from docx import Document
from docx.shared import Pt, Inches, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement

doc = Document()

# Page margins
from docx.shared import Inches
section = doc.sections[0]
section.top_margin = Inches(1)
section.bottom_margin = Inches(1)
section.left_margin = Inches(1.2)
section.right_margin = Inches(1.2)

# Normal style
style = doc.styles["Normal"]
style.font.name = "Times New Roman"
style.font.size = Pt(12)

# Title
title = doc.add_heading("E-Log Book: Short Discussions on Core Competencies in Internal Medicine", level=1)
title.alignment = WD_ALIGN_PARAGRAPH.CENTER
for run in title.runs:
    run.font.color.rgb = RGBColor(0x1F, 0x39, 0x7D)
    run.font.size = Pt(14)

subtitle = doc.add_paragraph("Department of Internal Medicine | Postgraduate Training Programme")
subtitle.alignment = WD_ALIGN_PARAGRAPH.CENTER
subtitle.runs[0].font.size = Pt(11)
subtitle.runs[0].font.italic = True

doc.add_paragraph()

# Helper to add section heading
def add_topic_heading(doc, text):
    h = doc.add_heading(text, level=2)
    for run in h.runs:
        run.font.color.rgb = RGBColor(0x1F, 0x39, 0x7D)
        run.font.size = Pt(12)
    return h

def add_body(doc, text):
    p = doc.add_paragraph(text)
    p.paragraph_format.space_after = Pt(6)
    p.paragraph_format.first_line_indent = Pt(18)
    for run in p.runs:
        run.font.name = "Times New Roman"
        run.font.size = Pt(12)
    return p

# ─────────────────────────────────────────────────────────────
# COGNITIVE (C) COMPETENCIES
# ─────────────────────────────────────────────────────────────
doc.add_heading("COGNITIVE COMPETENCIES", level=1).runs[0].font.size = Pt(13)

# 1
add_topic_heading(doc, "1. Pharmaco-therapeutics of Various Diseases and Complications")
add_body(doc,
    "Pharmacotherapeutics is the cornerstone of clinical medicine, encompassing the rational use of drugs to prevent, treat, and manage disease. "
    "In internal medicine, clinicians must understand not only the mechanism of action and pharmacokinetics of drugs but also their therapeutic indices, "
    "drug interactions, and adverse effect profiles. For instance, in hypertension management, ACE inhibitors are preferred in diabetic nephropathy owing "
    "to their renoprotective effects, while beta-blockers remain first-line post-myocardial infarction. In chronic conditions like heart failure, a "
    "combination of evidence-based therapies - RAAS inhibitors, beta-blockers, mineralocorticoid antagonists, and SGLT2 inhibitors - has dramatically "
    "improved mortality outcomes. Complications such as drug-induced nephrotoxicity, hepatotoxicity, or QT prolongation demand vigilant monitoring. "
    "Polypharmacy, especially in elderly patients, increases the risk of adverse events, necessitating periodic medication reconciliation. Prescribing "
    "must always balance efficacy with safety, guided by patient-specific factors including renal and hepatic function, comorbidities, and co-medications."
)

# 2
add_topic_heading(doc, "2. Health Issues Related to Environmental and Ecological Factors")
add_body(doc,
    "The environment exerts a profound influence on human health. Air pollution - including particulate matter (PM2.5), nitrogen oxides, and ground-level "
    "ozone - contributes to respiratory diseases such as asthma, COPD, and lung cancer, as well as cardiovascular morbidity. Water contamination with "
    "heavy metals (arsenic, lead) and microbial pathogens causes gastrointestinal illnesses, neurological damage, and chronic kidney disease. Climate "
    "change is recognised as a major public health threat: rising temperatures increase heat-related illness, vector-borne diseases (malaria, dengue) "
    "expand geographically, and extreme weather events displace populations. Occupational exposures - asbestos, silica, benzene - are linked to "
    "mesothelioma, silicosis, and haematological malignancies. Physicians must take detailed environmental and occupational histories, advocate for "
    "pollution control, and educate patients about reducing personal exposures. A healthy ecosystem is a prerequisite for community health."
)

# 3
add_topic_heading(doc, "3. Methods and Mechanisms of Rehabilitation Following Diseases")
add_body(doc,
    "Rehabilitation aims to restore functional capacity, improve quality of life, and facilitate reintegration into society following acute illness or "
    "chronic disability. It operates on the biopsychosocial model, addressing physical, psychological, and social domains. Cardiac rehabilitation "
    "post-myocardial infarction includes structured exercise, risk factor modification, and psychosocial support, reducing re-hospitalisation by up to "
    "30%. Pulmonary rehabilitation in COPD improves exercise tolerance and reduces exacerbation frequency. Neurological rehabilitation after stroke "
    "employs physiotherapy, occupational therapy, and speech-language pathology to optimise recovery through neuroplasticity. Multidisciplinary teams - "
    "comprising physicians, physiotherapists, occupational therapists, psychologists, social workers, and nurses - are essential. Early mobilisation, "
    "goal-setting, patient education, and family involvement are key principles. Rehabilitation is not merely restoration of function; it also "
    "encompasses vocational training and community reintegration to support long-term independence."
)

# 4
add_topic_heading(doc, "4. Palliative and Terminal Care")
add_body(doc,
    "Palliative care focuses on relieving suffering and improving quality of life for patients with serious, life-limiting illness and their families. "
    "It is not restricted to the terminal phase but should be integrated early alongside curative or disease-modifying treatments. Core components "
    "include effective pain management (using the WHO analgesic ladder), control of distressing symptoms such as dyspnoea, nausea and delirium, "
    "psychological and spiritual support, and honest, compassionate communication about prognosis and goals of care. Terminal care specifically "
    "addresses the final days of life, prioritising comfort, dignity, and family support. Advance care planning - including do-not-resuscitate orders "
    "and advance directives - ensures that patient wishes are honoured. The physician's role includes recognising the dying process, withdrawing futile "
    "interventions appropriately, and facilitating bereavement support. Palliative care requires cultural sensitivity and awareness, as attitudes to "
    "death and dying vary significantly across communities."
)

# 5
add_topic_heading(doc, "5. National and International Guidelines in Day-to-Day Practice and Teaching")
add_body(doc,
    "Clinical practice guidelines synthesise best available evidence to support clinical decision-making and standardise care. In India, national bodies "
    "such as ICMR, RSSDI, and API publish guidelines tailored to local epidemiology, resource availability, and population characteristics. "
    "Internationally, guidelines from the WHO, ACC/AHA, ESC, GOLD, and GINA are widely referenced. For example, the GOLD guidelines for COPD "
    "stratify patients by symptom burden and exacerbation risk to guide pharmacotherapy, while JNC/ISH hypertension guidelines provide blood pressure "
    "targets. In teaching, guidelines form the framework for evidence-based discussions, clinical case conferences, and audit. However, guidelines must "
    "be applied judiciously: they are derived from population-level evidence and may not suit every individual patient. Critical appraisal of guidelines "
    "- including the strength of underlying evidence and potential conflicts of interest - is a core academic skill for the practising physician."
)

# 6
add_topic_heading(doc, "6. Social and Economic Aspects of Illnesses, Outbreaks, and Epidemics")
add_body(doc,
    "Disease does not occur in isolation from its social context. Social determinants - poverty, education, housing, nutrition, and access to "
    "healthcare - are powerful drivers of morbidity and mortality. Non-communicable diseases disproportionately affect lower socioeconomic groups due "
    "to limited health literacy, dietary insecurity, and reduced access to preventive care. Outbreaks and epidemics carry significant economic "
    "consequences: the COVID-19 pandemic caused a global GDP contraction, catastrophic health expenditure for millions, and widened pre-existing "
    "inequalities. Infectious disease outbreaks disrupt trade, agriculture, and schooling, perpetuating cycles of poverty. Physicians must advocate "
    "for universal health coverage, engage with social welfare systems, and recognise catastrophic out-of-pocket expenditure as a barrier to care "
    "compliance. Community engagement, intersectoral collaboration, and addressing structural inequities are as important as biomedical interventions "
    "in epidemic response."
)

# 7
add_topic_heading(doc, "7. Analysis of Disease Patterns and Suggestions for Improvement in Management and Prevention")
add_body(doc,
    "Systematic observation of disease patterns - through clinical audits, surveillance data, and epidemiological studies - is fundamental to "
    "improving health outcomes. In clinical practice, recognising clusters of unusual presentations, treatment failures, or drug-resistant infections "
    "prompts investigation and reporting. Population-level analysis identifies risk factor trends, geographic disparities, and vulnerable sub-groups. "
    "For example, rising incidence of type 2 diabetes in urban youth points to lifestyle transitions requiring targeted preventive programmes. "
    "Audit cycles - comparing outcomes against benchmarks, implementing changes, and re-auditing - drive quality improvement. At the community level, "
    "sentinel surveillance and integrated disease surveillance (IDSP in India) enable early outbreak detection. Physicians should participate "
    "actively in disease notification systems, engage with public health teams, and contribute to evidence generation through case series, "
    "observational studies, and clinical trials to inform policy."
)

# 8
add_topic_heading(doc, "8. National Health Programs")
add_body(doc,
    "India's national health programmes address priority diseases and health challenges through structured, government-led initiatives. The National "
    "Tuberculosis Elimination Programme (NTEP) aims to end TB by 2025 through universal drug susceptibility testing and Nikshay Poshan Yojana "
    "nutritional support. The National Vector Borne Disease Control Programme (NVBDCP) targets malaria, dengue, filariasis, and kala-azar. The "
    "National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) provides screening and treatment "
    "infrastructure. Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PMJAY) provides health insurance coverage to economically vulnerable "
    "families. The Universal Immunisation Programme (UIP) prevents vaccine-preventable diseases in children. Physicians have a responsibility to be "
    "familiar with these programmes, to align their clinical practice with programme objectives, to counsel patients on available benefits, and to "
    "contribute to programme monitoring and evaluation."
)

# 9
add_topic_heading(doc, "9. Critique of Publications and Evidence-Based Medicine")
add_body(doc,
    "Evidence-based medicine (EBM) integrates the best available research evidence with clinical expertise and patient values. Critical appraisal "
    "skills allow clinicians to evaluate the validity, results, and applicability of published literature. Key questions include: Was the study design "
    "appropriate for the research question? Was randomisation and blinding adequate? What is the risk of bias? Are the results clinically, not just "
    "statistically, significant? For randomised controlled trials, the CONSORT checklist guides appraisal; for observational studies, STROBE; for "
    "systematic reviews, PRISMA. Understanding concepts such as number needed to treat (NNT), confidence intervals, p-values, and hazard ratios is "
    "essential. Publication bias - the tendency to publish positive trials - can distort the evidence base. Physicians should regularly engage with "
    "journal clubs, critically appraise guidelines, and apply findings in a patient-centred manner, recognising when evidence from trials may not "
    "generalise to their patients."
)

# 10
add_topic_heading(doc, "10. Levels of Prevention in Communicable and Non-Communicable Diseases")
add_body(doc,
    "Prevention is conceptualised across three levels. Primary prevention aims to prevent disease before it occurs: examples include vaccination "
    "against hepatitis B, vector control for malaria, tobacco cessation counselling, and dietary modification to prevent type 2 diabetes. "
    "Secondary prevention involves early detection and prompt treatment to halt disease progression: cervical cancer screening (Pap smear), blood "
    "pressure monitoring to detect hypertension, and TB contact tracing are key examples. Tertiary prevention focuses on minimising disability and "
    "complications once disease is established: diabetic foot care programmes, cardiac rehabilitation, and antiretroviral therapy to prevent "
    "immunological deterioration in HIV represent this level. In communicable diseases, isolation, quarantine, and contact tracing are additional "
    "tools. Primordial prevention - preventing the emergence of risk factors themselves through social and environmental policy - is increasingly "
    "recognised as the most upstream and impactful level of prevention."
)

# 11
add_topic_heading(doc, "11. Legislations Related to Organ Transplant, Brain Death, Informed Consent, and Human Rights")
add_body(doc,
    "The legal framework governing medical practice protects patient rights and ensures ethical conduct. The Transplantation of Human Organs and "
    "Tissues Act (THOTA), 1994 (amended 2011) in India regulates organ donation, including deceased (brain-dead) donor programmes and living "
    "donor transplantation, with safeguards against commercialisation. Brain death is legally defined and certified by a panel of four doctors, "
    "enabling organ retrieval. Informed consent is a cornerstone of medical ethics and law: a valid consent must be voluntary, given by a competent "
    "individual, and based on adequate information about diagnosis, proposed treatment, alternatives, and risks. The Indian Medical Council "
    "(Professional Conduct, Etiquette and Ethics) Regulations, 2002 codify physician duties. The Protection of Human Rights Act, 1993 and "
    "international instruments such as the UN Convention on the Rights of Persons with Disabilities affirm patient rights to dignity, "
    "non-discrimination, confidentiality, and autonomous decision-making. Knowledge of these frameworks guides ethical clinical practice."
)

# 12
add_topic_heading(doc, "12. Recent Advances in Internal Medicine")
add_body(doc,
    "Internal medicine continues to evolve rapidly, driven by advances in diagnostics, therapeutics, and technology. SGLT2 inhibitors have "
    "transformed the management of type 2 diabetes, heart failure, and chronic kidney disease through cardiorenal protective mechanisms beyond "
    "glycaemic control. GLP-1 receptor agonists offer significant cardiovascular and weight-loss benefits. In oncology, immune checkpoint inhibitors "
    "have revolutionised the treatment of lung cancer, melanoma, and haematological malignancies. Advances in genomics - including next-generation "
    "sequencing and pharmacogenomics - enable precision medicine by tailoring therapy to individual genetic profiles. Artificial intelligence "
    "applications in radiology, pathology, and risk prediction are gaining clinical traction. Point-of-care ultrasound (POCUS) has become an "
    "extension of the clinical examination. The COVID-19 pandemic accelerated mRNA vaccine technology and highlighted the role of telemedicine. "
    "Continuous professional development and engagement with journals, conferences, and CME activities are essential to staying current."
)

doc.add_page_break()

# ─────────────────────────────────────────────────────────────
# AFFECTIVE (A) COMPETENCIES
# ─────────────────────────────────────────────────────────────
doc.add_heading("AFFECTIVE COMPETENCIES", level=1).runs[0].font.size = Pt(13)

# 13
add_topic_heading(doc, "13. Teamwork, Cooperation, and Comprehensive Patient Care")
add_body(doc,
    "Modern medicine is inherently collaborative. No single clinician possesses the full breadth of expertise required to manage complex patients "
    "optimally; effective teamwork is therefore not optional but essential. In the hospital setting, the multidisciplinary team (MDT) - comprising "
    "physicians, surgeons, nurses, pharmacists, physiotherapists, dietitians, and social workers - coordinates care around the patient. Effective "
    "team function requires clear communication, mutual respect, defined roles, shared goals, and a willingness to learn from colleagues. Handover "
    "of care, a high-risk activity, must be structured and thorough to prevent errors. The postgraduate trainee must develop professional humility, "
    "recognise the limits of personal knowledge, seek consultation appropriately, and contribute constructively to ward rounds and case discussions. "
    "Interaction with patients and relatives must be compassionate, informative, and supportive. Ultimately, team-based care results in improved "
    "patient safety, better outcomes, and a more sustainable working environment for all healthcare professionals."
)

# 14
add_topic_heading(doc, "14. Ethical Principles, Professional Etiquette, and Patient Rights")
add_body(doc,
    "Medical ethics rests on four principles: autonomy (respecting patient self-determination), beneficence (acting in the patient's best interest), "
    "non-maleficence (avoiding harm), and justice (fair distribution of healthcare resources). Professional etiquette encompasses punctuality, "
    "appropriate dress, respectful language, maintenance of boundaries, and confidentiality. Patients have the right to be fully informed about their "
    "condition and treatment options, to refuse treatment, to seek a second opinion, and to have their privacy and dignity maintained. Disclosure of "
    "errors (the duty of candour) is both an ethical obligation and, increasingly, a legal one. Physicians must avoid conflicts of interest, declare "
    "them transparently when unavoidable, and never allow financial incentives to compromise clinical judgment. In all interactions, the physician "
    "must model integrity - demonstrating that the interests of the patient take precedence over personal, institutional, or commercial interests."
)

# 15
add_topic_heading(doc, "15. Communication Skills: Breaking Bad News and Patient Interaction")
add_body(doc,
    "Effective communication is a clinical skill of equal importance to technical medical competence. The SPIKES protocol is a widely taught framework "
    "for breaking bad news: Setting (private, comfortable environment), Perception (assess what the patient already knows), Invitation (ask how much "
    "detail the patient wishes), Knowledge (give information clearly and in simple language), Emotions (respond with empathy), Summarise and "
    "Strategise (outline next steps). Bad news must never be delivered abruptly, and the patient's emotional response must be acknowledged before "
    "further medical information is given. With relatives, the physician must balance confidentiality with the family's need for information, guided "
    "by patient consent. Communication with paramedical staff should be respectful, precise, and collaborative. Written communication - discharge "
    "summaries, referral letters - must be accurate and timely. Active listening, non-verbal cues, and the avoidance of medical jargon are fundamental "
    "skills that significantly improve patient satisfaction, adherence, and trust."
)

# 16
add_topic_heading(doc, "16. Equity, Equality, and Inclusive Care for Special Groups (Differently Abled and LGBTQIA+)")
add_body(doc,
    "Every patient, regardless of disability, sexual orientation, gender identity, religion, caste, or socioeconomic status, is entitled to equitable, "
    "non-judgmental, and dignified healthcare. Differently abled individuals face physical, communicative, and attitudinal barriers in healthcare "
    "settings. Physicians must ensure accessible consultations, use appropriate communication aids, and advocate for disability-friendly facilities. "
    "LGBTQIA+ individuals experience significant health disparities - higher rates of mental health conditions, substance use, HIV, and delayed "
    "presentations - partly due to discrimination, stigma, and past negative healthcare experiences. A non-judgmental approach, use of preferred "
    "pronouns, and an inclusive clinical environment are essential. Physicians must be aware of specific health needs: hormone therapy monitoring in "
    "transgender patients, sexual health screening in MSM, and mental health support across the spectrum. Cultural humility - recognising and "
    "continuously reflecting on one's own biases - is the foundation of equitable care, and must be cultivated throughout postgraduate training and "
    "beyond."
)

# Footer note
doc.add_paragraph()
footer_para = doc.add_paragraph(
    "Note: These discussions are intended as concise academic reflections for the postgraduate e-log book. "
    "Each topic may be expanded further with case-based examples from clinical postings."
)
footer_para.runs[0].font.size = Pt(10)
footer_para.runs[0].font.italic = True
footer_para.alignment = WD_ALIGN_PARAGRAPH.CENTER

# Save
output_path = "/tmp/workspace/elog-book/Elog_Book_Internal_Medicine_Competencies.docx"
doc.save(output_path)
print(f"Saved to: {output_path}")

from docx import Document
from docx.shared import Pt, Inches, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
import os

OUTPUT_DIR = "/tmp/workspace/elog-book/topics"
os.makedirs(OUTPUT_DIR, exist_ok=True)

def make_doc(filename, heading, category, body_text):
    doc = Document()
    section = doc.sections[0]
    section.top_margin = Inches(1)
    section.bottom_margin = Inches(1)
    section.left_margin = Inches(1.2)
    section.right_margin = Inches(1.2)

    style = doc.styles["Normal"]
    style.font.name = "Times New Roman"
    style.font.size = Pt(12)

    # Category label
    cat = doc.add_paragraph(category)
    cat.alignment = WD_ALIGN_PARAGRAPH.CENTER
    cat.runs[0].font.size = Pt(10)
    cat.runs[0].font.italic = True
    cat.runs[0].font.color.rgb = RGBColor(0x88, 0x88, 0x88)

    # Main heading
    h = doc.add_heading(heading, level=1)
    h.alignment = WD_ALIGN_PARAGRAPH.CENTER
    for run in h.runs:
        run.font.name = "Times New Roman"
        run.font.size = Pt(13)
        run.font.color.rgb = RGBColor(0x1F, 0x39, 0x7D)

    doc.add_paragraph()

    # Body
    p = doc.add_paragraph(body_text)
    p.paragraph_format.space_after = Pt(8)
    p.paragraph_format.first_line_indent = Pt(18)
    p.paragraph_format.line_spacing = Pt(22)
    for run in p.runs:
        run.font.name = "Times New Roman"
        run.font.size = Pt(12)

    doc.add_paragraph()
    footer = doc.add_paragraph("E-Log Book | Department of Internal Medicine | Postgraduate Training Programme")
    footer.alignment = WD_ALIGN_PARAGRAPH.CENTER
    footer.runs[0].font.size = Pt(9)
    footer.runs[0].font.italic = True
    footer.runs[0].font.color.rgb = RGBColor(0x88, 0x88, 0x88)

    path = os.path.join(OUTPUT_DIR, filename)
    doc.save(path)
    print(f"Saved: {path}")

# ── COGNITIVE ──────────────────────────────────────────────────────────────

make_doc(
    "01_Pharmaco_Therapeutics.docx",
    "Pharmaco-therapeutics of Various Diseases and Complications",
    "Cognitive Competency | E-Log Book Topic 1",
    "Pharmacotherapeutics is the cornerstone of clinical medicine, encompassing the rational use of drugs to prevent, treat, and manage disease. "
    "In internal medicine, clinicians must understand not only the mechanism of action and pharmacokinetics of drugs but also their therapeutic indices, "
    "drug interactions, and adverse effect profiles. For instance, in hypertension management, ACE inhibitors are preferred in diabetic nephropathy owing "
    "to their renoprotective effects, while beta-blockers remain first-line post-myocardial infarction. In chronic conditions like heart failure, a "
    "combination of evidence-based therapies - RAAS inhibitors, beta-blockers, mineralocorticoid antagonists, and SGLT2 inhibitors - has dramatically "
    "improved mortality outcomes. Complications such as drug-induced nephrotoxicity, hepatotoxicity, or QT prolongation demand vigilant monitoring. "
    "Polypharmacy, especially in elderly patients, increases the risk of adverse events, necessitating periodic medication reconciliation. Drug dosing "
    "adjustments are required in renal and hepatic impairment, and therapeutic drug monitoring is essential for narrow-therapeutic-index agents such as "
    "digoxin, vancomycin, and aminoglycosides. Prescribing must always balance efficacy with safety, guided by patient-specific factors including "
    "comorbidities, co-medications, age, and organ function. A thorough understanding of pharmacotherapy enables the clinician to optimise treatment "
    "outcomes while minimising preventable harm."
)

make_doc(
    "02_Environmental_Ecological_Health.docx",
    "Health Issues Related to Environmental and Ecological Factors",
    "Cognitive Competency | E-Log Book Topic 2",
    "The environment exerts a profound influence on human health. Air pollution - including particulate matter (PM2.5), nitrogen oxides, and ground-level "
    "ozone - contributes to respiratory diseases such as asthma, COPD, and lung cancer, as well as cardiovascular morbidity and premature mortality. "
    "Water contamination with heavy metals (arsenic, lead) and microbial pathogens causes gastrointestinal illnesses, neurological damage, and chronic "
    "kidney disease. Climate change is recognised as a major public health threat: rising temperatures increase heat-related illness, vector-borne "
    "diseases (malaria, dengue, chikungunya) expand geographically, and extreme weather events displace populations and disrupt health services. "
    "Occupational exposures - asbestos, silica, benzene, organophosphates - are linked to mesothelioma, silicosis, leukaemia, and acute toxic syndromes. "
    "Indoor air pollution from biomass fuel combustion remains a leading cause of COPD and pneumonia in rural India. Noise pollution contributes to "
    "cardiovascular disease and hearing loss. Physicians must take detailed environmental and occupational histories, maintain a high index of "
    "suspicion for exposure-related illness, advocate for pollution control policy, and educate patients on reducing personal exposures. A healthy "
    "ecosystem and sustainable environment are prerequisites for community health and wellbeing."
)

make_doc(
    "03_Rehabilitation.docx",
    "Methods and Mechanisms of Rehabilitation Following Diseases",
    "Cognitive Competency | E-Log Book Topic 3",
    "Rehabilitation aims to restore functional capacity, improve quality of life, and facilitate reintegration into society following acute illness or "
    "chronic disability. It operates on the biopsychosocial model, addressing physical, psychological, and social domains simultaneously. Cardiac "
    "rehabilitation post-myocardial infarction includes structured exercise training, risk factor modification, psychosocial support, and patient "
    "education, and has been shown to reduce re-hospitalisation by up to 30% and improve survival. Pulmonary rehabilitation in COPD improves exercise "
    "tolerance, reduces exacerbation frequency, and enhances health-related quality of life. Neurological rehabilitation after stroke employs "
    "physiotherapy, occupational therapy, and speech-language pathology to optimise recovery through neuroplasticity - the brain's capacity to "
    "reorganise functional pathways. Diabetic rehabilitation encompasses podiatry, nutritional counselling, and structured self-management education. "
    "Multidisciplinary teams - comprising physicians, physiotherapists, occupational therapists, psychologists, social workers, and nurses - are "
    "essential for coordinated rehabilitation. Key principles include early mobilisation, individualised goal-setting, patient and family education, "
    "and community reintegration. Rehabilitation is not merely restoration of physical function; it also encompasses vocational training and "
    "psychological recovery, supporting long-term independence and social participation."
)

make_doc(
    "04_Palliative_Terminal_Care.docx",
    "Palliative and Terminal Care",
    "Cognitive Competency | E-Log Book Topic 4",
    "Palliative care focuses on relieving suffering and improving quality of life for patients with serious, life-limiting illness and their families. "
    "It is not restricted to the terminal phase but should be integrated early alongside curative or disease-modifying treatments - a model supported "
    "by evidence showing that early palliative care improves both quality of life and, in some cancers, survival. Core components include effective "
    "pain management using the WHO analgesic ladder (progressing from non-opioids to weak opioids to strong opioids with adjuvants as needed), "
    "control of distressing symptoms such as dyspnoea, nausea, delirium, and constipation, and provision of psychological, social, and spiritual "
    "support. Terminal care specifically addresses the final hours to days of life, prioritising comfort, dignity, and the presence of family. "
    "Advance care planning - including do-not-resuscitate orders and advance directives - ensures that patient wishes regarding resuscitation and "
    "life-sustaining treatment are documented and honoured. The physician's role includes recognising the dying process, communicating prognosis "
    "honestly and compassionately, withdrawing futile interventions appropriately, and facilitating bereavement support. Cultural sensitivity "
    "regarding death and dying practices is essential to providing truly patient-centred end-of-life care."
)

make_doc(
    "05_National_International_Guidelines.docx",
    "National and International Guidelines in Day-to-Day Practice and Teaching",
    "Cognitive Competency | E-Log Book Topic 5",
    "Clinical practice guidelines synthesise the best available evidence to support clinical decision-making and standardise the quality of care. "
    "In India, national bodies such as ICMR, RSSDI, API, and the Ministry of Health publish guidelines tailored to local epidemiology, resource "
    "availability, and population characteristics. Internationally, guidelines from the WHO, ACC/AHA, ESC, GOLD, GINA, KDIGO, and ISTH are widely "
    "referenced. For example, the GOLD guidelines for COPD stratify patients by symptom burden and exacerbation risk to guide stepwise "
    "pharmacotherapy, while JNC/ISH hypertension guidelines provide blood pressure targets and first-line drug recommendations. ADA/EASD consensus "
    "reports guide the management of type 2 diabetes, incorporating cardiovascular and renal risk. In teaching, guidelines form the framework for "
    "evidence-based ward rounds, clinical case conferences, and postgraduate examination revision. However, guidelines must be applied judiciously: "
    "they are derived from population-level evidence and may not suit every individual patient. Critical appraisal of guidelines - including the "
    "strength of underlying evidence (GRADE classification), panel composition, and potential conflicts of interest - is a core academic skill. "
    "Incorporating guidelines into daily practice reduces unwarranted clinical variation and improves patient outcomes."
)

make_doc(
    "06_Social_Economic_Aspects.docx",
    "Social and Economic Aspects of Illnesses, Outbreaks, and Epidemics",
    "Cognitive Competency | E-Log Book Topic 6",
    "Disease does not occur in isolation from its social context. Social determinants of health - poverty, education, housing, nutrition, sanitation, "
    "and access to healthcare - are powerful drivers of morbidity and mortality, often more influential than biological risk factors. Non-communicable "
    "diseases disproportionately affect lower socioeconomic groups due to limited health literacy, dietary insecurity, occupational hazards, and "
    "reduced access to preventive care. Outbreaks and epidemics carry significant economic consequences: the COVID-19 pandemic caused global GDP "
    "contraction, catastrophic out-of-pocket health expenditure for millions of households, workforce disruption, and the widening of pre-existing "
    "social inequalities. Infectious disease outbreaks disrupt trade, agriculture, tourism, and schooling, perpetuating cycles of poverty. Social "
    "stigma associated with conditions such as tuberculosis, HIV/AIDS, and mental illness leads to delayed presentation and treatment default. "
    "Physicians must advocate for universal health coverage and equitable resource allocation, engage with social welfare systems on behalf of "
    "patients, and recognise catastrophic expenditure as a barrier to care compliance. Community engagement, intersectoral collaboration across "
    "health, education, agriculture, and finance sectors, and addressing structural inequities are as important as biomedical interventions in "
    "both epidemic response and the long-term prevention of disease."
)

make_doc(
    "07_Disease_Pattern_Analysis.docx",
    "Analysis of Disease Patterns and Suggestions for Improvement in Management and Prevention",
    "Cognitive Competency | E-Log Book Topic 7",
    "Systematic observation and analysis of disease patterns - through clinical audits, hospital surveillance data, and epidemiological studies - "
    "is fundamental to improving health outcomes at both individual and population levels. In clinical practice, recognising clusters of unusual "
    "presentations, treatment failures, or drug-resistant infections prompts timely investigation, reporting to public health authorities, and "
    "protocol review. Population-level analysis identifies risk factor trends, geographic disparities, seasonal variation, and vulnerable "
    "sub-groups who require targeted interventions. For example, a rising incidence of type 2 diabetes in urban youth points to lifestyle "
    "transitions driven by sedentary behaviour and dietary change, requiring targeted school- and community-based preventive programmes. "
    "Audit cycles - comparing clinical outcomes against evidence-based benchmarks, implementing changes, and re-auditing - are a well-established "
    "quality improvement tool. The Plan-Do-Study-Act (PDSA) cycle provides a structured framework for iterative improvement. At the national level, "
    "sentinel surveillance networks and India's Integrated Disease Surveillance Programme (IDSP) enable early outbreak detection and rapid response. "
    "Physicians should actively participate in disease notification systems, engage with public health teams, and contribute to evidence generation "
    "through case series, observational studies, and clinical trials to inform management protocols and prevention policy."
)

make_doc(
    "08_National_Health_Programs.docx",
    "National Health Programs",
    "Cognitive Competency | E-Log Book Topic 8",
    "India's national health programmes address priority diseases and health challenges through structured, government-led initiatives with "
    "defined targets, protocols, and monitoring systems. The National Tuberculosis Elimination Programme (NTEP) - formerly RNTCP - aims to end "
    "TB by 2025, five years ahead of the global target, through universal drug susceptibility testing, Nikshay Poshan Yojana nutritional support, "
    "and the provision of free DOTS therapy. The National Vector Borne Disease Control Programme (NVBDCP) targets malaria, dengue, filariasis, "
    "kala-azar, Japanese encephalitis, and chikungunya. The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular "
    "Diseases and Stroke (NPCDCS) provides population-level screening and district-level treatment infrastructure. Ayushman Bharat - Pradhan "
    "Mantri Jan Arogya Yojana (PMJAY) provides health insurance coverage of up to Rs. 5 lakhs per family per year to economically vulnerable "
    "households. The Universal Immunisation Programme (UIP) prevents vaccine-preventable diseases and has been expanded to include newer vaccines "
    "such as rotavirus, pneumococcal conjugate, and HPV vaccines. The National Mental Health Programme and the National Programme for Health Care "
    "of the Elderly address other priority areas. Physicians have a responsibility to be familiar with these programmes, align clinical practice "
    "with programme objectives, counsel patients on available benefits, and contribute to programme monitoring, data collection, and evaluation."
)

make_doc(
    "09_Evidence_Based_Medicine.docx",
    "Critique of Publications and Evidence-Based Medicine (EBM)",
    "Cognitive Competency | E-Log Book Topic 9",
    "Evidence-based medicine (EBM) integrates the best available research evidence with clinical expertise and patient values to guide clinical "
    "decision-making. Critical appraisal skills allow clinicians to evaluate the validity, results, and applicability of published literature "
    "before incorporating findings into practice. Key appraisal questions include: Was the study design appropriate for the research question? "
    "Was randomisation and allocation concealment adequate in an RCT? Was blinding maintained? What are the potential sources of bias? Are the "
    "results clinically significant, not merely statistically significant? Reporting guidelines assist appraisal: CONSORT for randomised trials, "
    "STROBE for observational studies, PRISMA for systematic reviews, and STARD for diagnostic accuracy studies. Statistical literacy is essential - "
    "understanding p-values, confidence intervals, hazard ratios, number needed to treat (NNT), and number needed to harm (NNH) allows "
    "clinicians to contextualise findings meaningfully. Publication bias - the tendency to publish positive trials while negative trials remain "
    "unpublished - can distort the evidence base; funnel plot asymmetry and trial registration records help detect this. The hierarchy of evidence "
    "places systematic reviews and meta-analyses at the apex, followed by RCTs, cohort studies, case-control studies, and expert opinion. "
    "Physicians should regularly engage with journal clubs, critically appraise clinical guidelines, and apply EBM findings in a patient-centred "
    "manner, always recognising when trial evidence may not generalise to the individual patient before them."
)

make_doc(
    "10_Levels_of_Prevention.docx",
    "Levels of Prevention in Communicable and Non-Communicable Diseases",
    "Cognitive Competency | E-Log Book Topic 10",
    "Prevention of disease is conceptualised across four levels, each targeting a different stage of the disease process. Primordial prevention "
    "is the most upstream level, aiming to prevent the emergence and establishment of risk factors themselves through social, economic, and "
    "environmental policy - for example, regulating trans-fat content in processed foods or reducing tobacco advertising to prevent cardiovascular "
    "risk factors from developing in the population. Primary prevention aims to prevent disease occurrence in susceptible individuals: vaccination "
    "against hepatitis B and HPV, vector control for malaria, tobacco cessation counselling, dietary modification to prevent type 2 diabetes, and "
    "safe sex education for HIV prevention are key examples. Secondary prevention involves early detection and prompt treatment to halt disease "
    "progression before symptoms or complications arise: cervical cancer screening with Pap smear or VIA, blood pressure monitoring to detect "
    "hypertension, HbA1c screening in at-risk populations, and tuberculosis contact tracing represent this level. Tertiary prevention focuses on "
    "minimising disability and complications once disease is established: diabetic foot care programmes, cardiac rehabilitation post-MI, "
    "antiretroviral therapy to prevent immunological deterioration in HIV, and physiotherapy after stroke are important examples. In communicable "
    "diseases, additional tools include case isolation, quarantine of contacts, ring vaccination, and chemoprophylaxis. A comprehensive preventive "
    "strategy deploys interventions at all four levels simultaneously for maximum population impact."
)

make_doc(
    "11_Legislation_Ethics.docx",
    "Legislations Related to Organ Transplant, Brain Death, Informed Consent, and Human Rights",
    "Cognitive Competency | E-Log Book Topic 11",
    "The legal framework governing medical practice is designed to protect patient rights, ensure ethical conduct, and regulate complex biomedical "
    "practices. The Transplantation of Human Organs and Tissues Act (THOTA), 1994, amended in 2011, regulates organ donation and transplantation "
    "in India, permitting both deceased (brain-dead) donor programmes and living donor transplantation, with strict safeguards against "
    "commercialisation and organ trafficking. Brain death is legally defined under THOTA as the irreversible cessation of all brain functions "
    "including the brainstem, and must be certified by a panel of four doctors (including a neurologist/neurosurgeon and the treating physician) "
    "before organ retrieval can proceed. Informed consent is a cornerstone of both medical ethics and law: a valid consent must be voluntary, given "
    "by a competent individual with decision-making capacity, and based on adequate information about the diagnosis, proposed treatment, available "
    "alternatives, expected benefits, and material risks. Documentation of consent is mandatory. The Indian Medical Council (Professional Conduct, "
    "Etiquette and Ethics) Regulations, 2002 codify physician duties and professional standards. The Protection of Human Rights Act, 1993 and "
    "international instruments including the UN Convention on the Rights of Persons with Disabilities (UNCRPD) and the Universal Declaration of "
    "Human Rights affirm patients' rights to dignity, autonomy, non-discrimination, confidentiality, and access to healthcare. Knowledge of these "
    "legislative and ethical frameworks is indispensable to ethical, lawful, and patient-centred clinical practice."
)

make_doc(
    "12_Recent_Advances.docx",
    "Recent Advances in Internal Medicine",
    "Cognitive Competency | E-Log Book Topic 12",
    "Internal medicine is a rapidly evolving specialty, driven by advances in therapeutics, diagnostics, and technology. In cardiometabolic "
    "medicine, SGLT2 inhibitors have transformed the management of type 2 diabetes, heart failure with reduced and preserved ejection fraction, "
    "and chronic kidney disease through cardiorenal protective mechanisms that extend well beyond glycaemic control. GLP-1 receptor agonists "
    "offer significant cardiovascular risk reduction and substantial weight loss, with tirzepatide (dual GLP-1/GIP agonist) representing the "
    "next generation of this class. In infectious diseases, novel direct-acting antivirals have achieved cure rates above 95% in hepatitis C, "
    "and long-acting injectable antiretrovirals have transformed HIV management. In oncology, immune checkpoint inhibitors targeting PD-1/PD-L1 "
    "and CTLA-4 pathways have improved survival in lung cancer, melanoma, and haematological malignancies. CAR-T cell therapy offers curative "
    "potential in refractory haematological cancers. Advances in genomics - including next-generation sequencing and pharmacogenomics - enable "
    "precision medicine by tailoring therapy to individual genetic and molecular profiles. Artificial intelligence applications in radiology, "
    "pathology image analysis, ECG interpretation, and clinical risk prediction are entering mainstream practice. Point-of-care ultrasound (POCUS) "
    "has become a valued extension of the clinical examination. The COVID-19 pandemic accelerated mRNA vaccine technology and demonstrated the "
    "value of platform vaccine approaches for rapid response to emerging pathogens. Continuous professional development through peer-reviewed "
    "journals, international conferences, and accredited CME programmes is essential to remaining current in this dynamic field."
)

