from docx import Document
from docx.shared import Pt, RGBColor, Inches
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement

doc = Document()

# ── Page margins ──
from docx.shared import Inches
section = doc.sections[0]
section.left_margin = Inches(1)
section.right_margin = Inches(1)
section.top_margin = Inches(1)
section.bottom_margin = Inches(1)

# ── Styles ──
normal_style = doc.styles["Normal"]
normal_style.font.name = "Arial"
normal_style.font.size = Pt(11)

def add_title(doc, text):
    p = doc.add_heading(text, level=0)
    p.alignment = WD_ALIGN_PARAGRAPH.CENTER
    run = p.runs[0]
    run.font.color.rgb = RGBColor(0x1F, 0x49, 0x7D)
    run.font.size = Pt(18)

def add_h1(doc, text):
    p = doc.add_heading(text, level=1)
    run = p.runs[0]
    run.font.color.rgb = RGBColor(0x1F, 0x49, 0x7D)
    run.font.size = Pt(14)

def add_h2(doc, text):
    p = doc.add_heading(text, level=2)
    run = p.runs[0]
    run.font.color.rgb = RGBColor(0x2E, 0x74, 0xB5)
    run.font.size = Pt(12)

def add_h3(doc, text):
    p = doc.add_heading(text, level=3)
    run = p.runs[0]
    run.font.color.rgb = RGBColor(0x21, 0x96, 0xF3)
    run.font.size = Pt(11)

def add_body(doc, text):
    doc.add_paragraph(text)

def add_bullet(doc, text, level=0):
    p = doc.add_paragraph(style="List Bullet")
    p.paragraph_format.left_indent = Inches(0.25 * (level + 1))
    p.add_run(text)

def add_key_box(doc, text):
    """Add a shaded key concepts paragraph."""
    p = doc.add_paragraph()
    run = p.add_run(text)
    run.font.bold = True
    run.font.color.rgb = RGBColor(0xC0, 0x00, 0x00)
    shd = OxmlElement('w:shd')
    shd.set(qn('w:val'), 'clear')
    shd.set(qn('w:color'), 'auto')
    shd.set(qn('w:fill'), 'FFF2CC')
    p._p.get_or_add_pPr().append(shd)

def add_mcq(doc, num, question, options, answer, explanation):
    p = doc.add_paragraph()
    run = p.add_run(f"Q{num}. {question}")
    run.font.bold = True
    run.font.size = Pt(11)
    for opt in options:
        doc.add_paragraph(opt, style="List Number")
    p2 = doc.add_paragraph()
    r2 = p2.add_run(f"Answer: {answer}")
    r2.font.bold = True
    r2.font.color.rgb = RGBColor(0x1F, 0x78, 0x1F)
    r2.font.size = Pt(10)
    p3 = doc.add_paragraph()
    r3 = p3.add_run(f"Explanation: {explanation}")
    r3.font.italic = True
    r3.font.size = Pt(10)
    doc.add_paragraph("")

# ════════════════════════════════════════════════════
#  TITLE PAGE
# ════════════════════════════════════════════════════
add_title(doc, "ROBBINS PATHOLOGY — CHAPTER 10: THE HEART")
p = doc.add_paragraph("Comprehensive Notes + UHS-Pattern MCQs")
p.alignment = WD_ALIGN_PARAGRAPH.CENTER
p.runs[0].font.size = Pt(13)
p.runs[0].font.italic = True
doc.add_paragraph("")
doc.add_page_break()

# ════════════════════════════════════════════════════
#  SECTION 1: CARDIAC STRUCTURE AND SPECIALIZATIONS
# ════════════════════════════════════════════════════
add_h1(doc, "1. CARDIAC STRUCTURE AND SPECIALIZATIONS")
add_body(doc, "Heart weight averages ~0.4–0.5% of body weight (300–375 g in females; 360–450 g in males).")
add_bullet(doc, "Cardiomegaly = increased weight/size due to hypertrophy and/or dilation")
add_bullet(doc, "Hypertrophy = increased wall thickness (pressure overload)")
add_bullet(doc, "Dilation = enlarged chamber (volume overload)")

add_h2(doc, "1.1 Myocardium")
add_bullet(doc, "Left ventricular myocytes: spiral circumferential orientation → vigorous contraction apex to base")
add_bullet(doc, "Right ventricular myocytes: longitudinal fiber contraction + bellows-like effect")
add_bullet(doc, "Atrial cardiomyocytes store Atrial Natriuretic Peptide (ANP) in cytoplasmic granules")
add_bullet(doc, "Ventricular myocytes produce B-type Natriuretic Peptide (BNP)")
add_bullet(doc, "Both ANP and BNP: promote vasodilation + renal salt & water excretion (natriuresis/diuresis)")
add_bullet(doc, "Myocardium is terminally differentiated — largely nonproliferative after neonatal life")
add_bullet(doc, "Myocardial stem cells have very limited replicative potential in vivo")

add_h2(doc, "1.2 Cardiac Valves")
add_bullet(doc, "Four valves: Tricuspid, Pulmonary, Mitral, Aortic — maintain unidirectional blood flow")
add_bullet(doc, "Semilunar valves (aortic, pulmonary): function depends on cusp integrity and root dimension")
add_bullet(doc, "Atrioventricular valves (mitral, tricuspid): depend on leaflets, chordae tendineae, papillary muscles, ventricular configuration")
add_bullet(doc, "Valve layers:")
add_bullet(doc, "Fibrosa: dense collagenous layer at outflow surface", level=1)
add_bullet(doc, "Spongiosa: loose connective tissue / proteoglycans on inflow side", level=1)
add_bullet(doc, "Ventricularis/Atrialis: endothelium-lined inflow surface", level=1)
add_bullet(doc, "Normal valves are avascular — nourished by diffusion from blood")

add_h2(doc, "1.3 Conduction System")
add_bullet(doc, "SA node (pacemaker) → AV node → Bundle of His → Left/Right bundle branches → Purkinje fibers")
add_bullet(doc, "SA node: intramural coronary artery branch of RCA or LCx")
add_bullet(doc, "AV node: blood supply from posterior descending artery (RCA in 90% of patients)")
add_bullet(doc, "Accessory pathways (e.g., Bundle of Kent) → Wolff-Parkinson-White (WPW) syndrome")

add_h2(doc, "1.4 Effects of Aging on the Heart")
add_bullet(doc, "Sigmoid septum: age-related hypertrophy of basal ventricular septum → LVOT obstruction")
add_bullet(doc, "Calcification of the mitral annulus and aortic valve cusps")
add_bullet(doc, "Brown atrophy: lipofuscin accumulation in myocytes of elderly/cachectic patients")
add_bullet(doc, "Increased LV wall thickness, decreased compliance (diastolic dysfunction)")
add_bullet(doc, "Aortic atherosclerosis, reduced arterial elasticity")

doc.add_page_break()

# ════════════════════════════════════════════════════
#  SECTION 2: OVERVIEW OF CARDIAC PATHOPHYSIOLOGY
# ════════════════════════════════════════════════════
add_h1(doc, "2. OVERVIEW OF CARDIAC PATHOPHYSIOLOGY")

add_h2(doc, "2.1 Cardiac Hypertrophy")
add_bullet(doc, "Concentric hypertrophy: increased wall thickness without chamber dilation — pressure overload (e.g., hypertension, aortic stenosis)")
add_bullet(doc, "Eccentric hypertrophy: chamber dilation WITH wall thickening — volume overload (e.g., mitral/aortic regurgitation)")
add_bullet(doc, "Molecular signals: mechanical stretch, neurohumoral factors (catecholamines, angiotensin II, IGF-1)")
add_bullet(doc, "Hypertrophied myocytes: larger, more mitochondria, more myofilaments, increased protein synthesis")
add_bullet(doc, "Long-term: pathological hypertrophy → apoptosis → fibrosis → heart failure")

add_h2(doc, "2.2 Response to Pressure vs Volume Overload")
add_bullet(doc, "Pressure overload → parallel sarcomere addition → wall thickening (concentric)")
add_bullet(doc, "Volume overload → series sarcomere addition → chamber dilation (eccentric)")

doc.add_page_break()

