#!/usr/bin/env python3
"""Build General Medicine exam notes (2 A4 pages/topic) for Physiotherapy students."""
from docx import Document
from docx.shared import Pt, Inches, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.enum.table import WD_TABLE_ALIGNMENT
from docx.oxml.ns import qn
from docx.oxml import OxmlElement

doc = Document()

# ---------- base styles ----------
style = doc.styles["Normal"]
style.font.name = "Calibri"
style.font.size = Pt(11)

sections = doc.sections
for s in sections:
    s.page_height = Inches(11.69)
    s.page_width = Inches(8.27)
    s.top_margin = Inches(0.7)
    s.bottom_margin = Inches(0.7)
    s.left_margin = Inches(0.8)
    s.right_margin = Inches(0.8)

NAVY = RGBColor(0x1F, 0x3A, 0x5F)
ACCENT = RGBColor(0x2E, 0x74, 0xB5)
DARK = RGBColor(0x22, 0x22, 0x22)


def add_title_page():
    p = doc.add_paragraph()
    p.alignment = WD_ALIGN_PARAGRAPH.CENTER
    run = p.add_run("GENERAL MEDICINE\nExam Notes for Physiotherapy Students")
    run.bold = True
    run.font.size = Pt(26)
    run.font.color.rgb = NAVY
    for _ in range(2):
        doc.add_paragraph()
    p2 = doc.add_paragraph()
    p2.alignment = WD_ALIGN_PARAGRAPH.CENTER
    r2 = p2.add_run("Topics Covered")
    r2.bold = True
    r2.font.size = Pt(14)
    r2.font.color.rgb = ACCENT
    topics_list = ["1. COPD (Chronic Obstructive Pulmonary Disease)", "2. Leprosy (Hansen's Disease)",
                   "3. Dermatitis (Eczema)", "4. Psoriasis", "5. Bronchitis (Acute & Chronic)",
                   "6. Bronchiectasis"]
    for t in topics_list:
        pp = doc.add_paragraph(t)
        pp.alignment = WD_ALIGN_PARAGRAPH.CENTER
        pp.runs[0].font.size = Pt(12)
    doc.add_page_break()


def h1(text):
    p = doc.add_heading(level=1)
    r = p.add_run(text)
    r.font.color.rgb = NAVY
    r.font.size = Pt(20)
    # bottom border
    pPr = p._p.get_or_add_pPr()
    pBdr = OxmlElement('w:pBdr')
    bottom = OxmlElement('w:bottom')
    bottom.set(qn('w:val'), 'single')
    bottom.set(qn('w:sz'), '12')
    bottom.set(qn('w:space'), '4')
    bottom.set(qn('w:color'), '1F3A5F')
    pBdr.append(bottom)
    pPr.append(pBdr)
    return p


def h2(text):
    p = doc.add_heading(level=2)
    r = p.add_run(text)
    r.font.color.rgb = ACCENT
    r.font.size = Pt(13.5)
    r.bold = True
    return p


def para(text, bold_lead=None):
    p = doc.add_paragraph()
    p.paragraph_format.space_after = Pt(4)
    if bold_lead:
        r = p.add_run(bold_lead + " ")
        r.bold = True
    r2 = p.add_run(text)
    r2.font.color.rgb = DARK
    return p


def bullets(items, bold_lead=False):
    for it in items:
        p = doc.add_paragraph(style="List Bullet")
        p.paragraph_format.space_after = Pt(2)
        if isinstance(it, tuple):
            lead, rest = it
            r = p.add_run(lead)
            r.bold = True
            p.add_run(rest)
        else:
            p.add_run(it)


def numbered(items):
    for it in items:
        p = doc.add_paragraph(style="List Number")
        p.paragraph_format.space_after = Pt(2)
        if isinstance(it, tuple):
            lead, rest = it
            r = p.add_run(lead)
            r.bold = True
            p.add_run(rest)
        else:
            p.add_run(it)


def simple_table(headers, rows, widths=None):
    t = doc.add_table(rows=1, cols=len(headers))
    t.style = "Light Grid Accent 1"
    t.alignment = WD_TABLE_ALIGNMENT.CENTER
    hdr = t.rows[0].cells
    for i, htext in enumerate(headers):
        hdr[i].text = ""
        r = hdr[i].paragraphs[0].add_run(htext)
        r.bold = True
        r.font.size = Pt(10)
        r.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
        hdr[i].paragraphs[0].alignment = WD_ALIGN_PARAGRAPH.CENTER
        shading_elm = OxmlElement('w:shd')
        shading_elm.set(qn('w:fill'), '1F3A5F')
        hdr[i]._tc.get_or_add_tcPr().append(shading_elm)
    for row in rows:
        cells = t.add_row().cells
        for i, val in enumerate(row):
            cells[i].text = ""
            r = cells[i].paragraphs[0].add_run(str(val))
            r.font.size = Pt(10)
    doc.add_paragraph()
    return t