# ── AFFECTIVE ──────────────────────────────────────────────────────────────

make_doc(
    "13_Teamwork_Comprehensive_Care.docx",
    "Teamwork, Cooperation, and Comprehensive Patient Care",
    "Affective Competency | E-Log Book Topic 13",
    "Modern medicine is inherently collaborative. No single clinician possesses the full breadth of expertise required to manage complex patients "
    "optimally; effective teamwork is therefore not optional but essential to safe and high-quality care. In the hospital setting, the "
    "multidisciplinary team (MDT) - comprising physicians, surgeons, nurses, pharmacists, physiotherapists, dietitians, and social workers - "
    "coordinates care around the patient's individual needs and goals. Effective team function requires clear and respectful communication, "
    "mutual trust, well-defined roles and responsibilities, shared goals, psychological safety, and a genuine willingness to learn from "
    "colleagues of all disciplines. Structured handover of care at shift transitions, a high-risk activity, must be thorough and standardised "
    "(using tools such as SBAR - Situation, Background, Assessment, Recommendation) to prevent errors of omission. The postgraduate trainee "
    "must cultivate professional humility, recognise the limits of personal knowledge, seek consultation appropriately and in a timely manner, "
    "and contribute constructively to ward rounds, MDT meetings, and case conferences. Interaction with patients and relatives must be "
    "compassionate, informative, and supportive at all times. A positive team culture, characterised by open communication and mutual respect, "
    "reduces medical errors, improves patient outcomes, enhances staff wellbeing, and creates a more sustainable working environment for all "
    "healthcare professionals. The postgraduate physician must aspire to be both a capable team member and, in time, an effective team leader."
)

make_doc(
    "14_Ethics_Professionalism.docx",
    "Ethical Principles, Professional Etiquette, and Patient Rights",
    "Affective Competency | E-Log Book Topic 14",
    "Medical ethics rests on four foundational principles as articulated by Beauchamp and Childress: autonomy (respecting the patient's right "
    "to self-determination and informed decision-making), beneficence (acting in the patient's best interest), non-maleficence (avoiding "
    "unnecessary harm), and justice (fair and equitable distribution of healthcare resources). These principles frequently come into tension - "
    "for example, when a patient's autonomous choice conflicts with clinical best interest - and navigating these tensions requires careful, "
    "contextualised ethical reasoning. Professional etiquette encompasses punctuality, appropriate dress and demeanour, respectful and courteous "
    "language, maintenance of professional boundaries, and strict preservation of patient confidentiality. Patients have the legal and ethical "
    "right to be fully informed about their condition and all treatment options in language they can understand, to provide or withhold consent, "
    "to refuse treatment even if life-saving, to seek a second opinion, and to have their privacy, dignity, and religious and cultural beliefs "
    "respected at all times. The duty of candour - the obligation to be open and honest with patients when things go wrong - is both an ethical "
    "requirement and, increasingly, a legal one. Physicians must be vigilant about conflicts of interest, declare them transparently, and never "
    "allow financial incentives, gifts, or institutional pressures to compromise clinical judgment. In all professional interactions, the "
    "physician must model integrity, demonstrating unequivocally that the interests of the patient take precedence over personal, "
    "institutional, or commercial considerations."
)

make_doc(
    "15_Communication_Skills.docx",
    "Communication Skills: Breaking Bad News and Patient Interaction",
    "Affective Competency | E-Log Book Topic 15",
    "Effective communication is a clinical skill of equal importance to technical medical competence, yet it is often underemphasised in "
    "traditional medical training. Poor communication is a leading cause of patient dissatisfaction, treatment non-adherence, medico-legal "
    "complaints, and avoidable harm. The SPIKES protocol provides a structured, evidence-informed framework for breaking bad news: Setting "
    "(ensure a private, quiet, comfortable environment with the patient's chosen support person present), Perception (explore what the patient "
    "already understands about their condition), Invitation (ask the patient how much information they wish to receive), Knowledge (deliver "
    "information clearly, in plain language, pausing frequently to check understanding and avoiding medical jargon), Emotions (acknowledge and "
    "respond to the patient's emotional reaction with empathy before proceeding with further clinical information), and Summarise and Strategise "
    "(outline the management plan and immediate next steps clearly). Bad news must never be delivered abruptly or by telephone without prior "
    "preparation, and adequate time must be allocated. Communication with family members must respect patient confidentiality while providing "
    "appropriate support. With paramedical and nursing colleagues, communication must be respectful, precise, and collaborative. Written "
    "communication - discharge summaries, referral letters, death certificates - must be accurate, legible, and completed in a timely manner, "
    "as these documents directly affect continuity of care. Active listening, appropriate use of silence, open-ended questioning, and attention "
    "to non-verbal cues are skills that require deliberate practice and significantly improve patient trust, satisfaction, and clinical outcomes."
)

make_doc(
    "16_Equity_Inclusion_LGBTQIA.docx",
    "Equity, Equality, and Inclusive Care for Differently Abled and LGBTQIA+ Individuals",
    "Affective Competency | E-Log Book Topic 16",
    "Every patient, regardless of disability, sexual orientation, gender identity, religion, caste, ethnicity, or socioeconomic status, is "
    "entitled to equitable, non-judgmental, and dignified healthcare. Equity recognises that different individuals require different levels "
    "of support to achieve equal health outcomes, and is distinct from equality, which provides the same resource to all. Differently abled "
    "individuals face physical, communicative, and attitudinal barriers in healthcare settings: inaccessible buildings, lack of sign language "
    "interpreters, and unconscious bias among clinicians. Physicians must ensure accessible consultations, use appropriate communication aids, "
    "involve caregivers with patient consent, and advocate for disability-friendly health infrastructure. LGBTQIA+ individuals experience "
    "significant health disparities - higher rates of depression, anxiety, suicidality, substance use, HIV, and cervical and anal cancers - "
    "partly as a consequence of minority stress, discrimination, stigma, and prior negative healthcare experiences that create barriers to "
    "seeking care. A non-judgmental, affirming clinical approach is essential: using patients' preferred names and pronouns, asking about "
    "sexual and gender identity sensitively and only when clinically relevant, and maintaining a visibly inclusive clinical environment. "
    "Clinicians must be aware of specific health needs of this population: hormone therapy monitoring and bone health in transgender patients, "
    "sexual health screening and PrEP provision in men who have sex with men (MSM), and mental health support across the LGBTQIA+ spectrum. "
    "Cultural humility - the ongoing practice of recognising and reflecting on one's own biases and assumptions - rather than mere cultural "
    "competence, is the foundation of equitable care and must be cultivated actively throughout postgraduate training and lifelong practice."
)

print("\nAll 16 files created successfully in:", OUTPUT_DIR)

from docx import Document
from docx.shared import Pt, Inches, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
import os

OUTPUT_DIR = "/tmp/workspace/elog-book/topics_full"
os.makedirs(OUTPUT_DIR, exist_ok=True)

def make_doc(filename, topic_num, category, heading, sections):
    """
    sections: list of (subheading, body_text) tuples
    """
    doc = Document()
    sec = doc.sections[0]
    sec.top_margin = Inches(1)
    sec.bottom_margin = Inches(1)
    sec.left_margin = Inches(1.2)
    sec.right_margin = Inches(1.2)

    normal = doc.styles["Normal"]
    normal.font.name = "Times New Roman"
    normal.font.size = Pt(12)

    # ── Header bar ────────────────────────────────────────────
    cat_para = doc.add_paragraph(f"{category}  |  Topic {topic_num}")
    cat_para.alignment = WD_ALIGN_PARAGRAPH.CENTER
    r = cat_para.runs[0]
    r.font.size = Pt(10)
    r.font.italic = True
    r.font.color.rgb = RGBColor(0x55, 0x55, 0x55)

    # ── Main title ────────────────────────────────────────────
    title = doc.add_heading(heading, level=1)
    title.alignment = WD_ALIGN_PARAGRAPH.CENTER
    for run in title.runs:
        run.font.name = "Times New Roman"
        run.font.size = Pt(14)
        run.font.bold = True
        run.font.color.rgb = RGBColor(0x1A, 0x35, 0x6E)

    # divider
    div = doc.add_paragraph("─" * 80)
    div.alignment = WD_ALIGN_PARAGRAPH.CENTER
    div.runs[0].font.size = Pt(8)
    div.runs[0].font.color.rgb = RGBColor(0xAA, 0xAA, 0xAA)
    div.paragraph_format.space_after = Pt(4)

    # ── Sections ──────────────────────────────────────────────
    for (subheading, body) in sections:
        sh = doc.add_heading(subheading, level=2)
        sh.paragraph_format.space_before = Pt(10)
        sh.paragraph_format.space_after = Pt(4)
        for run in sh.runs:
            run.font.name = "Times New Roman"
            run.font.size = Pt(12)
            run.font.bold = True
            run.font.color.rgb = RGBColor(0x1A, 0x35, 0x6E)

        p = doc.add_paragraph(body)
        p.paragraph_format.space_after = Pt(8)
        p.paragraph_format.first_line_indent = Pt(18)
        p.paragraph_format.line_spacing = Pt(22)
        for run in p.runs:
            run.font.name = "Times New Roman"
            run.font.size = Pt(12)

    # ── Footer ────────────────────────────────────────────────
    doc.add_paragraph()
    foot = doc.add_paragraph(
        "E-Log Book  |  Department of Internal Medicine  |  Postgraduate Training Programme"
    )
    foot.alignment = WD_ALIGN_PARAGRAPH.CENTER
    foot.runs[0].font.size = Pt(9)
    foot.runs[0].font.italic = True
    foot.runs[0].font.color.rgb = RGBColor(0x88, 0x88, 0x88)

    path = os.path.join(OUTPUT_DIR, filename)
    doc.save(path)
    print(f"Saved: {path}")


# ══════════════════════════════════════════════════════════════════
# TOPIC 1
# ══════════════════════════════════════════════════════════════════
make_doc("01_Pharmaco_Therapeutics.docx", "1", "Cognitive Competency",
"Pharmaco-therapeutics of Various Diseases and Complications",
[
("Introduction",
 "Pharmacotherapeutics is the study of the rational use of drugs in the prevention, treatment, and management of disease. It bridges pharmacology "
 "and clinical medicine, requiring the clinician to understand not only how a drug works but also how it behaves in the body and how best to deploy "
 "it for maximum benefit and minimum harm. In internal medicine, virtually every patient encounter involves a therapeutic decision, making this "
 "domain central to daily practice."),

("Principles of Rational Drug Use",
 "Rational prescribing demands that the right drug be given to the right patient, at the right dose, by the right route, for the right duration. "
 "The clinician must weigh efficacy against safety, considering the therapeutic index (the ratio of toxic to effective dose), pharmacokinetics "
 "(absorption, distribution, metabolism, excretion), and pharmacodynamics (mechanism and site of action). Drug interactions - pharmacokinetic "
 "(e.g. rifampicin inducing CYP450 enzymes, reducing drug levels) and pharmacodynamic (e.g. additive QT prolongation) - must be actively sought. "
 "Dose adjustments are mandatory in renal impairment (e.g. reducing metformin, LMWH) and hepatic dysfunction (e.g. avoiding NSAIDs, high-dose "
 "paracetamol). Therapeutic drug monitoring (TDM) is essential for narrow-therapeutic-index drugs such as digoxin, vancomycin, phenytoin, and "
 "aminoglycosides."),

("Disease-Specific Pharmacotherapy",
 "In hypertension, ACE inhibitors are preferred in diabetic nephropathy for renoprotection, while calcium channel blockers are first-line in "
 "isolated systolic hypertension in the elderly. In heart failure with reduced ejection fraction, the evidence-based quadruple therapy - RAAS "
 "inhibitor (ACEi/ARB/ARNI), beta-blocker, mineralocorticoid antagonist, and SGLT2 inhibitor - has transformed mortality outcomes. In type 2 "
 "diabetes, SGLT2 inhibitors and GLP-1 receptor agonists are now preferred beyond HbA1c control due to cardiovascular and renal benefits. "
 "In COPD, inhaled bronchodilators (LABA, LAMA) and ICS are stratified by symptom burden and exacerbation risk. Antimicrobial stewardship "
 "principles - culture-guided therapy, shortest effective duration, de-escalation - must govern antibiotic prescribing to limit resistance."),

("Complications and Adverse Drug Reactions",
 "Adverse drug reactions (ADRs) are a major cause of morbidity and hospital admission. Type A reactions (dose-related, predictable) include "
 "ACE inhibitor-induced cough, metformin-associated lactic acidosis in renal failure, and corticosteroid-induced hyperglycaemia. Type B "
 "reactions (idiosyncratic, unpredictable) include penicillin anaphylaxis and sulphonamide-induced Stevens-Johnson syndrome. Drug-induced "
 "nephrotoxicity (NSAIDs, contrast agents, aminoglycosides), hepatotoxicity (antitubercular drugs, statins, paracetamol), and QT prolongation "
 "(fluoroquinolones, macrolides, antipsychotics) require vigilant monitoring. Polypharmacy in elderly patients dramatically increases ADR "
 "risk; the Beers Criteria identifies potentially inappropriate medications in this group. Medication reconciliation at every care transition "
 "is a safety-critical practice."),

("Pharmacotherapy in Special Populations",
 "Prescribing in pregnancy requires avoidance of teratogenic agents (ACE inhibitors, warfarin, tetracyclines, valproate in the first trimester) "
 "and preference for drugs with established safety profiles. Paediatric dosing must be weight-based; many adult drugs lack paediatric licensing. "
 "In the elderly, reduced renal clearance, altered volume of distribution, increased sensitivity to CNS drugs, and polypharmacy demand a "
 "'start low, go slow' approach. Genetic polymorphisms in CYP enzymes (e.g. CYP2D6 poor metabolisers and codeine toxicity) underpin the "
 "emerging field of pharmacogenomics, enabling precision prescribing tailored to individual metabolic profiles. The pharmacist is an essential "
 "partner in optimising drug therapy and identifying medication errors.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 2
# ══════════════════════════════════════════════════════════════════
make_doc("02_Environmental_Ecological_Health.docx", "2", "Cognitive Competency",
"Health Issues Related to Environmental and Ecological Factors",
[
("Introduction",
 "The environment in which people live, work, and play is one of the most powerful determinants of health. The World Health Organization estimates "
 "that 23% of all global deaths are attributable to modifiable environmental factors. Environmental medicine examines the relationship between "
 "physical, chemical, biological, and social environmental exposures and human health outcomes, informing both clinical practice and public health "
 "policy."),

("Air Pollution",
 "Outdoor air pollution - particulate matter (PM2.5 and PM10), nitrogen oxides, sulphur dioxide, carbon monoxide, and ground-level ozone - is "
 "the leading environmental cause of disease globally, causing respiratory illnesses (asthma, COPD, lung cancer), cardiovascular disease "
 "(ischaemic heart disease, stroke), and adverse pregnancy outcomes. India bears a disproportionate burden, with several cities consistently "
 "recording PM2.5 levels many times above WHO safe limits. Indoor air pollution from biomass fuel combustion (chulha cooking) is a major cause "
 "of COPD, pneumonia, and low birth weight in rural populations, particularly affecting women and children. Physicians should inquire about "
 "cooking fuel type, ventilation, and occupational exposures in all respiratory and cardiovascular cases."),

("Water, Soil, and Food Contamination",
 "Waterborne pathogens (Vibrio cholerae, Salmonella typhi, hepatitis A and E viruses) cause diarrhoeal diseases and hepatitis, contributing "
 "significantly to child mortality in developing nations. Chronic arsenic contamination of groundwater (West Bengal, Bangladesh) causes "
 "arsenicosis, peripheral neuropathy, skin cancers, and visceral malignancies. Lead exposure from paints, petrol, and industrial processes "
 "causes irreversible neurodevelopmental damage in children and cardiovascular disease in adults. Pesticide residues in food and "
 "organophosphate exposure in agricultural workers cause acute cholinergic toxicity and chronic neurological impairment."),

("Climate Change and Health",
 "Climate change is now recognised as the greatest health threat of the 21st century. Rising ambient temperatures increase heat stroke and "
 "heat exhaustion, particularly in urban heat islands and among outdoor workers and the elderly. Altered rainfall patterns and warming "
 "temperatures expand the geographic range of vector-borne diseases: malaria is spreading to previously unaffected highland areas, dengue "
 "has become hyperendemic across South Asia, and Lyme disease is extending northward. Extreme weather events - floods, cyclones, droughts - "
 "displace populations, destroy health infrastructure, and precipitate waterborne disease outbreaks. Climate-related food insecurity worsens "
 "malnutrition. Mental health consequences of climate disasters (post-traumatic stress disorder, anxiety, depression) are increasingly recognised."),

("Occupational and Ecological Factors",
 "Occupational exposures represent a significant but often under-recognised category of environmental disease. Asbestos causes mesothelioma "
 "and asbestosis with a latency of decades; silica causes silicosis and increases TB risk; benzene is leukaemogenic; coal dust causes "
 "pneumoconiosis. A thorough occupational history - covering all jobs held, materials handled, and protective equipment used - is an "
 "essential component of the clinical assessment. Deforestation and biodiversity loss increase zoonotic disease spillover events (Nipah, "
 "Ebola, COVID-19). Physicians have a professional duty to advocate for environmental protection, counsel patients on exposure reduction, "
 "and report occupational diseases to regulatory authorities.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 3
# ══════════════════════════════════════════════════════════════════
make_doc("03_Rehabilitation.docx", "3", "Cognitive Competency",
"Methods and Mechanisms of Rehabilitation Following Diseases",
[
("Introduction",
 "Rehabilitation is the process of helping individuals who have experienced illness, injury, or disability to achieve and maintain optimal "
 "physical, sensory, intellectual, psychological, and social functional levels. The WHO defines rehabilitation as a set of interventions "
 "designed to optimise functioning and reduce disability in individuals with health conditions in interaction with their environment. It "
 "is guided by the biopsychosocial model, addressing not just the biological impairment but also the person's activity limitations and "
 "participation restrictions within their social context. Early and structured rehabilitation consistently improves outcomes across a wide "
 "range of conditions."),

("Cardiac Rehabilitation",
 "Cardiac rehabilitation (CR) is a medically supervised programme delivered following myocardial infarction, coronary artery bypass grafting, "
 "percutaneous coronary intervention, or heart failure. It comprises three phases: inpatient mobilisation (Phase 1), supervised outpatient "
 "exercise and education (Phase 2), and long-term maintenance (Phase 3). Core components include structured aerobic exercise training, "
 "cardiovascular risk factor modification (smoking cessation, lipid management, blood pressure control, dietary counselling), psychosocial "
 "support for depression and anxiety (which are highly prevalent post-MI), and patient education on medications and lifestyle. Meta-analyses "
 "demonstrate that CR reduces cardiovascular mortality by 26% and re-hospitalisation by 18-25%. Despite strong evidence, CR remains "
 "underutilised, particularly among women and lower-income patients."),

("Pulmonary Rehabilitation",
 "Pulmonary rehabilitation (PR) is a comprehensive intervention for patients with chronic respiratory disease, most extensively studied in "
 "COPD. It combines supervised exercise training (aerobic and resistance), breathing techniques, education on inhaler technique and "
 "exacerbation self-management, and nutritional support. PR improves exercise capacity (six-minute walk distance), reduces dyspnoea, "
 "decreases exacerbation-related hospitalisations, and improves health-related quality of life. The mechanisms include peripheral muscle "
 "reconditioning, reduced dynamic hyperinflation, improved breathing efficiency, and reduced anxiety. PR is equally beneficial in "
 "interstitial lung diseases, bronchiectasis, and post-COVID respiratory sequelae."),

("Neurological Rehabilitation",
 "Stroke rehabilitation exploits neuroplasticity - the brain's capacity to reorganise neural pathways in response to learning and "
 "experience - to restore lost function. It must begin within 24-48 hours of stabilisation. Physiotherapy addresses motor deficits, "
 "spasticity, and gait. Occupational therapy focuses on activities of daily living and fine motor skills. Speech-language therapy manages "
 "dysphasia and dysphagia. Neuropsychological support addresses cognitive impairment, depression (present in 30-40% post-stroke), and "
 "behavioural changes. Constraint-induced movement therapy, mirror therapy, and robotic-assisted rehabilitation are emerging modalities. "
 "Rehabilitation after Guillain-Barre syndrome, traumatic brain injury, and spinal cord injury follows similar multidisciplinary principles."),

("Principles and Multidisciplinary Team",
 "Effective rehabilitation is delivered by a coordinated multidisciplinary team (MDT) comprising the physician, physiotherapist, "
 "occupational therapist, speech-language therapist, neuropsychologist, dietitian, social worker, and nursing staff. Key principles "
 "include: early commencement, individualised goal-setting using tools such as the SMART framework, active patient and family "
 "participation, and regular re-assessment to adjust the programme. Outcome measures - Barthel Index, FIM score, six-minute walk test, "
 "modified Rankin Scale - quantify progress objectively. Community reintegration, vocational rehabilitation, and peer support groups "
 "are integral to long-term recovery. Telemedicine-based rehabilitation is expanding access for patients in remote areas.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 4
# ══════════════════════════════════════════════════════════════════
make_doc("04_Palliative_Terminal_Care.docx", "4", "Cognitive Competency",
"Palliative and Terminal Care",
[
("Introduction and Philosophy",
 "Palliative care is an approach that improves the quality of life of patients and their families facing problems associated with life-threatening "
 "illness through the prevention and relief of suffering by means of early identification, impeccable assessment, and treatment of pain and other "
 "physical, psychosocial, and spiritual problems. Crucially, it is not limited to the terminal phase; the WHO and NICE guidelines recommend "
 "integrating palliative care early alongside disease-modifying treatment. The landmark NEJM study by Temel et al. (2010) demonstrated that early "
 "palliative care in metastatic lung cancer improved quality of life and median survival by nearly three months compared to standard oncology care alone."),

("Symptom Management",
 "Pain is the most feared symptom in serious illness. The WHO analgesic ladder provides a stepwise framework: Step 1 (non-opioids: paracetamol, "
 "NSAIDs), Step 2 (weak opioids: codeine, tramadol), Step 3 (strong opioids: morphine, oxycodone, fentanyl). Adjuvant analgesics - "
 "gabapentinoids (neuropathic pain), corticosteroids (nerve compression, bone pain), tricyclic antidepressants - are added at any step. "
 "Morphine is the opioid of choice for severe cancer pain; fears of addiction and respiratory depression must not prevent adequate dosing. "
 "Dyspnoea is managed with low-dose opioids, anxiolytics, and a fan directed at the face. Nausea and vomiting require antiemetics tailored "
 "to the likely mechanism (metoclopramide, cyclizine, haloperidol, ondansetron). Terminal restlessness and delirium are managed with "
 "midazolam and haloperidol via subcutaneous infusion (syringe driver)."),

("Psychosocial and Spiritual Support",
 "Psychological distress - anxiety, depression, fear of death, unfinished business - is nearly universal in life-limiting illness and "
 "requires active assessment and management. Validated tools such as the PHQ-9 and GAD-7 can identify depression and anxiety requiring "
 "pharmacological or psychological intervention. Social workers address financial concerns, housing, caregiver burden, and benefits "
 "entitlement. Chaplains and spiritual care professionals support patients and families of all faith traditions and none. Family meetings, "
 "involving the patient (unless they decline), clarify prognosis, align expectations, and plan care. Bereavement support for families "
 "begins before death and continues after, recognising that grief can be prolonged and complicated."),

("Advance Care Planning and Terminal Care",
 "Advance care planning (ACP) is the process by which patients, in dialogue with their healthcare team and family, express their values, "
 "goals, and wishes regarding future medical care. Advance directives (living wills) and DNAR (do not attempt resuscitation) orders must "
 "be documented clearly, respected, and reviewed regularly. The recognition of dying - typically characterised by reduced consciousness, "
 "Cheyne-Stokes breathing, mottling, and absent radial pulse - should trigger a shift to comfort-focused care, discontinuation of futile "
 "interventions (routine blood tests, monitoring, non-essential medications), and attention to mouth care, positioning, and family "
 "presence. Adequate symptom control must never be withheld out of misplaced concern about hastening death."),

("Palliative Care in India",
 "Palliative care services in India remain severely underdeveloped relative to need. Kerala has pioneered a community-based palliative care "
 "model that has achieved nationwide and international recognition. The National Programme for Palliative Care (NPPC) aims to integrate "
 "palliative services into the public health system. Access to oral morphine - the cornerstone of cancer pain management - has historically "
 "been restricted by regulatory barriers, though the Narcotic Drugs and Psychotropic Substances (NDPS) Act amendments have partially "
 "addressed this. Medical curricula must embed palliative care training to equip all doctors with fundamental skills in communication, "
 "symptom management, and end-of-life care.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 5
# ══════════════════════════════════════════════════════════════════
make_doc("05_National_International_Guidelines.docx", "5", "Cognitive Competency",
"National and International Guidelines in Day-to-Day Practice and Teaching",
[
("Introduction",
 "Clinical practice guidelines (CPGs) are systematically developed statements designed to assist practitioners and patients in making "
 "appropriate healthcare decisions for specific clinical circumstances. They represent the distillation of large bodies of evidence into "
 "actionable recommendations, graded by the strength and quality of supporting data. Incorporating guidelines into clinical practice "
 "reduces unwarranted variation in care, improves patient outcomes, and forms the foundation of evidence-based medicine in daily clinical work."),

("National Guidelines",
 "In India, several bodies produce guidelines relevant to internal medicine practice. The Indian Council of Medical Research (ICMR) "
 "publishes evidence-based guidelines on infectious diseases, diabetes, and cancer. The Research Society for the Study of Diabetes in "
 "India (RSSDI) provides consensus guidelines on type 2 diabetes management adapted to Indian metabolic and dietary patterns. The "
 "Association of Physicians of India (API) publishes clinical practice guidelines on hypertension, heart failure, and antimicrobial use. "
 "The Central TB Division's NTEP guidelines govern TB diagnosis and treatment. The National AIDS Control Organisation (NACO) provides "
 "ART protocols for HIV. These national guidelines account for local epidemiology, drug availability, resource constraints, and "
 "affordability - factors that global guidelines may not adequately address."),

("International Guidelines",
 "International guidelines from organisations such as the WHO, American College of Cardiology / American Heart Association (ACC/AHA), "
 "European Society of Cardiology (ESC), Global Initiative for Obstructive Lung Disease (GOLD), Global Initiative for Asthma (GINA), "
 "Kidney Disease Improving Global Outcomes (KDIGO), and the International Society on Thrombosis and Haemostasis (ISTH) are widely "
 "consulted. The GOLD guidelines categorise COPD patients by spirometry grade and symptom/exacerbation risk (ABCD groups, updated to "
 "ABE groups in 2023) to guide pharmacotherapy. ACC/AHA and ESC guidelines provide detailed algorithms for the management of acute "
 "coronary syndromes, heart failure, atrial fibrillation, and dyslipidaemia. ADA/EASD consensus reports guide individualised "
 "glycaemic targets and drug selection in diabetes."),

("Application in Teaching",
 "Guidelines are invaluable teaching tools in postgraduate medical education. Ward rounds structured around guideline-based care create "
 "teachable moments: why is this patient on an ARNI rather than an ACE inhibitor? Why has triple antiplatelet therapy not been used? "
 "Journal clubs and case conferences can use guideline recommendations as reference standards against which actual care is audited. "
 "Trainees should be taught not just the recommendations but the underlying evidence and the GRADE rating system (Grading of "
 "Recommendations Assessment, Development and Evaluation) that underpins recommendation strength (Strong vs. Conditional) and "
 "evidence quality (High, Moderate, Low, Very Low)."),

("Critical Appraisal of Guidelines",
 "Guidelines must be applied with critical intelligence, not followed blindly. Several important caveats apply. Guidelines are derived "
 "from trial populations that may not reflect the patient before you - trials systematically under-represent elderly patients, women, "
 "those with multiple comorbidities, and populations from low-income countries. Conflicts of interest among guideline panel members "
 "can influence recommendations, and disclosure of these must be scrutinised. Guidelines may lag behind emerging evidence by several "
 "years. Resource constraints may make adherence impossible in certain settings. The clinician's duty is to be aware of guidelines, "
 "understand their basis, and apply them intelligently with reference to the individual patient's values, comorbidities, and context.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 6
# ══════════════════════════════════════════════════════════════════
make_doc("06_Social_Economic_Aspects.docx", "6", "Cognitive Competency",
"Social and Economic Aspects of Illnesses, Outbreaks, and Epidemics",
[
("Social Determinants of Health",
 "Health is shaped far more by social, economic, and environmental conditions than by healthcare alone. The WHO Commission on Social "
 "Determinants of Health identified the 'causes of causes' - the structural conditions that generate health inequity: income and wealth "
 "distribution, education, employment, housing quality, food security, access to clean water and sanitation, and social support networks. "
 "These upstream factors explain why tuberculosis disproportionately affects the urban poor, why malnutrition co-exists with obesity in "
 "the same community, and why cardiovascular mortality is higher in lower socioeconomic groups despite effective treatments being available."),

("Impact of Illness on Individuals and Families",
 "Serious illness imposes profound social and economic burdens on patients and their families. In India, over 60% of healthcare expenditure "
 "is out-of-pocket, and a single hospitalisation for a major illness (stroke, cancer, myocardial infarction) can push a family into "
 "catastrophic expenditure and poverty. Chronic illness reduces workforce participation, impairs educational attainment in children of "
 "affected parents, and disrupts family functioning. Stigmatised conditions - tuberculosis, HIV/AIDS, epilepsy, mental illness, leprosy - "
 "cause social isolation, marital breakdown, and occupational discrimination, compounding the clinical disease burden. Physicians must "
 "screen for financial toxicity as part of holistic patient care and connect patients with available welfare schemes."),

("Economic Impact of Outbreaks and Epidemics",
 "Infectious disease outbreaks cause economic disruption far beyond the healthcare system. The 2003 SARS outbreak caused an estimated "
 "USD 54 billion in economic losses despite relatively limited mortality. The COVID-19 pandemic caused the largest global economic "
 "contraction since World War II, with global GDP declining by 3.5% in 2020. Mechanisms include workforce absenteeism, disruption of "
 "supply chains and trade, collapse of tourism and hospitality, school closures with long-term educational consequences, and the "
 "diversion of health budgets away from non-communicable disease care. In India, the economic burden fell most heavily on informal "
 "sector workers, migrant labourers, and small businesses with no social protection safety net."),

("Social Consequences of Epidemics",
 "Epidemics reshape societies. Social distancing measures during COVID-19 increased domestic violence, mental health disorders, and "
 "loneliness-related morbidity. School closures during the pandemic caused estimated learning losses equivalent to months of schooling, "
 "with disproportionate impact on girls and children from low-income households. Vaccine hesitancy - driven by misinformation, mistrust "
 "of institutions, and historical injustices in medical research - poses a growing social threat to epidemic control. Stigma and "
 "discrimination during outbreaks (as seen with HIV in the 1980s and COVID-19 against certain communities) impede public health "
 "responses by driving affected individuals away from testing and treatment services."),

("Role of the Physician in Addressing Social Determinants",
 "The clinician's role extends beyond the consultation room. Social prescribing - connecting patients with non-medical community "
 "resources such as housing assistance, food banks, employment support, and social groups - is an emerging model. Advocacy for "
 "universal health coverage (UHC), equitable distribution of healthcare infrastructure, and social protection policies is a "
 "professional responsibility. Participation in intersectoral taskforces that address housing, sanitation, nutrition, and education "
 "alongside health represents the most effective approach to improving population health. Physicians must document social risk factors "
 "systematically and integrate social workers into their teams to address them comprehensively.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 7
# ══════════════════════════════════════════════════════════════════
make_doc("07_Disease_Pattern_Analysis.docx", "7", "Cognitive Competency",
"Analysis of Disease Patterns and Suggestions for Improvement in Management and Prevention",
[
("Introduction",
 "The systematic observation, documentation, and analysis of disease patterns is the bridge between individual clinical care and population "
 "health. At the bedside, the astute clinician identifies outliers - unusual presentations, treatment failures, unexpected complications - "
 "that may signal emerging resistance, a misdiagnosis, or a novel pathogen. At the population level, surveillance data reveal incidence "
 "trends, geographic clusters, seasonal patterns, and at-risk subgroups, informing targeted public health interventions. The physician's "
 "role in generating and acting upon disease pattern data is indispensable to improving both individual and community health."),

("Clinical Audit and Quality Improvement",
 "Clinical audit is a quality improvement cycle that compares actual practice against defined evidence-based standards, identifies gaps, "
 "implements changes, and re-measures outcomes. The PDSA (Plan-Do-Study-Act) cycle is the standard framework for iterative quality "
 "improvement. For example, an audit of antibiotic prescribing practices in a medicine ward might reveal high rates of broad-spectrum "
 "antibiotic use without prior culture, prompting the implementation of an antimicrobial stewardship programme with subsequent "
 "re-audit demonstrating improved culture-guided prescribing. Key performance indicators (KPIs) - door-to-needle time in STEMI, "
 "30-day readmission rates in heart failure, glycaemic control rates in admitted diabetic patients - provide measurable benchmarks "
 "for quality improvement efforts."),

("Epidemiological Surveillance",
 "Disease surveillance is the ongoing, systematic collection, analysis, and interpretation of health data, used to plan, implement, "
 "and evaluate public health interventions. India's Integrated Disease Surveillance Programme (IDSP) operates a three-tiered system "
 "(community, primary health centre, district hospital) with weekly syndromic surveillance data reported through S, P, and L forms. "
 "Mandatory notifiable diseases under the Epidemic Diseases Act must be reported by clinicians promptly. Clinicians who fail to "
 "report a notifiable disease breach both legal and professional obligations. Sentinel surveillance - using a defined subset of "
 "healthcare facilities to monitor trends in specific conditions - is used for influenza, HIV, and antimicrobial resistance."),

("Recognising and Responding to Clusters",
 "The recognition of disease clusters - an unusual aggregation of cases in time, place, or person - is a core clinical and public "
 "health skill. A cluster of febrile illness with haemorrhagic features should prompt consideration of viral haemorrhagic fever; "
 "multiple cases of unexplained acute liver failure from a locality may indicate toxic hepatitis from contaminated food or water. "
 "When a cluster is recognised, the clinician should take detailed exposure histories across cases, liaise immediately with the "
 "district or state public health authority, collect appropriate microbiological specimens, and implement infection control measures "
 "while awaiting confirmation. Early identification of clusters and rapid public health response has contained outbreaks of Nipah "
 "virus, scrub typhus, and leptospirosis in India."),

("Suggestions for Improvement",
 "Based on disease pattern analysis, several improvement strategies may be implemented. First, strengthening disease notification "
 "compliance through training and simplified reporting systems. Second, using antimicrobial resistance data from institutional "
 "antibiograms to guide empirical therapy protocols. Third, employing risk stratification tools (e.g. CHA2DS2-VASc for AF, "
 "GRACE score for ACS) systematically to guide therapy. Fourth, establishing condition-specific registries to generate real-world "
 "outcomes data for Indian populations. Fifth, developing and validating clinical decision support tools embedded in electronic "
 "health records. Engaging with community health workers (ASHA, ANM) to improve case detection and referral pathways is also "
 "essential, particularly for tuberculosis, malnutrition, and maternal and child health.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 8
# ══════════════════════════════════════════════════════════════════
make_doc("08_National_Health_Programs.docx", "8", "Cognitive Competency",
"National Health Programs",
[
("Introduction",
 "National health programmes are structured, government-led public health initiatives designed to address priority diseases and health "
 "challenges at a population scale. They provide standardised protocols, supply chains, monitoring systems, and human resources to "
 "ensure consistent, equitable care across the country. Familiarity with these programmes enables the physician to align clinical "
 "practice with programme objectives, counsel patients on available benefits, link patients to programme services, and contribute "
 "to data collection and quality improvement."),

("Tuberculosis: National TB Elimination Programme (NTEP)",
 "Formerly the Revised National TB Control Programme (RNTCP), the NTEP aims to end TB in India by 2025, five years ahead of the "
 "global Sustainable Development Goal target. Key elements include universal access to free molecular testing (CBNAAT/TrueNat) for "
 "all presumptive TB cases, universal drug susceptibility testing, provision of free DOTS (Directly Observed Treatment, Short-course) "
 "and DR-TB regimens, Nikshay Poshan Yojana (Rs. 500/month nutritional support to all TB patients), and Ni-kshay digital platform "
 "for patient tracking. Active case finding and household contact investigation are mandated. Physicians must ensure all diagnosed TB "
 "patients are notified on Nikshay, as private sector notification is legally mandatory."),

("Vector-Borne and Communicable Disease Programmes",
 "The National Vector Borne Disease Control Programme (NVBDCP) controls malaria, dengue, chikungunya, filariasis, kala-azar, and "
 "Japanese encephalitis through integrated vector management, case detection, and treatment. The national kala-azar elimination "
 "target (< 1 case per 10,000 population at block level) has largely been achieved through indoor residual spraying and miltefosine "
 "therapy. The National AIDS Control Programme (NACP), under NACO, provides free antiretroviral therapy, prevention of parent-to-child "
 "transmission services, and targeted interventions for high-risk groups. The Universal Immunisation Programme (UIP) delivers ten "
 "antigens through the national schedule, with recent additions including rotavirus, pneumococcal conjugate, IPV, and the HPV "
 "vaccine for adolescent girls (Cervavac)."),

("Non-Communicable Disease and Other Programmes",
 "The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) provides "
 "population-level screening at health and wellness centres (HWC) under Ayushman Bharat - Health and Wellness Centres, and "
 "treatment support at district hospitals. The National Mental Health Programme (NMHP) aims to integrate mental health services "
 "into primary care. The Pradhan Mantri National Dialysis Programme provides free dialysis to BPL patients with CKD. The National "
 "Programme for Health Care of the Elderly (NPHCE) addresses the growing burden of geriatric disease."),

("Ayushman Bharat and Universal Health Coverage",
 "Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PMJAY), launched in 2018, is the world's largest government-funded health "
 "insurance scheme, providing cashless hospitalisation coverage of up to Rs. 5 lakhs per family per year to approximately 500 "
 "million economically vulnerable individuals. Empanelled hospitals (public and private) provide covered services without any "
 "out-of-pocket payment. Physicians must be aware of the scheme's benefits and covered packages, counsel eligible patients proactively, "
 "and ensure that administrative processes do not delay necessary care. The National Health Mission (NHM) provides the overarching "
 "framework for strengthening rural and urban primary healthcare infrastructure, with Reproductive and Child Health (RCH) and "
 "communicable disease control as core components.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 9
# ══════════════════════════════════════════════════════════════════
make_doc("09_Evidence_Based_Medicine.docx", "9", "Cognitive Competency",
"Critical Appraisal of Publications and Evidence-Based Medicine",
[
("Introduction and Definition",
 "Evidence-based medicine (EBM) was formally defined by Sackett et al. in 1996 as 'the conscientious, explicit, and judicious use of "
 "current best evidence in making decisions about the care of individual patients.' It integrates three elements: the best available "
 "external evidence from systematic research, the clinician's individual expertise and experience, and the patient's values, "
 "preferences, and circumstances. EBM does not replace clinical judgment; rather, it informs and disciplines it, ensuring that "
 "treatment decisions are grounded in reliable evidence rather than habit, anecdote, or authority."),

("Hierarchy of Evidence",
 "Evidence is arranged in a hierarchy according to the strength of inference it permits. At the apex are systematic reviews and "
 "meta-analyses, which pool data from multiple high-quality studies to provide the most precise and generalisable estimates. "
 "Well-conducted randomised controlled trials (RCTs) with adequate blinding and allocation concealment sit below, followed by "
 "cohort studies, case-control studies, cross-sectional studies, case series, and expert opinion. The GRADE system (Grading of "
 "Recommendations Assessment, Development and Evaluation) rates evidence quality as High, Moderate, Low, or Very Low, and "
 "recommendation strength as Strong or Conditional (Weak), providing a transparent framework for guideline development. "
 "Clinicians should always ask: what is the study design, and what level of evidence does it provide?"),

("Critical Appraisal of Randomised Controlled Trials",
 "For RCTs, the critical appraisal framework asks: Was the research question clear (PICO format: Population, Intervention, "
 "Comparator, Outcome)? Was randomisation truly random, and was allocation concealed? Were participants, clinicians, and outcome "
 "assessors blinded where feasible? Was the analysis intention-to-treat? Was the sample size adequate (sufficient power)? What "
 "were the primary and secondary outcomes, and were they clinically meaningful? Were adverse events reported comprehensively? "
 "Was there selective outcome reporting? The CONSORT checklist provides a standardised reporting framework for RCTs. Common "
 "biases include selection bias (non-random allocation), performance bias (differential care), detection bias (subjective outcome "
 "assessment without blinding), and attrition bias (differential dropout)."),

("Statistical Literacy",
 "Interpreting trial results requires statistical literacy. The p-value indicates the probability of observing the results by "
 "chance if the null hypothesis is true; a p < 0.05 is conventionally significant but does not indicate clinical importance. "
 "The confidence interval (CI) provides the range within which the true effect likely lies; a CI crossing 1.0 for relative "
 "risk or hazard ratio, or crossing 0 for absolute risk difference, indicates non-significance. The absolute risk reduction (ARR) "
 "and number needed to treat (NNT) contextualise the clinical benefit: a highly statistically significant relative risk reduction "
 "may correspond to a trivially small absolute benefit. Hazard ratios from survival analyses represent instantaneous relative risk "
 "of the event over the study period. Heterogeneity in meta-analyses (I² statistic) indicates whether studies are measuring the "
 "same effect or different populations."),

("Journal Clubs and Applying Evidence",
 "Regular journal clubs are the cornerstone of evidence-based postgraduate training. A structured journal club session should "
 "select a clinically relevant paper, systematically appraise its validity and results using a standard tool (CASP checklist), "
 "determine applicability to the local patient population, and discuss how (or whether) findings should change practice. "
 "Publication bias - the systematic under-publication of negative and null trials - inflates apparent treatment effects in "
 "meta-analyses; registered trial databases (ClinicalTrials.gov, CTRI) allow detection of unreported studies. Physicians have "
 "a professional obligation to remain current with the literature, to apply evidence critically and contextually, and to update "
 "their practice when high-quality new evidence emerges.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 10
# ══════════════════════════════════════════════════════════════════
make_doc("10_Levels_of_Prevention.docx", "10", "Cognitive Competency",
"Levels of Prevention in Communicable and Non-Communicable Diseases",
[
("Introduction",
 "Prevention is the cornerstone of public health and a fundamental responsibility of all clinicians. It operates along a continuum "
 "from population-level policy to individual clinical intervention. The traditional model describes three levels of prevention; "
 "a fourth level - primordial prevention - is now widely recognised as the most upstream and ultimately most impactful approach. "
 "An understanding of all levels allows the physician to contribute meaningfully to health promotion, early detection, and "
 "disability limitation in both communicable and non-communicable disease."),

("Primordial Prevention",
 "Primordial prevention aims to prevent the development of risk factors themselves within populations that have not yet manifested "
 "them, by targeting social, economic, and environmental conditions. It operates at the policy level rather than the individual "
 "clinical level. Examples include: taxation and advertising restrictions on tobacco and alcohol to prevent uptake in youth; "
 "urban planning policies that mandate green spaces and cycling infrastructure to promote physical activity; food labelling "
 "regulations and trans-fat bans to reduce cardiovascular risk factors; and air quality legislation to reduce the incidence of "
 "chronic respiratory disease. The physician's role at this level is one of advocacy and community engagement rather than "
 "direct clinical intervention."),

("Primary Prevention",
 "Primary prevention aims to prevent disease occurrence in susceptible individuals. Vaccination is the paradigmatic primary "
 "prevention intervention: the Universal Immunisation Programme (UIP) prevents measles, polio, diphtheria, tetanus, pertussis, "
 "hepatitis B, and rotavirus; HPV vaccination prevents cervical cancer; typhoid conjugate vaccine reduces enteric fever. "
 "Vector control (insecticide-treated bed nets, indoor residual spraying) prevents malaria and dengue. Tobacco cessation "
 "counselling and nicotine replacement therapy prevent COPD and lung cancer. Dietary modification and structured exercise "
 "programmes prevent type 2 diabetes in high-risk individuals (DPP trial: 58% risk reduction with lifestyle intervention). "
 "Chemoprophylaxis - isoniazid preventive therapy (IPT) for latent TB, PrEP (tenofovir/emtricitabine) for HIV in high-risk "
 "individuals - represents primary prevention using pharmacological means."),

