Cvs case Name / age/sex/occupation/address Presenting complaints: History of presenting complaints: Chest Pain:  Duration  Site  Mode of onset  Nature  Severity and duration of episode  Radiation  Continuous/intermittent  Brought on by  Aggravating / Reliving factors  Associated features - sweating, palpitation  Associated with food intake Dyspnea:  Duration  Mode of onset  Progression  Grade  Aggravating / reliving factors  H/o PND, orthopnea  Associated symptoms - wheeze, cough with expectoration, chest pain Palpitation:  Duration  Regular / Irregular  Paroxysmal/ not  Brought on by  Aggravating/ Reliving factors  Associated chest pain, syncope Loss of consciousness:  Episodes/day  Duration  Total/ partial loss of consciousness  Recovery time  Associated fits, bladder/bowel disturbances  Time of last episode Cough with expectoration:  Duration  Mode of onset  Quantity  Colour / odour  Postural / Reliving factors  Blood on coughing o No of episodes o Colour o Followed by malena o Associated with food particles Negative History:  Symptoms of RHF o H/o pedal edema o H/o abdominal distension o H/o dyspepsia o H/o right hypochondrial pain o H/o puffiness of face  Symptoms of RF o H/o fever with pain, sore throat o H/o involuntary movements o H/o skin manifestations like rash, nodules  Symptoms of Left sided disease o H/o voice change, dysphagia o H/o oliguria  Symptoms of congenital disease o H/o cyanotic episodes o H/o squatting  Symptoms of PHT o Recurrent respiratory infection o Syncope o Hemoptysis(pulmonary apoplexy) o Chest pain Past History:  H/o previous similar episodes  H/o Rheumatic fever - elaborate(any epistaxis)  H/o HT, DM, TB, IHD, STD, Surgery  H/o chronic respiratory tract infection, cyanotic spells  H/o chronic fever (subacute bacterial endocarditis) Family History:  Elaborate  H/o HT, DM  H/o abortions in female Personal History:  Smoking  Alcohol  Diet  Sexual History  Menstrual History Treatment History: Summary: Age/sex/name? Personal History? Family history? PC  Other relevant positive features  Probable system? CVS The disease is probably ………………..(cong/acq). Probably a ………………(recurrent) heart disease involving the ……………(lt/rt/both) side(s), the probable valve(s) involved are …………………… The patient shows the signs/symptoms of ………………………….(LVF/RVF/CCF) Examination of CVS case: General examination:  Conscious  Comfortable  Oriented  Build  Nourishment  Febrile/ afebrile  Jaundiced/not  Pallor  Clubbing - grade  Cyanosis  Pedal edema with refilling time o Rapid - renal < 45 secs o Slow - CCF  Significant lymphadenopathy Markers of Congenital HD  Hypertension  Low set ears  Polydactyly  Syndactyly  Arachnodactyly  Amelia, hyomelia  Kyphoscoliosis  Webbed neck Markers of IE  Anemia, jaundice, fever  Osler’s nodules, clubbing, splinter haemorrhages - Hand  Jane way lesions  Spleenomegaly  Roth’s spots(Ophthalmoscopy) Markers of Rheumatic HD Markers of Ischemic HD Markers of syphilis  Alopecia  AR pupil  Retinitis  Gummatous lesions - Tibia, palate, tongue, sternum  Septal perforation  Testicular sensation loss Markers of HIV, TB Vital signs: Pulse:  Rate  Rhythm  Volume  Character  Felt in all peripheral vessels  Any RF / any PD  Condition of vessel wall BP Respiratory rate  Rate  Rhythm  Type Temperature JVP Peripheral signs of AR - signs of wide pulse pressure:  Lighthouse sign - Alternate flushing and blanching of forehead  Landolfi’s sign - pupil size varies with each heart beat  Becker’s sign - Retinal artery pulsations  Muller’s sign - Systolic pulsations of uvula  De Musset’s sign - Head bobbing with each heartbeat  Corrigan’s sign - Dancing carotids  Quincke’s sign - Capillary pulsation of nail bed  Collapsing pulse  Pulsus bisferans - severe AR  Rosenbach’s sign - Pulsation of liver  Gerhardt’s sign - Pulsation of spleen  Traube’s sign - Pistol shot femoral  Hill’s sign - Popliteal systolic BP > Brachial BP >20 mm o Mile - 20 - 40 o Moderate - 40 - 60 o Severe - >60  Duroziez’s murmur - Double murmur in femoral artery Local Examination of CVS: Inspection:  Chest wall symmetry and shape  Kyphoscoliosis  Apical impulse  Tracheal position  Pulsations o Epigastric, hypochondrial o Parasternal o Supra & infraclavicular o Suprasternal, neck o Interscapular, suprascapular  Precordial bulge  Dilated veins  Signs of surgeries, scars  Drooping of shoulders  Oral cavity Palpation:  Apical impulse - site/type/ associated thrill or sound  Epigastric pulsations  Parasternal heave  Thrills over precordium / carotids  Palpable sounds (P2)  Tracheal position Percussion:  Right border corresponds to right border of sternum  Left border corresponds to apical impulse  Liver dullness is felt in ……………. Auscultation  Mitral o First and second heart sounds are heard o S1 / S2 - loud/normal/soft o Any S3 or S4 o MDM: A rough rumbling low pitched MDM(of grade) heard with the bell of the stethoscope with opening snap and PSA (pre systolic attenuation) and the patient put left lateral position with breath held in expiratory apnea o PSM: A high pitched, soft blowing PSM (of grade) heard with the diaphragm of the stethoscope, conducted to the axilla and back, the patient put in left lateral with breath held in expiratory apnea  Aortic: o First and second heart sounds are heard o S1/S2 - loud/normal /soft o Any ejection click o ESM: A crescendo decrescendo ESM(of grade) heard with the diaphragm of the stethoscope and conducted to the carotids, the patient leaning forward and breath held in expiratory apnea o EDM: A decrescendo pitched EDM( of grade) is heard with diaphragm of the stethoscope (better heard in the II aortic area say as LT with ICS parasternal) with the patient leaning forward with breath held in expiratory apnea  Pulmonary: o First and second heart sounds are heard o S1/S2 - loud/normal/soft o S2? Split? Narrow/ normal/ wide fixed / reverse o Any ejection click o For murmurs  See the aortic area  Say as in inspiratory apnea  No conduction as in ESM of AS  Patient in lying posture  Tricuspid: o First and second heart sound heard o S1/S2 - loud/ normal / soft o Any S3/ S4  Refer mitral area  Say as in inspiratory apnea  MDM: Patient leaning forward  PSM: Patient leaning forward, conduction to right sternum Other systems:  Respiratory system: o NVBS o Basal crepitations  Abdomen: o Any added sounds o No organomegaly o No free fluid  CNS: o No focal neurological deficit Diagnosis: Acquired/congenital heart disease of ………………….(rheumatic) etiology with MS/MR/AS/AR. The patient is ……………………(not)in sound rhythm,………………../ not in failure…………….. with /without infective endocarditis complications Gi case Name/age/sex/occupation/address Presenting complaints H/o presenting complaints  Abdominal pain: o Duration o Site o Nature(continuous/intermittent) o Character(constant/colicky) o Severity o Radiation o Aggravating / relieving factors o Associated features(fever/nausea/ vomiting/ defecation)  Abdominal distension: o Duration o Onset(insidious/acute) o Site(localised/uniform) o Progress o RVF features  Leg swelling  Breathlessness  Chest pain o Liver features:  Loss of appetite  Hematemesis/ Malena  Constipation/ Obstipation o Renal:  Oliguria  Puffiness of face  Frothy urine(Nephrotic syndrome) o Vomiting/ Blood in vomit  No of episodes  Duration  Projectile  Associated with nausea/ headache/ blurring of vision  Quantity  Character(colour/smell/blood streaks)  Associated with food intake  Associated features(pain/malena/hematemesis/ loss of consciousness)  H/o drug intake(NSAIDS, Steroids) o Jaundice  Duration  Itching  Colour of urine/ Stools  Any fever with rigor  Treatment taken o Stools:  Frequency  Colour(dark/ tarry black/ pale)  Consistency(Solid/ liquid)  Nature(Sticky/mucoid)  Associated pain  Blood streaks o Mass in abdomen  Site  Duration  Progression  Associated pain  Negative History: o Fever  Duration/ Time of occurrence  Grade (high/low)  Nature(continuous / remittent)  Associated with rigors/ sweating o Upper GIT:  Dysphagia(solids/liquids/both)  Heart burn  Vomiting o Urinary Tract  Dysuria  Pain/Burning micturition  Oliguria  Hematuria  Frequency  Fever with rigor o H/o bleeding diathesis  Epistaxis  Bleeding gums  Menorrhagia  Prolonged bleeding after trauma  H/o loss of appetite/ weight loss - TB & malignancy  H/o swelling of legs  H/o puffiness of face - renal  H/o pruritides, bleeding per rectum  H/o altered sleep pattern Past History:  H/o previous similar episode  H/o surgery, drug intake  Jaundice o H/o tattooing o H/o drug intake o H/o blood transfusion o H/o exposure to STD’s o H/o vaccination  Ascites o Previous abdomen surgeries(Scar - irritation) o H/o TB, DM, IHD, HT o H/o renal colic Family History: Any similar history(cirrhosis/wilson’s disease/AT / Hep A/B/E) Personal history:  Smoking  Alcohol  Diet(appetite)  Sexual history  Menstrual history, Obstetric history Treatment history: Summary: Age/sex/name? Personal H/o? Family H/o? presenting complaints? Other relevant positive features Examination of Abdomen General examination:  Conscious  Co-operative  Built  Afebrile  Cyanosis  Anemia  Jaundice  Clubbing(cirrhosis/ IBD/ Malabsorption syndrome)  Significant lymphadenopathy  Pedal oedema  Markers of liver cell failure o Head:  Alopecia o Eye:  Bitot spots(Vit A)  Sub conjunctival haemorrhage(Vit K)  Colour(Anemia - pale/ jaundice - yellow)  Metabolism(KF ring/ wilson’s/ xanthelasma - fat) o Face:  Medial supraciliary madarosis  Sunken eyes, cheeks  Loss of facial hair  Parotid enlargement  Bleeding gums  Fetor hepaticus o Mouth o Chest  Spider naevi  Gynaecomastia  Atrophy of breast  Loss of pectoral hair, axillary hair  Pectoral muscle atrophy  Dilated veins o Hands:  Anemia  Bounding pulse  Clubbing  Duputryen’s contracture  Flapping tremor/ asterexis  Erythema palmar  Leuconychia o Abdomen:  Distension  Dilated veins(caput medusa) o Testis:  Atrophy  Pubic hairloss  Tumour o Lower limbs:  Pedal oedema  Chronic leg ulcers o General:  Pruritis/spiderman appearance  Markers of TB  Markers of HIV Vital signs: Pulse - Rate/Rhythm/Volume/Character/RF delay/felt in all peripheral vessels/ condition of vessel wall BP - …………………….mm Hg, ……………..limb, ………………posture Respiratory rate - Rate/Rhythm / Type Temperature JVP Systemic examination of Abdomen: Inspection:  Shape: o Scaphoid/ flat/ distended - uniform or localised o Flanks (free / full)  Umbilicus o Position o Shape(slit/inverted/ everted) o Nodules - Sister Mary Joseph’s nodules  Movement of abdomen wall o Movement with respiration o Visible pulsations o Visible peristalsis  Skin and surface of abdomen o Supine position Stretched, shiny, scars, surgeries, sinuses, strine(Cushing’s - purple strine) o Head rising o Divarication of recti o Standing position o Dilated veins o External Genitalia o Cough impulse o Genitalia normal Palpation: 1. Superficial palpation o Warmth o Tenderness o Thrills 2. Deep palpation o Liver: A tender/non tender swelling is palpable…………………cm below/above right costal margin in MCL. Extending from ……………………(medial) to ………………(lateral), with ….…………..(smooth/ nodular) surface and ……………(sharp/rounded) margins, …………………..(soft/firm/hard) in consistency. It ……………… (moves/not) with respiration, not bimanually palpable, not able to insinuate fingers under the costal margin. o Spleen: o Site o Surface o Tender - spleenic abscess or IMV o Extent o Notch on the medial border o Consistency  It moves with respiration, not bimanually palpable, not ballotable, upper border, cannot be felt, colonic band of resonance not felt o Kidney: o Normally lower rt. Pole in thin individuals o It moves with respiration, bimanually palpable, ballotable, colonic band of resonance felt o Others: o Direction of blood flow o Fluid thrill o Abdominal girth movement o Inguinal/Para Aortic/supraclavicular nodes Percussion:  Fluid o Shifting dullness o Puddle sign  Liver  Spleen  Kidney o Dullness and span o Dullness o Traube’s space o Colonic band of resonance Auscultation:  Bowel sounds: o 10 to 15/min small bowel o 3 to 5/min large bowel  Bruit: o Renal(Mid abdomen, around midline) o Liver(haemangioma, HCC, Acute alcoholic hepatitis) o Aortic bruit  Venous hum: o Midway between umbilicus and rt. Costal margin  PDV  Collaterals in Portal HT  Cruvilhier - Baumgartner syndrome  Rub: o Perispleenitis o Perihepatitis  Succussion splash: Other systems:  CVS: o S1, S2 heard (to rule out RVF)  RS: o NVBS, Basal crepitation(PE, TB)  CNS: o Normal (Hepatic encephalopathy, Peripheral neuropathy) Diagnosis: Chronic decompensated liver disease with portal hypertension and ascite Rs case Name/Age/sex/Occupation/address Presenting Complaints: History of presenting complaints: Cough with expectoration:  Duration  Mode of onset  Paroxysmal  Dry / productive  Postural / diurnal  Aggravating / reliving factors  Associated factors - chest pain, syncope Sputum:  Duration and mode of onset  Quantity  Colour and odour  Character - mucoid /serous, purulent / mucopurulent  With / without blood  Postural and diurnal variation Hemoptysis:  Duration  Episodes  Fresh or altered blood  Associated with purulent sputum or food particles Breathlessness:  Duration  Onset  Grade  Progression  Aggravating/relieving factors  PND/orthopnea Chest pain:  Duration  Site  Mode of onset  Nature - pricking/stabbing  Severity  Radiation  Postural variation  Aggravating or relieving factors  Associated with food intake  Associated with nausea, vomiting Negative History:  H/o wheeze(duration, diurnal variation, aggravating/relieving factors)  H/o halitosis  Symptoms of TB: o H/o fever with evening rise of temperature o H/o loss of weight o H/o loss of appetite o H/o night sweats  Symptoms of cardiac involvement o H/o pedal edema o H/o abdominal distension o H/o right hypochondrial pain o H/o puffiness of face o H/o palpitation o H/o syncope o H/o oliguria  Symptoms suggestive of malignancy o H/o hoarseness o H/o dysphagia  Mode of onset  Solids/liquids  Progression o H/o loss of appetite Past History:  H/o previous similar episodes  H/o HT/DM  H/o TB o Any contact o Age o Treatment - if incomplete - why?  History suggestive of pneumonia o Aspiration(A - aspiration, B - Booze, C - coma, D - Drowning, E - Epilepsy, F - Foreign body) o Exanthematous fever o Tooth, extraction, tonsillectomy, allergy o Trauma o Exposure to STDs  History suggestive of PE o Acute abdominal distress (Subphrenic abscess, amoebic abscess, Pancreatitis)  H/o past infections o Measles, Whooping cough o Recurrent respiratory tract infections Family History:  Elaborate  Ask for o H/o TB/primary complex o H/o allergies o H/o infertility/abortions Personal History:  Smoking  Alcohol  Diet  Exposure - occupational, STD elaboration Treatment history: Summary: Age/sex/name? Personal History? Family history? Presenting complaints? Other relevant positive findings System RS  Acute/Chronic  Rt/Lt/Both  Parenchyma/pleura/airway  Obstructive/restrictive  Suppurative/non suppurative  Etiology  With/without complications? Cor pulmonale Obstructive lung diseases(Hypercarbia)  Head ache  Drowsiness Restrictive Lung disease  Tachypnea  Convulsions( O2  tetany)  Extra pyramidal symptoms( O2 of basal ganglia)  Muscle twitching Examination of Respiratory system General examination:  Comfortable  Conscious  Oriented  Built  Nourishment  Febrile/ afebrile  Pallor (Anemic/not anemic)  Icteric/not  Clubbing  Cyanosis  Pedal oedema  Significant lymphadenopathy  Conjunctival suffusion See for  IVC obstruction  Halitosis  Horner’s syndrome: Ptosis, anhydrosis, miosis, enophthalmos, loss of ciliospinal reflex  Troiser’s sign: Enlargement of Lt. supraclavicular lymph node  Markers of pulmonary malignancy: o Acanthosis nigricans o Gynaecomastia o Clubbing, HPOA  Markers of sarcoidosis: o Hilar, mediastinal lymph node enlargement o Tonsillar enlargement o Hepatospleenomegaly o Eye: iritis, iridocyclitis, choroid retinitis o Skin: SC nodules, erythematous plaques, Erythema nodosum o Parotitis o Nasal polyps o Joint pain  Markers of TB: o Phlycten, choroids, tubercles o Scars/sinuses in the neck o Scrofula - SC lymphadenitis in neck o Lupus vulgaris o Erythema nodosum o Cold abscess/ collar stud abscess o Tinea versicolor o Gynaecomastia - INH (bronchogenic CA)  Markers of HIV o Hairy Leucoplakia o Oral candidiasis o Molluscum contagiosum o Premature greying of hair o Long eye lashes(trichomegaly) o Herpetic infections o Generalised lymphadenopathy Vital signs:  Pulse rate: elaborate (expect pulsus paradoxus)  BP: ………….. mm Hg …………..limbs……………posture  Respiratory rate, rhythm, type  Temperature  JVP Systemic examination of Respiratory system: 1. Inspection:  Upper respiratory tract o Nasal septum o Sinus tenderness o Polyps o Tonsils o Oral hygiene o Halitosis o Post nasal drip  Chest o Symmetry o Shape - flat, barrel chest(emphysema, pigeon chest, funnel chest (marfan syndrome) o Costochondral bending ( Rachitic rosary), Scorbutic rosary o Movement with respiration o Scars, IC fullness, IC indrawing, crowding of ribs, discharging sinuses(TB) o Tracheal position with Trail’s sign o Apical impulse o Drooping of shoulders o Supraclavicular and IC hallowing o Harrison’s sulcus o Prominence of medial border of scapula o Kyphoscoliosis o Dilated veins over chest, tracheal movement during inspiration 2. Palpation: o Tracheal position o Apical impulse o AP diameter o Transverse diameter o Ratio o Chest movement by palpation o Chest expansion measurement - bilateral and hemi thorax o Tactile fremitus, IC tenderness o Vocal fremitus o Lymph nodes - Cervical, Supraaxillary, axillary, Scalene 3. Percussion o Directly on clavicle o Anteriorly o Supraclavicular (apex) o Infraclavicular o Mammary o Axilla o Axillary o Infra axillary o Posterior o Suprascapular o Infrascapular o Interscapular  Upper  Middle  Lower o Tidal percussion o Traube’s space - left sixth rib, the left axillary line and the left costal margin o Shifting dullness, straightline dullness 4. Auscultation: o Auscultation in above areas o Breath sounds o Normal vesicular breath sound(harsh / normal) o Bronchial breath sound  Pitch tubular  Pitch cavernous  Amphoric o Bronchovesicular breath sound o Absent breath sounds o Added sounds o Crepitations/ crackles  Inspiratory/ expiratory / both phases  Fine/medium/coarse leathery  Change afer coughing o Ronchi/ wheeze  Inspiratory / expiratory both  Pitch  Monophonic / polyphonic  Change after coughing o Pleural rub o Post tussive suction o Vocal resonance o Compare both sides o Bronchophony o Aegophony (E to A) o Whispering pectoriloquy o Others o Succession splash o Coin test Other systems: CVS : see for RHF, CCF Abdomen: see for liver abscess - tenderness CNS: see for asterexis Diagnosis: …………………….sided……………………..disease(PE/fibrosis) probably due to ……………………(with / without signs of RHF 1 Cns case Name/Age/Sex/Occupation/Address/handedness Presenting Complaints: • H/o weakness / inability to use limbs • H/o mouth angle defect • H/o speech defect History of Presenting complaints: Weakness/ inability: o Sequence of events in patients own words which includes Duration Onset – sudden / insidious Time of occurence – sleep / work Progression Tone – flaccid / rigid Weakness of • Upper limb o Proximal: H/o combing hair, lifting hand o Distal: H/o mixing food, buttoning shirt, writing • Lower limb o Proximal: H/o standing, climbing stairs o Distal: H/o slippers slipping • Trunk o H/o turning from side to side • Neck o H/o difficulty to lift head from bed H/o fasciculation / atrophy H/o sensory loss o Temperature sense: warm / cold water o Touch sense: feeling shirts, dresses o Pain sense: pinching o Others: tingling, numbness, root pain H/o loss of consciousness o Duration o Complete / partial o Aura +/- o Associated with (to rule out odd’s palsy) o Bowel / Bladder disturbance o Recovery period o Frequency of occurence 2 History suggestive of etiology • H/o thrombus • H/o embolism • H/o haemorrhage diathesis Level of lesion o H/o cortex Vomiting, diarrhoea (calf tenderness) Chest pain, palpitation, fever with meningitis, TB Trauma, headache, projectile vomitting, blurring of vision, convulsions, bleeding Aphasia Bladder involvement Convulsion o H/o corona radiata o H/o Internal capsule o H/o brain stem Cranial nerves o I : H/o loss of sense of smell / altered o II : H/o disturbance of vision o III, IV, VI : H/o diplopia, difficulty in eye movements o V : H/o sensory loss over face, chewing disturbances o VII : H/o loss of taste, salivation, angle deviation, drooling of saliva from mouth o VIII : H/o hearing loss, vertigo, tinnitus o IX, X : H/o nasal regurgitation, nasal twang, dysphagia, hoarseness of voice o XII : H/o dysarthria ANS history: o H/o bowel: Constipation / loss of control o H/o bladder: Difficulty in feeling the filling / Difficulty in initiating / Difficulty in controlling / Difficulty in complete evacuation / Dribbling o Impotence: o Sweating: Past History: o H/o previous episodes o H/o TIA, RIND (Reversible Ischemic Neurological Deficit) o H/o DM, TB, HT, STD o H/o recurrent headache, vomiting, diarrhoea, fever o H/o cardiac disease, epilepsy, trauma o H/o CSOM, ARV, dogbite 3 o H/o drugs, surgery, OCPs, poisoning Family History: o Consanguinity o Siblings o Any similar episodes Personal History: o Smoking o Alcohol o Diet --> lathyrism, SACD o STD history Treatment History: Summary: Age/sex/name ? Handedness ? Personal H/o ? Family H/o ? PC ? other relevant positive findings Probable system involved ? CNS History Diagnosis: Acute CVA, which is probably due to ...................... which is.........................(progression) in nature, with associated cranial nerve involvement and ...........(no) sensory loss. The probable site of lesion is ........................... Examination of CNS case: General Examination: o comfortable o cooperative o conscious o oriented o built o nourishment o febrile / afebrile o pallor / not anemic o Icteric / not o Clubbing o Cyanosis o Pedal oedema o Significant lymphadenopathy 4 Neurocutaneous markers: o Adenoma sebaceum o Ash leaf patches o Shagreen patches o Cafe au lait spots o Multiple neurofibromas o Tuft of hair in the back – spina bifida o Capillary haemangioma – Sturge weber syndrome (port wine stain) o Conjunctival haemangioma – Von Hippel Lindau syndrome o (with cerebellar haemangioma) o Pes cavum – Friedreich’s ataxia Markers of HIV Markers of TB Markers of FF syphilis o peripheral nerve thickening o spine angulation Vital signs: o Pulse: rate, rhythm, volume, character, PV, RF, vessel wall o BP o RR o Temperature o JVP Local Examination of CVS: A. Higher Function: a. Consciousness b. Orientation – time, place, person c. Memory – short, place, person d. Intelligence e. Speech f. Handedness g. Emotion B. Cranial nerves: I. Olfactory nerve: a. Clove - +/- (Rt & Lt) b. Oil of peppermint - +/- c. Asafoetida - +/- II. Optic nerve: a. Visual acuity 5 i. Gross vision Distant vision Near vision b. Field of vision c. Colour vision d. Fundoscopy III, IV, VI Occulomotor , Trochlear, abducent Extra ocular movements Pupil o Size o Reflexes Direct Consensual Accommodation Nystagmus Ptosis V Trigeminal Sensory – sensation over face and buccal mucosa Motor – Clenching of teeth ( masseter, temporalis, pterygoids) Reflex o Corneal o Conjunctival o Jaw jerk VII Facial nerve Motor o Wrinkling of forehead o Closing of eyelids o Showing teeth o Blowing of cheeks, whistling o Nasolabial folds o platysma o Hyperacusis (Stapedius) Sensory o Taste of Ant. 2/3 of tongue (Sugar, salt, vinegar) o Sensation over tongue Reflex 6 o Corneal o Conjunctival Secretomotor o Salivation o Lacrimation(Shirmer’s tear) VIII Vestibulocochlear nerve Cochlear o Rinne’s test o Weber test Vestibular o Caloric test IX X Glossopharyngeal, Vagus Taste (posterior 2/3 of tongue) IX Gag reflex Palatal reflex XI Spinal accessory nerve Shrugging of shoulders Turning head against resistance XII Hypoglossal nerve Tongue protrusion Fibrillation Wasting Power C. Motor System: Bulk o Inspection o Palpation UL – 10 cm from acromion – 10 cm below olecranon process LL – 18 cm from upper end of patella - 10 cm lower end of patella Tone Power o UL – N / clasp knife spasticity in flexors o LL – N / clasp knife spasticity in extensors o UL Shoulder • Flexion – extension 7 • Abduction – adduction • Rotation Elbow • Flexion – extension Wrist • Flexion – extension • pronation – Supination • Adduction – Abduction Fingers • Flexion – extension • Abduction – Adduction Thumb • Flexion – extension • Abduction – Adduction • Opposition o Lower Limb Hip Jt • Flexion – extension • Abduction – adduction • Rotation Knee Jt. • Flexion Extension Ankle Jt • Dorsal – plantar flexion • Inversion – Eversion Toes • Flexion – extension • Adduction – Abduction Coordination: o Upper limb o Lower limb Finger nose test Finger – finger nose test Disdiadochokinesia Knee – heel test Drawing circle Gait o In hemiplegia – Adducted shoulder, Flexed elbow, Flexed and semipronated wrist, Flexion at MP jts, extension at IP jts Involuntary movements Reflexes 8 o Superficial reflexes Corneal (CN 5, 7) Conjunctival (CN 5,7) Pharyngeal (CN 9, 10) Abdominal (T8 – T12) Cremasteric (L1, L2) Plantar ( L5, S1) o Deep reflexes Jaw jerk (CN 5) Biceps (C5, C6) Triceps (C6, C7, C8) Supinator (C5, C6) Knee jerk (L3, L4) clonus Ankle jerk (S1, S2) clonus D. Sensory System: a. Superficial Touch Pain Temperature b. Deep • Pressure • Deep pain • Vibration sense • Position sense c. Cortical sense • Tactile localisation • Two point discrimination • Stereopsis • Graphesthesia d. meningeal irritation: • Neck rigidity • Kernig’s sign • Brudzinski’s sign Diagnosis: ...............................(Lt/Rt) sided hemiplegia .............................(with / without Lt/Rt) UMN facial palsy with lesion at .............................. (Rt/Lt) Internal capsule in the ..................................(Rt/Lt MCA territory) probably due to .........................(thrombosis / embolism / haemorrgage Why we will do each thing and why are we asking each thing in each examination tell me each each particular thing why are we asking/ to rule out what/ system wise case wise

