mkdir -p /home/daytona/workspace/prabha-devi-report && ls /home/daytona/workspac…

~/prabha-devi-report/generate_report.js

const {
  Document, Packer, Paragraph, TextRun, Table, TableRow, TableCell,
  AlignmentType, HeadingLevel, BorderStyle, WidthType, ShadingType,
  VerticalAlign, PageNumber, Header, Footer, TabStopType, TabStopPosition
} = require('docx');
const fs = require('fs');

// Color scheme
const HEADER_COLOR = "4A235A";   // deep purple
const SECTION_BG   = "EDE7F6";   // light lavender
const FLAG_COLOR   = "C0392B";   // red for abnormal
const NORMAL_COLOR = "1A5276";   // dark blue for normal
const TABLE_HDR_BG = "6A1B9A";   // purple table header
const BORDER_NONE  = { style: BorderStyle.NONE, size: 0, color: "FFFFFF" };

function bold(text, size = 22, color = "000000") {
  return new TextRun({ text, bold: true, size, color });
}
function normal(text, size = 20, color = "000000") {
  return new TextRun({ text, size, color });
}
function flag(text) {
  return new TextRun({ text, bold: true, size: 20, color: FLAG_COLOR });
}

function sectionHeading(title) {
  return new Paragraph({
    children: [new TextRun({ text: title, bold: true, size: 26, color: "FFFFFF" })],
    shading: { type: ShadingType.SOLID, color: HEADER_COLOR, fill: HEADER_COLOR },
    spacing: { before: 240, after: 120 },
    indent: { left: 120 },
  });
}

function subHeading(title) {
  return new Paragraph({
    children: [new TextRun({ text: title, bold: true, size: 22, color: HEADER_COLOR })],
    shading: { type: ShadingType.SOLID, color: SECTION_BG, fill: SECTION_BG },
    spacing: { before: 180, after: 80 },
    indent: { left: 80 },
  });
}

function labelValue(label, value, flagged = false) {
  return new Paragraph({
    children: [
      new TextRun({ text: label + ":  ", bold: true, size: 20, color: "333333" }),
      flagged
        ? new TextRun({ text: value, bold: true, size: 20, color: FLAG_COLOR })
        : new TextRun({ text: value, size: 20, color: "222222" }),
    ],
    spacing: { after: 60 },
    indent: { left: 360 },
  });
}

function bullet(text, flagged = false) {
  return new Paragraph({
    bullet: { level: 0 },
    children: [
      flagged
        ? new TextRun({ text, bold: true, size: 20, color: FLAG_COLOR })
        : new TextRun({ text, size: 20, color: "222222" }),
    ],
    spacing: { after: 60 },
    indent: { left: 720 },
  });
}

function makeTableRow(cells, isHeader = false) {
  return new TableRow({
    children: cells.map((c, i) =>
      new TableCell({
        children: [
          new Paragraph({
            children: [
              new TextRun({
                text: c.text || "",
                bold: isHeader || c.bold || false,
                size: isHeader ? 19 : 18,
                color: isHeader ? "FFFFFF" : (c.flag ? FLAG_COLOR : "222222"),
              }),
            ],
            alignment: c.center ? AlignmentType.CENTER : AlignmentType.LEFT,
          }),
        ],
        shading: isHeader
          ? { type: ShadingType.SOLID, color: TABLE_HDR_BG, fill: TABLE_HDR_BG }
          : { type: ShadingType.SOLID, color: c.shade || "FFFFFF", fill: c.shade || "FFFFFF" },
        width: c.width ? { size: c.width, type: WidthType.DXA } : undefined,
        verticalAlign: VerticalAlign.CENTER,
      })
    ),
  });
}

function spacer(pts = 100) {
  return new Paragraph({ children: [], spacing: { after: pts } });
}

// ─── Build Document ───────────────────────────────────────────────────────────
const doc = new Document({
  sections: [
    {
      headers: {
        default: new Header({
          children: [
            new Paragraph({
              children: [
                new TextRun({ text: "CONSOLIDATED MEDICAL INVESTIGATION REPORT", bold: true, size: 28, color: HEADER_COLOR }),
              ],
              alignment: AlignmentType.CENTER,
              shading: { type: ShadingType.SOLID, color: "F3E5F5", fill: "F3E5F5" },
              spacing: { after: 60 },
              border: { bottom: { style: BorderStyle.SINGLE, size: 6, color: HEADER_COLOR } },
            }),
          ],
        }),
      },
      footers: {
        default: new Footer({
          children: [
            new Paragraph({
              children: [
                new TextRun({ text: "Galaxy CARE Multispeciality Hospital  |  Near Garware College, 25-A, Karve Road, Pune - 411004  |  +91-20-30244100/139", size: 16, color: "888888" }),
              ],
              alignment: AlignmentType.CENTER,
              border: { top: { style: BorderStyle.SINGLE, size: 4, color: HEADER_COLOR } },
            }),
          ],
        }),
      },
      children: [
        // ── TITLE BLOCK ─────────────────────────────────────────────────────
        spacer(80),
        new Paragraph({
          children: [bold("CONSOLIDATED MEDICAL INVESTIGATION REPORT", 32, "FFFFFF")],
          alignment: AlignmentType.CENTER,
          shading: { type: ShadingType.SOLID, color: HEADER_COLOR, fill: HEADER_COLOR },
          spacing: { before: 120, after: 120 },
        }),
        new Paragraph({
          children: [bold("Galaxy CARE Multispeciality Hospital", 24, HEADER_COLOR)],
          alignment: AlignmentType.CENTER,
          spacing: { after: 60 },
        }),
        new Paragraph({
          children: [normal("Near Garware College, 25-A, Karve Road, Pune - 411004  |  Phone: +91-20-30244100/139", 18, "555555")],
          alignment: AlignmentType.CENTER,
          spacing: { after: 200 },
        }),

        // ── PATIENT DEMOGRAPHICS ─────────────────────────────────────────────
        sectionHeading("PATIENT INFORMATION"),
        new Table({
          width: { size: 9000, type: WidthType.DXA },
          rows: [
            makeTableRow([
              { text: "Patient Name", bold: true, shade: "EDE7F6", width: 2200 },
              { text: "MRS. PRABHA DEVI", width: 2300 },
              { text: "Age / Gender", bold: true, shade: "EDE7F6", width: 2000 },
              { text: "47 Years / Female", width: 2500 },
            ]),
            makeTableRow([
              { text: "Referral", bold: true, shade: "EDE7F6", width: 2200 },
              { text: "Galaxy Care (Galaxy Hospital)", width: 2300 },
              { text: "Examining Physician (NCV/EMG)", bold: true, shade: "EDE7F6", width: 2000 },
              { text: "Dr. Nilesh Bhandari", width: 2500 },
            ]),
            makeTableRow([
              { text: "Primary Report Date", bold: true, shade: "EDE7F6", width: 2200 },
              { text: "June 11-12, 2026", width: 2300 },
              { text: "NCV/EMG Date", bold: true, shade: "EDE7F6", width: 2000 },
              { text: "August 06, 2026", width: 2500 },
            ]),
          ],
        }),
        spacer(160),

        // ── 1. CSF ANALYSIS ──────────────────────────────────────────────────
        sectionHeading("1. CEREBROSPINAL FLUID (CSF) ANALYSIS"),
        new Paragraph({
          children: [normal("All CSF samples collected on June 09–10, 2026. Multiple tubes sent for biochemistry, microbiology, and cytology.", 18, "555555")],
          spacing: { after: 120 },
          indent: { left: 120 },
        }),

