Local Examination of the Thyroid Gland

import matplotlib
matplotlib.use('Agg')
import matplotlib.pyplot as plt
import matplotlib.patches as mpatches
from matplotlib.patches import FancyBboxPatch, FancyArrowPatch
import matplotlib.patheffects as pe
from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import cm, mm
from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Image as RLImage, PageBreak, Table, TableStyle
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT
from reportlab.platypus import HRFlowable
import os

OUT_DIR = "/tmp/workspace/thyroid-exam/"
IMG_DIR = OUT_DIR + "imgs/"
os.makedirs(IMG_DIR, exist_ok=True)

# ─── Color Palette ────────────────────────────────────────────────────────────
C_HEADER   = "#1a3a5c"   # dark navy
C_BOX      = "#2471a3"   # blue
C_BOX2     = "#1a8a6e"   # teal
C_BOX3     = "#8e44ad"   # purple
C_BOX4     = "#c0392b"   # red
C_BOX5     = "#d68910"   # amber
C_ARROW    = "#2c3e50"
C_LIGHT    = "#d6eaf8"
C_LIGHT2   = "#d5f5e3"
C_LIGHT3   = "#e8daef"
C_LIGHT4   = "#fadbd8"
C_LIGHT5   = "#fef9e7"
C_WHITE    = "#ffffff"
C_TEXT     = "#1c2833"
C_SUBTEXT  = "#566573"

# ─── Helper: draw a rounded box ───────────────────────────────────────────────
def rbox(ax, x, y, w, h, text, bg, fg="#ffffff", fontsize=9, bold=False,
         radius=0.04, wrap=True, border=None):
    box = FancyBboxPatch((x - w/2, y - h/2), w, h,
                         boxstyle=f"round,pad=0.01,rounding_size={radius}",
                         facecolor=bg, edgecolor=border or bg,
                         linewidth=1.5, zorder=3)
    ax.add_patch(box)
    weight = "bold" if bold else "normal"
    ax.text(x, y, text, ha="center", va="center", fontsize=fontsize,
            color=fg, weight=weight, wrap=wrap, zorder=4,
            multialignment="center",
            bbox=dict(boxstyle="round,pad=0.01", fc="none", ec="none"))

def arrow(ax, x1, y1, x2, y2, color=C_ARROW, lw=1.5, style="-|>"):
    ax.annotate("", xy=(x2, y2), xytext=(x1, y1),
                arrowprops=dict(arrowstyle=style, color=color,
                                lw=lw, connectionstyle="arc3,rad=0.0"))

def diamond(ax, cx, cy, w, h, text, bg, fg="#ffffff", fontsize=8.5):
    xs = [cx, cx+w/2, cx, cx-w/2, cx]
    ys = [cy+h/2, cy, cy-h/2, cy, cy+h/2]
    ax.fill(xs, ys, color=bg, zorder=3)
    ax.plot(xs, ys, color=bg, lw=1.5, zorder=4)
    ax.text(cx, cy, text, ha="center", va="center", fontsize=fontsize,
            color=fg, weight="bold", zorder=5, multialignment="center")

def save_fig(fig, name):
    path = IMG_DIR + name
    fig.savefig(path, dpi=160, bbox_inches="tight", facecolor="white")
    plt.close(fig)
    return path

# ══════════════════════════════════════════════════════════════════════════════
# FLOWCHART 1 – OVERALL LOCAL EXAMINATION OVERVIEW
# ══════════════════════════════════════════════════════════════════════════════
def fc_overview():
    fig, ax = plt.subplots(figsize=(14, 9))
    ax.set_xlim(0, 14); ax.set_ylim(0, 9)
    ax.axis("off")
    ax.set_facecolor("#f7f9fc")
    fig.patch.set_facecolor("#f7f9fc")

    ax.text(7, 8.55, "LOCAL EXAMINATION OF THYROID GLAND",
            ha="center", va="center", fontsize=14, color=C_HEADER,
            weight="bold", style="italic")
    ax.text(7, 8.2, "A Systematic Approach",
            ha="center", va="center", fontsize=10, color=C_SUBTEXT)

    # Main start node
    rbox(ax, 7, 7.7, 3.2, 0.55, "START: Patient Seated / Positioned", C_HEADER, fontsize=9.5, bold=True)
    arrow(ax, 7, 7.42, 7, 7.05)