I'll provide a comprehensive explanation of why each question and examination step is asked in each system case. This is a detailed clinical reasoning guide.

Clinical Reasoning Behind CVS, GI, RS, and CNS Case Taking & Examination

CARDIOVASCULAR SYSTEM (CVS) CASE

HISTORY TAKING

CHEST PAIN - Why we ask each parameter:

Parameter	Why we ask / What we rule out
Duration	Acute (<24h) suggests ACS/dissection; chronic suggests stable angina or musculoskeletal
Site	Central/retrosternal = cardiac; left mammary = Da Costa syndrome; right = pleuritic/musculoskeletal
Mode of onset	Sudden onset = dissection, PE, pneumothorax; gradual = angina, pericarditis
Nature	Crushing/squeezing = MI; tearing/ripping = aortic dissection; sharp/stabbing = pleuritic/pericarditic
Severity + duration of episode	Unstable angina: >20 min at rest; stable angina: <20 min with exertion
Radiation	To left arm/jaw = MI (referred via C8-T1 dermatomes); to back = dissection; to shoulder = diaphragmatic irritation
Continuous/intermittent	Intermittent = angina; continuous = MI, pericarditis
Brought on by	Exertion = angina; rest = Prinzmetal/unstable angina; inspiration = pleuritic
Aggravating/relieving factors	Relieved by nitrates = angina; relieved by leaning forward = pericarditis; worsened by food = GERD/esophageal
Sweating, palpitation	Sweating = sympathetic activation in MI; palpitation = arrhythmia co-existing with ischemia
Associated with food	Food-related = GERD, esophageal spasm (mimics cardiac pain - to differentiate)

DYSPNEA - Why we ask each parameter:

Parameter	Why we ask / What we rule out
Duration	Chronic progressive = heart failure; acute = flash pulmonary edema, PE
Mode of onset	Sudden = acute LVF, PE; insidious = chronic HF, valvular disease
Progression	Rapid progression = decompensation; stable = chronic compensated HF
Grade (NYHA I-IV)	To classify severity of heart failure and guide management
Aggravating/relieving factors	Exertion worsening = HF; positional (worse supine) = orthopnea = LVF
PND (Paroxysmal Nocturnal Dyspnea)	Waking from sleep breathless = classic LVF - due to redistribution of fluid when supine, plus nocturnal reduction in sympathetic tone
Orthopnea	Number of pillows = degree of LVF severity; fluid moves from legs to lungs when lying flat
Wheeze	Cardiac asthma (LVF) vs bronchial asthma - important differentiation
Cough with expectoration	Pink frothy sputum = acute pulmonary edema (LVF); white frothy = chronic LVF
Associated chest pain	Pain + dyspnea = ACS with LVF (worse prognosis)

PALPITATION - Why we ask:

Parameter	Why we ask
Duration	Acute = new arrhythmia; chronic = longstanding AF, SVT
Regular/irregular	Regular = SVT, VT; irregular = AF, frequent ectopics
Paroxysmal	Sudden onset and termination = re-entrant tachycardia (SVT, WPW), AF
Brought on by	Exertion = LVOTO, catecholamine-sensitive VT; caffeine/stress = ectopics
Associated chest pain	Pain + palpitation = ischemia-induced arrhythmia
Associated syncope	Syncope + palpitation = dangerous arrhythmia (VT, complete heart block) - emergency!

LOSS OF CONSCIOUSNESS - Why we ask:

Parameter	Why we ask
Episodes/day, duration	Frequent brief = Stokes-Adams attacks (complete heart block); prolonged = epilepsy
Total/partial	Partial = TIA, complex partial seizure; total = cardiac syncope or tonic-clonic
Recovery time	Rapid recovery = vasovagal/cardiac syncope; slow = post-ictal (epilepsy)
Associated fits	Fits = epilepsy (to rule out); anoxic seizures can occur in cardiac syncope
Bladder/bowel disturbance	Incontinence = true epileptic seizure (not cardiac syncope)
Time of last episode	To assess frequency and urgency

COUGH WITH EXPECTORATION (in CVS) - Why we ask:

Parameter	Why we ask
Duration, onset	Acute = acute LVF; chronic = chronic HF
Quantity	Large volume frothy = pulmonary edema
Colour/odour	Pink frothy = pulmonary edema; rust coloured = MS (hemoptysis)
Blood on coughing	Hemoptysis in CVS = mitral stenosis (pulmonary hypertension rupturing bronchial veins), pulmonary embolism, pulmonary apoplexy
Followed by malena	To rule out GI source of bleeding (swallowed blood)
Associated with food particles	To rule out aspiration/esophageal source

NEGATIVE HISTORY - Why we ask (system by system):

Symptoms of RHF (Right Heart Failure):

Question	Reason
Pedal edema	RHF causes systemic venous congestion - fluid accumulates in dependent parts
Abdominal distension	Ascites from hepatic venous congestion (congestive hepatomegaly, portal hypertension)
Dyspepsia	Gut edema in RHF causes poor digestion
Right hypochondrial pain	Tender hepatomegaly from hepatic congestion (stretching of Glisson's capsule)
Puffiness of face	Severe RHF or SVC obstruction

Symptoms of Rheumatic Fever (RF):

Question	Reason
Fever with sore throat	Group A Strep pharyngitis precedes RF by 2-4 weeks (Jones criteria)
Involuntary movements	Sydenham's chorea = major criterion of RF
Rash, nodules	Erythema marginatum + subcutaneous nodules = major criteria of RF

Symptoms of Left-sided disease:

Question	Reason
Voice change	Ortner's syndrome - enlarged left atrium (MS) compresses left recurrent laryngeal nerve
Dysphagia	Enlarged left atrium compresses esophagus - classic in severe MS
Oliguria	Reduced cardiac output reduces renal perfusion (cardiorenal syndrome)

Symptoms of Congenital disease:

Question	Reason
Cyanotic episodes	Right-to-left shunt (Fallot's, Eisenmenger's)
Squatting	Classic in Fallot's - squatting increases systemic vascular resistance, reducing R-to-L shunt, relieving cyanosis

Symptoms of Pulmonary Hypertension (PHT):

Question	Reason
Recurrent respiratory infections	Increased pulmonary blood flow (L-to-R shunts like ASD, VSD) makes lungs vulnerable
Syncope	Pulmonary hypertension reduces cardiac output on exertion
Hemoptysis	Pulmonary apoplexy - rupture of dilated pulmonary vessels
Chest pain	Right ventricular ischemia in PHT

PAST HISTORY - Why we ask:

Question	Why
Previous similar episodes	To assess chronicity, recurrence, disease progression
Rheumatic fever	Most common cause of valvular heart disease in developing countries - mitral/aortic/tricuspid involvement
Epistaxis in RF	Minor criterion; nasal mucosal vessel fragility
HT, DM	Major risk factors for IHD, cardiomyopathy, accelerated atherosclerosis
TB	Constrictive pericarditis (tuberculosis is #1 cause in India)
STD (syphilis)	Syphilitic aortitis causes AR; aortic root dilatation
Surgery	Previous cardiac/valve surgery; scarring; anticoagulation status
Chronic respiratory infection	Cor pulmonale (RHF from chronic lung disease)
Cyanotic spells	Congenital cyanotic heart disease
Chronic fever	Subacute bacterial endocarditis (SBE) - low-grade fever for weeks/months

FAMILY HISTORY:

HT, DM - familial predisposition to IHD
Abortions in female - antiphospholipid syndrome (thrombotic tendency, valvular disease)
Congenital HD - genetic syndromes (Marfan's, Down's, Turner's)

PERSONAL HISTORY:

Smoking - major risk factor for IHD, peripheral vascular disease
Alcohol - alcoholic cardiomyopathy, dilated cardiomyopathy, arrhythmias
Diet - high fat/salt = hypertension, IHD
Sexual history - syphilitic aortitis (AR), HIV cardiomyopathy
Menstrual history - iron deficiency anemia worsening HF; peripartum cardiomyopathy

GENERAL EXAMINATION - Why we look for each sign:

Finding	Why we look / What it indicates
Conscious, comfortable, oriented	Baseline neurological status; confusion = low cardiac output, cerebral hypoperfusion
Build/nourishment	Cardiac cachexia in advanced HF; obesity = risk factor for HF/IHD
Febrile	Infective endocarditis, rheumatic fever, pericarditis
Jaundice	Hepatic congestion (RHF - "cardiac jaundice"), hemolysis in mechanical valve
Pallor	Anemia worsens HF; anemia of IE; anemia worsens angina
Clubbing	Cyanotic CHD (grade 3+), infective endocarditis, Eisenmenger's syndrome
Cyanosis	Central = R-to-L shunt, Eisenmenger's; peripheral = low output state
Pedal edema	RHF/CCF; pitting edema - slow refilling (>45 sec) = CCF; fast refilling (<45 sec) = hypoalbuminemia/renal
Lymphadenopathy	Rule out malignancy, TB, HIV - all can have cardiac manifestations

Markers of Congenital HD:

Feature	Syndrome
Low set ears	Down's syndrome (ASD, VSD, AV canal)
Polydactyly	Ellis-van Creveld syndrome (ASD)
Arachnodactyly	Marfan's syndrome (AR, MVP, aortic dissection)
Webbed neck	Turner's syndrome (coarctation of aorta, bicuspid aortic valve)
Kyphoscoliosis	Marfan's, Holt-Oram syndrome

Markers of Infective Endocarditis:

Feature	Mechanism
Osler's nodules (painful, hand)	Immune complex deposition in digital pulp
Splinter hemorrhages (nails)	Microemboli in nail bed capillaries
Janeway lesions (painless, palmar)	Septic emboli in thenar/hypothenar area
Roth's spots (retinal)	Immune complex vasculitis of retinal vessels (fundoscopy needed)
Splenomegaly	Immune hyperplasia + septic splenic emboli
Anemia + fever + jaundice	Hemolytic anemia + bacteremia + hepatic involvement

VITAL SIGNS - Why each component:

Pulse:

Parameter	Why
Rate	Tachycardia = HF, fever, anemia, hyperthyroidism; bradycardia = heart block, BB use
Rhythm	Irregularly irregular = AF (most common arrhythmia in valvular disease); regularly irregular = ectopics
Volume	Low = poor CO, AS, cardiac tamponade; high = AR, AV fistula, fever
Character	Collapsing = AR; plateau/slow-rising = AS; bisferiens = severe AR or HOCM
All peripheral vessels	Peripheral vascular disease, coarctation (absent femoral), subclavian steal
RF/PD (Radiofemoral delay)	Coarctation of aorta - femoral pulse delayed compared to radial
Condition of vessel wall	Atherosclerosis (hard, non-pulsatile), diabetes (calcification)

BP:

Wide pulse pressure = AR, hyperthyroidism, anemia
Narrow = AS, tamponade, severe HF
Asymmetric in both arms = dissection, subclavian stenosis
Postural drop = hypovolemia, autonomic neuropathy

JVP:

Elevated = RHF, tricuspid stenosis, tamponade, constrictive pericarditis
Absent = hypovolemia
Waveform: absent X descent = TR; cannon waves = complete heart block

PERIPHERAL SIGNS OF AR (Wide Pulse Pressure Signs) - Why each:

All these signs arise because of the wide pulse pressure in aortic regurgitation - high systolic pressure (from large stroke volume) + low diastolic pressure (blood regurgitates back into LV):

Sign	Mechanism	Why we look
De Musset's (head bobbing)	High stroke volume pulsation transmitted to head/neck	Confirms severe AR
Corrigan's (dancing carotids)	Exaggerated carotid pulsation from wide pulse pressure	Visible neck pulsation in AR
Quincke's (capillary nail pulsation)	Capillary filling and emptying with each beat	Press nail lightly - blanche rhythmically
Collapsing/water hammer pulse	Rapid rise + rapid fall of pulse from regurgitation	Quick wrist elevation amplifies it
Traube's (pistol shot femoral)	Loud systolic sound over femoral artery	Wide pulse pressure causes loud sound
Duroziez's murmur	Double murmur (systolic + diastolic) over femoral	Press femoral partially - to-and-fro flow
Hill's sign	Popliteal BP > brachial BP by >20 mmHg	Peripheral amplification of wide pulse pressure
Pulsus bisferiens	Two systolic peaks	Severe AR or AR+AS combined

LOCAL EXAMINATION - CVS:

Inspection:

Finding	What it suggests
Precordial bulge	Cardiomegaly since childhood (congenital HD); pushes chest wall out
Kyphoscoliosis	Marfan's syndrome, pushes heart to one side
Apical impulse	Position = cardiac enlargement (displaced outward/down = LV enlargement)
Epigastric pulsations	RV enlargement, aortic aneurysm
Parasternal pulsations	RV hypertrophy (pulmonary hypertension, RVH)
Suprasternal pulsations	Aortic aneurysm, high output states
Dilated veins on chest	SVC obstruction
Scars	Previous cardiac surgeries (mitral valvotomy scar - left submammary)

Palpation:

Finding	What it tells us
Apical impulse site	Normal = 5th ICS MCL; displaced = LV enlargement; tapping = MS (loud S1 palpable)
Type of apical impulse	Heaving = LV pressure overload (AS, HT); thrusting/hyperdynamic = LV volume overload (AR, MR)
Thrills	Palpable murmurs = significant valvular disease (grade 4+ murmur)
Parasternal heave	RV pressure overload = pulmonary hypertension, PS
Palpable P2	Loud P2 felt at left 2nd ICS = pulmonary hypertension
Tracheal position	Mediastinal shift (also relevant in RS)

Percussion:

Right border of heart = right sternal border (enlarged = RV/RA dilatation)
Left border = apical impulse (enlarged = LV dilatation)
Liver dullness position = to detect hepatomegaly (RHF)

Auscultation:

Mitral area:

Sound	Why/What it means
Loud S1	Mitral stenosis - valve snaps shut from high LA pressure
Soft S1	MR (valve does not close properly), long PR interval
Opening snap (OS)	MS - stiff mitral leaflets snap open; shorter S2-OS interval = more severe MS
MDM (Mid-diastolic murmur)	MS - turbulent flow across narrowed mitral valve; bell, left lateral position, expiratory apnea brings it out best
PSA (Pre-systolic accentuation)	Sinus rhythm + MS - LA contraction increases gradient just before mitral closes
PSM (Pan-systolic murmur)	MR - regurgitation throughout systole; conducted to axilla (direction of regurgitant jet)
S3	Volume overload of LV (MR, AR, DCM) - passive rapid filling sound
S4	LV stiffness (AS, hypertrophy, ischemia) - atrial kick into stiff ventricle

Why left lateral position + expiratory apnea for mitral:

Left lateral: brings apex (mitral valve) closer to chest wall
Expiratory apnea: reduces lung interference, blood pools in pulmonary circulation

Aortic area:

Sound	Why/What it means
Ejection click	Bicuspid aortic valve / mild AS - sudden tensing of valve
ESM (Ejection systolic murmur)	AS - crescendo-decrescendo (diamond-shaped); conducted to carotids (direction of flow)
EDM (Early diastolic murmur)	AR - decrescendo; heard in 2nd right ICS and left sternal border (Erb's point); forward leaning + expiratory apnea
Soft A2	AS - calcified aortic valve doesn't close loudly
Loud A2	AR - high aortic diastolic pressure (early in disease)

Why leaning forward + expiratory apnea for aortic EDM:

Brings aortic root closer to chest wall
Increases blood pooling in aorta, accentuating regurgitation

Pulmonary area:

Finding	Meaning
Loud P2	Pulmonary hypertension
Fixed split S2	ASD (equalization of pressures in both ventricles throughout respiration)
Wide split S2	RBBB, pulmonary stenosis (delayed RV emptying)
Reverse split	LBBB, severe AS (delayed LV emptying)
Ejection click	Pulmonary stenosis
ESM at pulmonary	PS, ASD (flow murmur), pulmonary hypertension

Why inspiratory for pulmonary/tricuspid:

Inspiration increases venous return to right heart - murmurs of right-sided valves increase (Carvallo's sign)

Tricuspid area:

MDM = Tricuspid stenosis (rare; often with MS in rheumatic)
PSM conducted to right sternal border = Tricuspid regurgitation
S3, S4 = RV failure

GASTROINTESTINAL (GI) CASE

ABDOMINAL PAIN - Why each parameter:

Parameter	Why
Site	Epigastric = peptic ulcer, pancreatitis, gastritis; RUQ = liver/gallbladder; LLQ = sigmoid/colon; periumbilical = small bowel; RIF = appendix; LUQ = spleen/stomach
Nature (continuous vs intermittent)	Intermittent/colicky = hollow viscus (intestinal obstruction, biliary, renal colic); continuous = inflammation/peritonitis
Character (colicky vs constant)	Colicky = waves of smooth muscle contraction (obstructive); constant = inflammatory/ischemic
Radiation	To back = pancreatitis, aortic aneurysm; to right shoulder = diaphragm/liver (phrenic nerve C3-5 = shoulder tip pain); to groin = renal colic
Relieving factors	Relieved by eating = duodenal ulcer; worsened by eating = gastric ulcer, ischemic bowel, pancreatitis
Associated fever	Infection, cholangitis, appendicitis, diverticulitis
Associated vomiting	Early vomiting = gastric/duodenal; late = distal obstruction
Associated defecation	IBS - pain relieved by defecation; obstruction - no flatus/stool

ABDOMINAL DISTENSION - Why we ask:

Question	Reason
Duration, onset	Acute = obstruction, perforation, acute ascites; chronic = cirrhosis, malignancy, chronic constipation
Site (localised/uniform)	Localised = organomegaly, mass; uniform = ascites, gas, obesity
RVF features (leg swelling, breathlessness, chest pain)	RVF causes hepatic venous congestion → ascites; cardiac ascites - important to distinguish from portal/hepatic ascites
Liver features (loss of appetite, hematemesis, malena)	Portal hypertension: varices bleed → hematemesis/malena; liver failure → hypoalbuminemia → ascites
Renal features (oliguria, facial puffiness, frothy urine)	Nephrotic syndrome → hypoalbuminemia → ascites; hepatorenal syndrome
Vomiting/blood in vomit	Upper GI bleed (varices, peptic ulcer) - amount, character assesses severity
Projectile vomiting	Pyloric obstruction / raised ICP
Drug intake (NSAIDs, steroids)	Peptic ulcer, GI bleed - major risk factor

JAUNDICE - Why each parameter:

Parameter	Why
Duration	Acute = viral hepatitis, hemolysis; chronic = cirrhosis, malignancy
Itching (pruritus)	Cholestatic jaundice (bile salts deposit in skin) - obstructive jaundice (stones, malignancy)
Dark urine	Conjugated hyperbilirubinemia (conjugated = water-soluble, excreted in urine) = hepatic/obstructive jaundice
Pale stools	Obstructive jaundice (bile cannot reach gut) = acholic stools
Fever with rigors	Charcot's triad (fever + jaundice + RUQ pain) = cholangitis - emergency
Treatment taken	Drug-induced jaundice (anti-TB, paracetamol overdose, statins)

STOOLS - Why we ask:

Parameter	Why
Frequency	>3 loose/day = diarrhea; obstipation = complete obstruction
Dark/tarry black (melena)	Upper GI bleed (blood digested = black + tarry + foul odor); > 100 mL of blood from proximal to cecum
Pale/clay-colored	Obstructive jaundice (no bile pigment in stool)
Blood streaks	Lower GI bleed (bright red = distal colon/rectum); mixed = proximal colon
Sticky/mucoid	Mucous in stool = IBS, IBD, colorectal malignancy
Associated pain	Pain before = small bowel; during = colonic; after = anorectal

NEGATIVE HISTORY (GI):

Fever: Duration/nature/rigor - to differentiate infective (hepatitis A/E, cholangitis, amoebic abscess, typhoid) from non-infective (malignancy, autoimmune)

Upper GIT symptoms:

Dysphagia - esophageal pathology, extrinsic compression by enlarged liver/spleen
Heartburn - GERD, esophagitis
Vomiting - gastric outflow obstruction

Urinary tract symptoms: To rule out renal/hepatorenal syndrome, urinary tract as source of pain mimicking GI pain (renal colic, UTI)

Bleeding diathesis: Epistaxis, gum bleeding, prolonged bleeding = liver failure (impaired clotting factor synthesis), DIC, platelet dysfunction in portal hypertension (hypersplenism)

Loss of appetite/weight loss: Malignancy (hepatocellular carcinoma, GI malignancy), TB, cirrhosis

PAST HISTORY (GI):

Question	Why
Tattooing	Hepatitis B and C transmission (needle sharing)
Blood transfusion	Hep B, C, HIV transmission
STD exposure	Hep B, C, HIV - all cause hepatic disease
Vaccination	Hep A and B vaccines - prior vaccination reduces likelihood
Previous abdominal surgeries	Adhesion-related obstruction, scar-related peritonitis, ascites (surgical scar may be irritated)
TB history	TB peritonitis, TB hepatitis, portal hypertension from TB
Renal colic	Renal/ureteric stone causing pain that mimics GI pain

MARKERS OF LIVER CELL FAILURE - Why each finding:

Marker	Why present / Mechanism
Alopecia	Hypogonadism from hepatic failure → hormonal imbalance → hair loss
Bitot spots (Vit A)	Malabsorption of fat-soluble vitamins in cholestatic liver disease
Subconjunctival hemorrhage (Vit K)	Liver fails to synthesize clotting factors (II, VII, IX, X) - all vitamin K dependent; bleeding tendency
KF ring (Kayser-Fleischer)	Wilson's disease - copper deposition in Descemet's membrane of cornea - only seen in Wilson's
Xanthelasma	Cholestatic liver disease → hyperlipidemia → fat deposits around eyes
Parotid enlargement	Alcoholic liver disease - direct toxic effect of alcohol on parotid gland
Fetor hepaticus	Mercaptans produced by gut bacteria (normally metabolized by liver) escape into systemic circulation → sweet/musty breath; indicates hepatic encephalopathy
Spider naevi	Elevated estrogen (liver fails to metabolize estrogen) → vasodilation of arterioles; >5 spider naevi = significant liver disease
Gynecomastia	Elevated estrogen (not metabolized by failing liver)
Palmar erythema	Elevated estrogen → vasodilation of palmar skin
Dupuytren's contracture	Alcoholic liver disease (fibrosis of palmar fascia)
Flapping tremor/asterixis	Hepatic encephalopathy - impaired cerebral metabolism, ammonia accumulation
Leukonychia	Hypoalbuminemia (liver fails to synthesize albumin) → white nails
Caput medusae	Portal hypertension → blood flows back through paraumbilical veins → dilated epigastric/abdominal veins radiating from umbilicus
Testicular atrophy + pubic hair loss	Elevated estrogen + reduced testosterone (liver fails to clear estrogen); hypogonadism
Pedal edema	Hypoalbuminemia (reduced oncotic pressure) + portal hypertension + secondary hyperaldosteronism

ABDOMINAL EXAMINATION - Why each step:

Inspection:

Finding	Significance
Scaphoid abdomen	Starvation, malignancy with cachexia
Uniformly distended	Ascites (fluid), gas (obstruction), obesity, pregnancy
Full flanks	Ascites
Everted umbilicus	Ascites/increased intra-abdominal pressure
Sister Mary Joseph's nodule	Umbilical metastasis from intra-abdominal malignancy (stomach, colon, ovary)
Movement with respiration	Absent = peritonitis (patient splints abdomen to avoid pain)
Visible peristalsis	Gastric outflow obstruction (gastric peristalsis, left to right) or small bowel obstruction
Dilated veins	Direction of flow tells us: upward = IVC obstruction; radiating from umbilicus = portal hypertension (caput medusae)
Head rising test	Divarication of recti (abdominal muscle weakness) - seen in ascites, post-pregnancy
Striae	Purple = Cushing's syndrome; white = old/healed (pregnancy, obesity)

Palpation:

Why we describe liver this way:

Size (cm below costal margin): degree of hepatomegaly
Surface (smooth vs nodular): Smooth = hepatitis, congestive; nodular = cirrhosis, metastases, HCC
Consistency (soft/firm/hard): Hard + irregular = malignancy; firm = cirrhosis; soft = acute hepatitis, congestion
Tender: Tender = acute hepatitis, congestive hepatomegaly (RHF); non-tender = cirrhosis, malignancy
Moving with respiration: Confirms it is liver (diaphragm moves it); if it doesn't move = cannot confirm it is liver, or peritoneal adhesions
Cannot insinuate fingers under costal margin: Confirms the mass is liver, not something else

Spleen features:

Notch on medial border: Pathognomonic of spleen
Moves with respiration: Like liver, diaphragm moves it
Not bimanually palpable: Unlike kidney
Not ballotable: Unlike kidney
Cannot feel upper border: Goes under ribcage
No colonic band of resonance: Unlike kidney

Kidney features (to differentiate from spleen/liver):

Bimanually palpable: Can be felt by placing one hand behind and one in front (ballotable)
Ballotable: Kidney "bounces" between two hands
Colonic band of resonance: Colon overlies anterior surface of kidney

Percussion:

Test	Why
Shifting dullness	Detects free fluid (ascites) ≥ 500 mL; dull in flanks, shifts when patient turns (fluid redistributes)
Fluid thrill	Detects large ascites; vibration transmits through fluid
Puddle sign	Detects small amounts of ascites (as little as 120 mL); patient on all fours, percuss in dependent area
Liver span	Normal 12-15 cm; increased = hepatomegaly; decreased = cirrhosis (shrunken liver), hyperinflated lungs
Traube's space	Left 6th rib, left axillary line, costal margin = normally tympanitic (stomach gas); dull = splenomegaly, left pleural effusion, full stomach
Colonic resonance over kidney	Distinguishes kidney (resonant front from overlying colon) from spleen (dull throughout)

Auscultation:

Sound	Why
Bowel sounds	Increased tinkling = obstruction; absent = paralytic ileus, peritonitis
Renal bruit	Renal artery stenosis (renovascular hypertension)
Liver bruit	HCC (vascular tumor), alcoholic hepatitis, hemangioma
Venous hum	Portosystemic collaterals (portal hypertension) - continuous hum heard near umbilicus
Cruveilhier-Baumgartner syndrome	Venous hum + palpable varicose veins at umbilicus + portal hypertension (patent paraumbilical vein)
Peritoneal rub	Friction over liver (perihepatitis - Fitz-Hugh-Curtis) or spleen (perisplenitis, splenic infarct)
Succussion splash	Fluid + gas in stomach (gastric outflow obstruction); heard when patient shaken side to side ≥ 3 hours after meal

RESPIRATORY SYSTEM (RS) CASE

HISTORY PARAMETERS - Why we ask:

Cough:

Parameter	Why
Duration	Acute < 3 weeks (URTI, pneumonia); subacute 3-8 weeks (post-infectious, TB); chronic > 8 weeks (COPD, asthma, malignancy)
Paroxysmal	Whooping cough (pertussis), foreign body, asthma
Dry vs productive	Dry = ILD, viral, malignancy, ACE inhibitor cough; productive = infection, bronchiectasis, COPD
Postural	Increased on lying (postnasal drip, GERD, bronchiectasis)
Diurnal	Worse at night = asthma; worse in morning = bronchiectasis, COPD (overnight secretion accumulation)

Sputum:

Parameter	Why
Quantity	Large volume (>200 mL/day) = bronchiectasis, lung abscess
Color	Yellow/green = infection (neutrophils); rust = pneumococcal pneumonia; pink frothy = pulmonary edema; black = coal miner's
Purulent	Bacterial infection
Postural variation	Increases when lying on affected side = bronchiectasis (gravity drains)
With blood	See hemoptysis