        // 1a. CSF Glucose
        subHeading("1a. CSF Glucose  (Reg. ID: 33273)"),
        new Table({
          width: { size: 9000, type: WidthType.DXA },
          rows: [
            makeTableRow([
              { text: "Parameter", width: 3000 },
              { text: "Result", width: 2000 },
              { text: "Unit", width: 1500 },
              { text: "Reference Range", width: 2500 },
            ], true),
            makeTableRow([
              { text: "CSF Glucose", shade: "FFF9C4", width: 3000 },
              { text: "109.0  ▲  HIGH", flag: true, width: 2000 },
              { text: "mg/dL", width: 1500 },
              { text: "40 – 70 mg/dL", width: 2500 },
            ]),
          ],
        }),
        spacer(80),
        new Paragraph({
          children: [
            new TextRun({ text: "Interpretation: ", bold: true, size: 20, color: HEADER_COLOR }),
            new TextRun({ text: "CSF glucose is significantly elevated above the normal range. Elevated CSF glucose (hyperglycorrhachia) is most commonly a reflection of systemic hyperglycaemia; a simultaneous blood glucose was not provided. This finding should be interpreted alongside blood glucose levels. Isolated hyperglycorrhachia does not indicate infection.", size: 19, color: "333333" }),
          ],
          spacing: { before: 80, after: 120 },
          indent: { left: 360 },
        }),

        // 1b. CSF Protein
        subHeading("1b. CSF Protein  (Reg. ID: 33272)"),
        new Table({
          width: { size: 9000, type: WidthType.DXA },
          rows: [
            makeTableRow([
              { text: "Parameter", width: 3000 },
              { text: "Result", width: 2000 },
              { text: "Unit", width: 1500 },
              { text: "Reference Range", width: 2500 },
            ], true),
            makeTableRow([
              { text: "CSF Protein", shade: "FFF9C4", width: 3000 },
              { text: "111.7  ▲  HIGH", flag: true, width: 2000 },
              { text: "mg/dL", width: 1500 },
              { text: "15 – 45 mg/dL", width: 2500 },
            ]),
          ],
        }),
        spacer(80),
        new Paragraph({
          children: [
            new TextRun({ text: "Interpretation: ", bold: true, size: 20, color: HEADER_COLOR }),
            new TextRun({ text: "CSF protein is markedly elevated (more than 2x upper limit of normal). Elevated CSF protein is a hallmark finding in Guillain-Barré Syndrome (GBS) and its variants including AMAN, as it reflects albuminocytologic dissociation (high protein with normal/near-normal cell count). This finding is consistent with the EMG/NCV conclusions.", size: 19, color: "333333" }),
          ],
          spacing: { before: 80, after: 120 },
          indent: { left: 360 },
        }),

        // 1c. CSF Cytology
        subHeading("1c. CSF Cytology (Fluid for Cytology)  (Reg. ID: 33271  |  KD 862/2026)"),
        labelValue("Sample Date", "June 10, 2026, 06:09 PM"),
        labelValue("Report Date", "June 11, 2026, 12:33 PM"),
        labelValue("Gross – Volume & Appearance", "1 mL, colourless, clear"),
        labelValue("Microscopy", "Paucicellular smears showing occasional lymphocytes. No malignant cells seen."),
        new Paragraph({
          children: [bold("IMPRESSION: ", 20, "1A5276"), normal("No malignant cells seen. – CSF", 20, "1A5276")],
          spacing: { before: 80, after: 120 },
          indent: { left: 360 },
        }),

        // 1d. KOH Mount
        subHeading("1d. CSF KOH Mount 10%  (Reg. ID: 33266)"),
        labelValue("Sample Date", "June 10, 2026, 06:15 PM"),
        labelValue("Report Date", "June 12, 2026, 10:45 AM"),
        labelValue("Specimen", "CSF  |  Volume: 0.5 cc  |  Appearance: Clear"),
        new Paragraph({
          children: [bold("RESULT: ", 20, "1A5276"), normal("No fungal elements seen.", 20, "1A5276")],
          spacing: { before: 80, after: 120 },
          indent: { left: 360 },
        }),

        // 1e. Gram Stain
        subHeading("1e. CSF Gram Stain Report  (Reg. ID: 33267)"),
        labelValue("Sample Date", "June 10, 2026, 06:16 PM"),
        labelValue("Report Date", "June 11, 2026, 12:34 PM"),
        labelValue("Specimen", "CSF"),
        new Paragraph({
          children: [bold("RESULT: ", 20, "1A5276"), normal("No organism seen.", 20, "1A5276")],
          spacing: { before: 80, after: 120 },
          indent: { left: 360 },
        }),

        spacer(120),

        // ── 2. NERVE CONDUCTION STUDY ────────────────────────────────────────
        sectionHeading("2. MOTOR NERVE CONDUCTION STUDY (NCV)"),
        new Paragraph({
          children: [normal("Examining Physician: Dr. Nilesh Bhandari  |  Referred by: Galaxy Hospital  |  Date: August 06, 2026", 18, "555555")],
          spacing: { after: 120 },
          indent: { left: 120 },
        }),
        new Paragraph({
          children: [bold("Patient: ", 19, "333333"), normal("Mrs. Devi Prabha  |  Age: 47  |  Female", 19, "333333")],
          spacing: { after: 100 },
          indent: { left: 120 },
        }),