# =====================================================================
add_title_page()

# =====================================================================================
# TOPIC 1: COPD
# =====================================================================================
h1("1. COPD - Chronic Obstructive Pulmonary Disease")

h2("Definition")
para("Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease "
     "characterised by persistent respiratory symptoms and progressive, largely irreversible airflow "
     "limitation, caused by a mixture of small-airway disease (chronic bronchiolitis) and parenchymal "
     "destruction (emphysema). It most commonly presents as a combination of chronic bronchitis and "
     "emphysema, which frequently coexist in the same patient.")

h2("Aetiology / Risk Factors")
bullets([
    ("Cigarette smoking - ", "the single most important risk factor (active and passive smoking)."),
    ("Occupational exposure - ", "coal dust, silica, cotton, biomass fuel/chulha smoke (major cause in rural India)."),
    ("Air pollution - ", "indoor and outdoor pollutants."),
    ("Genetic factor - ", "alpha-1 antitrypsin deficiency (causes early-onset panacinar emphysema)."),
    ("Recurrent respiratory infections", ""),
    ("Ageing and low socioeconomic status", ""),
])

h2("Pathophysiology / Types")
para("COPD has two overlapping components:")
bullets([
    ("Chronic Bronchitis - ", "defined clinically as a productive cough for at least 3 consecutive months "
     "in at least 2 consecutive years. Caused by hypertrophy of mucous glands and goblet-cell hyperplasia in "
     "large airways with inflammation and fibrosis of small airways (chronic bronchiolitis), which is the "
     "true site of airflow obstruction."),
    ("Emphysema - ", "permanent enlargement of air spaces distal to the terminal bronchiole due to destruction "
     "of alveolar walls by proteases (elastase) released from neutrophils/macrophages, unopposed by "
     "alpha-1 antitrypsin. Subtypes: Centriacinar (most common, smoking related, upper lobes) and "
     "Panacinar (alpha-1 antitrypsin deficiency, lower lobes)."),
])
para("Functionally, COPD is characterised by a reduced FEV1 with normal/near-normal FVC, giving a low "
     "FEV1/FVC ratio (<0.7 post-bronchodilator) - the spirometric hallmark used for diagnosis.")

h2("Clinical Features")
bullets([
    "Progressive exertional dyspnoea (usually the first and most disabling symptom)",
    "Chronic productive cough with mucoid/mucopurulent sputum, worse in the morning",
    "Wheeze and chest tightness",
    "Two classic clinical phenotypes:",
])
simple_table(
    ["Feature", "'Pink Puffer' (Emphysema)", "'Blue Bloater' (Chronic Bronchitis)"],
    [["Build", "Thin, barrel chest", "Overweight/obese"],
     ["Cough", "Mild, late", "Prominent, early, productive"],
     ["Dyspnoea", "Severe, prominent", "Milder"],
     ["Blood gases", "Near-normal (compensated)", "Hypoxia, hypercapnia, cyanosis"],
     ["Cor pulmonale", "Late feature", "Earlier, more common"]])
bullets([
    "Use of accessory muscles of respiration, pursed-lip breathing",
    "Prolonged expiration, hyperinflated chest, reduced chest expansion",
    "Advanced disease: cyanosis, raised JVP, pedal oedema (cor pulmonale/right heart failure)",
    "Recurrent acute exacerbations precipitated by infection or pollutants",
])

h2("Investigations")
bullets([
    ("Spirometry - ", "gold standard; post-bronchodilator FEV1/FVC < 0.70 confirms persistent airflow limitation "
     "(GOLD criteria); FEV1 % predicted grades severity (GOLD 1-4)."),
    ("Chest X-ray - ", "hyperinflation, flattened diaphragm, increased retrosternal air space, bullae."),
    ("HRCT chest - ", "detects and characterises emphysema."),
    ("Arterial blood gas (ABG) - ", "hypoxaemia +/- hypercapnia in advanced disease."),
    ("Pulse oximetry (SpO2), 6-minute walk test, DLCO", ""),
    ("Alpha-1 antitrypsin level - ", "if early-onset/family history."),
])

h2("Medical Management")
bullets([
    "Smoking cessation - single most effective intervention to slow progression",
    "Bronchodilators: short/long-acting beta2-agonists (SABA/LABA) and antimuscarinics (SAMA/LAMA)",
    "Inhaled corticosteroids in combination for frequent exacerbators with eosinophilia",
    "Pulmonary rehabilitation, long-term oxygen therapy (LTOT) if PaO2 <55 mmHg",
    "Vaccination - annual influenza and pneumococcal vaccine",
    "Treat exacerbations with bronchodilators, systemic steroids, antibiotics if indicated",
    "Surgical options in selected cases: lung volume reduction surgery, bullectomy, transplantation",
])

h2("Complications")
bullets(["Cor pulmonale (right heart failure)", "Respiratory failure (Type I or Type II)",
         "Secondary polycythaemia", "Pneumothorax (ruptured bullae)", "Recurrent chest infections",
         "Weight loss/cachexia, osteoporosis, depression"])

