EPIPHORA — Complete ENT/Ophthalmology PG Exam Notes

ls -la /home/daytona/workspace/ 2>/dev/null || mkdir -p /home/daytona/workspace

mkdir -p /home/daytona/workspace/epiphora-pdf

~/epiphora-pdf/generate_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 mm, cm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether, Image as RLImage
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import PageBreak
from reportlab.lib.colors import HexColor
import urllib.request
import os
import io

# ── colour palette ──────────────────────────────────────────────────────────
DARK_BLUE   = HexColor('#1a3a5c')
MID_BLUE    = HexColor('#2563a8')
LIGHT_BLUE  = HexColor('#dbeafe')
ACCENT      = HexColor('#0ea5e9')
TABLE_HEAD  = HexColor('#1e3a5f')
TABLE_ALT   = HexColor('#f0f7ff')
WHITE       = colors.white
BLACK       = colors.black
GREY_TEXT   = HexColor('#374151')
BORDER      = HexColor('#93c5fd')

OUTPUT = '/home/daytona/workspace/epiphora-pdf/Epiphora_PG_Exam_Notes.pdf'

# ── document ─────────────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=2*cm, rightMargin=2*cm,
    topMargin=2.5*cm, bottomMargin=2.5*cm,
    title='Epiphora — PG Exam Notes',
    author='Orris Medical'
)

W = A4[0] - 4*cm   # usable width

styles = getSampleStyleSheet()

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

title_style   = S('MyTitle',  fontSize=22, textColor=WHITE,
                  alignment=TA_CENTER, fontName='Helvetica-Bold',
                  spaceAfter=4, leading=28)
subtitle_style= S('MySub',    fontSize=11, textColor=LIGHT_BLUE,
                  alignment=TA_CENTER, fontName='Helvetica', spaceAfter=2)
date_style    = S('MyDate',   fontSize=9,  textColor=LIGHT_BLUE,
                  alignment=TA_CENTER, fontName='Helvetica-Oblique')

h1_style      = S('H1',  fontSize=14, textColor=WHITE,
                  fontName='Helvetica-Bold', spaceAfter=4, spaceBefore=14,
                  leading=18)
h2_style      = S('H2',  fontSize=11, textColor=DARK_BLUE,
                  fontName='Helvetica-Bold', spaceAfter=3, spaceBefore=10,
                  leading=15)
h3_style      = S('H3',  fontSize=10, textColor=MID_BLUE,
                  fontName='Helvetica-Bold', spaceAfter=2, spaceBefore=6,
                  leading=14)

body_style    = S('Body', fontSize=9.5, textColor=GREY_TEXT,
                  fontName='Helvetica', spaceAfter=4, leading=14,
                  alignment=TA_JUSTIFY)
bullet_style  = S('Bullet', fontSize=9.5, textColor=GREY_TEXT,
                  fontName='Helvetica', spaceAfter=3, leading=13,
                  leftIndent=14, bulletIndent=4)
bullet2_style = S('Bullet2', fontSize=9, textColor=GREY_TEXT,
                  fontName='Helvetica', spaceAfter=2, leading=12,
                  leftIndent=28, bulletIndent=18)
tip_style     = S('Tip',  fontSize=9, textColor=HexColor('#1e40af'),
                  fontName='Helvetica-Oblique', spaceAfter=4, leading=13,
                  leftIndent=10)
source_style  = S('Source', fontSize=8, textColor=HexColor('#6b7280'),
                  fontName='Helvetica-Oblique', alignment=TA_CENTER,
                  spaceAfter=6, spaceBefore=2)
key_style     = S('Key', fontSize=9, textColor=HexColor('#166534'),
                  fontName='Helvetica-Bold', spaceAfter=2, leading=13,
                  leftIndent=14)