        new Table({
          width: { size: 9000, type: WidthType.DXA },
          rows: [
            makeTableRow([
              { text: "Nerve & Site", width: 1600 },
              { text: "Latency (ms)", width: 1200, center: true },
              { text: "Amplitude", width: 1200, center: true },
              { text: "Segment", width: 1900, center: true },
              { text: "Latency Diff", width: 1100, center: true },
              { text: "Distance (mm)", width: 1000, center: true },
              { text: "CV (m/s)", width: 900, center: true },
            ], true),
            // Median Left
            makeTableRow([{ text: "Median – Left", bold: true, shade: "F3E5F5", width: 1600 }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }]),
            makeTableRow([{ text: "  Wrist", width: 1600 }, { text: "4.0", center: true }, { text: "3.5 mV", center: true }, { text: "*Wrist", center: true }, { text: "4.0", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            makeTableRow([{ text: "  Elbow", width: 1600 }, { text: "7.6", center: true }, { text: "3.9 mV", center: true }, { text: "Wrist–Elbow", center: true }, { text: "3.7", center: true }, { text: "240", center: true }, { text: "65.8", center: true }]),
            makeTableRow([{ text: "  Axilla", width: 1600 }, { text: "8.3", center: true }, { text: "3.9 mV", center: true }, { text: "Elbow–Axilla", center: true }, { text: "0.7", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            // Median Right
            makeTableRow([{ text: "Median – Right", bold: true, shade: "F3E5F5", width: 1600 }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }]),
            makeTableRow([{ text: "  Wrist", width: 1600 }, { text: "3.5", center: true }, { text: "3.7 mV", center: true }, { text: "*Wrist", center: true }, { text: "3.5", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            makeTableRow([{ text: "  Elbow", width: 1600 }, { text: "7.3", center: true }, { text: "3.6 mV", center: true }, { text: "Wrist–Elbow", center: true }, { text: "3.8", center: true }, { text: "240", center: true }, { text: "63.2", center: true }]),
            makeTableRow([{ text: "  Axilla", width: 1600 }, { text: "8.3", center: true }, { text: "3.7 mV", center: true }, { text: "Elbow–Axilla", center: true }, { text: "1.1", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            // Ulnar Left
            makeTableRow([{ text: "Ulnar – Left", bold: true, shade: "F3E5F5", width: 1600 }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }]),
            makeTableRow([{ text: "  Wrist", width: 1600 }, { text: "2.1", center: true }, { text: "5.8 mV", center: true }, { text: "*Wrist", center: true }, { text: "2.1", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            makeTableRow([{ text: "  Elbow", width: 1600 }, { text: "6.3", center: true }, { text: "5.7 mV", center: true }, { text: "Wrist–Elbow", center: true }, { text: "4.2", center: true }, { text: "250", center: true }, { text: "59.5", center: true }]),
            makeTableRow([{ text: "  Axilla", width: 1600 }, { text: "7.5", center: true }, { text: "5.1 mV", center: true }, { text: "Elbow–Axilla", center: true }, { text: "1.2", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            // Ulnar Right
            makeTableRow([{ text: "Ulnar – Right", bold: true, shade: "F3E5F5", width: 1600 }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }]),
            makeTableRow([{ text: "  Wrist", width: 1600 }, { text: "2.3", center: true }, { text: "4.8 mV", center: true }, { text: "*Wrist", center: true }, { text: "2.3", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            makeTableRow([{ text: "  Elbow", width: 1600 }, { text: "6.3", center: true }, { text: "4.9 mV", center: true }, { text: "Wrist–Elbow", center: true }, { text: "4.0", center: true }, { text: "250", center: true }, { text: "63.3", center: true }]),
            makeTableRow([{ text: "  Axilla", width: 1600 }, { text: "7.3", center: true }, { text: "4.7 mV", center: true }, { text: "Elbow–Axilla", center: true }, { text: "1.1", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            // Peroneal Left
            makeTableRow([{ text: "Peroneal – Left", bold: true, shade: "FFF9C4", width: 1600 }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }]),
            makeTableRow([{ text: "  Ankle", width: 1600 }, { text: "5.2", center: true }, { text: "0.2 mV  ▼", flag: true, center: true }, { text: "Ankle", center: true }, { text: "5.2", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            makeTableRow([{ text: "  Head of Fibula", width: 1600 }, { text: "10.5", center: true }, { text: "0.6 mV  ▼", flag: true, center: true }, { text: "Ankle–Head of Fibula", center: true }, { text: "5.4", center: true }, { text: "360", center: true }, { text: "67.3", center: true }]),
            makeTableRow([{ text: "  Popliteal", width: 1600 }, { text: "11.5", center: true }, { text: "0.5 mV  ▼", flag: true, center: true }, { text: "Head of Fibula–Popliteal", center: true }, { text: "1.0", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            // Peroneal Right
            makeTableRow([{ text: "Peroneal – Right", bold: true, shade: "FFF9C4", width: 1600 }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }]),
            makeTableRow([{ text: "  Ankle", width: 1600 }, { text: "3.9", center: true }, { text: "1.1 mV  ▼", flag: true, center: true }, { text: "Ankle", center: true }, { text: "3.9", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            makeTableRow([{ text: "  Head of Fibula", width: 1600 }, { text: "9.7", center: true }, { text: "0.5 mV  ▼", flag: true, center: true }, { text: "Ankle–Head of Fibula", center: true }, { text: "5.8", center: true }, { text: "360", center: true }, { text: "62.1", center: true }]),
            makeTableRow([{ text: "  Popliteal", width: 1600 }, { text: "10.5", center: true }, { text: "0.6 mV  ▼", flag: true, center: true }, { text: "Head of Fibula–Popliteal", center: true }, { text: "0.9", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            // Tibial Left
            makeTableRow([{ text: "Tibial – Left", bold: true, shade: "FFF9C4", width: 1600 }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }]),
            makeTableRow([{ text: "  Ankle", width: 1600 }, { text: "10.2", center: true }, { text: "1.0 mV  ▼", flag: true, center: true }, { text: "Ankle", center: true }, { text: "10.2", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            makeTableRow([{ text: "  Popliteal", width: 1600 }, { text: "15.0", center: true }, { text: "0.3 mV  ▼", flag: true, center: true }, { text: "Ankle–Popliteal", center: true }, { text: "4.8", center: true }, { text: "370", center: true }, { text: "77.1", center: true }]),
            // Tibial Right
            makeTableRow([{ text: "Tibial – Right", bold: true, shade: "FFF9C4", width: 1600 }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }]),
            makeTableRow([{ text: "  Ankle", width: 1600 }, { text: "5.5", center: true }, { text: "0.5 mV  ▼", flag: true, center: true }, { text: "Ankle", center: true }, { text: "5.5", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
            makeTableRow([{ text: "  Popliteal", width: 1600 }, { text: "14.3", center: true }, { text: "0.4 mV  ▼", flag: true, center: true }, { text: "Ankle–Popliteal", center: true }, { text: "8.9", center: true }, { text: "370", center: true }, { text: "41.8  ▼", flag: true, center: true }]),
            // Femoral Left
            makeTableRow([{ text: "Femoral – Left", bold: true, shade: "FFF9C4", width: 1600 }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }, { text: "" }]),
            makeTableRow([{ text: "  –", width: 1600 }, { text: "No response", flag: true, center: true }, { text: "–", center: true }, { text: "–", center: true }, { text: "–", center: true }, { text: "–", center: true }, { text: "–", center: true }]),
          ],
        }),

        spacer(100),
        new Paragraph({
          children: [
            new TextRun({ text: "Key NCV Findings: ", bold: true, size: 20, color: HEADER_COLOR }),
            new TextRun({ text: "Upper limb (Median & Ulnar) motor responses are preserved with normal amplitudes and conduction velocities bilaterally. Lower limb nerves (Peroneal bilateral, Tibial bilateral, Femoral Left) show severely reduced or absent CMAP amplitudes with conduction velocities at the lower limits or reduced – consistent with axonal motor neuropathy in lower limbs. No significant conduction slowing or block in upper limbs. Left Femoral shows no response.", size: 19, color: "333333" }),
          ],
          spacing: { before: 80, after: 120 },
          indent: { left: 360 },
        }),

        spacer(120),

        // ── 3. NEEDLE EMG ────────────────────────────────────────────────────
        sectionHeading("3. NEEDLE EMG EXAMINATION"),

        new Table({
          width: { size: 9000, type: WidthType.DXA },
          rows: [
            makeTableRow([
              { text: "Muscle Tested", width: 2000 },
              { text: "Fibrillation", width: 1200, center: true },
              { text: "Activation", width: 1400, center: true },
              { text: "Recruitment", width: 1300, center: true },
              { text: "Amplitude", width: 1100, center: true },
              { text: "Polyphasic", width: 1000, center: true },
              { text: "Impression", width: 1000, center: true },
            ], true),
            makeTableRow([
              { text: "R/L Tibialis Anterior\nR Quadriceps", shade: "FFF9C4", width: 2000 },
              { text: "–", center: true },
              { text: "↓↓ (Reduced)", flag: true, center: true },
              { text: "↓↓ (Reduced)", flag: true, center: true },
              { text: "↑ (Increased)", center: true },
              { text: "+ (Present)", center: true },
              { text: "Chronic partial denervation", bold: true, center: true },
            ]),
            makeTableRow([
              { text: "L Quadriceps\nR/L Medial Gastrocnemius", shade: "FFF9C4", width: 2000 },
              { text: "–", center: true },
              { text: "No activation", flag: true, center: true },
              { text: "–", center: true },
              { text: "–", center: true },
              { text: "–", center: true },
              { text: "Total denervation", bold: true, flag: true, center: true },
            ]),
          ],
        }),

