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// ── DOCUMENT ────────────────────────────────────────────────────────────────
const doc = new Document({
  creator: "Orris Medical AI",
  title: "Case Evaluation & SIRS — Clinical Reference Document",
  description: "Comprehensive clinical case evaluation with SIRS criteria and management",
  styles: {
    default: {
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        run: { font: "Calibri", size: 20 },
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  sections: [{
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            children: [
              new TextRun({ text: "Clinical Case Evaluation & SIRS  |  Date: 30/04/2026", size: 18, color: BLUE, font: "Calibri", italic: true }),
            ],
          }),
        ],
      }),
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            children: [
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            ],
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        ],
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    },
    children: [

      // ── TITLE BLOCK ──────────────────────────────────────────────────────
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        children: [new TextRun({ text: "Systemic Inflammatory Response Syndrome (SIRS) & Urosepsis", bold: true, size: 26, color: WHITE, font: "Calibri" })],
      }),
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        spacing: { after: 300 },
        children: [new TextRun({ text: "Date of Presentation: 30 April 2026  |  Time: 3:30 PM", size: 20, color: "555555", italic: true, font: "Calibri" })],
      }),

      // ── SECTION 1: VITAL SIGNS ───────────────────────────────────────────
      heading1("SECTION 1 — VITAL SIGNS & INITIAL ASSESSMENT"),
      spacer(),
      makeTable(
        ["Parameter", "Recorded Value", "Normal Range", "Interpretation"],
        [
          ["Temperature", "100°F (37.8°C)", "36.1–37.2°C", "Low-grade fever"],
          ["SpO₂", "96%", "≥98%", "Borderline low — monitor closely"],
          ["Pulse Rate", "125 bpm", "60–100 bpm", "⚠ TACHYCARDIA"],
          ["Blood Pressure", "90/70 mmHg", "100–140/60–90 mmHg", "⚠ HYPOTENSION"],
        ]
      ),
      spacer(),
      alertBox("⚠  HAEMODYNAMIC INSTABILITY DETECTED: HR 125 + BP 90/70 → Early Septic Shock Pattern"),
      spacer(),

      // ── SECTION 2: CLINICAL HISTORY ──────────────────────────────────────
      heading1("SECTION 2 — CLINICAL HISTORY"),
      spacer(),
      heading2("Chief Complaints (×2 days)"),
      bullet("Fever and chills — worse at night (cyclical pattern)"),
      bullet("Abdominal pain (lower)"),
      bullet("Lower back pain — stated as the FIRST/initial symptom (suggests renal/retroperitoneal origin)"),
      bullet("Dark urine (haematuria / haemoglobinuria / pyuria)"),
      bullet("Irregular menstrual periods"),
      spacer(),
      heading2("Negative History (Symptoms Absent at Presentation)"),
      bullet("No nausea / vomiting"),
      bullet("No dysuria"),
      bullet("No loose stools"),
      bullet("No cough / cold"),
      spacer(),
      heading2("On Examination"),
      makeTable(
        ["System", "Finding"],
        [
          ["General", "Conscious and Oriented"],
          ["RS (Respiratory)", "Clear, AEBE — Air Entry Bilateral Equal"],
          ["CVS (Cardiovascular)", "S1 S2 + (normal heart sounds heard)"],
          ["P/A (Per Abdomen)", "Soft, Non-tender"],
          ["CNS", "NFND — No Focal Neurological Deficit"],
        ]
      ),
      spacer(),