h2("Physiotherapy Management")
bullets([
    ("Assessment - ", "chest expansion, breathing pattern, exercise tolerance (6-MWT), MRC dyspnoea scale, SpO2."),
    ("Breathing exercises - ", "diaphragmatic breathing, pursed-lip breathing to reduce dynamic hyperinflation and dyspnoea."),
    ("Airway clearance techniques - ", "active cycle of breathing technique (ACBT), postural drainage, percussion/vibration if secretions present."),
    ("Pulmonary rehabilitation - ", "graded aerobic and resistance exercise training to improve exercise capacity and quality of life."),
    ("Energy conservation techniques and pacing for activities of daily living (ADLs)"),
    ("Inspiratory muscle training (IMT) for selected patients"),
    ("Patient education - ", "correct inhaler technique, smoking cessation counselling, self-management of exacerbations."),
    ("Positioning - ", "high side-lying/forward lean sitting to ease work of breathing during acute dyspnoea."),
])

doc.add_page_break()

# =====================================================================================
# TOPIC 2: LEPROSY
# =====================================================================================
h1("2. Leprosy (Hansen's Disease)")

h2("Definition")
para("Leprosy (Hansen's disease) is a chronic granulomatous infectious disease caused by Mycobacterium "
     "leprae (and rarely M. lepromatosis), primarily affecting the skin, peripheral nerves, upper respiratory "
     "tract mucosa and eyes. It remains endemic in several low-resource tropical countries, especially India, "
     "Brazil, and Indonesia, which together report the majority of new cases globally.")

h2("Aetiology")
bullets([
    ("Causative organism - ", "Mycobacterium leprae, an obligate intracellular acid-fast bacillus that cannot "
     "be cultured in vitro; grows best at 32-34°C (skin/cooler body parts)."),
    ("Transmission - ", "prolonged close contact via nasal/respiratory droplets from untreated multibacillary "
     "cases; rare zoonotic transmission from armadillos."),
    ("Host immune response (cell-mediated immunity, CMI) determines the clinical spectrum of disease."),
])

h2("Classification (Ridley-Jopling / WHO)")
simple_table(
    ["Type", "Immunity", "Skin Lesions", "Bacillary Load"],
    [["Tuberculoid (TT)", "Strong CMI", "Few, asymmetric, well-defined, anaesthetic plaques", "Paucibacillary"],
     ["Borderline (BT/BB/BL)", "Intermediate", "Variable number, less defined", "Variable"],
     ["Lepromatous (LL)", "Poor/absent CMI", "Numerous, symmetric nodules/plaques, 'leonine facies'", "Multibacillary"]])
para("WHO operational classification for treatment purposes:", bold_lead="Simplified WHO classification:")
bullets([
    ("Paucibacillary (PB) - ", "1-5 skin lesions and/or only one nerve involved."),
    ("Multibacillary (MB) - ", "6 or more skin lesions and/or more than one nerve involved, or positive skin smear."),
])

h2("Clinical Features")
bullets([
    "Hypopigmented or erythematous skin patches/plaques with definite loss of sensation (hallmark of tuberculoid leprosy)",
    "Thickened peripheral nerves - ulnar, common peroneal, posterior tibial, great auricular, radial cutaneous",
    "Sensory loss - glove-and-stocking pattern; earliest to be lost is temperature, then light touch, then pain",
    "Motor weakness leading to characteristic deformities: claw hand (ulnar/median nerve), wrist drop (radial nerve), foot drop (common peroneal nerve), lagophthalmos (facial nerve)",
    "Trophic changes - plantar ulcers due to insensitive weight-bearing surfaces, absorption of digits",
    "Lepromatous leprosy: diffuse skin infiltration, madarosis (loss of eyebrows/eyelashes), leonine facies, saddle-nose deformity, nasal stuffiness",
    "Lepra reactions - Type 1 (reversal reaction, cell-mediated) and Type 2 (Erythema Nodosum Leprosum, immune complex mediated) causing acute inflammation of skin/nerves",
])

h2("Investigations")
bullets([
    ("Slit-skin smear - ", "for acid-fast bacilli (AFB); calculates bacterial index."),
    ("Skin biopsy - ", "histopathology showing granulomas (tuberculoid) or foamy macrophages laden with bacilli/Virchow cells (lepromatous)."),
    ("Lepromin test - ", "assesses host cell-mediated immunity (positive in tuberculoid, negative in lepromatous)."),
    ("Nerve conduction studies", "to assess extent of nerve damage."),
    ("PCR for M. leprae DNA", ""),
])