    # 5 branches
    steps = [
        (2.0, "A\nINSPECTION", C_BOX),
        (4.5, "B\nPALPATION", C_BOX2),
        (7.0, "C\nPERCUSSION", C_BOX3),
        (9.5, "D\nAUSCULTATION", C_BOX4),
        (12.0, "E\nMEASUREMENT", C_BOX5),
    ]

    for bx, label, col in steps:
        arrow(ax, 7, 7.05, bx, 6.6, color=col)
        rbox(ax, bx, 6.3, 1.8, 0.6, label, col, fontsize=10, bold=True)

    # Sub-bullets for each
    subs = {
        2.0: ["Pizzillo's Method", "Swelling type\n(uniform / nodular)", "Movement on\ndeglutition", "Thyroglossal cyst\nvs Thyroid", "Retrosternal signs\n& Pemberton's sign"],
        4.5: ["Neck flexed", "From behind\n& front", "Lahey's Method", "Crile's Method", "10 Key Points\nto Note"],
        7.0: ["Over manubrium\nsterni", "Detect retrosternal\ngoiter", "(Mainly theoretical)"],
        9.5: ["Systolic bruit\nin toxic goiter", "Trachea position\nby stethoscope"],
        12.0: ["Circumference\nat prominent part", "Serial measurements\nto track change"],
    }

    ycur = {bx: 5.8 for bx, _, _ in steps}
    colors_map = {2.0: C_LIGHT, 4.5: C_LIGHT2, 7.0: C_LIGHT3, 9.5: C_LIGHT4, 12.0: C_LIGHT5}
    fg_map     = {2.0: C_BOX,   4.5: C_BOX2,   7.0: C_BOX3,   9.5: C_BOX4,  12.0: C_BOX5}

    for bx, _, col in steps:
        for txt in subs[bx]:
            arrow(ax, bx, ycur[bx] - 0.1, bx, ycur[bx] - 0.45, color=fg_map[bx])
            rbox(ax, bx, ycur[bx] - 0.6, 1.75, 0.42,
                 txt, colors_map[bx], fg=fg_map[bx], fontsize=7.5, border=fg_map[bx])
            ycur[bx] -= 1.05

    # End node
    rbox(ax, 7, 0.45, 4.5, 0.5, "RECORD FINDINGS & FORM CLINICAL DIAGNOSIS", C_HEADER, fontsize=9.5, bold=True)

    save_fig(fig, "fc_overview.png")


# ══════════════════════════════════════════════════════════════════════════════
# FLOWCHART 2 – INSPECTION FLOWCHART
# ══════════════════════════════════════════════════════════════════════════════
def fc_inspection():
    fig, ax = plt.subplots(figsize=(13, 17))
    ax.set_xlim(0, 13); ax.set_ylim(0, 17)
    ax.axis("off")
    ax.set_facecolor("#f7f9fc")
    fig.patch.set_facecolor("#f7f9fc")

    ax.text(6.5, 16.6, "FLOWCHART: INSPECTION OF THYROID GLAND",
            ha="center", fontsize=13, color=C_HEADER, weight="bold")

    # ── Step 1
    rbox(ax, 6.5, 16.0, 5.5, 0.55, "STEP 1: Position the Patient", C_HEADER, fontsize=10, bold=True)
    arrow(ax, 6.5, 15.72, 6.5, 15.3)

    rbox(ax, 6.5, 15.1, 8.0, 0.5,
         "Normal neck - is thyroid visible? (Obese / short-necked → harder to inspect)",
         C_BOX, fontsize=9)
    arrow(ax, 6.5, 14.85, 6.5, 14.45)

    diamond(ax, 6.5, 14.1, 3.2, 0.6, "Is thyroid\nvisible?", C_BOX, fontsize=9)

    # YES branch → right
    arrow(ax, 8.1, 14.1, 10.5, 14.1, color="green")
    rbox(ax, 11.5, 14.1, 2.0, 0.5, "YES → Note\nswelling type", "#1a8a6e", fontsize=8.5)

    # NO branch → down → Pizzillo
    arrow(ax, 6.5, 13.8, 6.5, 13.4, color="#c0392b")
    rbox(ax, 6.5, 13.15, 6.5, 0.45, "NO → Use PIZZILLO'S METHOD", C_BOX2, fontsize=9, bold=True)
    rbox(ax, 6.5, 12.55, 8.5, 0.75,
         "Patient: Hands behind head, push head\nbackwards against clasped hands on occiput",
         C_LIGHT2, fg=C_BOX2, fontsize=8.5, border=C_BOX2)
    arrow(ax, 6.5, 12.17, 6.5, 11.75)

    # ── Step 2: Swelling Type
    rbox(ax, 6.5, 11.52, 5.5, 0.55, "STEP 2: Classify Swelling Type", C_HEADER, fontsize=10, bold=True)
    arrow(ax, 6.5, 11.24, 6.5, 10.85)

    diamond(ax, 6.5, 10.5, 3.8, 0.6, "Uniform OR\nNodular?", C_BOX, fontsize=9)