Hemoptysis:

Parameter	Why
Duration/episodes	Recurrent = bronchiectasis, TB, malignancy; acute single = PE, pneumonia
Fresh vs altered	Fresh bright red = active bleeding (bronchiectasis, malignancy, TB); altered = old bleed
With purulent sputum	Blood + pus = bronchiectasis, lung abscess
With food particles	Hematemesis misidentified as hemoptysis - important to differentiate (hematemesis = dark, coffee-ground, with nausea; hemoptysis = bright red, frothy, with cough)

Breathlessness (in RS):

Parameter	Why
Grade (MRC scale)	1 = on hills; 2 = on flat; 3 = after 100m; 4 = on dressing; 5 = at rest - severity classification
PND/orthopnea	Cardiac involvement - left heart failure causing pulmonary edema
Aggravating factors	Exercise = COPD/ILD; allergens = asthma; cold = asthma/COPD

Chest pain (in RS):

Parameter	Why
Pricking/stabbing	Pleuritic pain = pleurisy, pleuritis, pneumonia with pleural involvement, PE with infarction
Postural variation	Pleuritic pain worse on deep breathing/movement
Site	Lateral = pleurisy; central = mediastinitis, PE with central embolus

NEGATIVE HISTORY (RS):

Question	Why
Wheeze	Asthma/COPD - obstructive airway disease; cardiac asthma (to differentiate)
Halitosis	Bronchiectasis (putrid odor = anaerobic infection), lung abscess
Fever with evening rise, night sweats, weight loss	Classic TB triad - must always ask in RS
Pedal edema, abdominal distension, puffiness of face	Cor pulmonale (RHF secondary to chronic lung disease - COPD, ILD, pulmonary hypertension)
Palpitation, syncope	Arrhythmia from hypoxia, cor pulmonale
Hoarseness of voice	Bronchogenic carcinoma compressing left recurrent laryngeal nerve (runs near left hilum), or mediastinal lymphadenopathy
Dysphagia	Mediastinal mass/lymph node from malignancy or TB compressing esophagus

PAST HISTORY (RS):

Question	Why
TB contact, age, incomplete treatment	TB is most common chronic lung disease in India; incomplete treatment = MDR-TB
Aspiration history (ABCDEF mnemonic)	Aspiration pneumonia: Alcohol, Booze level (altered consciousness), Coma, Drowning, Epilepsy, Foreign body
Exanthematous fever	Measles → giant cell pneumonia; chickenpox → varicella pneumonia
Tooth extraction, tonsillectomy	Aspiration of bacteria during procedure → lung abscess
Measles, whooping cough	Both cause bronchiectasis through childhood lower respiratory tract damage
Subphrenic/amoebic abscess, pancreatitis	Can track up through diaphragm → pleural effusion (sympathetic or direct extension)

MARKERS IN RS EXAMINATION:

Horner's syndrome (Ptosis + Miosis + Anhidrosis + Enophthalmos):

Cause in RS: Pancoast tumor (apex of lung) invading cervical sympathetic chain (T1 root + stellate ganglion)

Troussier's sign (left supraclavicular lymph node):

Virchow's node = metastasis from bronchogenic carcinoma (or GI malignancy)
Left because thoracic duct drains here

Markers of pulmonary malignancy:

Acanthosis nigricans = paraneoplastic (TGF-alpha, insulin-like substance from tumor)
Gynecomastia = ectopic HCG secretion from large cell carcinoma
Clubbing + HPOA (Hypertrophic Pulmonary Osteoarthropathy) = periosteal reaction from lung cancer

Markers of sarcoidosis: Multisystem granulomatous disease affecting lungs, lymph nodes, eyes, skin, liver, spleen, parotid, joints, nerves

Markers of TB:

Sign	Explanation
Scrofula	TB lymphadenitis of cervical nodes - classically drains and forms collar stud abscess
Collar stud abscess	Deep abscess ruptures fascia → two connected collections (collar stud shape)
Erythema nodosum	Hypersensitivity reaction to TB (also: sarcoidosis, Strep, drugs)
Lupus vulgaris	Chronic cutaneous TB - apple jelly nodules on face
Tinea versicolor	Associated with immunosuppression (HIV/TB)

CHEST EXAMINATION (RS):

Inspection:

Finding	Significance
Barrel chest	Increased AP diameter; emphysema (hyperinflation of lungs)
Pigeon chest (pectus carinatum)	Childhood chronic respiratory disease (asthma, rickets) → sternal protrusion
Funnel chest (pectus excavatum)	Marfan's syndrome, connective tissue disorders
Rachitic rosary	Rickets - widening of costochondral junctions from poor mineralization
Harrison's sulcus	Groove along lower ribs at diaphragm attachment from chronic childhood asthma/rickets
IC indrawing	Severe airway obstruction (asthma attack), COPD exacerbation
Intercostal fullness	Pleural effusion (pushes ribs apart)
Crowding of ribs	Fibrosis/collapse on that side (lung shrinks)
Discharging sinuses	TB empyema necessitans - pus tracks through chest wall
Trail's sign	Tracheal tug with each heartbeat = aortic arch aneurysm
Kyphoscoliosis	Restrictive lung disease (reduces chest compliance)

Palpation:

Finding	Significance
Tracheal deviation	Pulled toward = fibrosis, collapse; pushed away = effusion, pneumothorax, tension pneumothorax
Reduced chest expansion	On affected side in pneumonia, effusion, fibrosis, pneumothorax
Tactile fremitus	Increased = consolidation (solid lung transmits better); decreased = effusion (fluid attenuates), pneumothorax (air attenuates)
Vocal fremitus	Same as tactile

Percussion:

Note	Significance
Dull	Consolidation (pneumonia), pleural effusion, collapse, fibrosis
Stony dull	Pleural effusion (fluid conducts sound differently from solid)
Hyper-resonant	Pneumothorax, emphysema
Tidal percussion	Changes in liver dullness with breathing - tests diaphragm mobility
Shifting dullness (chest)	Pleural effusion - fluid shifts with posture
Straight line dullness	Pleural effusion with patient upright - fluid forms horizontal level

Auscultation:

Sound	Mechanism	Significance
Normal vesicular breath sound	Air movement in alveoli and small bronchioles	Present = normal lung
Bronchial breath sound	Turbulent flow in large airways conducted through consolidated lung	Pneumonia (consolidation), fibrosis adjacent to bronchus
Bronchovesicular	Intermediate	Normal over manubrium, right apex; abnormal elsewhere
Absent breath sounds	Air/fluid/solid barrier between lung and stethoscope	Pneumothorax (air), effusion (fluid), massive consolidation
Fine crackles	Explosive reopening of collapsed alveoli on inspiration	Fibrosis (ILD), pulmonary edema (LVF)
Coarse crackles	Secretions in large airways	Bronchiectasis, pneumonia, COPD
Wheeze (rhonchi)	Airway narrowing with turbulent flow	Asthma (polyphonic = multiple levels), COPD; monophonic = single obstruction (foreign body, tumor)
Pleural rub	Inflamed pleural surfaces rubbing	Pleuritis, pneumonia with pleuritis, PE with infarct, mesothelioma
Post-tussive suction	After cough, air sucked back in	Lung cavity (TB, abscess)

Vocal resonance tests:

Test	What it detects
Bronchophony	Increased transmission of spoken voice = consolidation
Aegophony (E→A change)	Over pleural effusion - voice changes quality at fluid-lung interface
Whispering pectoriloquy	Consolidation - whispered sounds clearly heard through consolidated lung

CNS CASE

HISTORY TAKING:

Weakness/inability - Why each parameter:

Parameter	Why
Onset (sudden vs insidious)	Sudden = CVA (stroke/hemorrhage/embolism); insidious = tumor, abscess, demyelination
Time of occurrence (sleep vs work)	During sleep = thrombotic stroke (reduced BP at night, slower flow, clot forms); during work = embolic/hemorrhagic
Progression	Stepwise = lacunar infarcts; gradual = tumor; rapid = hemorrhage; fluctuating = TIA
Proximal vs distal weakness (UL)	Proximal = myopathy; distal = peripheral neuropathy; combined = motor neuron disease
Combing, lifting (proximal UL)	Deltoid, supraspinatus, biceps - C5 root
Mixing food, buttoning, writing (distal UL)	Hand intrinsic muscles - T1 root (ulnar nerve); writing = fine motor = corticospinal tract
Standing, climbing stairs (proximal LL)	Quadriceps, hip flexors - L3/L4
Slippers slipping (distal LL)	Foot drop = L4/L5 (deep peroneal nerve); tibialis anterior weakness
Trunk weakness	Cord lesion at thoracic level
Head lifting	Neck flexors - C1-3 roots; helps determine level of cord lesion

Fasciculation/atrophy:

Fasciculations = lower motor neuron (anterior horn cell disease, e.g., MND)
Atrophy (wasting) = denervation (LMN) or disuse

Sensory loss - why we ask each modality:

Modality	Pathway	Why
Temperature sense	Spinothalamic tract (crosses in cord)	Dissociated sensory loss = syringomyelia, Brown-Sequard
Touch	Dorsal columns + spinothalamic
Pain	Spinothalamic
Tingling/numbness	Partial nerve damage	Peripheral neuropathy, radiculopathy
Root pain	Dermatomal distribution	Disk prolapse, radiculopathy

LEVEL OF LESION HISTORY - Why we ask:

History feature	Localization
Headache, projectile vomiting, convulsions, blurring of vision	Raised intracranial pressure = cortical/meningeal pathology
Aphasia	Dominant cortex (Broca's/Wernicke's area)
Bladder involvement	Frontal lobe or cord; corticospinal tract above S2-4 = upper motor neuron bladder
Convulsions	Cortex (seizure focus)
Cranial nerve involvement	Brain stem lesion (CN 3-12 nuclei)

Cranial nerve history - what each question localizes:

CN	Question	Localizes
I (olfactory)	Loss of smell	Frontal lobe, olfactory groove meningioma, trauma
II (optic)	Disturbance of vision	Optic nerve, chiasm, optic tract, visual cortex
III, IV, VI	Diplopia, eye movement difficulty	Midbrain (III, IV), pons (VI), orbital apex, cavernous sinus
V (trigeminal)	Facial numbness, chewing difficulty	Pons, foramen ovale (V3)
VII (facial)	Taste loss, drooling, angle deviation	Pons (UMN lesion spares forehead), facial nerve canal
VIII	Hearing loss, vertigo, tinnitus	Pons/cerebellopontine angle
IX, X	Nasal regurgitation, dysphagia, hoarseness	Medulla, jugular foramen, vagal lesion
XII	Dysarthria, tongue deviation	Medulla

ANS history:

Question	Why
Constipation/loss of bowel control	Autonomic neuropathy (diabetes, Parkinson's), cord lesion
Difficulty initiating micturition	UMN bladder (cord lesion) - detrusor-sphincter dyssynergia
Dribbling	Overflow incontinence (LMN bladder, autonomic neuropathy)
Impotence	Sacral cord (S2-4), autonomic neuropathy
Sweating	Sympathetic trunk lesion, autonomic neuropathy

PAST HISTORY (CNS):

Question	Why
TIA, RIND	Preceding events before completed stroke; TIA is warning sign
DM, HT	Major risk factors for ischemic stroke (atherosclerosis, lacunar infarcts)
Cardiac disease	Atrial fibrillation, MI with mural thrombus, valvular disease → cardioembolism
CSOM (chronic suppurative otitis media)	Can cause intracranial complications - brain abscess, meningitis (through petrous bone)
Dog bite	Rabies - encephalitis with specific CNS features
OCPs	Oral contraceptives → cerebral venous thrombosis, stroke in young women

NEUROCUTANEOUS MARKERS - Why each:

Marker	Syndrome	Why look
Adenoma sebaceum (angiofibromas on face)	Tuberous sclerosis	Cortical tubers → seizures, intellectual disability
Ash leaf patches (hypopigmented)	Tuberous sclerosis	Same - autosomal dominant
Cafe au lait spots	Neurofibromatosis type 1	NF1 - peripheral nerve tumors, optic glioma, CNS tumors
Multiple neurofibromas	NF1	As above
Port wine stain (facial capillary hemangioma)	Sturge-Weber syndrome	Ipsilateral leptomeningeal angioma → seizures, glaucoma
Tuft of hair over spine	Spina bifida occulta	Incomplete closure of neural tube → cord tethering
Conjunctival hemangioma	Von Hippel-Lindau	Cerebellar hemangioblastoma, retinal angioma
Pes cavus (high arched foot)	Friedreich's ataxia	Spinocerebellar degeneration

HIGHER FUNCTIONS - Why we test:

Function	Why
Consciousness	GCS - severity of encephalopathy, stroke, raised ICP
Orientation	Cortical function, hepatic encephalopathy, metabolic encephalopathy
Memory	Hippocampus (short-term); Herpes encephalitis; Alzheimer's; Korsakoff's (thiamine deficiency)
Intelligence	Cortical function, premorbid status
Speech (Broca's/Wernicke's/dysarthria)	Left frontal = Broca's (expressive); left temporal = Wernicke's (receptive); dysarthria = motor (pons, cerebellum, CN 7, 9, 10, 12)
Handedness	Determines which hemisphere is dominant (usually left hemisphere dominant in right-handed)
Emotion	Frontal lobe (disinhibition, lability); Pseudobulbar palsy

MOTOR SYSTEM - Why each component:

Bulk:

Why measure	Interpretation
Measured precisely (10 cm from acromion, etc.)	Detects wasting (LMN, disuse) vs hypertrophy (myopathy)
Comparison between sides	Asymmetric wasting = denervation (LMN) or disuse; symmetric = myopathy, motor neuron disease

Tone:

Finding	Meaning
Increased (spasticity)	UMN lesion (stroke, cord) - clasp knife in UL flexors, LL extensors (explains posture)
Increased (rigidity)	Extrapyramidal (Parkinson's) - lead pipe or cogwheel
Decreased (flaccidity)	LMN lesion (anterior horn cell, peripheral nerve), early phase after acute UMN lesion (spinal shock)

Power - Why each joint tested:

Each joint movement tests specific nerve roots and peripheral nerves
Comparing sides identifies which limbs and which roots are involved
Proximal vs distal pattern identifies myopathy vs neuropathy

Coordination:

Test	What it detects
Finger-nose test	Cerebellar ataxia (ipsilateral) - intention tremor, past pointing
Diadochokinesia	Cerebellar - inability to perform rapid alternating movements
Knee-heel test	Lower limb cerebellar ataxia
Gait	Hemiplegic gait (circumduction), cerebellar (wide-based, ataxic), scissor gait (spastic paraplegia), high stepping (foot drop), Parkinsonian (festinating)

Hemiplegic posture (adducted shoulder, flexed elbow, extended leg):

UMN lesion → flexor spasticity in UL, extensor spasticity in LL
This posture is maintained at rest and during walking (circumduction gait)

REFLEXES - Why each:

Superficial reflexes:

Reflex	Arc	Why test
Corneal	CN V + VII	Pons lesion - absent in ipsilateral V or VII
Abdominal	T8-T12	Absent in UMN lesion above T8; also absent in obesity, multiparity
Cremasteric	L1-L2	Tests L1/L2 - absent in UMN, ipsilateral in LMN
Plantar	L5-S1	UMN → Babinski's sign (extensor plantar) = major sign of corticospinal tract involvement

Deep reflexes:

Reflex	Level	Why
Jaw jerk	CN V (pons)	Exaggerated = bilateral UMN above pons (pseudobulbar palsy)
Biceps	C5-C6	Reduced = LMN at C5-6; exaggerated = UMN above C5
Triceps	C6-C7	Reduced = LMN at C6-7; exaggerated = UMN above
Knee jerk	L3-L4	Reduced = LMN at L3-4 (diabetic neuropathy); exaggerated = UMN above L3
Ankle jerk	S1-S2	First reflex lost in peripheral neuropathy; absent = S1 disk prolapse
Clonus		Sustained rhythmic contractions = UMN lesion (sustained clonus)

SENSORY SYSTEM - Why each modality:

Modality	Pathway	Why test
Touch	Dorsal columns + spinothalamic	General screening
Pain	Spinothalamic (crosses immediately)	Dissociation: spinothalamic lost + dorsal columns intact = Brown-Sequard, syringomyelia
Temperature	Spinothalamic	As above
Vibration sense	Dorsal columns	Lost in B12 deficiency (SACD), tabes dorsalis, peripheral neuropathy
Position sense (proprioception)	Dorsal columns	Romberg positive = dorsal column loss; pseudoathetosis
Tactile localization	Parietal cortex	Parietal lobe lesion
Two-point discrimination	Parietal cortex	As above
Stereognosis	Parietal cortex	Cannot identify objects by touch = parietal lesion
Graphesthesia	Parietal cortex	Cannot identify numbers written on skin = parietal lesion

MENINGEAL SIGNS - Why we test:

Sign	How to test	Significance
Neck rigidity	Passive neck flexion resisted	Meningeal irritation (meningitis, SAH) - reflex spasm of paravertebral muscles
Kernig's sign	Flex hip 90°, try to extend knee - causes resistance/pain	Meningeal irritation stretches inflamed meninges over lumbar roots
Brudzinski's sign	Passive neck flexion → involuntary hip/knee flexion	Reflex flexion to reduce stretch on inflamed meninges

SUMMARY: Why Other Systems Are Examined in Each Case

Case	Other System Exam	Why
CVS + RS	Basal crepitations	Pulmonary edema (LVF)
CVS + Abdomen	Organomegaly, free fluid	Hepatomegaly (RHF), ascites (CCF)
GI + CVS	S1, S2	Rule out RHF causing cardiac ascites/congestive hepatomegaly
GI + RS	Basal crepitations	PE (sympathetic effusion from pancreatitis/amoebic abscess)
GI + CNS	Asterixis, encephalopathy	Hepatic encephalopathy (grade I-IV)
RS + CVS	RHF/CCF signs	Cor pulmonale (RHF from chronic lung disease)
RS + Abdomen	Liver abscess tenderness	Amoebic abscess tracking to right pleural space
CNS + CVS	Arrhythmias, valvular disease	Cardiac source of embolism (AF, IE, rheumatic)

This is the complete clinical reasoning behind every question asked and every examination performed in CVS, GI, RS, and CNS case presentations. Each step exists to either confirm a diagnosis, identify its severity, find its etiology, or rule out complications and mimics.