h2("Medical Management - WHO Multidrug Therapy (MDT)")
simple_table(
    ["Regimen", "Drugs", "Duration"],
    [["Paucibacillary (PB)", "Rifampicin 600 mg monthly (supervised) + Dapsone 100 mg daily", "6 months"],
     ["Multibacillary (MB)", "Rifampicin 600 mg monthly + Clofazimine 300 mg monthly & 50 mg daily + Dapsone 100 mg daily", "12 months"]])
bullets([
    "Steroids (prednisolone) and clofazimine for management of lepra reactions",
    "Analgesics/NSAIDs for neuritis and ENL",
    "Cure rate with MDT is around 99%; relapse is uncommon but possible",
])

h2("Complications & Deformities")
bullets(["Claw hand, wrist drop, foot drop", "Lagophthalmos and corneal exposure keratitis/blindness",
         "Plantar/palmar trophic ulcers", "Absorption/resorption of digits", "Nasal septal collapse (saddle nose)",
         "Social stigma and psychological impact"])

h2("Physiotherapy Management")
bullets([
    ("Assessment - ", "sensory mapping (monofilament testing), manual muscle testing, deformity assessment, gait analysis."),
    ("Splinting - ", "static/dynamic splints to prevent and correct claw hand, wrist drop, and foot drop and to rest inflamed nerves during neuritis."),
    ("Prevention of deformity - ", "patient education on protecting anaesthetic hands/feet from burns and trauma; regular self-inspection."),
    ("Care of insensitive feet - ", "custom footwear/MCR (micro-cellular rubber) footwear, pressure redistribution, ulcer care and offloading."),
    ("Exercise therapy - ", "passive and active-assisted ROM exercises to maintain joint mobility and prevent contractures; strengthening of weak muscles."),
    ("Nerve gliding exercises and desensitisation/sensory re-education techniques"),
    ("Physical modalities - ", "wax bath, paraffin therapy for stiff hands (with caution given sensory loss)."),
    ("Gait training and mobility aids for foot drop; post-surgical rehabilitation after tendon transfer surgery"),
    ("Psychosocial support and community-based rehabilitation to reduce stigma"),
])

doc.add_page_break()

# =====================================================================================
# TOPIC 3: DERMATITIS
# =====================================================================================
h1("3. Dermatitis (Eczema)")

h2("Definition")
para("Dermatitis (used interchangeably with eczema) is a non-infectious inflammatory reaction pattern of "
     "the skin characterised clinically by erythema, oedema, vesiculation, oozing, crusting, scaling and "
     "intense pruritus (\"the itch that rashes\"). It is not a single disease but a group of conditions with "
     "a common inflammatory pathway.")

h2("Types / Classification")
bullets([
    ("Atopic dermatitis - ", "a chronic, relapsing, Th2-mediated allergic skin disease occurring in individuals "
     "with a personal/family history of atopy (asthma, allergic rhinitis). Involves genetic (filaggrin gene "
     "mutations affecting skin barrier) and immunological factors."),
    ("Contact dermatitis - ", "Irritant (direct toxic damage from a substance, e.g. detergents, acids) or "
     "Allergic (Type IV delayed hypersensitivity reaction to an allergen, e.g. nickel, poison ivy, cosmetics)."),
    ("Seborrhoeic dermatitis - ", "chronic condition affecting sebum-rich areas (scalp, face, chest) associated "
     "with Malassezia yeast overgrowth."),
    ("Dermatitis herpetiformis - ", "autoimmune, intensely pruritic condition linked with gluten sensitivity/coeliac disease."),
    ("Stasis (varicose) dermatitis - ", "due to chronic venous insufficiency of the lower limbs."),
    ("Nummular (discoid) dermatitis - ", "coin-shaped plaques, often on limbs."),
])

h2("Aetiology / Risk Factors")
bullets([
    "Genetic predisposition and family history of atopy",
    "Impaired skin barrier function (loss of filaggrin, reduced ceramides)",
    "Environmental allergens/irritants - soaps, detergents, dust mites, pollen, nickel, latex",
    "Dry climate, low humidity, excessive bathing/washing",
    "Stress and emotional factors can precipitate flares",
    "Secondary bacterial (Staphylococcal) or fungal colonisation",
])

h2("Clinical Features")
bullets([
    ("Acute stage - ", "erythematous, oedematous plaques with tiny vesicles that may weep/ooze."),
    ("Subacute stage - ", "erythema with scaling."),
    ("Chronic stage - ", "thickened, lichenified skin with exaggerated skin markings from repeated scratching, "
     "excoriations and post-inflammatory pigmentation."),
    "Intense pruritus, characteristically worse at night and aggravated by heat/sweating",
    "Atopic dermatitis: flexural distribution (antecubital and popliteal fossae, neck, wrists) in older children/adults; face and extensor surfaces in infants",
    "Contact dermatitis: sharply demarcated area confined to the site of contact, may show linear/geographic pattern",
    "Secondary infection: crusting, exudate, pustules (Staph/Strep superinfection)",
])

h2("Investigations")
bullets([
    ("Mainly clinical diagnosis", ""),
    ("Patch testing - ", "identifies causative allergen in suspected allergic contact dermatitis."),
    ("Serum IgE and eosinophil count - ", "often raised in atopic dermatitis."),
    ("Skin swab/culture - ", "if secondary bacterial infection is suspected."),
    ("Skin biopsy - ", "occasionally, to exclude other papulosquamous disorders."),
])