("Secondary Prevention",
 "Secondary prevention involves the early detection of disease in its asymptomatic or minimally symptomatic phase, followed by "
 "prompt treatment to prevent progression. Screening programmes are its primary instrument. Cancer screening - cervical cancer "
 "by VIA/Pap smear, breast cancer by mammography, colorectal cancer by faecal occult blood test and colonoscopy - reduces "
 "disease-specific mortality by enabling treatment at an earlier, more curable stage. Hypertension screening in adults detects "
 "the 'silent killer' before end-organ damage; diabetic screening in at-risk populations prevents long-term complications. "
 "In communicable disease, tuberculosis contact tracing and testing identifies latent infection before progression to active "
 "disease; HIV testing programmes detect infection before AIDS-defining illness. The criteria for a successful screening "
 "programme (Wilson and Jungner criteria) include: the condition should be an important health problem, with a recognisable "
 "latent stage, a suitable test, an acceptable treatment, and an agreed policy on treatment."),

("Tertiary Prevention and Disability Limitation",
 "Tertiary prevention seeks to minimise the impact of established disease by reducing disability, preventing complications, "
 "and optimising long-term function. It overlaps substantially with treatment and rehabilitation. Examples include: intensive "
 "glycaemic control, blood pressure management, and foot care in diabetes to prevent retinopathy, nephropathy, and amputation; "
 "cardiac rehabilitation after myocardial infarction to reduce recurrence; antiretroviral therapy to maintain CD4 counts and "
 "prevent AIDS-defining infections in HIV; and physiotherapy after stroke to maximise neurological recovery. Patient education "
 "on self-management (inhalation technique in asthma/COPD, sick-day rules in diabetes, anticoagulation in AF) is a cost-effective "
 "component of tertiary prevention. The physician must operate simultaneously across all levels of prevention, integrating "
 "preventive counselling into every clinical encounter.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 11
# ══════════════════════════════════════════════════════════════════
make_doc("11_Legislation_Ethics.docx", "11", "Cognitive Competency",
"Legislations Related to Organ Transplant, Brain Death, Informed Consent, and Human Rights",
[
("Introduction",
 "The practice of medicine is governed by a complex framework of legislation, professional regulations, and international human "
 "rights instruments designed to protect patient rights, ensure ethical conduct, and regulate complex biomedical practices. "
 "Physicians must be fluent in this framework - not as a defensive shield against litigation, but as a positive expression of "
 "professional commitment to the rights and dignity of their patients. Key domains include organ transplantation, the legal "
 "definition and certification of brain death, the doctrine of informed consent, and broader human rights principles as applied "
 "to medical practice."),

("Transplantation of Human Organs and Tissues Act (THOTA)",
 "The Transplantation of Human Organs Act was enacted in India in 1994 and significantly amended in 2011 (becoming THOTA). It "
 "legalises organ donation from both living and deceased (brain-dead) donors while establishing strict safeguards against "
 "commercialisation and organ trafficking. Living donors may be near relatives (as defined by the Act: spouse, son, daughter, "
 "father, mother, brother, sister, grandfather, grandmother, grandson, granddaughter) or, with authorisation committee approval, "
 "unrelated donors with documented altruistic motivation. Commercial transactions in organs are a criminal offence. Hospital "
 "transplant committees and authorisation committees provide institutional oversight. The 2011 amendment introduced the concept "
 "of swap donation and expanded the list of organs and tissues covered, including eyes, skin, bone, and heart valves."),

("Brain Death: Definition and Certification",
 "Brain death is defined under THOTA as the irreversible cessation of all functions of the entire brain, including the brainstem. "
 "It must be distinguished from a persistent vegetative state (in which brainstem reflexes are preserved) and from other causes "
 "of coma. Legal certification of brain death in India requires: a panel of four doctors (the treating physician, a nominated "
 "specialist from the hospital, a neurologist or neurosurgeon nominated by the in-charge of the hospital, and a physician "
 "nominated by an appropriate authority of the hospital); two sets of clinical tests performed at least six hours apart; "
 "and documentation on prescribed forms. Prerequisite conditions for brain death testing must be confirmed: normothermia, "
 "normal blood pressure, absence of drug effect, and absence of metabolic causes of coma. Apnoea testing and brainstem reflex "
 "testing (corneal, vestibulo-ocular, oculocephalic, gag, and cough reflexes) constitute the clinical examination."),

("Informed Consent",
 "Informed consent is the legal and ethical cornerstone of the doctor-patient relationship. A valid informed consent must satisfy "
 "four conditions: disclosure (the physician must provide all material information that a reasonable patient would wish to know, "
 "including the diagnosis, proposed procedure, expected benefits, material risks, available alternatives, and consequences of "
 "declining treatment), comprehension (the information must be provided in language and format the patient can understand, "
 "using interpreters if needed), voluntariness (consent must be freely given without coercion, undue influence, or manipulation), "
 "and competence (the patient must have the decision-making capacity to understand and weigh the information). In emergencies "
 "where the patient is incapacitated and no surrogate is available, treatment necessary to save life may be provided without "
 "consent under the doctrine of necessity. Consent must be documented in the medical record; for procedures carrying significant "
 "risk, written consent is standard. Consent is a process, not a single signed form."),

("Human Rights in Medical Practice",
 "Patients possess fundamental rights guaranteed by the Constitution of India, the Protection of Human Rights Act (1993), and "
 "international instruments including the Universal Declaration of Human Rights (1948) and the UN Convention on the Rights of "
 "Persons with Disabilities (UNCRPD, ratified by India in 2007). These include the right to dignity and non-discrimination, "
 "the right to privacy and confidentiality of medical information, the right to access healthcare without arbitrary refusal, "
 "the right to be informed and to participate in treatment decisions, and the right to seek a second opinion. The Mental "
 "Healthcare Act (2017) gives persons with mental illness the right to refuse treatment, make advance directives, and have "
 "a nominated representative. The Rights of Persons with Disabilities Act (2016) prohibits discrimination in healthcare "
 "settings. Physicians must be advocates for their patients' rights, particularly for marginalised and vulnerable groups "
 "who are most at risk of rights violations within healthcare systems.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 12
# ══════════════════════════════════════════════════════════════════
make_doc("12_Recent_Advances.docx", "12", "Cognitive Competency",
"Recent Advances in Internal Medicine",
[
("Introduction",
 "Internal medicine is one of the most intellectually dynamic specialties in clinical medicine, with therapeutic and diagnostic "
 "advances transforming the prognosis of conditions that were previously associated with high morbidity and mortality. The pace "
 "of change demands continuous professional development; it is estimated that the medical knowledge base doubles approximately "
 "every seventy-three days in the current era. Staying current requires structured engagement with peer-reviewed literature, "
 "national and international conferences, and accredited continuing medical education (CME) programmes."),

("Cardiometabolic Advances",
 "The last decade has been transformative for cardiometabolic medicine. SGLT2 inhibitors (empagliflozin, dapagliflozin, "
 "canagliflozin) have demonstrated cardiovascular mortality reduction (EMPA-REG OUTCOME), hospitalisation reduction in heart "
 "failure with both reduced and preserved ejection fraction (DAPA-HF, EMPEROR-Reduced, EMPEROR-Preserved), and slowing of CKD "
 "progression (CREDENCE, DAPA-CKD) - benefits that are largely independent of glycaemic control. GLP-1 receptor agonists "
 "(semaglutide, liraglutide, dulaglutide) reduce major adverse cardiovascular events in high-risk type 2 diabetes and produce "
 "substantial weight loss (LEADER, SUSTAIN-6, REWIND). Tirzepatide (dual GLP-1/GIP agonist) achieves weight reductions of "
 "up to 22% in obesity trials (SURMOUNT). In heart failure, sacubitril-valsartan (ARNI) has superseded ACE inhibitors as the "
 "preferred RAAS agent in HFrEF. Inclisiran (siRNA targeting PCSK9) offers twice-yearly injectable lipid lowering."),

("Infectious Disease and Respiratory Advances",
 "Direct-acting antivirals (sofosbuvir/velpatasvir, glecaprevir/pibrentasvir) have achieved cure rates exceeding 95% for all "
 "hepatitis C genotypes, representing a public health transformation. Long-acting injectable antiretrovirals (cabotegravir + "
 "rilpivirine, administered monthly or two-monthly) have transformed HIV treatment adherence. Bedaquiline and pretomanid have "
 "improved outcomes in extensively drug-resistant tuberculosis. In COVID-19, nirmatrelvir/ritonavir (Paxlovid) reduces "
 "hospitalisation in high-risk individuals by 89%. The integration of POCUS (point-of-care ultrasound) into respiratory "
 "assessment - lung ultrasound for pneumonia, effusion, and pulmonary oedema - has improved diagnostic accuracy at the bedside. "
 "Treatable traits-based approaches in COPD and asthma guide precision selection of inhaler therapy."),

("Oncology and Immunotherapy",
 "Immune checkpoint inhibitors (ICIs) targeting PD-1 (pembrolizumab, nivolumab), PD-L1 (atezolizumab, durvalumab), and CTLA-4 "
 "(ipilimumab) have redefined the management of multiple malignancies including non-small cell lung cancer, melanoma, urothelial "
 "cancer, gastric cancer, and hepatocellular carcinoma. Long-term survival in metastatic melanoma and NSCLC - previously measured "
 "in months - now extends to years in responders. CAR-T cell therapy (axicabtagene ciloleucel, tisagenlecleucel) offers "
 "curative potential in relapsed/refractory B-cell lymphomas and ALL. Antibody-drug conjugates (ADCs) combine targeted delivery "
 "with cytotoxic payload. Bispecific antibodies (blinatumomab) recruit T-cells to tumour cells. Minimal residual disease (MRD) "
 "testing by next-generation sequencing guides treatment intensity in haematological malignancies."),

("Technology, AI, and Precision Medicine",
 "Next-generation sequencing (NGS) enables comprehensive tumour genomic profiling, identifying actionable driver mutations "
 "(EGFR, ALK, BRAF, ROS1 in lung cancer; BRCA1/2 in ovarian and breast cancer) that predict response to targeted therapies. "
 "Pharmacogenomic testing informs drug selection and dosing based on individual metabolic genotype (e.g. CYP2D6 for tamoxifen, "
 "TPMT for thiopurines). Artificial intelligence applications in medicine include: deep learning algorithms for ECG interpretation "
 "(detecting AF, LVH, structural disease from 12-lead ECG), chest radiograph analysis (detecting pneumonia, pneumothorax, nodules), "
 "retinal fundus analysis (detecting diabetic retinopathy), and clinical risk prediction models (e.g. sepsis early warning). "
 "Continuous glucose monitoring (CGM) and wearable cardiac monitors are expanding ambulatory diagnostics. The COVID-19 pandemic "
 "validated mRNA vaccine technology, which is now being applied to influenza, RSV, and cancer vaccines. Telemedicine has been "
 "integrated into routine outpatient practice, expanding access particularly for patients in remote and underserved areas.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 13
# ══════════════════════════════════════════════════════════════════
make_doc("13_Teamwork_Comprehensive_Care.docx", "13", "Affective Competency",
"Teamwork, Cooperation, and Comprehensive Patient Care",
[
("Introduction",
 "The increasing complexity of modern medical care - driven by multimorbidity, polypharmacy, subspecialty knowledge, and the "
 "expanding role of allied health professionals - makes teamwork not merely desirable but essential. No single clinician possesses "
 "the breadth of expertise, availability, or energy required to manage complex patients optimally across all dimensions of their "
 "care. Research consistently demonstrates that effective multidisciplinary teamwork reduces medical errors, improves patient "
 "outcomes, shortens hospital stays, and enhances the wellbeing of healthcare workers. The postgraduate physician must develop "
 "genuine team orientation from the outset of training."),

("The Multidisciplinary Team",
 "The multidisciplinary team (MDT) in internal medicine encompasses physicians (including consultants, registrars, and interns), "
 "nursing staff, clinical pharmacists, physiotherapists, occupational therapists, speech and language therapists, dietitians, "
 "social workers, and chaplains. Each professional brings unique expertise; the value of the team derives from the integration "
 "of these perspectives rather than any hierarchy. Structured MDT meetings - weekly for complex patients in oncology, heart "
 "failure, or stroke units - ensure that all team members share information, align goals, and coordinate discharge planning. "
 "The patient and family should, wherever possible and appropriate, be considered active members of their own care team."),

("Communication Within the Team",
 "Effective intra-team communication is the most critical determinant of patient safety. The SBAR (Situation, Background, "
 "Assessment, Recommendation) tool structures handovers and clinical escalations to ensure complete, unambiguous information "
 "transfer. Structured daily ward rounds with nursing presence and pharmacist input improve medication safety and flag "
 "deteriorating patients earlier. Closed-loop communication - where the receiver explicitly confirms receipt and understanding "
 "of a message - reduces errors in high-stakes situations such as resuscitation and procedural handover. Electronic health "
 "records, when used well, provide a shared communication platform; when used poorly, they fragment care with duplicate "
 "documentation and information silos."),

("Interaction with Patients and Relatives",
 "Comprehensive care requires that the team's technical expertise be delivered within a framework of compassionate, informed "
 "communication with the patient and family. Patients and relatives should be updated daily during acute admissions, given "
 "the opportunity to ask questions, and involved in decision-making according to the patient's preferences and capacity. "
 "Family meetings, particularly in complex or deteriorating cases, should be structured: introductions, understanding of "
 "what is already known, information provision, questions, and an agreed plan. Conflicting information from different team "
 "members is a significant source of distress and mistrust; the team must agree on a consistent message before communicating "
 "with families. Cultural and linguistic barriers require interpreter services rather than reliance on family members for "
 "clinical translation."),

("Professional Attitudes in Teamwork",
 "Effective teamwork demands a set of professional attitudes that must be consciously cultivated. Psychological safety - "
 "the belief that one can speak up, ask questions, or raise concerns without fear of ridicule or retaliation - is the "
 "foundation of high-functioning teams. Hierarchies that silence nurses or junior doctors from raising patient safety "
 "concerns are a recognised threat to patient welfare. Mutual respect across professional disciplines is non-negotiable. "
 "The postgraduate trainee must develop professional humility - acknowledging the limits of their knowledge and seeking "
 "input rather than proceeding with uncertainty. Conflict in teams, which is inevitable, should be addressed constructively "
 "through open discussion focused on patient welfare. Leadership skills - facilitating meetings, delegating appropriately, "
 "and supporting junior staff - should be developed progressively throughout training.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 14
# ══════════════════════════════════════════════════════════════════
make_doc("14_Ethics_Professionalism.docx", "14", "Affective Competency",
"Ethical Principles, Professional Etiquette, and Patient Rights",
[
("Foundations of Medical Ethics",
 "Medical ethics provides the philosophical framework within which clinical decisions are made and professional conduct is "
 "evaluated. The four-principles framework of Beauchamp and Childress - autonomy, beneficence, non-maleficence, and justice - "
 "remains the dominant paradigm in Western bioethics. Autonomy respects the patient's right to make informed, voluntary "
 "decisions about their own healthcare. Beneficence obligates the physician to act in the patient's best interest. "
 "Non-maleficence requires the avoidance of unnecessary harm - captured in the Hippocratic injunction primum non nocere "
 "(first, do no harm). Justice demands fair allocation of healthcare resources and non-discriminatory treatment. "
 "These principles frequently come into tension, and resolving these tensions requires careful, contextualised moral reasoning "
 "rather than algorithmic application of rules."),

("Professional Etiquette and Conduct",
 "Medical professionalism encompasses the behaviours, values, and attitudes expected of a physician in the exercise of their "
 "role. It includes punctuality and reliability, appropriate professional dress, courteous and respectful language towards "
 "patients, relatives, and all colleagues regardless of seniority, maintenance of appropriate professional boundaries, "
 "and meticulous record-keeping. The medical record is a legal and clinical document; entries must be accurate, dated, "
 "signed, and legible. Professional misconduct - which includes breach of confidentiality, sexual impropriety, dishonesty, "
 "financial exploitation of patients, and practising under the influence of substances - is subject to disciplinary action "
 "by the National Medical Commission (NMC) and State Medical Councils, and may result in removal from the medical register."),

("Patient Rights",
 "Patients are not passive recipients of care; they hold active rights that must be respected. The right to information "
 "obliges the physician to explain the diagnosis, prognosis, proposed treatment, alternatives, and risks in language the "
 "patient can understand. The right to consent (and to refuse treatment, even if life-saving) derives from the principle "
 "of autonomy and is protected by law. The right to confidentiality means that patient information must not be disclosed "
 "to third parties without consent, with defined exceptions for public health necessity (notifiable diseases), court orders, "
 "and immediate risk of serious harm. The right to a second opinion is protected, and physicians must not impede or "
 "discourage patients from seeking one. The right to dignity requires that patients be treated with respect regardless "
 "of their diagnosis, behaviour, or social circumstances."),

("Conflicts of Interest and the Duty of Candour",
 "Conflicts of interest arise when a physician's personal interests - financial, academic, or relational - have the potential "
 "to influence clinical decisions to the detriment of the patient. Common scenarios include receipt of gifts or hospitality "
 "from pharmaceutical companies, financial relationships with diagnostic laboratories, and self-referral to facilities in "
 "which the physician has a financial stake. The NMC Code of Ethics prohibits such conflicts and requires transparency. "
 "The duty of candour - the professional and, increasingly, legal obligation to be open and honest with patients when "
 "clinical care has caused or may cause harm - requires the physician to acknowledge the adverse event, apologise sincerely, "
 "explain what happened, and describe what will be done to prevent recurrence. Open disclosure does not increase litigation "
 "risk and demonstrably improves patient trust."),

("Ethics in Resource-Limited Settings",
 "Justice in healthcare requires equitable resource allocation, but resource scarcity in low-income settings creates "
 "complex ethical dilemmas. ICU triage during a surge - who receives the available ventilator? - requires transparent, "
 "pre-agreed criteria rather than ad hoc decisions subject to bias. Clinical trial ethics in developing countries raises "
 "questions of post-trial access, standard-of-care comparators, and community consultation. Research conducted without "
 "adequate local ethical review or community engagement exploits rather than benefits populations. The Declaration of "
 "Helsinki (revised 2013) provides the international ethical framework for medical research involving human subjects, "
 "emphasising independent ethics committee oversight, voluntary informed consent, and the primacy of participant welfare "
 "over scientific or societal interests. Every physician engaged in research must be familiar with and adhere to "
 "these principles.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 15
# ══════════════════════════════════════════════════════════════════
make_doc("15_Communication_Skills.docx", "15", "Affective Competency",
"Communication Skills: Breaking Bad News and Patient Interaction",
[
("Introduction",
 "Communication is the most frequently performed clinical skill in medicine, yet it receives comparatively little structured "
 "training relative to technical procedural skills. Mounting evidence links poor clinician communication to patient "
 "dissatisfaction, treatment non-adherence, avoidable complaints, and medico-legal claims. Conversely, good communication "
 "improves patient understanding, adherence, psychological wellbeing, and clinical outcomes across a range of conditions "
 "from cancer to diabetes to heart failure. Communication skills are not a fixed personality trait; they are teachable and "
 "improvable through deliberate practice, reflection, and feedback."),

("The SPIKES Protocol for Breaking Bad News",
 "Breaking bad news is among the most challenging communication tasks in medicine. The SPIKES protocol (Baile et al., 2000) "
 "provides a structured, validated six-step framework. Step 1 - Setting: arrange a private, quiet space; invite the patient's "
 "nominated support person; sit at the same level; ensure sufficient uninterrupted time. Step 2 - Perception: open with "
 "open-ended questions to explore the patient's current understanding ('What do you understand about your condition so far?'). "
 "Step 3 - Invitation: ask how much detail the patient wishes to receive ('Some people want all the details; others prefer "
 "the bigger picture - what would you prefer?'). Step 4 - Knowledge: give information in manageable portions using plain "
 "language, avoiding medical jargon; pause frequently to check comprehension; deliver the 'warning shot' before the "
 "actual diagnosis ('I'm afraid the results show something serious...'). Step 5 - Emotions: acknowledge the patient's "
 "emotional response empathetically before proceeding ('I can see this is very difficult news to hear; take a moment...'). "
 "Step 6 - Summarise and Strategise: summarise the key information, outline the immediate plan, and provide written "
 "information and contact details. Schedule a follow-up appointment."),

("Active Listening and Non-Verbal Communication",
 "Active listening is a purposeful, skilled activity distinct from passive hearing. It requires making eye contact "
 "(culturally adapted), adopting open, non-defensive body posture, nodding and using verbal affirmations ('I see', "
 "'go on'), minimising interruptions, and reflecting back what has been said to confirm understanding ('So what I'm "
 "hearing is that your main concern is...?'). Non-verbal communication constitutes a significant proportion of the "
 "total message conveyed: facial expression, proximity, touch (where culturally appropriate and consented), and tone "
 "of voice all transmit empathy, authority, or disengagement. The physician who maintains eye contact with their "
 "computer screen rather than the patient communicates disinterest, regardless of the words used. Patients consistently "
 "report that feeling heard and respected is as important to them as the technical quality of their medical care."),

("Communication with Relatives and Colleagues",
 "Communication with relatives requires balancing the duty of confidentiality with the family's legitimate need for "
 "information. The starting point is always the patient's consent: what information has the patient agreed to share, "
 "and with whom? In patients who lack capacity, the family plays a consultative role in best-interests decision-making "
 "but does not hold legal proxy decision-making authority under most Indian law (unlike jurisdictions with formal lasting "
 "power of attorney). Structured family meetings require preparation, a nominated clinician to lead, and a plan for "
 "managing emotional reactions. Communication with nursing staff and paramedics must be clear, specific, and "
 "respectful: verbal orders should be avoided where possible, and all instructions should be documented. Escalation "
 "communications (e.g. to a senior colleague about a deteriorating patient) should use SBAR structure."),

("Written Communication and Documentation",
 "Written communication - discharge summaries, referral letters, clinic letters, operative notes, and death certificates "
 "- forms the legal and clinical record of care and directly affects the safety of care transitions. Discharge summaries "
 "must include: diagnosis, significant investigations, treatments initiated, outstanding results, follow-up arrangements, "
 "and a clear medication list reconciled against the admission medications. Referral letters must provide sufficient "
 "clinical context to allow the receiving clinician to prioritise and prepare. Letters to general practitioners must "
 "be comprehensible to a non-specialist. The electronic health record, when properly used, creates a longitudinal "
 "record accessible to all treating clinicians; fragmented documentation and copy-paste errors are patient safety risks. "
 "All entries must be dated, timed, and signed with the author's name and designation printed clearly.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC 16
# ══════════════════════════════════════════════════════════════════
make_doc("16_Equity_Inclusion_LGBTQIA.docx", "16", "Affective Competency",
"Equity, Equality, and Inclusive Care for Differently Abled and LGBTQIA+ Individuals",
[
("Introduction: Equity vs. Equality",
 "Equality in healthcare means providing the same resource or treatment to every patient. Equity recognises that identical "
 "treatment does not produce identical outcomes when patients start from different positions - due to disability, "
 "discrimination, poverty, or marginalisation - and that achieving equal health outcomes requires providing additional "
 "or different support to those who face greater barriers. True patient-centred medicine is inherently equity-oriented. "
 "The physician's professional and ethical obligation to all patients - regardless of their identity, background, or "
 "circumstances - is to provide the highest possible standard of care without discrimination or prejudice."),

("Care for Differently Abled Individuals",
 "Disability encompasses a wide spectrum of physical, sensory, cognitive, and mental health impairments that interact "
 "with environmental barriers to limit participation. The Rights of Persons with Disabilities Act (2016) recognises 21 "
 "categories of disability and mandates non-discrimination in all public services, including healthcare. In clinical "
 "practice, differently abled patients face multiple barriers: physically inaccessible buildings, examination couches "
 "and imaging equipment that cannot accommodate wheelchair users, lack of sign language interpreters for deaf patients, "
 "written materials and consent forms that are inaccessible to those with visual impairment or low literacy, and "
 "implicit biases among clinicians that lead to diagnostic overshadowing (attributing physical symptoms to the "
 "underlying disability rather than investigating them). Physicians must proactively identify and mitigate these "
 "barriers, use communication aids (picture boards, sign language services, audio materials), involve caregivers "
 "with the patient's consent, and advocate for accessible healthcare infrastructure."),

("Health Disparities in LGBTQIA+ Populations",
 "Lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) individuals experience significant and "
 "well-documented health disparities compared with heterosexual, cisgender populations. These disparities are not "
 "biological in origin; they are the product of minority stress - the chronic psychological burden of stigma, "
 "discrimination, concealment of identity, and internalised homophobia or transphobia. Higher rates of depression, "
 "anxiety, post-traumatic stress disorder, suicidality, self-harm, and substance use are consistently documented. "
 "LGBTQIA+ individuals are more likely to delay seeking healthcare due to prior experiences of discrimination or "
 "anticipated rejection in healthcare settings. Specific disease risks include elevated HIV prevalence among men who "
 "have sex with men (MSM) and transgender women, higher rates of anal and oropharyngeal HPV-related cancers in MSM, "
 "and the health consequences of gender dysphoria and gender affirmation interventions in transgender individuals."),

("Clinical Care for Transgender and Gender-Diverse Patients",
 "Transgender and gender-diverse patients have specific, often unmet healthcare needs. Gender-affirming hormone therapy "
 "(oestrogen for transgender women, testosterone for transgender men) requires baseline assessment and ongoing monitoring "
 "of cardiovascular risk, haematological parameters, bone density, liver function, and psychological wellbeing. "
 "Transgender women on oestrogen have increased venous thromboembolism and cardiovascular risk. Transgender men on "
 "testosterone may develop polycythaemia, acne, and require counselling on fertility preservation prior to commencing "
 "hormones. Clinicians must recognise that standard organ-based screening guidelines apply based on anatomy rather than "
 "gender identity: a transgender man who retains a cervix still requires cervical cancer screening; a transgender woman "
 "with a prostate still requires PSA monitoring per age-based guidelines. Using a patient's chosen name and pronouns "
 "correctly is not merely courtesy - it is associated with measurable reductions in depression and suicidal ideation."),

("Creating an Inclusive Clinical Environment",
 "An inclusive clinical environment begins with the attitudes and behaviours of its clinicians and staff. Self-reflection "
 "on implicit biases - tested through validated tools such as the Implicit Association Test - is the first step. "
 "Using inclusive intake forms that ask for gender identity, pronouns, and sexual orientation (where clinically relevant) "
 "rather than binary sex alone signals a welcoming environment. Avoiding assumptions about relationship status, sexual "
 "behaviour, or gender identity based on appearance is fundamental. Non-judgmental, open-ended sexual history taking "
 "using inclusive language ('Do you have a partner or partners? What are the genders of your partners?') enables "
 "accurate risk assessment without alienating patients. Visible symbols of inclusion in clinical spaces - rainbow "
 "lanyards, inclusive posters - are associated with increased disclosure of sexual orientation and gender identity "
 "by patients. Cultural humility - the commitment to ongoing self-reflection and learning, rather than a fixed state "
 "of 'cultural competence' - is the appropriate professional orientation towards all aspects of diversity, and must "
 "be cultivated as a lifelong professional practice.")
])

print("\n✓ All 16 full-length files created in:", OUTPUT_DIR)

from docx import Document
from docx.shared import Pt, Inches, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
import os

OUTPUT_DIR = "/tmp/workspace/elog-book/p_competencies/docs"
os.makedirs(OUTPUT_DIR, exist_ok=True)

def make_doc(filename, topic_num, category, heading, sections):
    """
    sections: list of (subheading, body_text) tuples
    Each doc will be 1-2 pages with 5 subsections.
    """
    doc = Document()
    sec = doc.sections[0]
    sec.top_margin = Inches(1)
    sec.bottom_margin = Inches(1)
    sec.left_margin = Inches(1.2)
    sec.right_margin = Inches(1.2)

    normal = doc.styles["Normal"]
    normal.font.name = "Times New Roman"
    normal.font.size = Pt(12)

    # Category label
    cat_para = doc.add_paragraph(f"Psychomotor Competency  |  {category}  |  Topic {topic_num}")
    cat_para.alignment = WD_ALIGN_PARAGRAPH.CENTER
    r = cat_para.runs[0]
    r.font.size = Pt(10)
    r.font.italic = True
    r.font.color.rgb = RGBColor(0x55, 0x55, 0x55)

    # Main title
    title = doc.add_heading(heading, level=1)
    title.alignment = WD_ALIGN_PARAGRAPH.CENTER
    for run in title.runs:
        run.font.name = "Times New Roman"
        run.font.size = Pt(14)
        run.font.bold = True
        run.font.color.rgb = RGBColor(0x1A, 0x35, 0x6E)

    # Divider
    div = doc.add_paragraph("─" * 80)
    div.alignment = WD_ALIGN_PARAGRAPH.CENTER
    div.runs[0].font.size = Pt(8)
    div.runs[0].font.color.rgb = RGBColor(0xAA, 0xAA, 0xAA)
    div.paragraph_format.space_after = Pt(4)

    # Sections
    for (subheading, body) in sections:
        sh = doc.add_heading(subheading, level=2)
        sh.paragraph_format.space_before = Pt(10)
        sh.paragraph_format.space_after = Pt(4)
        for run in sh.runs:
            run.font.name = "Times New Roman"
            run.font.size = Pt(12)
            run.font.bold = True
            run.font.color.rgb = RGBColor(0x1A, 0x35, 0x6E)

        p = doc.add_paragraph(body)
        p.paragraph_format.space_after = Pt(8)
        p.paragraph_format.first_line_indent = Pt(18)
        p.paragraph_format.line_spacing = Pt(22)
        for run in p.runs:
            run.font.name = "Times New Roman"
            run.font.size = Pt(12)

    # Footer
    doc.add_paragraph()
    foot = doc.add_paragraph(
        "E-Log Book  |  Department of Internal Medicine  |  Postgraduate Training Programme"
    )
    foot.alignment = WD_ALIGN_PARAGRAPH.CENTER
    foot.runs[0].font.size = Pt(9)
    foot.runs[0].font.italic = True
    foot.runs[0].font.color.rgb = RGBColor(0x88, 0x88, 0x88)

    path = os.path.join(OUTPUT_DIR, filename)
    doc.save(path)
    print(f"Saved: {path}")

import sys
sys.path.insert(0, "/tmp/workspace/elog-book/p_competencies")
from helper import make_doc

# ══════════════════════════════════════════════════════════════════
# TOPIC P1 - Non-invasive and Mechanical Ventilation
# ══════════════════════════════════════════════════════════════════
make_doc("P01_Non_Invasive_Mechanical_Ventilation.docx", "P1",
"Respiratory Management",
"Non-Invasive and Mechanical Ventilation",
[
("Introduction",
 "Ventilatory support - both non-invasive and invasive - is a cornerstone of critical care medicine and a core competency for "
 "the internal medicine postgraduate. The goal of ventilatory support is to maintain adequate gas exchange (oxygenation and "
 "carbon dioxide elimination), relieve the work of breathing, and buy time for the underlying pathology to be treated. "
 "The decision between non-invasive ventilation (NIV) and invasive mechanical ventilation (IMV) depends on the clinical "
 "presentation, underlying diagnosis, degree of respiratory failure, and the patient's conscious level and ability to protect "
 "their airway."),

("Non-Invasive Ventilation (NIV)",
 "NIV delivers positive pressure ventilatory support through a tight-fitting mask (nasal, oronasal, full-face, or helmet) "
 "without the need for endotracheal intubation. The two main modalities are CPAP (Continuous Positive Airway Pressure - "
 "a single level of pressure that maintains airway patency and recruits alveoli) and BiPAP/NPPV (Bi-level Positive Airway "
 "Pressure - separate inspiratory and expiratory pressures, providing both oxygenation support and ventilatory assistance). "
 "NIV is the treatment of choice in acute hypercapnic respiratory failure due to COPD exacerbation (reduces intubation rate "
 "and mortality - Brochard 1995, Plant 2000), acute cardiogenic pulmonary oedema (CPAP reduces need for intubation by 50%), "
 "and immunocompromised patients with acute respiratory failure (avoids infective complications of intubation). "
 "Absolute contraindications include cardiac or respiratory arrest, inability to protect airway, copious secretions, "
 "facial trauma precluding mask fitting, and uncooperative patient. NIV initiation: set IPAP 10-12 cmH2O and EPAP "
 "4-5 cmH2O, titrating to SpO2 >90% and clinical improvement; monitor ABG at 1-2 hours."),

("Indications and Initiation of Invasive Mechanical Ventilation",
 "IMV via endotracheal tube is indicated when NIV fails or is contraindicated, in airway compromise requiring protection "
 "(GCS <8, aspiration risk), haemodynamic instability, refractory hypoxaemia (PaO2/FiO2 <100), or apnoea. Key ventilator "
 "settings: FiO2 (initially 1.0, titrate to SpO2 94-98%), Tidal Volume (6 mL/kg ideal body weight - lung-protective "
 "ventilation, proven to reduce ARDS mortality in ARDSNet trial), Respiratory Rate (12-20/min, adjust for PaCO2), "
 "PEEP (5-8 cmH2O baseline; higher in ARDS to recruit alveoli), and I:E ratio (usually 1:2). Modes include: Assist "
 "Control (AC) - delivers a full breath with every patient effort plus backup rate; SIMV (Synchronized Intermittent "
 "Mandatory Ventilation) - fixed mandatory breaths synchronised with patient effort; Pressure Support Ventilation (PSV) - "
 "patient-triggered with pressure-augmented breaths, used for weaning."),

("Monitoring and Complications",
 "Continuous monitoring on IMV includes: SpO2, ETCO2 (end-tidal CO2), arterial blood gas analysis (at initiation, then "
 "every 4-6 hours or after setting changes), peak airway pressure (<30 cmH2O), plateau pressure (<28 cmH2O), and dynamic "
 "compliance. Ventilator-associated lung injury (VILI) results from volutrauma (excess tidal volume), barotrauma (excess "
 "pressure), atelectrauma (repeated alveolar opening/closing), and biotrauma (inflammatory mediator release). "
 "Ventilator-associated pneumonia (VAP) is prevented by head-of-bed elevation to 30-45 degrees, oral decontamination "
 "with chlorhexidine, subglottic suctioning, minimal sedation protocols, and early mobilisation. Auto-PEEP (air trapping) "
 "is common in obstructive lung disease and can cause haemodynamic compromise."),

("Weaning from Mechanical Ventilation",
 "Weaning should be assessed daily once the precipitating cause is resolving. Prerequisites: FiO2 ≤0.4-0.5, PEEP ≤5-8 "
 "cmH2O, SpO2 >90%, haemodynamic stability, adequate consciousness (able to follow commands), and absence of agitation. "
 "The spontaneous breathing trial (SBT) - 30-120 minutes on T-piece or low-level pressure support (5-8 cmH2O) - "
 "predicts extubation success. The RSBI (Rapid Shallow Breathing Index = respiratory rate / tidal volume in litres) "
 "<105 predicts successful weaning. Extubation follows successful SBT; the patient must be able to cough effectively, "
 "have minimal secretions, and a patent upper airway. Post-extubation NIV reduces re-intubation in high-risk patients. "
 "Prolonged weaning failure (>7 days) suggests need for tracheostomy to reduce work of breathing and improve secretion "
 "clearance.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P2 - Monitoring a Sick Person
# ══════════════════════════════════════════════════════════════════
make_doc("P02_Monitoring_Sick_Person.docx", "P2",
"Critically Ill Person",
"Monitoring a Sick Person",
[
("Introduction",
 "Effective monitoring of critically ill patients is the foundation of intensive care medicine. Monitoring serves to detect "
 "physiological deterioration early, guide therapeutic interventions, evaluate treatment response, and prevent secondary "
 "organ injury. The choice and intensity of monitoring must be individualised to the severity of illness, the clinical "
 "setting, and the available resources. A fundamental principle is that monitoring data must always be interpreted in the "
 "context of the clinical picture; isolated numbers without clinical context can mislead rather than guide."),

("Basic Monitoring: Vital Signs and Neurological Assessment",
 "Continuous monitoring of heart rate, blood pressure, respiratory rate, SpO2 (pulse oximetry), and temperature is "
 "mandatory in all critically ill patients. The respiratory rate is the most sensitive early indicator of deterioration "
 "and is frequently underrecorded. In mechanically ventilated patients, ETCO2 monitoring provides continuous non-invasive "
 "assessment of ventilation adequacy and is used to confirm endotracheal tube placement. Neurological monitoring using "
 "the Glasgow Coma Scale (GCS) assesses level of consciousness (eye, verbal, motor responses, scored 3-15) and should "
 "be documented at least hourly in obtunded patients. Pupillary responses (size, symmetry, reactivity) assess brainstem "
 "function. Pain and sedation levels are assessed using validated scales: CPOT (Critical-Care Pain Observation Tool) "
 "for pain, RASS (Richmond Agitation-Sedation Scale) for sedation depth."),

("Haemodynamic Monitoring",
 "Invasive arterial blood pressure monitoring via arterial line (radial preferred; femoral, brachial as alternatives) "
 "provides beat-to-beat BP measurement and ready arterial access for blood gases. The arterial waveform provides "
 "additional information: pulse pressure variation (PPV) >13% during mechanical ventilation predicts fluid responsiveness. "
 "Central venous pressure (CVP) via central line reflects right ventricular preload (normal 5-12 mmHg), though its "
 "use to guide fluid therapy is now questioned. Cardiac output can be measured non-invasively (echocardiography, "
 "lithium dilution) or invasively (pulmonary artery catheter - thermodilution; now rarely used). Bedside POCUS "
 "(point-of-care ultrasound) has largely replaced the pulmonary artery catheter for dynamic haemodynamic assessment. "
 "Serum lactate is a key marker of tissue perfusion; persistent lactataemia (>2 mmol/L) despite resuscitation "
 "indicates inadequate oxygen delivery."),

("Laboratory and Organ-Specific Monitoring",
 "Serial laboratory monitoring includes: arterial blood gases (oxygenation, ventilation, acid-base), full blood count "
 "(haemoglobin, white cell count, platelets), renal function (creatinine, urea, electrolytes), liver function tests, "
 "coagulation (PT, APTT, fibrinogen), blood glucose (target 7.8-10 mmol/L in critically ill patients - NICE-SUGAR trial), "
 "and inflammatory markers (CRP, procalcitonin). Urine output is a crucial marker of renal perfusion; a target of "
 "≥0.5 mL/kg/hour is conventional. Continuous ECG monitoring detects arrhythmias; 12-lead ECG is performed when "
 "clinically indicated. Intracranial pressure (ICP) monitoring via ventricular catheter or parenchymal probe is used "
 "in severe TBI, fulminant hepatic failure, and post-neurosurgical patients."),

("Track and Trigger Systems and Escalation",
 "Early Warning Scores (EWS) - such as the National Early Warning Score 2 (NEWS2) - aggregate vital sign parameters "
 "into a composite score to identify patients at risk of deterioration and guide escalation of care. NEWS2 incorporates "
 "heart rate, respiratory rate, SpO2 (with COPD-specific scale), systolic BP, temperature, and level of consciousness. "
 "A score of ≥7 warrants urgent medical review and consideration of critical care admission. Daily assessment of "
 "organ dysfunction using the Sequential Organ Failure Assessment (SOFA) score quantifies the burden of multi-organ "
 "failure and predicts ICU mortality. Regular structured reassessment, clear documentation, and prompt escalation "
 "when monitoring signals deterioration are the hallmarks of safe critical care.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P3 - Endotracheal Intubation
# ══════════════════════════════════════════════════════════════════
make_doc("P03_Endotracheal_Intubation.docx", "P3",
"Critically Ill Person",
"Endotracheal Intubation",
[
("Introduction",
 "Endotracheal intubation (ETI) is the definitive method of securing the airway in critically ill patients. It establishes "
 "a protected, patent conduit for ventilation, oxygenation, and the prevention of aspiration. It is a high-stakes procedure "
 "that must be performed by trained personnel with appropriate preparation, as failed or delayed intubation in a critically "
 "ill patient is associated with significant morbidity and mortality. The internal medicine postgraduate must be proficient "
 "in emergency airway management, understanding both the technique and the clinical decision-making surrounding airway control."),

("Indications and Pre-procedure Assessment",
 "Absolute indications for ETI include: cardiac or respiratory arrest, apnoea, Glasgow Coma Scale ≤8 (inability to protect "
 "airway), refractory hypoxaemia (PaO2/FiO2 <100) unresponsive to NIV, and haemodynamic instability with impending "
 "respiratory arrest. Relative indications include anticipated clinical deterioration, copious secretions with inability "
 "to clear, and uncooperative patient requiring procedures. Pre-intubation assessment uses the LEMON mnemonic: Look "
 "(for obvious abnormalities, obesity, short neck), Evaluate (3-3-2 rule - 3 finger mouth opening, 3 finger "
 "hyoid-to-chin, 2 finger hyoid-to-thyroid), Mallampati score, Obstruction (stridor, foreign body), and Neck "
 "mobility. The 'difficult airway' should be anticipated and backup plans (videolaryngoscope, LMA, surgical airway) "
 "prepared in advance."),

("Preparation: STOP MAID",
 "Systematic preparation using the STOP MAID checklist ensures safety. Suction - functioning at bedside; Team - "
 "designated roles for each team member; Oxygen - pre-oxygenation with high-flow O2 for minimum 3 minutes (target "
 "SpO2 >95%) to maximise apnoea time; Positioning - 'sniffing position' (neck flexed, head extended) or ramped "
 "position for obese patients; Monitoring - SpO2, ECG, ETCO2, BP; Airway equipment - ETT (sizes 7.0-8.0 for adults, "
 "10x size for children), laryngoscope (Macintosh blade), 10mL syringe, tape/holder, ETCO2 capnograph; IV access and "
 "drugs - induction agent (ketamine 1-2 mg/kg or propofol 1.5-2.5 mg/kg or etomidate 0.3 mg/kg) and neuromuscular "
 "blocking agent (suxamethonium 1.5 mg/kg for RSI, rocuronium 1.2 mg/kg for RSI if suxamethonium contraindicated)."),