Give it to me in a PDF please

Reading File

Running Command

ls /home/daytona/workspace/ 2>/dev/null && echo "exists" || mkdir -p /home/daytona/workspace/clinical-reasoning && echo "created"

Running Command

mkdir -p /home/daytona/workspace/clinical-reasoning && python3 -c "from reportlab.lib import colors; print('reportlab ok')" && python3 -c "from reportlab.platypus import Table; print('table ok')"

Writing File

~/clinical-reasoning/make_pdf.py

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

OUTPUT = "/home/daytona/workspace/clinical-reasoning/Clinical_Reasoning_Guide.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
DARK_BLUE   = colors.HexColor("#1B3A6B")
MED_BLUE    = colors.HexColor("#2E6DA4")
LIGHT_BLUE  = colors.HexColor("#D6E8F7")
ACCENT      = colors.HexColor("#E8523A")
GOLD        = colors.HexColor("#C8960C")
GREEN       = colors.HexColor("#2D6A4F")
LIGHT_GREEN = colors.HexColor("#D8F3DC")
PURPLE      = colors.HexColor("#5E35B1")
LIGHT_PURP  = colors.HexColor("#EDE7F6")
ORANGE      = colors.HexColor("#E65100")
LIGHT_ORANG = colors.HexColor("#FFF3E0")
TEAL        = colors.HexColor("#00695C")
LIGHT_TEAL  = colors.HexColor("#E0F2F1")
ROW_ALT     = colors.HexColor("#F0F4F8")
WHITE       = colors.white
BLACK       = colors.black
GREY        = colors.HexColor("#555555")
LIGHT_GREY  = colors.HexColor("#F5F5F5")

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=1.8*cm, leftMargin=1.8*cm,
    topMargin=2*cm, bottomMargin=2*cm
)
W = A4[0] - 3.6*cm   # usable width

styles = getSampleStyleSheet()

# Custom paragraph styles
def S(name, **kw):
    base = kw.pop("parent", "Normal")
    s = ParagraphStyle(name, parent=styles[base], **kw)
    return s

sTitle     = S("sTitle",     fontSize=22, textColor=WHITE,    alignment=TA_CENTER, fontName="Helvetica-Bold", leading=28)
sSubtitle  = S("sSubtitle",  fontSize=12, textColor=LIGHT_BLUE, alignment=TA_CENTER, fontName="Helvetica", leading=16)
sH1        = S("sH1",        fontSize=15, textColor=WHITE,    fontName="Helvetica-Bold", leading=20, spaceAfter=2)
sH2        = S("sH2",        fontSize=12, textColor=DARK_BLUE, fontName="Helvetica-Bold", leading=16, spaceBefore=8, spaceAfter=4)
sH3        = S("sH3",        fontSize=10, textColor=MED_BLUE,  fontName="Helvetica-Bold", leading=14, spaceBefore=4, spaceAfter=2)
sBody      = S("sBody",      fontSize=9,  textColor=BLACK,    fontName="Helvetica", leading=13, spaceAfter=3)
sNote      = S("sNote",      fontSize=8,  textColor=GREY,     fontName="Helvetica-Oblique", leading=12)
sTH        = S("sTH",        fontSize=9,  textColor=WHITE,    fontName="Helvetica-Bold", leading=12, alignment=TA_CENTER)
sTD        = S("sTD",        fontSize=8.5,textColor=BLACK,    fontName="Helvetica", leading=12)
sTDsmall   = S("sTDsmall",   fontSize=8,  textColor=BLACK,    fontName="Helvetica", leading=11)
sBullet    = S("sBullet",    fontSize=9,  textColor=BLACK,    fontName="Helvetica", leading=12, leftIndent=12, spaceAfter=2, bulletIndent=4)
sTOC       = S("sTOC",       fontSize=10, textColor=DARK_BLUE, fontName="Helvetica", leading=16, leftIndent=10)
sTOCH      = S("sTOCH",      fontSize=11, textColor=DARK_BLUE, fontName="Helvetica-Bold", leading=18)

# ── Helper builders ─────────────────────────────────────────────────────────

def cover_block():
    """Returns flowables for the cover page."""
    elems = []
    # Background banner via a 1-row table
    elems.append(Spacer(1, 1.5*cm))
    banner_data = [[Paragraph("CLINICAL REASONING GUIDE", sTitle)]]
    bt = Table(banner_data, colWidths=[W])
    bt.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), DARK_BLUE),
        ("TOPPADDING",    (0,0), (-1,-1), 18),
        ("BOTTOMPADDING", (0,0), (-1,-1), 18),
        ("LEFTPADDING",   (0,0), (-1,-1), 12),
        ("RIGHTPADDING",  (0,0), (-1,-1), 12),
        ("ROUNDEDCORNERS", [8]),
    ]))
    elems.append(bt)
    elems.append(Spacer(1, 0.4*cm))

    sub_data = [[Paragraph("Why We Ask Every Question & Examine Every Finding", sSubtitle)]]
    st = Table(sub_data, colWidths=[W])
    st.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), MED_BLUE),
        ("TOPPADDING",    (0,0), (-1,-1), 10),
        ("BOTTOMPADDING", (0,0), (-1,-1), 10),
    ]))
    elems.append(st)
    elems.append(Spacer(1, 0.6*cm))

    systems = [
        ("CVS", "Cardiovascular System", ACCENT),
        ("GI",  "Gastrointestinal System", GREEN),
        ("RS",  "Respiratory System", TEAL),
        ("CNS", "Central Nervous System", PURPLE),
    ]
    for code, name, col in systems:
        row = [[Paragraph(f"<b>{code}</b>  –  {name}", S("tmp", parent=styles["Normal"],
               fontSize=13, textColor=WHITE, fontName="Helvetica-Bold", leading=18))]]
        t = Table(row, colWidths=[W])
        t.setStyle(TableStyle([
            ("BACKGROUND",    (0,0), (-1,-1), col),
            ("TOPPADDING",    (0,0), (-1,-1), 9),
            ("BOTTOMPADDING", (0,0), (-1,-1), 9),
            ("LEFTPADDING",   (0,0), (-1,-1), 16),
            ("ROUNDEDCORNERS",[4]),
        ]))
        elems.append(t)
        elems.append(Spacer(1, 0.25*cm))

    elems.append(Spacer(1, 0.8*cm))
    elems.append(Paragraph("A comprehensive system-wise clinical case guide for medical students", sNote))
    elems.append(PageBreak())
    return elems


def section_header(title, color=DARK_BLUE, text_color=WHITE):
    data = [[Paragraph(title, sH1)]]
    t = Table(data, colWidths=[W])
    t.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), color),
        ("TOPPADDING",    (0,0), (-1,-1), 10),
        ("BOTTOMPADDING", (0,0), (-1,-1), 10),
        ("LEFTPADDING",   (0,0), (-1,-1), 14),
        ("RIGHTPADDING",  (0,0), (-1,-1), 14),
        ("ROUNDEDCORNERS",[6]),
    ]))
    return [t, Spacer(1, 0.3*cm)]


def sub_header(title, color=MED_BLUE):
    data = [[Paragraph(title, S("sh2", parent=styles["Normal"],
             fontSize=11, textColor=WHITE, fontName="Helvetica-Bold", leading=15))]]
    t = Table(data, colWidths=[W])
    t.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), color),
        ("TOPPADDING",    (0,0), (-1,-1), 6),
        ("BOTTOMPADDING", (0,0), (-1,-1), 6),
        ("LEFTPADDING",   (0,0), (-1,-1), 10),
        ("ROUNDEDCORNERS",[4]),
    ]))
    return [t, Spacer(1, 0.2*cm)]


def two_col_table(headers, rows, col_ratio=(0.42, 0.58), header_color=MED_BLUE, alt=True):
    """Simple two-column table."""
    cw = [W * r for r in col_ratio]
    data = [[Paragraph(h, sTH) for h in headers]] + \
           [[Paragraph(str(c), sTDsmall) for c in row] for row in rows]
    style = [
        ("BACKGROUND",    (0,0), (-1,0),  header_color),
        ("TEXTCOLOR",     (0,0), (-1,0),  WHITE),
        ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#C0C0C0")),
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("RIGHTPADDING",  (0,0), (-1,-1), 5),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, ROW_ALT]) if alt else ("",)
    ]
    if alt:
        style = style[:-1]
        style += [("ROWBACKGROUNDS", (0,1), (-1,-1), [WHITE, ROW_ALT])]
    t = Table(data, colWidths=cw, repeatRows=1)
    t.setStyle(TableStyle(style))
    return [t, Spacer(1, 0.3*cm)]


def three_col_table(headers, rows, col_ratio=(0.35, 0.33, 0.32), header_color=MED_BLUE):
    cw = [W * r for r in col_ratio]
    data = [[Paragraph(h, sTH) for h in headers]] + \
           [[Paragraph(str(c), sTDsmall) for c in row] for row in rows]
    style = [
        ("BACKGROUND",    (0,0), (-1,0),  header_color),
        ("TEXTCOLOR",     (0,0), (-1,0),  WHITE),
        ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#C0C0C0")),
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("RIGHTPADDING",  (0,0), (-1,-1), 5),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, ROW_ALT]),
    ]
    t = Table(data, colWidths=cw, repeatRows=1)
    t.setStyle(TableStyle(style))
    return [t, Spacer(1, 0.3*cm)]


def info_box(text, bg=LIGHT_BLUE, border=MED_BLUE):
    data = [[Paragraph(text, S("ib", parent=styles["Normal"], fontSize=9,
                               textColor=DARK_BLUE, fontName="Helvetica-Oblique", leading=13))]]
    t = Table(data, colWidths=[W])
    t.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), bg),
        ("LINEAFTER",     (0,0), (0,-1),  1.5, border),
        ("LINEBEFORE",    (0,0), (0,-1),  3, border),
        ("TOPPADDING",    (0,0), (-1,-1), 7),
        ("BOTTOMPADDING", (0,0), (-1,-1), 7),
        ("LEFTPADDING",   (0,0), (-1,-1), 10),
    ]))
    return [t, Spacer(1, 0.25*cm)]


# ════════════════════════════════════════════════════════════════════════════
# BUILD CONTENT
# ════════════════════════════════════════════════════════════════════════════
story = []

# ─ Cover ────────────────────────────────────────────────────────────────────
story += cover_block()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 1 – CVS
# ════════════════════════════════════════════════════════════════════════════
story += section_header("SECTION 1 — CARDIOVASCULAR SYSTEM (CVS)", ACCENT)

story += sub_header("CHEST PAIN — Why We Ask Each Parameter", ACCENT)
story += two_col_table(
    ["Parameter", "Why We Ask / What We Rule Out"],
    [
        ["Duration", "Acute (<24 h) = ACS / aortic dissection; chronic = stable angina or musculoskeletal"],
        ["Site", "Central/retrosternal = cardiac; left mammary = Da Costa syndrome; right = pleuritic"],
        ["Mode of onset", "Sudden = dissection, PE, pneumothorax; gradual = angina, pericarditis"],
        ["Nature", "Crushing/squeezing = MI; tearing/ripping = aortic dissection; sharp = pleuritic"],
        ["Severity + duration of episode", "Unstable angina: >20 min at rest; stable angina: <20 min with exertion"],
        ["Radiation", "Left arm/jaw = MI (C8-T1 dermatomes); to back = dissection; to shoulder = diaphragmatic irritation"],
        ["Continuous / intermittent", "Intermittent = angina; continuous = MI, pericarditis"],
        ["Brought on by", "Exertion = angina; rest = Prinzmetal/unstable; inspiration = pleuritic"],
        ["Aggravating / relieving factors", "Relieved by nitrates = angina; leaning forward = pericarditis; worsened by food = GERD/esophageal"],
        ["Sweating, palpitation", "Sweating = sympathetic activation in MI; palpitation = co-existing arrhythmia"],
        ["Associated with food", "Food-related = GERD, esophageal spasm — important cardiac mimic to exclude"],
    ],
    header_color=ACCENT
)

story += sub_header("DYSPNEA — Why We Ask Each Parameter", ACCENT)
story += two_col_table(
    ["Parameter", "Why We Ask / What We Rule Out"],
    [
        ["Duration", "Chronic progressive = heart failure; acute = flash pulmonary edema, PE"],
        ["Mode of onset", "Sudden = acute LVF, PE; insidious = chronic HF, valvular disease"],
        ["Progression", "Rapid = decompensation; stable = chronic compensated HF"],
        ["Grade (NYHA I-IV)", "Classifies severity of heart failure; guides management"],
        ["Aggravating / relieving factors", "Exertion worsening = HF; positional worse supine = orthopnea = LVF"],
        ["PND (Paroxysmal Nocturnal Dyspnea)", "Waking from sleep breathless = classic LVF — fluid redistributes from legs to lungs when supine + reduced nocturnal sympathetic tone"],
        ["Orthopnea (no. of pillows)", "Number of pillows = degree of LVF severity; fluid pools in lungs when lying flat"],
        ["Wheeze", "Cardiac asthma (LVF) vs bronchial asthma — vital differentiation"],
        ["Cough with expectoration", "Pink frothy sputum = acute pulmonary edema; white frothy = chronic LVF"],
        ["Associated chest pain", "Pain + dyspnea = ACS with LVF (worse prognosis)"],
    ],
    header_color=ACCENT
)

story += sub_header("PALPITATION — Why We Ask", ACCENT)
story += two_col_table(
    ["Parameter", "Why"],
    [
        ["Duration", "Acute = new arrhythmia; chronic = longstanding AF, SVT"],
        ["Regular / irregular", "Regular = SVT, VT; irregularly irregular = AF, ectopics"],
        ["Paroxysmal", "Sudden onset + termination = re-entrant tachycardia (SVT, WPW), AF"],
        ["Brought on by", "Exertion = LVOTO, catecholamine-sensitive VT; caffeine/stress = ectopics"],
        ["Associated chest pain", "Pain + palpitation = ischemia-induced arrhythmia"],
        ["Associated syncope", "Syncope + palpitation = dangerous arrhythmia (VT, complete heart block) — emergency"],
    ],
    header_color=ACCENT
)

story += sub_header("LOSS OF CONSCIOUSNESS — Why We Ask", ACCENT)
story += two_col_table(
    ["Parameter", "Why"],
    [
        ["Episodes/day, duration", "Frequent brief = Stokes-Adams attacks (complete heart block); prolonged = epilepsy"],
        ["Total / partial", "Partial = TIA, complex partial seizure; total = cardiac syncope or tonic-clonic"],
        ["Recovery time", "Rapid = vasovagal/cardiac syncope; slow = post-ictal state (epilepsy)"],
        ["Associated fits", "Fits = epilepsy to rule out; anoxic seizures can occur in cardiac syncope"],
        ["Bladder / bowel disturbance", "Incontinence = true epileptic seizure (not cardiac syncope)"],
        ["Time of last episode", "To assess frequency and urgency of intervention"],
    ],
    header_color=ACCENT
)

story += sub_header("NEGATIVE HISTORY (CVS) — System-Wise Reasoning", ACCENT)

story.append(Paragraph("<b>Symptoms of Right Heart Failure (RHF):</b>", sH3))
story += two_col_table(
    ["Question", "Reason"],
    [
        ["H/o pedal edema", "RHF → systemic venous congestion → fluid in dependent parts"],
        ["H/o abdominal distension", "Ascites from hepatic venous congestion (congestive hepatomegaly, portal hypertension)"],
        ["H/o dyspepsia", "Gut edema in RHF causes impaired digestion"],
        ["H/o right hypochondrial pain", "Tender hepatomegaly from hepatic congestion (stretching of Glisson's capsule)"],
        ["H/o puffiness of face", "Severe RHF or SVC obstruction"],
    ],
    header_color=MED_BLUE
)

story.append(Paragraph("<b>Symptoms of Rheumatic Fever (RF):</b>", sH3))
story += two_col_table(
    ["Question", "Reason"],
    [
        ["Fever with sore throat", "Group A Strep pharyngitis precedes RF by 2-4 weeks — Jones criteria major/minor"],
        ["Involuntary movements", "Sydenham's chorea = major Jones criterion for RF"],
        ["Rash, nodules", "Erythema marginatum + subcutaneous nodules = major Jones criteria"],
    ],
    header_color=MED_BLUE
)

story.append(Paragraph("<b>Symptoms of Left-Sided Disease:</b>", sH3))
story += two_col_table(
    ["Question", "Reason"],
    [
        ["Voice change", "Ortner's syndrome — enlarged left atrium (MS) compresses left recurrent laryngeal nerve"],
        ["Dysphagia", "Enlarged left atrium compresses esophagus — classic in severe MS"],
        ["Oliguria", "Reduced cardiac output reduces renal perfusion (cardiorenal syndrome)"],
    ],
    header_color=MED_BLUE
)

story.append(Paragraph("<b>Symptoms of Congenital Heart Disease:</b>", sH3))
story += two_col_table(
    ["Question", "Reason"],
    [
        ["Cyanotic episodes", "Right-to-left shunt (Fallot's tetralogy, Eisenmenger's syndrome)"],
        ["Squatting", "Classic in Fallot's — squatting increases SVR, reducing R-to-L shunt, relieving cyanosis"],
    ],
    header_color=MED_BLUE
)

story.append(Paragraph("<b>Symptoms of Pulmonary Hypertension (PHT):</b>", sH3))
story += two_col_table(
    ["Question", "Reason"],
    [
        ["Recurrent respiratory infections", "Increased pulmonary blood flow (L-to-R shunts like ASD, VSD) → recurrent lung infections"],
        ["Syncope", "PHT reduces cardiac output on exertion → cerebral hypoperfusion"],
        ["Hemoptysis", "Pulmonary apoplexy — rupture of dilated pulmonary vessels"],
        ["Chest pain", "Right ventricular ischemia in PHT (from RV hypertrophy with inadequate coronary supply)"],
    ],
    header_color=MED_BLUE
)

story += sub_header("PAST HISTORY — Why We Ask", ACCENT)
story += two_col_table(
    ["Question", "Why"],
    [
        ["Previous similar episodes", "Assess chronicity, recurrence, disease progression"],
        ["Rheumatic fever (elaborate)", "Most common cause of valvular HD in developing countries — mitral/aortic/tricuspid involvement"],
        ["HT, DM", "Major risk factors for IHD, cardiomyopathy, accelerated atherosclerosis"],
        ["TB", "Constrictive pericarditis — TB is #1 cause in India"],
        ["STD (syphilis)", "Syphilitic aortitis causes AR; aortic root dilatation"],
        ["Surgery", "Previous cardiac/valve surgery — scarring, anticoagulation status"],
        ["Chronic respiratory infection", "Cor pulmonale (RHF from chronic lung disease)"],
        ["Cyanotic spells", "Congenital cyanotic heart disease"],
        ["Chronic fever", "Subacute bacterial endocarditis (SBE) — low-grade fever for weeks/months"],
    ],
    header_color=ACCENT
)