h2("Medical Management")
bullets([
    "Avoidance of identified irritants/allergens and trigger factors",
    "Regular emollients/moisturisers to restore skin barrier (applied within minutes of bathing)",
    "Topical corticosteroids - mild (hydrocortisone) for face/flexures, potent (betamethasone, clobetasol) for thicker/lichenified skin, used in short courses",
    "Topical calcineurin inhibitors (tacrolimus, pimecrolimus) as steroid-sparing agents",
    "Oral antihistamines for pruritus, especially at night",
    "Short tapering course of oral corticosteroids for severe flares",
    "Antibiotics (oral/topical) for secondary infection",
    "Phototherapy (narrowband UVB) and systemic immunosuppressants/biologics (dupilumab) for severe refractory atopic dermatitis",
])

h2("Complications")
bullets(["Secondary bacterial infection (impetiginisation)", "Lichenification from chronic scratching",
         "Eczema herpeticum (disseminated HSV infection - dermatological emergency)",
         "Sleep disturbance and psychosocial impact", "Post-inflammatory hyper/hypopigmentation"])

h2("Physiotherapy-Relevant Points & Management")
bullets([
    ("General skin/wound care principles - ", "physiotherapists must be aware of skin fragility when applying "
     "tape, electrodes, or manual techniques over dermatitic skin; avoid friction and adhesive products on active lesions."),
    ("Hydrotherapy precautions - ", "avoid chlorinated pools during active flares; ensure adequate post-session moisturising."),
    ("Manual therapy modifications - ", "use hypoallergenic lubricants/oils; avoid direct pressure over open/weeping lesions."),
    ("Electrotherapy precautions - ", "avoid placing electrodes directly over inflamed or broken skin (infection risk, altered sensation)."),
    ("Patient education - ", "temperature regulation during exercise (avoid overheating/sweating which triggers itching), loose breathable clothing during rehabilitation sessions."),
    ("Stress management techniques - ", "relaxation training as psychological stress is a recognised flare trigger."),
    ("Where dermatitis coexists with lymphoedema/stasis dermatitis - ", "compression therapy and manual lymphatic drainage under physiotherapy guidance."),
])

doc.add_page_break()

# =====================================================================================
# TOPIC 4: PSORIASIS
# =====================================================================================
h1("4. Psoriasis")

h2("Definition")
para("Psoriasis is a common, chronic, immune-mediated inflammatory skin disorder characterised by "
     "well-demarcated, erythematous plaques covered with thick silvery-white scales, resulting from "
     "hyperproliferation and abnormal differentiation of epidermal keratinocytes driven by T-cell "
     "(particularly Th17) mediated inflammation. It affects roughly 1-2% of the population and often has a "
     "genetic basis (up to 50% risk if both parents affected).")

h2("Aetiology / Pathogenesis")
bullets([
    "Genetic susceptibility - HLA-Cw6 association; positive family history common",
    "Immune-mediated - activation of Th17 cells producing IL-17, IL-22, and IL-23, driving keratinocyte hyperproliferation",
    "Triggers: streptococcal throat infection (guttate psoriasis), trauma/Koebner phenomenon, stress, alcohol, smoking",
    "Drugs that can exacerbate: beta-blockers, lithium, antimalarials, abrupt withdrawal of systemic steroids",
    "Cold weather typically worsens; sunlight often improves lesions",
])

h2("Types of Psoriasis")
bullets([
    ("Plaque (psoriasis vulgaris) - ", "80-90% of cases; well-defined erythematous plaques with silvery scale, "
     "typically on extensor surfaces - elbows, knees, scalp, lower back."),
    ("Guttate psoriasis - ", "small, drop-like lesions, often post-streptococcal, common in children/young adults."),
    ("Inverse (flexural) psoriasis - ", "affects skin folds (axilla, groin); lacks classic scale, often mistaken for fungal infection."),
    ("Palmoplantar psoriasis - ", "involves palms and soles, can be disabling for weight-bearing/hand function."),
    ("Pustular psoriasis - ", "localized or generalised sterile pustules; generalised form is a medical emergency."),
    ("Erythrodermic psoriasis - ", "widespread erythema and scaling >90% body surface area; can be life-threatening."),
    ("Nail psoriasis - ", "pitting, onycholysis, oil-drop discolouration, subungual hyperkeratosis."),
    ("Psoriatic arthritis - ", "affects up to 30% of psoriasis patients; involves hands, feet, knees, spine (see below)."),
])

h2("Clinical Features")
bullets([
    "Well-demarcated erythematous plaques with silvery-white scale, symmetric distribution",
    "Common sites: extensor surface of elbows and knees, scalp, sacrum, umbilicus",
    "Auspitz sign - pinpoint bleeding when scale is scraped off",
    "Koebner phenomenon - new lesions at sites of skin trauma",
    "Nail changes - pitting, onycholysis, oil-spots",
    "Psoriatic arthritis: asymmetric oligoarthritis, dactylitis ('sausage digits'), enthesitis (Achilles tendon, plantar fascia), spondylitis/sacroiliitis, DIP joint involvement",
])

