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

~/marmaghata_shock.py

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

OUTPUT = "/home/daytona/workspace/Marmaghata_Shock_University_Essay.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=2*cm, leftMargin=2*cm,
    topMargin=2*cm, bottomMargin=2*cm
)

styles = getSampleStyleSheet()

# Custom styles
title_style = ParagraphStyle(
    'MainTitle', parent=styles['Title'],
    fontSize=20, textColor=colors.HexColor('#1a237e'),
    spaceAfter=6, spaceBefore=4, alignment=TA_CENTER,
    fontName='Helvetica-Bold'
)
section_style = ParagraphStyle(
    'SectionTitle', parent=styles['Heading1'],
    fontSize=14, textColor=colors.white,
    backColor=colors.HexColor('#1a237e'),
    spaceAfter=6, spaceBefore=12,
    leftIndent=-0.5*cm, rightIndent=-0.5*cm,
    borderPad=6, fontName='Helvetica-Bold'
)
subsection_style = ParagraphStyle(
    'SubSection', parent=styles['Heading2'],
    fontSize=12, textColor=colors.HexColor('#0d47a1'),
    spaceAfter=4, spaceBefore=8,
    borderPad=3, fontName='Helvetica-Bold',
    borderWidth=0, borderColor=colors.HexColor('#1a237e'),
    leftIndent=0
)
subsubsection_style = ParagraphStyle(
    'SubSubSection', parent=styles['Heading3'],
    fontSize=11, textColor=colors.HexColor('#283593'),
    spaceAfter=3, spaceBefore=6,
    fontName='Helvetica-Bold'
)
body_style = ParagraphStyle(
    'Body', parent=styles['Normal'],
    fontSize=10, leading=15, spaceAfter=4, spaceBefore=2,
    alignment=TA_JUSTIFY, fontName='Helvetica'
)
bullet_style = ParagraphStyle(
    'Bullet', parent=styles['Normal'],
    fontSize=10, leading=14, spaceAfter=2, spaceBefore=1,
    leftIndent=20, bulletIndent=8,
    fontName='Helvetica'
)
subbullet_style = ParagraphStyle(
    'SubBullet', parent=styles['Normal'],
    fontSize=10, leading=14, spaceAfter=1, spaceBefore=1,
    leftIndent=38, bulletIndent=24,
    fontName='Helvetica'
)
note_style = ParagraphStyle(
    'Note', parent=styles['Normal'],
    fontSize=9.5, leading=13,
    backColor=colors.HexColor('#e8eaf6'),
    borderColor=colors.HexColor('#3949ab'),
    borderWidth=1, borderPad=6,
    spaceAfter=6, spaceBefore=4,
    fontName='Helvetica-Oblique'
)
examtip_style = ParagraphStyle(
    'ExamTip', parent=styles['Normal'],
    fontSize=9.5, leading=13,
    backColor=colors.HexColor('#fff8e1'),
    borderColor=colors.HexColor('#f9a825'),
    borderWidth=1, borderPad=6,
    spaceAfter=6, spaceBefore=4,
    fontName='Helvetica'
)

def section(text):
    return Paragraph(f"  {text}", section_style)

def subsection(text):
    return Paragraph(text, subsection_style)

def subsubsection(text):
    return Paragraph(text, subsubsection_style)

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

def bullet(text):
    return Paragraph(f"• {text}", bullet_style)

def subbullet(text):
    return Paragraph(f"– {text}", subbullet_style)

def note(text):
    return Paragraph(f"<b>Note:</b> {text}", note_style)

def examtip(text):
    return Paragraph(f"<b>Exam Tip:</b> {text}", examtip_style)

def hr():
    return HRFlowable(width="100%", thickness=1, color=colors.HexColor('#9fa8da'), spaceAfter=4, spaceBefore=4)

def make_table(headers, rows, col_widths=None):
    data = [headers] + rows
    t = Table(data, colWidths=col_widths, repeatRows=1)
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1a237e')),
        ('TEXTCOLOR', (0,0), (-1,0), colors.white),
        ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
        ('FONTSIZE', (0,0), (-1,0), 10),
        ('ALIGN', (0,0), (-1,-1), 'LEFT'),
        ('VALIGN', (0,0), (-1,-1), 'TOP'),
        ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#e8eaf6'), colors.white]),
        ('FONTNAME', (0,1), (-1,-1), 'Helvetica'),
        ('FONTSIZE', (0,1), (-1,-1), 9),
        ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#9fa8da')),
        ('TOPPADDING', (0,0), (-1,-1), 5),
        ('BOTTOMPADDING', (0,0), (-1,-1), 5),
        ('LEFTPADDING', (0,0), (-1,-1), 6),
        ('RIGHTPADDING', (0,0), (-1,-1), 6),
    ]))
    return t

story = []

# ─── COVER / MAIN TITLE ──────────────────────────────────────────────────────
story.append(Spacer(1, 1*cm))
story.append(Paragraph("ILLUSTRATED SALYA VIJNANA", ParagraphStyle(
    'SubTitle2', parent=styles['Normal'], fontSize=11,
    textColor=colors.HexColor('#5c6bc0'), alignment=TA_CENTER, fontName='Helvetica'
)))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph("Chapter 19D", ParagraphStyle(
    'ChNo', parent=styles['Normal'], fontSize=13,
    textColor=colors.HexColor('#283593'), alignment=TA_CENTER, fontName='Helvetica-Bold'
)))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph("Marmāghāta (Shock)", title_style))
story.append(Paragraph("University Exam Essay Notes", ParagraphStyle(
    'SubTitle', parent=styles['Normal'], fontSize=12,
    textColor=colors.HexColor('#5c6bc0'), alignment=TA_CENTER, fontName='Helvetica-Oblique'
)))
story.append(Spacer(1, 0.3*cm))
story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1a237e'), spaceAfter=8))
story.append(Spacer(1, 0.5*cm))