# ════════════════════════════════════════════════════
#  SECTION 3: HEART FAILURE
# ════════════════════════════════════════════════════
add_h1(doc, "3. HEART FAILURE (CONGESTIVE HEART FAILURE)")
add_body(doc, "Heart failure (HF) is the inability of the heart to pump sufficient blood to meet the body's metabolic demands, or can do so only at elevated filling pressures.")

add_h2(doc, "3.1 Pathophysiology and Compensatory Mechanisms")
add_bullet(doc, "Frank-Starling mechanism: increased preload → increased contractility (limited in severe HF)")
add_bullet(doc, "Neurohormonal activation: catecholamines, RAAS, ADH, ANP/BNP")
add_bullet(doc, "Myocardial hypertrophy and remodeling")
add_bullet(doc, "Tachycardia (increased HR)")
add_bullet(doc, "Long-term: these compensatory mechanisms become maladaptive → worsening failure")

add_h2(doc, "3.2 Left-Sided Heart Failure")
add_bullet(doc, "Causes: ischemic heart disease (most common), hypertension, aortic/mitral valve disease, myocardial disease")
add_bullet(doc, "Pathology:")
add_bullet(doc, "Left ventricular hypertrophy/dilation", level=1)
add_bullet(doc, "Lung congestion: pulmonary edema, hemosiderin-laden macrophages ('heart failure cells') in alveoli", level=1)
add_bullet(doc, "Brown induration of the lung (chronic congestion)", level=1)
add_bullet(doc, "Clinical features:")
add_bullet(doc, "Dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND)", level=1)
add_bullet(doc, "Pulmonary rales/crackles", level=1)
add_bullet(doc, "S3 gallop, displaced apex beat", level=1)
add_bullet(doc, "Reduced exercise tolerance", level=1)

add_h2(doc, "3.3 Right-Sided Heart Failure")
add_bullet(doc, "Most common cause: left-sided heart failure (cor pulmonale = RHF due to lung disease)")
add_bullet(doc, "Pathology:")
add_bullet(doc, "Right ventricular hypertrophy/dilation", level=1)
add_bullet(doc, "Hepatomegaly, splenomegaly, congestive hepatopathy ('nutmeg liver')", level=1)
add_bullet(doc, "Peripheral pitting edema, ascites, pleural effusion", level=1)
add_bullet(doc, "Congestive splenomegaly", level=1)
add_bullet(doc, "Clinical features:")
add_bullet(doc, "Jugular venous distension (JVD)", level=1)
add_bullet(doc, "Dependent edema (ankle/sacral)", level=1)
add_bullet(doc, "Hepatojugular reflux", level=1)
add_bullet(doc, "Right upper quadrant pain (liver capsule distension)", level=1)

add_key_box(doc, "KEY: Heart failure cells = hemosiderin-laden alveolar macrophages in left HF. Nutmeg liver = centrilobular congestion in right HF.")

doc.add_page_break()

# ════════════════════════════════════════════════════
#  SECTION 4: CONGENITAL HEART DISEASE
# ════════════════════════════════════════════════════
add_h1(doc, "4. CONGENITAL HEART DISEASE (CHD)")
add_body(doc, "CHD occurs in 0.5–1% of live births. Most common cause of cardiovascular disease under 30 years old in developed countries. Precise cause unknown in ~90% of cases.")

add_h2(doc, "4.1 Etiology")
add_bullet(doc, "Multifactorial: genetic + environmental")
add_bullet(doc, "Key transcription factors: GATA4, TBX5, NKX2.5 (mutations → ASD, VSD)")
add_bullet(doc, "Notch pathway mutations → bicuspid aortic valve (NOTCH1), Tetralogy of Fallot (JAG1, NOTCH2)")
add_bullet(doc, "Marfan syndrome (fibrillin mutations) → valvular defects, aortic aneurysm")
add_bullet(doc, "Environmental: maternal rubella → PDA, pulmonary stenosis; thalidomide; alcohol → fetal alcohol syndrome (ASD/VSD)")
add_bullet(doc, "Chromosomal: Trisomy 21 (Down syndrome) → AV septal defects; Turner syndrome → bicuspid aortic valve, coarctation")

add_h2(doc, "4.2 Shunts: Left-to-Right (Acyanotic — Initially)")
add_body(doc, "L→R shunts increase pulmonary blood flow. Cyanosis is absent initially but can develop (Eisenmenger syndrome).")

add_h3(doc, "Ventricular Septal Defect (VSD)")
add_bullet(doc, "Most common CHD (~30% of all CHD)")
add_bullet(doc, "90% in membranous (perimembranous) septum")
add_bullet(doc, "Small VSDs may close spontaneously; large ones → pulmonary hypertension → Eisenmenger syndrome")
add_bullet(doc, "Loud, harsh pansystolic murmur at left lower sternal border")

add_h3(doc, "Atrial Septal Defect (ASD)")
add_bullet(doc, "Three types: Ostium secundum (most common, ~90%), Ostium primum (near AV valves), Sinus venosus (near SVC)")
add_bullet(doc, "Fixed split S2, pulmonary flow murmur")
add_bullet(doc, "May present in adults as AF, paradoxical embolism")

add_h3(doc, "Patent Ductus Arteriosus (PDA)")
add_bullet(doc, "Failure of ductus arteriosus to close after birth")
add_bullet(doc, "Continuous 'machinery' murmur, wide pulse pressure")
add_bullet(doc, "Associated with maternal rubella and prematurity")
add_bullet(doc, "Treatment: indomethacin (prostaglandin synthesis inhibitor); surgical ligation")

add_h3(doc, "Atrioventricular Septal Defect (AVSD)")
add_bullet(doc, "Combined ASD + VSD + malformation of AV valves")
add_bullet(doc, "Strong association with Down syndrome (Trisomy 21)")

add_h2(doc, "4.3 Shunts: Right-to-Left (Cyanotic)")
add_body(doc, "R→L shunts: hypoxemia, cyanosis, polycythemia, clubbing, paradoxical embolism.")

add_h3(doc, "Tetralogy of Fallot (TOF)")
add_bullet(doc, "Most common cyanotic CHD (~5% of all CHD)")
add_bullet(doc, "FOUR components (mnemonic: PROVE):")
add_bullet(doc, "Pulmonary stenosis (RVOT obstruction) — KEY lesion", level=1)
add_bullet(doc, "Right ventricular hypertrophy", level=1)
add_bullet(doc, "Overriding aorta", level=1)
add_bullet(doc, "VSD", level=1)
add_bullet(doc, "Pathogenesis: anterosuperior displacement of the infundibular septum")
add_bullet(doc, "Boot-shaped heart (coeur en sabot) on X-ray")
add_bullet(doc, "Tet spells: hypercyanotic episodes, relieved by squatting (increases SVR → reduces R→L shunt)")
add_bullet(doc, "Degree of cyanosis depends on severity of pulmonary stenosis")

add_h3(doc, "Transposition of the Great Arteries (TGA)")
add_bullet(doc, "Aorta arises from RV; pulmonary artery from LV → two parallel circulations")
add_bullet(doc, "Not compatible with life unless mixing occurs (ASD, VSD, PDA)")
add_bullet(doc, "Most common cyanotic CHD in the NEONATAL period")
add_bullet(doc, "Treatment: prostaglandin E1 (keeps PDA open), Rashkind balloon atrial septostomy, arterial switch operation")

add_h3(doc, "Truncus Arteriosus")
add_bullet(doc, "Failure of separation of embryologic truncus → single great vessel overrides both ventricles")
add_bullet(doc, "Always associated with a VSD")
add_bullet(doc, "Immediate mixing → mild cyanosis")

add_h3(doc, "Tricuspid Atresia")
add_bullet(doc, "Complete absence of tricuspid valve → obligate R→L shunt via ASD")
add_bullet(doc, "Hypoplastic right ventricle")

add_h2(doc, "4.4 Obstructive Lesions (No Shunt)")

add_h3(doc, "Coarctation of the Aorta")
add_bullet(doc, "Narrowing of the aorta, usually at or near ductus arteriosus (ligamentum arteriosum)")
add_bullet(doc, "Infantile type: preductal (proximal to ductus) — cyanosis in lower body, HF in infancy")
add_bullet(doc, "Adult type: postductal — hypertension in upper extremities, weak femoral pulses")
add_bullet(doc, "Collateral circulation via intercostal arteries → rib notching on X-ray")
add_bullet(doc, "Associated with: Turner syndrome, bicuspid aortic valve, berry aneurysms of Circle of Willis")
add_bullet(doc, "Radio-femoral delay; 3-sign on CXR")

add_h3(doc, "Aortic Stenosis (Congenital)")
add_bullet(doc, "Valvular AS: most common — may be bicuspid (fusion of 2 cusps)")
add_bullet(doc, "Subvalvular: fibromuscular ring or shelf below valve")
add_bullet(doc, "Supravalvular: Williams syndrome (ELN gene mutation — Elfin facies, hypercalcemia)")

add_h2(doc, "4.5 Eisenmenger Syndrome")
add_bullet(doc, "Reversal of L→R shunt → R→L shunt due to pulmonary hypertension")
add_bullet(doc, "Irreversible pulmonary vascular disease → surgery contraindicated once established")
add_bullet(doc, "Late cyanosis, clubbing, polycythemia")

add_key_box(doc, "KEY: TOF = most common cyanotic CHD overall; TGA = most common in neonates. VSD = most common CHD overall.")