h2("Investigations")
bullets([
    "Usually a clinical diagnosis based on characteristic morphology and distribution",
    "Skin biopsy - if diagnosis uncertain; shows epidermal hyperplasia, parakeratosis, Munro's microabscesses, elongated rete ridges",
    "X-ray/MRI of joints - for suspected psoriatic arthritis (erosions, 'pencil-in-cup' deformity, new bone formation)",
    "Rheumatoid factor - typically negative (helps distinguish from RA in psoriatic arthritis)",
])

h2("Medical Management")
bullets([
    ("Topical therapy (mild-moderate disease) - ", "corticosteroids, vitamin D analogues (calcipotriol), "
     "coal tar, dithranol, topical retinoids (tazarotene)."),
    ("Phototherapy - ", "narrowband UVB, PUVA for moderate-severe or widespread disease."),
    ("Systemic conventional agents - ", "methotrexate, cyclosporine, acitretin (oral retinoid) for moderate-severe/refractory disease and psoriatic arthritis."),
    ("Biologic agents - ", "TNF-alpha inhibitors (etanercept, adalimumab, infliximab), IL-17 inhibitors "
     "(secukinumab), IL-23 inhibitors (guselkumab) for severe disease/psoriatic arthritis."),
    ("Emollients - ", "adjunct to reduce scaling and improve skin barrier."),
    ("Lifestyle - ", "smoking/alcohol cessation, weight management (obesity worsens severity and treatment response)."),
])

h2("Complications")
bullets(["Psoriatic arthritis and joint destruction/deformity", "Erythrodermic psoriasis (fluid/electrolyte loss, sepsis risk)",
         "Generalized pustular psoriasis (life-threatening)", "Increased cardiovascular risk (metabolic syndrome association)",
         "Psychological impact - depression, social withdrawal due to visible lesions"])

h2("Physiotherapy Management")
bullets([
    ("Psoriatic arthritis rehabilitation - ", "joint protection techniques, range-of-motion and stretching "
     "exercises to maintain mobility, strengthening around affected joints, and management of enthesitis "
     "(e.g. Achilles tendon, plantar fascia) with graded loading and stretching."),
    ("Spinal involvement (axial psoriatic arthritis/spondylitis) - ", "postural correction exercises, spinal "
     "mobility and extension exercises similar to ankylosing spondylitis protocols."),
    ("Hydrotherapy - ", "warm pool exercise can relieve joint pain and improve mobility, though chlorinated water may irritate active skin plaques - monitor and moisturise after sessions."),
    ("Manual therapy precautions - ", "avoid direct pressure/friction over active plaques; use non-irritant lubricants."),
    ("Electrotherapy - ", "avoid electrode placement on active/broken plaques; TENS/ultrasound may otherwise be used for associated musculoskeletal pain."),
    ("Patient education - ", "activity pacing, energy conservation for chronic fatigue, joint protection, and psychological support/counselling referral given the impact of visible skin disease on self-esteem."),
    ("Exercise prescription - ", "low-impact aerobic exercise to help weight management (important given cardiovascular/metabolic comorbidity)."),
])

doc.add_page_break()

# =====================================================================================
# TOPIC 5: BRONCHITIS
# =====================================================================================
h1("5. Bronchitis (Acute and Chronic)")

h2("Definition")
para("Bronchitis is inflammation of the bronchial mucosa. It exists in two clinically distinct forms: "
     "Acute bronchitis - a short-lived, usually self-limiting inflammation of the large airways, typically "
     "viral in origin; and Chronic bronchitis - a component of COPD, defined clinically as a productive "
     "cough present for at least 3 consecutive months in at least 2 consecutive years.")

h2("Acute Bronchitis")
para("", bold_lead="Aetiology:")
bullets(["Predominantly viral (rhinovirus, RSV, influenza, parainfluenza, adenovirus)",
         "Occasionally bacterial - Mycoplasma pneumoniae, Chlamydia pneumoniae, Bordetella pertussis",
         "Risk increased by smoking, air pollution, cold weather"])
para("", bold_lead="Clinical Features:")
bullets(["Acute cough (may persist 1-3 weeks), initially dry then productive of mucoid/purulent sputum",
         "Wheeze, chest discomfort/burning retrosternal pain, low-grade fever, malaise",
         "Auscultation - coarse crackles, rhonchi/wheeze; chest X-ray usually normal (helps exclude pneumonia)"])
para("", bold_lead="Management:")
bullets(["Mainly supportive: rest, hydration, antipyretics/analgesics, humidification",
         "Antibiotics generally NOT indicated (viral aetiology) unless bacterial superinfection suspected (cough >10-14 days, purulent sputum) or in smokers/COPD patients",
         "Bronchodilators only if demonstrable airway obstruction/wheeze"])