# ══════════════════════════════════════════════════════════════════════════════
# PART 1 - MARMAGHATA (SHOCK)
# ══════════════════════════════════════════════════════════════════════════════
story.append(Paragraph("PART I: MARMĀGHĀTA (SHOCK) — COMPLETE ESSAY", ParagraphStyle(
    'PartTitle', parent=styles['Normal'], fontSize=15,
    textColor=colors.HexColor('#b71c1c'), alignment=TA_CENTER, fontName='Helvetica-Bold',
    backColor=colors.HexColor('#ffebee'), borderPad=8, spaceAfter=10
)))

# DEFINITION
story.append(section("DEFINITION"))
story.append(body("Marmāghāta (Shock) is a clinical condition in which the circulatory system fails to provide the nutritional requirements of the cells and at the same time fails to remove the metabolic waste products."))
story.append(body("Shock is characterized by clinical features arising when the <b>cardiac output is insufficient</b> to provide adequate blood flow to all the organs and tissues. The diminished blood flow in the vital organs is the chief cause of shock."))
story.append(body("Shock is a condition in which total body cellular metabolism is malfunctioned. Inadequate tissue perfusion can result in:"))
story.append(bullet("<b>Generalized cellular hypoxia</b> (starvation)"))
story.append(bullet("<b>Widespread impairment</b> of cellular metabolism"))
story.append(bullet("<b>Tissue damage and organ failure</b>"))
story.append(bullet("<b>Death</b>"))

# CLASSIFICATION
story.append(section("CLASSIFICATION"))
story.append(body("Shock is classified into <b>four categories</b> by etiology:"))
story.append(Spacer(1, 0.2*cm))

class_data = [
    [Paragraph("<b>Type</b>", body_style), Paragraph("<b>Mechanism</b>", body_style)],
    [Paragraph("<b>1. Hypovolemic Shock</b>", body_style), Paragraph("Caused by inadequate circulating volume", body_style)],
    [Paragraph("<b>2. Cardiogenic Shock</b>", body_style), Paragraph("Caused by inadequate cardiac pump function", body_style)],
    [Paragraph("<b>3. Distributive Shock</b>\n(Septic, Anaphylactic, Neurogenic)", body_style), Paragraph("Caused by peripheral vasodilatation and mal-distribution of blood flow", body_style)],
    [Paragraph("<b>4. Obstructive Shock</b>", body_style), Paragraph("Caused by extra-cardiac obstruction to blood flow", body_style)],
]
t_class = Table(class_data, colWidths=[7*cm, 10*cm])
t_class.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1a237e')),
    ('TEXTCOLOR', (0,0), (-1,0), colors.white),
    ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
    ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#e8eaf6'), colors.white]),
    ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#9fa8da')),
    ('VALIGN', (0,0), (-1,-1), 'TOP'),
    ('TOPPADDING', (0,0), (-1,-1), 5),
    ('BOTTOMPADDING', (0,0), (-1,-1), 5),
    ('LEFTPADDING', (0,0), (-1,-1), 6),
]))
story.append(t_class)
story.append(Spacer(1, 0.3*cm))

# ETIOPATHOGENESIS
story.append(section("ETIOPATHOGENESIS"))

story.append(subsection("1. Hypovolemic Shock"))
story.append(body("Hypovolemia is probably the <b>most common form of shock</b>. It is characterized by a loss in circulatory volume which results in decreased venous return, decreased filling of the cardiac chambers, and hence decreased cardiac output leading to shock."))
story.append(body("Hypovolemia may be due to hemorrhagic or non-hemorrhagic conditions."))
story.append(body("<b>Common causes:</b>"))
story.append(bullet("Hemorrhage (both internal or external)"))
story.append(bullet("Severe inflammation or infection"))
story.append(bullet("Trauma (intra-abdominal injury, crush injury, rupture of spleen or liver, fractures, etc.)"))
story.append(bullet("Pancreatitis or other causes of peritonitis"))
story.append(bullet("Burns — rapid plasma loss from damaged tissues (worsens with >20% TBSA; toxins from infected burns aggravate shock)"))
story.append(bullet("Vomiting or other intestinal losses"))
story.append(bullet("Excessive diuresis, excessive sweating, inadequate oral intake"))
story.append(body("This is clinically manifested by low cardiac output, tachycardia, low blood pressure, vasoconstriction, and cold clammy extremities. Trauma activates intravascular inflammatory response; vascular permeability also increases, resulting in further hypovolemia."))

story.append(subsection("2. Cardiogenic Shock"))
story.append(body("Caused by the <b>failure of the heart to pump effectively</b>. The left ventricle mainly fails leading to overdistension of the right ventricle and increased back pressure in pulmonary capillaries, causing <b>pulmonary edema and hypoxia</b>."))
story.append(body("<b>Causes:</b>"))
story.append(bullet("Large myocardial infarction (most common)"))
story.append(bullet("Dysrhythmias"))
story.append(bullet("Cardiomyopathy / Myocarditis"))
story.append(bullet("Congestive heart failure (CHF)"))
story.append(bullet("Cardiac valve problems"))
story.append(body("Depressed myocardial function also causes fluid and salt retention due to hypoperfusion of kidneys. Fluid infusion may worsen this condition, whereas use of diuretics is beneficial."))