    # UNIFORM → left
    arrow(ax, 4.6, 10.5, 2.5, 10.5, color=C_BOX2)
    rbox(ax, 1.5, 10.5, 2.0, 0.55, "UNIFORM", C_BOX2, fontsize=9, bold=True)
    subs_u = ["Physiological\nGoiter", "Colloid Goiter", "Hashimoto's\nDisease"]
    for i, s in enumerate(subs_u):
        arrow(ax, 1.5, 10.22 - i*0.9, 1.5, 9.85 - i*0.9, color=C_BOX2)
        rbox(ax, 1.5, 9.7 - i*0.9, 1.9, 0.4, s, C_LIGHT2, fg=C_BOX2, fontsize=8, border=C_BOX2)

    # NODULAR → right
    arrow(ax, 8.4, 10.5, 10.5, 10.5, color=C_BOX3)
    rbox(ax, 11.5, 10.5, 2.0, 0.55, "NODULAR", C_BOX3, fontsize=9, bold=True)
    subs_n = ["Multinodular\nGoiter", "Lateral neck:\nLymph node\nmets from hidden\nthyroid ca."]
    for i, s in enumerate(subs_n):
        arrow(ax, 11.5, 10.22 - i*1.0, 11.5, 9.8 - i*1.0, color=C_BOX3)
        rbox(ax, 11.5, 9.6 - i*1.0, 1.9, 0.5, s, C_LIGHT3, fg=C_BOX3, fontsize=8, border=C_BOX3)

    # ── Step 3: Deglutition
    arrow(ax, 6.5, 10.2, 6.5, 9.3)
    rbox(ax, 6.5, 9.1, 5.5, 0.55, "STEP 3: Ask Patient to SWALLOW", C_HEADER, fontsize=10, bold=True)
    arrow(ax, 6.5, 8.82, 6.5, 8.45)

    diamond(ax, 6.5, 8.1, 4.0, 0.6, "Does swelling move\nUPWARDS?", C_BOX, fontsize=9)

    # YES
    arrow(ax, 8.5, 8.1, 10.5, 8.1, color="green")
    rbox(ax, 11.5, 8.1, 2.3, 0.5, "YES: Likely\nTHYROID / related", "#1a8a6e", fontsize=8.5)
    subs_yes = ["Thyroid goiter", "Thyroglossal cyst", "Subhyoid bursitis", "Prelaryngeal LN\nfixed to larynx"]
    for i, s in enumerate(subs_yes):
        arrow(ax, 11.5, 7.85 - i*0.75, 11.5, 7.55 - i*0.75, color="#1a8a6e")
        rbox(ax, 11.5, 7.4 - i*0.75, 2.1, 0.38, s, C_LIGHT2, fg="#1a8a6e", fontsize=7.5, border="#1a8a6e")

    # NO
    arrow(ax, 4.5, 8.1, 2.5, 8.1, color="#c0392b")
    rbox(ax, 1.5, 8.1, 2.2, 0.5, "NO: Movement\nlimited / fixed", C_BOX4, fontsize=8.5)
    subs_no = ["Malignant\ninfiltration", "Chronic\nthyroiditis", "Retrosternal\ngoiter"]
    for i, s in enumerate(subs_no):
        arrow(ax, 1.5, 7.85 - i*0.75, 1.5, 7.55 - i*0.75, color=C_BOX4)
        rbox(ax, 1.5, 7.4 - i*0.75, 2.1, 0.38, s, C_LIGHT4, fg=C_BOX4, fontsize=7.5, border=C_BOX4)

    # ── Step 4: Thyroglossal cyst check
    arrow(ax, 6.5, 7.8, 6.5, 7.0)
    rbox(ax, 6.5, 6.78, 5.5, 0.55, "STEP 4: Protrude the TONGUE", C_HEADER, fontsize=10, bold=True)
    arrow(ax, 6.5, 6.5, 6.5, 6.1)

    diamond(ax, 6.5, 5.75, 4.2, 0.6, "Does swelling move UP\nwith tongue protrusion?", C_BOX, fontsize=9)
    arrow(ax, 8.6, 5.75, 10.5, 5.75, color="green")
    rbox(ax, 11.5, 5.75, 2.3, 0.65, "YES:\nTHYROGLOSSAL\nCYST\n(Pathognomonic)", "#1a8a6e", fontsize=8.5, bold=True)

    arrow(ax, 4.4, 5.75, 2.3, 5.75, color="#c0392b")
    rbox(ax, 1.4, 5.75, 2.3, 0.5, "NO:\nNot thyroglossal\ncyst", C_BOX4, fontsize=8.5)