("Technique of Rapid Sequence Intubation (RSI)",
 "RSI is the standard technique in emergency intubation to minimise the risk of aspiration. Steps: (1) Pre-oxygenation - "
 "3 minutes of 100% O2 via non-rebreather mask or BVM; (2) Pre-treatment - atropine 0.02 mg/kg in children to prevent "
 "bradycardia; (3) Induction agent IV push; (4) Suxamethonium 1.5 mg/kg (or rocuronium 1.2 mg/kg) IV push simultaneously; "
 "(5) Apply cricoid pressure (Sellick's manoeuvre) during induction until cuff inflated; (6) Laryngoscopy at 60 seconds "
 "- insert blade to right of tongue, sweep tongue left, visualise epiglottis then vocal cords; (7) Pass ETT (cuff "
 "just below cords, typically 21-23 cm at lips); (8) Inflate cuff with 10 mL air; (9) Confirm placement - ETCO2 "
 "waveform (gold standard), bilateral chest expansion, auscultation (axillae and epigastrium), CXR. Cuff pressure "
 "maintained at 20-30 cmH2O."),

("Complications and Post-intubation Management",
 "Immediate complications: oesophageal intubation (detected by absent ETCO2 waveform - requires immediate removal), "
 "right mainstem bronchus intubation (detected by unilateral chest expansion, unilateral air entry), haemodynamic "
 "collapse (from induction agents in hypovolaemic patients - manage with IV fluid bolus and vasopressors), "
 "dental/lip trauma, and bradyarrhythmia. Late complications: VAP, subglottic stenosis, tracheomalacia from prolonged "
 "intubation. Post-intubation management: confirm ETT position on CXR (tip should be 2-3 cm above carina), secure "
 "tube firmly, initiate lung-protective ventilation (TV 6 mL/kg IBW), provide analgesia and sedation (Richmond "
 "Agitation-Sedation Scale target -1 to -2), commence VAP prevention bundle, and plan for earliest possible extubation "
 "or tracheostomy if prolonged ventilation anticipated.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P4 - Cardiopulmonary Resuscitation
# ══════════════════════════════════════════════════════════════════
make_doc("P04_Cardiopulmonary_Resuscitation.docx", "P4",
"Critically Ill Person",
"Cardiopulmonary Resuscitation (CPR)",
[
("Introduction",
 "Cardiac arrest is the abrupt cessation of effective cardiac mechanical activity resulting in absence of circulation. "
 "Without immediate intervention, irreversible brain injury begins within 4-6 minutes. Cardiopulmonary resuscitation (CPR) "
 "is the combination of chest compressions and rescue breaths that maintains a minimum level of circulation and oxygenation "
 "until the return of spontaneous circulation (ROSC) can be achieved. The chain of survival concept - early recognition, "
 "early CPR, early defibrillation, advanced care, and post-resuscitation care - defines the framework for improving "
 "cardiac arrest outcomes. The physician must be proficient in both Basic Life Support (BLS) and Advanced Cardiac "
 "Life Support (ACLS) per current ILCOR/AHA/ERC guidelines."),

("Basic Life Support (BLS)",
 "On identifying an unresponsive patient: (1) Ensure scene safety; (2) Check responsiveness - shout and shake; "
 "(3) Simultaneously call for help/activate emergency response and send for AED; (4) Check for normal breathing "
 "(look/listen/feel for no more than 10 seconds - agonal gasps are not normal breathing); (5) Begin chest compressions "
 "immediately - heel of hand on lower half of sternum, arms straight, compress 5-6 cm depth at 100-120/min with "
 "complete chest recoil between compressions; (6) Provide rescue breaths (30:2 ratio) - tilt head, lift chin, seal "
 "over mouth, deliver over 1 second until chest rises; (7) Attach AED as soon as available and follow prompts without "
 "interrupting CPR unnecessarily. Hands-only CPR is effective and appropriate if rescuer is not trained in ventilation. "
 "The C-A-B sequence (Compressions-Airway-Breathing) is preferred to A-B-C to minimise time to first compression."),

("Advanced Cardiac Life Support (ACLS): Shockable Rhythms",
 "The two shockable rhythms are ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT). "
 "Management: (1) Continue CPR while charging defibrillator; (2) Deliver single shock (biphasic 120-200 J; "
 "monophasic 360 J); (3) Resume CPR immediately for 2 minutes without rhythm check; (4) Check rhythm at 2 minutes; "
 "(5) If still shockable - repeat shock; (6) After 3rd shock, administer adrenaline 1 mg IV (repeat every 3-5 minutes) "
 "and amiodarone 300 mg IV (second dose 150 mg after 5th shock); (7) Continue 2-minute CPR cycles with rhythm checks. "
 "Defibrillation pads are placed in anterolateral position (right infraclavicular and left lateral chest at V4-V6 "
 "level) or anteroposterior position. Gel pads must be dry for safe defibrillation."),

("ACLS: Non-Shockable Rhythms and Reversible Causes",
 "Non-shockable rhythms are pulseless electrical activity (PEA) and asystole. Management: (1) Continue high-quality "
 "CPR; (2) Administer adrenaline 1 mg IV as soon as IV access obtained (repeat every 3-5 minutes); (3) Do not "
 "interrupt CPR to administer drugs; (4) Search actively for reversible causes. The 4 Hs and 4 Ts: Hypoxia (ensure "
 "adequate ventilation), Hypovolaemia (IV fluid challenge), Hypo/Hyperkalaemia/metabolic (check ABG/electrolytes), "
 "Hypothermia (rewarm); Tension pneumothorax (needle decompression), Tamponade (pericardiocentesis), Toxins "
 "(antidotes), Thromboembolism - PE (thrombolysis during CPR) or ACS (PCI post-ROSC). Atropine is no longer "
 "recommended for PEA/asystole. Waveform capnography (ETCO2) guides quality of CPR (target >10-20 mmHg during "
 "compressions) and indicates ROSC (sudden rise in ETCO2)."),

("Post-Resuscitation Care",
 "Survival to discharge after cardiac arrest depends as much on post-resuscitation care as on the resuscitation itself. "
 "Key components of post-ROSC management: (1) Targeted Temperature Management (TTM) - maintain temperature 32-36°C "
 "for 24 hours to reduce neurological injury (HYPERION trial supports benefit of 33°C in non-shockable rhythms); "
 "(2) Haemodynamic optimisation - MAP >65-70 mmHg with vasopressors if needed, avoid hypotension; (3) Oxygenation - "
 "target SpO2 94-98%, avoid hyperoxia (PaO2 >300 mmHg associated with worse outcomes); (4) Normocapnia (PaCO2 "
 "35-45 mmHg); (5) Urgent coronary angiography and PCI if ST elevation or suspected ACS; (6) Neurological assessment "
 "- prognostication deferred to 72 hours post-ROSC (or 72 hours after rewarming from TTM) using clinical examination, "
 "EEG, SSEP, NSE, and brain CT/MRI. Documentation of the arrest duration, no-flow and low-flow times, and all "
 "interventions is essential.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P5 - Central Vein Cannulation and CVP Monitoring
# ══════════════════════════════════════════════════════════════════
make_doc("P05_Central_Vein_Cannulation_CVP.docx", "P5",
"Critically Ill Person",
"Central Vein Cannulation and CVP Monitoring",
[
("Introduction",
 "Central venous catheterisation (CVC) provides secure venous access for administration of vasoactive drugs, concentrated "
 "electrolyte solutions, total parenteral nutrition, and monitoring of central venous pressure. It is a fundamental "
 "procedural skill in intensive care and general medicine. The three principal sites are the internal jugular vein (IJV), "
 "subclavian vein (SCV), and femoral vein (FV), each with distinct advantages and risk profiles. Ultrasound guidance "
 "is now the standard of care, having significantly reduced the rates of arterial puncture, haematoma, and failed "
 "cannulation compared with landmark technique."),

("Indications, Contraindications, and Site Selection",
 "Indications: vasopressor infusion (dopamine, noradrenaline), concentrated potassium or sodium infusions, TPN, "
 "CVP monitoring, haemodialysis (triple-lumen catheter or dedicated Vascath), and lack of peripheral venous access. "
 "Contraindications: coagulopathy (relative - correct to INR <1.5 and platelets >50,000 before elective insertion), "
 "local site infection, thrombosis at the intended site. Site comparison: IJV - preferred site with ultrasound; lower "
 "pneumothorax risk than SCV; risk of carotid artery puncture. SCV - lower infection rate; higher pneumothorax risk; "
 "preferred for long-term access. Femoral - easiest access in emergency; highest infection and thrombosis risk; "
 "avoid if possible in ambulatory patients. Right IJV is preferred due to straight path to SVC-RA junction."),

("Procedure: Seldinger Technique",
 "Equipment: CVC kit (introducer needle, guidewire, dilator, catheter), sterile drape, ultrasound machine with sterile "
 "probe cover, chlorhexidine 2% skin preparation, local anaesthetic (lidocaine 1-2%). Steps: (1) Position patient "
 "supine, 15-degree Trendelenburg for IJV/SCV; (2) Full aseptic technique - sterile gown, gloves, mask, hat, large "
 "sterile drape; (3) Prepare skin with chlorhexidine, allow to dry; (4) Ultrasound identification of vein (compressible, "
 "non-pulsatile, expands with Valsalva); (5) Local anaesthetic to skin and deeper tissues; (6) Insert introducer "
 "needle at 45 degrees under real-time ultrasound guidance, aspirating until venous blood confirmed; (7) Advance "
 "guidewire through needle (J-tip first) - ECG changes (PVCs) indicate wire in right ventricle, withdraw slightly; "
 "(8) Nick skin with scalpel; (9) Advance dilator over wire; (10) Thread catheter (15-17 cm for right IJV) over wire; "
 "(11) Withdraw wire; (12) Aspirate and flush all ports; (13) Secure catheter; (14) CXR to confirm tip position "
 "(SVC-RA junction, right border of trachea at carina level) and exclude pneumothorax."),

("CVP Measurement and Interpretation",
 "CVP is measured via the distal (blue) port of the CVC connected to a water manometer or electronic pressure transducer. "
 "The transducer must be zeroed at the phlebostatic axis (4th intercostal space, midaxillary line) with the patient "
 "supine. Normal CVP is 5-12 mmHg (7-16 cmH2O). Low CVP (<5 mmHg) suggests hypovolaemia or vasodilation. High CVP "
 "(>15 mmHg) suggests right ventricular failure, cardiac tamponade, tension pneumothorax, fluid overload, or increased "
 "intrathoracic pressure (PEEP, tension pneumothorax). The CVP waveform has characteristic components: 'a' wave "
 "(atrial contraction), 'c' wave (tricuspid valve closure), 'x' descent (atrial relaxation), 'v' wave (venous filling "
 "with closed tricuspid valve), 'y' descent (tricuspid opening). Cannon 'a' waves in AV dissociation (complete heart "
 "block, VT) and absent 'a' waves in AF are clinically significant findings."),

("Complications and Prevention",
 "Immediate complications: arterial puncture (withdraw needle, apply pressure; inadvertent arterial catheterisation "
 "requires vascular surgery referral), pneumothorax (post-procedure CXR mandatory; symptomatic pneumothorax requires "
 "chest drain), air embolism (Trendelenburg position and Valsalva during wire/catheter changes), haemothorax, cardiac "
 "arrhythmias (guidewire in right ventricle). Late complications: CLABSI (central line-associated bloodstream "
 "infection) - prevented by maximal barrier precautions, chlorhexidine skin preparation, avoiding femoral site, "
 "daily review of line necessity (remove at earliest opportunity), and chlorhexidine-impregnated dressing; CVC "
 "thrombosis - use 0.9% saline flushes, anticoagulation if symptomatic; catheter malposition requiring repositioning. "
 "A formal daily checklist for CVC necessity reduces line days and CLABSI rates significantly.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P6 - Using a Defibrillator
# ══════════════════════════════════════════════════════════════════
make_doc("P06_Defibrillator.docx", "P6",
"Critically Ill Person",
"Using a Defibrillator",
[
("Introduction",
 "Defibrillation is the delivery of a controlled electrical shock to the myocardium to depolarise a critical mass of "
 "cardiac muscle simultaneously, terminating chaotic electrical activity and allowing the sinus node to resume "
 "coordinated pacemaker function. It is the definitive treatment for ventricular fibrillation (VF) and pulseless "
 "ventricular tachycardia (pVT), the two shockable cardiac arrest rhythms. For every minute of delay in defibrillation, "
 "survival from VF falls by approximately 10%; rapid defibrillation is therefore the single most impactful intervention "
 "in out-of-hospital cardiac arrest. The physician must be fully competent in the safe and effective use of both "
 "automated external defibrillators (AEDs) and manual defibrillators."),

("Types of Defibrillators",
 "Automated External Defibrillators (AEDs) are designed for use by minimally trained lay rescuers. They attach via "
 "self-adhesive pads, automatically analyse the cardiac rhythm, and provide voice-guided instructions including "
 "prompts to deliver a shock if a shockable rhythm is detected. Modern AEDs deliver biphasic shocks at 150-200 J. "
 "Manual defibrillators are used in clinical settings by trained healthcare professionals. They display continuous "
 "ECG, allow rhythm interpretation and manual shock delivery, and can also function as synchronised cardioverters "
 "and transcutaneous pacemakers. Modern devices deliver biphasic truncated exponential waveform (BTE) or rectilinear "
 "biphasic (RLB) shocks, which are more effective and safer than the older monophasic waveform. AED programmes in "
 "public locations have significantly improved out-of-hospital cardiac arrest survival in countries with wide "
 "deployment."),

("Defibrillation Technique",
 "Safety check before every shock: ensure no one is touching the patient or the bed; remove oxygen mask/nasal prongs "
 "and move oxygen source at least 1 metre from patient to prevent ignition; ensure ECG leads are not overlying "
 "electrode positions; do not place pad over cardiac implanted device. Pad placement: anterolateral position "
 "(right infraclavicular and left V4-V6 lateral chest wall) is standard; anteroposterior position (anterior over "
 "left precordium, posterior below left scapula) may be used if anterolateral access is limited. Ensure good pad "
 "contact - do not use gel pads over wet skin; wipe excess moisture. Steps: (1) Confirm cardiac arrest and shockable "
 "rhythm; (2) Apply pads; (3) Continue CPR while charging; (4) Announce 'Stand back - delivering shock'; (5) Visually "
 "confirm all clear; (6) Deliver shock; (7) Resume CPR immediately for 2 minutes without rhythm check. "
 "Single-shock strategy (versus stacked shocks) is current guidance."),

("Synchronised Cardioversion",
 "Synchronised cardioversion delivers a shock timed to the R-wave of the QRS complex (triggered by the 'sync' mode "
 "on the defibrillator) to avoid the vulnerable period of repolarisation (T-wave) and prevent induction of VF. "
 "It is used for haemodynamically unstable tachyarrhythmias with a pulse: AF (120-200 J biphasic), atrial flutter "
 "(50-100 J biphasic), SVT (50-100 J biphasic), and monomorphic VT with pulse (100-200 J biphasic). Sedation "
 "(midazolam + fentanyl, or propofol) is required unless the patient is unconscious. Correct anticoagulation must "
 "be confirmed before elective cardioversion of AF (minimum 3 weeks therapeutic anticoagulation, or TOE to exclude "
 "left atrial thrombus). Post-cardioversion monitoring for at least 1 hour is mandatory."),

("Transcutaneous Pacing and Troubleshooting",
 "Manual defibrillators with pacing capability can provide transcutaneous pacing (TCP) in haemodynamically significant "
 "bradycardia unresponsive to atropine. Pads are placed in anteroposterior position. Set demand mode, rate 60-80/min, "
 "and increase output (mA) from minimum until electrical capture (pacing spike followed by broad QRS) is confirmed; "
 "then confirm mechanical capture by palpation of femoral pulse. TCP is painful and sedation/analgesia must be "
 "provided. It is a bridge to transvenous pacing. Common defibrillation failures: suboptimal pad position, inadequate "
 "contact, persistent hypoxia/acidosis reducing defibrillation threshold, and electrolyte disturbance (hypokalaemia, "
 "hypomagnesaemia). Refractory VF may respond to double sequential defibrillation (simultaneous shocks from two "
 "defibrillators), amiodarone, lidocaine, or correction of underlying cause (hypothermia, toxins).")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P7 - Hemodialysis
# ══════════════════════════════════════════════════════════════════
make_doc("P07_Hemodialysis.docx", "P7",
"Critically Ill Person",
"Hemodialysis",
[
("Introduction",
 "Hemodialysis (HD) is an extracorporeal renal replacement therapy (RRT) that removes waste products, excess electrolytes, "
 "and fluid from the blood of patients with severe acute or chronic kidney disease. Blood is pumped through a "
 "semipermeable membrane (dialyser) where solutes are removed by diffusion along concentration gradients (dialysis) "
 "and fluid is removed by ultrafiltration driven by a transmembrane pressure gradient. The internal medicine "
 "postgraduate must understand the indications, prescription, vascular access, principles, and complications of HD, "
 "as well as the distinction between intermittent HD and continuous RRT (CRRT) in the critically ill."),

("Indications for Dialysis: AEIOU",
 "The classic indications for urgent dialysis are captured in the AEIOU mnemonic. A - Acidosis: metabolic acidosis "
 "refractory to medical management (pH <7.1 or bicarbonate <10 mEq/L). E - Electrolytes: hyperkalaemia refractory "
 "to medical treatment (K+ >6.5 mEq/L with ECG changes, or K+ >7 mEq/L regardless of ECG). I - Ingestion/Intoxication: "
 "removal of dialysable toxins - ethylene glycol, methanol, salicylates, lithium, certain other drugs. O - Overload "
 "(fluid): acute pulmonary oedema or peripheral oedema refractory to diuretics. U - Uraemia: symptomatic uraemia - "
 "uraemic encephalopathy (asterixis, confusion, seizures), uraemic pericarditis (friction rub, effusion), uraemic "
 "bleeding. In chronic kidney disease (CKD), HD is initiated when GFR falls to 5-10 mL/min/1.73m2 in the presence "
 "of symptoms, or at GFR <5-7 mL/min/1.73m2 regardless of symptoms."),

("Vascular Access",
 "Adequate vascular access is the lifeline of dialysis. Options: (1) Temporary vascular access via double- or "
 "triple-lumen dialysis catheter (Vascath/permcath) - inserted under ultrasound guidance into IJV (preferred), "
 "SCV, or femoral vein; used for acute HD or as a bridge while permanent access matures. (2) Arteriovenous fistula "
 "(AVF) - surgical anastomosis between radial artery and cephalic vein at the wrist (Brescia-Cimino fistula, "
 "preferred), or brachiocephalic/basilic fistula; requires 6-12 weeks to mature; lowest infection and thrombosis "
 "rates; gold standard for long-term HD access. (3) AV graft - synthetic graft connecting artery and vein when "
 "native vessels are inadequate; ready for use in 2-4 weeks; higher thrombosis rate than AVF. Assessing AVF/graft: "
 "palpate thrill (normal), auscultate bruit (normal); absent thrill/bruit suggests thrombosis or stenosis."),

("HD Prescription and Procedure",
 "The HD prescription specifies: dialysate composition (sodium 135-145 mEq/L, potassium 2-3 mEq/L, bicarbonate "
 "32-38 mEq/L, calcium 1.25-1.75 mmol/L, glucose 5.5 mmol/L), blood flow rate (200-400 mL/min), dialysate "
 "flow rate (500-800 mL/min), session duration (typically 3-5 hours, 3 times/week for ESRD), and ultrafiltration "
 "goal (excess fluid to be removed). Heparin anticoagulation (UFH) is standard during HD to prevent circuit "
 "clotting; citrate-based or low-molecular-weight heparin alternatives are used in high-bleeding-risk patients. "
 "In ICU patients with haemodynamic instability, CRRT (Continuous Renal Replacement Therapy) is preferred over "
 "intermittent HD as it provides gentle, continuous fluid and solute removal over 24 hours, avoiding the "
 "haemodynamic shifts associated with rapid solute and fluid removal in intermittent HD."),

("Complications and Adequacy",
 "Intradialytic complications: hypotension (most common - due to rapid fluid removal; managed with saline bolus, "
 "reducing UFR, Trendelenburg position), muscle cramps (osmotic shifts), dialysis disequilibrium syndrome "
 "(rapid urea removal in initial sessions causing cerebral oedema - prevented by gradual initiation), arrhythmias, "
 "air embolism, and dialyser reactions. Access complications: infection (most serious - MRSA bacteraemia risk "
 "with tunnelled catheters), thrombosis, stenosis, aneurysm formation (AVF). Adequacy of dialysis is measured by "
 "Kt/V (K = dialyser clearance, t = time, V = urea distribution volume; target Kt/V ≥1.2-1.4 per session) and "
 "urea reduction ratio (URR >65%). Inadequate dialysis is associated with increased cardiovascular morbidity and "
 "mortality. The nephrologist leads HD prescription; the internist must recognise when dialysis is indicated "
 "and facilitate timely referral and access.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P8 - Certification of Brain Death
# ══════════════════════════════════════════════════════════════════
make_doc("P08_Brain_Death_Certification.docx", "P8",
"Critically Ill Person",
"Certification of Brain Death",
[
("Introduction and Legal Framework",
 "Brain death (BD) is defined as the irreversible cessation of all functions of the entire brain, including the "
 "brainstem, while the heart continues to beat with ventilatory support. It is legally equivalent to death in "
 "India under the Transplantation of Human Organs and Tissues Act (THOTA), 1994 (amended 2011). Certification of "
 "brain death has profound implications: it permits withdrawal of life-sustaining treatment, allows families to "
 "begin the grieving process with clarity, and forms the legal basis for deceased donor organ donation. The "
 "process must be conducted with meticulous care, compassion, and full documentation to ensure validity and "
 "to respect the deceased and their family."),

("Prerequisites Before Brain Death Testing",
 "Brain death testing must only be performed once all reversible causes of deep unresponsive coma have been "
 "excluded. Prerequisites: (1) Known cause of irreversible structural brain injury (TBI, hypoxic-ischaemic "
 "injury, intracranial haemorrhage, cerebral infarction); (2) Normothermia (core temperature >36°C - "
 "hypothermia depresses brainstem reflexes and mimics brain death); (3) Normotension (SBP >90 mmHg); "
 "(4) Normoglycaemia; (5) No CNS-depressant drugs active (opioids, benzodiazepines, barbiturates, "
 "propofol, neuromuscular blocking agents - adequate time for metabolism/elimination must have elapsed "
 "or drug levels confirmed undetectable); (6) No severe metabolic disturbance (Na, glucose, phosphate). "
 "Brainstem auditory and visual evoked potentials, or drug levels, may be required to confirm absence of "
 "drug effect."),

("Clinical Brain Death Testing: Brainstem Reflexes",
 "Under THOTA, a panel of four doctors must certify brain death (treating physician, specialist nominated by "
 "the hospital, neurologist/neurosurgeon nominated by the hospital, and a physician nominated by an "
 "appropriate authority). Tests must be performed twice, at least 6 hours apart. Brainstem reflex tests: "
 "(1) Pupillary light reflex - pupils should be fixed and dilated (4-9 mm), unresponsive to bright light; "
 "(2) Corneal reflex - no blink response to cotton wool touching the cornea; (3) Vestibulo-ocular (caloric) "
 "reflex - no eye movement in response to 50 mL of ice-cold water slowly irrigated into the external "
 "auditory canal (ensure tympanic membrane is intact, head at 30 degrees); (4) Gag reflex - no response "
 "to posterior pharyngeal stimulation; (5) Cough reflex - no cough response to tracheal suction; "
 "(6) Oculocephalic reflex - no eye movement when head is rotated (doll's eyes) - only test if C-spine "
 "injury excluded."),

("Apnoea Test",
 "The apnoea test confirms the absence of medullary respiratory centre function. Preconditions: SpO2 >95%, "
 "PaCO2 35-45 mmHg (normocarbia), haemodynamic stability. Procedure: (1) Pre-oxygenate with FiO2 1.0 "
 "for 10 minutes; (2) Obtain baseline ABG confirming PaCO2 35-45 mmHg; (3) Disconnect from ventilator; "
 "(4) Deliver O2 at 6-10 L/min via catheter placed in endotracheal tube to maintain oxygenation (apnoeic "
 "oxygenation); (5) Observe for any spontaneous respiratory effort for 8-10 minutes; (6) Obtain terminal "
 "ABG - PaCO2 must rise to ≥60 mmHg (or ≥20 mmHg above baseline) to confirm apnoea; (7) Reconnect "
 "ventilator. If SpO2 falls <85%, haemodynamic instability occurs, or cardiac arrhythmia develops, "
 "abort test and reconnect ventilator. A positive apnoea test (no respiratory effort with PaCO2 ≥60 mmHg) "
 "confirms apnoea. Ancillary tests (EEG, cerebral angiography, CTPA, nuclear scan) may be used when "
 "clinical testing is inconclusive."),

("Communication and Documentation",
 "The certification of brain death must be followed by sensitive, empathetic communication with the family. "
 "The diagnosis must be explained clearly - brain death is legal death; the heart is beating only because "
 "of the mechanical ventilator. Families often struggle to understand this concept, particularly when the "
 "patient appears 'asleep'. Time should be given for questions and for the family to be with their loved "
 "one. The option of organ donation should be raised sensitively, ideally by a trained transplant "
 "coordinator in collaboration with the medical team, after the family has been informed of death "
 "(decoupling). Organ donation must never be raised as a condition or precondition of care. Documentation "
 "in the medical record must include: date and time of each examination, names and signatures of all four "
 "certifying doctors, results of each brainstem reflex test, apnoea test results including ABG values, "
 "and the time of death. THOTA-prescribed forms must be completed.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P9 - Treadmill Testing
# ══════════════════════════════════════════════════════════════════
make_doc("P09_Treadmill_Testing.docx", "P9",
"Interpretation Skills",
"Treadmill Testing (Exercise Stress Testing)",
[
("Introduction",
 "The exercise stress test (EST), commonly performed using a motorised treadmill, is a non-invasive investigation "
 "that assesses the cardiovascular response to graded physical exercise. It has broad clinical applications "
 "including the diagnosis of obstructive coronary artery disease (CAD), risk stratification post-MI, functional "
 "capacity assessment, evaluation of exercise-induced arrhythmias, and assessment of chronotropic incompetence. "
 "The Bruce protocol is the most widely used, consisting of seven 3-minute stages with progressively increasing "
 "speed and gradient. The physician must be proficient in pre-test assessment, test conduct, and systematic "
 "interpretation of results."),

("Indications and Contraindications",
 "Indications: evaluation of chest pain in intermediate pre-test probability of CAD (Bayes theorem - EST "
 "most diagnostically useful when pre-test probability is 30-70%); risk stratification after acute coronary "
 "syndrome; assessment of haemodynamic significance of known CAD; evaluation of exercise-induced arrhythmias "
 "or symptoms; functional capacity assessment for disability or fitness for work. Absolute contraindications: "
 "acute MI within 2 days, unstable angina, uncontrolled arrhythmias with haemodynamic compromise, "
 "symptomatic severe aortic stenosis, decompensated heart failure, acute pulmonary embolism, acute myocarditis "
 "or pericarditis, aortic dissection. Relative contraindications: left main stenosis, moderate valvular disease, "
 "electrolyte abnormalities, severe hypertension (BP >200/110 mmHg), LBBB/pacemaker (ST changes uninterpretable), "
 "hypertrophic cardiomyopathy, inability to exercise adequately."),

("Test Protocol and Endpoints",
 "The Bruce protocol begins at 1.7 mph / 10% gradient (Stage 1) and increases in 3-minute increments to "
 "5.5 mph / 20% gradient (Stage 5). Target heart rate = 85% of maximum predicted heart rate (220 - age). "
 "Monitoring throughout: 12-lead ECG (continuous), blood pressure every stage, symptoms, RPE (Borg scale). "
 "Indications to terminate the test: (1) Patient requests to stop; (2) ST depression >2 mm in multiple "
 "leads; (3) ST elevation >1 mm; (4) Ventricular tachycardia or significant arrhythmia; (5) BP fall >10 mmHg "
 "from baseline with other ischaemic features; (6) Symptomatic severe hypertension (SBP >250 mmHg, "
 "DBP >115 mmHg); (7) Severe angina; (8) CNS symptoms (ataxia, dizziness, near-syncope); (9) Technical "
 "problems with ECG monitoring. Post-exercise monitoring continues for at least 6 minutes."),

("Interpretation of ECG and Haemodynamic Responses",
 "Positive test criteria: horizontal or downsloping ST depression ≥1 mm at 80 ms after the J-point in ≥2 "
 "contiguous leads. Upsloping ST depression ≥1.5 mm is also significant. ST elevation in a non-infarct lead "
 "suggests severe ischaemia or vasospasm. Duke Treadmill Score = exercise time (minutes) - (5 × ST deviation "
 "in mm) - (4 × angina index [0=none, 1=non-limiting, 2=exercise-limiting]). Score ≥5 = low risk (1% annual "
 "mortality), -10 to 4 = intermediate risk, <-11 = high risk. Haemodynamic features of high risk: failure "
 "to achieve 5 METs, exercise-induced hypotension, chronotropic incompetence (failure to achieve 85% max HR "
 "without beta-blockade). Limitations: sensitivity 68%, specificity 77% for significant CAD; false positives "
 "in women, LVH, digoxin use, hypokalaemia, Wolff-Parkinson-White; false negatives with single-vessel disease."),

("Reporting and Clinical Application",
 "A structured EST report should include: indication for test, patient demographics, resting ECG findings, "
 "maximum heart rate and % of target achieved, maximum workload (METs), blood pressure response, symptoms "
 "during exercise, ECG changes (location, degree, time of onset and recovery), reason for termination, Duke "
 "Treadmill Score, and overall interpretation (positive/negative/equivocal). A negative test in a patient "
 "with low-intermediate pre-test probability provides strong reassurance and reduces the need for invasive "
 "testing. A high-risk positive test (early onset, widespread ST depression, exercise hypotension, Duke "
 "score <-11) warrants urgent coronary angiography. Nuclear perfusion imaging or stress echocardiography "
 "adds specificity when the resting ECG is abnormal (LBBB, LVH, pre-excitation) or when the EST result "
 "is equivocal.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P10 - ABG Analysis
# ══════════════════════════════════════════════════════════════════
make_doc("P10_ABG_Analysis.docx", "P10",
"Interpretation Skills",
"Arterial Blood Gas (ABG) Analysis",
[
("Introduction",
 "Arterial blood gas analysis is one of the most frequently performed and clinically informative investigations "
 "in acute medicine and intensive care. It provides simultaneous assessment of oxygenation, ventilation, and "
 "acid-base status - information that is not available from any other single test. A systematic approach to "
 "ABG interpretation is essential; piecemeal or unsystematic reading of ABG results is a common source of "
 "clinical error. The ABG should always be interpreted in the context of the clinical presentation and "
 "alongside other investigations."),

("Normal Values and Collection",
 "Arterial blood is collected from the radial artery (after Allen's test to confirm ulnar collateral supply), "
 "brachial artery, or femoral artery, using a pre-heparinised syringe. Samples must be analysed within "
 "15-30 minutes or stored on ice. Normal values: pH 7.35-7.45, PaO2 80-100 mmHg (10.6-13.3 kPa), PaCO2 "
 "35-45 mmHg (4.7-6.0 kPa), HCO3- 22-26 mEq/L, base excess -2 to +2 mEq/L, SpO2 >95%. The A-a gradient "
 "(alveolar-arterial oxygen difference) = PAO2 - PaO2; PAO2 = (FiO2 × 713) - PaCO2/0.8 at sea level. "
 "Normal A-a gradient = 4 + age/4 (approximate). An elevated A-a gradient indicates a pulmonary cause of "
 "hypoxaemia (V/Q mismatch, shunt, diffusion impairment)."),

("Step-by-Step Interpretation",
 "Step 1 - Oxygenation: Is PaO2 adequate? <60 mmHg = hypoxaemia, <40 mmHg = severe. Type 1 RF (hypoxaemia, "
 "normal PaCO2) vs Type 2 RF (hypoxaemia + hypercapnia, PaCO2 >45 mmHg). Step 2 - pH: is it acidaemia "
 "(<7.35) or alkalaemia (>7.45)? Step 3 - Primary disorder: if pH <7.35, is HCO3- low (metabolic acidosis) "
 "or PaCO2 high (respiratory acidosis)? If pH >7.45, is HCO3- high (metabolic alkalosis) or PaCO2 low "
 "(respiratory alkalosis)? Step 4 - Compensation: check if compensation is appropriate (Winter's formula "
 "for metabolic acidosis: expected PaCO2 = 1.5 × HCO3- + 8 ± 2; if actual PaCO2 ≠ expected, a mixed "
 "disorder is present). Step 5 - Anion gap (AG) in metabolic acidosis: AG = Na+ - (Cl- + HCO3-), normal "
 "8-12. Elevated AG acidosis: MUDPILES (Methanol, Uraemia, DKA, Propylene glycol, Isoniazid, Lactic "
 "acidosis, Ethylene glycol, Salicylates). Step 6 - Delta-delta ratio in elevated AG acidosis: if AG "
 "excess/HCO3- deficit ratio >2, concurrent metabolic alkalosis; if <1, concurrent NAGMA."),

("Common Clinical Scenarios",
 "Respiratory acidosis (pH↓, PaCO2↑, HCO3- compensatory↑): acute - pneumonia, pulmonary oedema, status "
 "asthmaticus, COPD exacerbation, opioid OD, neuromuscular disease; chronic - COPD, OHS. Respiratory "
 "alkalosis (pH↑, PaCO2↓, HCO3-↓): anxiety, pain, pregnancy, early salicylate poisoning, hepatic failure, "
 "high-altitude. Metabolic acidosis with high AG: DKA (beta-hydroxybutyrate), lactic acidosis (Type A - "
 "hypoperfusion; Type B - metformin, liver failure), uraemia, toxin ingestion. NAGMA (normal AG metabolic "
 "acidosis): diarrhoea, RTA, saline infusion, ileostomy, Addison's disease. Metabolic alkalosis: "
 "vomiting (Cl- depletion), diuretics, hypokalaemia, primary hyperaldosteronism, excess alkali ingestion; "
 "characterised by high HCO3-, often with elevated PaCO2 compensation."),

("Lactate, SpO2, and Special Calculations",
 "Serum lactate (often reported with ABG on modern analysers) reflects the balance between tissue oxygen "
 "delivery and demand. Normal <2 mmol/L. Elevated lactate (>2 mmol/L) indicates tissue hypoperfusion "
 "(sepsis, cardiogenic shock, severe anaemia) or impaired clearance (liver failure, metformin toxicity, "
 "thiamine deficiency/Type B lactic acidosis). Lactate >4 mmol/L in sepsis defines septic shock. "
 "Lactate clearance (>10% fall at 2 hours) is a treatment response marker in septic shock. SpO2 from "
 "pulse oximetry may be unreliable in states of poor perfusion, carboxyhaemoglobinaemia (CO poisoning "
 "- SpO2 falsely normal despite COHb elevation), and methaemoglobinaemia (SpO2 plateaus at 85%). "
 "Co-oximetry on ABG directly measures COHb and metHb. The PF ratio (PaO2/FiO2): >400 = normal; "
 "300-400 = mild hypoxaemia; 200-300 = moderate (mild ARDS); 100-200 = severe ARDS; <100 = very severe.")
])

print("Part 1 (Topics P1-P10) complete.")

import sys
sys.path.insert(0, "/tmp/workspace/elog-book/p_competencies")
from helper import make_doc

# ══════════════════════════════════════════════════════════════════
# TOPIC P11 - Ultrasonography
# ══════════════════════════════════════════════════════════════════
make_doc("P11_Ultrasonography.docx", "P11",
"Interpretation Skills",
"Ultrasonography",
[
("Introduction",
 "Ultrasonography (USG) uses high-frequency sound waves (2-18 MHz) to generate real-time images of internal "
 "structures. It is widely available, inexpensive, radiation-free, and portable - making it invaluable in both "
 "outpatient and critical care settings. The clinician-performed Point-of-Care Ultrasound (POCUS) has emerged as "
 "an extension of the clinical examination, enabling rapid bedside assessment of the heart, lungs, abdomen, "
 "and vessels. The internal medicine postgraduate must be proficient in interpreting formal USG reports across "
 "the common clinical domains, and increasingly, in performing and interpreting basic POCUS."),

("Abdominal Ultrasonography",
 "USG of the abdomen is the first-line imaging modality for most abdominal complaints. Key findings to recognise: "
 "Liver - echogenicity (increased = fatty liver/steatosis; heterogeneous = cirrhosis, metastases), size (normal "
 "<16 cm in MCL), focal lesions (hypoechoic = metastases, abscesses; hyperechoic = haemangiomas; complex = HCC), "
 "portal vein diameter (>13 mm = portal hypertension), hepatic vein and IVC patency (Budd-Chiari). Gallbladder - "
 "stones (echogenic with posterior acoustic shadowing), wall thickening >3 mm, pericholecystic fluid (acute "
 "cholecystitis), polyps. Biliary tree - CBD >8 mm = dilation (normal <6 mm), CBD stones. Spleen - size "
 "(>13 cm = splenomegaly), focal lesions. Kidneys - size (normal 9-12 cm), echogenicity, corticomedullary "
 "differentiation loss (CKD), hydronephrosis (graded I-IV), stones (echogenic + shadowing), cysts, masses. "
 "Ascites - free fluid (anechoic) in hepatorenal space (Morrison's pouch), splenorenal space, pelvis."),

("Cardiac Ultrasound (Echocardiography)",
 "2D echocardiography assesses cardiac structure and function. Standard views: parasternal long-axis (PLAX), "
 "parasternal short-axis (PSAX), apical 4-chamber, apical 2-chamber, subcostal. Key parameters: LV size and "
 "function - LV internal diameter (normal LVEDD <56 mm), ejection fraction (EF; normal ≥55%); regional wall "
 "motion abnormalities (RWMA) - hypokinesia/akinesia/dyskinesia suggesting ischaemia or infarction in coronary "
 "territories. RV size and function (dilated, hypokinetic RV suggests acute cor pulmonale - PE, ARDS). "
 "Valves - mitral (MR, MS), aortic (AR, AS with peak gradient and valve area), tricuspid (TR - severity, "
 "RVSP estimation), pulmonary. Pericardial effusion - graded mild (<10 mm), moderate (10-20 mm), large "
 "(>20 mm); tamponade features: RV diastolic collapse, RA collapse, IVC plethora, respiratory variation "
 "in mitral inflow. Diastolic function - E/A ratio, tissue Doppler E'."),

("Lung Ultrasonography",
 "Lung USG has largely replaced chest X-ray for bedside diagnosis of common pulmonary pathology. Key findings: "
 "A-lines (horizontal reverberation artefacts from normal aerated lung or pneumothorax), B-lines (vertical "
 "laser-like artefacts from interstitial fluid - 3 or more per field indicates interstitial syndrome / pulmonary "
 "oedema), consolidation (tissue-like echogenicity with air bronchograms), pleural effusion (anechoic/complex "
 "fluid between visceral and parietal pleura), and absence of lung sliding + A-lines = pneumothorax (confirmed "
 "by M-mode showing 'stratosphere/bar code sign' instead of normal 'seashore sign'). The BLUE protocol uses "
 "lung USG patterns to rapidly differentiate causes of acute dyspnoea: bilateral B-lines = cardiogenic oedema; "
 "unilateral B-lines + consolidation = pneumonia; absent sliding + A-lines = pneumothorax; A-lines + DVT = PE."),

("Vascular and Other Applications",
 "Venous Doppler: DVT assessment - absence of compressibility of femoral/popliteal vein with probe pressure is "
 "the primary diagnostic criterion; absence of venous Doppler flow, vein distension, and echogenic thrombus "
 "are supportive. Carotid Doppler: intima-media thickness (IMT) as surrogate of atherosclerosis, plaque "
 "characterisation (echogenic = fibrous/calcified; echolucent = lipid-rich, higher embolic risk), stenosis "
 "grading by peak systolic velocity. Renal artery Doppler: resistive index (RI) >0.7 suggests renal artery "
 "stenosis or intrinsic renal disease. FAST exam (Focused Assessment with Sonography in Trauma): screens "
 "for haemoperitoneum (Morrison's pouch, splenorenal, pelvic), pericardial effusion, and haemothorax in "
 "trauma. Thyroid USG: nodule characterisation (size, echogenicity, margins, calcification, vascularity) "
 "guides FNA decision using TIRADS scoring.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P12 - CT Scan Chest and Abdomen
# ══════════════════════════════════════════════════════════════════
make_doc("P12_CT_Chest_Abdomen.docx", "P12",
"Interpretation Skills",
"CT Scan - Chest and Abdomen",
[
("Introduction",
 "Computed tomography (CT) of the chest and abdomen is a cornerstone of diagnostic imaging in internal medicine. "
 "It provides high-resolution cross-sectional images that allow detailed evaluation of mediastinal, pulmonary, "
 "vascular, hepatic, pancreatic, renal, and retroperitoneal structures. The ability to interpret CT scans "
 "systematically and identify key pathological findings is an essential competency for the internist, ensuring "
 "that radiological information is correctly contextualised and integrated with clinical findings."),

