"],
        ["Cerebellar Ataxic", "Wide-based, reeling, irregular, falls to side of lesion; worse on tandem",
         "Ipsilateral cerebellum / cerebellar tracts",
         "Sway with eyes open AND closed (not Romberg)"],
        ["Sensory Ataxic", "Wide-based, high-stepping, 'stamping'; watches feet; worsens in dark",
         "Posterior columns or large-fiber peripheral neuropathy",
         "Romberg positive (eyes closed markedly worse)"],
        ["Parkinsonian", "Shuffling small steps; stooped; reduced arm swing; festination; en-bloc turns",
         "Basal ganglia (dopaminergic pathway)",
         "Retropulsion on pull test; hypomimia"],
        ["Apraxic / Magnetic", "'Feet glued to floor'; short shuffling steps; normal arm swing; normal on lying",
         "Frontal lobe (NPH, bilateral frontal lesions)",
         "Classic triad of NPH: gait + dementia + incontinence"],
        ["Antalgic", "Shortened stance phase on painful limb; limp",
         "Pain (musculoskeletal / radicular)",
         "Not neurological in origin"],
        ["Myopathic", "Wide-based; Trendelenburg; difficulty rising from chair; waddling",
         "Proximal muscle weakness (myopathy, muscular dystrophy)",
         "Gowers' sign positive"],
    ]

    t = Table(
        [[Paragraph(h, S['cell_hdr']) for h in ["Gait Type", "Features", "Localization", "Associated Signs"]]]+
        [[Paragraph(str(r[i]), S['cell_body']) for i in range(4)] for r in gait_rows],
        colWidths=[30*mm, 55*mm, 58*mm, 37*mm],
        repeatRows=1
    )
    t.setStyle(TableStyle([
        ('BACKGROUND',    (0,0),(-1,0), BLUE_MID),
        ('TEXTCOLOR',     (0,0),(-1,0), WHITE),
        ('ROWBACKGROUNDS',(0,1),(-1,-1),[WHITE, BLUE_LIGHT]),
        ('GRID',          (0,0),(-1,-1), 0.4, GREY_RULE),
        ('TOPPADDING',    (0,0),(-1,-1),3),('BOTTOMPADDING',(0,0),(-1,-1),3),
        ('LEFTPADDING',   (0,0),(-1,-1),4),('RIGHTPADDING', (0,0),(-1,-1),4),
        ('VALIGN',        (0,0),(-1,-1),'TOP'),
    ]))
    elems.append(t)
    elems.append(sp(3))

    elems.append(Paragraph("Romberg Test", S['sub_header']))
    elems.append(shaded_box([
        Paragraph("<b>Technique:</b> Patient stands with feet together, arms at sides. Observe for 30 seconds with eyes open, then 30 seconds with eyes closed. Stand close to catch the patient.", S['body']),
        Paragraph("<b>Positive Romberg:</b> Markedly increased sway or falls with eyes closed = proprioceptive/posterior column loss or large-fiber peripheral neuropathy. Vision was compensating for lost proprioception.", S['body']),
        Paragraph("<b>Important:</b> Cerebellar ataxia produces sway with eyes BOTH open and closed — this is NOT a positive Romberg test.", S['warning']),
    ], bg=BLUE_LIGHT, border=BLUE_MID))
    elems.append(sp(3))

    elems.append(Paragraph("Additional Station Tests", S['sub_header']))
    add_rows = [
        ["Tandem (heel-to-toe) gait", "Walk on a straight line; unmasks subtle cerebellar or vestibular imbalance"],
        ["One-leg standing", "Stand on each leg separately; Trendelenburg detected; detects unilateral weakness/imbalance"],
        ["Hopping on one foot", "Inability = proximal weakness or balance impairment"],
        ["Rising from chair", "Without arm support tests quadriceps and hip extensors (L3-L4, L5-S1)"],
        ["Walk on heels / toes", "Foot drop = cannot heel-walk (L4-5); S1 weakness = cannot toe-walk"],
    ]
    elems.append(standard_table(["Test", "Purpose"], add_rows,
                                [55*mm, CONTENT_W - 55*mm], TEAL))
    elems.append(sp(2))
    return elems


def build_special_signs():
    elems = []
    elems.append(section_banner("VII. SPECIAL SIGNS & SYNDROMES", TEAL))
    elems.append(sp(3))