story += sub_header("GENERAL EXAMINATION — What Each Finding Means", ACCENT)
story += two_col_table(
    ["Finding", "Significance"],
    [
        ["Conscious, comfortable, oriented", "Baseline CNS status; confusion = low cardiac output, cerebral hypoperfusion"],
        ["Build / nourishment", "Cardiac cachexia in advanced HF; obesity = risk factor for HF/IHD"],
        ["Febrile", "Infective endocarditis, rheumatic fever, pericarditis"],
        ["Jaundice", "Hepatic congestion (RHF — 'cardiac jaundice'), hemolysis in mechanical valve patients"],
        ["Pallor", "Anemia worsens HF; anemia of IE; anemia worsens angina"],
        ["Clubbing", "Cyanotic CHD (grade 3+), infective endocarditis, Eisenmenger's syndrome"],
        ["Cyanosis", "Central = R-to-L shunt, Eisenmenger's; peripheral = low output state"],
        ["Pedal edema (refilling time)", "Slow refilling (>45 sec) = CCF; fast (<45 sec) = hypoalbuminemia/renal; indicates RHF/CCF"],
        ["Lymphadenopathy", "Rule out malignancy, TB, HIV — all can have cardiac manifestations"],
    ],
    header_color=ACCENT
)

story.append(Paragraph("<b>Markers of Congenital Heart Disease:</b>", sH3))
story += two_col_table(
    ["Feature", "Syndrome / Significance"],
    [
        ["Low set ears", "Down's syndrome (ASD, VSD, AV canal defect)"],
        ["Polydactyly", "Ellis-van Creveld syndrome (ASD)"],
        ["Arachnodactyly", "Marfan's syndrome (AR, MVP, aortic dissection)"],
        ["Webbed neck", "Turner's syndrome (coarctation of aorta, bicuspid aortic valve)"],
        ["Kyphoscoliosis", "Marfan's, Holt-Oram syndrome"],
    ],
    header_color=MED_BLUE
)

story.append(Paragraph("<b>Markers of Infective Endocarditis (IE):</b>", sH3))
story += three_col_table(
    ["Feature", "Mechanism", "Why We Look"],
    [
        ["Osler's nodules (painful, fingertip)", "Immune complex deposition in digital pulp", "IE marker — peripheral embolic/immune phenomena"],
        ["Splinter hemorrhages (nails)", "Microemboli in nail bed capillaries", "Look under fingernails"],
        ["Janeway lesions (painless, palmar)", "Septic emboli in thenar/hypothenar", "Distinguish from Osler's by painless nature"],
        ["Roth's spots (retinal)", "Immune complex vasculitis of retinal vessels", "Fundoscopy required to visualise"],
        ["Splenomegaly", "Immune hyperplasia + splenic emboli", "Palpate spleen in IE workup"],
        ["Anemia + fever + jaundice", "Hemolytic anemia + bacteremia + hepatic involvement", "Classic triad of IE"],
    ],
    header_color=MED_BLUE
)

story += sub_header("VITAL SIGNS — Detailed Reasoning", ACCENT)

story.append(Paragraph("<b>Pulse — Why Each Component:</b>", sH3))
story += two_col_table(
    ["Parameter", "Why"],
    [
        ["Rate", "Tachycardia = HF, fever, anemia, hyperthyroidism; bradycardia = heart block, beta-blocker use"],
        ["Rhythm", "Irregularly irregular = AF (most common arrhythmia in valvular disease); regularly irregular = ectopics"],
        ["Volume", "Low = poor CO, AS, cardiac tamponade; high = AR, AV fistula, fever, anemia"],
        ["Character", "Collapsing/water-hammer = AR; plateau/slow-rising = AS; bisferiens = severe AR or HOCM"],
        ["All peripheral vessels", "Peripheral vascular disease, coarctation (absent femoral), subclavian steal syndrome"],
        ["RF delay (Radiofemoral)", "Coarctation of aorta — femoral pulse delayed compared to radial pulse"],
        ["Condition of vessel wall", "Atherosclerosis (hard, non-pulsatile), diabetic calcification"],
    ],
    header_color=ACCENT
)

story.append(Paragraph("<b>Blood Pressure:</b>", sH3))
story += two_col_table(
    ["Finding", "Significance"],
    [
        ["Wide pulse pressure", "AR, hyperthyroidism, anemia, AV fistula — high SV + low diastolic"],
        ["Narrow pulse pressure", "AS, tamponade, severe HF — low SV"],
        ["Asymmetric in both arms", "Aortic dissection, subclavian stenosis"],
        ["Postural drop", "Hypovolemia, autonomic neuropathy, antihypertensive overtreatment"],
    ],
    header_color=ACCENT
)

story.append(Paragraph("<b>JVP:</b>", sH3))
story += two_col_table(
    ["Finding", "Significance"],
    [
        ["Elevated JVP", "RHF, tricuspid stenosis, cardiac tamponade, constrictive pericarditis"],
        ["Absent JVP", "Hypovolemia"],
        ["Absent X descent", "Tricuspid regurgitation (systolic expansion of jugular veins)"],
        ["Cannon waves", "Complete heart block (atria contract against closed tricuspid valve)"],
    ],
    header_color=ACCENT
)

story += sub_header("PERIPHERAL SIGNS OF AR — Wide Pulse Pressure Signs", ACCENT)
story += info_box(
    "All peripheral signs of aortic regurgitation arise from the wide pulse pressure: "
    "high systolic pressure (from large stroke volume) + low diastolic pressure (blood regurgitates back into LV). "
    "The peripheral vasculature reflects this hyperdynamic circulation."
)
story += two_col_table(
    ["Sign", "Mechanism + Why We Look"],
    [
        ["De Musset's sign (head bobbing)", "High stroke volume pulsation transmitted to head/neck with each beat"],
        ["Corrigan's sign (dancing carotids)", "Exaggerated carotid pulsation from wide pulse pressure — visible in neck"],
        ["Quincke's sign (capillary nail pulsation)", "Capillary bed fills and empties with each beat — press nail lightly and observe"],
        ["Collapsing / water-hammer pulse", "Rapid rise + rapid fall from regurgitation — elevate wrist to amplify"],
        ["Traube's sign (pistol-shot femoral)", "Wide pulse pressure causes a loud systolic sound over femoral artery"],
        ["Duroziez's murmur (femoral)", "Press femoral partially — to-and-fro flow creates double murmur"],
        ["Hill's sign (popliteal BP > brachial BP)", "Peripheral amplification of wide pulse pressure (mild 20-40, moderate 40-60, severe >60 mmHg)"],
        ["Pulsus bisferiens", "Two systolic peaks = severe AR, or AR + AS combined"],
        ["Rosenbach's sign", "Pulsation of liver in AR"],
        ["Gerhardt's sign", "Pulsation of spleen in AR"],
    ],
    header_color=ACCENT
)

story += sub_header("LOCAL EXAMINATION (CVS) — Why Each Step", ACCENT)

story.append(Paragraph("<b>Inspection:</b>", sH3))
story += two_col_table(
    ["Finding", "Significance"],
    [
        ["Precordial bulge", "Cardiomegaly since childhood (congenital HD) pushing chest wall outward"],
        ["Kyphoscoliosis", "Marfan's syndrome — pushes heart to one side, causes pseudo-cardiomegaly on X-ray"],
        ["Apical impulse position", "Displaced outward/down = LV enlargement"],
        ["Epigastric pulsations", "RV enlargement, aortic aneurysm"],
        ["Parasternal pulsations", "RV hypertrophy (pulmonary hypertension, RVH)"],
        ["Suprasternal pulsations", "Aortic aneurysm, high output states"],
        ["Dilated veins on chest", "SVC obstruction — blood flows downward (away from face)"],
        ["Scars", "Mitral valvotomy — left submammary scar; median sternotomy for CABG/valve replacement"],
    ],
    header_color=ACCENT
)

story.append(Paragraph("<b>Palpation:</b>", sH3))
story += two_col_table(
    ["Finding", "What It Tells Us"],
    [
        ["Apical impulse — site", "Normal = 5th ICS MCL; displaced = LV enlargement; tapping = MS (loud S1 palpable)"],
        ["Apical impulse — type", "Heaving = LV pressure overload (AS, HT); thrusting/hyperdynamic = LV volume overload (AR, MR)"],
        ["Thrills", "Palpable murmurs = significant valvular disease (grade ≥4 murmur)"],
        ["Parasternal heave", "RV pressure overload — pulmonary hypertension, pulmonary stenosis"],
        ["Palpable P2", "Loud P2 felt at left 2nd ICS = pulmonary hypertension (normal P2 not palpable)"],
    ],
    header_color=ACCENT
)

story.append(Paragraph("<b>Auscultation — Mitral Area:</b>", sH3))
story += two_col_table(
    ["Sound", "Why / What It Means"],
    [
        ["Loud S1", "Mitral stenosis — valve snaps shut from high LA pressure"],
        ["Soft S1", "MR (valve does not close properly), prolonged PR interval"],
        ["Opening snap", "MS — stiff leaflets snap open; shorter S2-OS interval = more severe MS"],
        ["MDM (Mid-diastolic murmur)", "MS — turbulent flow across narrowed mitral valve; bell, left lateral position, expiratory apnea"],
        ["PSA (Pre-systolic accentuation)", "Sinus rhythm + MS — LA contraction increases gradient just before mitral closes"],
        ["PSM (Pan-systolic murmur)", "MR — regurgitation throughout systole; conducted to axilla (direction of jet)"],
        ["S3", "Volume overload of LV (MR, AR, DCM) — passive rapid filling sound"],
        ["S4", "LV stiffness (AS, hypertrophy, ischemia) — atrial kick into stiff ventricle"],
    ],
    header_color=MED_BLUE
)

story += info_box(
    "Why left lateral position + expiratory apnea for mitral: "
    "Left lateral brings apex (mitral valve) closer to chest wall. "
    "Expiratory apnea reduces lung interference and pools blood in pulmonary circulation, accentuating mitral murmurs."
)

story.append(Paragraph("<b>Auscultation — Aortic Area:</b>", sH3))
story += two_col_table(
    ["Sound", "Why / What It Means"],
    [
        ["Ejection click", "Bicuspid aortic valve / mild AS — sudden tensing/doming of valve leaflets"],
        ["ESM (Ejection systolic murmur)", "AS — crescendo-decrescendo; conducted to carotids (direction of flow)"],
        ["EDM (Early diastolic murmur)", "AR — decrescendo; Erb's point and 2nd right ICS; leaning forward + expiratory apnea"],
        ["Soft A2", "AS — calcified valve does not close loudly"],
        ["Loud A2", "AR — high aortic diastolic pressure (early in disease)"],
    ],
    header_color=MED_BLUE
)

story += info_box(
    "Why leaning forward + expiratory apnea for aortic EDM: "
    "Brings aortic root closer to chest wall. Pools blood in aorta, accentuating regurgitation. "
    "Gravity also helps maintain aortic diastolic pressure."
)

story.append(Paragraph("<b>Auscultation — Pulmonary Area:</b>", sH3))
story += two_col_table(
    ["Finding", "Meaning"],
    [
        ["Loud P2", "Pulmonary hypertension"],
        ["Fixed split S2", "ASD — equalization of pressures in both ventricles throughout respiration"],
        ["Wide split S2", "RBBB, pulmonary stenosis (delayed RV emptying)"],
        ["Reverse split S2", "LBBB, severe AS (delayed LV emptying)"],
        ["Ejection click", "Pulmonary stenosis — domed valve snaps open"],
        ["ESM at pulmonary area", "PS, ASD (flow murmur), pulmonary hypertension"],
        ["Inspiratory accentuation", "Carvallo's sign — right-sided murmurs increase with inspiration (more venous return to RV)"],
    ],
    header_color=MED_BLUE
)

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# SECTION 2 – GI
# ════════════════════════════════════════════════════════════════════════════
story += section_header("SECTION 2 — GASTROINTESTINAL SYSTEM (GI)", GREEN)

story += sub_header("ABDOMINAL PAIN — Why Each Parameter", GREEN)
story += two_col_table(
    ["Parameter", "Why"],
    [
        ["Site", "Epigastric = PU/pancreatitis; RUQ = liver/gallbladder; RIF = appendix; LIF = sigmoid; periumbilical = small bowel; LUQ = spleen/stomach"],
        ["Nature (continuous vs intermittent)", "Intermittent/colicky = hollow viscus obstruction (intestinal, biliary, renal); continuous = inflammation/ischemia/peritonitis"],
        ["Character (colicky vs constant)", "Colicky = waves of smooth muscle contraction (obstructive); constant = inflammatory/ischemic"],
        ["Radiation", "To back = pancreatitis, aortic aneurysm; right shoulder = diaphragm/liver (phrenic nerve C3-5); groin = renal colic"],
        ["Relieving factors", "Relieved by eating = duodenal ulcer; worsened by eating = gastric ulcer, ischemic bowel, pancreatitis"],
        ["Associated fever", "Infection, cholangitis (Charcot's triad), appendicitis, diverticulitis"],
        ["Associated vomiting", "Early vomiting = gastric/duodenal; late = distal obstruction"],
        ["Associated defecation", "IBS — pain relieved by defecation; obstruction — no flatus or stool (obstipation)"],
    ],
    header_color=GREEN
)

story += sub_header("ABDOMINAL DISTENSION — Why We Ask", GREEN)
story += two_col_table(
    ["Question", "Reason"],
    [
        ["Duration and onset", "Acute = obstruction, perforation, acute ascites; chronic = cirrhosis, malignancy"],
        ["Localised vs uniform", "Localised = organomegaly, mass; uniform = ascites, gas, obesity"],
        ["RVF features (leg swelling, breathlessness)", "RVF causes hepatic venous congestion → ascites — cardiac ascites must be distinguished from portal ascites"],
        ["Liver features (hematemesis, malena, anorexia)", "Portal hypertension: varices → hematemesis/malena; liver failure → hypoalbuminemia → ascites"],
        ["Renal features (oliguria, frothy urine)", "Nephrotic syndrome → hypoalbuminemia → ascites; hepatorenal syndrome"],
        ["Projectile vomiting", "Pyloric obstruction (hypertrophic pyloric stenosis, peptic stricture) or raised ICP"],
        ["Drug intake (NSAIDs, steroids)", "Major risk factors for peptic ulcer disease and GI bleed"],
    ],
    header_color=GREEN
)

story += sub_header("JAUNDICE — Why Each Parameter", GREEN)
story += two_col_table(
    ["Parameter", "Why"],
    [
        ["Duration", "Acute = viral hepatitis, hemolysis; chronic = cirrhosis, malignancy, PBC"],
        ["Itching (pruritus)", "Cholestatic jaundice — bile salts deposit in skin = obstructive jaundice (stones, malignancy)"],
        ["Dark urine", "Conjugated bilirubin (water-soluble) excreted in urine = hepatic/obstructive jaundice"],
        ["Pale/clay-coloured stools", "Obstructive jaundice — bile cannot reach gut = acholic stools"],
        ["Fever with rigors", "Charcot's triad (fever + jaundice + RUQ pain) = cholangitis — surgical emergency"],
        ["Treatment taken", "Drug-induced jaundice (anti-TB, paracetamol, statins, rifampicin)"],
    ],
    header_color=GREEN
)

story += sub_header("STOOLS — Why We Ask Each Feature", GREEN)
story += two_col_table(
    ["Parameter", "Why"],
    [
        ["Frequency", ">3 loose/day = diarrhea; no flatus/stool = complete obstruction (obstipation)"],
        ["Dark/tarry black (melena)", "Upper GI bleed — blood digested = black + tarry + foul odor; > 100 mL blood from proximal to cecum"],
        ["Pale/clay-coloured", "Obstructive jaundice — no bile pigment in stool"],
        ["Bright red blood", "Lower GI bleed — distal colon/rectum; mixed = proximal colon"],
        ["Sticky/mucoid", "Mucous in stool = IBS, IBD, colorectal malignancy"],
        ["Associated pain", "Before defecation = small bowel; during = colonic; after = anorectal (hemorrhoids, fissure)"],
    ],
    header_color=GREEN
)

story += sub_header("NEGATIVE HISTORY (GI) — Why We Ask", GREEN)
story += two_col_table(
    ["Question", "Why"],
    [
        ["Fever (nature/rigor)", "Infective (hepatitis A/E, cholangitis, amoebic abscess, typhoid) vs non-infective (malignancy, autoimmune)"],
        ["Dysphagia", "Esophageal pathology, extrinsic compression by enlarged liver/mediastinal nodes"],
        ["Heartburn", "GERD, esophagitis"],
        ["Epistaxis, gum bleeding, menorrhagia", "Bleeding diathesis = liver failure (impaired clotting factor synthesis) or hypersplenism"],
        ["Loss of appetite / weight loss", "Malignancy (HCC, GI CA), TB, cirrhosis"],
        ["Puffiness of face", "Renal — nephrotic syndrome causing hypoalbuminemia and ascites"],
        ["Pruritus", "Cholestatic liver disease — bile salt deposition"],
        ["Altered sleep pattern", "Hepatic encephalopathy (day-night reversal is early sign)"],
    ],
    header_color=GREEN
)

story += sub_header("PAST HISTORY (GI) — Why We Ask", GREEN)
story += two_col_table(
    ["Question", "Why"],
    [
        ["Tattooing", "Hepatitis B and C transmission via needle sharing"],
        ["Blood transfusion", "Hep B, C, HIV transmission (before universal screening)"],
        ["STD exposure", "Hep B, C, HIV — all cause hepatic disease"],
        ["Vaccination history", "Hep A and B vaccines — prior vaccination reduces likelihood"],
        ["Previous abdominal surgeries", "Adhesion-related obstruction, scar-related peritonitis"],
        ["TB history", "TB peritonitis, TB hepatitis, portal hypertension from TB"],
        ["Renal colic", "Renal/ureteric stone causing pain mimicking GI pain"],
    ],
    header_color=GREEN
)