# ── helpers ──────────────────────────────────────────────────────────────────

def section_header(text, number):
    """Blue banner heading."""
    tbl = Table([[Paragraph(f'{number}. {text}', h1_style)]], colWidths=[W])
    tbl.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), DARK_BLUE),
        ('TOPPADDING',    (0,0), (-1,-1), 7),
        ('BOTTOMPADDING', (0,0), (-1,-1), 7),
        ('LEFTPADDING',   (0,0), (-1,-1), 10),
        ('RIGHTPADDING',  (0,0), (-1,-1), 10),
        ('ROWBACKGROUNDS',(0,0), (-1,-1), [DARK_BLUE]),
    ]))
    return tbl

def sub_header(text):
    return Paragraph(text, h2_style)

def sub_sub_header(text):
    return Paragraph(text, h3_style)

def body(text):
    return Paragraph(text, body_style)

def bullet(text, level=1):
    prefix = '• ' if level == 1 else '◦ '
    st = bullet_style if level == 1 else bullet2_style
    return Paragraph(prefix + text, st)

def tip(text):
    tbl = Table([[Paragraph('💡 TIP: ' + text, tip_style)]], colWidths=[W])
    tbl.setStyle(TableStyle([
        ('BACKGROUND',    (0,0), (-1,-1), HexColor('#eff6ff')),
        ('LEFTPADDING',   (0,0), (-1,-1), 10),
        ('RIGHTPADDING',  (0,0), (-1,-1), 10),
        ('TOPPADDING',    (0,0), (-1,-1), 6),
        ('BOTTOMPADDING', (0,0), (-1,-1), 6),
        ('BOX',           (0,0), (-1,-1), 0.5, HexColor('#bfdbfe')),
        ('ROUNDEDCORNERS',(0,0), (-1,-1), 3),
    ]))
    return tbl

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

def hr():
    return HRFlowable(width='100%', thickness=0.5, color=BORDER, spaceAfter=4, spaceBefore=4)

def make_table(headers, rows, col_widths=None):
    if col_widths is None:
        col_widths = [W/len(headers)]*len(headers)
    hdr_style = ParagraphStyle('th', fontSize=9, textColor=WHITE,
                               fontName='Helvetica-Bold', leading=12)
    cell_style= ParagraphStyle('td', fontSize=8.5, textColor=GREY_TEXT,
                               fontName='Helvetica', leading=12)
    data = [[Paragraph(h, hdr_style) for h in headers]]
    for i, row in enumerate(rows):
        data.append([Paragraph(str(c), cell_style) for c in row])
    tbl = Table(data, colWidths=col_widths, repeatRows=1)
    cmd = [
        ('BACKGROUND',    (0,0), (-1,0), TABLE_HEAD),
        ('TEXTCOLOR',     (0,0), (-1,0), WHITE),
        ('TOPPADDING',    (0,0), (-1,-1), 5),
        ('BOTTOMPADDING', (0,0), (-1,-1), 5),
        ('LEFTPADDING',   (0,0), (-1,-1), 7),
        ('RIGHTPADDING',  (0,0), (-1,-1), 7),
        ('GRID',          (0,0), (-1,-1), 0.4, BORDER),
        ('VALIGN',        (0,0), (-1,-1), 'TOP'),
    ]
    for i in range(1, len(data)):
        bg = TABLE_ALT if i % 2 == 0 else WHITE
        cmd.append(('BACKGROUND', (0,i), (-1,i), bg))
    tbl.setStyle(TableStyle(cmd))
    return tbl

def download_image(url, filename):
    path = f'/home/daytona/workspace/epiphora-pdf/{filename}'
    if not os.path.exists(path):
        try:
            urllib.request.urlretrieve(url, path)
        except Exception as e:
            print(f'Image download failed: {e}')
            return None
    return path

# ── download images ───────────────────────────────────────────────────────────
img1_path = download_image(
    'https://cdn.orris.care/cdss_images/3a8a23ad5c9d6f2155842d46f4f6c5e369ee22d9348a7b6f6fcee983280f86ac.png',
    'anatomy.png')
img2_path = download_image(
    'https://cdn.orris.care/cdss_images/bb7f941f6f8bbcd929daf997a6d4ced1623339a125df7b0bef1d163fd4c3d321.png',
    'epiphora_clinical.png')

# ── title page flowable ───────────────────────────────────────────────────────
def title_block():
    tbl = Table([
        [Paragraph('EPIPHORA', title_style)],
        [Paragraph('Complete PG Exam Notes — ENT / Ophthalmology', subtitle_style)],
        [Paragraph('Source: Kanski\'s Clinical Ophthalmology 10th Ed. | KJ Lee\'s Otolaryngology | Goldman-Cecil Medicine', date_style)],
    ], colWidths=[W])
    tbl.setStyle(TableStyle([
        ('BACKGROUND',    (0,0), (-1,-1), DARK_BLUE),
        ('TOPPADDING',    (0,0), (0,0),   20),
        ('BOTTOMPADDING', (0,-1),(-1,-1), 20),
        ('TOPPADDING',    (0,1), (-1,-2), 4),
        ('BOTTOMPADDING', (0,0), (-1,-2), 4),
        ('LEFTPADDING',   (0,0), (-1,-1), 16),
        ('RIGHTPADDING',  (0,0), (-1,-1), 16),
    ]))
    return tbl