        spacer(100),
        new Paragraph({
          children: [bold("Conclusions (EMG/NCV Study): ", 20, FLAG_COLOR)],
          spacing: { after: 60 },
          indent: { left: 360 },
        }),
        bullet("The EMG/NCV study shows a pure motor axonal neuropathy in the lower limbs with neurogenic changes in all muscles tested.", true),
        bullet("Possible root level involvement (??Root level involvement)."),
        bullet("Clinical differential: To rule out AMAN (Acute Motor Axonal Neuropathy) variant of GBS (Guillain-Barré Syndrome).", true),

        spacer(160),

        // ── 4. SUMMARY TABLE ─────────────────────────────────────────────────
        sectionHeading("4. SUMMARY OF ALL INVESTIGATIONS"),

        new Table({
          width: { size: 9000, type: WidthType.DXA },
          rows: [
            makeTableRow([
              { text: "Test", width: 2500 },
              { text: "Result / Finding", width: 3500 },
              { text: "Reference Range", width: 1500 },
              { text: "Status", width: 1500, center: true },
            ], true),
            makeTableRow([
              { text: "CSF Glucose", shade: "FFFFFF", width: 2500 },
              { text: "109.0 mg/dL", flag: true, width: 3500 },
              { text: "40–70 mg/dL", width: 1500 },
              { text: "HIGH ▲", flag: true, center: true, width: 1500 },
            ]),
            makeTableRow([
              { text: "CSF Protein", shade: "FFFFFF", width: 2500 },
              { text: "111.7 mg/dL", flag: true, width: 3500 },
              { text: "15–45 mg/dL", width: 1500 },
              { text: "HIGH ▲", flag: true, center: true, width: 1500 },
            ]),
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              { text: "Paucicellular; occasional lymphocytes. No malignant cells.", width: 3500 },
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              { text: "NORMAL", center: true, width: 1500 },
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              { text: "Reduced activation, reduced recruitment, increased amplitude, polyphasic MUPs", flag: true, width: 3500 },
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        bullet("CSF analysis shows ALBUMINOCYTOLOGIC DISSOCIATION: markedly elevated protein (111.7 mg/dL) with essentially normal cell count (only occasional lymphocytes) and no infectious organisms. This pattern is the hallmark of Guillain-Barré Syndrome (GBS).", true),
        bullet("CSF is sterile: no organisms on Gram stain, no fungal elements on KOH mount, no malignant cells on cytology – effectively ruling out bacterial meningitis, fungal meningitis, and CNS malignancy as primary diagnoses."),
        bullet("NCV/EMG findings demonstrate a PURE MOTOR AXONAL neuropathy predominantly affecting the lower limbs, with preserved sensory/upper limb conduction. The pattern of axonal loss (reduced CMAP amplitudes without significant conduction slowing) points to the AMAN (Acute Motor Axonal Neuropathy) subtype of GBS.", true),
        bullet("The combination of CSF albuminocytologic dissociation + pure motor axonal pattern on electrophysiology is strongly supportive of the AMAN variant of Guillain-Barré Syndrome."),
        bullet("CSF glucose elevation (109 mg/dL) is likely a reflection of systemic hyperglycaemia; correlation with simultaneous blood glucose is advised."),

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cd /home/daytona/workspace/prabha-devi-report && node generate_report.js 2>&1

ls -lh /home/daytona/workspace/prabha-devi-report/Prabha_Devi_Consolidated_Repor…

cd /home/daytona/workspace/prabha-devi-report && python /home/daytona/skills/doc…

cd /home/daytona/workspace/prabha-devi-report && python3 -c " import zipfile, sy…

Guillain-Barre syndrome physiotherapy rehabilitation

AMAN axonal neuropathy exercise rehabilitation motor recovery

GBS AMAN physiotherapy protocol phases 2024 2025 evidence based lower limb denervation

~/prabha-devi-report/generate_physio.js

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// ─────────────────────────────────────────────────────────────────────────────
// DOCUMENT
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const doc = new Document({
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        children: [p([
          tr("PHYSIOTHERAPY REHABILITATION PROTOCOL  |  Mrs. Prabha Devi  |  AMAN-GBS  |  Confidential", { size: 16, color: C.teal, bold: true })
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      // ══════════════════════════════════════════════════════════════════
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      new Paragraph({
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      makeTbl(
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        [
          ["Patient Name", "Mrs. Prabha Devi"],
          ["Age / Gender", "47 years / Female"],
          ["Primary Diagnosis", "AMAN Variant of Guillain-Barré Syndrome (GBS)"],
          ["EMG Finding", "Chronic partial denervation (Tibialis Anterior, R Quadriceps) + Total denervation (L Quadriceps, Medial Gastrocnemius B/L)"],
          ["NCV Finding", "Pure motor axonal neuropathy lower limbs; Femoral L – no response; Upper limbs preserved"],
          ["CSF Finding", "Protein 111.7 mg/dL (↑↑); Glucose 109.0 mg/dL (↑); No infection"],
          ["Protocol Date", "July 2026"],
          ["Referring Facility", "Galaxy CARE Multispeciality Hospital, Pune"],
          ["NCV/EMG Examiner", "Dr. Nilesh Bhandari"],
          ["Evidence Base", "EAN/PNS 2023 GBS Guidelines; Kiper et al. 2025 Scoping Review (J Clin Med); De León-Muñoz et al. 2026 Syst Review (Arch PMR); Physio-Pedia Tri-Phasic GBS Protocol"],
        ],
        [2400, 6600]
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      spacer(100),
      warningBox("IMPORTANT: This protocol must be implemented under close neurological and physiotherapy supervision. Autonomic instability, pain sensitivity, and axonal fragility in AMAN require ongoing clinical monitoring. Do NOT push to fatigue."),
      spacer(120),

      // ══════════════════════════════════════════════════════════════════
      // SECTION 1 – CLINICAL PROFILE & RATIONALE
      // ══════════════════════════════════════════════════════════════════
      sectionBanner("SECTION 1: CLINICAL PROFILE & PHYSIOTHERAPY RATIONALE", C.teal),

      subLabel("1.1  Diagnosis Summary"),
      bul("Subtype: AMAN (Acute Motor Axonal Neuropathy) – pure motor, axonal, predominantly lower limb."),
      bul("Mechanism: Anti-GM1 antibody-mediated axonal degeneration at nodes of Ranvier. Sensory fibres spared."),
      bul("CSF albuminocytologic dissociation: Protein 111.7 mg/dL (ref 15–45), minimal pleocytosis → classic GBS pattern."),
      bul("EMG denervation pattern indicates both chronic partial (Tibialis Anterior, R Quadriceps) and total denervation (L Quadriceps, Bilateral Gastrocnemius) → prolonged recovery timeline expected."),
      bul("Upper limb NCV fully preserved → protocol focuses exclusively on lower limb and truncal rehabilitation."),