    # ── Step 5: Retrosternal
    arrow(ax, 6.5, 5.45, 6.5, 4.85)
    rbox(ax, 6.5, 4.65, 5.5, 0.55, "STEP 5: Check for RETROSTERNAL GOITER", C_HEADER, fontsize=10, bold=True)
    arrow(ax, 6.5, 4.37, 6.5, 4.0)

    rbox(ax, 6.5, 3.72, 9.0, 0.55,
         "Ask patient to raise BOTH ARMS above head until they touch the ears\n(Maintain position for a while) — PEMBERTON'S SIGN",
         C_BOX5, fontsize=8.5, bold=True)
    arrow(ax, 6.5, 3.44, 6.5, 3.05)

    diamond(ax, 6.5, 2.7, 4.5, 0.6, "Congestion of face\n+ distress appear?", C_BOX5, fontsize=8.5)
    arrow(ax, 8.75, 2.7, 10.5, 2.7, color="#d68910")
    rbox(ax, 11.5, 2.7, 2.4, 0.55, "POSITIVE:\nRetrosternal\nGoiter suspected", C_BOX5, fontsize=8.5, bold=True)
    arrow(ax, 4.25, 2.7, 2.3, 2.7, color="#566573")
    rbox(ax, 1.3, 2.7, 2.2, 0.5, "NEGATIVE:\nNo retrosternal\ngoiter", C_SUBTEXT, fontsize=8.5)

    # Also: subcutaneous veins
    rbox(ax, 6.5, 1.9, 9.0, 0.55,
         "Also inspect: Dilated subcutaneous veins over upper anterior thorax\n→ Also suggests retrosternal goiter / great vein compression",
         C_LIGHT4, fg=C_BOX4, fontsize=8.5, border=C_BOX4)

    arrow(ax, 6.5, 1.62, 6.5, 1.2)
    rbox(ax, 6.5, 1.0, 5.0, 0.45, "PROCEED TO PALPATION", C_HEADER, fontsize=10, bold=True)

    save_fig(fig, "fc_inspection.png")


# ══════════════════════════════════════════════════════════════════════════════
# FLOWCHART 3 – PALPATION FLOWCHART
# ══════════════════════════════════════════════════════════════════════════════
def fc_palpation():
    fig, ax = plt.subplots(figsize=(14, 20))
    ax.set_xlim(0, 14); ax.set_ylim(0, 20)
    ax.axis("off")
    ax.set_facecolor("#f7f9fc")
    fig.patch.set_facecolor("#f7f9fc")

    ax.text(7, 19.6, "FLOWCHART: PALPATION OF THYROID GLAND",
            ha="center", fontsize=13, color=C_HEADER, weight="bold")

    # Setup
    rbox(ax, 7, 19.1, 5.5, 0.55, "SETUP: Patient seated, neck slightly FLEXED", C_HEADER, fontsize=10, bold=True)
    arrow(ax, 7, 18.82, 7, 18.45)

    # Method choice
    diamond(ax, 7, 18.1, 4.5, 0.6, "Choose palpation\napproach", C_BOX, fontsize=9)

    # From behind
    arrow(ax, 4.75, 18.1, 2.5, 18.1, color=C_BOX2)
    rbox(ax, 1.5, 18.1, 2.5, 0.7, "FROM BEHIND\n(Standard)", C_BOX2, fontsize=9, bold=True)
    rbox(ax, 1.5, 17.3, 2.5, 0.85,
         "Examiner behind patient\nThumbs on back of neck\n4 fingers on each lobe\n& isthmus",
         C_LIGHT2, fg=C_BOX2, fontsize=8, border=C_BOX2)

    # From front - Lahey
    arrow(ax, 9.25, 18.1, 11.0, 18.1, color=C_BOX3)
    rbox(ax, 12.0, 18.1, 2.5, 0.7, "LAHEY'S METHOD\n(From front)", C_BOX3, fontsize=9, bold=True)
    rbox(ax, 12.0, 17.3, 2.5, 0.95,
         "Examiner in front\nPush gland to LEFT\n→ palpate LEFT lobe\nwith right hand\n(vice versa)",
         C_LIGHT3, fg=C_BOX3, fontsize=8, border=C_BOX3)