# ── BUILD STORY ───────────────────────────────────────────────────────────────
story = []

# Title
story.append(title_block())
story.append(sp(12))

# ═══════════════════════════════════════════════════════════════════════════════
# 1. DEFINITION
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_header('DEFINITION', 1))
story.append(sp(6))
story.append(body(
    '<b>Epiphora</b> is the overflow of tears onto the cheek/face due to either '
    '<b>hypersecretion</b> of tears beyond normal drainage capacity, or '
    '<b>defective drainage</b> of tears through the lacrimal drainage system.'
))
story.append(sp(4))
story.append(tip(
    'It is common for a watering eye to be caused by reflex hypersecretion of tears '
    'secondary to a dry ocular surface ("paradoxical watering").'
))

# ═══════════════════════════════════════════════════════════════════════════════
# 2. ANATOMY
# ═══════════════════════════════════════════════════════════════════════════════
story.append(sp(10))
story.append(section_header('RELEVANT ANATOMY', 2))
story.append(sp(6))

if img1_path:
    img = RLImage(img1_path, width=10*cm, height=8*cm, kind='proportional')
    story.append(img)
    story.append(Paragraph(
        'Fig. 3.1 — Anatomy of the lacrimal drainage system (Kanski\'s Clinical Ophthalmology)',
        source_style))
    story.append(sp(6))

anat_rows = [
    ['Ampulla (vertical canaliculus)', '2 mm; part of tarsal plate'],
    ['Horizontal canaliculus',         '~8 mm; surrounded by Horner muscle (palpebral orbicularis)'],
    ['Common canaliculus',             'Superior + inferior canaliculi unite (>90%); opens into lateral wall of lacrimal sac'],
    ['Valve of Rosenmüller',           'Mucosal flap at junction of common canaliculus and sac; prevents reflux'],
    ['Lacrimal sac',                   '10–12 mm; lies in lacrimal fossa between anterior & posterior lacrimal crests'],
    ['Nasolacrimal duct (NLD)',        '12–18 mm; opens into inferior nasal meatus below inferior turbinate'],
    ['Valve of Hasner',                'Mucosal fold at lower end of NLD; last part to canalise at birth'],
]
story.append(make_table(['Structure', 'Key Details'], anat_rows, [6.5*cm, 11.5*cm]))
story.append(sp(8))

story.append(sub_header('Physiology of Tear Drainage'))
for t in [
    'Tears flow along marginal strips → lacus lacrimalis → enter canaliculi by capillarity + suction.',
    'On <b>blinking</b>: orbicularis compresses ampullae, shortens canaliculi, closes puncta medially → forces tears down NLD.',
    'On <b>eye opening</b>: canaliculi and sac expand, creating negative pressure that draws tears from canaliculi into sac.',
]:
    story.append(bullet(t))

# ═══════════════════════════════════════════════════════════════════════════════
# 3. ETIOLOGY
# ═══════════════════════════════════════════════════════════════════════════════
story.append(sp(10))
story.append(section_header('ETIOLOGY / CAUSES', 3))
story.append(sp(6))

story.append(sub_header('A. Hypersecretion (Lacrimation) — Reflex Overproduction'))
for t in [
    '<b>Dry eye</b> — "paradoxical watering" (commonest cause overall)',
    'Conjunctivitis, keratitis, uveitis, scleritis',
    'Entropion / trichiasis / aberrant eyelashes / corneal foreign body',
    'Congenital hereditary endothelial dystrophy',
    'Sclerocornea (neonates)',
    'Congenital glaucoma (rare)',
]:
    story.append(bullet(t))

story.append(sp(6))
story.append(sub_header('B. Defective Drainage'))

story.append(sub_sub_header('I. Punctal / Lid Malposition'))
for t in [
    '<b>Ectropion</b> (commonest lid cause) — punctum everts away from globe',
    '<b>Centurion syndrome</b> — medial lid displaced anteriorly by prominent nasal bridge',
    'Lower lid laxity / involutional changes',
]:
    story.append(bullet(t))