      spacer(80),
      subLabel("1.2  Functional Deficit Profile"),
      makeTbl(
        ["Muscle Group", "Side", "EMG Status", "Functional Impact"],
        [
          ["Tibialis Anterior", "Bilateral", "Chronic partial denervation", "Foot drop; inability to dorsiflex; tripping risk"],
          ["Quadriceps (rectus femoris + vastus group)", "Right", "Chronic partial denervation", "Weak knee extension; stair/sit-to-stand difficulty"],
          ["Quadriceps", "Left", "Total denervation", "Absent knee extension; falls risk; non-weight-bearing"],
          ["Medial Gastrocnemius", "Bilateral", "Total denervation", "No plantar flexion; unable to push-off; gait severely impaired"],
          ["Femoral Nerve", "Left", "No NCV response", "Hip flexion/knee extension power severely compromised L side"],
          ["Peroneal Nerve", "Bilateral", "Very low amplitude (0.2–1.1 mV)", "Weak foot eversion and dorsiflexion"],
          ["Tibial Nerve", "Bilateral", "Very low amplitude (0.3–1.0 mV)", "Absent plantar flexion power"],
        ],
        [1800, 900, 2400, 3900]
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      subLabel("1.3  Goals of Physiotherapy"),
      bul("Prevent secondary complications: contractures, pressure sores, DVT, muscle shortening, disuse atrophy.", 0, C.teal, true),
      bul("Maintain joint range of motion (ROM) through all stages."),
      bul("Facilitate axonal re-innervation by providing appropriate sensory input, graded loading, and neuroplasticity stimulation."),
      bul("Progress from passive → active-assisted → active → resisted exercises as re-innervation occurs."),
      bul("Restore safe mobility, gait, and functional independence."),
      bul("Prevent fatigue-related setbacks: AMAN recovery is energy-demanding; pacing is essential."),
      bul("Provide patient and caregiver education for home management."),

      spacer(120),

      // ══════════════════════════════════════════════════════════════════
      // SECTION 2 – TRI-PHASIC FRAMEWORK
      // ══════════════════════════════════════════════════════════════════
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      makeTbl(
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          ["Phase 1", "Acute / Plateau", "Weeks 1–4 (or while progressing/plateauing)", "Active disease; new deficits possible; autonomic instability", "Protection, prevention of complications, passive care"],
          ["Phase 2", "Early Recovery / Rehabilitation", "Weeks 4–16", "Deficit stable ≥1 week; no new neurological decline; medically stable", "Active-assisted and active exercise; functional re-training"],
          ["Phase 3", "Late Recovery / Community Reintegration", "Months 4–18+", "Independent transfers; partial weight-bearing possible; fatigue manageable", "Strengthening, gait training, ADL independence, community mobility"],
        ],
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      spacer(120),

      // ══════════════════════════════════════════════════════════════════
      // SECTION 3 – PHASE 1
      // ══════════════════════════════════════════════════════════════════
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      subLabel("3.1  Monitoring & Precautions (MUST assess every session)"),
      warningBox("Assess autonomic status before each session. Cease exercise immediately if: HR >120 bpm or <50 bpm, SBP >180 or <90, SpO2 <94%, new pain, or patient requests to stop."),
      bul("Monitor: Heart rate, blood pressure, SpO2, respiratory rate, pain (NRS 0–10), fatigue level.", 0, C.red),
      bul("Autonomic dysfunction (labile BP, arrhythmia) is a contraindication to active exercise – switch to positioning only."),
      bul("Pain management: coordinate with medical team; physiotherapy may worsen neuropathic pain if poorly controlled."),
      bul("Avoid: Strenuous exercise, overheating, prolonged static postures."),

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      subLabel("3.2  Positioning & Pressure Care (Daily, 2-hourly turns)"),
      bul("Supine with neutral spine alignment; small pillow under knees to reduce lumbar strain."),
      bul("Foot-drop prevention: Ankle foot orthoses (AFOs) or posterior splints at 90° when in bed; remove 2 hourly for skin checks."),
      bul("Heel protection: Heel-offloading boots or foam padding; inspect skin at every turn."),
      bul("2-hourly repositioning schedule: Supine → Right lateral → Supine → Left lateral. Document."),
      bul("Knee/hip flexion contracture prevention: Prone positioning 20–30 min twice daily if tolerated and cardiovascularly stable."),

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        ["Joint", "Movements", "Reps × Sets", "Special Notes"],
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          ["Ankle", "Dorsiflexion, plantarflexion, inversion, eversion", "10–15 × 2", "Gentle; avoid forceful stretch over denervated muscle"],
          ["Subtalar / Midfoot", "Circumduction", "10 × 2", "Maintain accessory movement"],
          ["Knee", "Flexion 0–120°, extension", "10–15 × 2", "Support heel; do not hyperextend"],
          ["Hip", "Flexion, extension, abduction, adduction, IR, ER", "10–15 × 2", "Log-roll for hip rotation to protect spine"],
          ["Toe MTP/IP joints", "Flexion, extension", "10 × 2", "Prevent clawing"],
          ["Upper limb", "Full PROM if any tightness develops", "As needed", "Upper limb NCV intact – focus lower limb"],
        ],
        [1600, 2500, 1400, 3500]
      ),
      noteBox("PROM should be smooth and rhythmic. STOP if patient reports sharp pain >5/10 NRS."),

      spacer(80),
      subLabel("3.4  Respiratory Physiotherapy"),
      bul("Assess FVC and respiratory rate at each session. Alert medical team if FVC <20 mL/kg or declining."),
      bul("Deep breathing exercises: Diaphragmatic breathing 3× 10 reps, 3× daily."),
      bul("Active cycle of breathing technique (ACBT) to clear secretions."),
      bul("Incentive spirometry if available: target 80% of predicted FVC."),
      bul("Positioning: 30–45° head-of-bed elevation to aid ventilation."),
      bul("This patient's upper limbs are intact – may assist with huffing and coughing."),

      spacer(80),
      subLabel("3.5  Oedema & DVT Prevention"),
      bul("Compression bandaging/stockings (TED) to bilateral lower limbs; apply daily."),
      bul("Passive ankle pumps and calf muscle massage: 5 min/limb, 3× daily."),
      bul("Sequential pneumatic compression devices if prescribed by physician."),
      bul("Elevation of lower limbs 15–20° at rest."),
      bul("Co-ordinate with medical team regarding pharmacological DVT prophylaxis."),

      spacer(80),
      subLabel("3.6  Sensory Stimulation & Neuroplasticity Input"),
      bul("Despite pure motor axonal loss in AMAN, sensory input drives cortical reorganisation and enhances motor re-learning."),
      bul("Tactile stimulation: Light stroking with varied textures (soft brush, rough cloth) over lower limbs, 5 min/limb, 1× daily."),
      bul("Thermal stimulation: Warm/cool contrast (if no autonomic instability), 2 min/area."),
      bul("Neuromuscular electrical stimulation (NMES / FES): Apply to tibialis anterior and quadriceps using surface electrodes. Recommended parameters: frequency 30–50 Hz, pulse width 200–300 µs, intensity to visible contraction, 20 min/session, 1× daily. [Evidence: EAN/PNS 2023]"),

      spacer(80),
      subLabel("3.7  Psychological Support & Patient Education"),
      bul("Explain the AMAN recovery trajectory: axonal regeneration is slow (1–2 mm/day); recovery is measured in months."),
      bul("Set realistic short-term goals (e.g., maintain joint range, prevent sores) rather than immediate motor recovery goals."),
      bul("Involve family/caregiver in positioning and passive exercise training."),
      bul("Screen for depression and anxiety (common in GBS): refer to clinical psychologist if PHQ-9 ≥10."),
      bul("Pain diary: Record pain type (neuropathic vs. musculoskeletal), location, triggers. Share with team."),

      spacer(120),

      // ══════════════════════════════════════════════════════════════════
      // SECTION 4 – PHASE 2
      // ══════════════════════════════════════════════════════════════════
      sectionBanner("SECTION 4: PHASE 2 — EARLY RECOVERY / REHABILITATION PHASE", C.blue),

      p([tr("Entry criteria: neurological deficit stable ≥1 week, no new weakness, medically stable, FVC adequate. Continue Phase 1 elements (PROM, positioning) in parallel.", { size: 18, italics: true, color: C.grey })],
        { indent: 120, before: 60, after: 100 }),