doc.add_page_break()

# ════════════════════════════════════════════════════
#  SECTION 5: ISCHEMIC HEART DISEASE
# ════════════════════════════════════════════════════
add_h1(doc, "5. ISCHEMIC HEART DISEASE (IHD)")
add_body(doc, "IHD is the leading cause of death in developed countries. >90% caused by coronary artery atherosclerosis.")

add_h2(doc, "5.1 Pathogenesis")
add_bullet(doc, "Mismatch between coronary supply and myocardial demand")
add_bullet(doc, "Critical stenosis: >70% fixed stenosis → stable angina on exertion")
add_bullet(doc, "Plaque rupture/erosion → acute thrombosis → unstable angina/NSTEMI/STEMI")
add_bullet(doc, "Vasospasm (Prinzmetal angina), embolism: less common causes")

add_h2(doc, "5.2 Syndromes of IHD")
add_h3(doc, "Stable Angina")
add_bullet(doc, "Chronic stenosing atherosclerosis (>70% stenosis)")
add_bullet(doc, "Chest pain with exertion, relieved by rest/nitroglycerin")
add_bullet(doc, "Crushing/squeezing substernal pain radiating to left arm/jaw")
add_bullet(doc, "ST depression on ECG during episode")

add_h3(doc, "Prinzmetal (Variant) Angina")
add_bullet(doc, "Coronary artery spasm (vasospasm) — NOT related to exertion")
add_bullet(doc, "Can occur at rest, responds to vasodilators/calcium channel blockers")
add_bullet(doc, "Transient ST elevation on ECG")

add_h3(doc, "Unstable Angina")
add_bullet(doc, "Plaque fissure/rupture → platelet aggregation, vasoconstriction, mural thrombus (non-occlusive)")
add_bullet(doc, "Pain at rest or with minimal exertion; increasing frequency/severity")
add_bullet(doc, "Part of Acute Coronary Syndrome (ACS) spectrum — no troponin rise")

add_h3(doc, "Acute Myocardial Infarction (MI)")
add_bullet(doc, "Typically from acute occlusive thrombosis after plaque rupture (often not critically stenotic beforehand)")
add_bullet(doc, "Ischemia → loss of function within 1–2 minutes")
add_bullet(doc, "Necrosis after 20–40 minutes of sustained ischemia")

add_h2(doc, "5.3 Morphology of Myocardial Infarction")
add_h3(doc, "Gross Changes (Temporal Sequence)")
add_bullet(doc, "0–6 hours: NO gross changes (only electron microscopy changes)")
add_bullet(doc, "6–12 hours: Pallor, mottling begins")
add_bullet(doc, "12–24 hours: Pallor becomes evident; coagulative necrosis begins")
add_bullet(doc, "1–3 days: Yellow pallor; neutrophil infiltration at margins")
add_bullet(doc, "3–7 days: Hyperemic borders; yellow-tan center, maximal softening → risk of RUPTURE")
add_bullet(doc, "7–10 days: MAXIMUM softening — highest risk of ventricular rupture")
add_bullet(doc, "10 days–8 weeks: Grey-white scar formation begins; depressed scar")
add_bullet(doc, ">8 weeks: Dense, white fibrous scar")

add_h3(doc, "Histological Changes")
add_bullet(doc, "0–6 hrs: Wavy fibers (earliest change); coagulative necrosis beginning")
add_bullet(doc, "12–24 hrs: Eosinophilic, hypereosinophilic myocytes; contraction band necrosis in reperfused areas")
add_bullet(doc, "1–3 days: Neutrophil infiltration")
add_bullet(doc, "3–7 days: Macrophage infiltration (phagocytosis of dead myocytes)")
add_bullet(doc, "1–3 weeks: Granulation tissue; fibroblasts; neovascularization")
add_bullet(doc, ">6 weeks: Dense collagen scar (white fibrous scar)")

add_h3(doc, "Laboratory Diagnosis of MI")
add_bullet(doc, "Troponin I and T: most sensitive/specific — rise at 3–4 hrs, peak at 12–24 hrs, normalize in 10–14 days")
add_bullet(doc, "CK-MB: rises at 4–8 hrs, peaks 18–24 hrs, normalizes in 48–72 hrs (used for reinfarction)")
add_bullet(doc, "Myoglobin: earliest (1–4 hrs) but NOT cardiac-specific")
add_bullet(doc, "LDH: late rise — useful for late presenters; LDH1 > LDH2 = 'flipped LDH' pattern in MI")
add_bullet(doc, "ECG changes: STEMI = ST elevation → Q waves; NSTEMI = ST depression/T-wave changes, no Q waves")

add_h2(doc, "5.4 Complications of MI")
add_bullet(doc, "Arrhythmias (most common cause of DEATH in first 24 hours — VF)")
add_bullet(doc, "Cardiogenic shock: massive infarction (>40% LV), pump failure")
add_bullet(doc, "Free wall rupture (Day 3–7): hemopericardium → cardiac tamponade; 'catastrophic' — often fatal")
add_bullet(doc, "Ventricular septal rupture (Day 3–7): sudden VSD → acute RHF/LHF")
add_bullet(doc, "Papillary muscle rupture: acute mitral regurgitation → acute pulmonary edema")
add_bullet(doc, "Mural thrombus: overlying infarcted endocardium → systemic embolism")
add_bullet(doc, "Ventricular aneurysm: late complication — fibrous outpouching, arrhythmias, thrombus; paradoxical motion on echo")
add_bullet(doc, "Pericarditis: Dressler syndrome (autoimmune, 2–8 weeks post-MI — fever, pleuritis, pericarditis)")
add_bullet(doc, "Chronic IHD / ischemic cardiomyopathy: progressive HF from prior infarctions")

add_h2(doc, "5.5 Reperfusion Injury")
add_bullet(doc, "Reperfusion salvages ischemic myocardium but may cause additional injury")
add_bullet(doc, "Reperfusion injury: due to reactive oxygen species, Ca2+ overload, inflammation")
add_bullet(doc, "Contraction band necrosis: pathognomonic of reperfused infarction")
add_bullet(doc, "Can paradoxically cause arrhythmias (reperfusion VF), microvascular obstruction ('no-reflow')")

add_key_box(doc, "KEY CONCEPT: Earliest histologic change in MI = wavy fibers (4–12 hrs). Earliest biochemical = myoglobin (1–4 hrs). Most specific = Troponin. Peak risk of rupture = Day 3–7.")

doc.add_page_break()

# ════════════════════════════════════════════════════
#  SECTION 6: SUDDEN CARDIAC DEATH
# ════════════════════════════════════════════════════
add_h1(doc, "6. SUDDEN CARDIAC DEATH (SCD)")
add_body(doc, "Unexpected death from cardiac causes within 1 hour of symptom onset (or in previously asymptomatic individuals, within 24 hours of last known alive).")
add_bullet(doc, "Leading cause of SCD: coronary artery disease (CAD) — >80% of cases")
add_bullet(doc, "Mechanism: lethal arrhythmia (usually VF) due to ischemic injury/scar")
add_bullet(doc, "Structural causes in young adults: HCM (most common), ARVC, channelopathies, congenital anomalies")
add_bullet(doc, "Non-structural: Long QT syndrome, Brugada syndrome, WPW syndrome")
add_bullet(doc, "Commotio cordis: blunt chest trauma causing VF without structural damage")
add_bullet(doc, "Pathology: critical coronary atherosclerosis (even without acute thrombosis); old scars; LVH")

doc.add_page_break()