story.append(sp(4))
story.append(sub_sub_header('II. Obstruction at Any Level'))
obs_rows = [
    ['Punctal',       'Stenosis (chronic blepharitis, herpes, radiation, cicatrising conjunctivitis, 5-FU, topical glaucoma drops); congenital atresia'],
    ['Canalicular',   'Canaliculitis (Actinomyces israelii), trauma, herpes simplex, cicatrising conditions'],
    ['Lacrimal sac',  'Dacryocystitis, dacryolithiasis, tumour, mucocele'],
    ['NLD',           'PANDO (Primary Acquired NLD Obstruction) — commonest acquired adult cause; congenital NLD obstruction (Hasner valve); secondary — sinusitis, trauma, tumour, post-surgical'],
]
story.append(make_table(['Level', 'Causes'], obs_rows, [4*cm, 14*cm]))
story.append(sp(4))

story.append(sub_sub_header('III. Lacrimal Pump Failure'))
for t in [
    '<b>Facial nerve palsy</b> (orbicularis weakness)',
    'Lower lid laxity / involutional change',
    '<b>Conjunctivochalasis</b> — redundant conjunctival fold blocking punctum',
]:
    story.append(bullet(t))

# ═══════════════════════════════════════════════════════════════════════════════
# 4. CLINICAL FEATURES
# ═══════════════════════════════════════════════════════════════════════════════
story.append(sp(10))
story.append(section_header('CLINICAL FEATURES', 4))
story.append(sp(6))

story.append(sub_header('Symptoms'))
for t in [
    '<b>Tears overflowing onto the cheek</b> — cardinal symptom',
    'Worse in cold, windy weather; better in warm, dry room (→ drainage failure)',
    'Mucopurulent discharge (especially in NLD obstruction)',
    'Crusting of lashes on waking',
    'Skin maceration / excoriation at medial canthus',
    'Swelling at medial canthus (dacryocystitis, mucocele, dacryocoele)',
]:
    story.append(bullet(t))

story.append(sp(6))
story.append(sub_header('In Neonates / Congenital NLD Obstruction'))
for t in [
    'Epiphora in ~20% of normal babies at birth',
    'Spontaneous resolution in ~<b>90% by age 1 year</b>',
    'Mucopurulent sticky discharge',
    '<b>Congenital dacryocoele (amniotocoele)</b>: bluish cystic swelling at/below medial canthus at birth; must not be confused with encephalocoele (pulsatile, above medial canthal ligament)',
]:
    story.append(bullet(t))

story.append(sp(6))
if img2_path:
    img = RLImage(img2_path, width=12*cm, height=9*cm, kind='proportional')
    story.append(img)
    story.append(Paragraph(
        'Fig. 3.18 — (A) Child with watering eye; (B) probing of NLD; (C) congenital dacryocele '
        '(Kanski\'s Clinical Ophthalmology)',
        source_style))

# ═══════════════════════════════════════════════════════════════════════════════
# 5. EXAMINATION
# ═══════════════════════════════════════════════════════════════════════════════
story.append(sp(10))
story.append(section_header('EXAMINATION', 5))
story.append(sp(6))