      // ── SECTION 3: DIFFERENTIAL DIAGNOSIS ───────────────────────────────
      heading1("SECTION 3 — DIFFERENTIAL DIAGNOSES"),
      spacer(),
      makeTable(
        ["Priority", "Diagnosis", "Supporting Features", "Against"],
        [
          ["🔴 Most Likely", "Acute Pyelonephritis / Urosepsis", "Fever + loin pain + dark urine; tachycardia; hypotension (sepsis); non-tender abdomen (visceral/referred pain)", "No documented dysuria at presentation"],
          ["🟡 Likely", "Pelvic Inflammatory Disease (PID)", "Lower abdominal pain, irregular periods, young female", "No pelvic tenderness; dark urine unexplained"],
          ["🟡 Must Exclude", "Malaria (P. falciparum/vivax)", "Night chills, cyclical fever, dark urine (haemoglobinuria), South Asian context", "No travel hx documented"],
          ["🟠 Possible", "Typhoid / Enteric Fever", "Prolonged fever, abdominal pain", "Tachycardia atypical for typhoid"],
          ["🟢 Consider", "Haemolytic Anaemia / G6PD Crisis", "Dark urine, fever, chills, abdominal cramps", "No precipitant identified"],
        ]
      ),
      spacer(),
      body("Key Clinical Clue: Non-tender abdomen despite abdominal pain → visceral/referred pain from retroperitoneal source (kidney capsule distension), NOT peritoneal irritation.", { bold: true, color: RED }),
      spacer(),

      // ── SECTION 4: SIRS ──────────────────────────────────────────────────
      heading1("SECTION 4 — SIRS: SYSTEMIC INFLAMMATORY RESPONSE SYNDROME"),
      spacer(),
      heading2("Definition"),
      body("SIRS is a non-specific, exaggerated systemic inflammatory response to a stressor — infectious or non-infectious. It is NOT a diagnosis; it is a physiological stratification tool. Dominant mediators: IL-1, IL-6, TNF, nitric oxide, prostaglandin I₂.", { color: DARK }),
      spacer(),

      heading2("The 4 Classic SIRS Criteria (1992 Bone Consensus)"),
      body("Diagnosis requires ≥2 of the following 4 criteria:", { bold: true }),
      spacer(),
      makeTable(
        ["#", "Parameter", "Threshold", "Direction"],
        [
          ["1", "Temperature", ">38°C (>100.4°F)  OR  <36°C (<96.8°F)", "Fever OR Hypothermia"],
          ["2", "Heart Rate", ">90 bpm", "Tachycardia"],
          ["3", "Respiratory Rate", ">20 breaths/min  OR  PaCO₂ <32 mmHg", "Tachypnoea / Hypocapnia"],
          ["4", "WBC Count", ">12,000/μL  OR  <4,000/μL  OR  >10% band forms", "Leukocytosis / Leukopenia / Bandaemia"],
        ]
      ),
      spacer(),

      heading2("SIRS Assessment in This Patient"),
      makeTable(
        ["SIRS Criterion", "Patient Value", "Threshold", "Met?"],
        [
          ["Temperature", "100°F = 37.8°C", ">38°C", "❌ Borderline (just below)"],
          ["Heart Rate", "125 bpm", ">90 bpm", "✅ YES"],
          ["Respiratory Rate", "Not documented", ">20/min", "⚠ Pending assessment"],
          ["WBC", "Pending CBC", ">12,000 or <4,000", "⚠ Pending result"],
          ["SBP (extended)", "90 mmHg", "<90 mmHg", "✅ MEETS hypotension criterion"],
        ]
      ),
      spacer(),
      alertBox("SIRS CRITERIA MET: ≥2 confirmed (HR 125 + SBP 90). Likely ≥3 once CBC returns. Treat as SEPSIS."),
      spacer(),

      heading2("Sepsis Spectrum & Mortality"),
      makeTable(
        ["Stage", "Definition", "This Patient"],
        [
          ["SIRS", "≥2 of 4 criteria, any cause", "✅ Met"],
          ["Sepsis", "SIRS + confirmed/suspected infection", "✅ Presumed (urosepsis)"],
          ["Severe Sepsis", "Sepsis + organ hypoperfusion/dysfunction", "⚠ Likely (SpO₂ 96%, hypotension)"],
          ["Septic Shock", "Sepsis + hypotension despite adequate fluids", "⚠ Pending fluid challenge response"],
        ]
      ),
      spacer(),
      makeTable(
        ["SIRS Criteria Met", "Estimated Mortality"],
        [
          ["2 criteria", "~5%"],
          ["3 criteria", "~10%"],
          ["4 criteria", "15–20%"],
        ],
        DARK
      ),
      spacer(),