story.append(subsection("3. Distributive Shock"))
story.append(body("Due to impaired utilization of oxygen and mal-distribution of blood flow to organs. Includes: Septic shock, Anaphylactic shock, and Neurogenic shock."))

story.append(subsubsection("A. Septic Shock"))
story.append(body("<b>Most common cause of distributive shock.</b> Caused by Gram-negative bacteria such as <i>Escherichia coli</i>, <i>Proteus</i> species, <i>Klebsiella</i>, which release endotoxins causing adverse biochemical, immunological, and neurological effects."))
story.append(body("Vascular permeability increases → hypovolemia in intravascular compartment → advanced cases: cardiac function damaged by toxins → <b>MODS</b> (multiple organ dysfunction syndrome)."))
story.append(body("<b>Two stages of septic shock:</b>"))
story.append(bullet("<b>Early Warm Stage:</b> CO well maintained or increased; vasodilation; warm skin, warm extremities, normal capillary refill"))
story.append(bullet("<b>Late Cold Stage:</b> CO and stroke volume fall; cool extremities, delayed capillary refill — ominous sign"))
story.append(note("Detect and manage septic shock in the early warm stage for better outcome. Cold stage is ominous."))

story.append(subsubsection("B. Anaphylactic Shock"))
story.append(body("Due to severe widespread systemic allergic reaction to an allergen, antigen, drug (e.g., penicillin) or foreign protein. Releases histamine → widespread vasodilation → hypotension and increased capillary permeability. Characterized by rapidly developing life-threatening bronchospasm, laryngeal edema, respiratory distress, pruritus, and skin changes."))

story.append(subsubsection("C. Neurogenic Shock"))
story.append(body("Results from severe CNS damage (brain injury or spinal cord injury). Decreased systemic vascular resistance → pooling in dilated peripheral venous system. Presents with low BP, normal/bradycardic pulse rate, and <b>warm dry skin</b>."))
story.append(body("Low BP corrected by: Trendelenburg position (legs raised) + rapid IV fluids + vasopressor drug."))

story.append(subsubsection("D. Vasovagal / Psychogenic Shock"))
story.append(body("Vasovagal shock is the most common cause of syncope; mediated by emotional/orthostatic stress. Upright position → 1L blood pools in lower limbs → reduced venous return → cerebral hypoxia → unconsciousness. Corrected by Trendelenburg position."))

story.append(subsection("4. Obstructive Shock"))
story.append(body("Reduction in preload due to mechanical obstruction of cardiac filling."))
story.append(body("<b>Causes:</b>"))
story.append(bullet("Pericardial tamponade — fluid in pericardium prevents venous return"))
story.append(bullet("Tension pneumothorax — increased intra-thoracic pressure prevents venous return"))
story.append(bullet("Large diaphragmatic hernia — heart compressed from outside"))
story.append(bullet("Pulmonary embolism — thromboembolism in lung vessels prohibits blood return to heart"))
story.append(bullet("Aortic stenosis — obstructs ventricular outflow tract"))

# COMPENSATORY MECHANISMS
story.append(section("COMPENSATORY MECHANISMS OF SHOCK"))
story.append(body("The body responds to shock through <b>six compensatory mechanisms</b>:"))
story.append(bullet("<b>1. Adrenergic discharge</b> — vasoconstriction, increased heart rate, constricts vascular sphincters in kidneys/splanchnic viscera/skin. Starts within <b>60 seconds</b> of blood loss."))
story.append(bullet("<b>2. Hyperventilation</b> — compensates metabolic acidosis; sucks blood to heart/lungs, increases LV filling. Also starts within 60 seconds."))
story.append(bullet("<b>3. Release of vasoactive hormones</b> — Renin (JGA) → Angiotensin I (liver) → Angiotensin II (lungs) = strong vasoconstrictor; Vasopressin (baroreceptors); Epinephrine (adrenal medulla)."))
story.append(bullet("<b>4. Resorption of fluid from interstitial tissues</b>"))
story.append(bullet("<b>5. Resorption of fluid from intracellular to extracellular compartment</b>"))
story.append(bullet("<b>6. Renal conservation</b> via Aldosterone (from zona glomerulosa of adrenal cortex) — sodium and water conservation in kidney"))

# EFFECTS ON ORGAN SYSTEMS
story.append(section("EFFECTS OF SHOCK ON ORGAN SYSTEMS"))
story.append(bullet("<b>Brain:</b> CNS neurons are extremely sensitive to ischemia; irreversible injury may occur in cerebral cortex. Altered consciousness from confusion to unconsciousness."))
story.append(bullet("<b>Respiratory system:</b> Increased workload; impairment of respiratory and diaphragmatic muscles → ARDS (acute respiratory distress syndrome)."))
story.append(bullet("<b>Heart:</b> Heart rate increases; systemic hypotension compromises coronary perfusion → cardiac ischemia."))
story.append(bullet("<b>Metabolic:</b> Hypoxia → anaerobic metabolism → lactic acidosis."))