# ════════════════════════════════════════════════════
#  SECTION 7: VALVULAR HEART DISEASE
# ════════════════════════════════════════════════════
add_h1(doc, "7. VALVULAR HEART DISEASE")

add_h2(doc, "7.1 Mitral Valve Prolapse (MVP)")
add_bullet(doc, "Ballooning/floppy mitral leaflets prolapse into LA during systole")
add_bullet(doc, "Most common valvular abnormality (2–3% of population)")
add_bullet(doc, "Myxomatous degeneration of valve substance (spongiosa expansion)")
add_bullet(doc, "Associations: Marfan syndrome, Ehlers-Danlos, OI")
add_bullet(doc, "Clinical: mid-systolic click followed by late systolic murmur")
add_bullet(doc, "Complications: MR, infective endocarditis, arrhythmias, rarely SCD")
add_bullet(doc, "Gross: billowing leaflets; histology: myxomatous change (mucoid degeneration)")

add_h2(doc, "7.2 Rheumatic Heart Disease (RHD)")
add_bullet(doc, "Follows Group A beta-hemolytic Streptococcus (GAS) pharyngitis — 2–4 weeks later")
add_bullet(doc, "Molecular mimicry: anti-strep antibodies cross-react with cardiac antigens")
add_bullet(doc, "Pancarditis (endocarditis + myocarditis + pericarditis)")

add_h3(doc, "Acute Rheumatic Fever — Jones Criteria")
add_bullet(doc, "MAJOR criteria: Carditis, Polyarthritis (migratory), Sydenham chorea, Subcutaneous nodules, Erythema marginatum")
add_bullet(doc, "MINOR criteria: Fever, Arthralgia, Elevated ESR/CRP, Prolonged PR interval")
add_bullet(doc, "Diagnosis: evidence of preceding GAS infection + 2 major OR 1 major + 2 minor")

add_h3(doc, "Pathology of Acute Rheumatic Carditis")
add_bullet(doc, "ASCHOFF BODIES: pathognomonic — foci of fibrinoid necrosis surrounded by lymphocytes + Anitschkow cells ('caterpillar cells' — large macrophages with elongated wavy chromatin)")
add_bullet(doc, "Verrucous vegetations: small, wart-like, along line of valve closure (mitral most common)")
add_bullet(doc, "MacCallum patches: irregular thickening of posterior left atrial wall")
add_bullet(doc, "Pericarditis: 'bread and butter' fibrinous pericarditis")

add_h3(doc, "Chronic Rheumatic Heart Disease")
add_bullet(doc, "Mitral valve most commonly affected (65–70%), then mitral + aortic, aortic alone, rarely others")
add_bullet(doc, "Mitral stenosis: commissural fusion → 'fish-mouth' stenosis; calcification")
add_bullet(doc, "Complications: LA dilation → AF → mural thrombus → systemic embolism")
add_bullet(doc, "Pulmonary hypertension → RV hypertrophy")
add_bullet(doc, "Histology: neovascularization, transmural fibrosis; Aschoff bodies rare in chronic disease")

add_h2(doc, "7.3 Degenerative Calcific Aortic Stenosis")
add_bullet(doc, "Most common cause of aortic stenosis in adults >65 years old")
add_bullet(doc, "Calcification of aortic valve cusps WITHOUT commissural fusion (distinguishes from RHD)")
add_bullet(doc, "Tricuspid aortic valve calcification: age-related wear and tear")
add_bullet(doc, "Bicuspid aortic valve: congenital; calcifies earlier (50s–60s) vs tricuspid (70s–80s)")
add_bullet(doc, "Classic triad of AS: Syncope, Angina, Heart Failure (Dyspnea)")
add_bullet(doc, "Crescendo-decrescendo systolic murmur at right second intercostal space → radiates to neck")

add_h2(doc, "7.4 Mitral Annular Calcification")
add_bullet(doc, "Degenerative calcification of the mitral annulus")
add_bullet(doc, "Usually asymptomatic; may cause MR, arrhythmias, conduction defects")
add_bullet(doc, "More common in elderly women, Marfan syndrome, elevated LV pressure")

add_h2(doc, "7.5 Infective Endocarditis (IE)")
add_bullet(doc, "Microbial infection of heart valves or endocardium, forming vegetations")

add_h3(doc, "Classification")
add_bullet(doc, "Acute IE: highly virulent organism (e.g., S. aureus) → normal valve, rapid destruction")
add_bullet(doc, "Subacute IE (SBE): low virulence (e.g., Streptococcus viridans) → abnormal/prosthetic valve, insidious onset")

add_h3(doc, "Organisms")
add_bullet(doc, "Native valve IE: S. viridans (most common overall), S. aureus (increasing, esp. IVDA), Enterococcus")
add_bullet(doc, "IVDA (IV drug abusers): S. aureus (most common), right-sided (tricuspid) endocarditis")
add_bullet(doc, "Prosthetic valve (early, <60 days): S. epidermidis (coagulase-negative staph)")
add_bullet(doc, "Prosthetic valve (late, >60 days): S. viridans")
add_bullet(doc, "Culture-negative IE: HACEK organisms (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella), Coxiella burnetti (Q fever), Bartonella")
add_bullet(doc, "Dental/oral procedures → S. viridans")
add_bullet(doc, "GI/GU procedures → Enterococcus, S. bovis (colorectal cancer marker)")

add_h3(doc, "Pathology")
add_bullet(doc, "Vegetations: large, irregular, friable, destructive masses on valve leaflets")
add_bullet(doc, "Acute IE: large, destructive vegetations → perforation/rupture of leaflets")
add_bullet(doc, "Subacute IE: smaller vegetations with less destruction")
add_bullet(doc, "Histology: fibrin, inflammatory cells, bacteria within vegetation")

add_h3(doc, "Clinical Features and Osler's Triad")
add_bullet(doc, "Fever, new/changing murmur, embolic phenomena")
add_bullet(doc, "Peripheral stigmata:")
add_bullet(doc, "Osler nodes: tender, red nodules on finger/toe pads (immune complex deposition)", level=1)
add_bullet(doc, "Janeway lesions: non-tender hemorrhagic macules on palms/soles (septic emboli)", level=1)
add_bullet(doc, "Roth spots: oval retinal hemorrhages with pale centers", level=1)
add_bullet(doc, "Splinter hemorrhages: subungual", level=1)
add_bullet(doc, "Petechiae, splenomegaly, hematuria (glomerulonephritis)", level=1)
add_bullet(doc, "Duke criteria used for diagnosis (major + minor criteria)")
add_bullet(doc, "Complications: valvular destruction → HF; septic emboli → stroke, abscess; glomerulonephritis; myocardial abscess")

add_h2(doc, "7.6 Non-Bacterial Thrombotic Endocarditis (NBTE)")
add_bullet(doc, "Also called Marantic endocarditis")
add_bullet(doc, "Small, sterile vegetations along line of valve closure")
add_bullet(doc, "Associated with: debilitating illness (cancer, sepsis, burns, malnutrition, DIC)")
add_bullet(doc, "No valve destruction; emboli can occur")
add_bullet(doc, "Vegetations at the line of closure (unlike IE where they are on both surfaces)")

add_h2(doc, "7.7 Libman-Sacks Endocarditis (LSE)")
add_bullet(doc, "Seen in Systemic Lupus Erythematosus (SLE)")
add_bullet(doc, "Small, irregular, sterile vegetations on BOTH surfaces of mitral and tricuspid valves")
add_bullet(doc, "Most characteristic feature: vegetations on UNDERSURFACE of valve (unlike NBTE/RHD)")
add_bullet(doc, "Associated with antiphospholipid antibody syndrome")

add_key_box(doc, "KEY COMPARISON: RHD = vegetations along line of closure, commissural fusion, fish-mouth. IE = large, destructive vegetations. NBTE = small, sterile, line of closure. LSE (SLE) = both surfaces, no commissural fusion.")