exam_steps = [
    ('Step 1 — Slit-lamp Examination (Before any manipulation)',
     [
         '<b>Marginal tear strip (meniscus)</b>: Normal = 0.2–0.4 mm; Elevated ≥0.6 mm = abnormal',
         'Examine <b>puncta BEFORE cannulation</b> (irrigation dilates punctum, masking stenosis)',
         'Punctal stenosis — commonest cause of drainage failure',
         'Ectropion / eversion of punctum',
         'Pouting punctum → canaliculitis',
         'Conjunctivochalasis occluding punctum',
         'Eyelash in ampulla; large caruncle displacing punctum',
     ]),
    ('Step 2 — Lacrimal Sac Palpation',
     [
         '<b>Mucocele</b>: Regurgitation of mucopurulent material on pressure → NLD obstruction with patent canaliculi',
         '<b>Acute dacryocystitis</b>: Tender swelling — do NOT press (do NOT irrigate in acute phase)',
         'Hard mass on palpation → stone or tumour',
     ]),
    ('Step 3 — Fluorescein Disappearance Test (FDT)',
     [
         'Instil fluorescein 1–2% drops into both conjunctival fornices',
         'Normal: little/no dye remains at 5–10 min under blue light in darkened room',
         '<b>Prolonged retention</b> = inadequate lacrimal drainage',
     ]),
    ('Step 4 — Jones Dye Tests',
     [
         '<b>Jones I (Primary Dye Test)</b>: Fluorescein instilled; nasal pledget checked at 5 min.',
         'Positive (normal): fluorescein recovered from nose → drainage intact',
         'Negative: proceed to Jones II',
         '<b>Jones II (Secondary Dye Test)</b>: Irrigate canaliculus with saline after prior fluorescein:',
         'Fluorescein-stained saline from nose → partial NLD obstruction (fluorescein entered sac)',
         'Unstained saline from nose → upper lacrimal (punctal/canalicular) dysfunction or pump failure',
     ]),
    ('Step 5 — Lacrimal Syringing (Irrigation)',
     [
         'Dilate punctum → insert blunt 26/27G lacrimal cannula into lower punctum',
         '<b>Hard stop</b> (cannula hits medial lacrimal bone) = canalicular system patent to sac level',
         '<b>Soft stop</b> (soft resistance before hard stop) = canalicular obstruction',
         'Free flow to nasopharynx → NLD patent',
         'Regurgitation from <i>same</i> punctum → complete canalicular block',
         'Regurgitation from <i>opposite</i> punctum → NLD obstruction (common canaliculus patent)',
         'Partial flow with resistance → partial NLD obstruction / functional block',
     ]),
]

for (header, bullets) in exam_steps:
    story.append(KeepTogether([
        sub_header(header),
        *[bullet(t) for t in bullets],
        sp(4),
    ]))

# ═══════════════════════════════════════════════════════════════════════════════
# 6. INVESTIGATIONS / DIAGNOSIS
# ═══════════════════════════════════════════════════════════════════════════════
story.append(sp(10))
story.append(section_header('INVESTIGATIONS / DIAGNOSIS', 6))
story.append(sp(6))

inv_rows = [
    ['Fluorescein Disappearance Test',  'Screening; highly specific for congenital NLD obstruction'],
    ['Jones I & II Tests',              'Localise level of obstruction (upper vs lower drainage system)'],
    ['Lacrimal Syringing',              'Confirm and localise obstruction; gold standard functional test'],
    ['Probing',                         'Diagnose AND treat congenital NLD obstruction'],
    ['Dacryocystography (DCG)',         'Radio-opaque contrast injected into canaliculi; shows anatomy, site of block, diverticula, filling defects (stones, tumours); digital subtraction DCG most detailed'],
    ['Nuclear Lacrimal Scintigraphy',   'Physiological assessment with radiolabelled tears; identifies partial or functional blocks; less anatomical detail than DCG'],
    ['CT / MRI',                        'Paranasal sinus disease, lacrimal sac tumour, complex anatomy'],
    ['Nasal Endoscopy',                 'Polyps, deviated septum, intranasal pathology'],
    ['Microbiological swab',            'Discharge in canaliculitis (Actinomyces) or dacryocystitis'],
]
story.append(make_table(['Investigation', 'Purpose'], inv_rows, [6*cm, 12*cm]))

# ═══════════════════════════════════════════════════════════════════════════════
# 7. MANAGEMENT
# ═══════════════════════════════════════════════════════════════════════════════
story.append(sp(10))
story.append(section_header('MANAGEMENT', 7))
story.append(sp(6))

story.append(sub_header('A. Treat Hypersecretion (Medical)'))
for t in [
    'Artificial tears / lubricants for dry eye paradoxical watering',
    'Anti-inflammatory drops (ciclosporin, topical steroids) for blepharitis / dry eye',
    'Treat underlying conjunctivitis, trichiasis, entropion',
]:
    story.append(bullet(t))