# CLINICAL FEATURES
story.append(section("CLINICAL FEATURES"))
story.append(body("Clinical features depend on the degree and duration of blood volume loss:"))
story.append(Spacer(1, 0.2*cm))

cf_headers = [
    Paragraph("<b>Grade</b>", body_style),
    Paragraph("<b>Blood Loss</b>", body_style),
    Paragraph("<b>Features</b>", body_style)
]
cf_rows = [
    [Paragraph("Mild shock", body_style), Paragraph("< 20%", body_style),
     Paragraph("Pale/cool extremities, sweating, polydipsia; pulse, BP, and urine output remain normal", body_style)],
    [Paragraph("Moderate shock", body_style), Paragraph("20–40%", body_style),
     Paragraph("Oliguria, tachycardia (< 100 bpm), BP normal initially then falls", body_style)],
    [Paragraph("Severe shock", body_style), Paragraph("> 40%", body_style),
     Paragraph("Pallor, low urine output, tachycardia, thready pulse, hypotension", body_style)],
]
story.append(make_table(cf_headers, cf_rows, col_widths=[3.5*cm, 3.5*cm, 10*cm]))
story.append(Spacer(1, 0.3*cm))

story.append(body("<b>General features (all types of shock):</b>"))
story.append(bullet("<b>Neurological:</b> Restlessness, anxiety, lethargy, confusion"))
story.append(bullet("<b>Cardiovascular:</b> Tachycardia, thready pulse, low cardiac output, low BP"))
story.append(bullet("<b>Respiratory:</b> Rapid, shallow breathing"))
story.append(bullet("<b>Skin:</b> Pale, clammy, cool"))
story.append(bullet("<b>Metabolic:</b> Low temperature, thirst, acidosis, low urine output"))

# DIAGNOSIS AND MONITORING
story.append(section("DIAGNOSIS AND MONITORING"))
story.append(bullet("<b>Blood pressure and pulse rate</b> — regular monitoring essential (Note: may remain normal in mild shock, so not the sole indicators)"))
story.append(bullet("<b>Respiration</b> — shock causes hyperventilation or air hunger"))
story.append(bullet("<b>Urine output</b> — must be measured in every patient with shock"))
story.append(bullet("<b>CVP (Central Venous Pressure)</b> — normal is 5–15 mmHg"))
story.append(bullet("<b>ECG</b> — indicates cardiac function"))
story.append(bullet("<b>Blood oxygen level</b> — normally arterial oxygen content is 20%"))
story.append(bullet("<b>Echocardiogram</b> — ventricular wall motion and valve function (especially in cardiogenic shock)"))

story.append(Spacer(1, 0.2*cm))
story.append(body("<b>Common laboratory abnormalities with shock:</b>"))
story.append(bullet("Metabolic acidosis"))
story.append(bullet("Elevated BUN and creatinine"))
story.append(bullet("Leukocytosis or leukopenia"))
story.append(bullet("Elevated blood glucose"))
story.append(bullet("Decreased platelet count"))
story.append(bullet("Decreased ionized calcium"))

story.append(Spacer(1, 0.3*cm))
story.append(body("<b>Feature Table of Various Types of Shock:</b>"))
story.append(Spacer(1, 0.2*cm))
vsh = [
    Paragraph("<b>Type</b>", body_style),
    Paragraph("<b>Clinical Features</b>", body_style),
    Paragraph("<b>Physiological Effect</b>", body_style)
]
vsr = [
    [Paragraph("Hypovolemic", body_style),
     Paragraph("Hypotension, tachycardia, weak thready pulse, cool pale moist skin, decreased U/O", body_style),
     Paragraph("Decreased CO, Increased SVR", body_style)],
    [Paragraph("Cardiogenic", body_style),
     Paragraph("Hypotension, tachycardia, weak thready pulse, cool pale moist skin, U/O < 30 ml/hr, tachypnea", body_style),
     Paragraph("Decreased CO, Increased SVR", body_style)],
    [Paragraph("Neurogenic", body_style),
     Paragraph("Hypotension, bradycardia, warm dry skin", body_style),
     Paragraph("Decreased CO, venous & arterial vasodilation, loss of sympathetic tone", body_style)],
    [Paragraph("Anaphylactic", body_style),
     Paragraph("Hypotension, tachycardia, cough, dyspnea, pruritus, urticaria, restlessness", body_style),
     Paragraph("Decreased CO, Decreased SVR", body_style)],
    [Paragraph("Septic", body_style),
     Paragraph("Hypotension, tachycardia, full bounding pulse, tachypnea, fever, pink warm flushed skin, decreased U/O", body_style),
     Paragraph("Decreased CO, Decreased SVR", body_style)],
]
story.append(make_table(vsh, vsr, col_widths=[3.5*cm, 9*cm, 4.5*cm]))
story.append(body("Abbreviations: CO = Cardiac output, SVR = Systemic vascular resistance, U/O = Urinary output"))

# MANAGEMENT
story.append(section("MANAGEMENT OF SHOCK"))
story.append(body("<b>ABCDE approach:</b> Airway → Breathing → Circulation → Disability → Expose"))

story.append(subsection("1. Resuscitation"))
story.append(body("Immediate positive pressure ventilation. Patient should be resuscitated immediately."))

story.append(subsection("2. Position"))
story.append(body("<b>Trendelenburg's position</b> — head end lowered, legs elevated to improve venous return."))

story.append(subsection("3. Control of Bleeding"))
story.append(body("Immediate control of bleeding to prevent further loss."))

story.append(subsection("4. Fluid Replacement"))
story.append(body("A <b>non-sugar, non-protein crystalloid</b> solution with sodium concentration is preferred — <b>Ringer's Lactate</b>."))
story.append(bullet("3 liters of fluid given over 45 minutes usually resuscitates the patient in shock whose bleeding has been controlled."))
story.append(bullet("NEVER use 5% glucose — causes osmotic diuresis, which further reduces the patient's vascular volume."))