("CT Chest: Technical Considerations and Windows",
 "CT chest is viewed in three windows: lung window (WL -600, WW 1500) optimises assessment of lung parenchyma, "
 "airways, and pleura; mediastinal window (WL 40, WW 400) for mediastinal structures, nodes, heart, and vessels; "
 "bone window (WL 300, WW 1500) for ribs, spine, and sternum. With IV contrast, pulmonary arteries (CT "
 "pulmonary angiogram - CTPA) and aorta (CT aortogram) are clearly defined. HRCT chest (thin slices without "
 "contrast) is optimised for interstitial lung disease characterisation. Key structures to systematically "
 "assess: trachea and main bronchi (deviation, stenosis, foreign body), lungs (opacity pattern, distribution), "
 "pleura (effusion, thickening, calcification, pneumothorax), mediastinum (widening, lymphadenopathy, masses), "
 "heart (size, pericardial effusion), great vessels, and incidental bone/soft tissue findings."),

("CT Chest: Common Pathological Patterns",
 "Consolidation: airspace filling with air bronchograms - causes: pneumonia (lobar, segmental), organising "
 "pneumonia, pulmonary haemorrhage, pulmonary infarction. Ground-glass opacity (GGO): hazy increased density "
 "not obscuring vessels - causes: pulmonary oedema, early pneumonia (especially viral, PCP), hypersensitivity "
 "pneumonitis, early IPF. Reticulation (fine linear opacities): IPF/UIP pattern, NSIP. Honeycombing (subpleural "
 "cystic spaces with thick walls): advanced fibrosis, IPF. Tree-in-bud: centrilobular nodules with linear "
 "branching - endobronchial spread of infection (TB, MAI), bronchiectasis. Cavitation: necrotising pneumonia "
 "(Klebsiella, Staph aureus), TB, lung abscess, septic emboli, cavitating malignancy. CTPA for PE: filling "
 "defects in pulmonary arteries; right heart strain signs (RV:LV ratio >1.0, IVS bowing, reflux into IVC). "
 "Mediastinal lymphadenopathy >10 mm short-axis: sarcoidosis (bilateral hilar, paratracheal), TB, lymphoma, "
 "metastases."),

("CT Abdomen: Systematic Assessment",
 "CT abdomen is performed without contrast (to detect calcifications and haemorrhage), with arterial phase "
 "(25-35 seconds - arteries, HCC, vascular anatomy), portal venous phase (60-70 seconds - liver parenchyma, "
 "veins, most abdominal organs), and delayed phase (3-5 minutes - urothelial, collecting system). Systematic "
 "approach - assess each organ in sequence: liver (size, contour, echogenicity, focal lesions), gallbladder "
 "and biliary tree, pancreas (attenuation, ductal dilation, peripancreatic fat stranding, necrosis), spleen, "
 "adrenal glands (size, attenuation - adenoma vs malignancy - Hounsfield units <10 on non-contrast CT), "
 "kidneys (cortical thickness, collecting system), retroperitoneum (lymph nodes, aorta - aneurysm, "
 "dissection), bowel (wall thickening, pneumatosis, free air), mesentery, and peritoneum."),

("CT Abdomen: Key Pathological Findings",
 "Free air (pneumoperitoneum): crescents of air under the diaphragm on coronal reconstruction - indicates "
 "visceral perforation. Free fluid: density characterises content (water 0-20 HU, blood 35-60 HU, bile, "
 "urine). Acute pancreatitis: pancreatic enlargement, peripancreatic fat stranding; CT Severity Index "
 "(Balthazar grade + necrosis percentage) predicts morbidity. Pancreatic necrosis: unenhancing parenchyma "
 "on contrast CT (>30% necrosis = severe). Aortic aneurysm: diameter >3 cm infrarenal aorta; >5.5 cm "
 "for elective repair. Aortic dissection: intimal flap creating true and false lumens (DeBakey/Stanford "
 "classification). Bowel obstruction: dilated loops proximal to transition point; closed-loop obstruction "
 "with C or U shape; ischaemia indicated by wall thickening, pneumatosis intestinalis, portal venous gas. "
 "Appendicitis: dilated appendix >6 mm, periappendiceal fat stranding, appendicolith.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P13 - CT Scan Head and Spine
# ══════════════════════════════════════════════════════════════════
make_doc("P13_CT_Head_Spine.docx", "P13",
"Interpretation Skills",
"CT Scan - Head and Spine",
[
("Introduction",
 "Non-contrast CT (NCCT) of the head is the most widely available and rapidly performed neuroimaging modality, "
 "making it the first-line investigation in acute neurological emergencies. CT spine is pivotal in the assessment "
 "of trauma, degenerative disease, and cord compression. Contrast-enhanced CT brain adds diagnostic value in "
 "the assessment of infection, tumours, and vascular lesions when MRI is unavailable. The internist must be "
 "able to perform an initial systematic interpretation of head and spine CT and recognise the key findings "
 "that require immediate action."),

("CT Head: Technical Approach and Windows",
 "NCCT head is viewed in two principal windows: brain window (WL 35, WW 80) for parenchyma, grey-white "
 "differentiation, and blood; and bone window (WL 600, WW 3000) for calvarium, skull base, and facial bones. "
 "Subdural window (WL 75, WW 250) helps identify isodense subdural collections. Systematic review: scalp "
 "and skull (fractures, subgaleal haematoma), extra-axial spaces (epidural, subdural, subarachnoid), "
 "parenchyma (haemorrhage, infarction, oedema, mass), ventricles (size, symmetry, blood), midline (shift "
 "measured at septum pellucidum), posterior fossa (cerebellum, brainstem, 4th ventricle), and incidental "
 "findings (sinusitis, calcifications). Hyperacute blood is hyperdense on NCCT (55-90 HU); chronic blood "
 "becomes isodense then hypodense."),

("CT Head: Common Pathological Findings",
 "Intracerebral haemorrhage (ICH): hyperdense parenchymal collection; assess volume (ABC/2 method: A × B × C/2 "
 "in cm³), location (basal ganglia/thalamus = hypertensive; lobar = amyloid angiopathy, AVM, tumour), "
 "ventricular extension (IVH), surrounding oedema, and midline shift. Subarachnoid haemorrhage (SAH): "
 "hyperdense blood in basal cisterns, Sylvian fissures, interhemispheric fissure - sensitivity of NCCT "
 "is 98% at 6 hours (reduces to 85-90% at 24 hours); LP remains necessary if NCCT negative and SAH suspected. "
 "Epidural haematoma (EDH): biconvex (lens-shaped) hyperdense collection, does not cross suture lines; "
 "usually from middle meningeal artery rupture in temporal bone fracture. Subdural haematoma (SDH): "
 "crescent-shaped collection following brain contour, crosses suture lines; acute = hyperdense, chronic "
 "= hypodense. Ischaemic stroke: in first 6 hours, early signs - loss of grey-white differentiation, "
 "insular ribbon sign, dense MCA sign; established infarct = hypodense area in vascular territory."),

("CT Head: Hydrocephalus and Space-Occupying Lesions",
 "Hydrocephalus: enlargement of ventricles; obstructive (non-communicating) - due to blockage of CSF flow "
 "at aqueduct, foramen of Monro, or posterior fossa lesion (dilated ventricles proximal to obstruction); "
 "communicating - impaired CSF reabsorption (meningitis, SAH, tumour) - all ventricles dilated including "
 "4th. Features suggesting raised ICP: obliteration of sulci, effacement of basal cisterns, uncal herniation "
 "(temporal lobe displacing through tentorial notch compressing CN III - 'blown pupil'). Ring-enhancing "
 "lesions (on contrast CT): solitary - brain abscess (thin smooth ring, surrounding oedema) vs high-grade "
 "glioma (irregular thick ring) vs metastasis; multiple ring-enhancing lesions - cerebral metastases (most "
 "common), multiple abscesses, toxoplasmosis (in HIV). Leptomeningeal enhancement suggests meningitis or "
 "carcinomatous meningitis."),

("CT Spine",
 "CT spine (C/T/L-spine) provides excellent bone detail - superior to MRI for fracture detection, particularly "
 "in trauma. Cervical spine CT is mandatory in high-energy trauma (GCS <14, neck pain, distracting injury) "
 "before removing cervical collar. Key findings: fractures (assess alignment, body height, posterior "
 "elements, facets - burst fracture with retropulsion into canal requires urgent neurosurgical review), "
 "subluxation and dislocation (>3.5 mm at any level = unstable), spondylolisthesis (graded I-IV), "
 "degenerative changes (disc space narrowing, osteophytes, facet arthropathy), spinal canal stenosis "
 "(assess from axial images - AP diameter <10 mm = critical stenosis). Epidural haematoma/abscess: "
 "CT poorly characterises soft tissue; MRI preferred. CT myelogram (intrathecal contrast) is used when "
 "MRI is contraindicated (pacemaker, metallic implants). Always correlate with neurological examination "
 "level to confirm radiological-clinical correspondence.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P14 - MRI Brain and Spine
# ══════════════════════════════════════════════════════════════════
make_doc("P14_MRI_Brain_Spine.docx", "P14",
"Interpretation Skills",
"MRI - Brain and Spine",
[
("Introduction",
 "Magnetic resonance imaging (MRI) provides superior soft-tissue contrast compared with CT, making it the "
 "modality of choice for detailed assessment of the brain, spinal cord, intervertebral discs, and surrounding "
 "soft tissues. It does not use ionising radiation, making it safe for repeated use. Key MRI sequences "
 "used in neuroimaging include T1-weighted, T2-weighted, FLAIR, DWI (diffusion-weighted imaging), GRE/SWI "
 "(gradient echo/susceptibility-weighted imaging), and gadolinium-enhanced T1. Understanding what each "
 "sequence demonstrates allows systematic interpretation of brain and spine MRI reports and images."),

("MRI Sequences and Signal Characteristics",
 "T1-weighted: fat and subacute blood (methaemoglobin) are bright (hyperintense); CSF is dark; grey matter "
 "is slightly darker than white matter; gadolinium contrast causes T1 shortening (enhancing lesions appear "
 "bright). Used for anatomy, post-contrast enhancement, and identifying fat/haemorrhage. T2-weighted: CSF "
 "is bright; most pathological processes (oedema, infarction, demyelination, tumour, infection) are "
 "hyperintense (water content increased); haemosiderin and calcium are dark. FLAIR (Fluid-Attenuated "
 "Inversion Recovery): suppresses CSF signal; periventricular lesions and subarachnoid blood (SAH not "
 "visible on NCCT after 24-48 hours) become visible. DWI: restricted diffusion (cytotoxic oedema in "
 "acute infarction, abscess, dense tumour) appears bright on DWI and dark on ADC map - the hallmark "
 "of acute ischaemic stroke. SWI/GRE: very sensitive to blood products, calcium, and iron - detects "
 "microhaemorrhages in cerebral amyloid angiopathy, cavernomas, and diffuse axonal injury."),

("MRI Brain: Common Findings",
 "Acute ischaemic stroke: DWI hyperintensity + ADC hypointensity within minutes of onset (allows diagnosis "
 "when NCCT is normal); MR angiography (MRA) identifies arterial occlusion; the DWI-FLAIR mismatch (DWI "
 "positive, FLAIR negative) suggests stroke onset <4.5 hours enabling thrombolysis in patients with "
 "unknown onset time. Demyelination (MS): T2/FLAIR hyperintense plaques in periventricular white matter "
 "(Dawson's fingers perpendicular to ventricles), corpus callosum, juxtacortical, infratentorial, and "
 "spinal cord; active lesions enhance on contrast T1. Tumours: low-grade gliomas are T2 bright without "
 "enhancement; high-grade (GBM) show central necrosis, irregular ring enhancement, surrounding oedema, "
 "and mass effect. Metastases: multiple ring or nodular enhancing lesions at grey-white junction. "
 "Meningitis: leptomeningeal enhancement on post-contrast T1; cerebral abscess shows ring enhancement "
 "with restricted diffusion centrally. Herpes encephalitis: T2/FLAIR signal in medial temporal lobes "
 "and insular cortex bilaterally."),

("MRI Spine",
 "MRI spine is the gold standard for assessment of the spinal cord, intervertebral discs, nerve roots, "
 "and surrounding soft tissues. Cervical/thoracic/lumbar spine studies are performed separately. Key "
 "findings: disc herniation - posterior disc protrusion compressing thecal sac or nerve root; nuclear "
 "herniation shows T2 bright disc material; canal compromise graded mild/moderate/severe. Spinal cord "
 "compression: reduced cord diameter, T2 hyperintensity within cord (myelomalacia) indicates chronic "
 "compression or cord injury. Epidural spinal cord compression (ESCC): from metastatic disease (most "
 "commonly breast, lung, prostate, myeloma) - T1 hypointense vertebral body replacement, epidural "
 "mass compressing cord - a neurosurgical/radiotherapy emergency. Spondylodiscitis: T2 hyperintensity "
 "and T1 hypointensity of adjacent vertebral endplates with disc, enhancement on contrast, paraspinal "
 "or epidural abscess. Transverse myelitis: T2 cord signal extending over multiple segments (>3 = LETM, "
 "suggests neuromyelitis optica spectrum disorder/NMOSD or MS)."),

("MRI Contraindications and Clinical Integration",
 "Absolute contraindications: cochlear implants, certain cardiac pacemakers and ICDs (MRI-conditional "
 "devices now available), ferromagnetic intracranial aneurysm clips, metallic intraocular foreign bodies. "
 "Relative: first trimester pregnancy (gadolinium avoided throughout pregnancy), severe claustrophobia "
 "(conscious sedation or open MRI), non-MRI-compatible ventilators (ICU patients). Gadolinium-based "
 "contrast agents: nephrogenic systemic fibrosis (NSF) risk in severe CKD (eGFR <30 mL/min) - macrocyclic "
 "agents preferred over linear; gadolinium deposition in brain (globus pallidus, dentate nucleus) with "
 "repeated administration - clinical significance uncertain. Functional MRI (fMRI), MR spectroscopy, "
 "arterial spin labelling, and perfusion imaging are advanced sequences providing information on brain "
 "function, metabolites, and cerebral blood flow, increasingly available at tertiary centres.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P15 - Barium Studies
# ══════════════════════════════════════════════════════════════════
make_doc("P15_Barium_Studies.docx", "P15",
"Interpretation Skills",
"Barium Studies",
[
("Introduction",
 "Barium studies use insoluble barium sulphate as a radio-opaque contrast agent to delineate the mucosal "
 "surface and lumen of the gastrointestinal tract under fluoroscopic imaging. While largely superseded by "
 "endoscopy and CT for many indications, barium studies retain important roles in specific clinical scenarios "
 "where dynamic assessment of swallowing or motility is required, when endoscopy is technically difficult "
 "or refused, or where mucosal detail and functional information are needed simultaneously. "
 "Water-soluble contrast (Gastrografin) is used when perforation is suspected (barium in the peritoneum "
 "or mediastinum causes severe granulomatous reaction)."),

("Barium Swallow",
 "The barium swallow evaluates the oropharynx, oesophagus, and gastro-oesophageal junction under real-time "
 "fluoroscopy. Indications: dysphagia (particularly for pharyngeal and upper oesophageal causes), odynophagia, "
 "suspected oesophageal stricture, post-surgical anatomy, and hiatus hernia assessment. Modified barium "
 "swallow (video fluoroscopy) with speech therapist involvement assesses swallowing mechanics and "
 "aspiration risk in neurological dysphagia. Key findings: oesophageal stricture (benign = smooth, "
 "tapered, symmetric; malignant = irregular, shouldered, rat-tail); pharyngeal pouch (Zenker's diverticulum "
 "- posterior midline, C5-6 level, barium pools in the pouch); achalasia (bird-beak or rat-tail narrowing "
 "at GOJ with proximal oesophageal dilation, air-fluid level); hiatus hernia (gastric fundus above "
 "diaphragm in sliding or rolling/para-oesophageal type); oesophageal web (smooth shelf-like projection, "
 "associated with iron deficiency - Plummer-Vinson syndrome); GORD - reflux of barium above GOJ."),

("Barium Meal and Small Bowel Studies",
 "Barium meal (upper GI series) evaluates the stomach and duodenum. Key findings: gastric ulcer - "
 "benign features: round, regular margin, Hampton's line, Meniscus sign, smooth mucosal folds converging "
 "to ulcer; malignant features: irregular, inside the expected margin of the stomach, absent mucosal folds, "
 "thick irregular rim. Gastric carcinoma: 'leather bottle' stomach (linitis plastica) from infiltrating "
 "carcinoma causing reduced distensibility. Duodenal ulcer: constant projection, duodenal deformity, "
 "cloverleaf deformity of duodenal cap. Small bowel follow-through (SBFT) or dedicated small bowel "
 "series: evaluates jejunum and ileum over 2-4 hours as barium transits through. Key findings: Crohn's "
 "disease (skip lesions, cobblestone mucosa, strictures - 'string sign of Kantor', fistulae, 'rose-thorn' "
 "ulcers in terminal ileum); malabsorption (diluted barium, flocculation, segmentation - coeliac disease); "
 "small bowel obstruction (dilated loops with barium column stopping at point of obstruction)."),

("Barium Enema",
 "Barium enema (BE) evaluates the large bowel. Double-contrast technique (air + barium) provides superior "
 "mucosal detail compared with single-contrast. Largely replaced by colonoscopy for polyp and cancer "
 "detection; retained for patients who cannot tolerate colonoscopy, for colostomy evaluation, and for "
 "demonstrating large bowel anatomy post-operatively. Key findings: carcinoma - 'apple core' lesion "
 "(irregular annular narrowing with shouldered edges, mucosal destruction); polyps (filling defects); "
 "diverticular disease (flask-shaped outpouchings along the sigmoid and descending colon); UC - "
 "continuous mucosal granularity from rectum proximally, loss of haustration, 'lead-pipe colon' "
 "in long-standing disease, pseudopolyps; Crohn's colitis - discontinuous involvement, rectal sparing, "
 "aphthous ulcers, skip areas, deep fissuring ulcers; fistulae (rectovaginal, colovesical); Hirschsprung's "
 "disease (in infants) - narrow rectum with transition zone to dilated proximal bowel."),

("Clinical Relevance and Limitations",
 "Barium studies provide functional and anatomical information simultaneously - for example, demonstrating "
 "that a stricture has no mucosal irregularity (suggesting benign aetiology) or showing aspiration during "
 "swallowing that CT cannot demonstrate. Limitations: no direct tissue sampling (unlike endoscopy), "
 "radiation exposure, poor sensitivity for flat mucosal lesions and early cancer, contraindicated in "
 "suspected perforation or complete obstruction (use water-soluble contrast instead), and reduced "
 "diagnostic yield if bowel preparation is inadequate. CT colonography (virtual colonoscopy) has largely "
 "replaced barium enema at centres with CT availability, offering comparable sensitivity for polyps "
 ">6 mm and cancer with the addition of extra-colonic information. The physician must select the "
 "appropriate investigation based on the clinical question, patient factors, and local availability.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P16 - Pulmonary Function Tests
# ══════════════════════════════════════════════════════════════════
make_doc("P16_Pulmonary_Function_Tests.docx", "P16",
"Interpretation Skills",
"Pulmonary Function Tests (PFTs)",
[
("Introduction",
 "Pulmonary function tests (PFTs) are a group of non-invasive investigations that objectively quantify "
 "respiratory mechanics, lung volumes, and gas exchange capacity. They are essential in the diagnosis, "
 "characterisation, severity assessment, and monitoring of respiratory diseases. The key components "
 "are spirometry (measuring flow and volume), lung volume measurement, and diffusing capacity (DLCO). "
 "PFT results must always be interpreted in conjunction with clinical findings; isolated results without "
 "clinical context can be misleading."),

("Spirometry: Measurements and Quality Criteria",
 "Spirometry measures the volume of air exhaled during a forced expiratory manoeuvre. Key parameters: "
 "FVC (Forced Vital Capacity) - total volume exhaled from full inspiration to full expiration; FEV1 "
 "(Forced Expiratory Volume in 1 second) - volume exhaled in the first second; FEV1/FVC ratio (Tiffeneau "
 "index) - normal ≥0.70-0.75; PEF (Peak Expiratory Flow). Values are expressed as percentage predicted "
 "based on age, sex, height, and ethnicity (reference equations: GLI 2012 recommended). Quality criteria "
 "(ATS/ERS): three technically acceptable efforts, with the two largest FVC and FEV1 within 150 mL of "
 "each other, and a good start of test (extrapolated volume <5% of FVC or <150 mL) and satisfactory end "
 "of test (≥6 seconds exhalation or plateau). Suboptimal effort is a common cause of misdiagnosis."),

("Pattern Recognition: Obstructive vs Restrictive",
 "Obstructive pattern: FEV1/FVC <0.70 (post-bronchodilator), with reduced FEV1 and preserved or reduced FVC. "
 "Causes: asthma, COPD, bronchiectasis, obliterative bronchiolitis. COPD severity (GOLD): GOLD 1 - FEV1 "
 "≥80% predicted (mild); GOLD 2 - 50-79% (moderate); GOLD 3 - 30-49% (severe); GOLD 4 - <30% (very "
 "severe). Significant bronchodilator reversibility: increase in FEV1 ≥200 mL AND ≥12% from baseline "
 "after salbutamol 400 mcg - suggests asthma (though present in some COPD). Fixed obstruction = no "
 "reversibility. Restrictive pattern: FEV1/FVC ratio normal or elevated (>0.70), with reduced FVC. "
 "True restriction is confirmed by reduced TLC (<80% predicted on body plethysmography or gas dilution). "
 "Causes: interstitial lung disease (UIP/IPF, NSIP, sarcoidosis), pleural disease, obesity, chest wall "
 "deformity (kyphoscoliosis), neuromuscular disease. Mixed pattern: both FEV1/FVC <0.70 AND reduced TLC "
 "- COPD with air trapping coexisting with ILD, or extensive bullous disease."),

("Lung Volumes and DLCO",
 "Lung volumes by body plethysmography or helium dilution: TLC (Total Lung Capacity) - all air in lungs "
 "at full inspiration; RV (Residual Volume) - air remaining after full expiration; FRC (Functional "
 "Residual Capacity) - air remaining after normal expiration. Increased RV and RV/TLC ratio (>40%) "
 "indicates air trapping - COPD, asthma. Increased TLC with increased RV = emphysema (hyperinflation). "
 "Reduced TLC = restriction. DLCO (Diffusing Capacity for Carbon Monoxide, also termed TLCO): measures "
 "the transfer of CO across the alveolar-capillary membrane; reflects the combined effects of alveolar "
 "surface area, membrane thickness, pulmonary capillary blood volume, and haemoglobin concentration. "
 "Reduced DLCO: emphysema (loss of alveolar surface), ILD (membrane thickening), pulmonary hypertension "
 "(reduced vascular bed), anaemia (correct for Hb). Elevated DLCO: polycythaemia, left-to-right "
 "intracardiac shunt, pulmonary haemorrhage (acute - CO bound by intraalveolar RBCs)."),

("Bronchoprovocation, FeNO, and Clinical Application",
 "Bronchoprovocation testing (methacholine or mannitol challenge): used when spirometry is normal but "
 "asthma is suspected clinically. A fall in FEV1 ≥20% (PC20 <8 mg/mL methacholine) indicates "
 "bronchial hyperreactivity. Highly sensitive (positive test supports asthma); a negative test effectively "
 "rules out asthma as a cause of current symptoms. FeNO (Fractional exhaled Nitric Oxide): biomarker "
 "of eosinophilic airway inflammation; FeNO ≥50 ppb suggests eosinophilic asthma likely to respond to "
 "inhaled corticosteroids; used in phenotyping and guiding step-up therapy. 6-Minute Walk Test (6MWT): "
 "measures functional exercise capacity; 6MWD <350 m predicts mortality in IPF and PAH; used to monitor "
 "disease progression and response to therapy. Flow-volume loop shape: obstructive loops show scooped "
 "(concave) expiratory limb; restrictive loops show narrow, tall shape; variable extrathoracic obstruction "
 "(vocal cord dysfunction, tracheal stenosis) shows flattening of the inspiratory limb.")
])

# ══════════════════════════════════════════════════════════════════
# TOPIC P17 - Immunological Investigations
# ══════════════════════════════════════════════════════════════════
make_doc("P17_Immunological_Investigations.docx", "P17",
"Interpretation Skills",
"Immunological Investigations",
[
("Introduction",
 "Immunological investigations are central to the diagnosis and monitoring of autoimmune, inflammatory, "
 "and immunodeficiency disorders encountered in internal medicine. A systematic understanding of the "
 "sensitivity, specificity, and clinical relevance of autoantibodies and immunological markers allows "
 "the clinician to use them rationally - avoiding both under-investigation and the over-interpretation "
 "of weakly positive results. Immunological results must always be interpreted in the context of clinical "
 "findings and disease probability; isolated positive autoantibodies in the absence of clinical features "
 "are rarely diagnostic."),

("Antinuclear Antibodies (ANA) and Specific Autoantibodies",
 "ANA (indirect immunofluorescence on HEp-2 cells): screening test for systemic autoimmune diseases; "
 "titre ≥1:80 is significant; 95% of SLE patients are ANA positive but ANA is also positive in 5-15% "
 "of healthy individuals (low specificity). ANA pattern guides further testing: homogeneous = anti-dsDNA "
 "(SLE); speckled = anti-Sm (SLE, specific), anti-Ro/SS-A and anti-La/SS-B (Sjögren's, neonatal lupus, "
 "subacute cutaneous lupus), anti-Scl-70 (dcSSc), anti-U1-RNP (MCTD); centromere = lcSSc (CREST syndrome); "
 "nucleolar = anti-Scl-70, anti-PM-Scl (overlap myositis-SSc). Anti-dsDNA: 70% sensitivity, 95% "
 "specificity for SLE; titres correlate with disease activity; useful for monitoring. Anti-Sm: 25% "
 "sensitivity, >99% specificity for SLE (highly specific). Anti-histone: drug-induced lupus. "
 "Anti-Ro/SS-A: Sjögren's syndrome, subacute cutaneous lupus, congenital heart block in neonates "
 "of anti-Ro positive mothers."),

("ANCA and Myositis-Specific Antibodies",
 "ANCA (Anti-Neutrophil Cytoplasmic Antibodies): c-ANCA (cytoplasmic pattern) - anti-PR3 (proteinase 3) "
 "antibodies: granulomatosis with polyangiitis (GPA/Wegener's) - sensitivity 66-90%, specificity >95%; "
 "p-ANCA (perinuclear pattern) - anti-MPO (myeloperoxidase) antibodies: microscopic polyangiitis (MPA) "
 "and eosinophilic GPA (EGPA/Churg-Strauss). Titre correlates with disease activity. False positive "
 "p-ANCA: IBD, drug-induced (minocycline, propylthiouracil). Always confirm positive ELISA with "
 "antigen-specific testing (PR3/MPO). Myositis-specific antibodies (MSA): anti-Jo-1 (antisynthetase "
 "syndrome: ILD, myositis, arthritis, mechanic's hands, Raynaud's - most common MSA), anti-Mi-2 "
 "(dermatomyositis - classic skin features, good prognosis), anti-MDA5 (amyopathic DM with rapidly "
 "progressive ILD - poor prognosis), anti-SRP (immune-mediated necrotising myopathy - severe, "
 "cardiac involvement), anti-TIF1-γ (paraneoplastic DM in adults >40 years)."),

("Complement, Antiphospholipid, and Inflammatory Markers",
 "Complement: C3, C4, and CH50 (total haemolytic complement). Low C3 and C4 = consumption (active SLE "
 "glomerulonephritis, cryoglobulinaemia); low C4 alone = C4 deficiency (predisposition to SLE) or "
 "hereditary angio-oedema; normal C3/C4 with low CH50 = classical pathway component deficiency. "
 "Antiphospholipid antibodies (aPL): lupus anticoagulant, anticardiolipin IgG/IgM (>40 GPL/MPL "
 "units), anti-β2-glycoprotein-I IgG/IgM. Antiphospholipid syndrome (APS) requires ≥1 clinical "
 "criterion (arterial/venous thrombosis or pregnancy morbidity) AND ≥1 laboratory criterion (positive "
 "aPL on 2 occasions ≥12 weeks apart). Triple positive aPL (all 3 positive) carries highest thrombotic "
 "risk. Inflammatory markers: CRP (acute phase reactant, rises rapidly with infection/inflammation); "
 "ESR (influenced by fibrinogen, immunoglobulins - elevated in myeloma, SLE, temporal arteritis); "
 "ferritin (markedly elevated - >10,000 µg/L - in haemophagocytic lymphohistiocytosis (HLH) and "
 "adult-onset Still's disease); IL-6 (cytokine storm marker in COVID-19/CRS)."),

("Immunoglobulins and Cryoglobulins",
 "Serum immunoglobulins (IgG, IgA, IgM): polyclonal elevation = chronic infection, autoimmune disease, "
 "cirrhosis; monoclonal paraprotein (M-spike on SPEP) = MGUS (most common), myeloma, lymphoma, "
 "Waldenström's macroglobulinaemia. Free light chain assay (FLC): kappa/lambda ratio; abnormal ratio "
 "in myeloma and AL amyloidosis. Serum protein electrophoresis (SPEP) + immunofixation: identifies and "
 "characterises monoclonal protein type (IgG kappa most common). 24-hour urine for Bence Jones protein: "
 "free light chains in urine - myeloma cast nephropathy. Cryoglobulins: immunoglobulins that precipitate "
 "in the cold; Type I = monoclonal (myeloma, lymphoma); Type II/III = mixed (HCV most common cause - "
 "palpable purpura, peripheral neuropathy, glomerulonephritis, arthralgias). Complement low (C4 "
 "particularly) in mixed cryoglobulinaemia. Samples must be collected and transported at 37°C.")
])

print("Part 2 (Topics P11-P17) complete.")

from docx import Document
from docx.shared import Pt, Inches, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
import os

OUT = "/tmp/workspace/elog-book/p_docs"
os.makedirs(OUT, exist_ok=True)

def make_doc(filename, topic_num, category, heading, sections):
    doc = Document()
    s = doc.sections[0]
    s.top_margin = Inches(1); s.bottom_margin = Inches(1)
    s.left_margin = Inches(1.2); s.right_margin = Inches(1.2)
    doc.styles["Normal"].font.name = "Times New Roman"
    doc.styles["Normal"].font.size = Pt(12)

    cp = doc.add_paragraph(f"Psychomotor Competency  |  {category}  |  {topic_num}")
    cp.alignment = WD_ALIGN_PARAGRAPH.CENTER
    cp.runs[0].font.size = Pt(10); cp.runs[0].font.italic = True
    cp.runs[0].font.color.rgb = RGBColor(0x55,0x55,0x55)

    t = doc.add_heading(heading, level=1)
    t.alignment = WD_ALIGN_PARAGRAPH.CENTER
    for r in t.runs:
        r.font.name="Times New Roman"; r.font.size=Pt(14)
        r.font.bold=True; r.font.color.rgb=RGBColor(0x1A,0x35,0x6E)

    dv = doc.add_paragraph("─"*80)
    dv.alignment = WD_ALIGN_PARAGRAPH.CENTER
    dv.runs[0].font.size = Pt(8); dv.runs[0].font.color.rgb=RGBColor(0xAA,0xAA,0xAA)

    for sh_text, body in sections:
        sh = doc.add_heading(sh_text, level=2)
        sh.paragraph_format.space_before=Pt(10); sh.paragraph_format.space_after=Pt(4)
        for r in sh.runs:
            r.font.name="Times New Roman"; r.font.size=Pt(12)
            r.font.bold=True; r.font.color.rgb=RGBColor(0x1A,0x35,0x6E)
        p = doc.add_paragraph(body)
        p.paragraph_format.space_after=Pt(8)
        p.paragraph_format.first_line_indent=Pt(18)
        p.paragraph_format.line_spacing=Pt(22)
        for r in p.runs:
            r.font.name="Times New Roman"; r.font.size=Pt(12)

    doc.add_paragraph()
    f = doc.add_paragraph("E-Log Book  |  Department of Internal Medicine  |  Postgraduate Training Programme")
    f.alignment = WD_ALIGN_PARAGRAPH.CENTER
    f.runs[0].font.size=Pt(9); f.runs[0].font.italic=True
    f.runs[0].font.color.rgb=RGBColor(0x88,0x88,0x88)

    doc.save(os.path.join(OUT, filename))
    print(f"  {filename}")

# ─────────────────────────────────────────────────────────────────
# P01  Non-invasive and Mechanical Ventilation
# ─────────────────────────────────────────────────────────────────
make_doc("P01_Non_Invasive_Mechanical_Ventilation.docx","P1","Respiratory Management",
"Non-Invasive and Mechanical Ventilation",[
("Introduction",
 "Ventilatory support is a cornerstone of critical care medicine. The goal is to maintain adequate gas exchange "
 "(oxygenation and CO2 elimination), relieve the work of breathing, and buy time for the underlying pathology to resolve. "
 "The choice between non-invasive ventilation (NIV) and invasive mechanical ventilation (IMV) depends on the clinical "
 "presentation, underlying diagnosis, degree of respiratory failure, conscious level, and ability to protect the airway."),
("Non-Invasive Ventilation (NIV)",
 "NIV delivers positive pressure support through a tight-fitting mask without endotracheal intubation. CPAP provides a "
 "single pressure level that recruits alveoli and reduces work of breathing (first-line in cardiogenic pulmonary oedema). "
 "BiPAP/NPPV provides separate inspiratory (IPAP) and expiratory (EPAP) pressures, assisting ventilation and improving "
 "CO2 clearance. NIV is the treatment of choice in acute hypercapnic COPD exacerbation (reduces intubation rate and "
 "mortality - Brochard 1995, Plant 2000), cardiogenic pulmonary oedema (CPAP reduces intubation rate by ~50%), and "
 "immunocompromised patients with ARF. Contraindications: cardiac arrest, inability to protect airway, copious secretions, "
 "facial trauma, uncooperative patient. Initial NIV setting: IPAP 10-12 cmH2O, EPAP 4-5 cmH2O; titrate to SpO2 >90% "
 "and clinical improvement; check ABG at 1-2 hours."),
("Invasive Mechanical Ventilation: Initiation",
 "IMV via endotracheal tube is indicated when NIV fails or is contraindicated, in airway compromise (GCS <8), haemodynamic "
 "instability, refractory hypoxaemia (PaO2/FiO2 <100), or apnoea. Key initial settings: FiO2 1.0 (titrate to SpO2 "
 "94-98%), tidal volume 6 mL/kg ideal body weight (lung-protective ventilation - ARDSNet trial reduces ARDS mortality), "
 "respiratory rate 12-20/min (adjust to PaCO2), PEEP 5-8 cmH2O (higher in ARDS). Modes: Assist Control (AC) - full "
 "breath each triggered effort plus backup rate; SIMV - fixed mandatory breaths synchronised with patient effort; Pressure "
 "Support Ventilation (PSV) - patient-triggered, pressure-augmented breaths, used in weaning."),
("Monitoring and Complications",
 "Monitor: SpO2, ETCO2, ABG (at initiation, then 4-6 hourly or after setting changes), peak airway pressure (<30 cmH2O), "
 "plateau pressure (<28 cmH2O), and dynamic compliance. Ventilator-associated lung injury (VALI) results from volutrauma "
 "(excess tidal volume), barotrauma (excess pressure), atelectrauma, and biotrauma. Ventilator-associated pneumonia (VAP) "
 "prevention: head-of-bed elevation 30-45°, chlorhexidine oral care, subglottic suctioning, minimal sedation, and early "
 "mobilisation. Auto-PEEP (air trapping) in obstructive disease can cause haemodynamic compromise; detected by end-expiratory "
 "occlusion manoeuvre and managed by reducing respiratory rate and increasing expiratory time."),
("Weaning and Extubation",
 "Daily assessment for weaning readiness once precipitating cause is resolving. Prerequisites: FiO2 ≤0.4, PEEP ≤8 cmH2O, "
 "SpO2 >90%, haemodynamic stability, GCS adequate (follows commands). Spontaneous Breathing Trial (SBT): 30-120 minutes "
 "on T-piece or low PSV (5-8 cmH2O) - predicts extubation success. RSBI (Rapid Shallow Breathing Index = RR/Vt in litres) "
 "<105 predicts successful weaning. Extubation requires adequate cough, minimal secretions, and patent upper airway. "
 "Post-extubation NIV reduces re-intubation in high-risk patients (COPD, obesity hypoventilation, cardiac failure). "
 "Prolonged weaning failure (>7 days) warrants tracheostomy consideration to reduce work of breathing and facilitate "
 "secretion clearance.")
])

# ─────────────────────────────────────────────────────────────────
# P02  Monitoring a Sick Person
# ─────────────────────────────────────────────────────────────────
make_doc("P02_Monitoring_Sick_Person.docx","P2","Critically Ill Person",
"Monitoring a Sick Person",[
("Introduction",
 "Effective monitoring of the critically ill patient is the foundation of intensive care. Monitoring detects physiological "
 "deterioration early, guides therapeutic interventions, evaluates treatment response, and prevents secondary organ injury. "
 "The intensity and invasiveness of monitoring must be proportionate to illness severity. A cardinal principle is that "
 "numbers must always be interpreted in the clinical context - isolated values without clinical correlation can mislead."),
("Basic Monitoring: Vital Signs and Neurology",
 "Continuous monitoring of heart rate, non-invasive blood pressure, SpO2, respiratory rate, and temperature is mandatory. "
 "Respiratory rate is the most sensitive early indicator of deterioration and is frequently under-documented. ETCO2 "
 "(waveform capnography) provides continuous non-invasive ventilation assessment and confirms ETT placement. Neurological "
 "monitoring uses the Glasgow Coma Scale (GCS - eye, verbal, motor; 3-15) at minimum hourly in obtunded patients. "
 "Pupillary size and reactivity assess brainstem function. Sedation depth is quantified by the RASS (Richmond "
 "Agitation-Sedation Scale; target -1 to -2 in ventilated patients), and pain by the CPOT (Critical-Care Pain "
 "Observation Tool)."),
("Haemodynamic Monitoring",
 "Invasive arterial line (radial preferred) provides beat-to-beat BP monitoring and arterial access. Pulse pressure "
 "variation (PPV) >13% during controlled mechanical ventilation predicts fluid responsiveness. Central venous pressure "
 "(CVP) via CVC reflects RV preload (normal 5-12 mmHg) but its use to guide fluid therapy is now questioned. Cardiac "
 "output can be measured non-invasively by echocardiography or lithium dilution. Bedside POCUS (point-of-care ultrasound) "
 "has largely replaced the pulmonary artery catheter for dynamic haemodynamic assessment - IVC collapsibility, RV/LV "
 "function, and volumetric assessment. Serum lactate (normal <2 mmol/L) reflects tissue perfusion adequacy; lactate "
 ">4 mmol/L in context of sepsis defines septic shock."),
("Laboratory and Organ-Specific Monitoring",
 "Serial laboratory monitoring: ABG (oxygenation, ventilation, acid-base), FBC, renal function (creatinine, urea, "
 "electrolytes), LFTs, coagulation, blood glucose (target 7.8-10 mmol/L - NICE-SUGAR trial), inflammatory markers "
 "(CRP, procalcitonin). Urine output is a key renal perfusion marker - target ≥0.5 mL/kg/hour. Continuous ECG "
 "monitoring detects arrhythmias. 12-lead ECG is performed when clinically indicated. Intracranial pressure (ICP) "
 "monitoring via ventricular catheter or parenchymal probe is used in severe TBI, fulminant hepatic failure, and "
 "post-neurosurgical patients (normal ICP <20 cmH2O; cerebral perfusion pressure = MAP - ICP, target CPP 60-70 mmHg)."),
("Track-and-Trigger Systems and Escalation",
 "Early Warning Scores (EWS) aggregate vital sign parameters to identify deteriorating patients. NEWS2 (National Early "
 "Warning Score 2) incorporates HR, RR, SpO2 (standard + COPD-adjusted), systolic BP, temperature, and level of "
 "consciousness. NEWS2 ≥7 warrants urgent medical review and consideration of critical care admission. The SOFA "
 "(Sequential Organ Failure Assessment) score quantifies multi-organ dysfunction and predicts ICU mortality - assessed "
 "daily. Regular structured reassessment, clear legible documentation, and prompt escalation when monitoring signals "
 "deterioration are the hallmarks of safe critical care practice.")
])