story += sub_header("MARKERS OF LIVER CELL FAILURE — Mechanism of Each Sign", GREEN)
story += three_col_table(
    ["Marker", "Mechanism", "Significance"],
    [
        ["Alopecia", "Hypogonadism from hepatic failure → hormonal imbalance", "Chronic liver disease marker"],
        ["Bitot spots", "Malabsorption of fat-soluble Vit A in cholestatic disease", "Vitamin A deficiency"],
        ["Subconjunctival hemorrhage", "Liver fails to synthesize Vit K-dependent clotting factors (II, VII, IX, X)", "Bleeding tendency in liver failure"],
        ["KF ring (Kayser-Fleischer)", "Copper deposition in Descemet's membrane of cornea", "Wilson's disease ONLY"],
        ["Xanthelasma", "Cholestatic liver disease → hyperlipidemia → fat deposits around eyes", "Cholestasis"],
        ["Parotid enlargement", "Direct toxic effect of alcohol on parotid gland", "Alcoholic liver disease"],
        ["Fetor hepaticus", "Mercaptans escape into blood (normally metabolised by liver) → sweet/musty breath", "Hepatic encephalopathy"],
        ["Spider naevi", "Elevated estrogen (liver fails to metabolise) → arteriolar vasodilation; >5 = significant", "Chronic liver disease"],
        ["Gynecomastia", "Elevated estrogen not cleared by failing liver", "Liver failure / alcoholic"],
        ["Palmar erythema", "Elevated estrogen → palmar vasodilation", "Chronic liver disease"],
        ["Dupuytren's contracture", "Alcoholic liver disease — fibrosis of palmar fascia", "Alcohol association"],
        ["Flapping tremor / asterixis", "Hepatic encephalopathy — impaired cerebral metabolism, ammonia accumulation", "Hepatic encephalopathy grade"],
        ["Leukonychia (white nails)", "Hypoalbuminemia — liver fails to synthesise albumin", "Hypoalbuminemia marker"],
        ["Caput medusae", "Portal hypertension → blood flows through paraumbilical veins → dilated abdominal veins", "Portal hypertension sign"],
        ["Testicular atrophy + pubic hair loss", "Elevated estrogen + reduced testosterone (liver fails to clear estrogen)", "Hypogonadism in liver failure"],
    ],
    header_color=GREEN
)

story += sub_header("ABDOMINAL EXAMINATION — Why Each Step", GREEN)

story.append(Paragraph("<b>Inspection:</b>", sH3))
story += two_col_table(
    ["Finding", "Significance"],
    [
        ["Scaphoid abdomen", "Starvation, malignancy with cachexia"],
        ["Uniformly distended + full flanks", "Ascites (fluid), gas (obstruction), obesity"],
        ["Everted umbilicus", "Ascites / increased intra-abdominal pressure"],
        ["Sister Mary Joseph's nodule (umbilical)", "Umbilical metastasis from intra-abdominal malignancy (stomach, colon, ovary)"],
        ["Absent respiratory movement", "Peritonitis — patient splints abdomen to avoid pain"],
        ["Visible gastric peristalsis (left to right)", "Gastric outflow obstruction"],
        ["Dilated veins flowing upward from umbilicus", "IVC obstruction — blood diverted through superficial veins upward"],
        ["Dilated veins radiating from umbilicus (caput medusae)", "Portal hypertension — paraumbilical veins carry portal blood to systemic"],
        ["Head rising test", "Divarication of recti — abdominal wall weakness (ascites, post-pregnancy)"],
        ["Purple striae", "Cushing's syndrome (white striae = old — pregnancy, obesity)"],
    ],
    header_color=GREEN
)

story.append(Paragraph("<b>Palpation — Liver Description Rationale:</b>", sH3))
story += two_col_table(
    ["Feature", "Why We Describe It"],
    [
        ["Size (cm below costal margin)", "Degree of hepatomegaly"],
        ["Surface (smooth vs nodular)", "Smooth = hepatitis, congestive; nodular = cirrhosis, metastases, HCC"],
        ["Consistency (soft/firm/hard)", "Hard + irregular = malignancy; firm = cirrhosis; soft = acute hepatitis/congestion"],
        ["Tenderness", "Tender = acute hepatitis, congestive hepatomegaly (RHF); non-tender = cirrhosis, malignancy"],
        ["Moves with respiration", "Confirms it is liver (diaphragm moves it); non-moving = adhesions or not liver"],
        ["Cannot insinuate fingers under costal margin", "Confirms the mass is liver, not a sub-hepatic collection"],
    ],
    header_color=MED_BLUE
)

story.append(Paragraph("<b>Spleen vs Kidney vs Liver — Distinguishing Features:</b>", sH3))
story += three_col_table(
    ["Feature", "Spleen", "Kidney"],
    [
        ["Bimanually palpable", "No", "Yes"],
        ["Ballotable", "No", "Yes"],
        ["Moves with respiration", "Yes (down and medially)", "Yes (downward)"],
        ["Notch on medial border", "Yes (pathognomonic)", "No"],
        ["Colonic band of resonance", "No", "Yes (colon overlies)"],
        ["Upper border accessible", "No (under ribs)", "Sometimes"],
        ["Position", "Left upper quadrant", "Bilateral loin"],
    ],
    header_color=MED_BLUE
)

story.append(Paragraph("<b>Percussion:</b>", sH3))
story += two_col_table(
    ["Test", "Why"],
    [
        ["Shifting dullness", "Detects free fluid (ascites) ≥500 mL; dull in flanks, shifts when patient turns (fluid redistributes)"],
        ["Fluid thrill", "Detects large ascites — vibration transmits through fluid"],
        ["Puddle sign", "Detects small ascites (~120 mL); patient on all fours, percuss in dependent area"],
        ["Liver span percussion", "Normal 12-15 cm; increased = hepatomegaly; decreased = cirrhosis (shrunken liver)"],
        ["Traube's space (tympanitic)", "Left 6th rib, left axillary line, costal margin — dull = splenomegaly, left pleural effusion"],
        ["Colonic resonance over kidney", "Distinguishes kidney (resonant front) from spleen (dull throughout)"],
    ],
    header_color=GREEN
)

story.append(Paragraph("<b>Auscultation:</b>", sH3))
story += two_col_table(
    ["Sound", "Why"],
    [
        ["Bowel sounds — increased tinkling", "Intestinal obstruction — increased peristalsis above obstruction"],
        ["Absent bowel sounds", "Paralytic ileus, peritonitis — gut completely stops"],
        ["Renal bruit (mid-abdomen near midline)", "Renal artery stenosis (renovascular hypertension)"],
        ["Liver bruit (hepatic area)", "HCC (vascular tumor), acute alcoholic hepatitis, hemangioma"],
        ["Venous hum (near umbilicus)", "Portosystemic collaterals — portal hypertension"],
        ["Cruveilhier-Baumgartner syndrome", "Venous hum + palpable varicose veins at umbilicus = portal hypertension (patent paraumbilical vein)"],
        ["Peritoneal rub (liver/spleen)", "Perihepatitis (Fitz-Hugh-Curtis), perisplenitis, splenic infarct"],
        ["Succussion splash (>3 h after meal)", "Fluid + gas in stomach = gastric outflow obstruction"],
    ],
    header_color=GREEN
)

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# SECTION 3 – RS
# ════════════════════════════════════════════════════════════════════════════
story += section_header("SECTION 3 — RESPIRATORY SYSTEM (RS)", TEAL)

story += sub_header("COUGH & SPUTUM — Why Each Parameter", TEAL)
story += two_col_table(
    ["Parameter", "Why"],
    [
        ["Duration", "Acute <3 weeks = URTI/pneumonia; subacute 3-8 weeks = post-infectious/TB; chronic >8 weeks = COPD/asthma/malignancy"],
        ["Paroxysmal", "Whooping cough (pertussis), foreign body aspiration, asthma"],
        ["Dry vs productive", "Dry = ILD, viral, malignancy, ACE inhibitor cough; productive = infection, bronchiectasis, COPD"],
        ["Postural variation", "Increases on lying = postnasal drip, GERD, bronchiectasis (gravity drains)"],
        ["Diurnal variation", "Worse at night = asthma; worse in morning = bronchiectasis/COPD (overnight secretion accumulation)"],
        ["Sputum colour", "Yellow/green = bacterial infection; rust = pneumococcal pneumonia; pink frothy = pulmonary edema; black = coal miner's"],
        ["Sputum quantity (>200 mL/day)", "Bronchiectasis, lung abscess — 'mouthful' of sputum"],
        ["Postural increase of sputum", "Bronchiectasis — gravity drains pool of pus when position changes"],
    ],
    header_color=TEAL
)

story += sub_header("HEMOPTYSIS — Why Each Parameter", TEAL)
story += two_col_table(
    ["Parameter", "Why"],
    [
        ["Duration / episodes", "Recurrent = bronchiectasis, TB, malignancy; single acute = PE, pneumonia"],
        ["Fresh vs altered blood", "Fresh bright red = active bleed (bronchiectasis, malignancy, TB); altered = old bleed"],
        ["With purulent sputum", "Blood + pus = bronchiectasis, lung abscess"],
        ["With food particles", "Hematemesis misidentified — hematemesis = dark/coffee-ground with nausea; hemoptysis = bright red/frothy with cough"],
    ],
    header_color=TEAL
)

story += sub_header("BREATHLESSNESS (RS) — Why Each Parameter", TEAL)
story += two_col_table(
    ["Parameter", "Why"],
    [
        ["Grade (MRC scale)", "1 = hills only; 2 = flat; 3 = after 100m; 4 = on dressing; 5 = at rest — severity classification"],
        ["Aggravating factors", "Exercise = COPD/ILD; allergens/dust = asthma; cold = asthma/COPD"],
        ["PND / orthopnea", "Indicates cardiac involvement (LVF causing pulmonary edema) — must ask in RS to rule out cardiac cause"],
    ],
    header_color=TEAL
)

story += sub_header("NEGATIVE HISTORY (RS) — Why We Ask", TEAL)
story += two_col_table(
    ["Question", "Why"],
    [
        ["Wheeze (duration, diurnal, aggravating)", "Asthma/COPD — obstructive airway disease; or cardiac asthma (LVF) — critical differentiation"],
        ["Halitosis", "Bronchiectasis (putrid = anaerobic infection), lung abscess"],
        ["Fever + evening rise + night sweats + weight loss", "Classic TB tetrad — mandatory in all RS cases in India"],
        ["Pedal edema, abdominal distension, puffiness", "Cor pulmonale — RHF secondary to chronic lung disease (COPD, ILD, PHT)"],
        ["Palpitation, syncope", "Arrhythmia from hypoxia, cor pulmonale"],
        ["Hoarseness of voice", "Bronchogenic carcinoma compressing left recurrent laryngeal nerve (near left hilum)"],
        ["Dysphagia (mode/solid/liquid/progression)", "Mediastinal mass/lymph node from malignancy or TB compressing esophagus"],
    ],
    header_color=TEAL
)

story += sub_header("PAST HISTORY (RS) — Why We Ask", TEAL)
story += two_col_table(
    ["Question", "Why"],
    [
        ["TB contact, age, incomplete treatment", "TB most common chronic lung disease in India; incomplete treatment = MDR-TB risk"],
        ["Aspiration history (ABCDEF)", "Aspiration pneumonia: Alcohol, Booze (stupor), Coma, Drowning, Epilepsy, Foreign body"],
        ["Exanthematous fever (measles, chickenpox)", "Measles → giant cell pneumonia; chickenpox → varicella pneumonia"],
        ["Tooth extraction, tonsillectomy, allergy", "Aspiration of bacteria during procedure → lung abscess"],
        ["Measles, whooping cough in childhood", "Both cause bronchiectasis via childhood lower respiratory tract damage"],
        ["Subphrenic/amoebic abscess, pancreatitis", "Can track through diaphragm → pleural effusion (sympathetic or direct extension)"],
    ],
    header_color=TEAL
)

story += sub_header("MARKERS IN RS EXAMINATION — Why We Look", TEAL)

story.append(Paragraph("<b>Horner's Syndrome (Ptosis + Miosis + Anhidrosis + Enophthalmos + Loss of ciliospinal reflex):</b>", sH3))
story += info_box(
    "In RS: Pancoast tumor (apex of lung) invades cervical sympathetic chain (T1 root + stellate ganglion). "
    "Look for it in any apical lung lesion, especially with shoulder/arm pain — Pancoast (superior sulcus) syndrome.",
    bg=LIGHT_TEAL, border=TEAL
)

story.append(Paragraph("<b>Troussier's Sign:</b>", sH3))
story += info_box(
    "Left supraclavicular lymph node enlargement (Virchow's node) = metastasis from bronchogenic carcinoma or GI malignancy. "
    "Left because the thoracic duct drains into the left subclavian vein — carries lymphatic metastases here.",
    bg=LIGHT_TEAL, border=TEAL
)

story.append(Paragraph("<b>Markers of Pulmonary Malignancy:</b>", sH3))
story += two_col_table(
    ["Marker", "Mechanism"],
    [
        ["Acanthosis nigricans", "Paraneoplastic — TGF-alpha, insulin-like substance from tumor acting on skin receptors"],
        ["Gynecomastia", "Ectopic HCG secretion from large cell carcinoma"],
        ["Clubbing + HPOA", "Periosteal reaction (hypertrophic pulmonary osteoarthropathy) from lung cancer — mechanism unclear, possibly periosteal vasodilation from vagal stimulation"],
    ],
    header_color=TEAL
)

story.append(Paragraph("<b>Markers of TB:</b>", sH3))
story += two_col_table(
    ["Sign", "Explanation"],
    [
        ["Scrofula", "TB cervical lymphadenitis — classically becomes collar stud abscess"],
        ["Collar stud abscess", "Deep abscess ruptures fascia → two connected pus collections (collar stud shape)"],
        ["Erythema nodosum", "Hypersensitivity reaction to TB (also: sarcoidosis, Strep, drugs) — tender red nodules on shins"],
        ["Lupus vulgaris", "Chronic cutaneous TB — apple jelly nodules on face with diascopy"],
        ["Tinea versicolor", "Associated with immunosuppression (HIV/TB) — not TB itself but co-occurrence"],
        ["Phlyctenular conjunctivitis", "Hypersensitivity reaction to mycobacterial antigens — seen especially in children"],
    ],
    header_color=MED_BLUE
)

story += sub_header("CHEST EXAMINATION (RS) — Why Each Step", TEAL)

story.append(Paragraph("<b>Inspection:</b>", sH3))
story += two_col_table(
    ["Finding", "Significance"],
    [
        ["Barrel chest (increased AP diameter)", "Emphysema — hyperinflation of lungs, loss of elastic recoil"],
        ["Pigeon chest (pectus carinatum)", "Childhood chronic RS disease (asthma, rickets) → sternal protrusion"],
        ["Funnel chest (pectus excavatum)", "Marfan's syndrome, connective tissue disorders"],
        ["Harrison's sulcus", "Groove along lower ribs at diaphragm attachment — chronic childhood asthma/rickets"],
        ["IC indrawing", "Severe airway obstruction (asthma attack), COPD exacerbation — negative intrathoracic pressure"],
        ["IC fullness", "Pleural effusion — fluid pushes ribs apart"],
        ["Crowding of ribs", "Fibrosis/collapse on that side — lung shrinks, ribs crowd together"],
        ["Discharging sinuses", "TB empyema necessitans — pus tracks through chest wall to surface"],
        ["Trail's sign", "Tracheal tug with each heartbeat = aortic arch aneurysm"],
        ["Kyphoscoliosis", "Restrictive lung disease (reduces chest compliance, limits expansion)"],
    ],
    header_color=TEAL
)

story.append(Paragraph("<b>Palpation:</b>", sH3))
story += two_col_table(
    ["Finding", "Significance"],
    [
        ["Tracheal deviation toward affected side", "Fibrosis, collapse — lung/tissue pulls trachea toward it"],
        ["Tracheal deviation away from affected side", "Large effusion, tension pneumothorax — pushes trachea away"],
        ["Reduced chest expansion (affected side)", "Pneumonia, effusion, fibrosis, pneumothorax — all reduce movement"],
        ["Increased tactile fremitus", "Consolidation — solid lung transmits sound vibrations better than normal air-filled lung"],
        ["Decreased tactile fremitus", "Effusion (fluid attenuates), pneumothorax (air attenuates), collapse (no air to vibrate)"],
    ],
    header_color=TEAL
)

story.append(Paragraph("<b>Percussion:</b>", sH3))
story += two_col_table(
    ["Note", "Significance"],
    [
        ["Dull", "Consolidation (pneumonia), pleural effusion, collapse, fibrosis"],
        ["Stony dull", "Pleural effusion — fluid conducts differently from solid tissue"],
        ["Hyper-resonant", "Pneumothorax, emphysema — excess air in chest"],
        ["Tidal percussion", "Changes in liver dullness with breathing — tests diaphragm mobility"],
        ["Shifting dullness in chest", "Pleural effusion — fluid shifts with patient posture"],
        ["Straight-line dullness", "Pleural effusion with patient upright — fluid forms horizontal level (Ellis's S-curve)"],
    ],
    header_color=TEAL
)

story.append(Paragraph("<b>Auscultation — Breath Sounds & Added Sounds:</b>", sH3))
story += three_col_table(
    ["Sound", "Mechanism", "Significance"],
    [
        ["Bronchial breath sound", "Turbulent flow in large airways conducted through consolidated lung (no air cushion)", "Pneumonia (consolidation), fibrosis adjacent to bronchus"],
        ["Absent breath sounds", "Air/fluid/solid barrier between lung and stethoscope", "Pneumothorax (air), effusion (fluid), massive collapse"],
        ["Fine crackles", "Explosive reopening of collapsed alveoli on inspiration", "Fibrosis (ILD), pulmonary edema (LVF)"],
        ["Coarse crackles", "Secretions in large airways bubbling", "Bronchiectasis, pneumonia, COPD"],
        ["Polyphonic wheeze", "Multiple airway narrowings with turbulent flow", "Asthma (generalised bronchoconstriction)"],
        ["Monophonic wheeze", "Single airway obstruction", "Foreign body, endobronchial tumor"],
        ["Pleural rub", "Inflamed pleural surfaces rubbing together", "Pleuritis, pneumonia + pleuritis, PE with infarct, mesothelioma"],
        ["Post-tussive suction", "After cough, air sucked back into cavity", "Lung cavity (TB, abscess) — diagnostic sign"],
    ],
    header_color=TEAL
)

story.append(Paragraph("<b>Vocal Resonance Tests:</b>", sH3))
story += three_col_table(
    ["Test", "How", "What It Detects"],
    [
        ["Bronchophony", "Ask patient to say '99' — transmitted voice louder on consolidation", "Consolidation — sound transmits better through solid lung"],
        ["Aegophony (E → A change)", "Ask to say 'EEE' — heard as 'AAA' over effusion", "Pleural effusion — at fluid-lung interface voice changes quality"],
        ["Whispering pectoriloquy", "Whisper '1-2-3' — heard clearly over consolidation", "Consolidation — whispered sounds clearly heard through solid lung"],
    ],
    header_color=TEAL
)