story.append(subsection("5. Drug Therapy"))
drug_data = [
    [Paragraph("<b>Drug Class</b>", body_style), Paragraph("<b>Examples</b>", body_style), Paragraph("<b>Indication</b>", body_style)],
    [Paragraph("Sedatives", body_style), Paragraph("Morphine, Pethidine", body_style), Paragraph("To reduce pain", body_style)],
    [Paragraph("Chronotropic drugs", body_style), Paragraph("Atropine", body_style), Paragraph("For bradycardia", body_style)],
    [Paragraph("Inotropic drugs", body_style), Paragraph("Dopamine, Dobutamine", body_style), Paragraph("Improve cardiac contraction in cardiogenic shock", body_style)],
    [Paragraph("Vasoconstrictors", body_style), Paragraph("Phenylephrine", body_style), Paragraph("Beneficial in neurogenic shock", body_style)],
    [Paragraph("Beta blockers", body_style), Paragraph("Propranolol", body_style), Paragraph("Increase efficiency of ventricular contraction in cardiogenic shock", body_style)],
    [Paragraph("Diuretics", body_style), Paragraph("—", body_style), Paragraph("Beneficial in cardiogenic shock; NEVER in hypovolemic/traumatic shock", body_style)],
    [Paragraph("Antibiotics", body_style), Paragraph("Broad spectrum", body_style), Paragraph("For septic shock", body_style)],
    [Paragraph("Anti-histaminics + Corticosteroids", body_style), Paragraph("—", body_style), Paragraph("For anaphylactic shock", body_style)],
]
t_drug = Table(drug_data, colWidths=[4.5*cm, 4*cm, 8.5*cm])
t_drug.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1a237e')),
    ('TEXTCOLOR', (0,0), (-1,0), colors.white),
    ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
    ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#e8eaf6'), colors.white]),
    ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#9fa8da')),
    ('VALIGN', (0,0), (-1,-1), 'TOP'),
    ('TOPPADDING', (0,0), (-1,-1), 5),
    ('BOTTOMPADDING', (0,0), (-1,-1), 5),
    ('LEFTPADDING', (0,0), (-1,-1), 6),
]))
story.append(t_drug)

story.append(subsection("6. Surgery"))
story.append(body("To control bleeding in hypovolemic and traumatic shock; debridement in septic shock."))

story.append(Spacer(1, 0.3*cm))
story.append(body("<b>Bedside indicators of excellent circulation:</b>"))
story.append(bullet("Normal blood pressure and pulse for the individual"))
story.append(bullet("Normal mental status"))
story.append(bullet("Warm extremities"))
story.append(bullet("Urine output ≥ 0.5 mL/kg/hour"))
story.append(bullet("Resolution of metabolic acidosis"))

# ══════════════════════════════════════════════════════════════════════════════
# PART 2 - CARDIOGENIC SHOCK
# ══════════════════════════════════════════════════════════════════════════════
story.append(PageBreak())
story.append(Paragraph("PART II: CARDIOGENIC SHOCK — UNIVERSITY EXAM ESSAY", ParagraphStyle(
    'PartTitle2', parent=styles['Normal'], fontSize=15,
    textColor=colors.HexColor('#1b5e20'), alignment=TA_CENTER, fontName='Helvetica-Bold',
    backColor=colors.HexColor('#e8f5e9'), borderPad=8, spaceAfter=10
)))

story.append(section("DEFINITION"))
story.append(body("Cardiogenic shock is a type of shock caused by the <b>failure of the heart to pump effectively</b>, resulting in inadequate cardiac output to meet the body's metabolic demands. It is classified under the cardiogenic type of Marmāghāta."))

story.append(section("ETIOPATHOGENESIS"))
story.append(body("<b>Primary cause:</b> Damage to the heart muscle."))
story.append(body("<b>Causes:</b>"))
story.append(bullet("<b>Large myocardial infarction</b> — most common"))
story.append(bullet("Dysrhythmias (cardiac arrhythmias)"))
story.append(bullet("Cardiomyopathy / Myocarditis"))
story.append(bullet("Congestive heart failure (CHF)"))
story.append(bullet("Cardiac valve problems (stenosis/regurgitation)"))

story.append(Spacer(1, 0.2*cm))
story.append(body("<b>Pathophysiology:</b>"))
story.append(bullet("Left ventricle fails primarily"))
story.append(bullet("→ Overdistension of right ventricle"))
story.append(bullet("→ Increased back pressure in pulmonary capillaries"))
story.append(bullet("→ Pulmonary edema and hypoxia"))
story.append(bullet("→ Depressed myocardial function → fluid and salt retention due to renal hypoperfusion"))
story.append(bullet("→ Vicious cycle: reduced CO → poor renal perfusion → fluid retention → more cardiac stress"))
story.append(Spacer(1, 0.2*cm))
story.append(note("Cardiogenic shock is the ONLY major circulatory deficit that can be worsened by the administration of fluid because there is no volume deficit in this shock."))

story.append(section("CLINICAL FEATURES"))
story.append(bullet("Dyspnea, poor exercise tolerance"))
story.append(bullet("Confusion and restlessness"))
story.append(bullet("Sweating"))
story.append(bullet("Tachycardia"))
story.append(bullet("Cold, clammy skin"))
story.append(bullet("High JVP (jugular venous pressure)"))
story.append(bullet("Added heart sounds (S3, S4 gallop)"))
story.append(bullet("Engorged (congested) liver"))
story.append(bullet("Peripheral edema"))
story.append(bullet("Tachypnea"))
story.append(bullet("Urine output < 30 ml/hr"))
story.append(bullet("Hypotension, weak thready pulse"))