doc.add_page_break()

# ════════════════════════════════════════════════════
#  SECTION 8: CARDIOMYOPATHIES
# ════════════════════════════════════════════════════
add_h1(doc, "8. CARDIOMYOPATHIES")
add_body(doc, "Primary disease of the myocardium not explained by hypertension, valve disease, CAD, or congenital disease.")

add_h2(doc, "8.1 Dilated Cardiomyopathy (DCM)")
add_bullet(doc, "Most common cardiomyopathy (~90% of cases)")
add_bullet(doc, "Progressive cardiac dilation + systolic dysfunction (↓ EF)")
add_bullet(doc, "ALL four chambers dilated; ventricular walls thin (despite hypertrophy)")
add_bullet(doc, "Etiology:")
add_bullet(doc, "Idiopathic (most common — possibly post-viral)", level=1)
add_bullet(doc, "Familial/genetic: 25–35% of cases — mutations in sarcomeric proteins, cytoskeletal proteins (titin, dystrophin)", level=1)
add_bullet(doc, "Myocarditis (viral — Coxsackie B, adenovirus, HIV)", level=1)
add_bullet(doc, "Toxic: alcohol (#1 toxin), doxorubicin (anthracyclines), cobalt, cocaine", level=1)
add_bullet(doc, "Peripartum cardiomyopathy (last month of pregnancy or within 5 months of delivery)", level=1)
add_bullet(doc, "Hemochromatosis, sarcoidosis, amyloidosis, thyroid disease", level=1)
add_bullet(doc, "Morphology: globular, heavy heart; mural thrombi; microscopy = interstitial fibrosis")
add_bullet(doc, "Clinical: HF symptoms, low EF (<40%), S3 gallop, pulmonary congestion, JVD, edema")
add_bullet(doc, "ECG: LBBB common; arrhythmias; CXR: 'bottle-shaped' cardiac silhouette")
add_bullet(doc, "Treatment: ACE inhibitors, beta-blockers, diuretics; ICD for arrhythmia prevention; transplant")

add_h2(doc, "8.2 Hypertrophic Cardiomyopathy (HCM)")
add_bullet(doc, "Prevalence 1 in 500 (relatively common)")
add_bullet(doc, "DIASTOLIC dysfunction with preserved systolic function (unlike DCM)")
add_bullet(doc, "Leading cause of SCD in young athletes")
add_bullet(doc, "Mutations in sarcomeric proteins — most commonly beta-myosin heavy chain (MYH7) and MyBP-C")
add_bullet(doc, "Autosomal dominant with variable penetrance")

add_h3(doc, "Pathology")
add_bullet(doc, "Massive myocardial hypertrophy, usually asymmetric septal hypertrophy (ASH)")
add_bullet(doc, "Dynamic LVOT obstruction in 25–30% of cases")
add_bullet(doc, "SAM (Systolic Anterior Motion) of anterior mitral leaflet → dynamic obstruction + MR")
add_bullet(doc, "Microscopy (HALLMARK): myocyte disarray — disorganized, whirled bundles of hypertrophied myocytes with interstitial fibrosis")

add_h3(doc, "Clinical Features")
add_bullet(doc, "Dyspnea (most common symptom), angina, syncope")
add_bullet(doc, "Harsh systolic ejection murmur that INCREASES with Valsalva/standing and DECREASES with squatting/leg raise")
add_bullet(doc, "Sudden death during exertion (especially young athletes)")
add_bullet(doc, "Echo: asymmetric septal hypertrophy, dynamic LVOT gradient, SAM of mitral valve")

add_h2(doc, "8.3 Restrictive Cardiomyopathy (RCM)")
add_bullet(doc, "Diastolic dysfunction: reduced ventricular compliance/distensibility → impaired filling")
add_bullet(doc, "Normal or near-normal systolic function (EF preserved)")
add_bullet(doc, "Rigid, non-compliant ventricles")
add_bullet(doc, "Causes:")
add_bullet(doc, "Amyloidosis: most common cause of RCM; apple-green birefringence under Congo red stain", level=1)
add_bullet(doc, "Sarcoidosis: granulomas → fibrosis + arrhythmias", level=1)
add_bullet(doc, "Hemochromatosis: iron deposition → fibrosis", level=1)
add_bullet(doc, "Radiation-induced fibrosis", level=1)
add_bullet(doc, "Endomyocardial fibrosis (tropical Africa): Löffler endocarditis (hypereosinophilic syndrome)", level=1)
add_bullet(doc, "Clinical: features of biventricular HF with preserved EF; square root sign (dip-and-plateau) on pressure tracings")
add_bullet(doc, "Echo: sparkling appearance in amyloidosis; biatrial enlargement")
add_bullet(doc, "Must distinguish from constrictive pericarditis (similar hemodynamics but different etiology)")

add_h2(doc, "8.4 Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)")
add_bullet(doc, "Autosomal dominant — mutations in desmosomal proteins (plakoglobin, desmoplakin, desmin)")
add_bullet(doc, "Fatty/fibrous replacement of right ventricular myocardium")
add_bullet(doc, "RV wall severely attenuated with massive fatty infiltration and focal fibrosis")
add_bullet(doc, "Right-sided HF + ventricular arrhythmias → SCD (especially in young athletes)")
add_bullet(doc, "Naxos syndrome: ARVC + palmoplantar keratoderma + woolly hair (plakoglobin mutation)")
add_bullet(doc, "ECG: Epsilon wave in V1-V3 (pathognomonic), T-wave inversion in V1-V3, RBBB")
add_bullet(doc, "Diagnosis: cardiac MRI (gold standard for fatty infiltration)")

add_key_box(doc, "KEY: DCM = systolic dysfunction, all 4 chambers dilated. HCM = diastolic dysfunction, ASH, myocyte disarray, SCD in athletes. RCM = restricted filling, preserved EF. ARVC = fatty/fibrous RV replacement, desmosome mutations.")

doc.add_page_break()

# ════════════════════════════════════════════════════
#  SECTION 9: MYOCARDITIS
# ════════════════════════════════════════════════════
add_h1(doc, "9. MYOCARDITIS")
add_body(doc, "Inflammatory condition of the myocardium. Can be focal or diffuse.")
add_h2(doc, "9.1 Causes")
add_bullet(doc, "Viral (most common in developed world): Coxsackie B (most common), adenovirus, parvovirus B19, HIV, CMV, SARS-CoV-2")
add_bullet(doc, "Bacterial: Clostridium, meningococcus, S. aureus (toxin-mediated)")
add_bullet(doc, "Parasitic: Trypanosoma cruzi — Chagas disease (most common cause of cardiomyopathy worldwide; seen in Central/South America)")
add_bullet(doc, "Hypersensitivity/eosinophilic: drug reactions (penicillin, methyldopa, sulfonamides)")
add_bullet(doc, "Giant cell myocarditis: fulminant, often fatal; autoimmune mechanism; giant cells + eosinophils on biopsy")
add_bullet(doc, "Sarcoidosis: granulomatous myocarditis → arrhythmias, HF, SCD")
add_bullet(doc, "Radiation, toxins (doxorubicin, heavy metals)")

add_h2(doc, "9.2 Pathology")
add_bullet(doc, "Gross: flabby, dilated heart ± mural thrombi")
add_bullet(doc, "Histology: interstitial mononuclear infiltrate (lymphocytes predominant in viral) + myocyte necrosis")
add_bullet(doc, "Dallas criteria: myocyte damage + inflammatory infiltrate on endomyocardial biopsy")
add_bullet(doc, "May resolve completely or progress to DCM")

doc.add_page_break()