    # Crile
    arrow(ax, 7, 17.8, 7, 17.4)
    rbox(ax, 7, 17.15, 5.5, 0.6, "CRILE'S METHOD (During swallowing)", C_BOX5, fontsize=9, bold=True)
    rbox(ax, 7, 16.6, 7.5, 0.65,
         "Thumb placed on thyroid while patient swallows\n→ Slight enlargement / nodules detected by movement",
         C_LIGHT5, fg=C_BOX5, fontsize=8.5, border=C_BOX5)

    arrow(ax, 7, 16.27, 7, 15.85)

    # ── 10 Key Points
    rbox(ax, 7, 15.6, 7.0, 0.6, "10 KEY POINTS TO NOTE DURING PALPATION", C_HEADER, fontsize=10.5, bold=True)
    arrow(ax, 7, 15.3, 7, 14.9)

    pts = [
        ("(i) Whole Gland Enlargement?",
         C_BOX, C_LIGHT,
         ["Smooth surface → Primary thyrotoxicosis / Colloid goiter",
          "Bosselated → Multinodular goiter",
          "Firm → Primary thyrotoxicosis / Hashimoto's",
          "Soft → Colloid goiter",
          "Hard/variable → Riedel's thyroiditis / Carcinoma"]),
        ("(ii) Localized Swelling?",
         C_BOX2, C_LIGHT2,
         ["Note: position, size, shape, extent, consistency",
          "Cystic → often feels FIRM (high internal tension)",
          "Calcified cyst → may feel HARD"]),
        ("(iii) Mobility?",
         C_BOX3, C_LIGHT3,
         ["Check horizontal AND vertical planes",
          "FIXITY → Malignant tumor OR chronic thyroiditis"]),
        ("(iv) Retrosternal Extension Test?",
         C_BOX4, C_LIGHT4,
         ["Index finger on lower border",
          "Patient swallows → gland moves up",
          "Check if lower border has downward extension"]),
        ("(v) Pressure Effects?",
         "#7d6608", "#fef9e7",
         ["Trachea/Larynx → Stridor, dyspnea",
          "Esophagus → Dysphagia",
          "Recurrent laryngeal nerve → Hoarseness",
          "Carotid sheath (benign) → pulsation felt posteriorly",
          "Carotid sheath (malignant) → pulsation ABSENT",
          "Sympathetic trunk → Horner's syndrome",
          "Veins → Pemberton's sign positive"]),
        ("(vi) Toxic Manifestation?",
         C_BOX, C_LIGHT,
         ["Primary toxic: small gland, nervous system affected",
          "Secondary toxic: enlarged/nodular, cardiovascular affected"]),
        ("(vii) Myxedema?",
         C_BOX2, C_LIGHT2,
         ["Look for features of hypothyroidism"]),
        ("(viii) Malignant vs Benign?",
         C_BOX3, C_LIGHT3,
         ["Hard, fixed, irregular → malignant features",
          "Soft, mobile, smooth → benign features"]),
        ("(ix) Pulsation / Thrill?",
         C_BOX4, C_LIGHT4,
         ["Present in primary toxic goiter (hypervascular)"]),
        ("(x) Cervical Lymph Nodes?",
         "#6e2fa1", "#e8daef",
         ["Very important in malignancy",
          "Papillary carcinoma → early lymphatic spread",
          "Small primary + enlarged LN → 'aberrant thyroid'\n(actually metastatic nodes)"]),
    ]

    ypos = 14.65
    for label, bcol, lcol, subs in pts:
        rbox(ax, 7, ypos, 11.0, 0.5, label, bcol, fontsize=9.5, bold=True)
        ypos -= 0.65
        for s in subs:
            rbox(ax, 7, ypos, 10.8, 0.42, "• " + s, lcol, fg=C_TEXT, fontsize=8.5, border=bcol)
            ypos -= 0.5
        ypos -= 0.25
        if ypos < 0.5:
            break

    # Kocher test
    rbox(ax, 7, ypos - 0.1, 11.0, 0.55, "KOCHER'S TEST", C_BOX4, fontsize=10, bold=True)
    ypos -= 0.7
    rbox(ax, 7, ypos, 11.0, 0.55,
         "Gently compress lateral lobes → STRIDOR produced = POSITIVE (narrowed trachea)",
         C_LIGHT4, fg=C_BOX4, fontsize=9, border=C_BOX4)
    ypos -= 0.65
    rbox(ax, 7, ypos, 11.0, 0.42,
         "Positive in: Multinodular goiter | Carcinoma infiltrating trachea ('Scabbard trachea' on X-ray)",
         C_LIGHT4, fg=C_BOX4, fontsize=8.5, border=C_BOX4)

    save_fig(fig, "fc_palpation.png")