story.append(section("DIAGNOSIS"))
story.append(bullet("<b>Clinical history and examination</b> — signs of cardiac failure"))
story.append(bullet("<b>ECG</b> — reveals MI, dysrhythmias, cardiac function"))
story.append(bullet("<b>Echocardiogram</b> — provides information about ventricular wall motion and valve function"))
story.append(bullet("<b>Lab:</b> Elevated cardiac enzymes (troponin, CK-MB), elevated BUN/creatinine, metabolic acidosis"))
story.append(bullet("<b>CVP monitoring</b> — elevated in cardiogenic shock (vs low in hypovolemia)"))
story.append(bullet("<b>Chest X-ray</b> — shows pulmonary edema, cardiomegaly"))

story.append(section("MANAGEMENT"))
story.append(body("Treatment is based on the <b>etiology</b>."))
story.append(bullet("<b>Inotropic drugs</b> — Dopamine, Dobutamine to improve cardiac muscle contraction"))
story.append(bullet("<b>Beta blockers</b> (Propranolol) — increase efficiency of ventricular contraction"))
story.append(bullet("<b>Diuretics</b> — reduce fluid overload (beneficial, unlike hypovolemic shock)"))
story.append(bullet("<b>DO NOT give IV fluids</b> — this worsens the condition"))
story.append(bullet("<b>Sedatives</b> (morphine) — reduces pain and preload"))
story.append(bullet("<b>Treat underlying cause</b> — thrombolysis or PCI for MI; surgery for valve problems"))
story.append(bullet("<b>Oxygen therapy</b> and positive pressure ventilation"))
story.append(bullet("<b>Monitoring</b> — ECG, urine output, CVP, blood gases"))

# ══════════════════════════════════════════════════════════════════════════════
# PART 3 - SEPTIC SHOCK
# ══════════════════════════════════════════════════════════════════════════════
story.append(PageBreak())
story.append(Paragraph("PART III: SEPTIC SHOCK — UNIVERSITY EXAM ESSAY", ParagraphStyle(
    'PartTitle3', parent=styles['Normal'], fontSize=15,
    textColor=colors.HexColor('#4a148c'), alignment=TA_CENTER, fontName='Helvetica-Bold',
    backColor=colors.HexColor('#f3e5f5'), borderPad=8, spaceAfter=10
)))

story.append(section("DEFINITION"))
story.append(body("Septic shock is the <b>most common cause of distributive shock</b>. It is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, resulting in circulatory, cellular, and metabolic abnormalities."))

story.append(section("ETIOPATHOGENESIS"))
story.append(body("<b>Causative organisms (Gram-negative bacteria):</b>"))
story.append(bullet("<i>Escherichia coli</i>"))
story.append(bullet("<i>Proteus</i> species"))
story.append(bullet("<i>Klebsiella</i>"))
story.append(body("These bacteria release <b>endotoxins</b> which cause adverse biochemical, immunological, and occasionally neurological effects harmful to the body."))

story.append(Spacer(1, 0.2*cm))
story.append(body("<b>Pathophysiology (Step-by-step):</b>"))
story.append(bullet("Sources of infection → Bacteria enter blood"))
story.append(bullet("Endotoxins → vascular permeability increases"))
story.append(bullet("Blood volume decreases → hypovolemia in intravascular compartment (leaking blood vessels)"))
story.append(bullet("Advanced cases: toxins damage cardiac function → <b>MODS</b> (multiple organ dysfunction syndrome) → Death"))

story.append(Spacer(1, 0.2*cm))
story.append(body("<b>Two Stages of Septic Shock:</b>"))
story.append(Spacer(1, 0.15*cm))
stages_h = [
    Paragraph("<b>Stage</b>", body_style),
    Paragraph("<b>Characteristics</b>", body_style),
    Paragraph("<b>Prognosis</b>", body_style)
]
stages_r = [
    [Paragraph("Early Warm Stage", body_style),
     Paragraph("CO well maintained or increased; vasodilation; warm skin, warm extremities, normal capillary refill", body_style),
     Paragraph("Manageable — detect and treat here", body_style)],
    [Paragraph("Late Cold Stage", body_style),
     Paragraph("CO falls, stroke volume falls; cool skin, cool extremities, delayed capillary refill", body_style),
     Paragraph("Ominous — poor outcome", body_style)],
]
story.append(make_table(stages_h, stages_r, col_widths=[3.5*cm, 9*cm, 4.5*cm]))

story.append(section("CLINICAL FEATURES"))
story.append(bullet("Hypotension"))
story.append(bullet("Tachycardia with <b>full bounding pulse</b> (distinguishing feature)"))
story.append(bullet("Tachypnea"))
story.append(bullet("<b>Fever</b> — hallmark feature distinguishing septic from other types of shock"))
story.append(bullet("Pink, warm, flushed skin (warm stage) → cool extremities (cold stage)"))
story.append(bullet("Decreased urine output"))
story.append(bullet("Altered mental status / confusion"))
story.append(bullet("Signs of MODS in advanced cases"))

story.append(section("DIAGNOSIS"))
story.append(bullet("<b>Blood cultures</b> — identify causative organism (before starting antibiotics)"))
story.append(bullet("<b>CBC</b> — leukocytosis (or leukopenia in severe sepsis)"))
story.append(bullet("<b>Serum lactate</b> — elevated (> 2 mmol/L indicates tissue hypoperfusion)"))
story.append(bullet("<b>Procalcitonin</b> — elevated in sepsis"))
story.append(bullet("<b>Metabolic panel</b> — metabolic acidosis, elevated creatinine"))
story.append(bullet("<b>Imaging</b> — X-ray/CT to identify source of infection"))
story.append(bullet("<b>Echocardiogram</b> — assess cardiac function"))

story.append(section("MANAGEMENT"))
story.append(bullet("<b>Resuscitation</b> — early aggressive IV fluid resuscitation (crystalloids)"))
story.append(bullet("<b>Antibiotics</b> — broad spectrum antibiotics started immediately after blood cultures; guided by sensitivity"))
story.append(bullet("<b>Vasopressors</b> (Norepinephrine) — for persistent hypotension despite fluid resuscitation"))
story.append(bullet("<b>Source control</b> — surgical debridement or drainage of infected focus"))
story.append(bullet("<b>Oxygen therapy / mechanical ventilation</b> if needed"))
story.append(bullet("<b>Continuous monitoring</b> — urine output, CVP, blood pressure"))
story.append(bullet("<b>Corticosteroids</b> — in refractory septic shock"))
story.append(bullet("<b>Anti-histaminics</b> if anaphylactic component is present"))