      heading2("Sepsis-3 (2016) — Modern Definition"),
      body("Sepsis-3 abandoned SIRS criteria as insufficient and non-specific. Current definition:", { bold: true }),
      bullet("Sepsis = Life-threatening organ dysfunction caused by a dysregulated host response to infection"),
      bullet("Operationalised by SOFA score increase of ≥2 points"),
      bullet("Septic shock = Sepsis + vasopressor requirement + lactate >2 mmol/L despite adequate fluids"),
      spacer(),
      heading3("qSOFA — Bedside Screening Tool (no labs needed)"),
      body("Score 1 point each for: Altered mental status | SBP ≤100 mmHg | RR ≥22 breaths/min"),
      body("qSOFA ≥2 = suspected sepsis with risk of poor outcome → escalate care"),
      spacer(),
      makeTable(
        ["qSOFA Parameter", "This Patient", "Score"],
        [
          ["Altered mental status", "Conscious & Oriented", "0"],
          ["SBP ≤100 mmHg", "SBP = 90 mmHg", "1"],
          ["RR ≥22 breaths/min", "Not documented — assess now", "⚠"],
        ],
        RED
      ),
      spacer(),
      body("Current qSOFA = minimum 1. If RR ≥22 → qSOFA = 2 → SEPSIS FLAG.", { bold: true, color: RED }),
      spacer(),

      // ── SECTION 5: INVESTIGATIONS ────────────────────────────────────────
      heading1("SECTION 5 — INVESTIGATIONS"),
      spacer(),
      heading2("Ordered by Clinician"),
      bullet("CBC (Complete Blood Count)"),
      bullet("ESR (Erythrocyte Sedimentation Rate)"),
      bullet("URE (Urine Routine Examination)"),
      spacer(),
      heading2("Additional Investigations Required"),
      makeTable(
        ["Investigation", "Purpose", "Priority"],
        [
          ["Urine Culture & Sensitivity", "Identify organism, guide antibiotic choice", "🔴 Urgent"],
          ["Blood Cultures ×2", "Rule out bacteraemia before antibiotics", "🔴 Urgent"],
          ["Serum Lactate", "Prognostic — lactate 2–4 mmol/L = ~15% 28-day mortality", "🔴 Urgent"],
          ["Renal Function Tests (RFT)", "Baseline creatinine — monitor for AKI", "🔴 Urgent"],
          ["Urine β-hCG (Pregnancy Test)", "Mandatory in reproductive-age female", "🔴 Urgent"],
          ["Peripheral Blood Smear", "Malaria exclusion (night chills + dark urine)", "🟡 Urgent"],
          ["LFT (Liver Function Tests)", "Malaria / hepatitis / haemolysis screening", "🟡 Urgent"],
          ["Serum Electrolytes", "Derangement from fever and poor oral intake", "🟡 Urgent"],
          ["Pelvic Ultrasound + Renal USG", "Assess kidneys, rule out PID/TOA", "🟡 Same day"],
          ["CRP / Procalcitonin", "Inflammatory burden, sepsis marker", "🟢 Useful"],
        ]
      ),
      spacer(),