story.append(sp(6))
story.append(sub_header('B. Congenital NLD Obstruction'))
steps = [
    ('<b>Conservative (first-line, &lt;12 months)</b>',
     'Crigler massage — index finger over common canaliculus, rolled downwards over sac to create hydrostatic pressure rupturing Hasner membrane'),
    ('<b>Probing (definitive treatment)</b>',
     'Fine wire via canalicular system → NLD → disrupts obstructing membrane at valve of Hasner; '
     'delayed until 12–18 months (or 24 months if mild symptoms); under GA; can be repeated; '
     'follow with irrigation to confirm patency'),
    ('<b>If probing fails</b>',
     'Silicone tube intubation ± balloon dilatation of NLD; endoscopic procedures; dacryocystorhinostomy (DCR)'),
    ('<b>Congenital dacryocoele</b>',
     'Conservative first; probing if conservative management fails'),
]
for (bold, text) in steps:
    story.append(bullet(f'{bold}: {text}'))

story.append(sp(6))
story.append(sub_header('C. Acquired Punctal / Canalicular Obstruction'))
for t in [
    '<b>Punctal stenosis</b>: Punctal dilatation ± mini-Monoka stent (removed at 1 month); <b>Punctoplasty</b> (one-, two- or three-snip procedure) if dilation fails',
    '<b>Ectropion</b>: Lid tightening procedures (lateral tarsal strip, medial canthoplasty)',
    '<b>Conjunctivochalasis</b>: Topical lubricants / anti-inflammatories; surgical excision or conjunctival suturing',
    '<b>Canaliculitis (Actinomyces)</b>: Canaliculotomy + curettage + topical penicillin / cefuroxime',
]:
    story.append(bullet(t))

story.append(sp(6))
story.append(sub_header('D. Acquired NLD Obstruction / PANDO — Dacryocystorhinostomy (DCR)'))
story.append(body(
    'DCR creates an anastomosis between the lacrimal sac and nasal mucosa, bypassing NLD obstruction. '
    'Success rate ~90%.'
))

dcr_rows = [
    ['External DCR (standard)',
     'Vertical skin incision 10 mm medial to inner canthus; '
     'anterior lacrimal crest and lacrimal fossa bone removed; '
     'sac opened with H-shaped incision (anterior + posterior flaps); '
     'nasal mucosa opened; posterior then anterior flaps sutured; '
     'silicone tube often inserted (removed at 3–6 months)'],
    ['Endoscopic (Endonasal) DCR',
     'No skin incision; comparable success rates; preferred for functional failures or redo cases'],
]
story.append(make_table(['Procedure', 'Key Steps / Notes'], dcr_rows, [5.5*cm, 12.5*cm]))

story.append(sp(6))
story.append(sub_header('E. Dacryocystitis'))
for t in [
    '<b>Acute</b>: Systemic antibiotics (IV amoxicillin-clavulanate or cephalosporins in severe cases); warm compresses; DCR after infection resolves',
    '<b>Chronic</b>: DCR is the definitive treatment',
    '<b>Mucocele</b>: Pressure test confirms; DCR required',
]:
    story.append(bullet(t))

story.append(sp(6))
story.append(sub_header('F. Lacrimal Pump Failure (Facial Nerve Palsy)'))
for t in [
    'Treat underlying cause',
    'Lubricating eye drops / ointment to protect cornea',
    'Lateral tarsorrhaphy or lower lid tightening if lid laxity contributes',
]:
    story.append(bullet(t))

# ═══════════════════════════════════════════════════════════════════════════════
# 8. MNEMONIC
# ═══════════════════════════════════════════════════════════════════════════════
story.append(sp(10))
story.append(section_header('MNEMONIC — Causes of Epiphora', 8))
story.append(sp(6))

mnem_rows = [
    ['P', 'Punctal stenosis / malposition (Ectropion)'],
    ['E', 'Evaporation / Dry Eye (paradoxical hypersecretion) — COMMONEST'],
    ['C', 'Canalicular obstruction (trauma, Canaliculitis — Actinomyces)'],
    ['K', 'Keratoconjunctivitis / ocular surface disease'],
    ['D', 'Dacryocystitis / NLD obstruction (PANDO)'],
    ['F', 'Facial nerve palsy (pump failure)'],
    ['L', 'Lid laxity / conjunctivochalasis'],
]
style_mnem = TableStyle([
    ('BACKGROUND',    (0,0), (0,-1), MID_BLUE),
    ('TEXTCOLOR',     (0,0), (0,-1), WHITE),
    ('FONTNAME',      (0,0), (0,-1), 'Helvetica-Bold'),
    ('FONTSIZE',      (0,0), (-1,-1), 11),
    ('FONTNAME',      (1,0), (1,-1), 'Helvetica'),
    ('TEXTCOLOR',     (1,0), (1,-1), GREY_TEXT),
    ('FONTSIZE',      (1,0), (1,-1), 9.5),
    ('TOPPADDING',    (0,0), (-1,-1), 7),
    ('BOTTOMPADDING', (0,0), (-1,-1), 7),
    ('LEFTPADDING',   (0,0), (-1,-1), 12),
    ('RIGHTPADDING',  (0,0), (-1,-1), 12),
    ('GRID',          (0,0), (-1,-1), 0.4, BORDER),
])
for i in range(len(mnem_rows)):
    bg = TABLE_ALT if i % 2 == 0 else WHITE
    style_mnem.add('BACKGROUND', (1,i), (1,i), bg)