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# SECTION 4 – CNS
# ════════════════════════════════════════════════════════════════════════════
story += section_header("SECTION 4 — CENTRAL NERVOUS SYSTEM (CNS)", PURPLE)

story += sub_header("WEAKNESS / INABILITY — Why Each Parameter", PURPLE)
story += two_col_table(
    ["Parameter", "Why"],
    [
        ["Onset (sudden vs insidious)", "Sudden = CVA (stroke/hemorrhage/embolism); insidious = tumor, abscess, demyelination"],
        ["Time of occurrence (sleep vs work)", "During sleep = thrombotic stroke (reduced BP, slower flow, clot forms); during work = embolic/hemorrhagic"],
        ["Progression", "Stepwise = lacunar infarcts; gradual = tumor; rapid = hemorrhage; fluctuating = TIA"],
        ["Proximal vs distal weakness (UL)", "Proximal = myopathy; distal = peripheral neuropathy; combined = motor neuron disease"],
        ["Combing, lifting (proximal UL)", "Deltoid, supraspinatus, biceps — C5 root level"],
        ["Mixing food, buttoning, writing (distal UL)", "Hand intrinsic muscles — T1 root (ulnar nerve); fine motor = corticospinal tract"],
        ["Standing, climbing stairs (proximal LL)", "Quadriceps, hip flexors — L3/L4 root level"],
        ["Slippers slipping (distal LL)", "Foot drop = L4/L5 (deep peroneal nerve); tibialis anterior weakness"],
        ["Trunk weakness", "Cord lesion at thoracic level"],
        ["Head lifting difficulty", "Neck flexors C1-3; helps determine level of cord lesion"],
    ],
    header_color=PURPLE
)

story += sub_header("SENSORY LOSS — Why We Ask Each Modality", PURPLE)
story += three_col_table(
    ["Modality", "Pathway", "Why We Ask"],
    [
        ["Temperature sense", "Spinothalamic tract (crosses immediately in cord)", "Dissociated sensory loss = syringomyelia, Brown-Sequard syndrome"],
        ["Touch sense", "Both dorsal columns AND spinothalamic", "General screening for peripheral neuropathy, radiculopathy"],
        ["Pain sense", "Spinothalamic tract", "Dissociation = spinothalamic lost + dorsal columns intact"],
        ["Tingling / numbness", "Partial nerve/tract damage", "Peripheral neuropathy, radiculopathy, early cord compression"],
        ["Root pain (dermatomal)", "Nerve root compression", "Disk prolapse, radiculopathy — distribution tells the root level"],
    ],
    header_color=PURPLE
)

story += sub_header("LEVEL OF LESION HISTORY — What Each Symptom Localises", PURPLE)
story += two_col_table(
    ["History Feature", "Localisation"],
    [
        ["Headache, projectile vomiting, convulsions, blurring of vision", "Raised ICP = cortical / meningeal pathology"],
        ["Aphasia", "Dominant cortex (Broca's area = expressive; Wernicke's area = receptive)"],
        ["Bladder involvement", "Frontal lobe (UMN bladder) or cord lesion above S2-4"],
        ["Convulsions", "Cortex — seizure focus (scar, tumor, AVM, stroke)"],
        ["Cranial nerve involvement", "Brain stem lesion (CN 3-12 nuclei are here)"],
        ["Diplopia, eye movement disturbance", "Midbrain (CN III, IV), pons (CN VI), or orbital apex"],
        ["Nasal regurgitation, hoarseness", "Medulla (CN IX, X nuclei) or jugular foramen"],
    ],
    header_color=PURPLE
)

story += sub_header("CRANIAL NERVE HISTORY — What Each Question Localises", PURPLE)
story += three_col_table(
    ["CN", "Question Asked", "Localises To"],
    [
        ["I (Olfactory)", "Loss / alteration of smell", "Frontal lobe, olfactory groove meningioma, trauma, parkinsonism"],
        ["II (Optic)", "Visual disturbance", "Optic nerve, chiasm (bitemporal hemianopia = pituitary), optic tract, visual cortex"],
        ["III, IV, VI", "Diplopia, eye movement difficulty", "Midbrain (III, IV), pons (VI), cavernous sinus, orbital apex"],
        ["V (Trigeminal)", "Facial numbness, chewing difficulty", "Pons, Meckel's cave, foramen ovale (V3)"],
        ["VII (Facial)", "Taste loss, drooling, mouth angle deviation", "Pons (LMN — all face affected); UMN spares forehead (bilateral cortical supply)"],
        ["VIII (Vestibulocochlear)", "Hearing loss, vertigo, tinnitus", "Pons, cerebellopontine angle (acoustic neuroma)"],
        ["IX, X", "Nasal regurgitation, dysphagia, hoarseness", "Medulla, jugular foramen (glossopharyngeal neuralgia, vagal palsy)"],
        ["XII (Hypoglossal)", "Tongue deviation, dysarthria", "Medulla, hypoglossal canal"],
    ],
    header_color=PURPLE
)

story += sub_header("ANS HISTORY — Why We Ask", PURPLE)
story += two_col_table(
    ["Question", "Why"],
    [
        ["Constipation / loss of bowel control", "Autonomic neuropathy (diabetes, Parkinson's), cord lesion"],
        ["Difficulty initiating micturition", "UMN bladder (cord lesion) — detrusor-sphincter dyssynergia; or BPH in males"],
        ["Difficulty controlling micturition", "UMN bladder — hyperreflexic detrusor; cord lesion above S2-4"],
        ["Dribbling", "Overflow incontinence = LMN bladder (autonomic neuropathy, cauda equina)"],
        ["Impotence", "Sacral cord (S2-4), autonomic neuropathy — important disability question"],
        ["Sweating abnormality", "Sympathetic trunk lesion, autonomic neuropathy (diabetes, Parkinson's)"],
    ],
    header_color=PURPLE
)

story += sub_header("NEUROCUTANEOUS MARKERS — Why We Look", PURPLE)
story += three_col_table(
    ["Marker", "Syndrome", "CNS Implication"],
    [
        ["Adenoma sebaceum (angiofibromas on face)", "Tuberous sclerosis", "Cortical tubers → seizures, intellectual disability, subependymal giant cell astrocytoma"],
        ["Ash leaf patches (hypopigmented)", "Tuberous sclerosis", "Same — autosomal dominant, penetrance variable"],
        ["Cafe au lait spots", "Neurofibromatosis type 1", "Peripheral nerve tumors, optic glioma, CNS tumors, lisch nodules"],
        ["Multiple neurofibromas", "NF1", "Spinal cord compression from neurofibromas"],
        ["Port wine stain (facial capillary hemangioma)", "Sturge-Weber syndrome", "Ipsilateral leptomeningeal angioma → seizures, hemiplegia, glaucoma"],
        ["Tuft of hair over spine", "Spina bifida occulta", "Incomplete neural tube closure → tethered cord → progressive lower limb deficits"],
        ["Conjunctival hemangioma", "Von Hippel-Lindau syndrome", "Cerebellar hemangioblastoma, retinal angioma"],
        ["Pes cavus (high-arched foot)", "Friedreich's ataxia", "Spinocerebellar degeneration — ataxia, cardiomyopathy, diabetes"],
    ],
    header_color=PURPLE
)

story += sub_header("HIGHER FUNCTIONS — Why We Test Each", PURPLE)
story += two_col_table(
    ["Function", "Why"],
    [
        ["Consciousness (GCS)", "Severity of encephalopathy, stroke, raised ICP — baseline for monitoring progression"],
        ["Orientation (time/place/person)", "Cortical function, hepatic encephalopathy, metabolic encephalopathy — first orientation to go = time"],
        ["Memory (short-term, long-term)", "Hippocampus (short-term); Herpes encephalitis; Alzheimer's; Korsakoff's (thiamine deficiency from alcohol)"],
        ["Intelligence", "Cortical function, premorbid status assessment"],
        ["Broca's aphasia (expressive)", "Left frontal lesion — cannot speak but understands"],
        ["Wernicke's aphasia (receptive)", "Left temporal lesion — speaks fluently but makes no sense"],
        ["Dysarthria", "Motor — pons, cerebellum, CN 7/9/10/12 — speech is slurred but words are correct"],
        ["Handedness", "Determines dominant hemisphere — usually left hemisphere dominant in right-handed people"],
        ["Emotion", "Frontal lobe disinhibition; pseudobulbar palsy (forced crying/laughing)"],
    ],
    header_color=PURPLE
)

story += sub_header("MOTOR SYSTEM — Why Each Component", PURPLE)

story.append(Paragraph("<b>Tone:</b>", sH3))
story += two_col_table(
    ["Finding", "Meaning"],
    [
        ["Increased — spasticity (clasp-knife)", "UMN lesion (stroke, cord) — clasp-knife in UL flexors, LL extensors (explains hemiplegic posture)"],
        ["Increased — rigidity (lead pipe / cogwheel)", "Extrapyramidal (Parkinson's disease) — rigidity throughout range of movement"],
        ["Decreased — flaccidity", "LMN lesion (anterior horn cell, peripheral nerve) or early acute UMN (spinal shock)"],
    ],
    header_color=MED_BLUE
)

story.append(Paragraph("<b>Why Hemiplegic Posture (adducted shoulder, flexed elbow, extended leg):</b>", sH3))
story += info_box(
    "UMN lesion → flexor spasticity predominates in upper limb (gravity + UMN influence on flexors) and "
    "extensor spasticity predominates in lower limb. "
    "The gait is circumduction (swinging the stiff extended leg out to clear the ground). "
    "This posture distinguishes UMN (stroke) from LMN (flaccid) weakness.",
    bg=LIGHT_PURP, border=PURPLE
)

story.append(Paragraph("<b>Coordination Tests:</b>", sH3))
story += two_col_table(
    ["Test", "What It Detects"],
    [
        ["Finger-nose test", "Cerebellar ataxia (ipsilateral) — intention tremor, past-pointing"],
        ["Finger-finger-nose test", "Dysmetria — undershooting or overshooting target"],
        ["Diadochokinesia", "Cerebellar — inability to perform rapid alternating movements (dysdiadochokinesia)"],
        ["Knee-heel test", "Lower limb cerebellar ataxia"],
        ["Gait analysis", "Hemiplegic (circumduction), cerebellar (wide-based), scissor (spastic paraplegia), high-stepping (foot drop), Parkinsonian (festinating, shuffling)"],
    ],
    header_color=PURPLE
)

story += sub_header("REFLEXES — Why We Test Each", PURPLE)

story.append(Paragraph("<b>Superficial Reflexes:</b>", sH3))
story += three_col_table(
    ["Reflex", "Arc", "Why Test"],
    [
        ["Corneal", "CN V + VII; pons", "Absent in ipsilateral V or VII lesion; tests brainstem integrity"],
        ["Abdominal", "T8-T12; spinal cord", "Absent in UMN lesion above T8; also absent in obesity, multiparity"],
        ["Cremasteric", "L1-L2", "Absent in UMN above L1; ipsilateral absent in LMN; tests L1/L2"],
        ["Plantar (Babinski)", "L5-S1; corticospinal tract", "Extensor plantar (Babinski+) = major sign of corticospinal tract involvement (UMN)"],
    ],
    header_color=MED_BLUE
)

story.append(Paragraph("<b>Deep Tendon Reflexes:</b>", sH3))
story += three_col_table(
    ["Reflex", "Level", "Clinical Significance"],
    [
        ["Jaw jerk", "CN V (pons)", "Exaggerated = bilateral UMN above pons (pseudobulbar palsy); absent = LMN of V"],
        ["Biceps jerk", "C5-C6", "Absent = LMN at C5-6 (cervical disk); exaggerated = UMN above C5"],
        ["Triceps jerk", "C6-C7", "Absent = LMN at C6-7; exaggerated = UMN above"],
        ["Knee jerk (patellar)", "L3-L4", "Absent = LMN at L3-4 (diabetic neuropathy, disk); exaggerated = UMN above L3"],
        ["Ankle jerk", "S1-S2", "First deep reflex lost in peripheral neuropathy; absent = S1 disk prolapse"],
        ["Clonus", "Any deep reflex", "Sustained rhythmic contractions = definite UMN lesion"],
    ],
    header_color=PURPLE
)

story += sub_header("SENSORY SYSTEM — Why Each Modality", PURPLE)
story += three_col_table(
    ["Modality", "Pathway", "Why Test"],
    [
        ["Touch", "Dorsal columns + spinothalamic", "General screening for peripheral neuropathy"],
        ["Pain", "Spinothalamic (crosses in cord)", "Spinothalamic loss + dorsal column intact = Brown-Sequard / syringomyelia"],
        ["Temperature", "Spinothalamic (crosses in cord)", "Dissociated loss = syringomyelia (cavity in cord center damages crossing fibers first)"],
        ["Vibration sense", "Dorsal columns", "Lost in B12 deficiency (SACD), tabes dorsalis, peripheral neuropathy"],
        ["Position sense (proprioception)", "Dorsal columns", "Romberg positive = dorsal column loss; pseudoathetosis of fingers"],
        ["Tactile localisation", "Parietal cortex", "Parietal lobe lesion — cannot localise touch"],
        ["Two-point discrimination", "Parietal cortex", "Parietal lobe lesion — cannot distinguish two separate points"],
        ["Stereognosis", "Parietal cortex", "Cannot identify objects by touch = astereognosis = parietal lesion"],
        ["Graphesthesia", "Parietal cortex", "Cannot identify numbers written on skin = agraphesthesia = parietal lesion"],
    ],
    header_color=PURPLE
)

story += sub_header("MENINGEAL SIGNS — Why We Test Each", PURPLE)
story += three_col_table(
    ["Sign", "How to Test", "Significance"],
    [
        ["Neck rigidity", "Passive neck flexion resisted", "Meningeal irritation — reflex spasm of paravertebral muscles; meningitis, SAH"],
        ["Kernig's sign", "Flex hip 90° then try to extend knee — resistance/pain", "Stretches inflamed meninges over lumbar roots — meningitis, SAH"],
        ["Brudzinski's sign", "Passive neck flexion → involuntary hip/knee flexion", "Reflex hip flexion to reduce stretch on inflamed meninges"],
    ],
    header_color=PURPLE
)

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# SECTION 5 — OTHER SYSTEMS IN EACH CASE
# ════════════════════════════════════════════════════════════════════════════
story += section_header("SECTION 5 — WHY WE EXAMINE OTHER SYSTEMS IN EACH CASE", DARK_BLUE)

story += two_col_table(
    ["Case — Other System", "Why We Examine It"],
    [
        ["CVS case + Respiratory system", "Basal crepitations = pulmonary edema from LVF; pleural effusion in CCF"],
        ["CVS case + Abdomen", "Hepatomegaly (RHF — congestive), ascites (CCF), splenomegaly (IE, PHT)"],
        ["GI case + CVS (S1, S2 auscultation)", "Rule out RHF causing cardiac ascites and congestive hepatomegaly"],
        ["GI case + Respiratory", "Basal crepitations = pleural effusion from pancreatitis / amoebic liver abscess / TB"],
        ["GI case + CNS", "Asterixis (flapping tremor), confusion = hepatic encephalopathy grading"],
        ["RS case + CVS", "RHF / CCF signs = cor pulmonale (RHF from chronic lung disease — COPD, ILD, PHT)"],
        ["RS case + Abdomen (liver tenderness)", "Amoebic liver abscess tracking into right pleural space = important complication"],
        ["RS case + CNS (asterixis)", "CO2 retention (type II respiratory failure) — flapping tremor of hypercarbia"],
        ["CNS case + CVS", "AF, valvular disease, recent MI with mural thrombus = cardioembolic stroke source"],
        ["CNS case + RS", "Aspiration pneumonia (in bulbar palsy / unconscious patient), hypoventilation"],
    ],
    header_color=DARK_BLUE
)

story += info_box(
    "GOLDEN RULE: No system in medicine works in isolation. "
    "Every case examination systematically checks neighbouring systems because diseases overflow their primary domain. "
    "The purpose of 'other systems' examination is always to: "
    "(1) find the cause, (2) find complications, or (3) rule out mimics.",
    bg=LIGHT_BLUE, border=DARK_BLUE
)

story.append(Spacer(1, 0.5*cm))
story.append(HRFlowable(width=W, thickness=1, color=DARK_BLUE))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "Clinical Reasoning Guide — CVS | GI | RS | CNS  |  Prepared for Medical Students",
    S("footer", parent=styles["Normal"], fontSize=8, textColor=GREY,
      alignment=TA_CENTER, fontName="Helvetica-Oblique")
))

# ── Build PDF ────────────────────────────────────────────────────────────────
doc.build(story)
print("PDF built:", OUTPUT)

Running Command

cd /home/daytona/workspace/clinical-reasoning && python3 make_pdf.py 2>&1

Editing File

~/clinical-reasoning/make_pdf.py

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/clinical-reasoning/make_pdf.py'

Running Command

cd /home/daytona/workspace/clinical-reasoning && python3 make_pdf.py 2>&1

Your PDF is ready. Here's the download link:

Clinical Reasoning Guide

PDF Document · PDF

What's inside:

Cover page with colour-coded system sections (CVS, GI, RS, CNS)
Section 1 — CVS: Chest pain, dyspnea, palpitation, syncope, negative history (RHF/RF/Left-sided/Congenital/PHT), past history, general exam markers (IE, Congenital HD), vital signs reasoning, all peripheral AR signs, full auscultation logic
Section 2 — GI: Abdominal pain, distension, jaundice, stools, negative history, past history, all liver cell failure markers with mechanisms, full abdominal exam (inspection through auscultation)
Section 3 — RS: Cough/sputum, hemoptysis, breathlessness, negative history, past history, Horner's/Troussier's/paraneoplastic/TB markers, full chest examination with breath sound mechanisms
Section 4 — CNS: Weakness localisation, sensory modalities, cranial nerve history, ANS history, neurocutaneous markers, higher functions, motor/reflexes/sensory system exam, meningeal signs
Section 5 — Cross-system reasoning: Why each case needs examination of other systems

All presented as colour-coded tables with mechanisms clearly explained for each finding.

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