# ══════════════════════════════════════════════════════════════════════════════
# FLOWCHART 4 – PRESSURE EFFECTS DETAIL
# ══════════════════════════════════════════════════════════════════════════════
def fc_pressure():
    fig, ax = plt.subplots(figsize=(13, 11))
    ax.set_xlim(0, 13); ax.set_ylim(0, 11)
    ax.axis("off")
    ax.set_facecolor("#f7f9fc")
    fig.patch.set_facecolor("#f7f9fc")

    ax.text(6.5, 10.65, "FLOWCHART: PRESSURE EFFECTS OF THYROID SWELLING",
            ha="center", fontsize=13, color=C_HEADER, weight="bold")

    rbox(ax, 6.5, 10.1, 6.0, 0.55, "THYROID SWELLING (Enlargement)", C_HEADER, fontsize=10.5, bold=True)

    structures = [
        (1.0, "TRACHEA /\nLARYNX", C_BOX, ["Stridor\n(inspiratory noise)", "Dyspnea", "+Kocher's test"]),
        (3.3, "ESOPHAGUS", C_BOX2, ["Dysphagia"]),
        (5.5, "RECURRENT\nLARYNGEAL N.", C_BOX3, ["Hoarseness\nof voice"]),
        (7.8, "CAROTID\nSHEATH", C_BOX4, ["Benign:\nCarotid pulsation\nfelt POSTERIORLY", "Malignant:\nCarotid pulsation\nABSENT (engulfed)"]),
        (10.5, "SYMPATHETIC\nTRUNK", "#7d6608", ["HORNER'S\nSYNDROME\n(see below)"]),
    ]

    for bx, name, col, effects in structures:
        arrow(ax, 6.5, 9.82, bx, 9.3, color=col)
        rbox(ax, bx, 9.05, 2.2, 0.55, name, col, fontsize=9, bold=True)
        yy = 8.55
        for eff in effects:
            arrow(ax, bx, yy, bx, yy - 0.4, color=col)
            rbox(ax, bx, yy - 0.6, 2.1, 0.42, eff,
                 col + "33" if len(col) == 7 else "#d5f5e3",
                 fg=col, fontsize=8.5, border=col)
            yy -= 1.15

    # Horner's syndrome box
    rbox(ax, 6.5, 5.4, 9.5, 0.55, "HORNER'S SYNDROME (Sympathetic trunk compression)", "#7d6608", fontsize=10, bold=True)
    horner = [
        (2.5, "Enophthalmos", "Slight sinking\nof eyeball\ninto orbit"),
        (5.0, "Pseudoptosis", "Slight drooping\nof upper eyelid"),
        (7.8, "Miosis", "Contraction\nof pupil"),
        (10.5, "Anhidrosis", "Absence of sweating\non affected side\nof face"),
    ]
    for bx, title, desc in horner:
        arrow(ax, 6.5, 5.12, bx, 4.7, color="#7d6608")
        rbox(ax, bx, 4.45, 2.3, 0.55, title, "#7d6608", fontsize=9, bold=True)
        arrow(ax, bx, 4.17, bx, 3.82, color="#7d6608")
        rbox(ax, bx, 3.6, 2.2, 0.5, desc, "#fef9e7", fg="#7d6608", fontsize=8.5, border="#7d6608")

    # Venous obstruction
    rbox(ax, 6.5, 2.75, 9.5, 0.55, "GREAT VEIN OBSTRUCTION (Retrosternal extension)", C_BOX4, fontsize=10, bold=True)
    vein_items = [
        (3.0, "Neck vein\nengorgement"),
        (6.5, "Pemberton's Sign\n(Arms raised → face\ncongestion + distress)"),
        (10.5, "Dilated subcutaneous\nveins over upper\nanterior thorax"),
    ]
    for bx, desc in vein_items:
        arrow(ax, 6.5, 2.47, bx, 2.1, color=C_BOX4)
        rbox(ax, bx, 1.82, 2.8, 0.5, desc, C_LIGHT4, fg=C_BOX4, fontsize=8.5, border=C_BOX4)

    save_fig(fig, "fc_pressure.png")