    # UMN vs LMN
    elems.append(Paragraph("A. UMN vs LMN Differentiation", S['sub_header']))
    ulm_rows = [
        ["Tone",            "Spastic (clasp-knife); velocity-dependent", "Flaccid / hypotonia"],
        ["Weakness pattern","Pyramidal: extensors↓ in arm, flexors↓ in leg", "Distribution of nerve/root/muscle"],
        ["Reflexes",        "Brisk; clonus; spread", "Reduced or absent"],
        ["Plantar response","Extensor (Babinski +ve)",  "Flexor (normal)"],
        ["Fasciculations",  "Absent",                   "Present (anterior horn / LMN)"],
        ["Wasting",         "Late; disuse atrophy only", "Early; prominent; severe"],
        ["Abdominal reflex","Absent ipsilaterally",      "Present"],
        ["Clonus",          "May be present",            "Absent"],
    ]
    elems.append(standard_table(
        ["Feature", "UMN (Central)", "LMN (Peripheral)"],
        ulm_rows,
        [35*mm, 85*mm, 60*mm], NAVY))
    elems.append(sp(3))

    # Meningeal signs
    elems.append(Paragraph("B. Meningeal Irritation Signs", S['sub_header']))
    mening_rows = [
        ["Nuchal rigidity", "Passive neck flexion resisted; chin cannot touch chest",
         "Meningitis, SAH, cervical spondylosis"],
        ["Kernig's sign", "Flex hip 90°; extend knee; resistance / pain at <135° of extension",
         "Meningitis, SAH"],
        ["Brudzinski's sign", "Passive neck flexion → involuntary hip + knee flexion",
         "Meningitis, SAH"],
        ["Jolt accentuation", "Horizontal head rotation 2–3 Hz worsens headache",
         "Meningitis (sensitivity ~97%)"],
    ]
    elems.append(standard_table(
        ["Sign", "Technique", "Significance"],
        mening_rows,
        [35*mm, 80*mm, CONTENT_W - 115*mm], RED_DK))
    elems.append(sp(3))

    # Raised ICP
    elems.append(Paragraph("C. Signs of Raised Intracranial Pressure", S['sub_header']))
    elems.append(shaded_box([
        Paragraph("• <b>Papilloedema</b> on fundoscopy (blurring of disc margins, loss of venous pulsation, haemorrhages)", S['bullet']),
        Paragraph("• <b>Sixth nerve palsy</b> (false localising sign — CN VI has long intracranial course)", S['bullet']),
        Paragraph("• <b>Cushing's Triad:</b> Bradycardia + Hypertension + Irregular respiration (late ominous sign of herniation)", S['bullet']),
        Paragraph("• Declining level of consciousness, new cranial nerve palsies", S['bullet']),
    ], bg=RED_LT, border=RED_DK))
    elems.append(sp(3))

    # Cerebellar signs
    elems.append(Paragraph("D. Cerebellar Signs (DANISH)", S['sub_header']))
    danish_rows = [
        ["D", "Dysdiadochokinesia", "Impaired rapid alternating movements"],
        ["A", "Ataxia",            "Gait/truncal/limb ataxia; wide-based gait"],
        ["N", "Nystagmus",         "Horizontal; fast phase toward lesion (ipsilateral)"],
        ["I", "Intention tremor",  "Worsens as target approached; finger-nose test"],
        ["S", "Scanning speech",   "Dysarthria; slow, slurred, monotone ('staccato')"],
        ["H", "Hypotonia + Heel-shin", "Reduced tone; impaired heel-shin coordination"],
    ]
    elems.append(standard_table(
        ["Letter", "Sign", "Description"],
        danish_rows,
        [12*mm, 40*mm, CONTENT_W - 52*mm], TEAL))
    elems.append(sp(3))