      subLabel("4.1  Assessment at Phase Entry"),
      bul("Manual Muscle Testing (MMT, MRC scale 0–5) all lower limb muscle groups – document baseline."),
      bul("Functional Independence Measure (FIM) or Barthel Index baseline score."),
      bul("GBS Disability Scale (0–6) baseline."),
      bul("Fatigue assessment: GBS-Fatigue Scale or VAS fatigue."),
      bul("Pain: NRS and DN4 questionnaire for neuropathic character."),

      spacer(80),
      subLabel("4.2  Active-Assisted Exercises (AROM-A)"),
      noteBox("Begin when MRC ≥1 in any muscle group. Use gravity-eliminated positions initially (sidelying, supine, water/hydrotherapy)."),
      makeTbl(
        ["Exercise", "Target Muscle", "Position", "Progression Cue", "Frequency"],
        [
          ["Gravity-eliminated knee extension", "Quadriceps (partial reinnervation)", "Sidelying, knee supported", "Advance to seated when MRC ≥2", "3 × 10, 2×/day"],
          ["Active-assisted dorsiflexion", "Tibialis anterior", "Supine, physio assists", "Self-assisted with theraband when MRC ≥2", "3 × 10, 2×/day"],
          ["Hip abduction sidelying", "Gluteus medius", "Sidelying", "Add 0.5 kg cuff weight when MRC ≥3", "3 × 10, 2×/day"],
          ["Hip extension in prone", "Gluteus maximus, hamstrings", "Prone (if BP stable)", "Advance to standing hip extension at barre", "3 × 10, 1×/day"],
          ["Seated knee extension (gravity only)", "Quadriceps", "Seated at edge of bed/chair", "Add theraband when MRC ≥3", "3 × 10, 2×/day"],
          ["Ankle pumps – active", "Tibialis anterior / calf (when any return)", "Supine", "Increase speed and range progressively", "15 reps/hour"],
        ],
        [2200, 1800, 1600, 2200, 1200]
      ),

      spacer(80),
      subLabel("4.3  Core & Trunk Stabilisation"),
      bul("Abdominal bracing (transversus abdominis activation): 10 × 10 sec holds, 3×/day."),
      bul("Supine pelvic tilts: 3 × 15 reps."),
      bul("Bridging (if L quadriceps MRC ≥1): begin with bilateral, progress to single-leg."),
      bul("Seated balance training on stable surface → progress to unstable (foam, wobble board) as tolerated."),
      bul("Rationale: Core stability is prerequisite for safe sit-to-stand and gait retraining."),

      spacer(80),
      subLabel("4.4  Hydrotherapy / Pool-Based Rehabilitation"),
      bul("Warm water (34–36°C) supports buoyancy; reduces effective body weight ~80% at chest depth."),
      bul("Commence when wounds are healed and cardiovascular stability established."),
      bul("Pool activities: Walking in water (waist-deep), water-based knee extension, hip strengthening, lateral stepping."),
      bul("Session duration: 20–30 min, 3×/week."),
      bul("Water temperature monitoring essential for autonomic patients."),
      noteBox("Hydrotherapy evidence in GBS: Associated with improved fatigue, ROM, and functional scores (Kiper et al., J Clin Med 2025)."),

      spacer(80),
      subLabel("4.5  Neuromuscular Electrical Stimulation (NMES / FES)"),
      makeTbl(
        ["Muscle Group", "Electrode Placement", "Frequency", "Pulse Width", "Intensity", "Duration", "Session Freq."],
        [
          ["Tibialis Anterior", "Motor point + distal muscle belly", "35–50 Hz", "200–300 µs", "Visible contraction (patient comfort)", "20–30 min", "Once daily"],
          ["Quadriceps (R – partial reinn.)", "Rectus femoris + VMO motor points", "35 Hz", "250 µs", "Visible quad contraction", "20 min", "Once daily"],
          ["Gluteus Medius/Maximus", "Motor points", "30 Hz", "250 µs", "Visible contraction", "15 min", "Once daily"],
          ["Peroneal nerve (common)", "Fibular head area", "40 Hz (FES)", "300 µs", "Foot eversion/DF response", "20 min", "Once daily"],
        ],
        [1900, 2000, 1100, 1100, 1900, 1000, 1000]
      ),
      noteBox("NMES is not a substitute for active exercise. Use concurrently. Reassess motor response monthly and titrate parameters."),

      spacer(80),
      subLabel("4.6  Orthotic Management"),
      bul("Ankle-Foot Orthosis (AFO): Rigid or dynamic AFO for bilateral foot drop during ambulation and daily activities. Custom-moulded preferred.", 0, C.teal, true),
      bul("Knee-Ankle-Foot Orthosis (KAFO): Consider for L side if quadriceps MRC <2, to permit safe upright standing.", 0, C.teal, true),
      bul("Splinting at night: Resting ankle splints at 90° to prevent equinus contracture."),
      bul("Wheelchair with appropriate pressure cushion: while non-ambulatory or for long distances."),
      bul("Walking aids progression: Hoist/standing frame → parallel bars → wheeled walker → forearm crutches → single stick."),
      bul("Refer to orthotist for formal fitting and review at each phase transition."),

      spacer(80),
      subLabel("4.7  Sit-to-Stand and Early Weight-Bearing Training"),
      bul("Tilt table: Begin passive tilting at 30°, increase 10° every 2–3 sessions toward 80° vertical. Monitor BP and HR throughout."),
      bul("Standing frame: Once tilt table tolerance achieved to 70°+, transition to standing frame with upper limb weight-bearing support."),
      bul("Partial weight-bearing with hoist: Body-weight supported treadmill training (BWSTT) – 40–60% unloading, 0.3–0.8 km/h, 15–20 min, 3×/week."),
      bul("Progress to parallel bars for standing balance and stepping once MMT quadriceps R ≥2 and KAFO applied for L."),
      bul("Sit-to-stand training: Start with raised chair height, upper limb push-off; reduce chair height and arm support progressively."),

      spacer(80),
      subLabel("4.8  Session Structure (Phase 2 – Typical 60-min Session)"),
      makeTbl(
        ["Time", "Activity", "Duration"],
        [
          ["0–5 min", "Assessment: BP, HR, SpO2, fatigue/pain NRS", "5 min"],
          ["5–15 min", "Warm-up: PROM all lower limb joints + gentle AROM-A", "10 min"],
          ["15–30 min", "Targeted AROM-A / strengthening exercises (as above)", "15 min"],
          ["30–45 min", "NMES / FES or hydrotherapy (alternate days)", "15 min"],
          ["45–55 min", "Functional training: sitting balance, sit-to-stand, standing frame/BWSTT", "10 min"],
          ["55–60 min", "Cool-down: repositioning, splint application, documentation", "5 min"],
        ],
        [1200, 6000, 1800]
      ),

      spacer(120),

      // ══════════════════════════════════════════════════════════════════
      // SECTION 5 – PHASE 3
      // ══════════════════════════════════════════════════════════════════
      sectionBanner("SECTION 5: PHASE 3 — LATE RECOVERY & COMMUNITY REINTEGRATION", C.green),

      p([tr("Entry criteria: Independent transfers, partial weight-bearing, fatigue manageable on exertion, no autonomic instability. Typically months 4–18+ post-onset.", { size: 18, italics: true, color: C.grey })],
        { indent: 120, before: 60, after: 100 }),