h2("Chronic Bronchitis")
para("", bold_lead="Aetiology:")
bullets(["Cigarette smoking - the principal cause", "Chronic exposure to air pollutants (SO2, NO2, occupational dust/fumes)",
         "Recurrent respiratory infections perpetuate inflammation"])
para("", bold_lead="Pathophysiology:")
para("The hallmark is hypersecretion of mucus beginning in the large airways due to hypertrophy of "
     "submucosal mucous glands and increased goblet cells (Reid index raised). Airflow obstruction, however, "
     "arises from small airway disease - chronic bronchiolitis with mucous plugging, inflammation "
     "(macrophages, neutrophils, lymphocytes - notably NOT eosinophils, distinguishing it from asthma) and "
     "bronchiolar wall fibrosis.")
para("", bold_lead="Clinical Features:")
bullets(["Chronic productive cough, worse on waking, for 3+ months/2+ consecutive years",
         "Progressive dyspnoea, wheeze",
         "'Blue bloater' phenotype - overweight, cyanosed, may develop hypoxaemia, hypercapnia and cor pulmonale",
         "Frequent infective exacerbations with increased sputum purulence/volume and worsening dyspnoea"])

h2("Investigations (both forms)")
bullets(["Clinical diagnosis in acute bronchitis; chest X-ray to exclude pneumonia if red flags present",
         "Spirometry - to differentiate simple chronic bronchitis from COPD (obstructive pattern: reduced FEV1/FVC)",
         "Sputum culture - in prolonged/severe cases or exacerbations",
         "ABG and pulse oximetry - in chronic bronchitis with respiratory compromise",
         "FBC - polycythaemia may be seen in chronic hypoxaemia"])

h2("Medical Management (Chronic Bronchitis / overlap with COPD)")
bullets(["Smoking cessation - most important measure", "Bronchodilators (LAMA/LABA) and inhaled corticosteroids as per COPD guidelines",
         "Mucolytics (e.g. N-acetylcysteine) to aid sputum clearance",
         "Prompt antibiotics for infective exacerbations (increased purulence, sputum volume, dyspnoea)",
         "Vaccination against influenza and pneumococcus",
         "Long-term oxygen therapy in advanced hypoxaemic disease"])

h2("Complications")
bullets(["Progression to COPD/emphysema", "Recurrent chest infections/pneumonia", "Cor pulmonale and respiratory failure",
         "Secondary polycythaemia"])

h2("Physiotherapy Management")
bullets([
    ("Airway clearance techniques - ", "ACBT, postural drainage, percussion and vibration, and PEP (positive "
     "expiratory pressure) devices to mobilise and clear excess mucus in chronic bronchitis."),
    ("Breathing exercises - ", "diaphragmatic breathing and pursed-lip breathing to reduce breathlessness and improve ventilation."),
    ("Effective/huff coughing techniques", "to minimise fatigue while maximising secretion clearance."),
    ("Graded exercise training/pulmonary rehabilitation", "to improve exercise tolerance and reduce dyspnoea in chronic cases."),
    ("Patient/family education - ", "smoking cessation support, avoidance of irritants, early recognition of exacerbation signs."),
    ("In acute bronchitis - ", "physiotherapy is usually not required unless secretions are difficult to clear; rest and supportive advice are the mainstay."),
])

doc.add_page_break()

# =====================================================================================
# TOPIC 6: BRONCHIECTASIS
# =====================================================================================
h1("6. Bronchiectasis")

h2("Definition")
para("Bronchiectasis is an acquired, irreversible chronic condition characterised anatomically by abnormal, "
     "permanent dilatation and destruction of bronchial walls, and clinically by chronic productive cough "
     "with copious purulent sputum and recurrent lower respiratory tract infections.")

h2("Aetiology / Causes")
bullets([
    ("Post-infective - ", "severe/necrotising pneumonia, tuberculosis, whooping cough (pertussis), measles - a common cause where treatment is delayed."),
    ("Congenital/genetic - ", "cystic fibrosis (a leading cause, especially presenting cause in children), "
     "primary ciliary dyskinesia (dyskinetic cilia syndrome), alpha-1 antitrypsin deficiency."),
    ("Immunodeficiency - ", "primary (hypogammaglobulinaemia) or secondary (HIV) immune deficiency."),
    ("Allergic bronchopulmonary aspergillosis (ABPA) - ", "if diagnosis/treatment delayed."),
    ("Bronchial obstruction - ", "foreign body, tumour, enlarged lymph nodes causing distal dilatation."),
    ("Connective tissue/autoimmune disease - ", "rheumatoid arthritis, ulcerative colitis."),
    ("Idiopathic - ", "no cause identified in a significant proportion of cases."),
])

h2("Pathophysiology")
para("Recurrent cycles of infection and inflammation destroy the elastic and muscular components of the "
     "bronchial wall, leading to permanent dilatation. Impaired mucociliary clearance leads to mucus "
     "stagnation, which promotes chronic bacterial colonisation (commonly Haemophilus influenzae, "
     "Pseudomonas aeruginosa in advanced disease), perpetuating a vicious cycle of infection-inflammation-"
     "airway damage. Morphological patterns include cylindrical, varicose (fusiform), and cystic (saccular) "
     "bronchiectasis, in increasing order of severity.")