# ─────────────────────────────────────────────────────────────────
# P03  Endotracheal Intubation
# ─────────────────────────────────────────────────────────────────
make_doc("P03_Endotracheal_Intubation.docx","P3","Critically Ill Person",
"Endotracheal Intubation",[
("Introduction",
 "Endotracheal intubation (ETI) is the definitive method of securing the airway in critically ill patients. It "
 "establishes a protected, patent conduit for ventilation and oxygenation while preventing aspiration. It is a "
 "high-stakes procedure - failed or delayed intubation in the critically ill carries significant morbidity and mortality. "
 "The internal medicine postgraduate must be proficient in emergency airway management, including the decision to intubate, "
 "pre-procedure assessment, RSI technique, confirmation of placement, and recognition of complications."),
("Indications and Airway Assessment",
 "Absolute indications: cardiac or respiratory arrest, apnoea, GCS ≤8 (inability to protect airway), refractory "
 "hypoxaemia (PaO2/FiO2 <100) unresponsive to NIV, haemodynamic instability with impending arrest. Relative: "
 "anticipated deterioration, copious secretions, procedures requiring general anaesthesia. Airway assessment uses "
 "LEMON: Look (obvious abnormalities, obesity, short neck), Evaluate (3-3-2 rule: 3-finger mouth opening, 3-finger "
 "hyoid-chin, 2-finger hyoid-thyroid), Mallampati score (I-IV), Obstruction (stridor, mass), Neck mobility. "
 "Anticipated difficult airway requires videolaryngoscope, LMA, or surgical airway preparation in advance."),
("Preparation and Equipment: STOP MAID",
 "Suction (functioning), Team (roles assigned), Oxygen (pre-oxygenation with high-flow O2 for ≥3 min, target SpO2 "
 ">95%), Positioning (sniffing position: neck flexed, head extended; ramp for obese), Monitoring (SpO2, ETCO2, ECG, "
 "NIBP), Airway equipment (ETT sizes 7.0-8.0 adults, laryngoscope, 10 mL syringe, holder, ETCO2), IV access and "
 "Drugs. Induction agents: ketamine 1-2 mg/kg (haemodynamically stable, bronchospastic disease), propofol 1.5-2.5 "
 "mg/kg (normovolaemic), etomidate 0.3 mg/kg (haemodynamically compromised). Neuromuscular blockade for RSI: "
 "suxamethonium 1.5 mg/kg (avoid in hyperkalaemia, burns, denervation injuries) or rocuronium 1.2 mg/kg."),
("RSI Technique and Placement Confirmation",
 "Rapid Sequence Intubation (RSI) minimises aspiration risk. Steps: (1) Pre-oxygenate ≥3 minutes; (2) Simultaneous "
 "IV push of induction agent + neuromuscular blocker; (3) Apply cricoid pressure (Sellick's); (4) Laryngoscopy at "
 "60 seconds - blade to right of tongue, sweep left, identify epiglottis then vocal cords; (5) Pass ETT (cuff just "
 "below cords, 21-23 cm at lips for adults); (6) Inflate cuff with 10 mL air; (7) Confirm placement - waveform "
 "ETCO2 (gold standard - 6 consecutive waveforms), bilateral chest expansion, and auscultation. CXR confirms tip "
 "position (2-3 cm above carina). Maintain cuff pressure 20-30 cmH2O."),
("Complications and Post-intubation Management",
 "Immediate complications: oesophageal intubation (absent ETCO2 - remove and re-intubate immediately), right "
 "mainstem intubation (unilateral chest movement - withdraw tube), haemodynamic collapse from induction agents "
 "in hypovolaemia, dental/airway trauma, bradycardia. Late: VAP, tracheal stenosis, tracheomalacia. "
 "Post-intubation: confirm on CXR, initiate lung-protective ventilation (TV 6 mL/kg IBW), start analgesia and "
 "sedation (RASS target -1 to -2), implement VAP bundle (HOB 30-45°, chlorhexidine oral care, subglottic "
 "suctioning), consider early tracheostomy if prolonged ventilation anticipated, and plan daily for SBT and "
 "earliest safe extubation.")
])

# ─────────────────────────────────────────────────────────────────
# P04  CPR
# ─────────────────────────────────────────────────────────────────
make_doc("P04_CPR.docx","P4","Critically Ill Person",
"Cardiopulmonary Resuscitation (CPR)",[
("Introduction",
 "Cardiac arrest is the abrupt cessation of effective cardiac mechanical activity. Without immediate intervention, "
 "irreversible brain injury begins within 4-6 minutes. CPR maintains minimum circulation and oxygenation until return "
 "of spontaneous circulation (ROSC). The chain of survival - early recognition, early CPR, early defibrillation, "
 "advanced care, and post-resuscitation care - defines the framework for improving outcomes. The physician must be "
 "proficient in both Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS)."),
("Basic Life Support (BLS)",
 "Sequence: (1) Scene safety; (2) Check responsiveness; (3) Call for help and AED simultaneously; (4) Check breathing "
 "for ≤10 seconds (agonal gasps = not normal); (5) Begin chest compressions - heel of hand on lower sternum, compress "
 "5-6 cm at 100-120/min with full chest recoil; (6) Rescue breaths 30:2 - tilt head/lift chin, 1 second per breath "
 "until chest rises; (7) Attach AED and follow prompts. Hands-only CPR is acceptable and preferred if rescuer "
 "untrained in ventilation. C-A-B (Compressions-Airway-Breathing) sequence minimises time to first compression. "
 "High-quality CPR - minimal interruptions, adequate rate/depth, full recoil - is the single most impactful "
 "determinant of survival."),
("ACLS: Shockable Rhythms (VF/pVT)",
 "VF and pulseless VT require defibrillation. Protocol: (1) Continue CPR while charging; (2) Single shock (biphasic "
 "120-200 J); (3) Resume CPR immediately for 2 minutes; (4) Check rhythm; (5) Repeat shock if shockable; (6) After "
 "3rd shock: adrenaline 1 mg IV (repeat every 3-5 min) + amiodarone 300 mg IV (2nd dose 150 mg after 5th shock); "
 "(7) Continue 2-minute CPR cycles. Pad positions: anterolateral (right infraclavicular + left V4-V6) or "
 "anteroposterior. Remove O2 source ≥1 metre before shock. Waveform capnography: ETCO2 >10-20 mmHg during CPR "
 "indicates quality; sudden ETCO2 rise indicates ROSC."),
("ACLS: Non-Shockable Rhythms and 4Hs/4Ts",
 "PEA and asystole: (1) High-quality CPR; (2) Adrenaline 1 mg IV as soon as access obtained (repeat every 3-5 min); "
 "(3) Search actively for reversible causes. The 4 Hs: Hypoxia (optimise ventilation), Hypovolaemia (IV fluid "
 "bolus), Hypo/Hyperkalaemia-metabolic (check ABG/electrolytes), Hypothermia (rewarm). The 4 Ts: Tension "
 "pneumothorax (needle decompression 2nd ICS MCL), Tamponade (pericardiocentesis or thoracotomy), Toxins "
 "(antidotes), Thromboembolism - PE (thrombolysis during CPR) or ACS (urgent PCI post-ROSC). Atropine no longer "
 "recommended for PEA/asystole per current guidelines."),
("Post-Resuscitation Care",
 "Post-ROSC management: (1) Targeted Temperature Management (TTM) - 32-36°C for 24 hours to limit neurological "
 "injury; (2) Haemodynamic optimisation - MAP >65-70 mmHg (vasopressors if needed); (3) Avoid hyperoxia - titrate "
 "O2 to SpO2 94-98%; (4) Normocapnia (PaCO2 35-45 mmHg); (5) Urgent coronary angiography if ST elevation or "
 "suspected ACS; (6) Tight glycaemic control (7.8-10 mmol/L). Neurological prognostication deferred to ≥72 hours "
 "post-ROSC (or 72 hours after rewarming) using clinical examination (absence of pupillary light reflex and corneal "
 "reflex), EEG, SSEPs, NSE levels, and brain MRI/CT. Document: arrest duration, no-flow and low-flow times, "
 "all interventions, rhythm sequence, and total adrenaline dose.")
])

# ─────────────────────────────────────────────────────────────────
# P05  CVC and CVP
# ─────────────────────────────────────────────────────────────────
make_doc("P05_CVC_CVP.docx","P5","Critically Ill Person",
"Central Vein Cannulation and CVP Monitoring",[
("Introduction",
 "Central venous catheterisation (CVC) provides secure venous access for vasopressor infusion, concentrated "
 "electrolyte solutions, total parenteral nutrition, haemodialysis, and CVP monitoring. The three principal sites "
 "are the internal jugular vein (IJV), subclavian vein (SCV), and femoral vein (FV). Ultrasound guidance is the "
 "standard of care, significantly reducing arterial puncture, haematoma, and failed cannulation compared with "
 "landmark technique. Maximal sterile barrier precautions are mandatory to reduce CLABSI risk."),
("Site Selection and Indications",
 "Indications: vasopressor infusion (noradrenaline, dopamine), concentrated potassium/sodium infusions, TPN, CVP "
 "monitoring, haemodialysis (Vascath), lack of peripheral access. Site comparison: IJV (right preferred) - lowest "
 "pneumothorax risk, good compressibility if arterial puncture; SCV - lowest infection rate, preferred for long-term "
 "access, higher pneumothorax risk; FV - easiest in emergency, highest infection and DVT risk. Avoid FV in "
 "ambulatory patients and where IVC thrombosis suspected. Relative contraindications: coagulopathy (correct INR "
 "<1.5, platelets >50,000 for elective), local infection, ipsilateral pneumothorax."),
("Seldinger Technique",
 "Equipment: CVC kit, sterile drape, linear ultrasound probe with sterile cover, 2% chlorhexidine, lidocaine 1-2%. "
 "Steps: (1) Patient supine, 15° Trendelenburg; (2) Full aseptic technique (gown, gloves, mask, hat, large drape); "
 "(3) Chlorhexidine skin prep - allow to dry; (4) Ultrasound identification of vein (compressible, non-pulsatile, "
 "expands with Valsalva); (5) Local anaesthetic; (6) Insert introducer needle at 45° under real-time ultrasound, "
 "aspirating until venous blood; (7) Advance guidewire J-tip first (ECG changes/PVCs = wire in RV - withdraw); "
 "(8) Skin nick; (9) Dilator over wire; (10) Thread catheter (15-17 cm right IJV) over wire; (11) Withdraw wire; "
 "(12) Aspirate and flush all ports; (13) Secure; (14) CXR to confirm tip (SVC-RA junction) and exclude pneumothorax."),
("CVP Measurement and Waveform",
 "CVP is measured at the phlebostatic axis (4th ICS, midaxillary line) with patient supine. Transducer zeroed to "
 "atmospheric pressure at this level. Normal CVP: 5-12 mmHg. Low CVP (<5) = hypovolaemia or vasodilation. High "
 "CVP (>15) = RV failure, cardiac tamponade, tension pneumothorax, fluid overload, or high PEEP. CVP waveform "
 "components: 'a' wave (atrial contraction), 'c' wave (tricuspid closure), 'x' descent (atrial relaxation), 'v' "
 "wave (venous filling with closed tricuspid), 'y' descent (tricuspid opening). Cannon 'a' waves = AV dissociation "
 "(complete heart block, VT). Absent 'a' waves = AF. Prominent 'v' waves = severe tricuspid regurgitation."),
("Complications and Prevention",
 "Immediate: arterial puncture (withdraw, apply pressure; inadvertent arterial catheter → vascular surgery), "
 "pneumothorax (mandatory post-CXR; symptomatic → chest drain), air embolism (Trendelenburg + Valsalva during "
 "wire/catheter changes), haemothorax, arrhythmias (wire in RV). Late: CLABSI - prevented by maximal sterile "
 "precautions, chlorhexidine prep, non-femoral site preference, chlorhexidine dressing, and daily review of "
 "necessity (remove earliest opportunity); CVC thrombosis - anticoagulation if symptomatic; catheter malposition. "
 "CLABSI rate is a key patient safety metric; zero-tolerance bundle compliance is the target.")
])

# ─────────────────────────────────────────────────────────────────
# P06  Defibrillator
# ─────────────────────────────────────────────────────────────────
make_doc("P06_Defibrillator.docx","P6","Critically Ill Person",
"Using a Defibrillator",[
("Introduction",
 "Defibrillation delivers a controlled electrical shock to depolarise a critical mass of myocardium simultaneously, "
 "terminating chaotic VF/pVT and allowing the sinus node to resume coordinated pacemaker function. For every minute "
 "of delay in defibrillation, survival from VF falls approximately 10%. The clinician must be competent in both "
 "automated external defibrillators (AEDs) for out-of-hospital settings and manual defibrillators used in clinical "
 "care, and must be able to perform synchronised cardioversion and transcutaneous pacing."),
("Types and Technology",
 "AEDs are designed for minimally trained lay responders; self-adhesive pads attach, the device analyses rhythm "
 "automatically and prompts shock delivery. All modern AEDs deliver biphasic shocks at 150-200 J. Manual "
 "defibrillators display continuous ECG, allow rhythm interpretation, manual shock delivery, synchronised "
 "cardioversion, and transcutaneous pacing. Biphasic waveforms (BTE or RLB) are more effective and safer than "
 "older monophasic waveforms (360 J). AED public-access programmes have significantly improved out-of-hospital "
 "cardiac arrest survival globally."),
("Defibrillation Technique",
 "Safety checklist before every shock: (1) All personnel clear of patient and bed; (2) Oxygen source moved ≥1 metre "
 "away (fire risk); (3) ECG leads not overlying pad positions; (4) Pads not placed over implanted device. Pad "
 "placement: anterolateral (right infraclavicular + left V4-V6 lateral chest wall) - standard; anteroposterior "
 "(anterior left precordium + posterior below left scapula) if anterolateral access limited. Ensure good pad "
 "contact; wipe excess moisture. Procedure: (1) Confirm arrest + shockable rhythm; (2) Apply pads; (3) Continue "
 "CPR while charging; (4) Announce 'Stand clear - delivering shock'; (5) Visual check all clear; (6) Deliver "
 "shock; (7) Resume CPR immediately for 2 minutes. Single-shock strategy (not stacked) is current guidance."),
("Synchronised Cardioversion",
 "Synchronised cardioversion times the shock to the R-wave (sync mode) to avoid the vulnerable T-wave period and "
 "prevent VF induction. Used for haemodynamically unstable tachyarrhythmias with pulse: AF (120-200 J biphasic), "
 "atrial flutter (50-100 J biphasic), SVT (50-100 J biphasic), monomorphic VT with pulse (100-200 J biphasic). "
 "Sedation (midazolam + fentanyl, or propofol) is required unless patient is unconscious. For AF cardioversion: "
 "confirm minimum 3 weeks therapeutic anticoagulation or TOE excluding left atrial thrombus. Post-cardioversion "
 "monitoring for ≥1 hour. If sync mode active and device not detecting R-wave, increase ECG gain."),
("Transcutaneous Pacing and Troubleshooting",
 "Transcutaneous pacing (TCP) treats haemodynamically significant bradycardia unresponsive to atropine. Pads "
 "placed anteroposterior. Set demand mode, rate 60-80/min; increase output (mA) from minimum until electrical "
 "capture (pacing spike + broad QRS), then confirm mechanical capture by femoral pulse palpation. TCP is painful; "
 "provide sedation/analgesia. It is a bridge to transvenous pacing. Defibrillation failure: consider suboptimal "
 "pad contact, persistent acidosis/hypoxia (correct first), hypokalaemia/hypomagnesaemia (correct), hypothermia "
 "(rewarm). Refractory VF may respond to double-sequential defibrillation (two defibrillators simultaneously), "
 "amiodarone 300 mg IV, lidocaine 100 mg IV, or magnesium 2 g IV.")
])

# ─────────────────────────────────────────────────────────────────
# P07  Haemodialysis
# ─────────────────────────────────────────────────────────────────
make_doc("P07_Haemodialysis.docx","P7","Critically Ill Person",
"Haemodialysis",[
("Introduction",
 "Haemodialysis (HD) is an extracorporeal renal replacement therapy that removes waste products, excess electrolytes, "
 "and fluid via a semipermeable membrane. Blood is pumped through the dialyser where solutes are removed by diffusion "
 "(dialysis) and fluid by ultrafiltration (driven by transmembrane pressure). The internist must understand indications, "
 "vascular access, prescription, and complications of HD, and the distinction between intermittent HD and continuous "
 "renal replacement therapy (CRRT) in the critically ill."),
("Indications: AEIOU",
 "A - Acidosis: metabolic acidosis refractory to medical management (pH <7.1, HCO3- <10 mEq/L). E - Electrolytes: "
 "hyperkalaemia refractory to medical treatment (K+ >6.5 mEq/L with ECG changes, or >7 mEq/L regardless). I - "
 "Ingestion/Intoxication: dialysable toxins (ethylene glycol, methanol, salicylates, lithium). O - Overload (fluid): "
 "pulmonary oedema refractory to diuretics. U - Uraemia: symptomatic (uraemic encephalopathy, pericarditis, "
 "uraemic bleeding). In CKD, HD initiated at eGFR 5-10 mL/min/1.73m² with symptoms, or eGFR <5-7 regardless of "
 "symptoms. The decision is clinical, not based on a single eGFR value."),
("Vascular Access",
 "Options: (1) Temporary catheter (Vascath/permcath) - double-lumen dialysis catheter inserted under ultrasound "
 "into IJV (preferred), SCV, or femoral vein; used for acute HD or as bridge. (2) Arteriovenous fistula (AVF) - "
 "Brescia-Cimino (radial artery + cephalic vein at wrist) or brachiocephalic; requires 6-12 weeks maturation; "
 "lowest infection/thrombosis rate; gold standard for long-term HD. (3) AV graft - synthetic graft connecting "
 "artery and vein; usable in 2-4 weeks; higher thrombosis rate. AVF/graft assessment: palpate thrill (normal), "
 "auscultate bruit; absent thrill/bruit = thrombosis or stenosis requiring urgent vascular review."),
("HD Prescription and CRRT",
 "HD prescription: dialysate composition (Na 135-145 mEq/L, K 2-3 mEq/L, HCO3 32-38 mEq/L, Ca 1.25-1.75 mmol/L, "
 "glucose 5.5 mmol/L), blood flow 200-400 mL/min, dialysate flow 500-800 mL/min, session duration 3-5 hours, "
 "3 times/week for ESRD, ultrafiltration goal. Heparin anticoagulation is standard; citrate or LMWH alternatives "
 "in high bleeding risk. In ICU patients with haemodynamic instability, CRRT (Continuous Renal Replacement Therapy) "
 "is preferred - provides gentle 24-hour solute and fluid removal, avoiding the haemodynamic shifts of intermittent "
 "HD. CRRT modes include CVVH (haemofiltration), CVVHD (haemodialysis), and CVVHDF (haemodiafiltration)."),
("Complications and Adequacy",
 "Intradialytic complications: hypotension (most common - reduce UFR, Trendelenburg, saline bolus), muscle cramps "
 "(osmotic shifts - reduce UFR, hypertonic saline), dialysis disequilibrium syndrome (first sessions - "
 "prevent by gradual initiation), arrhythmias, air embolism. Access complications: infection (MRSA bacteraemia "
 "risk with tunnelled catheters), thrombosis, stenosis, aneurysm. Adequacy: Kt/V ≥1.2-1.4 per session (K = "
 "dialyser clearance, t = time, V = urea distribution volume) and URR >65% (urea reduction ratio). Inadequate "
 "dialysis increases cardiovascular morbidity and mortality. The internist must recognise HD indications, "
 "facilitate timely nephrology referral, ensure access is created early in progressive CKD (refer when eGFR <30), "
 "and understand the patient's dialysis schedule and intradialytic problems.")
])

# ─────────────────────────────────────────────────────────────────
# P08  Brain Death
# ─────────────────────────────────────────────────────────────────
make_doc("P08_Brain_Death.docx","P8","Critically Ill Person",
"Certification of Brain Death",[
("Introduction and Legal Framework",
 "Brain death is defined as the irreversible cessation of all functions of the entire brain, including the brainstem, "
 "while the heart continues to beat with ventilatory support. Under the Transplantation of Human Organs and Tissues "
 "Act (THOTA), 1994 (amended 2011), brain death is legally equivalent to death in India. Certification permits "
 "withdrawal of life support, provides families with clarity for the grieving process, and forms the legal basis "
 "for deceased donor organ donation. The process must be meticulous, compassionate, and fully documented."),
("Prerequisites Before Testing",
 "Brain death testing must only proceed once all reversible causes of deep unresponsive coma are excluded: "
 "(1) Known structural brain injury (TBI, hypoxic-ischaemic injury, ICH, large infarction) as the established "
 "cause; (2) Normothermia (core temperature >36°C - hypothermia mimics brain death); (3) Normotension "
 "(SBP >90 mmHg); (4) Normoglycaemia; (5) No CNS-depressant drugs active (opioids, benzodiazepines, "
 "barbiturates, propofol, NMBAs - adequate elimination time or levels confirmed); (6) No severe metabolic "
 "disturbance. Drug levels or brainstem evoked potentials may be required to confirm absence of drug effect."),
("Brainstem Reflex Testing (THOTA Requirements)",
 "Under THOTA, a panel of four doctors must certify: treating physician, hospital-nominated specialist, "
 "hospital-nominated neurologist/neurosurgeon, and authority-nominated physician. Two sets of tests at least "
 "6 hours apart. Brainstem reflexes tested: (1) Pupillary light reflex - pupils fixed, dilated (4-9 mm), "
 "unresponsive; (2) Corneal reflex - no blink to cotton-wool corneal touch; (3) Vestibulo-ocular (caloric) "
 "reflex - no eye movement with 50 mL ice water into ear canal (head at 30°, intact tympanic membrane); "
 "(4) Gag reflex - no response to posterior pharyngeal stimulation; (5) Cough reflex - no response to tracheal "
 "suction; (6) Oculocephalic reflex - no doll's eye movement (only if C-spine injury excluded)."),
("Apnoea Test",
 "Confirms absence of medullary respiratory function. Preconditions: SpO2 >95%, PaCO2 35-45 mmHg, haemodynamic "
 "stability. Procedure: (1) Pre-oxygenate FiO2 1.0 for 10 min; (2) Baseline ABG confirming PaCO2 35-45 mmHg; "
 "(3) Disconnect from ventilator; (4) Deliver O2 6-10 L/min via catheter in ETT (apnoeic oxygenation); "
 "(5) Observe for any spontaneous respiratory effort for 8-10 minutes; (6) Terminal ABG - PaCO2 must rise to "
 "≥60 mmHg (or ≥20 mmHg above baseline) to confirm apnoea; (7) Reconnect ventilator. Abort if SpO2 <85%, "
 "haemodynamic instability, or severe arrhythmia. Ancillary tests (EEG, cerebral angiography, radionuclide scan) "
 "used when clinical testing inconclusive."),
("Communication and Documentation",
 "Family communication must precede any discussion of organ donation. Brain death must be explained clearly and "
 "compassionately - the patient is legally dead; mechanical ventilation is maintaining circulation artificially. "
 "Families need time to absorb this; avoid rushing. Organ donation should be raised sensitively by a trained "
 "transplant coordinator after death is communicated (decoupling principle). Donation must never be raised as a "
 "condition or precondition of care. Documentation must include: date and time of each examination, names/signatures "
 "of all four certifying doctors, results of each brainstem reflex test, apnoea test ABG results, THOTA-prescribed "
 "forms, and time of death certified.")
])

# ─────────────────────────────────────────────────────────────────
# P09  Treadmill Testing
# ─────────────────────────────────────────────────────────────────
make_doc("P09_Treadmill_Testing.docx","P9","Interpretation Skills",
"Treadmill Testing (Exercise Stress Test)",[
("Introduction",
 "The exercise stress test (EST / TMT) assesses the cardiovascular response to graded physical exercise. Clinical "
 "applications include: diagnosis of obstructive CAD in intermediate pre-test probability, risk stratification "
 "post-ACS, functional capacity assessment, evaluation of exercise-induced arrhythmias, and assessment of "
 "chronotropic incompetence. The Bruce protocol (7 stages of 3 min each, increasing speed and gradient) is most "
 "widely used. The physician must be proficient in pre-test assessment, test conduct, and systematic interpretation."),
("Indications and Contraindications",
 "Indications: chest pain with intermediate pre-test CAD probability (30-70% by Bayes theorem - EST most useful "
 "here); risk stratification post-ACS; haemodynamic significance of known CAD; exercise-induced arrhythmias; "
 "functional capacity for disability or occupational assessment. Absolute contraindications: acute MI within 2 "
 "days, unstable angina, uncontrolled arrhythmias with haemodynamic compromise, symptomatic severe AS, "
 "decompensated HF, acute PE, acute myocarditis/pericarditis, aortic dissection. Relative: LBBB/pacemaker "
 "(uninterpretable ST changes), WPW, severe hypertension (>200/110), HCM, electrolyte disturbance, left main "
 "stenosis."),
("Protocol and Endpoints for Termination",
 "Bruce protocol: Stage 1 = 1.7 mph/10% grade (5 METs); each stage increases speed and grade over 3 minutes. "
 "Target heart rate = 85% maximum predicted HR (220 - age). Monitor continuously: 12-lead ECG, BP every stage, "
 "symptoms, and perceived exertion (Borg scale). Indications to terminate: patient requests to stop, ST "
 "depression >2 mm in multiple leads, ST elevation >1 mm, significant arrhythmia (VT), BP drop >10 mmHg with "
 "ischaemic features, SBP >250 mmHg or DBP >115 mmHg, severe angina, CNS symptoms (ataxia, near-syncope), "
 "or technical ECG failure. Post-exercise monitoring continues for minimum 6 minutes (many changes appear "
 "in recovery)."),
("Interpretation: ECG and Haemodynamic Responses",
 "Positive test: horizontal or downsloping ST depression ≥1 mm at 80 ms after J-point in ≥2 contiguous leads. "
 "Upsloping ST depression ≥1.5 mm is also significant. ST elevation in non-infarct territory = severe ischaemia "
 "or vasospasm. Duke Treadmill Score = exercise time (min) - (5 × max ST deviation mm) - (4 × angina index "
 "[0=none, 1=present, 2=limiting]). Score ≥5 = low risk (1% annual mortality); -10 to 4 = intermediate; "
 "<-11 = high risk (≥5% annual mortality). High-risk features: failure to achieve 5 METs, exercise hypotension, "
 "chronotropic incompetence, early-onset widespread ST depression. Sensitivity 68%, specificity 77% for "
 "significant CAD; false positives in women, LVH, digoxin use, WPW, hypokalaemia."),
("Reporting and Clinical Application",
 "Structured EST report: indication, demographics, resting ECG, maximum HR achieved (% of target), maximum "
 "workload (METs), BP response, symptoms, ECG changes (lead, degree, onset time, recovery), reason for "
 "termination, Duke Treadmill Score, and overall interpretation (positive/negative/equivocal). A negative "
 "test with adequate HR response in a patient with low-intermediate pre-test probability provides strong "
 "reassurance. A high-risk positive test warrants urgent coronary angiography. An equivocal result or "
 "inadequate test (failure to achieve 85% target HR, resting ECG abnormality - LBBB, LVH, pre-excitation) "
 "requires nuclear perfusion imaging or stress echocardiography for definitive assessment.")
])

# ─────────────────────────────────────────────────────────────────
# P10  ABG Analysis
# ─────────────────────────────────────────────────────────────────
make_doc("P10_ABG_Analysis.docx","P10","Interpretation Skills",
"Arterial Blood Gas (ABG) Analysis",[
("Introduction",
 "Arterial blood gas analysis simultaneously assesses oxygenation, ventilation, and acid-base status. It is among "
 "the most frequently performed and clinically informative investigations in acute and critical care medicine. "
 "A systematic, stepwise approach is essential; piecemeal interpretation is a common source of clinical error. "
 "ABG must always be interpreted alongside clinical context and other investigations."),
("Normal Values and Sample Collection",
 "Arterial blood is collected from the radial artery (after Allen's test), brachial artery, or femoral artery "
 "in a pre-heparinised syringe; analysed within 15-30 minutes or stored on ice. Normal values: pH 7.35-7.45, "
 "PaO2 80-100 mmHg, PaCO2 35-45 mmHg, HCO3- 22-26 mEq/L, base excess -2 to +2, SpO2 >95%. The A-a gradient "
 "(alveolar-arterial O2 difference) = PAO2 - PaO2; PAO2 = (FiO2 × 713) - PaCO2/0.8. Normal A-a gradient "
 "≈ 4 + age/4 mmHg. Elevated A-a gradient = pulmonary cause of hypoxaemia (V/Q mismatch, shunt, diffusion "
 "impairment). Normal A-a gradient with low PaO2 = hypoventilation or low FiO2."),
("Systematic Interpretation: Six Steps",
 "Step 1 - Oxygenation: PaO2 adequate? <60 mmHg = hypoxaemia; <40 mmHg = severe. Type 1 RF = PaO2 <60, PaCO2 "
 "normal. Type 2 RF = PaO2 <60, PaCO2 >45 mmHg. Step 2 - pH: acidaemia (<7.35) or alkalaemia (>7.45)? Step 3 - "
 "Primary disorder: if acidaemia, is HCO3- low (metabolic) or PaCO2 high (respiratory)? Step 4 - Compensation: "
 "Winter's formula for metabolic acidosis: expected PaCO2 = 1.5 × HCO3- + 8 ± 2; if actual ≠ expected → mixed "
 "disorder. Step 5 - Anion gap (AG): AG = Na+ - (Cl- + HCO3-), normal 8-12. High AG acidosis = MUDPILES "
 "(Methanol, Uraemia, DKA, Propylene glycol, Isoniazid, Lactic acidosis, Ethylene glycol, Salicylates). "
 "Normal AG metabolic acidosis (NAGMA) = diarrhoea, RTA, saline infusion. Step 6 - Delta-delta ratio in "
 "high AG acidosis: (AG excess)/(HCO3- deficit); >2 = concurrent metabolic alkalosis; <1 = concurrent NAGMA."),
("Common Clinical Scenarios",
 "Respiratory acidosis (pH↓, PaCO2↑): acute - COPD exacerbation, pneumonia, pulmonary oedema, opioid OD, "
 "neuromuscular disease; chronic - COPD, OHS (HCO3- elevated compensatorily). Respiratory alkalosis (pH↑, "
 "PaCO2↓): anxiety, pain, pregnancy, hepatic failure, early salicylate poisoning, high altitude. Metabolic "
 "acidosis with high AG: DKA (ketones), lactic acidosis (Type A = hypoperfusion in sepsis/shock; Type B = "
 "metformin, liver failure, thiamine deficiency), uraemia, toxin ingestion. Metabolic alkalosis (HCO3-↑, "
 "pH↑): vomiting, diuretics, hypokalaemia, mineralocorticoid excess, primary hyperaldosteronism, excess "
 "alkali ingestion; PaCO2 rises compensatorily."),
("Lactate, SpO2 Pitfalls, and PF Ratio",
 "Serum lactate: normal <2 mmol/L. Elevated (>2) = tissue hypoperfusion (sepsis, cardiogenic shock, severe "
 "anaemia) or impaired clearance (liver failure, metformin, thiamine deficiency). Lactate >4 mmol/L in "
 "sepsis = septic shock. Lactate clearance >10% at 2 hours = treatment response marker. SpO2 pitfalls: "
 "CO poisoning - SpO2 falsely normal as COHb absorbs same wavelength as oxyHb; methaemoglobinaemia - "
 "SpO2 plateaus at ~85% regardless of true saturation; poor peripheral perfusion - inaccurate. "
 "Co-oximetry on ABG directly measures COHb and metHb. PF ratio (PaO2/FiO2): >400 = normal; 300-400 = mild; "
 "200-300 = moderate (mild ARDS); 100-200 = moderate ARDS; <100 = severe ARDS. Used to classify ARDS "
 "severity (Berlin definition) and guide ventilator management.")
])

print("\nPart 1 (P01-P10): DONE")

from docx import Document
from docx.shared import Pt, Inches, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
import os

OUT = "/tmp/workspace/elog-book/p_docs"
os.makedirs(OUT, exist_ok=True)

def make_doc(filename, topic_num, category, heading, sections):
    doc = Document()
    s = doc.sections[0]
    s.top_margin=Inches(1); s.bottom_margin=Inches(1)
    s.left_margin=Inches(1.2); s.right_margin=Inches(1.2)
    doc.styles["Normal"].font.name="Times New Roman"
    doc.styles["Normal"].font.size=Pt(12)
    cp=doc.add_paragraph(f"Psychomotor Competency  |  {category}  |  {topic_num}")
    cp.alignment=WD_ALIGN_PARAGRAPH.CENTER
    cp.runs[0].font.size=Pt(10); cp.runs[0].font.italic=True
    cp.runs[0].font.color.rgb=RGBColor(0x55,0x55,0x55)
    t=doc.add_heading(heading,level=1); t.alignment=WD_ALIGN_PARAGRAPH.CENTER
    for r in t.runs:
        r.font.name="Times New Roman"; r.font.size=Pt(14)
        r.font.bold=True; r.font.color.rgb=RGBColor(0x1A,0x35,0x6E)
    dv=doc.add_paragraph("─"*80); dv.alignment=WD_ALIGN_PARAGRAPH.CENTER
    dv.runs[0].font.size=Pt(8); dv.runs[0].font.color.rgb=RGBColor(0xAA,0xAA,0xAA)
    for sh_text,body in sections:
        sh=doc.add_heading(sh_text,level=2)
        sh.paragraph_format.space_before=Pt(10); sh.paragraph_format.space_after=Pt(4)
        for r in sh.runs:
            r.font.name="Times New Roman"; r.font.size=Pt(12)
            r.font.bold=True; r.font.color.rgb=RGBColor(0x1A,0x35,0x6E)
        p=doc.add_paragraph(body)
        p.paragraph_format.space_after=Pt(8)
        p.paragraph_format.first_line_indent=Pt(18)
        p.paragraph_format.line_spacing=Pt(22)
        for r in p.runs:
            r.font.name="Times New Roman"; r.font.size=Pt(12)
    doc.add_paragraph()
    f=doc.add_paragraph("E-Log Book  |  Department of Internal Medicine  |  Postgraduate Training Programme")
    f.alignment=WD_ALIGN_PARAGRAPH.CENTER
    f.runs[0].font.size=Pt(9); f.runs[0].font.italic=True
    f.runs[0].font.color.rgb=RGBColor(0x88,0x88,0x88)
    doc.save(os.path.join(OUT,filename)); print(f"  {filename}")

# ─────────────────────────────────────────────────────────────────
# P11  Ultrasonography
# ─────────────────────────────────────────────────────────────────
make_doc("P11_Ultrasonography.docx","P11","Interpretation Skills","Ultrasonography",[
("Introduction",
 "Ultrasonography uses high-frequency sound waves (2-18 MHz) to generate real-time cross-sectional images. "
 "It is radiation-free, portable, widely available, and inexpensive. Point-of-care ultrasound (POCUS) has "
 "become an extension of the clinical examination in internal medicine and critical care, enabling rapid "
 "bedside assessment of the heart, lungs, abdomen, and vessels. The internist must interpret formal USG "
 "reports and increasingly perform basic POCUS."),
("Abdominal Ultrasonography",
 "Liver: echogenicity (increased = fatty liver; heterogeneous = cirrhosis, metastases), size (normal <16 cm "
 "in MCL), focal lesions (hypoechoic = metastases/abscess; hyperechoic = haemangioma; complex = HCC), portal "
 "vein >13 mm = portal hypertension, hepatic vein/IVC patency (Budd-Chiari). Gallbladder: stones (echogenic + "
 "posterior acoustic shadow), wall >3 mm + pericholecystic fluid = acute cholecystitis; CBD >8 mm = dilation. "
 "Pancreas: echogenicity, ductal dilation. Spleen: size >13 cm = splenomegaly. Kidneys: hydronephrosis (graded "
 "I-IV), stones (echogenic + shadow), cortical thinning (CKD), cysts, masses. Ascites: anechoic free fluid in "
 "Morrison's pouch, splenorenal recess, and pelvis."),
("Cardiac Ultrasound (Echocardiography)",
 "Standard views: PLAX, PSAX, apical 4-chamber, apical 2-chamber, subcostal. Key parameters: LV size (LVEDD "
 "normal <56 mm) and ejection fraction (EF ≥55% normal); regional wall motion abnormalities (RWMA) in coronary "
 "territories suggest ischaemia/infarction. RV dilatation + hypokinesia = acute cor pulmonale (PE, ARDS). "
 "Valve assessment: mitral (MR, MS), aortic (AS peak gradient + valve area, AR), tricuspid (TR, RVSP estimate). "
 "Pericardial effusion: mild (<10 mm), moderate (10-20 mm), large (>20 mm); tamponade = RV diastolic collapse + "
 "RA collapse + IVC plethora + respiratory mitral inflow variation."),
("Lung Ultrasonography",
 "A-lines (horizontal reverberation artefacts) = normal aerated lung or pneumothorax. B-lines (vertical 'laser' "
 "artefacts to screen edge) ≥3 per field = interstitial syndrome (pulmonary oedema, pneumonitis). Consolidation "
 "= tissue-like echogenicity with air/fluid bronchograms. Pleural effusion = anechoic/complex fluid between "
 "pleural layers. Pneumothorax = absent lung sliding + A-lines + M-mode 'stratosphere sign'. The BLUE protocol: "
 "bilateral B-lines = cardiogenic oedema; unilateral B-lines + consolidation = pneumonia; absent sliding + "
 "A-lines = pneumothorax; A-lines + DVT = PE."),
("Vascular and Other Applications",
 "DVT: absent compressibility of femoral/popliteal vein is the primary criterion; echogenic thrombus, absent "
 "Doppler flow are supportive. Carotid Doppler: IMT, plaque characterisation, stenosis grading by peak systolic "
 "velocity. Renal artery Doppler: resistive index >0.7 = stenosis or intrinsic renal disease. FAST exam: screens "
 "haemoperitoneum, pericardial effusion, and haemothorax in trauma. Thyroid USG: TIRADS scoring guides FNA for "
 "nodules. Procedural guidance: ultrasound-guided CVC insertion, thoracocentesis, paracentesis, and nerve blocks "
 "have significantly reduced complication rates compared with landmark technique.")
])

# ─────────────────────────────────────────────────────────────────
# P12  CT Chest and Abdomen
# ─────────────────────────────────────────────────────────────────
make_doc("P12_CT_Chest_Abdomen.docx","P12","Interpretation Skills","CT Scan - Chest and Abdomen",[
("Introduction",
 "CT of the chest and abdomen provides high-resolution cross-sectional imaging essential in internal medicine. "
 "CT chest is the modality of choice for pulmonary parenchyma, mediastinum, pleura, and vascular assessment. "
 "CT abdomen evaluates hepatic, pancreatic, renal, retroperitoneal, and bowel pathology. Systematic "
 "interpretation across appropriate windows is essential to avoid missing key findings."),
("CT Chest: Windows and Systematic Assessment",
 "Three windows: lung window (WL -600, WW 1500) - parenchyma, airways, pleura; mediastinal window (WL 40, "
 "WW 400) - mediastinal structures, nodes, vessels; bone window (WL 300, WW 1500) - ribs, spine. HRCT "
 "(thin slices, no contrast) for ILD. CTPA with IV contrast for pulmonary embolism; CT aortogram for "
 "aortic pathology. Systematic review: trachea/bronchi, lungs, pleura, mediastinum, heart, great vessels, "
 "bones."),
("CT Chest: Parenchymal Patterns",
 "Consolidation + air bronchograms: pneumonia (lobar/segmental), organising pneumonia, pulmonary infarction, "
 "haemorrhage. Ground-glass opacity (GGO): pulmonary oedema, viral pneumonitis (COVID-19, PCP), early fibrosis. "
 "Reticulation: IPF/UIP, NSIP. Honeycombing (subpleural cysts with thick walls): advanced fibrosis/IPF. "
 "Tree-in-bud (centrilobular nodules + linear branching): endobronchial infection (TB, MAI), bronchiectasis. "
 "Cavitation: TB, lung abscess, necrotising pneumonia (Klebsiella, Staph), malignancy. CTPA for PE: filling "
 "defects in pulmonary arteries; RV:LV >1.0, IVS bowing, IVC reflux = right heart strain. Mediastinal "
 "lymphadenopathy >10 mm short-axis: sarcoidosis, TB, lymphoma, metastases."),
("CT Abdomen: Systematic Assessment",
 "Phases: non-contrast (calcifications, haemorrhage), arterial (25-35 s - arteries, HCC, vascular), portal "
 "venous (60-70 s - liver parenchyma, organs), delayed (3-5 min - urothelium). Systematic organ review: "
 "liver (attenuation, focal lesions - characterise by phase enhancement pattern), gallbladder + biliary "
 "tree, pancreas (attenuation, duct diameter, peripancreatic fat stranding), spleen, adrenals (adenoma "
 "<10 HU on unenhanced CT), kidneys, retroperitoneum (nodes, aorta), bowel (wall thickening, pneumatosis, "
 "free air), mesentery, peritoneum."),
("CT Abdomen: Key Pathological Findings",
 "Free air (pneumoperitoneum): crescentic air under diaphragm = visceral perforation. Acute pancreatitis: "
 "pancreatic enlargement + peripancreatic fat stranding; CT Severity Index (Balthazar grade + necrosis %) "
 "guides management. Pancreatic necrosis: non-enhancing parenchyma on contrast CT. Aortic aneurysm: "
 "diameter >3 cm; repair indicated at >5.5 cm. Aortic dissection: intimal flap with true/false lumens. "
 "Bowel obstruction: dilated loops proximal to transition point; closed-loop obstruction (C/U shape), "
 "pneumatosis intestinalis, portal venous gas = ischaemia (emergency). Appendicitis: dilated appendix "
 ">6 mm + periappendiceal fat stranding + appendicolith.")
])