# ══════════════════════════════════════════════════════════════════════════════
# PART 4 - CRUSH SYNDROME
# ══════════════════════════════════════════════════════════════════════════════
story.append(PageBreak())
story.append(Paragraph("PART IV: CRUSH SYNDROME — UNIVERSITY EXAM ESSAY", ParagraphStyle(
    'PartTitle4', parent=styles['Normal'], fontSize=15,
    textColor=colors.HexColor('#b71c1c'), alignment=TA_CENTER, fontName='Helvetica-Bold',
    backColor=colors.HexColor('#fbe9e7'), borderPad=8, spaceAfter=10
)))

story.append(section("DEFINITION"))
story.append(body("Crush syndrome is a <b>systemic manifestation of rhabdomyolysis</b> (skeletal muscle breakdown) due to prolonged compression of muscle tissue, leading to the release of intracellular contents into the circulation."))
story.append(body("It causes significant morbidity and mortality due to <b>acute kidney injury</b> and electrolyte imbalances."))

story.append(section("ETIOLOGY"))
story.append(body("<b>Primary cause:</b> Prolonged compression of large muscles for several hours."))
story.append(body("<b>Common causes:</b>"))
story.append(bullet("Natural disasters (earthquakes, building collapses)"))
story.append(bullet("Industrial or agricultural accidents"))
story.append(bullet("Motor vehicle accidents"))
story.append(bullet("Crush injuries in war"))

story.append(section("ETIOPATHOGENESIS / PATHOPHYSIOLOGY"))

story.append(subsection("1. Muscle Injury and Ischemia"))
story.append(body("Prolonged compression → direct muscle damage and ischemia (reduced blood flow) → impaired oxygen and nutrient delivery → cell membrane damage and necrosis of muscle cells (<b>rhabdomyolysis</b>)."))

story.append(subsection("2. Release of Intracellular Contents"))
story.append(body("Upon release of compression and reperfusion, damaged muscle cells release various substances:"))
story.append(Spacer(1, 0.2*cm))

ic_h = [
    Paragraph("<b>Substance Released</b>", body_style),
    Paragraph("<b>Effect</b>", body_style)
]
ic_r = [
    [Paragraph("Myoglobin", body_style),
     Paragraph("Precipitates in renal tubules → obstruction and direct nephrotoxicity → Acute Kidney Injury (AKI)", body_style)],
    [Paragraph("Potassium", body_style),
     Paragraph("Released in large quantities → Hyperkalemia → Cardiac arrhythmia / cardiac arrest", body_style)],
    [Paragraph("Creatine Kinase (CK)", body_style),
     Paragraph("Marker of muscle damage; significantly elevated levels are characteristic of rhabdomyolysis", body_style)],
    [Paragraph("Lactic Acid", body_style),
     Paragraph("Anaerobic metabolism in ischemic muscle → Metabolic acidosis", body_style)],
    [Paragraph("Thromboplastin", body_style),
     Paragraph("Released from damaged tissue → potentially contributes to DIC (disseminated intravascular coagulation)", body_style)],
]
story.append(make_table(ic_h, ic_r, col_widths=[5*cm, 12*cm]))

story.append(subsection("3. Systemic Effects"))
story.append(bullet("<b>Hypovolemia</b> — fluid shifts into damaged muscle tissue → decreased circulating blood volume → hypovolemic shock"))
story.append(bullet("<b>Metabolic acidosis</b> — due to lactic acid accumulation and impaired kidney function"))
story.append(bullet("<b>Electrolyte imbalances</b> — primarily hyperkalemia and hyperphosphatemia"))
story.append(bullet("<b>Acute kidney injury</b> — caused by myoglobinuria, hypovolemia, and necrosis of renal tubules"))
story.append(bullet("<b>Compartment syndrome</b> — swelling within muscle compartments due to fluid accumulation → increased pressure → further compromising blood flow and exacerbating muscle damage"))
story.append(bullet("<b>Infection</b> — devitalized tissues are prone to infection"))

story.append(section("CLINICAL FEATURES"))

story.append(subsection("A. Local Signs (at site of crush):"))
story.append(bullet("Pain, tenderness, swelling, and tense muscles in the affected limb"))
story.append(bullet("Sensory and motor deficits in the compressed limb"))
story.append(bullet("In severe cases: pulselessness and pallor (signs of compartment syndrome)"))

story.append(subsection("B. Systemic Signs and Symptoms:"))
story.append(bullet("<b>Dark, tea-colored urine (myoglobinuria)</b> — hallmark sign"))
story.append(bullet("Oliguria or anuria"))
story.append(bullet("Nausea, vomiting"))
story.append(bullet("Confusion or altered mental status"))
story.append(bullet("Tachycardia, hypotension (signs of hypovolemic shock or hyperkalemia)"))
story.append(bullet("<b>Cardiac arrhythmias or cardiac arrest</b> (due to hyperkalemia)"))
story.append(bullet("Fever (may indicate infection)"))