# ════════════════════════════════════════════════════
#  SECTION 10: PERICARDIAL DISEASE
# ════════════════════════════════════════════════════
add_h1(doc, "10. PERICARDIAL DISEASE")

add_h2(doc, "10.1 Pericarditis")
add_bullet(doc, "Acute pericarditis: most common cause = viral (Coxsackie B, echovirus) — 'idiopathic'")
add_bullet(doc, "Other causes: MI (fibrinous — Day 1–3; Dressler syndrome — 2–8 weeks), uremia ('bread-and-butter'), SLE, RF, TB")
add_bullet(doc, "Clinical: pleuritic chest pain (relieved by leaning forward), friction rub, ST elevation (saddle-shaped, diffuse)")
add_bullet(doc, "Fibrinous pericarditis: 'bread-and-butter' appearance (shaggy fibrin deposits)")
add_bullet(doc, "Purulent: bacterial infection; may organize into constrictive pericarditis")
add_bullet(doc, "Hemorrhagic: cancer (malignant), TB")
add_bullet(doc, "Caseous: TB pathognomonic")

add_h2(doc, "10.2 Pericardial Effusion and Cardiac Tamponade")
add_bullet(doc, "Normal pericardial fluid: 30–50 mL")
add_bullet(doc, "Pericardial effusion: >50 mL; >200 mL = large")
add_bullet(doc, "Cardiac tamponade: rapid accumulation of fluid → compression of cardiac chambers → reduced filling → obstructive shock")
add_bullet(doc, "Beck's triad: Hypotension + Distended neck veins + Muffled heart sounds")
add_bullet(doc, "Pulsus paradoxus: >10 mmHg drop in systolic BP with inspiration")
add_bullet(doc, "ECG: electrical alternans (alternating QRS amplitude)")
add_bullet(doc, "Echocardiography: gold standard — RV diastolic collapse")
add_bullet(doc, "Treatment: pericardiocentesis")

add_h2(doc, "10.3 Constrictive Pericarditis")
add_bullet(doc, "Dense fibrocalcific thickening of pericardium → restriction of cardiac filling")
add_bullet(doc, "Causes: prior pericarditis (TB most common worldwide; viral, post-radiation, post-surgical)")
add_bullet(doc, "Clinical: similar to RCM — JVD, ascites, edema, hepatomegaly, low CO")
add_bullet(doc, "Kussmaul sign: JVP rises with inspiration (opposite of normal)")
add_bullet(doc, "Pericardial knock: early diastolic sound after S2")
add_bullet(doc, "Echo/CT: thickened, calcified pericardium; equalization of diastolic pressures in all chambers")
add_bullet(doc, "Treatment: pericardiectomy (surgical)")

doc.add_page_break()

# ════════════════════════════════════════════════════
#  SECTION 11: HYPERTENSIVE HEART DISEASE
# ════════════════════════════════════════════════════
add_h1(doc, "11. HYPERTENSIVE HEART DISEASE (HHD)")

add_h2(doc, "11.1 Systemic (Left-Sided) HHD")
add_bullet(doc, "Criteria: LV hypertrophy in absence of other cause of LVH, with history of hypertension")
add_bullet(doc, "Initially: concentric LVH (pressure overload → parallel sarcomere addition)")
add_bullet(doc, "Later: eccentric hypertrophy → heart failure")
add_bullet(doc, "Gross: increased heart weight; LV wall thickness >2 cm; 'banana-shaped' LV on cross-section")
add_bullet(doc, "Microscopy: myocyte hypertrophy, interstitial fibrosis")
add_bullet(doc, "Complications: IHD, HF, sudden death, aortic dissection")

add_h2(doc, "11.2 Pulmonary (Right-Sided) HHD — Cor Pulmonale")
add_bullet(doc, "RV hypertrophy/failure due to pulmonary hypertension from primary lung disease")
add_bullet(doc, "Causes: COPD (most common), pulmonary fibrosis, pulmonary embolism, sleep apnea")
add_bullet(doc, "Acute cor pulmonale: massive PE → acute RV dilation")
add_bullet(doc, "Chronic cor pulmonale: RV hypertrophy → eventual RV dilation and failure")

doc.add_page_break()

# ════════════════════════════════════════════════════
#  SECTION 12: TUMORS OF THE HEART
# ════════════════════════════════════════════════════
add_h1(doc, "12. TUMORS OF THE HEART")
add_body(doc, "Primary cardiac tumors are uncommon; most (fortunately) are benign. Top 5: myxomas, fibromas, lipomas, papillary fibroelastomas, rhabdomyomas (~90% of primary tumors).")

add_h2(doc, "12.1 Cardiac Myxoma")
add_bullet(doc, "Most common PRIMARY benign tumor of the ADULT heart")
add_bullet(doc, "~90% arise in the atria; L:R ratio ~4:1 (left >> right atrium)")
add_bullet(doc, "Site of origin: fossa ovalis region of atrial septum (most common)")
add_bullet(doc, "Gross: sessile or pedunculated; gelatinous, soft to hard; can cause intermittent valvular obstruction ('ball-valve' effect)")
add_bullet(doc, "Histology: stellate/globular myxoma cells in acid mucopolysaccharide ground substance; vessel-like structures; hemorrhage + mononuclear inflammation")
add_bullet(doc, "Clinical triad: Ball-valve obstruction + Embolization + Constitutional symptoms (fever, malaise due to IL-6 secretion)")
add_bullet(doc, "Syndromes: Carney complex (PRKAR1A mutation — AD inheritance, recurrent myxoma, skin pigmentation, adrenal hyperplasia); McCune-Albright syndrome (GNAS1 gain-of-function)")
add_bullet(doc, "Treatment: surgical excision (curative)")

add_h2(doc, "12.2 Rhabdomyoma")
add_bullet(doc, "Most common PRIMARY cardiac tumor in INFANTS and CHILDREN")
add_bullet(doc, "Associated with tuberous sclerosis complex (TSC1/TSC2 mutations)")
add_bullet(doc, "Gross: grey-white nodules in ventricular myocardium")
add_bullet(doc, "Histology: large 'spider cells' — glycogen-filled vacuolated cells with radiating cytoplasmic processes")
add_bullet(doc, "Often spontaneously regress after infancy")

add_h2(doc, "12.3 Papillary Fibroelastoma")
add_bullet(doc, "Most common tumor found ON valves (especially aortic valve > mitral valve)")
add_bullet(doc, "Small, frond-like lesion resembling a sea anemone")
add_bullet(doc, "Risk: embolism (stroke, TIA)")
add_bullet(doc, "Treatment: surgical excision if symptomatic or large")

add_h2(doc, "12.4 Lipoma and Fibroma")
add_bullet(doc, "Lipomas: fat cells; can cause arrhythmias by compressing conduction tissue")
add_bullet(doc, "Fibromas: most common in children; in ventricular septum; associated with Gorlin syndrome (PTCH mutations)")

add_h2(doc, "12.5 Primary Malignant Cardiac Tumors")
add_bullet(doc, "Exceedingly rare; usually ANGIOSARCOMA (most common primary malignant tumor of heart)")
add_bullet(doc, "Right atrium most common location")
add_bullet(doc, "Undifferentiated sarcomas with MDM2 amplification also described")

add_h2(doc, "12.6 Metastatic Tumors (More Common Than Primary)")
add_bullet(doc, "Lung cancer (most common due to proximity), breast cancer, melanoma (highest rate per tumor type), lymphoma, leukemia")
add_bullet(doc, "Pericardium most commonly involved (pericardial effusion)")

add_key_box(doc, "KEY: Myxoma = most common in ADULTS, left atrium, fossa ovalis. Rhabdomyoma = most common in CHILDREN, tuberous sclerosis. Papillary fibroelastoma = on valves. Angiosarcoma = primary malignant.")

doc.add_page_break()

# ════════════════════════════════════════════════════
#  SECTION 13: CARDIAC TRANSPLANTATION & DEVICES
# ════════════════════════════════════════════════════
add_h1(doc, "13. CARDIAC TRANSPLANTATION AND DEVICES")

add_h2(doc, "13.1 Cardiac Transplantation")
add_bullet(doc, "Indications: end-stage HF (DCM, ischemic cardiomyopathy, refractory HF)")
add_bullet(doc, "Main limitation: donor organ shortage")
add_bullet(doc, "Rejection:")
add_bullet(doc, "Hyperacute: pre-formed antibodies; rare due to crossmatching", level=1)
add_bullet(doc, "Acute cellular rejection: lymphocytic infiltration + myocyte damage (within weeks–months)", level=1)
add_bullet(doc, "Chronic rejection (cardiac allograft vasculopathy — CAV): concentric intimal thickening of coronary arteries; leading cause of late graft failure", level=1)
add_bullet(doc, "Complications: infection, malignancy (PTLD — post-transplant lymphoproliferative disorder — EBV-related), CAV")

add_h2(doc, "13.2 Cardiac Devices")
add_bullet(doc, "Pacemakers: treat bradycardia/heart block; fibrosis around leads")
add_bullet(doc, "ICDs (Implantable Cardioverter-Defibrillators): treat VT/VF (e.g., HCM, DCM, Brugada)")
add_bullet(doc, "VADs (Ventricular Assist Devices): bridge to transplant or destination therapy")
add_bullet(doc, "Prosthetic valves:")
add_bullet(doc, "Mechanical: more durable, lifelong anticoagulation required; risk of thromboembolism", level=1)
add_bullet(doc, "Bioprosthetic (tissue): no anticoagulation, but 10–15 year durability", level=1)
add_bullet(doc, "Device complications: infection (endocarditis), thrombosis, hemolysis, structural failure")

doc.add_page_break()