      // ── SECTION 6: MANAGEMENT ────────────────────────────────────────────
      heading1("SECTION 6 — IMMEDIATE MANAGEMENT"),
      spacer(),
      alertBox("DO NOT DELAY ANTIBIOTICS AND FLUIDS PENDING LAB RESULTS — TIME-CRITICAL", "FFCCCC"),
      spacer(),
      heading2("Resuscitation (First 30–60 Minutes)"),
      makeTable(
        ["Step", "Action", "Detail"],
        [
          ["1", "IV Access", "Two large-bore peripheral cannulae (14G or 16G)"],
          ["2", "IV Fluid Bolus", "500 mL 0.9% Normal Saline or Ringer's Lactate — reassess HR/BP after"],
          ["3", "Blood Cultures", "Draw ×2 from different sites BEFORE antibiotics"],
          ["4", "Urine Culture", "Mid-stream clean catch BEFORE antibiotics"],
          ["5", "Empirical Antibiotics", "Ceftriaxone 1g IV (or Piperacillin-Tazobactam 4.5g IV for complicated/severe)"],
          ["6", "Serum Lactate", "If lactate >4 mmol/L → septic shock protocol"],
          ["7", "Monitor Urine Output", "Catheterise if haemodynamically unstable — target >0.5 mL/kg/hr"],
          ["8", "Antipyretics", "Paracetamol 1g IV/oral for comfort and temperature control"],
          ["9", "Oxygen", "Maintain SpO₂ ≥94% — supplement if needed"],
          ["10", "Sepsis Bundle Activation", "Alert senior/ICU if qSOFA ≥2 or lactate >2 mmol/L"],
        ]
      ),
      spacer(),
      heading2("Ongoing Monitoring"),
      bullet("Repeat vitals every 30 minutes until stabilised"),
      bullet("Reassess BP after each fluid bolus — escalate to vasopressors (noradrenaline) if SBP remains <90 after 30 mL/kg fluids"),
      bullet("Serial lactate clearance — target >10% reduction per 2 hours"),
      bullet("Review culture results at 48–72 hours → de-escalate antibiotics based on sensitivity"),
      bullet("Consider ICU escalation if SOFA score increases or lactate fails to clear"),
      spacer(),

      // ── SECTION 7: PATHOPHYSIOLOGY ───────────────────────────────────────
      heading1("SECTION 7 — SIRS PATHOPHYSIOLOGY"),
      spacer(),
      heading2("Mechanism"),
      body("In the context of urinary tract infection/pyelonephritis, bacterial endotoxins (LPS from E. coli) trigger macrophage activation and cytokine storm:"),
      spacer(),
      makeTable(
        ["Step", "Event"],
        [
          ["1", "Bacterial invasion → endotoxin release (LPS)"],
          ["2", "Macrophage activation → IL-1, IL-6, TNF-α release"],
          ["3", "Endothelial activation → capillary leak → hypovolaemia"],
          ["4", "Vasodilation → hypotension → reduced organ perfusion"],
          ["5", "Tissue hypoxia → anaerobic metabolism → lactic acidosis"],
          ["6", "Coagulation cascade activation → risk of DIC"],
          ["7", "If uncontrolled → MODS (Multi-Organ Dysfunction Syndrome)"],
        ],
        DARK
      ),
      spacer(),
      heading2("Non-Infectious Causes of SIRS"),
      body("SIRS does NOT confirm infection — the same criteria occur in:"),
      bullet("Trauma"),
      bullet("Pancreatitis (acute)"),
      bullet("Burns"),
      bullet("Major surgery"),
      bullet("Autoimmune conditions"),
      spacer(),
      body("Sepsis = SIRS + INFECTION. This distinction is clinically vital.", { bold: true, color: RED }),
      spacer(),

      // ── SECTION 8: KEY REFERENCES ────────────────────────────────────────
      heading1("SECTION 8 — KEY REFERENCES"),
      spacer(),
      makeTable(
        ["Source", "Topic"],
        [
          ["Harrison's Principles of Internal Medicine, 22e (2025)", "Sepsis-3 definition, epidemiology, urosepsis"],
          ["Schwartz's Principles of Surgery, 11e", "SIRS criteria, mortality table, MODS"],
          ["Tintinalli's Emergency Medicine, Comprehensive Study", "SIRS prognosis, lactate, sepsis continuum"],
          ["Rosen's Emergency Medicine, Concepts and Clinical Practice", "UTI, pyelonephritis clinical features"],
          ["Campbell-Walsh Urology, 3-Volume Set", "Acute pyelonephritis definition and management"],
          ["Creasy & Resnik's Maternal-Fetal Medicine", "Pyelonephritis diagnosis, sepsis complications"],
        ]
      ),
      spacer(),

      // ── CLOSING NOTE ─────────────────────────────────────────────────────
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    ],
  }],
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