h2("Clinical Features")
bullets([
    "Chronic cough productive of large amounts of thick, mucopurulent, tenacious sputum (classically worse in the morning)",
    "'Dry bronchiectasis' - some patients have minimal/absent sputum, especially early disease",
    "Recurrent chest infections/exacerbations with fever and increased sputum purulence",
    "Haemoptysis - can range from streaking to massive, due to hypertrophied bronchial arteries",
    "Dyspnoea and wheeze in advanced/diffuse disease",
    "Finger clubbing (in significant chronic suppurative disease)",
    "Coarse crackles on auscultation, typically over the affected lobe(s), that may change with coughing",
    "Weight loss and fatigue in chronic severe disease",
])

h2("Investigations")
bullets([
    ("High-resolution CT (HRCT) chest - ", "investigation of choice; shows bronchial wall thickening, luminal "
     "dilatation ('tram-track' and 'signet ring' signs), lack of tapering of airways."),
    ("Chest X-ray - ", "may show dilated, thickened airways ('tramline shadows'), and cystic spaces; can be normal in mild disease."),
    ("Sputum culture (routine, AFB, fungal) - ", "identifies causative/colonising organisms, guides antibiotic choice."),
    ("Full blood count and differential - ", "eosinophilia raises suspicion for ABPA."),
    ("Serum immunoglobulins (IgA, IgG, IgM) - ", "to screen for immunodeficiency."),
    ("Sweat chloride test/CFTR genetic testing - ", "if cystic fibrosis suspected, especially in childhood-onset disease."),
    ("Spirometry - ", "typically shows an obstructive pattern."),
    ("Aspergillus IgE/precipitins - ", "screening for ABPA."),
])

h2("Medical Management")
bullets([
    "No cure other than surgical resection of a severely affected, localised segment/lobe in select cases",
    "High-dose/prolonged antibiotic therapy for exacerbations (fever with increased sputum volume/purulence), guided by sputum culture",
    "Long-term prophylactic/rotating antibiotics or inhaled antibiotics (e.g. for chronic Pseudomonas colonisation) in frequent exacerbators",
    "Bronchodilators for associated airflow obstruction/wheeze",
    "Mucolytics and hyperosmolar agents (hypertonic saline, mannitol) to aid secretion clearance",
    "Treatment of the underlying cause where identifiable (e.g. immunoglobulin replacement, CF-specific therapy, ABPA treatment with steroids/antifungals)",
    "Vaccination (influenza, pneumococcal)",
    "Surgery (lobectomy) - reserved for localised disease with recurrent severe symptoms or massive haemoptysis unresponsive to medical management/embolisation",
])

h2("Complications")
bullets(["Recurrent pneumonia", "Massive/life-threatening haemoptysis", "Lung abscess and empyema",
         "Cor pulmonale and respiratory failure in extensive disease", "Amyloidosis (secondary, rare, from chronic suppuration)",
         "Metastatic infection (rare)"])

h2("Physiotherapy Management")
para("Airway clearance is the cornerstone of bronchiectasis management, since cough alone is the most "
     "important natural mechanism of secretion clearance and physiotherapy augments this.", bold_lead="Key principle:")
bullets([
    ("Active Cycle of Breathing Technique (ACBT) - ", "combination of breathing control, thoracic expansion "
     "exercises, and the forced expiration technique (huffing) to mobilise and clear secretions."),
    ("Postural drainage - ", "positioning to use gravity to help drain secretions from specific bronchopulmonary segments, combined with percussion/vibration as tolerated."),
    ("Positive Expiratory Pressure (PEP) devices and oscillating PEP (e.g. Acapella, Flutter) - ", "to splint airways open and mobilise secretions."),
    ("Autogenic drainage - ", "controlled breathing at varying lung volumes to shift secretions from peripheral to central airways for expectoration."),
    ("High-frequency chest wall oscillation (vest therapy) - ", "in selected patients with copious secretions."),
    ("Exercise training/pulmonary rehabilitation - ", "improves exercise tolerance, aids secretion clearance, and reduces exacerbation frequency."),
    ("Inspiratory muscle training", "for patients with respiratory muscle weakness."),
    ("Precautions - ", "avoid vigorous percussion during active haemoptysis; adapt airway clearance intensity during acute exacerbations."),
    ("Patient education - ", "daily home airway clearance regimen, hydration, recognising early signs of exacerbation, and self-management plans."),
])

doc.save("/tmp/workspace/gen-med-notes/General_Medicine_Notes_Physiotherapy.docx")
print("Saved.")