# ════════════════════════════════════════════════════
#  MCQ SECTION — UHS PATTERN
# ════════════════════════════════════════════════════
add_h1(doc, "MCQs — UHS PATTERN (Single Best Answer)")
doc.add_paragraph("Based on Robbins Pathology Chapter 10: The Heart")
doc.add_paragraph("Instructions: Choose the SINGLE BEST answer for each question.")
doc.add_paragraph("")

mcqs = [
    # Q1
    ("A 70-year-old man dies of cardiac failure. Autopsy reveals heavy, globular heart with all four chambers dilated. Histology shows interstitial fibrosis without myocyte disarray. He had a history of heavy alcohol use for 30 years. What is the most likely diagnosis?",
     ["A. Hypertrophic cardiomyopathy", "B. Restrictive cardiomyopathy due to amyloidosis", "C. Dilated cardiomyopathy due to alcohol", "D. Arrhythmogenic right ventricular cardiomyopathy"],
     "C",
     "Alcohol is the #1 toxic cause of dilated cardiomyopathy (DCM). All 4 chambers dilate, systolic dysfunction predominates. Histology shows interstitial fibrosis without myocyte disarray (unlike HCM). ARVC predominantly affects the right ventricle with fatty replacement."),
    # Q2
    ("A 25-year-old male athlete collapses and dies during a basketball game. Autopsy shows massive concentric LV hypertrophy (600 g heart), asymmetric septal thickening, and histology reveals whorled bundles of disorganized myocytes with interstitial fibrosis. What is the most likely diagnosis?",
     ["A. Hypertensive heart disease", "B. Aortic stenosis", "C. Hypertrophic cardiomyopathy", "D. Dilated cardiomyopathy"],
     "C",
     "Hypertrophic cardiomyopathy (HCM) is the most common cause of SCD in young athletes. Hallmark histology = myocyte disarray (whorled, disorganized bundles). Asymmetric septal hypertrophy is characteristic. Most commonly caused by mutations in beta-myosin heavy chain (MYH7)."),
    # Q3
    ("A 10-day-old neonate presents with severe cyanosis. Echo shows the aorta arising from the right ventricle and the pulmonary artery from the left ventricle. Which of the following is the most immediate life-saving measure?",
     ["A. Indomethacin to close the PDA", "B. Surgical ligation of the ductus arteriosus", "C. Prostaglandin E1 infusion to maintain ductal patency", "D. Arterial switch operation as first-line treatment"],
     "C",
     "Transposition of the Great Arteries (TGA) creates two parallel circulations incompatible with life unless mixing occurs. PGE1 keeps the PDA open allowing mixing. Rashkind balloon atrial septostomy provides another method of mixing. Arterial switch is the definitive surgery but requires stabilization first."),
    # Q4
    ("A 45-year-old man with a history of rheumatic fever presents with progressive dyspnea and atrial fibrillation. Echo shows mitral valve with 'fish-mouth' appearance and commissural fusion. Pathologic specimen would show which of the following histologic findings MOST characteristic of the acute phase?",
     ["A. Calcified amorphous deposits without cellular reaction", "B. Fibrinoid necrosis with surrounding Anitschkow cells forming Aschoff bodies", "C. Large friable vegetations with gram-positive cocci", "D. Myocyte disarray with interstitial fibrosis"],
     "B",
     "Aschoff bodies are pathognomonic of rheumatic fever. They consist of foci of fibrinoid necrosis surrounded by Anitschkow cells (caterpillar cells — large macrophages with prominent nucleoli and elongated wavy chromatin). Chronic RHD shows commissural fusion ('fish-mouth') of mitral valve."),
    # Q5
    ("A 60-year-old woman with SLE presents with a cardiac murmur. Echocardiography reveals small vegetations on BOTH the atrial and ventricular surfaces of the mitral valve. What is the most likely diagnosis?",
     ["A. Rheumatic endocarditis", "B. Acute infective endocarditis", "C. Non-bacterial thrombotic endocarditis (NBTE)", "D. Libman-Sacks endocarditis"],
     "D",
     "Libman-Sacks endocarditis is characteristic of SLE. Vegetations occur on BOTH surfaces (atrial and ventricular) of the mitral and tricuspid valves — distinguishing it from RHD (line of closure) and NBTE (line of closure, one surface). Associated with antiphospholipid antibody syndrome."),
    # Q6
    ("A 7-year-old child is brought with recurrent episodes of cyanosis that worsen with crying. Squatting relieves the symptoms. CXR shows a 'boot-shaped' heart. What is the underlying pathology?",
     ["A. Atrial septal defect with Eisenmenger syndrome", "B. Tetralogy of Fallot", "C. Transposition of the great arteries", "D. Patent ductus arteriosus"],
     "B",
     "Tetralogy of Fallot: the 4 components are VSD, pulmonary stenosis (RVOT obstruction), right ventricular hypertrophy, and overriding aorta. 'Tet spells' (hypercyanotic episodes) are relieved by squatting (increases SVR, reduces R→L shunt). Boot-shaped heart on CXR due to RVH and upturned apex."),
    # Q7
    ("A 55-year-old man presents 6 weeks after an acute MI with fever, pleuritic chest pain, and a pericardial friction rub. His initial MI was managed conservatively. What is this complication?",
     ["A. Reinfarction", "B. Dressler syndrome", "C. Cardiac tamponade from free wall rupture", "D. Ventricular aneurysm"],
     "B",
     "Dressler syndrome is an autoimmune pericarditis occurring 2–8 weeks after an acute MI (or cardiac surgery). Features: fever, pleuritis, pericarditis, elevated ESR. Caused by autoantibodies against cardiac antigens exposed during myocardial necrosis. It is distinct from early post-MI pericarditis (Day 1–3, direct inflammation)."),
    # Q8
    ("On histologic examination of a heart specimen, scattered nodules are found within the myocardium consisting of central fibrinoid necrosis surrounded by large macrophages with elongated, ribbon-like chromatin. What is the name of these cells?",
     ["A. Aschoff cells", "B. Anitschkow cells (caterpillar cells)", "C. Reed-Sternberg cells", "D. Langhans giant cells"],
     "B",
     "Anitschkow cells (also called caterpillar cells) are the characteristic cells of Aschoff bodies in rheumatic fever. They are large activated macrophages with prominent nucleoli and chromatin condensed into long wavy ribbons ('caterpillar' appearance). The Aschoff body as a whole is pathognomonic of rheumatic fever."),
    # Q9
    ("A 30-year-old man presents with right-sided heart failure and ventricular arrhythmias causing syncope. He is a competitive swimmer. Cardiac MRI shows near-transmural replacement of the right ventricular free wall with fat and fibrous tissue. Genetic testing reveals a desmosomal gene mutation. What is the diagnosis?",
     ["A. Dilated cardiomyopathy", "B. Hypertrophic cardiomyopathy", "C. Arrhythmogenic right ventricular cardiomyopathy (ARVC)", "D. Right ventricular infarction"],
     "C",
     "ARVC is caused by autosomal dominant mutations in desmosomal proteins (plakoglobin, desmoplakin, desmin). Characteristic findings: fatty/fibrous replacement of RV myocardium; right-sided HF; ventricular arrhythmias (epsilon wave on ECG); SCD in young athletes. Naxos syndrome = ARVC + palmoplantar keratoderma."),
    # Q10
    ("A 50-year-old woman with recurrent episodes of dizziness and syncope is found to have a left atrial mass that intermittently obstructs the mitral valve. Histology shows stellate cells in an abundant mucoid matrix with hemorrhage. What is the most likely tumor?",
     ["A. Rhabdomyoma", "B. Cardiac fibroma", "C. Cardiac myxoma", "D. Papillary fibroelastoma"],
     "C",