      subLabel("5.1  Progressive Strengthening Program"),
      makeTbl(
        ["Exercise", "Equipment", "Starting Load", "Progression", "Frequency"],
        [
          ["Leg press (bilateral)", "Leg press machine / elastic band", "40–50% 1RM", "Add 5–10% load every 2 weeks if MMT stable", "3 × 10, 3×/week"],
          ["Knee extension machine (R side)", "Weight machine / theraband", "Light resistance", "Increase resistance when 3 × 15 comfortable", "3 × 12, 3×/week"],
          ["Hip abduction – standing", "Theraband / cable", "Light band", "Progress band resistance", "3 × 12, 3×/week"],
          ["Calf raises (bilateral, wall support)", "Bodyweight → weighted vest", "Bilateral partial", "Progress to unilateral when MRC ≥3", "3 × 15, 3×/week"],
          ["Tibialis anterior strengthening", "Theraband dorsiflexion", "Light band", "Progress band; add ankle weights", "3 × 15, daily"],
          ["Step-ups (low step 5→10→15 cm)", "Step board", "Handrail support", "Reduce handrail dependence", "3 × 8 each leg, 3×/week"],
          ["Cycling (recumbent)", "Recumbent bike", "Low resistance, 10 min", "Add 5 min/week; increase resistance monthly", "Daily, 20–40 min target"],
          ["Aquatic jogging / deep water running", "Pool with flotation belt", "15 min", "Progress to 30 min", "3×/week"],
        ],
        [2200, 1800, 1400, 2400, 1200]
      ),
      noteBox("Evidence: De León-Muñoz et al. 2026 systematic review (Arch Phys Med Rehabil, PMID 41038424) found exercise programs improved fatigue and functional capacity in GBS. Moderate intensity preferred; avoid maximal effort."),

      spacer(80),
      subLabel("5.2  Gait Retraining Program"),
      bul("Continue BWSTT – progressively reduce body weight support: 40% → 20% → 0%."),
      bul("Treadmill training without support: 0.5–2.5 km/h; increase 0.2 km/h per week as tolerated."),
      bul("Gait analysis: Address foot drop with FES during gait cycle; train heel-strike, stance phase, push-off sequence."),
      bul("Obstacle course: Low obstacles, varied surfaces (carpet, tile, outdoor), step negotiation."),
      bul("Stair training: Step-to pattern initially; progress to reciprocal pattern with banister; progress to without banister."),
      bul("Outdoor mobility: Uneven terrain, kerbs, slopes."),
      bul("Fall prevention education: Footwear, home hazard removal, emergency fall recovery techniques."),
      bul("AFO review: Reassess every 3 months; transition from rigid to dynamic AFO as dorsiflexion recovers (MRC ≥3)."),

      spacer(80),
      subLabel("5.3  Balance and Proprioception Training"),
      makeTbl(
        ["Exercise", "Equipment", "Progression"],
        [
          ["Single-leg stance (R side, AFO)", "Parallel bars / wall", "Eyes open → eyes closed; stable → foam surface"],
          ["Wobble board balance", "Wobble board", "Bilateral → unilateral; static → dynamic"],
          ["Perturbation training", "Therapist-applied gentle pushes", "Anticipated → unanticipated; standing → ambulation"],
          ["Tandem walking", "Corridor / balance beam", "Parallel bars → free; add dual task (counting, carrying)"],
          ["Sit-to-stand repeated", "Chair of varying heights", "High chair → standard → low; no arm support"],
          ["Virtual reality balance (if available)", "VR headset / Wii Balance Board", "Increase task complexity monthly"],
        ],
        [2400, 2100, 4500]
      ),

      spacer(80),
      subLabel("5.4  Fatigue Management"),
      bul("Fatigue is the #1 barrier to GBS recovery. De León-Muñoz et al. 2026 confirmed exercise programs significantly reduce GBS-related fatigue.", 0, C.teal, true),
      bul("Energy conservation techniques: Prioritise activities, use assistive devices, schedule rest."),
      bul("Pacing: Work:rest ratio 1:1 initially; progress to 2:1 as stamina builds."),
      bul("Sleep hygiene: 8–9 hours; avoid heavy exercise within 3 hours of sleep."),
      bul("Exercise timing: Mid-morning (avoid early morning stiffness; avoid afternoon heat)."),
      bul("Fatigue diary: Track daily energy levels, exercise tolerance, functional tasks completed. Review with physiotherapist weekly."),

      spacer(80),
      subLabel("5.5  Activities of Daily Living (ADL) & Occupational Integration"),
      bul("ADL training: Dressing (lower body), bathing, kitchen tasks in standing/sitting – graded by energy demands."),
      bul("Occupational therapy referral: Home assessment, adaptive equipment (shower chair, grab rails, raised toilet seat, perching stool)."),
      bul("Driving assessment: When bilateral lower limb MMT ≥4 and reaction time normalises."),
      bul("Return to work: Phased return; ergonomic workstation assessment; liaison with employer as required."),

      spacer(120),

      // ══════════════════════════════════════════════════════════════════
      // SECTION 6 – OUTCOME MEASURES
      // ══════════════════════════════════════════════════════════════════
      sectionBanner("SECTION 6: OUTCOME MEASURES & REVIEW SCHEDULE", C.purple),

      makeTbl(
        ["Outcome Measure", "Domain Assessed", "Frequency", "Target Threshold"],
        [
          ["MRC Manual Muscle Test (all lower limb groups)", "Muscle strength", "Weekly (Phase 1–2), Monthly (Phase 3)", "Progressive improvement; Phase 3 target ≥MRC 3 key groups"],
          ["GBS Disability Scale (0–6)", "Overall functional disability", "Every 2 weeks", "Achieve GBS ≤2 (walking independently 10 m) by 6 months"],
          ["Barthel Index (0–100)", "ADL independence", "Monthly", "Target ≥75/100 by 12 months"],
          ["10-Metre Walk Test (10MWT)", "Walking speed", "Phase 2 entry, then monthly", "Comfortable gait speed >0.6 m/s community ambulation"],
          ["Timed Up and Go (TUG)", "Mobility and fall risk", "Monthly from Phase 2", "<12 sec = low fall risk"],
          ["Berg Balance Scale (BBS)", "Balance", "Monthly from Phase 2", "BBS >45/56 = low fall risk"],
          ["Fatigue Severity Scale (FSS)", "Fatigue", "Monthly", "FSS <4 = mild fatigue"],
          ["Numeric Pain Rating Scale (NRS 0–10)", "Pain", "Each session", "Target NRS ≤3 during exercise"],
          ["Spirometry (FVC, FEV1)", "Respiratory function (Phase 1–2)", "Phase 1: twice weekly", "FVC >80% predicted = safe"],
          ["Patient-Reported Global Impression of Change (PGIC)", "Subjective recovery", "Monthly", "PGIC ≥5 ('much improved')"],
        ],
        [2700, 2000, 1700, 2600]
      ),

      spacer(80),
      subLabel("6.1  Multidisciplinary Review Schedule"),
      makeTbl(
        ["Review", "Frequency", "Team Members"],
        [
          ["Bedside/outpatient physiotherapy session", "5 days/week (acute); 3 days/week (recovery)", "Physiotherapist"],
          ["MDT case conference", "Every 2 weeks (Phase 1–2); monthly (Phase 3)", "Neurologist, Physiotherapist, OT, Nurse, Dietitian"],
          ["Neurological review + repeat EMG/NCV", "At 3 months, 6 months, 12 months post-onset", "Neurologist / Dr. Nilesh Bhandari"],
          ["Orthotist review", "At Phase transition and every 3 months", "Orthotist, Physiotherapist"],
          ["Psychological review", "Monthly; urgent if PHQ-9 ≥10", "Clinical Psychologist"],
          ["Nutritional review", "Monthly", "Dietitian (caloric demands for rehabilitation)"],
        ],
        [2600, 2800, 3600]
      ),