    # Autonomic examination
    elems.append(Paragraph("E. Autonomic Nervous System Assessment", S['sub_header']))
    auto_left = [
        Paragraph("<b>Cardiovascular</b>", S['body_bold']),
        Paragraph("• BP lying and standing (orthostatic hypotension: ≥20 mmHg systolic drop)", S['bullet']),
        Paragraph("• Heart rate variability (R-R intervals on ECG)", S['bullet']),
        Paragraph("• Valsalva manoeuvre response", S['bullet']),
        Paragraph("• Carotid sinus massage (with care)", S['bullet']),
    ]
    auto_right = [
        Paragraph("<b>Other Autonomic Functions</b>", S['body_bold']),
        Paragraph("• Pupil: Horner's syndrome (miosis, ptosis, anhidrosis)", S['bullet']),
        Paragraph("• Sweating: anhydrosis pattern", S['bullet']),
        Paragraph("• Bladder/bowel function", S['bullet']),
        Paragraph("• Sexual function", S['bullet']),
        Paragraph("• Skin: temperature, colour, trophic changes", S['bullet']),
    ]
    elems.append(two_col(auto_left, auto_right))
    elems.append(sp(2))
    return elems


def build_quick_screen():
    elems = []
    elems.append(section_banner("VIII. QUICK SCREENING EXAMINATION & MNEMONICS", NAVY))
    elems.append(sp(3))

    elems.append(Paragraph("A. 10-Point Bedside Neurological Screen", S['sub_header']))
    elems.append(Paragraph("(Adapted from Adams & Victor Table 1-4 — adds only minutes to the physical examination)", S['small']))
    elems.append(sp(2))

    screen_rows = [
        ["1", "Mental Status",     "Orientation, insight, language — assessed during history"],
        ["2", "Cranial Nerves II", "Pupil size, reactivity; visual acuity; fundoscopy"],
        ["3", "CN III, IV, VI, VII", "Eye movements; facial movements during speech and smile"],
        ["4", "Upper limb motor", "Pronator drift ×10 sec; grip strength; wrist dorsiflexion"],
        ["5", "Upper limb reflexes", "Biceps (C5-6), supinator (C6), triceps (C7)"],
        ["6", "Lower limb inspection", "Active flexion/extension of hips, knees, feet — observe"],
        ["7", "Lower limb reflexes", "Knee jerk (L3-4), ankle jerk (S1-2), plantars"],
        ["8", "Vibration sensation", "128 Hz tuning fork — toes and fingers"],
        ["9", "Coordination", "Finger-nose-finger; heel-shin"],
        ["10","Gait + Romberg", "Observation of gait; tandem walk; Romberg test"],
    ]

    t = Table(
        [[Paragraph(h, S['cell_hdr']) for h in ["#", "Component", "Key Test"]]]+
        [[Paragraph(r[0], S['cell_hdr']), Paragraph(r[1], S['body_bold']), Paragraph(r[2], S['cell_body'])]
         for r in screen_rows],
        colWidths=[10*mm, 45*mm, CONTENT_W - 55*mm],
        repeatRows=1
    )
    t.setStyle(TableStyle([
        ('BACKGROUND',    (0,0),(-1,0), NAVY),
        ('BACKGROUND',    (0,1),(-1,-1), WHITE),
        ('BACKGROUND',    (0,2),(-1,2), GREY_BG),
        ('BACKGROUND',    (0,4),(-1,4), GREY_BG),
        ('BACKGROUND',    (0,6),(-1,6), GREY_BG),
        ('BACKGROUND',    (0,8),(-1,8), GREY_BG),
        ('BACKGROUND',    (0,10),(-1,10), GREY_BG),
        ('TEXTCOLOR',     (0,0),(-1,0), WHITE),
        ('TEXTCOLOR',     (0,1),(-1,-1), NAVY),
        ('GRID',          (0,0),(-1,-1), 0.4, GREY_RULE),
        ('TOPPADDING',    (0,0),(-1,-1),4),('BOTTOMPADDING',(0,0),(-1,-1),4),
        ('LEFTPADDING',   (0,0),(-1,-1),5),('RIGHTPADDING', (0,0),(-1,-1),5),
        ('VALIGN',        (0,0),(-1,-1),'MIDDLE'),
        ('ALIGN',         (0,0),(0,-1), 'CENTER'),
    ]))
    elems.append(t)
    elems.append(sp(3))