     "Cardiac myxoma is the most common primary benign tumor of the adult heart. Most arise in the left atrium (fossa ovalis). Presents with the triad of obstruction, embolization, and constitutional symptoms (fever/malaise due to IL-6). Histology: stellate myxoma cells in mucopolysaccharide matrix."),
    # Q11
    ("A 4-year-old child is found to have cardiac masses on echocardiography. He also has seizures and facial angiofibromas. The cardiac tumors most likely consist of which cell type?",
     ["A. Stellate cells in mucopolysaccharide matrix", "B. Large spider cells with glycogen-filled vacuoles and cytoplasmic processes", "C. Frond-like fibrous projections on valve surfaces", "D. Spindle cells with vascular channels"],
     "B",
     "Rhabdomyoma is the most common primary cardiac tumor in children. Associated with tuberous sclerosis (TSC1/TSC2 mutations). Histology: 'spider cells' = large vacuolated cells with glycogen-filled vacuoles and radiating cytoplasmic processes. Often spontaneously regress."),
    # Q12
    ("A coarctation of the aorta is found in a 20-year-old woman with short stature, webbed neck, and primary amenorrhea. She has hypertension in the upper limbs and weak femoral pulses. What genetic syndrome does she most likely have?",
     ["A. Marfan syndrome", "B. Turner syndrome (45, X0)", "C. Williams syndrome", "D. Noonan syndrome"],
     "B",
     "Turner syndrome (45, X0) is strongly associated with coarctation of the aorta (postductal type) and bicuspid aortic valve. Clinical features: short stature, webbed neck, shield chest, primary amenorrhea, cubitus valgus, lymphedema at birth. Rib notching on CXR from collateral intercostal artery flow."),
    # Q13
    ("A patient in the ICU develops sudden hypotension, distended neck veins, and muffled heart sounds on Day 5 post-MI. ECG shows electrical alternans. What is the most likely diagnosis?",
     ["A. Tension pneumothorax", "B. Cardiac tamponade from free wall rupture", "C. Acute mitral regurgitation from papillary muscle rupture", "D. Ventricular septal rupture"],
     "B",
     "Beck's triad (hypotension, JVD, muffled heart sounds) + electrical alternans = cardiac tamponade. Free wall rupture peaks at Day 3–7 post-MI. The sudden accumulation of blood in the pericardium (hemopericardium) causes cardiac tamponade. Pericardiocentesis is life-saving."),
    # Q14
    ("A 68-year-old man with longstanding hypertension is found to have aortic valve disease. Pathologic examination shows calcification of the cusps WITHOUT commissural fusion. What is the most likely diagnosis?",
     ["A. Rheumatic aortic stenosis", "B. Infective endocarditis", "C. Degenerative calcific aortic stenosis", "D. Bicuspid aortic valve with calcification"],
     "C",
     "Degenerative calcific aortic stenosis (senile AS) is the most common cause of AS in adults >65 years. Calcification occurs in the cusps/sinuses WITHOUT commissural fusion — this distinguishes it from rheumatic AS (which HAS commissural fusion). Bicuspid aortic valve calcifies earlier (50s–60s); the question describes an older man with hypertension."),
    # Q15
    ("A 40-year-old IV drug user presents with high fever and a new pansystolic murmur. Blood cultures grow Staphylococcus aureus. Echocardiography reveals a large, destructive vegetation on the tricuspid valve. Which of the following peripheral stigmata consists of TENDER nodules on the finger pads?",
     ["A. Janeway lesions", "B. Splinter hemorrhages", "C. Roth spots", "D. Osler nodes"],
     "D",
     "Osler nodes = tender, red subcutaneous nodules on the finger/toe pads — caused by immune complex deposition (type III hypersensitivity). Janeway lesions = non-tender hemorrhagic macules on palms/soles — caused by septic emboli. Roth spots = oval retinal hemorrhages. Right-sided IE (tricuspid) is classic in IVDA due to S. aureus."),
    # Q16
    ("A neonate is born with cyanosis. Physical examination reveals a single second heart sound. CXR shows a normal cardiac silhouette but increased pulmonary vascular markings. Echo shows a single arterial trunk arising from both ventricles overriding a large VSD. What is the diagnosis?",
     ["A. Tetralogy of Fallot", "B. Truncus arteriosus", "C. Total anomalous pulmonary venous return", "D. Double outlet right ventricle"],
     "B",
     "Truncus arteriosus: failure of separation of the embryologic truncus arteriosus into aorta and pulmonary artery. A SINGLE vessel overrides a VSD and gives rise to aorta, pulmonary arteries, and coronary arteries. Single S2, increased pulmonary markings (unrestricted pulmonary flow). Associated with DiGeorge syndrome (22q11 deletion)."),
    # Q17
    ("A 35-year-old woman is diagnosed with a restrictive cardiomyopathy. Endomyocardial biopsy shows amorphous extracellular deposits that stain apple-green under polarized light with Congo red stain. What is the underlying diagnosis?",
     ["A. Hemochromatosis", "B. Sarcoidosis", "C. Cardiac amyloidosis", "D. Glycogen storage disease"],
     "C",
     "Apple-green birefringence under polarized light after Congo red staining is PATHOGNOMONIC of amyloid. Cardiac amyloidosis (AL or transthyretin type) is the most common cause of restrictive cardiomyopathy. Echo shows a 'sparkling' or 'granular' appearance. Hemochromatosis: iron (Prussian blue stain). Sarcoidosis: non-caseating granulomas."),
    # Q18
    ("Which of the following correctly describes the temporal sequence of myocardial infarction? The risk of ventricular free wall rupture is HIGHEST at which time point?",
     ["A. Within the first 24 hours", "B. Days 3–7 post-infarction", "C. Days 10–14 post-infarction", "D. After 4 weeks"],
     "B",
     "Maximum softening of the infarcted myocardium occurs at Days 3–7, when macrophage infiltration and enzymatic lysis of necrotic tissue is maximal — this is when risk of free wall rupture, ventricular septal defect, and papillary muscle rupture is highest. After Day 7–10, granulation tissue formation and fibrosis begin to stabilize the wall."),
    # Q19
    ("A 28-year-old man presents with progressive shortness of breath and lower extremity edema. Cardiac catheterization reveals equalization of diastolic pressures in all four chambers, and CT shows a calcified, thickened pericardium. What finding would be expected on physical examination?",
     ["A. Pulsus paradoxus >10 mmHg", "B. Kussmaul sign — JVP rises with inspiration", "C. Beck's triad", "D. Mid-systolic click"],
     "B",
     "Constrictive pericarditis: fibrous/calcified pericardium restricts ventricular filling. Kussmaul sign = paradoxical rise in JVP with inspiration (because the rigid pericardium cannot accommodate increased venous return during inspiration — it goes back into the jugular veins). Pulsus paradoxus is more characteristic of tamponade."),
    # Q20
    ("A 55-year-old woman presents to the emergency room with sudden-onset severe chest pain radiating to the left jaw. ECG shows ST elevation in leads II, III, aVF, and ST depression in I, aVL. Which coronary artery is most likely occluded?",
     ["A. Left anterior descending artery (LAD)", "B. Left circumflex artery (LCx)", "C. Right coronary artery (RCA)", "D. Left main coronary artery"],
     "C",
     "Inferior STEMI (ST elevation in II, III, aVF) is caused by RCA occlusion in ~80% of cases (RCA supplies the inferior wall of the LV, the RV, and the SA/AV nodes). Reciprocal changes appear in I and aVL. LAD occlusion → anterior STEMI (V1-V4). LCx → lateral STEMI (I, aVL, V5, V6)."),
]

for i, (q, opts, ans, exp) in enumerate(mcqs, 1):
    add_mcq(doc, i, q, opts, ans, exp)

# ── Save ──
output_path = "/tmp/workspace/robbins-heart/Robbins_Chapter10_Heart_Notes_MCQs.docx"
doc.save(output_path)
print(f"Saved: {output_path}")