# ══════════════════════════════════════════════════════════════════════════════
# FLOWCHART 5 – SPECIAL TESTS SUMMARY
# ══════════════════════════════════════════════════════════════════════════════
def fc_special_tests():
    fig, ax = plt.subplots(figsize=(13, 10))
    ax.set_xlim(0, 13); ax.set_ylim(0, 10)
    ax.axis("off")
    ax.set_facecolor("#f7f9fc")
    fig.patch.set_facecolor("#f7f9fc")

    ax.text(6.5, 9.65, "FLOWCHART: SPECIAL / EPONYMOUS TESTS",
            ha="center", fontsize=13, color=C_HEADER, weight="bold")
    ax.text(6.5, 9.25, "Local Examination of Thyroid",
            ha="center", fontsize=10, color=C_SUBTEXT)

    tests = [
        # (x-center, name, what, how, positive finding, significance, color)
        (2.2, "PIZZILLO'S\nMETHOD", "Inspection aid",
         "Hands behind head;\npatient pushes head\nback against clasped hands",
         "Thyroid swelling\nbecomes visible",
         "Makes inspection\neasier in obese /\nshort-necked",
         C_BOX),
        (5.1, "LAHEY'S\nMETHOD", "Palpation",
         "Examiner in front;\npush gland to one side\npalpate opposite lobe",
         "Better palpation\nof each lobe",
         "Detects nodules\nin single lobe",
         C_BOX2),
        (8.0, "CRILE'S\nMETHOD", "Palpation during\nswallowing",
         "Thumb on thyroid\npatient swallows",
         "Movement felt\nunder thumb",
         "Detects slight\nenlargement /<br/>small nodules",
         C_BOX3),
        (10.9, "KOCHER'S\nTEST", "Tracheal compression",
         "Gentle lateral\ncompression of\nboth lobes",
         "STRIDOR\nproduced",
         "Narrowed trachea\n(multinodular /\ncarcinoma)",
         C_BOX4),
    ]

    for bx, name, cat, how, positive, sig, col in tests:
        # Title
        rbox(ax, bx, 8.5, 2.3, 0.65, name, col, fontsize=10, bold=True)
        labels = ["Category", "How to perform", "Positive finding", "Clinical significance"]
        vals   = [cat, how, positive, sig]
        colors2 = [col+"44" if len(col)==7 else "#d5f5e3",
                   col+"22" if len(col)==7 else "#eaf7f0",
                   "#fadbd8", "#eaf0fb"]
        yy = 8.0
        for lbl, val, cc in zip(labels, vals, colors2):
            rbox(ax, bx, yy - 0.15, 2.3, 0.38, lbl, col, fontsize=7.5, bold=True)
            yy -= 0.48
            # count lines
            lines = val.count('\n') + 1
            h = 0.38 * lines
            rbox(ax, bx, yy - h/2 + 0.06, 2.3, max(0.4, h), val,
                 C_LIGHT if col==C_BOX else C_LIGHT2 if col==C_BOX2 else C_LIGHT3 if col==C_BOX3 else C_LIGHT4,
                 fg=col, fontsize=8.0, border=col)
            yy -= (h + 0.22)

    # Pemberton's Sign
    rbox(ax, 6.5, 2.2, 11.5, 0.6, "PEMBERTON'S SIGN", C_BOX5, fontsize=11, bold=True)
    rbox(ax, 6.5, 1.65, 11.5, 0.55,
         "How: Patient raises BOTH arms above head until they touch the ears (held for a while)",
         C_LIGHT5, fg=C_BOX5, fontsize=9, border=C_BOX5)
    rbox(ax, 6.5, 1.12, 5.5, 0.5,
         "POSITIVE: Congestion of face + distress",
         C_BOX5, fontsize=9, bold=True)
    rbox(ax, 6.5, 0.55, 8.0, 0.5,
         "Significance: Retrosternal goiter causing obstruction of great veins at thoracic inlet",
         C_LIGHT5, fg=C_BOX5, fontsize=8.5, border=C_BOX5)

    save_fig(fig, "fc_special_tests.png")


# ══════════════════════════════════════════════════════════════════════════════
# BUILD PDF
# ══════════════════════════════════════════════════════════════════════════════
def build_pdf():
    print("Generating flowchart images...")
    fc_overview()
    fc_inspection()
    fc_palpation()
    fc_pressure()
    fc_special_tests()
    print("All images generated.")

    pdf_path = OUT_DIR + "Thyroid_Local_Examination_Flowcharts.pdf"
    doc = SimpleDocTemplate(pdf_path, pagesize=A4,
                            topMargin=1.5*cm, bottomMargin=1.5*cm,
                            leftMargin=1.5*cm, rightMargin=1.5*cm)

    styles = getSampleStyleSheet()
    title_style = ParagraphStyle("title", parent=styles["Title"],
                                 fontSize=18, textColor=colors.HexColor(C_HEADER),
                                 spaceAfter=6, alignment=TA_CENTER)
    sub_style   = ParagraphStyle("sub", parent=styles["Normal"],
                                 fontSize=11, textColor=colors.HexColor(C_SUBTEXT),
                                 spaceAfter=12, alignment=TA_CENTER)
    head_style  = ParagraphStyle("head", parent=styles["Heading2"],
                                 fontSize=13, textColor=colors.HexColor(C_HEADER),
                                 spaceBefore=10, spaceAfter=6)
    body_style  = ParagraphStyle("body", parent=styles["Normal"],
                                 fontSize=9.5, textColor=colors.HexColor(C_TEXT),
                                 spaceAfter=4, leading=14)