    # Mnemonics
    elems.append(Paragraph("B. Key Mnemonics", S['sub_header']))

    left_mn = [
        Paragraph("<b>Cranial Nerves (I–XII)</b>", S['body_bold']),
        Paragraph('"Oh Oh Oh, To Touch And Feel Very Good Velvet, AHH"', S['body']),
        Paragraph("Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Vestibulocochlear, Glossopharyngeal, Vagus, Accessory, Hypoglossal", S['small']),
        sp(3),
        Paragraph("<b>CN Function (Sensory/Motor/Both)</b>", S['body_bold']),
        Paragraph('"Some Say Marry Money But My Brother Says Big Brains Matter More"', S['body']),
        Paragraph("S M B M B B S B B M M B → Sensory/Motor/Both for CN I–XII", S['small']),
        sp(3),
        Paragraph("<b>Cerebellar signs: DANISH</b>", S['body_bold']),
        Paragraph("Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Scanning speech, Hypotonia", S['body']),
    ]

    right_mn = [
        Paragraph("<b>Dermatomes — Quick reference</b>", S['body_bold']),
        Paragraph("C3-4: Shoulder cape; C6: Thumb; C7: Middle finger; C8: Little finger", S['small']),
        Paragraph("T4: Nipple line; T10: Umbilicus; T12: Inguinal ligament", S['small']),
        Paragraph("L2: Anterior thigh; L3: Medial knee; L4: Medial leg; L5: Dorsum foot; S1: Lateral foot + sole", S['small']),
        sp(3),
        Paragraph("<b>MRC Scale: 0–5</b>", S['body_bold']),
        Paragraph("0 = None; 1 = Flicker; 2 = Gravity-free; 3 = vs Gravity; 4 = vs Resistance; 5 = Normal", S['body']),
        sp(3),
        Paragraph("<b>Aphasia types</b>", S['body_bold']),
        Paragraph("Broca's (expressive): fluency↓, comprehension intact, repetition↓", S['small']),
        Paragraph("Wernicke's (receptive): fluency normal, comprehension↓, repetition↓", S['small']),
        Paragraph("Conduction: fluency ± normal, comprehension intact, repetition↓↓", S['small']),
        Paragraph("Global: all modalities impaired (large MCA territory)", S['small']),
    ]
    elems.append(two_col(left_mn, right_mn))
    elems.append(sp(3))

    # Sources
    elems.append(HRFlowable(width=CONTENT_W, thickness=0.5, color=GREY_RULE))
    elems.append(sp(2))
    elems.append(Paragraph("<b>References / Sources</b>", S['small']))
    elems.append(Paragraph(
        "1. Adams and Victor's Principles of Neurology, 12th Edition (2023), McGraw-Hill — Chapter 1, pp. 14–21\n"
        "2. Bradley and Daroff's Neurology in Clinical Practice, 8th Edition — Chapter 1: Neurological Examination, Table 1.1\n"
        "3. Harrison's Principles of Internal Medicine, 22nd Edition (2025) — Neurological Examination sections\n"
        "4. DeMyer's Technique of the Neurologic Examination, 6th Edition", S['small']))
    elems.append(sp(2))
    return elems


# ── Main Build ───────────────────────────────────────────────────────────────
def build_pdf():
    doc = SimpleDocTemplate(
        OUTPUT_PATH,
        pagesize=A4,
        leftMargin=MARGIN, rightMargin=MARGIN,
        topMargin=MARGIN, bottomMargin=22 * mm,
        title="CNS Examination Reference Card",
        author="Orris Medical AI",
        subject="Comprehensive Neurological Examination",
    )

    story = []

    # Cover
    story.append(CoverPage())
    story.append(PageBreak())

    # Sections
    story.extend(build_mental_status())
    story.append(PageBreak())

    story.extend(build_cranial_nerves())
    story.append(PageBreak())

    story.extend(build_motor())
    story.append(PageBreak())

    story.extend(build_reflexes())
    story.append(PageBreak())

    story.extend(build_sensory())
    story.append(PageBreak())

    story.extend(build_gait())
    story.append(PageBreak())

    story.extend(build_special_signs())
    story.append(PageBreak())

    story.extend(build_quick_screen())

    doc.build(story, canvasmaker=NumberedCanvas)
    print(f"PDF generated: {OUTPUT_PATH}")
    return OUTPUT_PATH


if __name__ == "__main__":
    build_pdf()

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/cns-reference-card/generate_cns_pdf.py'

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/cns-reference-card/generate_cns_pdf.py'