# ─────────────────────────────────────────────────────────────────
# P13  CT Head and Spine
# ─────────────────────────────────────────────────────────────────
make_doc("P13_CT_Head_Spine.docx","P13","Interpretation Skills","CT Scan - Head and Spine",[
("Introduction",
 "Non-contrast CT (NCCT) of the head is the first-line imaging in acute neurological emergencies - widely available "
 "and rapidly performed. CT spine is pivotal in trauma and degenerative disease. The internist must recognise key "
 "CT neuroimaging findings that demand immediate clinical action."),
("CT Head: Technical Approach",
 "Windows: brain window (WL 35, WW 80) for parenchyma and blood; bone window (WL 600, WW 3000) for calvarium; "
 "subdural window (WL 75, WW 250) for isodense subdural collections. Systematic review: scalp/skull (fractures, "
 "subgaleal haematoma), extra-axial spaces (epidural, subdural, subarachnoid), parenchyma (haemorrhage, "
 "infarction, oedema, mass), ventricles (size, blood), midline shift (measured at septum pellucidum), posterior "
 "fossa, incidental findings. Hyperdense blood = 55-90 HU on NCCT."),
("CT Head: Haemorrhage Patterns",
 "Intracerebral haemorrhage (ICH): hyperdense parenchymal collection; volume by ABC/2 method; location (basal "
 "ganglia/thalamus = hypertensive; lobar = amyloid angiopathy, AVM, tumour); IVH extension; surrounding oedema; "
 "midline shift. Subarachnoid haemorrhage (SAH): hyperdense blood in basal cisterns, Sylvian fissures, "
 "interhemispheric fissure; sensitivity 98% at 6 hours - LP required if NCCT negative and SAH suspected. "
 "Epidural haematoma (EDH): biconvex (lens-shaped) hyperdense collection, does not cross suture lines; "
 "middle meningeal artery rupture with temporal bone fracture. Subdural haematoma (SDH): crescent-shaped, "
 "crosses suture lines; acute = hyperdense, isodense at 1-3 weeks, chronic = hypodense."),
("CT Head: Ischaemia, Hydrocephalus, and SOL",
 "Ischaemic stroke: early signs (first 6 hours) - loss of grey-white differentiation, insular ribbon sign, "
 "dense MCA sign; established infarct = hypodense area in vascular territory. Hydrocephalus: obstructive "
 "(non-communicating) - ventricular dilation proximal to obstruction; communicating - all ventricles dilated. "
 "Features of raised ICP: sulcal effacement, basal cistern obliteration, uncal herniation (temporal lobe "
 "through tentorium compressing CN III). Ring-enhancing lesions (contrast CT): brain abscess (thin smooth "
 "ring) vs GBM (thick irregular ring) vs metastasis; multiple ring lesions = cerebral metastases, "
 "toxoplasmosis (HIV), multiple abscesses."),
("CT Spine",
 "CT spine provides superior bone detail compared with MRI - the modality of choice in trauma. C-spine CT "
 "mandatory in high-energy trauma (GCS <14, neck pain, distracting injury) before collar removal. Key "
 "findings: fractures (assess alignment, body height, posterior elements, facets; retropulsion of fragments "
 "into canal = neurosurgical emergency), subluxation/dislocation (>3.5 mm at any level = unstable), "
 "spondylolisthesis (grades I-IV), degenerative changes (disc space narrowing, osteophytes, facet "
 "arthropathy), spinal canal stenosis (AP diameter <10 mm = critical). MRI preferred for soft tissue "
 "(cord, disc, epidural), but CT myelogram used when MRI contraindicated. Correlate radiological level "
 "with clinical neurological level.")
])

# ─────────────────────────────────────────────────────────────────
# P14  MRI Brain and Spine
# ─────────────────────────────────────────────────────────────────
make_doc("P14_MRI_Brain_Spine.docx","P14","Interpretation Skills","MRI - Brain and Spine",[
("Introduction",
 "MRI provides superior soft-tissue contrast compared with CT and is the modality of choice for detailed brain "
 "and spinal cord assessment. It uses no ionising radiation, making it safe for repeated use. Key sequences - "
 "T1, T2, FLAIR, DWI, GRE/SWI, and gadolinium-enhanced T1 - each demonstrate different pathological processes. "
 "Understanding sequence characteristics enables systematic interpretation of brain and spine MRI."),
("MRI Sequences and Signal Characteristics",
 "T1-weighted: fat and subacute blood (methaemoglobin) are bright; CSF dark; anatomy/contrast enhancement "
 "(gadolinium = T1 bright). T2-weighted: CSF bright; most pathology (oedema, infarction, demyelination, "
 "tumour, infection) hyperintense (high water content); haemosiderin/calcium dark. FLAIR: CSF signal "
 "suppressed - periventricular lesions and subarachnoid blood (24-48 hours+) visible. DWI: restricted "
 "diffusion (acute infarction, abscess, dense tumour) bright on DWI, dark on ADC map - hallmark of acute "
 "ischaemic stroke. SWI/GRE: sensitive to blood products, calcium, iron - detects microhaemorrhages in "
 "amyloid angiopathy, cavernomas, and DAI."),
("MRI Brain: Common Pathological Findings",
 "Acute ischaemic stroke: DWI bright + ADC dark within minutes of onset; MRA identifies arterial occlusion; "
 "DWI-FLAIR mismatch (DWI positive, FLAIR negative) = onset <4.5 hours enabling thrombolysis in unknown-onset "
 "stroke. MS: T2/FLAIR periventricular plaques (Dawson's fingers perpendicular to ventricles), corpus callosum, "
 "juxtacortical, infratentorial; active plaques enhance on gadolinium T1. Tumours: low-grade glioma = T2 bright, "
 "no enhancement; GBM = central necrosis, irregular ring enhancement, oedema, mass effect; metastases = "
 "multiple enhancing lesions at grey-white junction. Brain abscess = ring enhancement + restricted diffusion "
 "centrally. Herpes encephalitis = T2/FLAIR signal in medial temporal lobes bilaterally."),
("MRI Spine",
 "Gold standard for spinal cord, disc, nerve root, and soft tissue assessment. Disc herniation: posterior "
 "protrusion compressing thecal sac/nerve root; T2 bright herniated nucleus. Spinal cord compression: reduced "
 "cord diameter + T2 hyperintensity (myelomalacia) = chronic or acute compression. Epidural spinal cord "
 "compression from metastases (breast, lung, prostate, myeloma): T1 hypointense + T2 hyperintense vertebral "
 "body replacement + epidural mass compressing cord = neurosurgical/radiotherapy emergency. Spondylodiscitis: "
 "T2 hyperintensity + T1 hypointensity of adjacent endplates and disc + enhancement + paraspinal/epidural "
 "abscess. Transverse myelitis: T2 cord signal >3 vertebral segments (LETM) = NMOSD or MS."),
("Contraindications and Special Sequences",
 "Absolute contraindications: non-MRI-conditional cochlear implants, pacemakers/ICDs (MRI-conditional devices "
 "now available), ferromagnetic intracranial aneurysm clips, metallic intraocular foreign bodies. Relative: "
 "first trimester pregnancy (gadolinium avoided throughout), severe claustrophobia, non-MRI-compatible ventilator. "
 "Gadolinium: NSF risk in severe CKD (eGFR <30) - use macrocyclic agents. Advanced sequences: fMRI (functional "
 "mapping pre-surgery), MR spectroscopy (metabolite profiles - NAA reduced in neuronal injury, choline elevated "
 "in tumour), arterial spin labelling (cerebral blood flow without contrast), perfusion-DWI mismatch (penumbra "
 "in acute stroke - identifies tissue salvageable by reperfusion therapy beyond 4.5 hours).")
])

# ─────────────────────────────────────────────────────────────────
# P15  Barium Studies
# ─────────────────────────────────────────────────────────────────
make_doc("P15_Barium_Studies.docx","P15","Interpretation Skills","Barium Studies",[
("Introduction",
 "Barium studies use insoluble barium sulphate as a radio-opaque contrast agent to delineate the mucosal "
 "surface and GI tract lumen under fluoroscopy. While largely superseded by endoscopy and CT, barium studies "
 "retain important roles for dynamic swallowing assessment, motility disorders, post-surgical anatomy, and "
 "when endoscopy is technically difficult or refused. Water-soluble contrast (Gastrografin) is used when "
 "perforation is suspected - barium in the peritoneum or mediastinum causes severe granulomatous inflammation."),
("Barium Swallow",
 "Evaluates oropharynx, oesophagus, and GOJ under real-time fluoroscopy. Indications: dysphagia, odynophagia, "
 "suspected oesophageal stricture, post-surgical anatomy, hiatus hernia assessment. Modified barium swallow "
 "(video fluoroscopy) with speech therapist assesses swallowing mechanics and aspiration risk in neurological "
 "dysphagia. Key findings: oesophageal stricture (benign = smooth, tapered, symmetric; malignant = irregular, "
 "shouldered, rat-tail narrowing); Zenker's diverticulum (posterior midline, C5-6, barium pools); achalasia "
 "(bird-beak at GOJ, proximal dilation, air-fluid level); hiatus hernia (gastric fundus above diaphragm); "
 "oesophageal web (Plummer-Vinson); GORD (barium reflux above GOJ)."),
("Barium Meal and Small Bowel Series",
 "Barium meal evaluates stomach and duodenum. Gastric ulcer: benign (round, regular, Hampton's line, folds "
 "converging to ulcer, inside gastric lumen) vs malignant (irregular, outside expected contour, absent folds). "
 "Linitis plastica: 'leather bottle' stomach from infiltrating carcinoma. Duodenal ulcer: constant projection, "
 "cloverleaf deformity of duodenal cap. Small bowel follow-through (SBFT): evaluates jejunum/ileum over 2-4 "
 "hours. Crohn's disease: skip lesions, cobblestone mucosa, 'string sign of Kantor' strictures, rose-thorn "
 "ulcers, fistulae. Coeliac disease/malabsorption: diluted barium, flocculation, segmentation. Small bowel "
 "obstruction: dilated loops, barium column stops at obstruction point."),
("Barium Enema",
 "Evaluates large bowel; double-contrast (barium + air) provides best mucosal detail. Largely replaced by "
 "colonoscopy; retained for patients who cannot tolerate colonoscopy and colostomy evaluation. Key findings: "
 "carcinoma - 'apple core' lesion (irregular annular narrowing, shouldered edges, mucosal destruction); "
 "polyps (filling defects); diverticular disease (flask-shaped outpouchings in sigmoid/descending colon); "
 "UC (continuous mucosal granularity from rectum, loss of haustration, 'lead-pipe' colon, pseudopolyps); "
 "Crohn's colitis (discontinuous, rectal sparing, aphthous ulcers, deep fissuring ulcers); fistulae "
 "(rectovaginal, colovesical)."),
("Clinical Application and Limitations",
 "Barium studies provide simultaneous functional and anatomical information - e.g. demonstrating aspiration "
 "during swallowing, or dynamic stricture assessment during peristalsis. Limitations: no tissue sampling "
 "(unlike endoscopy), radiation, poor sensitivity for flat lesions and early cancer, contraindicated in "
 "perforation or complete obstruction. CT colonography (virtual colonoscopy) has largely replaced barium "
 "enema where CT is available, offering comparable polyp sensitivity plus extra-colonic information. "
 "Capsule endoscopy has superseded SBFT for small bowel mucosal assessment. The physician must select "
 "the appropriate modality based on clinical question, patient factors, available local resources, and "
 "the need for tissue diagnosis.")
])

# ─────────────────────────────────────────────────────────────────
# P16  Pulmonary Function Tests
# ─────────────────────────────────────────────────────────────────
make_doc("P16_Pulmonary_Function_Tests.docx","P16","Interpretation Skills","Pulmonary Function Tests (PFTs)",[
("Introduction",
 "Pulmonary function tests non-invasively quantify respiratory mechanics, lung volumes, and gas exchange. "
 "They are essential for diagnosing, characterising severity, and monitoring respiratory diseases. Key "
 "components: spirometry (flow/volume), lung volume measurement (plethysmography or gas dilution), and "
 "diffusing capacity (DLCO). Results expressed as percentage of predicted values based on age, sex, height, "
 "and ethnicity (GLI 2012 reference equations). Always interpret in clinical context."),
("Spirometry: Measurements and Quality",
 "FVC (total volume exhaled from full inspiration to full expiration), FEV1 (volume in first second), "
 "FEV1/FVC ratio (Tiffeneau index, normal ≥0.70-0.75), and PEF. ATS/ERS quality criteria: three technically "
 "acceptable efforts, two largest FVC and FEV1 within 150 mL, good start (extrapolated volume <5% FVC), "
 "satisfactory end (≥6 seconds exhalation or plateau). Suboptimal effort is a common cause of misdiagnosis. "
 "Flow-volume loop: obstructive = scooped (concave) expiratory limb; restrictive = narrow, tall; fixed "
 "extrathoracic obstruction (tracheal stenosis) = flattened inspiratory limb; variable extrathoracic "
 "(vocal cord dysfunction) = flattened inspiratory limb only."),
("Pattern Recognition: Obstructive vs Restrictive",
 "Obstructive: FEV1/FVC <0.70 post-bronchodilator; FEV1 reduced; FVC normal or reduced. Causes: asthma, "
 "COPD, bronchiectasis, obliterative bronchiolitis. GOLD severity (COPD): GOLD 1 ≥80%, GOLD 2 50-79%, "
 "GOLD 3 30-49%, GOLD 4 <30% predicted FEV1. Bronchodilator reversibility: ≥200 mL AND ≥12% increase in "
 "FEV1 post-salbutamol 400 mcg = significant (suggests asthma). Restrictive: FEV1/FVC normal or elevated, "
 "FVC reduced; true restriction confirmed by reduced TLC (<80%) on plethysmography. Causes: ILD (UIP, NSIP, "
 "sarcoidosis, HP), pleural disease, obesity, chest wall deformity, neuromuscular disease. Mixed: FEV1/FVC "
 "<0.70 AND reduced TLC - COPD with ILD, extensive bullous disease."),
("Lung Volumes and DLCO",
 "Body plethysmography: TLC (normal; increased in emphysema - hyperinflation; reduced in restriction), "
 "RV (increased = air trapping in COPD/asthma), RV/TLC >40% = air trapping, FRC. DLCO measures transfer "
 "of CO across the alveolar-capillary membrane; reflects alveolar surface area, membrane thickness, "
 "pulmonary capillary blood volume, and Hb. Reduced DLCO: emphysema (loss of alveolar surface), ILD "
 "(membrane thickening), pulmonary hypertension (reduced vascular bed), anaemia (correct for Hb). "
 "Elevated DLCO: polycythaemia, L-to-R shunt, pulmonary haemorrhage (CO bound by intraalveolar RBCs). "
 "DLCO <40% predicted in ILD = severe disease, high mortality risk."),
("Bronchoprovocation, FeNO, and 6MWT",
 "Methacholine challenge test: used when spirometry is normal but asthma is suspected clinically. PC20 "
 "<8 mg/mL (fall in FEV1 ≥20%) = bronchial hyperreactivity. Highly sensitive; negative test effectively "
 "rules out active asthma as cause of symptoms. FeNO (fractional exhaled nitric oxide): biomarker of "
 "eosinophilic airway inflammation. ≥50 ppb = eosinophilic asthma likely, predicts steroid response; "
 "<25 ppb = eosinophilic inflammation unlikely. Used in asthma phenotyping and guiding step-up therapy. "
 "6-Minute Walk Test (6MWT): functional exercise capacity; 6MWD <350 m = poor prognosis in IPF and PAH; "
 "monitors disease progression and treatment response. Serial PFTs are the cornerstone of monitoring "
 "for fibrotic lung disease progression (rate of FVC decline >10%/year = poor prognosis in IPF).")
])

# ─────────────────────────────────────────────────────────────────
# P17  Immunological Investigations
# ─────────────────────────────────────────────────────────────────
make_doc("P17_Immunological_Investigations.docx","P17","Interpretation Skills","Immunological Investigations",[
("Introduction",
 "Immunological investigations are central to the diagnosis and monitoring of autoimmune, inflammatory, and "
 "immunodeficiency disorders. Understanding the sensitivity, specificity, and clinical relevance of autoantibodies "
 "and immunological markers allows rational use - avoiding over-investigation and over-interpretation of weakly "
 "positive results. Results must always be contextualised within the clinical picture; isolated positive "
 "autoantibodies without clinical features are rarely diagnostic."),
("ANA and Disease-Specific Autoantibodies",
 "ANA (indirect immunofluorescence on HEp-2 cells): screening test for systemic autoimmune disease; titre "
 "≥1:80 significant; 95% of SLE patients ANA positive; 5-15% of healthy individuals ANA positive (low "
 "specificity). Pattern guides further testing: homogeneous = anti-dsDNA (SLE); speckled = anti-Sm (SLE, "
 "specific), anti-Ro/SS-A (Sjögren's, neonatal lupus), anti-La/SS-B (Sjögren's), anti-Scl-70 (dcSSc), "
 "anti-U1-RNP (MCTD); centromere = lcSSc/CREST; nucleolar = dcSSc. Anti-dsDNA: 70% sensitivity, 95% "
 "specificity for SLE; titres correlate with disease activity. Anti-histone: drug-induced lupus. "
 "Anti-Ro/SS-A: risk of congenital heart block in neonates of positive mothers."),
("ANCA and Myositis Antibodies",
 "ANCA: c-ANCA (anti-PR3) = granulomatosis with polyangiitis (GPA/Wegener's), 66-90% sensitivity, >95% "
 "specificity; p-ANCA (anti-MPO) = microscopic polyangiitis (MPA) and eosinophilic GPA (EGPA/Churg-Strauss). "
 "Titres correlate with disease activity. False positive p-ANCA: IBD, minocycline, propylthiouracil. "
 "Always confirm by antigen-specific ELISA (PR3/MPO). Myositis-specific antibodies (MSA): anti-Jo-1 "
 "(antisynthetase syndrome: ILD + myositis + arthritis + mechanic's hands), anti-Mi-2 (DM, good prognosis), "
 "anti-MDA5 (amyopathic DM + rapidly progressive ILD, poor prognosis), anti-SRP (immune-mediated "
 "necrotising myopathy), anti-TIF1-γ (paraneoplastic DM in adults >40 years)."),
("Complement, Antiphospholipid, and Inflammatory Markers",
 "Complement: low C3+C4 = consumption (active SLE nephritis, cryoglobulinaemia); low C4 alone = C4 "
 "deficiency or hereditary angio-oedema; low CH50 with normal C3/C4 = classical pathway component "
 "deficiency. Antiphospholipid antibodies (aPL): lupus anticoagulant, anticardiolipin IgG/IgM (>40 GPL/MPL), "
 "anti-β2-GPI IgG/IgM. APS diagnosis: ≥1 clinical criterion (thrombosis or pregnancy morbidity) AND ≥1 "
 "laboratory criterion positive on 2 occasions ≥12 weeks apart. Triple positive aPL = highest thrombotic "
 "risk. Ferritin >10,000 µg/L = haemophagocytic lymphohistiocytosis (HLH) or adult Still's disease. "
 "CRP rises rapidly with infection/inflammation; ESR influenced by fibrinogen, immunoglobulins."),
("Immunoglobulins and Cryoglobulins",
 "Serum immunoglobulins (IgG, IgA, IgM): polyclonal elevation = chronic infection, autoimmune disease, "
 "cirrhosis; monoclonal paraprotein (M-spike on SPEP) = MGUS, myeloma, lymphoma, Waldenström's. Free "
 "light chains (kappa/lambda ratio): abnormal in myeloma and AL amyloidosis. SPEP + immunofixation: "
 "characterises monoclonal protein type. 24-hour urine for Bence Jones protein: free light chains = "
 "myeloma cast nephropathy. Cryoglobulins: precipitate in cold; Type I = monoclonal (myeloma, lymphoma); "
 "Type II/III = mixed (HCV most common - palpable purpura, neuropathy, GN, low C4). Specimens must be "
 "collected and transported at 37°C to prevent in vitro cryoprecipitation before laboratory processing.")
])

# ─────────────────────────────────────────────────────────────────
# P18  NCS / EMG
# ─────────────────────────────────────────────────────────────────
make_doc("P18_NCS_EMG.docx","P18","Interpretation Skills","Nerve Conduction Studies and Electromyography (NCS/EMG)",[
("Introduction",
 "Nerve conduction studies (NCS) and electromyography (EMG) are electrodiagnostic investigations that assess "
 "the integrity and function of peripheral nerves and muscles. Together they constitute the cornerstones of "
 "peripheral nervous system evaluation, enabling localisation of lesions, characterisation of pathological "
 "process (axonal vs demyelinating, neuropathy vs myopathy), and assessment of severity and prognosis. "
 "The internist must be proficient in interpreting NCS/EMG reports in the clinical context of common "
 "neuromuscular disorders encountered in internal medicine."),
("Nerve Conduction Studies: Principles and Parameters",
 "NCS involves applying a supramaximal electrical stimulus to a peripheral nerve and recording the evoked "
 "response. Motor NCS parameters: distal latency (time from stimulus to onset of CMAP - compound muscle "
 "action potential; prolonged in demyelination), amplitude (CMAP amplitude reflects number of functioning "
 "motor axons; reduced in axonal loss), and conduction velocity (CV, reduced in demyelination). Sensory NCS "
 "parameters: SNAP (sensory nerve action potential) amplitude (reduced in axonal sensory neuropathy or "
 "demyelination), sensory latency, and sensory CV. F-waves (assess proximal nerve segments) and H-reflex "
 "(tests monosynaptic arc through S1 - equivalent to ankle jerk). Normal values vary by nerve and age."),
("Axonal vs Demyelinating Neuropathy",
 "Demyelinating pattern: markedly slowed conduction velocities (<75% lower limit of normal), prolonged "
 "distal latencies (>130% upper limit), prolonged F-wave latencies, conduction block (>50% CMAP amplitude "
 "drop across a nerve segment), and temporal dispersion. Causes: CIDP (chronic inflammatory demyelinating "
 "polyneuropathy - symmetrical, proximal + distal weakness, increased CSF protein), GBS/AIDP (acute "
 "inflammatory demyelinating polyneuropathy - ascending paralysis), hereditary neuropathies (CMT1 - uniformly "
 "slow CVs), multifocal motor neuropathy with conduction block (MMN). Axonal pattern: reduced CMAP/SNAP "
 "amplitudes with relatively preserved CVs (within 80% lower limit). Causes: diabetic neuropathy (most "
 "common), uraemic neuropathy, alcohol, vasculitic neuropathy, axonal GBS (AMAN/AMSAN), toxic neuropathies."),
("EMG: Principles and Interpretation",
 "EMG involves inserting a needle electrode into muscle to record electrical activity at rest and during "
 "voluntary contraction. At rest, normal muscle is electrically silent. Abnormal spontaneous activity: "
 "fibrillation potentials and positive sharp waves (PSWs) = active denervation (appear 1-3 weeks after "
 "nerve injury or in myopathies); fasciculation potentials = motor neuron disease (ALS) or radiculopathy; "
 "complex repetitive discharges = chronic denervation/myopathies; myotonic discharges (waxing/waning sound "
 "like a dive-bomber) = myotonic disorders. During voluntary contraction: motor unit potential (MUP) "
 "morphology and recruitment pattern. Neuropathic MUPs: large amplitude, long duration, polyphasic "
 "(reinnervation). Myopathic MUPs: small amplitude, short duration, polyphasic, early full recruitment."),
("Clinical Application: Common Disorders",
 "Carpal tunnel syndrome (CTS): prolonged median nerve distal sensory latency and reduced SNAP amplitude; "
 "normal ulnar nerve (differentiates from generalised neuropathy); delayed median motor distal latency in "
 "severe cases. Radiculopathy: EMG showing denervation in muscles of a specific myotomal distribution with "
 "normal sensory NCS (dorsal root ganglion proximal to lesion); F-wave may be prolonged. ALS (motor neuron "
 "disease): EMG showing widespread active and chronic denervation in bulbar, cervical, thoracic, and "
 "lumbosacral regions with normal sensory NCS. GBS: acute, progressive areflexic paralysis; NCS pattern "
 "guides subtype (AIDP = demyelinating, AMAN = axonal motor). Critical illness polyneuropathy (CIP): "
 "axonal sensorimotor neuropathy in ICU patients with sepsis/SIRS - major cause of ICU-acquired weakness.")
])

# ─────────────────────────────────────────────────────────────────
# P19  EEG
# ─────────────────────────────────────────────────────────────────
make_doc("P19_EEG.docx","P19","Interpretation Skills","Electroencephalography (EEG)",[
("Introduction",
 "Electroencephalography (EEG) records the spontaneous electrical activity of the cerebral cortex via scalp "
 "electrodes, reflecting the summated postsynaptic potentials of cortical neurons. It is the primary "
 "investigation for seizure disorders, encephalopathies, and altered consciousness. The standard 10-20 "
 "electrode placement system provides spatial resolution across all cortical regions. The internist must "
 "understand EEG interpretation in the context of common clinical scenarios including epilepsy, "
 "encephalopathy, and status epilepticus."),
("Normal EEG Rhythms",
 "EEG activity is characterised by frequency (Hz), amplitude (µV), and distribution. Normal rhythms by "
 "frequency: Delta (<4 Hz) - normal in deep sleep (Stage N3), pathological if present in wakefulness "
 "(indicates severe encephalopathy or cortical injury). Theta (4-7 Hz) - normal in light sleep and "
 "children; mild abnormality in adults if focal and persistent. Alpha (8-13 Hz) - predominant resting "
 "rhythm in awake adults with eyes closed, maximal in occipital regions; attenuates with eye opening "
 "(alpha blocking). Beta (>13 Hz) - predominant with mental activity and in frontal/central regions; "
 "augmented by benzodiazepines and barbiturates; reduced over cortical injury. Mu rhythm: alpha-frequency "
 "motor cortex rhythm, blocks with movement or imagined movement. Sleep stages have characteristic "
 "EEG signatures (sleep spindles, K-complexes in N2; high-amplitude delta in N3)."),
("Epileptiform Abnormalities",
 "Interictal epileptiform discharges (IEDs): spikes (duration <70 ms) and sharp waves (duration 70-200 ms) - "
 "high-amplitude transients that stand out from background activity. They are the hallmark of epileptic "
 "predisposition. Generalised spike-wave discharges at 3 Hz = absence epilepsy (childhood); polyspike-wave "
 "= juvenile myoclonic epilepsy (JME). Focal spikes (temporal, centrotemporal, occipital) identify the "
 "epileptic focus for resection surgery planning. Ictal EEG (during seizure): rhythmic evolution of "
 "epileptiform activity (evolving frequency, amplitude, distribution). Ictal onset and offset must be "
 "identified. Non-convulsive status epilepticus (NCSE): continuous or recurring seizure activity on EEG "
 "without overt motor manifestations - presents as altered consciousness; continuous EEG monitoring "
 "(cEEG) is essential in unexplained coma in the ICU."),
("Encephalopathic EEG Patterns",
 "Encephalopathy produces generalised EEG slowing (alpha replaced by theta/delta) proportionate to severity. "
 "Triphasic waves (high-amplitude, triphasic morphology, fronto-central predominance, anterior-posterior "
 "lag): classically described in hepatic encephalopathy but also seen in uraemic, hypoxic-ischaemic, and "
 "other metabolic encephalopathies. Burst suppression: alternating bursts of activity with periods of "
 "isoelectricity (electrical silence) - seen in severe anoxic brain injury, deep anaesthesia, or "
 "barbiturate coma. Generalised periodic discharges (GPDs) over a suppressed background: post-anoxic "
 "brain injury (poor prognostic sign). Lateralised rhythmic delta activity (LRDA) and lateralised "
 "periodic discharges (LPDs): associated with focal cortical injury (infarction, haemorrhage, herpes "
 "encephalitis) and may represent ictal or peri-ictal patterns."),
("Clinical Applications in Internal Medicine",
 "Epilepsy diagnosis: EEG is the primary diagnostic tool; a normal interictal EEG does not exclude "
 "epilepsy (sensitivity ~50% for single routine EEG; increases with sleep deprivation, hyperventilation, "
 "photic stimulation activation, and prolonged/ambulatory recording). EEG guides AED selection by "
 "epilepsy syndrome: generalised epilepsy syndromes (sodium valproate, levetiracetam) vs focal epilepsy "
 "(carbamazepine, lamotrigine, oxcarbazepine). In ICU: cEEG monitoring is indicated in unexplained "
 "altered consciousness, post-cardiac arrest (detect NCSE and assess for burst suppression during "
 "TTM), post-neurosurgical procedures, and refractory status epilepticus management (anaesthesia "
 "titration to burst-suppression endpoint). In prion disease (CJD): periodic sharp wave complexes "
 "at 1 Hz are a characteristic but late finding.")
])

# ─────────────────────────────────────────────────────────────────
# P20  Evoked Potentials
# ─────────────────────────────────────────────────────────────────
make_doc("P20_Evoked_Potentials.docx","P20","Interpretation Skills","Evoked Potential Interpretation",[
("Introduction",
 "Evoked potentials (EPs) measure the electrical response of the nervous system to sensory or motor stimuli. "
 "They assess the functional integrity of specific neurological pathways with greater sensitivity than "
 "clinical examination alone, and are particularly valuable when clinical signs are absent or inconclusive. "
 "The three modalities most relevant to internal medicine and neurology are: visual evoked potentials (VEPs), "
 "brainstem auditory evoked potentials (BAEPs), and somatosensory evoked potentials (SSEPs). Motor evoked "
 "potentials (MEPs) assess the corticospinal tract."),
("Visual Evoked Potentials (VEPs)",
 "VEPs are generated by pattern reversal (checkerboard) visual stimulation and recorded at the occipital "
 "scalp. The primary component is the P100 wave (a positive deflection approximately 100 ms post-stimulus "
 "in normal individuals). Abnormalities: prolonged P100 latency = delayed conduction in the optic nerve "
 "or visual pathway (demyelination); reduced amplitude = axonal loss or incomplete stimulation. The most "
 "common clinical application is detection of prior or subclinical optic neuritis in multiple sclerosis "
 "- P100 latency is prolonged (>118 ms unilaterally or >10 ms interocular asymmetry) even after visual "
 "acuity has recovered, providing objective evidence of a prior episode (clinically silent lesion). "
 "VEPs also detect optic pathway compression from pituitary adenomas and ischaemic optic neuropathy. "
 "Monocular stimulation allows lateralisation of the lesion."),
("Brainstem Auditory Evoked Potentials (BAEPs)",
 "BAEPs (also called BAER/ABR) are generated by click-auditory stimuli and recorded from scalp electrodes. "
 "Five vertex-positive waves (I-V) arise sequentially from: I - cochlear nerve; II - cochlear nucleus; "
 "III - superior olivary complex; IV - lateral lemniscus; V - inferior colliculus. Abnormalities: prolonged "
 "interwave latencies (I-III, III-V, I-V intervals) indicate conduction delay between generators. Prolonged "
 "I-V interval = brainstem conduction abnormality; absent wave I with preserved III-V = peripheral hearing "
 "loss (cochlear/auditory nerve). Clinical applications: MS (brainstem involvement - prolongs III-V), "
 "acoustic neuroma/CPA tumour (prolonged I-III or absent waves), hearing loss assessment in infants, "
 "intraoperative monitoring during posterior fossa surgery, and brainstem function assessment in coma "
 "(absent BAEPs with preserved peripheral hearing = severe brainstem dysfunction, grave prognosis)."),
("Somatosensory Evoked Potentials (SSEPs)",
 "SSEPs are generated by electrical stimulation of peripheral nerves (median nerve at wrist for upper "
 "limb; posterior tibial nerve at ankle for lower limb) and recorded at multiple levels (Erb's point, "
 "cervical spine, scalp). Key components: N13/N14 (spinal/subcortical), N20/P25 (cortical response for "
 "median nerve), P40 (cortical response for posterior tibial nerve). Abnormalities: prolonged central "
 "conduction time (CCT = cortical peak - cervical peak) = delayed conduction in posterior columns (MS, "
 "cervical spondylotic myelopathy, subacute combined degeneration); absent cortical response with "
 "preserved peripheral response = severe spinal cord or cortical injury. Clinical applications: MS "
 "(subclinical posterior column involvement), cervical myelopathy assessment, intraoperative spinal "
 "cord monitoring during scoliosis/spinal surgery, and post-cardiac arrest prognostication."),
("SSEPs in Post-Cardiac Arrest Prognostication",
 "Bilateral absence of N20 cortical responses on median nerve SSEPs at 48-72 hours post-cardiac arrest "
 "is one of the most robust predictors of poor neurological outcome (false positive rate <1% in the "
 "absence of confounders). It is incorporated in the multimodal prognostication algorithm alongside: "
 "clinical examination (absence of pupillary and corneal reflexes), EEG (suppressed background, burst "
 "suppression, generalised periodic discharges), biomarkers (neuron-specific enolase NSE >60 µg/L at "
 "48-72 hours), and brain MRI (diffusion-weighted imaging showing extensive cortical restricted "
 "diffusion). No single test should be used in isolation for prognostication. Motor evoked potentials "
 "(MEPs) via transcranial magnetic stimulation (TMS) assess corticospinal tract integrity and are used "
 "pre-operatively in spinal surgery and in monitoring response to therapy in myelopathy.")
])

print("\nPart 2 (P11-P20): DONE")

from docx import Document
from docx.shared import Pt, Inches, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
import os

OUT = "/tmp/workspace/elog-book/p_docs"
os.makedirs(OUT, exist_ok=True)

def make_doc(filename, topic_num, category, heading, sections):
    doc = Document()
    s = doc.sections[0]
    s.top_margin=Inches(1); s.bottom_margin=Inches(1)
    s.left_margin=Inches(1.2); s.right_margin=Inches(1.2)
    doc.styles["Normal"].font.name="Times New Roman"
    doc.styles["Normal"].font.size=Pt(12)
    cp=doc.add_paragraph(f"Psychomotor Competency  |  {category}  |  {topic_num}")
    cp.alignment=WD_ALIGN_PARAGRAPH.CENTER
    cp.runs[0].font.size=Pt(10); cp.runs[0].font.italic=True
    cp.runs[0].font.color.rgb=RGBColor(0x55,0x55,0x55)
    t=doc.add_heading(heading,level=1); t.alignment=WD_ALIGN_PARAGRAPH.CENTER
    for r in t.runs:
        r.font.name="Times New Roman"; r.font.size=Pt(14)
        r.font.bold=True; r.font.color.rgb=RGBColor(0x1A,0x35,0x6E)
    dv=doc.add_paragraph("─"*80); dv.alignment=WD_ALIGN_PARAGRAPH.CENTER
    dv.runs[0].font.size=Pt(8); dv.runs[0].font.color.rgb=RGBColor(0xAA,0xAA,0xAA)
    for sh_text,body in sections:
        sh=doc.add_heading(sh_text,level=2)
        sh.paragraph_format.space_before=Pt(10); sh.paragraph_format.space_after=Pt(4)
        for r in sh.runs:
            r.font.name="Times New Roman"; r.font.size=Pt(12)
            r.font.bold=True; r.font.color.rgb=RGBColor(0x1A,0x35,0x6E)
        p=doc.add_paragraph(body)
        p.paragraph_format.space_after=Pt(8)
        p.paragraph_format.first_line_indent=Pt(18)
        p.paragraph_format.line_spacing=Pt(22)
        for r in p.runs:
            r.font.name="Times New Roman"; r.font.size=Pt(12)
    doc.add_paragraph()
    f=doc.add_paragraph("E-Log Book  |  Department of Internal Medicine  |  Postgraduate Training Programme")
    f.alignment=WD_ALIGN_PARAGRAPH.CENTER
    f.runs[0].font.size=Pt(9); f.runs[0].font.italic=True
    f.runs[0].font.color.rgb=RGBColor(0x88,0x88,0x88)
    doc.save(os.path.join(OUT,filename)); print(f"  {filename}")

# ─────────────────────────────────────────────────────────────────
# P21  Communicating Health and Disease
# ─────────────────────────────────────────────────────────────────
make_doc("P21_Communicating_Health_Disease.docx","P21","Communication Skills","Communicating Health and Disease",[
("Introduction",
 "Communicating information about health status and disease is one of the most frequently performed yet under-taught "
 "clinical tasks. Every patient encounter involves some element of explaining a diagnosis, a test result, a prognosis, "
 "or a management plan. Effective communication directly improves patient understanding, adherence, satisfaction, "
 "and clinical outcomes, while poor communication is a leading driver of complaints, non-adherence, and avoidable harm."),
("Principles of Effective Health Communication",
 "Key principles: use plain language and avoid medical jargon (or explain it immediately if used); check the patient's "
 "existing understanding before providing new information ('What do you already know about your condition?'); "
 "deliver information in small chunks, checking comprehension after each ('chunk and check'); use the teach-back "
 "method - ask the patient to repeat the information in their own words to confirm understanding; and always allow "
 "time for questions. Health literacy varies widely; written materials should be pitched at an appropriate reading "
 "level, and visual aids (diagrams, models) improve comprehension, particularly for anatomical or procedural "
 "explanations."),
("Explaining Diagnosis and Prognosis",
 "When explaining a new diagnosis, structure the conversation: state the diagnosis clearly and simply, explain what "
 "it means for the patient's body and daily life, outline the natural history and expected course, and describe "
 "the treatment plan and its goals. Prognosis should be discussed honestly but with realistic hope; avoid false "
 "reassurance and avoid unnecessarily bleak framing. Uncertainty should be acknowledged rather than concealed - "
 "phrases such as 'we cannot be certain, but based on what we know...' build trust. Cultural and religious beliefs "
 "about illness causation and treatment must be explored and respected without being dismissed."),
("Communicating Chronic Disease and Self-Management",
 "In chronic disease (diabetes, hypertension, COPD, CKD), communication must extend beyond a single encounter to "
 "support long-term self-management. This includes explaining the rationale for ongoing monitoring (why HbA1c "
 "matters, why blood pressure needs regular checking), teaching recognition of warning symptoms requiring urgent "
 "review, and setting collaborative, realistic goals with the patient rather than imposing targets. Motivational "
 "interviewing techniques - open questions, affirmations, reflective listening, summarising (OARS) - are effective "
 "in supporting behaviour change for lifestyle-related conditions."),
("Barriers and Special Considerations",
 "Common barriers include time pressure, language differences (requiring professional interpreters, not family "
 "members, for clinical conversations), low health literacy, cognitive impairment, and emotional distress that "
 "impairs information processing. In such situations, information should be repeated, written summaries provided, "
 "and family involvement arranged with patient consent. Telephone and telemedicine consultations require additional "
 "verbal clarity since visual cues are reduced or absent. Ultimately, the goal of health communication is a shared "
 "understanding between clinician and patient that empowers informed decision-making and sustained engagement with care.")
])

# ─────────────────────────────────────────────────────────────────
# P22  HIV Pre-test and Post-test Counseling
# ─────────────────────────────────────────────────────────────────
make_doc("P22_HIV_Counseling.docx","P22","Communication Skills","Pre-test and Post-test Counseling for HIV",[
("Introduction",
 "HIV counseling and testing is a critical public health and clinical intervention that must be conducted with "
 "sensitivity, confidentiality, and adherence to national guidelines (NACO in India). Counseling before and after "
 "testing ensures informed consent, provides risk-reduction education, and supports the patient psychologically "
 "regardless of the result. The 5 Cs of HIV testing services (WHO) are: Consent, Confidentiality, Counseling, "
 "Correct test results, and Connection to prevention, care, and treatment."),
("Pre-Test Counseling",
 "Pre-test counseling must cover: the purpose and benefits of testing, the meaning of positive and negative results "
 "(including the window period during which recent infection may not be detected), the voluntary nature of testing "
 "and the right to decline, confidentiality assurances, and an assessment of individual risk behaviours (unprotected "
 "sex, multiple partners, injecting drug use, occupational exposure) to provide tailored risk-reduction advice. "
 "Informed consent must be obtained and documented. The counselor should assess the patient's coping resources "
 "and existing support systems in anticipation of either result. Testing should never be performed without "
 "consent except in specific legally defined circumstances (e.g. unconscious patient requiring urgent treatment "
 "decisions, or as per court order)."),
("Post-Test Counseling: Negative Result",
 "A negative result should be communicated clearly, with explanation of the window period if recent exposure is "
 "possible (recommend repeat testing at an appropriate interval). Reinforce risk-reduction strategies: consistent "
 "condom use, harm reduction for people who inject drugs (needle exchange, opioid substitution), and consideration "
 "of pre-exposure prophylaxis (PrEP) for those at ongoing substantial risk (MSM, sex workers, discordant couples). "
 "A negative result is an opportunity for reinforcing preventive behaviour, not merely a reassurance."),
("Post-Test Counseling: Positive Result",
 "Delivering a positive HIV result requires the same principles as breaking bad news (SPIKES protocol): private "
 "setting, assessment of existing understanding, permission to share information, clear delivery without euphemism, "
 "empathetic response to emotional reaction, and a clear plan going forward. Key messages: HIV is a manageable "
 "chronic condition with antiretroviral therapy (ART); with effective treatment and adherence, life expectancy "
 "approaches that of the general population and viral suppression prevents transmission (Undetectable = "
 "Untransmittable, U=U). Immediate practical steps: referral to ART centre, baseline CD4 count and viral load, "
 "screening for opportunistic infections and co-infections (TB, hepatitis B/C, syphilis), and partner notification "
 "counseling (encouraging voluntary disclosure and partner testing, with support rather than coercion)."),
("Confidentiality, Ethics, and Ongoing Support",
 "Confidentiality is paramount - HIV status must not be disclosed to third parties (including family) without "
 "explicit patient consent, except where legally mandated. Stigma and discrimination remain significant barriers "
 "to testing and treatment adherence; counselors must actively address internalised stigma and fear of disclosure. "
 "Ongoing psychosocial support should be arranged, including linkage to support groups and mental health services "
 "as needed. Adherence counseling is a continuous process, addressing barriers to ART adherence (pill burden, "
 "side effects, disclosure concerns, socioeconomic factors) at every follow-up visit.")
])