    W = A4[0] - 3*cm   # usable width

    def img(name, scale=1.0):
        path = IMG_DIR + name
        from PIL import Image as PILImage
        pil = PILImage.open(path)
        iw, ih = pil.size
        aspect = ih / iw
        w = W * scale
        h = w * aspect
        return RLImage(path, width=w, height=h)

    story = []

    # ── Cover ──
    story.append(Spacer(1, 2*cm))
    story.append(Paragraph("LOCAL EXAMINATION OF", title_style))
    story.append(Paragraph("THYROID GLAND", title_style))
    story.append(Spacer(1, 0.4*cm))
    story.append(Paragraph("Detailed Flowcharts for Clinical Examination", sub_style))
    story.append(Spacer(1, 0.3*cm))
    story.append(HRFlowable(width="80%", thickness=2, color=colors.HexColor(C_HEADER)))
    story.append(Spacer(1, 0.5*cm))

    cover_items = [
        ("Flowchart 1", "Overview of Local Examination"),
        ("Flowchart 2", "Inspection — Step-by-Step"),
        ("Flowchart 3", "Palpation — Methods & 10 Key Points"),
        ("Flowchart 4", "Pressure Effects of Thyroid Swelling"),
        ("Flowchart 5", "Special / Eponymous Clinical Tests"),
    ]
    for num, title in cover_items:
        story.append(Paragraph(f"<b>{num}:</b>  {title}", body_style))

    story.append(Spacer(1, 0.5*cm))
    story.append(HRFlowable(width="80%", thickness=1, color=colors.HexColor(C_SUBTEXT)))
    story.append(PageBreak())

    # ── Pages ──
    pages = [
        ("fc_overview.png",      "Flowchart 1: Overview of Local Examination",
         "This flowchart presents the five pillars of local thyroid examination in sequence: Inspection → Palpation → Percussion → Auscultation → Measurement. Each step is broken into its key components. Use this as a quick-reference overview before diving into each step in detail."),
        ("fc_inspection.png",    "Flowchart 2: Inspection — Step-by-Step",
         "Inspection proceeds through five stages: (1) Positioning, including Pizzillo's method for difficult cases; (2) Classifying the swelling as uniform or nodular; (3) Observing movement on deglutition — the cardinal sign of thyroid origin; (4) Testing tongue protrusion for thyroglossal cyst; and (5) Pemberton's sign for retrosternal goiter."),
        ("fc_palpation.png",     "Flowchart 3: Palpation — Methods & 10 Key Points",
         "Palpation can be performed from behind (standard), using Lahey's method (from the front), or Crile's method (thumb during swallowing). The examiner must systematically assess 10 key points including surface character, consistency, mobility, retrosternal extension, pressure effects, toxic features, myxedema, malignancy signs, pulsation/thrill, and cervical lymph nodes. Kocher's test for tracheal compression is performed here."),
        ("fc_pressure.png",      "Flowchart 4: Pressure Effects of Thyroid Swelling",
         "An enlarging thyroid can compress five main structures: the trachea/larynx (stridor, dyspnea), esophagus (dysphagia), recurrent laryngeal nerve (hoarseness), carotid sheath (pulsation changes), and the sympathetic trunk (Horner's syndrome). Great vein obstruction in retrosternal goiter manifests as neck vein engorgement, dilated chest wall veins, and a positive Pemberton's sign."),
        ("fc_special_tests.png", "Flowchart 5: Special / Eponymous Clinical Tests",
         "Five named tests are used in thyroid examination: Pizzillo's method (inspection aid), Lahey's method (single-lobe palpation), Crile's method (swallowing palpation), Kocher's test (tracheal narrowing), and Pemberton's sign (retrosternal goiter / great vein obstruction). Each is shown with its technique, positive finding, and clinical significance."),
    ]

    for fc_img, heading, desc in pages:
        story.append(Paragraph(heading, head_style))
        story.append(Paragraph(desc, body_style))
        story.append(Spacer(1, 0.3*cm))
        story.append(img(fc_img, scale=1.0))
        story.append(PageBreak())

    doc.build(story)
    print(f"PDF saved: {pdf_path}")
    return pdf_path

path = build_pdf()
print("DONE:", path)

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/thyroid-exam/generate_pdf.py'