      spacer(120),

      // ══════════════════════════════════════════════════════════════════
      // SECTION 7 – HOME PROGRAMME
      // ══════════════════════════════════════════════════════════════════
      sectionBanner("SECTION 7: HOME EXERCISE PROGRAMME (HEP)", C.orange),

      p([tr("To be commenced when patient/carer is trained and Phase 2 exercises are established. Review and update at each outpatient visit.", { size: 18, italics: true, color: C.grey })],
        { indent: 120, before: 60, after: 100 }),

      makeTbl(
        ["Exercise", "Reps / Duration", "Frequency", "Key Points"],
        [
          ["Ankle PROM circles (carer-assisted)", "20 circles each direction, each ankle", "3×/day", "Gentle; full range; stop if pain"],
          ["Active ankle pumps (if any return)", "20 reps each foot", "Every waking hour", "Flex and extend as far as possible"],
          ["Seated knee extension (gravity or band)", "3 × 10 each leg", "2×/day", "Seated on chair; full extension; pause 2 sec"],
          ["Hip abduction in sidelying", "3 × 10 each side", "1×/day", "Support from surface; slow controlled"],
          ["Bridging (if able)", "3 × 10", "1×/day", "Feet flat, lift hips; hold 3 sec"],
          ["Deep breathing", "5 deep breaths, hold 3 sec", "3×/day", "Diaphragmatic; expand lower chest"],
          ["Repositioning (carer)", "Every 2 hours", "Day and night", "Supine → Right lateral → Supine → Left lateral"],
          ["AFO wear schedule", "Whenever out of bed / ambulating", "All waking hours", "Remove for skin check morning and night"],
          ["NMES at home (if device provided)", "20–30 min on Tibialis Anterior + Quad", "1–2×/day", "Follow settings prescribed by physiotherapist"],
        ],
        [2600, 1900, 1600, 2900]
      ),

      spacer(80),
      warningBox("Caregiver red flags: Call emergency services if patient develops difficulty breathing, swallowing, new arm weakness, racing/irregular heartbeat, inability to pass urine, or sudden severe headache."),

      spacer(120),

      // ══════════════════════════════════════════════════════════════════
      // SECTION 8 – SPECIAL CONSIDERATIONS
      // ══════════════════════════════════════════════════════════════════
      sectionBanner("SECTION 8: SPECIAL CONSIDERATIONS FOR AMAN", C.red),

      subLabel("8.1  AMAN vs. AIDP: Why This Matters for Rehab"),
      bul("AMAN involves axonal degeneration (not just demyelination). Recovery depends on axonal regeneration (1–2 mm/day) and collateral reinnervation – significantly slower than AIDP.", 0, C.red, true),
      bul("Two sub-patterns in AMAN: (a) Reversible conduction failure → fast recovery; (b) Extensive axonal degeneration (Mrs. Prabha Devi's pattern, given total denervation on EMG) → prolonged recovery over 12–24 months."),
      bul("This means Phase 1 and 2 may be extended. DO NOT rush strengthening or weight-bearing progression."),
      bul("Upper limb NCV is fully preserved → no upper limb physiotherapy needed beyond positioning. Upper limbs can assist in mobility aids and ADL."),

      spacer(80),
      subLabel("8.2  Pain Management in Physiotherapy"),
      bul("Neuropathic pain (burning, shooting) is common and may limit therapy. Coordinate with neurologist regarding gabapentin/pregabalin/amitriptyline."),
      bul("TENS (transcutaneous electrical nerve stimulation): High-frequency TENS (80–150 Hz) for pain modulation during sessions. 20–30 min, over painful areas."),
      bul("Heat therapy (caution): Moist heat to paraspinal and hip muscles to reduce muscular pain; AVOID direct heat over insensate skin."),
      bul("Positioning for pain: Side-lying with pillow between knees; leg elevation for aching."),

      spacer(80),
      subLabel("8.3  Nutritional Considerations"),
      bul("Rehabilitation increases caloric demand. Ensure adequate protein intake: 1.2–1.5 g/kg/day (≈56–70 g/day for 47 kg patient)."),
      bul("Vitamin D and calcium supplementation: Important for bone health during prolonged immobility."),
      bul("Hydration: ≥2L/day unless medically restricted."),
      bul("Refer to hospital dietitian for formal assessment."),

      spacer(80),
      subLabel("8.4  Prognosis Counselling Points (For Patient and Family)"),
      bul("Based on EAN/PNS 2023 guidelines: Needle EMG denervation and total muscle denervation are predictors of slower and incomplete recovery."),
      bul("Realistic timeline: Partial functional recovery possible within 12–18 months; full recovery less likely given total denervation pattern. Orthotic support may be lifelong for bilateral foot drop."),
      bul("However: AMAN with reversible conduction failure subtype CAN have rapid recovery. NCV/EMG at 3 months will clarify trajectory."),
      bul("Goal: Maximal achievable independence with appropriate assistive devices; community ambulation with AFO; manageable fatigue."),

      spacer(120),

      // ══════════════════════════════════════════════════════════════════
      // SECTION 9 – SUMMARY QUICK REFERENCE
      // ══════════════════════════════════════════════════════════════════
      sectionBanner("SECTION 9: QUICK REFERENCE SUMMARY CARD", C.teal),

      makeTbl(
        ["Phase", "Duration", "Key Interventions", "Contraindications / Cautions"],
        [
          [
            "Phase 1\nAcute",
            "Weeks 1–4",
            "PROM 2×/day all joints\nPositioning + AFOs\nRespiratory physio\nNMES (passive)\nDVT prevention\nTactile stimulation",
            "No active resistance\nMonitor BP/HR/SpO2\nNo heat over insensate areas\nStop if autonomic instability"
          ],
          [
            "Phase 2\nRecovery",
            "Weeks 4–16",
            "AROM-A gravity-eliminated\nCore stabilisation\nHydrotherapy\nNMES/FES\nTilt table → standing frame → BWSTT\nOrthotic fitting",
            "No high-resistance loads\nAvoid fatigue/overexertion\nMonitor for relapse\nFVC monitoring if respiratory symptoms"
          ],
          [
            "Phase 3\nRehabilitation",
            "Months 4–18+",
            "Progressive strengthening\nGait retraining\nBalance training\nADL training\nCycling / aquatic exercise\nFatigue pacing",
            "Respect fatigue limits\nAFO at all times until MRC ≥3 ankles\nFall prevention paramount\nAvoid overheating"
          ],
        ],
        [1400, 1000, 3300, 3300]
      ),

      spacer(100),
      noteBox("References: (1) van Doorn et al. EAN/PNS Guideline on GBS, J Periph Nerv Syst 2023; (2) Kiper P et al., Physical Exercise in GBS: A Scoping Review, J Clin Med 2025;14:2655; (3) De León-Muñoz A et al., Impact of Physical Exercise on Fatigue and Functional Capacity in GBS/CIDP, Arch Phys Med Rehabil 2026 [PMID 41038424]; (4) Physio-Pedia Tri-Phasic GBS Physiotherapy Protocol."),
      spacer(60),
      new Paragraph({
        children: [tr("Protocol prepared by: ______________________________   Date: ____________________   Designation: ____________________", { size: 18, color: C.grey })],
        spacing: { before: 160, after: 60 }, indent: { left: 360 },
        border: { top: { style: BorderStyle.SINGLE, size: 4, color: C.teal } },
      }),
      new Paragraph({
        children: [tr("Reviewed by Neurologist: ___________________________   Signature: _______________   Date: ____________________", { size: 18, color: C.grey })],
        spacing: { before: 80, after: 60 }, indent: { left: 360 },
      }),
      spacer(80),
    ],
  }],
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