story.append(section("DIAGNOSIS"))
story.append(bullet("<b>Clinical history</b> — clear history of crush injury is essential"))
story.append(bullet("<b>Physical examination</b> — assessment of local and systemic signs"))
story.append(body("<b>Lab investigations reveal:</b>"))
story.append(subbullet("Markedly elevated <b>creatine kinase (CK)</b> — characteristic"))
story.append(subbullet("<b>Urine myoglobin</b> — positive (myoglobinuria)"))
story.append(subbullet("<b>Hyperkalemia</b>"))
story.append(subbullet("Elevated creatinine"))
story.append(subbullet("<b>Hyperphosphatemia</b>"))
story.append(subbullet("Metabolic acidosis"))

story.append(section("MANAGEMENT"))
story.append(bullet("<b>1. Proper fluid therapy</b> — aggressive IV fluid resuscitation to maintain urine output and flush myoglobin from renal tubules (<u>most important step</u>)"))
story.append(bullet("<b>2. Tourniquet placement</b> — placed <b>proximally (above)</b> the crush injury on the affected limb to prevent migration of harmful substances into the circulation. Once fluid resuscitation has started, carefully remove the tourniquet."))
story.append(bullet("<b>3. Antibiotics and analgesics</b>"))
story.append(bullet("<b>4. Monitoring of urine output</b> — essential to assess renal function and adequacy of resuscitation"))
story.append(bullet("<b>5. Management of compartment syndrome</b> — <b>Fasciotomy</b> if needed (surgical decompression of muscle compartments)"))
story.append(bullet("<b>6. Management of electrolyte imbalance</b> — especially hyperkalemia (risk of cardiac arrest)"))
story.append(bullet("<b>7. Wound care and debridement</b> of devitalized tissues"))
story.append(bullet("<b>8. Dialysis</b> — indicated in acute kidney injury"))

# ══════════════════════════════════════════════════════════════════════════════
# SUMMARY TABLE
# ══════════════════════════════════════════════════════════════════════════════
story.append(PageBreak())
story.append(Paragraph("SUMMARY — ESSENCE OF THE CHAPTER", ParagraphStyle(
    'SummaryTitle', parent=styles['Normal'], fontSize=15,
    textColor=colors.HexColor('#0d47a1'), alignment=TA_CENTER, fontName='Helvetica-Bold',
    backColor=colors.HexColor('#e3f2fd'), borderPad=8, spaceAfter=10
)))

story.append(Spacer(1, 0.3*cm))
sum_h = [
    Paragraph("<b>Topic</b>", body_style),
    Paragraph("<b>Key Points</b>", body_style)
]
sum_r = [
    [Paragraph("Types of shock", body_style),
     Paragraph("4 types: Hypovolemic, Cardiogenic, Distributive, Obstructive", body_style)],
    [Paragraph("Distributive subtypes", body_style),
     Paragraph("Septic, Anaphylactic, Neurogenic", body_style)],
    [Paragraph("Compensatory mechanisms", body_style),
     Paragraph("Adrenergic discharge, hyperventilation, vasoactive hormones, fluid resorption, renal conservation", body_style)],
    [Paragraph("Preferred IV fluid", body_style),
     Paragraph("Non-sugar, non-protein crystalloid with sodium — Ringer's Lactate (NOT 5% glucose)", body_style)],
    [Paragraph("Cardiogenic shock", body_style),
     Paragraph("Only shock worsened by fluid; treat with inotropes + diuretics (Dopamine, Dobutamine, Propranolol)", body_style)],
    [Paragraph("Septic shock stages", body_style),
     Paragraph("Warm (early, manageable) → Cold (late, ominous); most common distributive shock", body_style)],
    [Paragraph("Crush syndrome definition", body_style),
     Paragraph("Systemic manifestation of rhabdomyolysis from prolonged muscle compression", body_style)],
    [Paragraph("Crush syndrome hallmark", body_style),
     Paragraph("Dark tea-colored urine (myoglobinuria) + markedly elevated CK", body_style)],
    [Paragraph("Crush syndrome most serious complication", body_style),
     Paragraph("Acute kidney injury (AKI) from myoglobin precipitation in renal tubules", body_style)],
    [Paragraph("Crush syndrome management key", body_style),
     Paragraph("Aggressive fluid therapy (most important) + fasciotomy for compartment syndrome + dialysis for AKI", body_style)],
]
story.append(make_table(sum_h, sum_r, col_widths=[5*cm, 12*cm]))

story.append(Spacer(1, 0.5*cm))
story.append(examtip(
    "For university essays, always write in this order: Definition → Classification → Etiopathogenesis → "
    "Clinical Features → Diagnosis → Management. Key points examiners look for: "
    "(1) Four types of shock and their mechanisms, "
    "(2) Why fluid worsens cardiogenic shock, "
    "(3) Two stages of septic shock (warm vs cold), "
    "(4) Triad of crush syndrome — rhabdomyolysis, myoglobinuria, acute kidney injury, "
    "(5) Compensatory mechanisms of shock (all six)."
))

story.append(Spacer(1, 0.5*cm))
story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor('#9fa8da')))
story.append(Paragraph(
    "Source: Illustrated Salya Vijnana — Chapter 19D: Marmāghāta (Shock)",
    ParagraphStyle('Footer', parent=styles['Normal'], fontSize=8,
                   textColor=colors.HexColor('#9e9e9e'), alignment=TA_CENTER,
                   fontName='Helvetica-Oblique', spaceBefore=4)
))

doc.build(story)
print("PDF created successfully:", OUTPUT)

cd /home/daytona/workspace && python marmaghata_shock.py