mnem_cell = ParagraphStyle('mc', fontSize=9.5, textColor=GREY_TEXT,
                            fontName='Helvetica', leading=13)
mnem_letter = ParagraphStyle('ml', fontSize=14, textColor=WHITE,
                              fontName='Helvetica-Bold', leading=18,
                              alignment=TA_CENTER)
mnem_data = [[Paragraph(r[0], mnem_letter),
              Paragraph(r[1], mnem_cell)] for r in mnem_rows]
mnem_tbl = Table(mnem_data, colWidths=[2*cm, 16*cm])
mnem_tbl.setStyle(style_mnem)
story.append(mnem_tbl)

# ═══════════════════════════════════════════════════════════════════════════════
# 9. KEY EXAM POINTS
# ═══════════════════════════════════════════════════════════════════════════════
story.append(sp(10))
story.append(section_header('KEY EXAM POINTS', 9))
story.append(sp(6))

key_rows = [
    ['Commonest cause of watering eye',              'Paradoxical dry eye (hypersecretion)'],
    ['Commonest acquired NLD obstruction (adults)',  'PANDO (Primary Acquired NLD Obstruction)'],
    ['Congenital NLD obstruction — spontaneous resolution', '~90% by age 1 year'],
    ['Site of congenital obstruction',               'Valve of Hasner (lower end of NLD)'],
    ['First-line Rx — congenital NLD obstruction',  'Crigler massage'],
    ['Definitive Rx — congenital NLD obstruction',  'Probing (under GA at 12–18 months)'],
    ['Definitive Rx — acquired NLD obstruction / PANDO', 'Dacryocystorhinostomy (DCR)'],
    ['Jones II positive (fluorescein-stained saline from nose)', 'Partial NLD obstruction — fluorescein entered sac'],
    ['Jones II negative (unstained saline from nose)', 'Upper lacrimal block (punctal/canalicular) or pump failure'],
    ['Hard stop on syringing',                       'Canalicular system patent to sac level'],
    ['Soft stop on syringing',                       'Canalicular obstruction'],
    ['Causative organism — canaliculitis',           'Actinomyces israelii (Gram-positive anaerobe)'],
    ['NLD drains into',                              'Inferior nasal meatus (below inferior turbinate)'],
    ['DCR — anastomosis between',                   'Lacrimal sac and nasal mucosa'],
    ['Congenital dacryocoele ≠',                    'Encephalocoele (pulsatile, ABOVE medial canthal ligament)'],
    ['Normal marginal tear strip',                   '0.2–0.4 mm; ≥0.6 mm = abnormal (epiphora)'],
    ['DCR success rate',                             '~90%'],
]
story.append(make_table(['Point', 'Answer'], key_rows, [8*cm, 10*cm]))

# ═══════════════════════════════════════════════════════════════════════════════
# Footer / Sources
# ═══════════════════════════════════════════════════════════════════════════════
story.append(sp(14))
story.append(hr())
story.append(Paragraph(
    '<b>Sources:</b> Kanski\'s Clinical Ophthalmology: A Systematic Approach, 10th Ed. (ISBN 9780443110993) '
    '| K.J. Lee\'s Essential Otolaryngology | Goldman-Cecil Medicine',
    source_style))

# ── BUILD PDF ─────────────────────────────────────────────────────────────────
doc.build(story)
print(f'PDF created: {OUTPUT}')

cd /home/daytona/workspace/epiphora-pdf && python generate_pdf.py

ls -lh /home/daytona/workspace/epiphora-pdf/Epiphora_PG_Exam_Notes.pdf