# ─────────────────────────────────────────────────────────────────
# P23  Pedagogy
# ─────────────────────────────────────────────────────────────────
make_doc("P23_Pedagogy.docx","P23","Communication Skills","Pedagogy: Teaching Students and Health Functionaries",[
("Introduction",
 "Teaching is a core professional responsibility of the postgraduate physician, extending to undergraduate medical "
 "students, junior residents, nursing staff, and other health functionaries. Effective medical education requires "
 "not only content expertise but also an understanding of adult learning principles and teaching methodology. "
 "The postgraduate trainee progressively develops from learner to teacher throughout training, a transition that "
 "should be actively cultivated rather than left to chance."),
("Principles of Adult Learning",
 "Malcolm Knowles' andragogy principles are foundational: adults learn best when the material is relevant to their "
 "immediate needs (problem-centred rather than subject-centred learning), when they can draw on prior experience, "
 "when they are self-directed participants rather than passive recipients, and when learning is applied "
 "immediately to real clinical scenarios. Miller's pyramid of clinical competence (knows, knows how, shows how, "
 "does) illustrates the progression from theoretical knowledge to workplace-based performance, guiding the "
 "choice of teaching and assessment method at each level."),
("Lectures and Large-Group Teaching",
 "Lectures remain useful for delivering foundational knowledge to large groups but are limited by passive learner "
 "engagement. Effective lecturing includes: clear learning objectives stated at the outset, logical structure "
 "(introduction, body, summary), interactive elements (audience response questions, think-pair-share), visual "
 "aids that support rather than duplicate spoken content, and a concise summary reinforcing key take-home points. "
 "Attention spans decline after 15-20 minutes; breaking lectures into segments with active engagement improves "
 "retention significantly compared with continuous monologue delivery."),
("Bedside Teaching and Clinical Discussions",
 "Bedside teaching integrates clinical skills, communication, and professionalism in the authentic clinical "
 "environment, and is regarded as one of the most powerful methods of clinical education. Effective bedside "
 "teaching requires: obtaining patient consent and involving the patient respectfully, structuring the session "
 "(brief pre-briefing of objectives, observation of history/examination, discussion away from bedside if sensitive "
 "content, feedback), and using the 'one-minute preceptor' model - get a commitment, probe for supporting evidence, "
 "teach a general rule, reinforce what was done well, correct errors. Case-based discussions (CBD) and problem-based "
 "learning (PBL) foster clinical reasoning by working through real or simulated cases collaboratively, encouraging "
 "learners to generate differential diagnoses and justify management decisions."),
("Feedback and Assessment in Teaching",
 "Constructive feedback is essential to learning and should be timely, specific, balanced, and focused on "
 "behaviour rather than personal characteristics. The 'sandwich' technique (positive-constructive-positive) and "
 "Pendleton's rules (learner self-assesses first, then observer provides feedback) are widely used frameworks. "
 "Teaching other health functionaries - nurses, pharmacists, ASHA workers, laboratory technicians - requires "
 "tailoring content and language to their scope of practice and prior training. In-service training sessions "
 "should be practical, case-based, and directly applicable to daily responsibilities. Documentation of teaching "
 "activities (topics covered, learners taught, feedback given) supports professional development portfolios and "
 "postgraduate training requirements.")
])

# ─────────────────────────────────────────────────────────────────
# P24  Health Education
# ─────────────────────────────────────────────────────────────────
make_doc("P24_Health_Education.docx","P24","Communication Skills","Health Education: Prevention, Lifestyle, Immunization, Screening, and Risk-Factor Counseling",[
("Introduction",
 "Health education is a planned communication process that enables individuals and communities to acquire the "
 "knowledge, skills, and motivation needed to adopt and maintain healthy behaviours. It underpins primary and "
 "secondary prevention across nearly every disease encountered in internal medicine practice. The physician's role "
 "extends beyond treating established disease to actively promoting health and preventing its loss."),
("Prevention of Common Medical Problems and Healthy Lifestyle Promotion",
 "Health education for common conditions should be tailored, actionable, and reinforced at every opportunity. "
 "Key lifestyle messages: tobacco cessation (single most impactful intervention for cardiovascular and respiratory "
 "disease - brief advice increases quit rates), physical activity (150 minutes/week moderate aerobic activity per "
 "WHO recommendations), dietary modification (reduced salt <5g/day, reduced saturated fat and trans-fat, increased "
 "fruit/vegetable intake, limited processed food), alcohol moderation, and weight management. Behaviour change "
 "counseling is most effective when specific, achievable goals are set collaboratively (SMART goals) rather than "
 "generic advice to 'eat healthy' or 'exercise more'."),
("Immunization Counseling",
 "Physicians must proactively counsel on immunization across the lifespan - not limited to childhood. Adult "
 "immunizations of particular relevance: influenza (annual, especially elderly and comorbid patients), pneumococcal "
 "vaccine (elderly, chronic lung/heart/renal disease, immunocompromised), hepatitis B (healthcare workers, "
 "high-risk groups), tetanus boosters, and HPV vaccination for adolescents. Vaccine hesitancy should be addressed "
 "empathetically - exploring specific concerns, providing evidence-based reassurance, and avoiding confrontational "
 "approaches that entrench resistance. The physician's personal recommendation is one of the strongest predictors "
 "of a patient accepting vaccination."),
("Periodic Health Screening",
 "Age- and risk-appropriate screening should be discussed proactively: blood pressure measurement (all adults "
 "periodically), blood glucose/HbA1c (at-risk adults), lipid profile (cardiovascular risk assessment), cervical "
 "cancer screening (Pap smear/HPV testing), breast cancer screening (mammography per national guidelines), "
 "colorectal cancer screening (FOBT, colonoscopy from age 45-50), and bone density screening in post-menopausal "
 "women. Health education should explain the rationale, benefits, and limitations (including risk of "
 "false-positives and overdiagnosis) of each screening test to support informed decision-making."),
("Risk-Factor Counseling for Malignancies, Cardiovascular Disease, and AIDS",
 "Malignancy risk reduction counseling: tobacco and alcohol cessation (oral, oesophageal, lung, hepatocellular "
 "cancers), sun protection (skin cancer), HPV vaccination and safe sexual practices (cervical cancer), and "
 "awareness of family history warranting genetic counseling referral. Cardiovascular risk counseling: use of "
 "validated risk calculators (ASCVD risk score, Framingham) to communicate absolute risk and the impact of "
 "modifiable factors; addressing the '5 pillars' - blood pressure, lipids, glucose, smoking, and weight. "
 "AIDS/HIV risk counseling: safe sexual practices (consistent condom use), harm reduction for injecting drug "
 "use, and PrEP counseling for high-risk individuals. Across all domains, health education is most effective "
 "when delivered repeatedly, reinforced across multiple encounters, and adapted to the individual's readiness "
 "to change (Stages of Change / Transtheoretical Model).")
])

# ─────────────────────────────────────────────────────────────────
# P25  Dietary Counseling
# ─────────────────────────────────────────────────────────────────
make_doc("P25_Dietary_Counseling.docx","P25","Communication Skills","Dietary Counseling in Health and Disease",[
("Introduction",
 "Dietary counseling is a fundamental therapeutic and preventive tool across almost every domain of internal "
 "medicine. Nutrition influences the onset, progression, and management of chronic diseases including diabetes, "
 "hypertension, dyslipidaemia, CKD, liver disease, and obesity. Effective dietary counseling requires an "
 "individualised, culturally sensitive, and practically achievable approach rather than generic prescriptive "
 "advice, recognising that dietary patterns are deeply embedded in culture, economics, and personal preference."),
("General Principles of Dietary Counseling",
 "Begin with a dietary history - typical meal patterns, portion sizes, frequency of eating out, and cultural or "
 "religious dietary practices. Assess readiness to change and identify specific, modifiable behaviours rather than "
 "attempting comprehensive dietary overhaul at once. Use the plate model (half vegetables/fruit, quarter protein, "
 "quarter whole grains) as an accessible visual tool. Address barriers - cost, availability, family food "
 "preparation practices, and time constraints. Where possible, involve a dietitian for detailed meal planning "
 "in complex cases (advanced CKD, complicated diabetes, eating disorders)."),
("Dietary Counseling in Diabetes and Cardiovascular Disease",
 "In diabetes: carbohydrate counting or consistent carbohydrate intake, preference for low glycaemic index foods, "
 "spacing of meals, and limiting simple sugars and refined carbohydrates. In cardiovascular disease and "
 "dyslipidaemia: reduced saturated and trans-fat intake, increased omega-3 fatty acids (oily fish), reduced "
 "dietary cholesterol, increased soluble fibre (oats, legumes), and sodium restriction (<5g salt/day, DASH diet "
 "principles) for hypertension. The Mediterranean dietary pattern (vegetables, fruits, whole grains, olive oil, "
 "fish, limited red meat) has robust evidence for cardiovascular risk reduction (PREDIMED trial)."),
("Dietary Counseling in Renal and Hepatic Disease",
 "In CKD: protein restriction is individualised by CKD stage (avoid excessive restriction which risks "
 "malnutrition); potassium and phosphate restriction in advanced CKD/dialysis (avoid high-potassium fruits like "
 "banana, orange in hyperkalaemia; avoid phosphate-rich processed foods and cola drinks); fluid restriction in "
 "dialysis patients based on residual urine output and interdialytic weight gain. In cirrhosis: adequate protein "
 "intake is essential (contrary to older practice of protein restriction, which risks sarcopenia and worsens "
 "outcomes) except in acute hepatic encephalopathy where temporary modification may be needed; frequent small "
 "meals and a late-evening snack reduce muscle catabolism; sodium restriction for ascites management."),
("Weight Management and Malnutrition Counseling",
 "For obesity: individualised caloric deficit (typically 500-750 kcal/day deficit for gradual sustainable weight "
 "loss), combined with increased physical activity; very-low-calorie diets and bariatric surgery reserved for "
 "specific indications under specialist supervision. For malnutrition (common in elderly, cancer, chronic "
 "illness): energy-dense, protein-rich foods, small frequent meals, oral nutritional supplements when intake is "
 "inadequate, and screening tools (MUST, MNA) to identify at-risk patients requiring formal dietitian referral. "
 "Dietary counseling must always be documented, with agreed goals reviewed and adjusted at follow-up visits to "
 "sustain long-term adherence.")
])

# ─────────────────────────────────────────────────────────────────
# P26  Linking Patients with Community Resources
# ─────────────────────────────────────────────────────────────────
make_doc("P26_Community_Resources.docx","P26","Communication Skills","Linking Patients with Community Resources",[
("Introduction",
 "Effective clinical care frequently depends on resources beyond the hospital or clinic. Social determinants of "
 "health - housing, food security, transportation, financial support, and social isolation - profoundly affect "
 "health outcomes and treatment adherence. The physician's role includes recognising unmet social needs and "
 "actively connecting patients with appropriate community resources, a practice increasingly formalised as "
 "'social prescribing'."),
("Identifying Social Needs",
 "Systematic social needs screening should be incorporated into clinical assessment, particularly for chronic "
 "disease, frequent hospital readmission, and vulnerable populations (elderly, disabled, low-income). Relevant "
 "domains include: financial hardship and catastrophic health expenditure, food insecurity, inadequate or unstable "
 "housing, lack of transportation to appointments, social isolation and lack of caregiver support, and literacy or "
 "language barriers. Brief validated screening tools can be incorporated into routine intake without significantly "
 "extending consultation time."),
("Government and National Programme Resources",
 "In India, physicians should be familiar with and actively refer eligible patients to: Ayushman Bharat - PMJAY "
 "(health insurance for economically vulnerable households), state-specific health insurance schemes, the "
 "Rashtriya Swasthya Bima Yojana, disability certification and pension schemes under the Rights of Persons with "
 "Disabilities Act, old-age pension schemes, and the Public Distribution System (PDS) for food security. "
 "National programme resources - NTEP nutritional support (Nikshay Poshan Yojana), NACO support services for "
 "HIV patients, and NPCDCS screening and treatment services - should be actively linked for eligible patients."),
("Non-Governmental and Community-Based Resources",
 "Community-based resources include NGOs providing free or subsidised medications, patient support groups "
 "(diabetes associations, cancer support groups, mental health peer support), palliative care and hospice "
 "services, home-based care programmes for bedbound or elderly patients, and rehabilitation services. "
 "Religious and community organisations frequently provide informal support networks, meal programmes, and "
 "transportation assistance. Medical social workers are key partners in identifying and coordinating access to "
 "these resources and should be involved early for complex cases."),
("Practical Implementation and Follow-up",
 "Effective linkage requires more than providing information - it involves active facilitation: providing written "
 "referral information with contact details, involving medical social workers or patient navigators where "
 "available, following up at subsequent visits to confirm the resource was accessed and was helpful, and "
 "documenting social needs and interventions in the medical record for continuity of care across the team. "
 "Physicians should build working relationships with local community organisations and maintain awareness of "
 "current resource availability, which changes over time. Successful social prescribing has been shown to "
 "reduce hospital readmissions and improve chronic disease control by addressing barriers that purely medical "
 "interventions cannot resolve.")
])

# ─────────────────────────────────────────────────────────────────
# P27  Providing Referral
# ─────────────────────────────────────────────────────────────────
make_doc("P27_Providing_Referral.docx","P27","Communication Skills","Providing Referral",[
("Introduction",
 "Referral is the process of formally transferring responsibility for an aspect of a patient's care to another "
 "healthcare provider or facility, typically for specialist opinion, investigation, or a level of care not "
 "available at the referring site. High-quality referral practice is essential to patient safety and continuity "
 "of care, and requires clear communication, appropriate urgency assessment, and follow-up to ensure the referral "
 "is completed and acted upon."),
("Indications and Types of Referral",
 "Referrals may be: for specialist consultation (diagnostic uncertainty, complex management decisions, procedures "
 "requiring specialist expertise), for a higher level of care (ICU transfer, tertiary centre for specialised "
 "treatment such as transplantation or cardiac surgery), for allied health input (physiotherapy, dietetics, "
 "psychology), or for diagnostic services not locally available. Referrals are categorised by urgency: emergency "
 "(immediate, same-day, e.g. suspected acute MI or stroke), urgent (within days, e.g. suspected malignancy), "
 "and routine (weeks to months, e.g. stable chronic disease follow-up). Correct urgency categorisation is "
 "critical - inappropriate urgency labelling is a common cause of delayed diagnosis and adverse outcomes."),
("Components of a High-Quality Referral Letter",
 "A complete referral communication should include: patient demographics and contact details, the specific "
 "clinical question or reason for referral (stated explicitly, not merely 'please see and advise'), relevant "
 "history including duration of symptoms and prior treatment tried, pertinent examination findings, relevant "
 "investigation results (with dates), current medications and allergies, and the requested urgency with "
 "justification. Vague or incomplete referrals delay appropriate triage and may result in inappropriate "
 "prioritisation or repeated, redundant investigations."),
("Communicating the Referral to the Patient",
 "The patient must understand why they are being referred, what to expect from the referral process (approximate "
 "waiting time, what the specialist visit will involve), and what they should do if their condition changes while "
 "awaiting the appointment (safety-netting advice - specific red-flag symptoms warranting urgent reattendance). "
 "Patients should be given a copy or summary of the referral information when appropriate, and informed if any "
 "action is required of them (bringing prior reports, fasting for tests, arranging transport for a distant "
 "tertiary centre). Financial and logistic barriers to attending the referral (cost, distance, time off work) "
 "should be discussed and, where possible, addressed."),
("Follow-up and Closing the Referral Loop",
 "Referral is not complete until feedback is received and acted upon - the 'closed referral loop'. The referring "
 "physician should have a system to track pending referrals, follow up if no response is received within an "
 "expected timeframe, and review specialist recommendations promptly upon receipt to implement changes to the "
 "patient's management plan. Failure to close the referral loop is a recognised patient safety hazard, "
 "particularly for urgent referrals such as suspected cancer, where delayed follow-up can result in significant "
 "harm. Electronic referral tracking systems, where available, substantially reduce lost or unactioned referrals.")
])

# ─────────────────────────────────────────────────────────────────
# P28  Genetic Counseling
# ─────────────────────────────────────────────────────────────────
make_doc("P28_Genetic_Counseling.docx","P28","Communication Skills","Genetic Counseling",[
("Introduction",
 "Genetic counseling is the process of helping individuals and families understand and adapt to the medical, "
 "psychological, and familial implications of genetic contributions to disease. As genetic and genomic testing "
 "becomes increasingly accessible and relevant in internal medicine (hereditary cancer syndromes, inherited "
 "cardiomyopathies, thrombophilias, monogenic diabetes), the physician must be able to identify patients who may "
 "benefit from genetic counseling and provide basic pre-test information, while recognising when formal referral "
 "to a clinical geneticist or genetic counselor is warranted."),
("Identifying Candidates for Genetic Counseling",
 "Red flags warranting consideration of genetic counseling referral include: early-onset disease (colorectal or "
 "breast cancer before age 50), multiple affected family members across generations, clustering of related "
 "cancers in a family (breast/ovarian, colorectal/endometrial), a known pathogenic variant in the family, "
 "consanguinity with an affected child, unexplained sudden cardiac death in young relatives (channelopathies, "
 "cardiomyopathies), and recurrent pregnancy loss or unexplained intellectual disability. A three-generation "
 "family history (pedigree) should be constructed, documenting age of onset and cause of death for relevant "
 "conditions."),
("The Genetic Counseling Process",
 "Formal genetic counseling follows a structured, non-directive approach: (1) detailed family and personal "
 "history collection and pedigree construction; (2) risk assessment using clinical criteria or validated models "
 "(e.g. Amsterdam criteria for Lynch syndrome, Manchester score for BRCA); (3) discussion of the availability, "
 "process, benefits, and limitations of genetic testing; (4) exploration of the psychological, social, and "
 "insurance/employment implications of a positive result; (5) informed consent for testing; and (6) post-test "
 "counseling addressing result interpretation, implications for the individual and relatives, and further "
 "management or surveillance recommendations. The principle of non-directiveness respects patient autonomy - "
 "the counselor provides information and support without dictating a specific decision about testing or "
 "subsequent actions."),
("Common Clinical Scenarios",
 "Hereditary breast/ovarian cancer (BRCA1/2): testing informs risk-reducing surgery, enhanced surveillance, and "
 "cascade testing of relatives. Lynch syndrome: mismatch repair gene mutations predisposing to colorectal, "
 "endometrial, and other cancers - identified cases require intensive colonoscopic surveillance and consideration "
 "for at-risk relatives. Familial hypercholesterolaemia: early identification through cascade testing of "
 "first-degree relatives of an index case dramatically improves early treatment and cardiovascular outcome. "
 "Inherited cardiomyopathies and channelopathies (HCM, long QT syndrome, Brugada syndrome): family screening "
 "of first-degree relatives (clinical and genetic) can identify at-risk individuals before a sentinel cardiac "
 "event."),
("Ethical Considerations",
 "Genetic testing raises unique ethical considerations: implications for currently asymptomatic relatives who "
 "have not consented to knowing this information ('right not to know'), potential for genetic discrimination in "
 "insurance or employment, and the psychological burden of a positive result, particularly for conditions without "
 "effective preventive intervention. Confidentiality must be carefully managed, particularly regarding the "
 "sharing of genetic information among family members, which should be encouraged but never coerced. Testing "
 "in children for adult-onset conditions with no childhood intervention is generally deferred until the child "
 "can participate in the decision as an adult.")
])

# ─────────────────────────────────────────────────────────────────
# P29  Communicating Bad News
# ─────────────────────────────────────────────────────────────────
make_doc("P29_Breaking_Bad_News.docx","P29","Communication Skills","Communicating Bad News to the Patient and Relatives",[
("Introduction",
 "Breaking bad news - any information that adversely and seriously affects an individual's view of their future "
 "- is among the most emotionally demanding communication tasks in medicine. It occurs in diverse contexts: new "
 "cancer diagnosis, treatment failure, unexpected death, disability, or a poor prognosis. Poor delivery of bad "
 "news causes lasting psychological harm and erodes trust, while skilled delivery, even of the worst news, can "
 "support patients and families through the experience and preserve the therapeutic relationship."),
("The SPIKES Protocol",
 "SPIKES provides a structured, evidence-informed six-step framework. Setting: private, quiet space, adequate "
 "time, support person present, phones silenced, seated at eye level. Perception: assess what the patient already "
 "understands ('What is your understanding of your illness so far?'). Invitation: ask how much detail they wish "
 "to receive. Knowledge: deliver a 'warning shot' ('I'm afraid I have serious news'), then give information in "
 "small chunks using plain language, pausing frequently. Emotions: acknowledge and respond empathetically to the "
 "emotional reaction before continuing with further information ('I can see this is very difficult to hear'). "
 "Summarise and Strategise: outline the plan, next steps, and arrange follow-up."),
("Delivering the News: Practical Considerations",
 "Never deliver bad news by telephone unless unavoidable, and never in a corridor or shared space. Sit down - "
 "standing conveys haste and reduces perceived empathy. Use direct, unambiguous language ('the biopsy shows "
 "cancer' rather than euphemisms like 'the results are not what we hoped for', which can be misunderstood). "
 "Allow silence after delivering the core information - resist the urge to fill silence with excessive detail. "
 "Observe non-verbal cues and adjust pace accordingly. Avoid information overload in the initial conversation; "
 "patients often retain little beyond the core message in the immediate aftermath of shocking news, and "
 "important details may need to be repeated at a follow-up conversation."),
("Responding to Emotional Reactions",
 "Emotional responses vary widely - shock, denial, anger, tearfulness, or apparent lack of reaction. All are "
 "normal and should be met with empathetic acknowledgement rather than premature reassurance or problem-solving. "
 "Techniques include naming the emotion ('You seem very shocked by this'), validating it ('This is completely "
 "understandable news to be upset about'), and exploring it further when appropriate ('Can you tell me more about "
 "what's worrying you most?'). Anger directed at the messenger should not be taken personally; it often reflects "
 "the magnitude of the news rather than the quality of its delivery."),
("Communicating with Relatives and Cultural Considerations",
 "When breaking news to relatives (e.g. sudden death of a family member), similar principles apply with attention "
 "to the family dynamic and the need to communicate with multiple people simultaneously, at different stages of "
 "understanding and coping. Cultural variation in attitudes to disclosure must be respected - in some cultures, "
 "family members may request that certain information (particularly terminal prognosis) be withheld from the "
 "patient; this request should be explored sensitively, balancing family wishes against the patient's own right "
 "to information and autonomy, ideally through direct, private conversation with the patient regarding their own "
 "preferences for information sharing. Follow-up support - written information, contact numbers, and a scheduled "
 "follow-up appointment - should always be arranged after breaking significant bad news.")
])

print("\nPart 3 (P21-P29, Communication Skills): DONE")

from docx import Document
from docx.shared import Pt, Inches, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
import os

OUT = "/tmp/workspace/elog-book/p_docs"
os.makedirs(OUT, exist_ok=True)

def make_doc(filename, topic_num, category, heading, sections):
    doc = Document()
    s = doc.sections[0]
    s.top_margin=Inches(1); s.bottom_margin=Inches(1)
    s.left_margin=Inches(1.2); s.right_margin=Inches(1.2)
    doc.styles["Normal"].font.name="Times New Roman"
    doc.styles["Normal"].font.size=Pt(12)
    cp=doc.add_paragraph(f"Psychomotor Competency  |  {category}  |  {topic_num}")
    cp.alignment=WD_ALIGN_PARAGRAPH.CENTER
    cp.runs[0].font.size=Pt(10); cp.runs[0].font.italic=True
    cp.runs[0].font.color.rgb=RGBColor(0x55,0x55,0x55)
    t=doc.add_heading(heading,level=1); t.alignment=WD_ALIGN_PARAGRAPH.CENTER
    for r in t.runs:
        r.font.name="Times New Roman"; r.font.size=Pt(14)
        r.font.bold=True; r.font.color.rgb=RGBColor(0x1A,0x35,0x6E)
    dv=doc.add_paragraph("─"*80); dv.alignment=WD_ALIGN_PARAGRAPH.CENTER
    dv.runs[0].font.size=Pt(8); dv.runs[0].font.color.rgb=RGBColor(0xAA,0xAA,0xAA)
    for sh_text,body in sections:
        sh=doc.add_heading(sh_text,level=2)
        sh.paragraph_format.space_before=Pt(10); sh.paragraph_format.space_after=Pt(4)
        for r in sh.runs:
            r.font.name="Times New Roman"; r.font.size=Pt(12)
            r.font.bold=True; r.font.color.rgb=RGBColor(0x1A,0x35,0x6E)
        p=doc.add_paragraph(body)
        p.paragraph_format.space_after=Pt(8)
        p.paragraph_format.first_line_indent=Pt(18)
        p.paragraph_format.line_spacing=Pt(22)
        for r in p.runs:
            r.font.name="Times New Roman"; r.font.size=Pt(12)
    doc.add_paragraph()
    f=doc.add_paragraph("E-Log Book  |  Department of Internal Medicine  |  Postgraduate Training Programme")
    f.alignment=WD_ALIGN_PARAGRAPH.CENTER
    f.runs[0].font.size=Pt(9); f.runs[0].font.italic=True
    f.runs[0].font.color.rgb=RGBColor(0x88,0x88,0x88)
    doc.save(os.path.join(OUT,filename)); print(f"  {filename}")

# ─────────────────────────────────────────────────────────────────
# P30  Professionalism
# ─────────────────────────────────────────────────────────────────
make_doc("P30_Professionalism.docx","P30","Others","Professionalism",[
("Introduction",
 "Professionalism is the set of values, attitudes, and behaviours that characterise ethical, competent, and "
 "trustworthy medical practice. It extends beyond technical clinical knowledge and skills to encompass reliability, "
 "accountability, humility, and a commitment to the welfare of patients and society. Professionalism is foundational "
 "to the social contract between medicine and the public - patients entrust physicians with intimate information and "
 "vulnerable moments, expecting that trust to be respected and that the physician will act in their best interests.")
("Core Principles of Medical Professionalism",
 "Core principles include competence (continuous professional development and staying current with evidence-based "
 "practice), altruism (prioritising patient welfare above personal interests), accountability (accepting responsibility "
 "for actions and outcomes), integrity (honesty and adherence to ethical principles even when inconvenient), respect "
 "for patient autonomy, and a commitment to improving the healthcare system and addressing inequities. Professionalism "
 "manifests in punctuality, responding promptly to patient needs and communication from colleagues, maintaining "
 "confidentiality, dressing appropriately for the clinical role, and treating patients and colleagues with courtesy "
 "and respect. The professional maintains emotional resilience while demonstrating compassion and empathy."),
("Professional Relationships with Patients and Colleagues",
 "Respect for patients includes listening without interruption, explaining in understandable language, involving them "
 "in decisions, and respecting their preferences and values even when they differ from the physician's recommendation. "
 "Professional boundaries - neither excessive familiarity nor harmful distance - should be maintained with patients. "
 "Dual relationships (e.g. treating a close friend or family member) introduce conflicts of interest and are generally "
 "avoided. In interactions with colleagues, professionalism includes mutual respect, constructive feedback rather than "
 "personal criticism, and collaborative problem-solving. Bullying, harassment, and discrimination of any form are "
 "incompatible with professionalism and have no place in medicine."),
("Conflict of Interest and Transparency",
 "Physicians must disclose and manage conflicts of interest - financial relationships with pharmaceutical/device "
 "companies, gifts, hospitality, consulting arrangements, or financial interests in tests/treatments they recommend. "
 "Such relationships do not automatically disqualify recommendations but must be transparent to patients and colleagues. "
 "Ego and the tendency to defend one's own decisions even in the face of contrary evidence ('cognitive bias') must be "
 "actively managed through reflective practice and willingness to reconsider prior decisions with new information."),
("Professionalism and System Accountability",
 "Professionalism includes a responsibility to contribute to improving healthcare systems and addressing inequities. "
 "This may involve participation in quality improvement initiatives, speaking up about patient safety concerns, and "
 "advocating for vulnerable populations. Medical errors should be disclosed transparently to patients and analysed "
 "constructively (not punitively) to prevent future harm. The professional demonstrates commitment to lifelong learning, "
 "reflecting on successes and failures, and seeking feedback to continuously improve.")
])

# ─────────────────────────────────────────────────────────────────
# P31  Ethical Behavior
# ─────────────────────────────────────────────────────────────────
make_doc("P31_Ethical_Behavior.docx","P31","Others","Ethical Behavior: Humane and Professional Care to Patients",[
("Introduction",
 "Medical ethics provides a framework for navigating the moral dimensions of clinical practice. The four core principles "
 "- autonomy, beneficence, non-maleficence, and justice - and related concepts of virtue ethics, care ethics, and "
 "human rights-based approaches guide ethical decision-making. The postgraduate physician must be able to recognise "
 "ethical dilemmas, apply ethical reasoning to difficult situations, and advocate for humane, fair, and professional "
 "patient care even in resource-limited settings."),
("Core Ethical Principles and Concepts",
 "Autonomy: respecting patients' right to make informed decisions about their own bodies and healthcare, even when "
 "those decisions differ from medical recommendation ('right to refuse treatment'). Beneficence: acting in ways that "
 "benefit the patient. Non-maleficence: 'first, do no harm' - the principle that avoidable harm should be prevented or "
 "minimised. Justice: fair distribution of resources, treatment without discrimination, and advocacy for vulnerable "
 "populations. Informed consent is a cornerstone - patients must understand the nature of proposed treatment, its "
 "benefits and risks, and alternative options before agreeing. Confidentiality protects the sanctity of the clinical "
 "relationship."),
("Consent and Capacity Assessment",
 "Valid consent requires: (1) capacity - the patient's ability to understand information, retain it, weigh it, and "
 "communicate a choice; (2) information - comprehensible explanation of diagnosis, treatment options, benefits, harms, "
 "and alternatives; (3) voluntariness - freedom from coercion or undue influence. Capacity is decision-specific and "
 "should be assessed for each significant decision, not assumed based on age or prior competence. Patients with impaired "
 "capacity (unconscious, severe dementia, intellectual disability, acute psychosis) require surrogate decision-makers "
 "(advance directives, legally appointed guardians, or ethically determined substituted judgment - what would the patient "
 "choose if they could) and heightened procedural protections. Special populations - children, pregnant women, prisoners "
 "- have additional ethical protections."),
("End-of-Life Care and Withholding/Withdrawing Treatment",
 "Ethical end-of-life care respects patient wishes, prioritises comfort, and acknowledges the limits of medical "
 "intervention. Advance directives and living wills should be discussed proactively and documented. In the ICU, futility "
 "discussions address situations where further aggressive treatment is unlikely to achieve the patient's goals and may "
 "cause harm. Withdrawal of life-sustaining treatment (mechanical ventilation, renal replacement therapy) is ethically "
 "equivalent to withholding it. Physician-assisted death remains ethically contested; in jurisdictions where it is legal, "
 "strict safeguards are required. Palliative care and symptom management should be offered universally alongside curative "
 "treatment when appropriate."),
("Vulnerability, Justice, and Advocacy",
 "Vulnerable patients (elderly, poor, illiterate, socially marginalised, migrants, sexual/gender minorities) face "
 "barriers to equitable healthcare and require heightened attentiveness to their autonomy and dignity. Discrimination on "
 "the basis of age, gender, sexuality, caste, religion, or economic status is ethically unacceptable and illegal. The "
 "physician has a professional obligation to advocate for equitable access to care and to challenge systemic injustices "
 "that compromise patient health. Resource allocation must be transparent and fair, particularly in resource-limited "
 "settings where not all patients can receive all possible interventions; prioritisation should follow explicit ethical "
 "frameworks rather than arbitrary selection."),
("Ethical Dilemmas and Institutional Resources",
 "Common ethical dilemmas include conflicts between patient autonomy and physician beneficence (patient refuses life-saving "
 "treatment), conflicts between individual patient care and resource justice (expensive intervention for one patient versus "
 "population benefit), and tensions between family and patient wishes. Most institutions have ethics committees or consultants "
 "available to discuss difficult cases in a structured forum. Reflecting on ethical dilemmas, even after the patient encounter "
 "has ended, is part of professional development and ethical maturity.")
])

# ─────────────────────────────────────────────────────────────────
# P32  Medline Search and Computer Usage
# ─────────────────────────────────────────────────────────────────
make_doc("P32_Medline_Search_Computer.docx","P32","Others","Medline Search, Internet Access, and Computer Usage",[
("Introduction",
 "Evidence-based practice requires efficient access to current medical literature and information resources. PubMed (the "
 "free, National Library of Medicine interface to MEDLINE) indexes over 34 million citations across journals, providing "
 "free full-text access to many articles and pre-print servers. The physician must be proficient in literature searching "
 "to answer clinical questions, stay current, and integrate evidence into practice. Beyond PubMed, internet-based resources "
 "(guidelines, decision-support tools, patient education materials) are integral to modern practice. Data security, "
 "professional boundaries, and critical appraisal of online information are essential competencies."),
("PubMed Search Strategies",
 "PubMed allows simple keyword searching but powerful results require strategic use of Medical Subject Headings (MeSH) "
 "terms, Boolean operators (AND, OR, NOT), phrase searching, and field limiters. Sample searches: 'stroke AND thrombolysis' "
 "limits results to articles about both terms; 'acute myocardial infarction'[MeSH Terms] retrieves articles indexed with that "
 "MeSH; '\"heart failure\"'[Title/Abstract] AND 'randomised'[Publication Type] finds trials in title/abstract focusing on heart "
 "failure. Limits can filter by publication date, publication type (clinical trial, systematic review, guidelines), language, "
 "and species. The Clinical Queries option ('Research article', 'Review', 'Clinical prediction guide') optimises searches for "
 "clinical evidence. Understanding the database structure and search logic prevents wasted time on unproductive searches."),
("Appraising Online Information and Avoiding Misinformation",
 "Not all internet content is reliable - misinformation, unsubstantiated claims, and commercially motivated content are "
 "widespread. Critical appraisal should address: source authority (peer-reviewed journal versus blog), author credentials, "
 "evidence type (randomised trial versus anecdote), and funding/conflict of interest. Red flags include sensationalism, "
 "claims of a 'cure-all', absence of citations, and emotional manipulation. Patient-facing materials should be vetted for "
 "accuracy before recommending. Social media has become a channel for rapid dissemination of medical information and "
 "misinformation; physicians should be aware of common misconceptions circulating in their patient populations and be prepared "
 "to address them respectfully with evidence."),
("Electronic Health Records and Data Security",
 "Electronic health records (EHRs) enable integrated care, decision-support, and population health management but introduce "
 "cybersecurity risks. Physicians must maintain password security, log off after use, avoid sharing access credentials, and "
 "report suspected breaches. Patient data should be protected against unauthorised access and used only for intended clinical "
 "purposes. Telemedicine and remote data access introduce additional security considerations; secure, encrypted communication "
 "channels must be used. Data privacy regulations (HIPAA in US, data protection laws in other countries) establish legal "
 "requirements for handling patient information."),
("Digital Professionalism and Boundaries",
 "The internet-enabled physician must maintain professional boundaries online - social media presence should be consistent "
 "with professional identity, avoiding sharing of patient information (even de-identified), venting of frustrations about "
 "patients or colleagues, or content that contradicts the profession's values. Online interactions with patients (e-mail, "
 "telemedicine, patient portals) should maintain the same professional standards as in-person encounters. Physicians should "
 "be aware of the permanence of online content and the potential for professional harm from injudicious social media use. "
 "On the positive side, social media can be a channel for health education, advocacy, and professional networking if used "
 "thoughtfully.")
])

# ─────────────────────────────────────────────────────────────────
# P33  Designing a Study
# ─────────────────────────────────────────────────────────────────
make_doc("P33_Designing_Study.docx","P33","Others","Designing a Study",[
("Introduction",
 "Clinical research - from pragmatic case reports to randomised controlled trials - advances medical knowledge and improves "
 "patient outcomes. Postgraduate physicians should understand the principles of research design, recognising strengths and "
 "limitations of different study types, so as to appraise the literature critically and potentially contribute to the "
 "evidence base. Basic research design principles apply whether conducting a small case series, a quality improvement project, "
 "or a clinical trial."),
("Steps in Study Design",
 "Defining the research question clearly is the first and most critical step - vague questions lead to poorly focused studies. "
 "The PICO framework (Population, Intervention, Comparison, Outcome) or similar structures ensure the question is specific, "
 "measurable, and researchable. A thorough literature review identifies existing evidence and justifies the need for the study. "
 "The study design is chosen based on the research question - observational (descriptive, case-control, cohort) versus "
 "experimental (RCT), prospective versus retrospective. Key parameters must be predefined: primary and secondary outcomes "
 "(which outcome will be the main basis for drawing conclusions), outcome measures and their definitions, sample size "
 "(calculated to have adequate statistical power to detect clinically meaningful differences), inclusion/exclusion criteria, "
 "and analysis plan (prespecified to prevent outcome-switching and p-hacking)."),
("Study Designs: Strengths and Limitations",
 "Randomised controlled trials (RCTs) are the gold standard for efficacy testing - randomisation minimises selection bias, "
 "blinding reduces bias in outcome assessment, and concurrent comparison prevents confounding by time. Observational studies "
 "(cohort, case-control) are feasible for rare outcomes or rare exposures but vulnerable to confounding and selection bias. "
 "Case reports and case series are descriptive, hypothesis-generating, and useful for recognising new disease or side effects "
 "but cannot establish causation. Cross-sectional surveys measure prevalence and identify associations but cannot determine "
 "temporal sequence or causation. Quality improvement studies using Plan-Do-Study-Act (PDSA) cycles rapidly test and refine "
 "interventions in real-world settings."),
("Ethical and Regulatory Approval",
 "All human subjects research requires ethics committee (Institutional Review Board/IRB) review and approval before commencing, "
 "assessing risks, benefits, informed consent procedures, confidentiality protections, and vulnerability safeguards. Trials may "
 "require registration in public registries (ClinicalTrials.gov) to ensure transparency and prevent selective outcome reporting. "
 "Conflicts of interest must be disclosed. Vulnerable populations (children, elderly, cognitively impaired, economically "
 "disadvantaged) require additional protections. Equipoise (genuine uncertainty about whether the intervention is superior) must "
 "exist before randomising patients to unproven treatments."),
("Sample Size and Statistical Power",
 "Sample size is calculated based on the expected effect size (smallest clinically meaningful difference one wants to detect), "
 "baseline event rate, significance level (alpha, typically 0.05), and power (1-beta, typically 0.80 or 0.90). Underpowered "
 "studies (insufficient sample size) may fail to detect true effects ('false negative' or Type II error), wasting resources and "
 "misleading the literature. Overpowered studies sometimes detect statistically significant but clinically negligible differences. "
 "Adjustments for multiple comparisons, multiplicity, and anticipated dropout rates affect sample size calculations.")
])

# ─────────────────────────────────────────────────────────────────
# P34  Interpretation and Presentation of Scientific Data
# ─────────────────────────────────────────────────────────────────
make_doc("P34_Scientific_Data_Interpretation.docx","P34","Others","Interpretation and Presentation of Scientific Data",[
("Introduction",
 "Interpretation of scientific data underpins evidence-based practice and research literacy. Data presentation via tables, "
 "figures, and statistical summaries shapes how information is understood and can either illuminate or obscure the truth. "
 "The physician must be adept at extracting meaning from data, recognising statistical versus clinical significance, identifying "
 "potential sources of bias or error, and communicating findings clearly to diverse audiences (patients, colleagues, public, "
 "policymakers)."),
("Descriptive Statistics and Data Visualisation",
 "Descriptive statistics summarise data in a comprehensible form: mean and standard deviation for approximately normal "
 "distributions; median and interquartile range (IQR) for skewed distributions; and proportions/percentages for categorical "
 "data. Visualisations - histograms, box plots, scatter plots, line graphs - convey patterns and distributions quickly. A well-designed "
 "figure should be self-explanatory with clear axis labels, a legend, and appropriate scale. Common pitfalls in data presentation "
 "include misleading axis scales (truncated y-axes that exaggerate small differences), inappropriate chart types (pie charts generally "
 "poor for comparing proportions; bar charts better), and cherry-picking of data to support a predetermined narrative."),
("Statistical Significance and Clinical Significance",
 "A p-value indicates the probability of observing the data (or more extreme data) if the null hypothesis is true - it is NOT the "
 "probability that the null hypothesis is true or that the result is clinically meaningful. Statistical significance (p <0.05) depends "
 "on sample size - large samples may yield significant p-values for clinically trivial differences, while small samples may fail to "
 "detect clinically important effects (underpowered). Confidence intervals (e.g. 95% CI) provide a range within which the true effect "
 "likely falls and convey both precision (width of interval) and point estimate (middle of interval). Clinical significance addresses "
 "whether a statistically significant difference matters to patients - a 1 mmHg blood pressure reduction is statistically detectable in "
 "large studies but clinically irrelevant."),
("Common Misinterpretations and Reporting Biases",
 "Multiple testing (testing many outcomes without statistical correction) increases the probability of false-positive findings by chance. "
 "Publication bias ('file-drawer problem') means null results are less likely to be published, skewing the literature toward positive "
 "findings. P-hacking (manipulating analysis approaches until a significant result emerges) and HARKing (hypothesising After Results are "
 "Known) are research integrity violations. Correlation is often confused with causation; observational associations may be confounded "
 "by unmeasured variables. Prespecification of analysis plans, trial registration, and transparent reporting of all outcomes (positive and "
 "negative) reduce these biases."),
("Presenting Data to Different Audiences",
 "Scientific presentations to peer audiences emphasise methods, results, and implications, with appropriate statistical detail and discussion "
 "of limitations. Patient-facing communication uses plain language, visual aids, and focuses on clinical meaning rather than p-values. "
 "Media communication of research requires additional translation and sensitivity to sensationalism and misrepresentation. Guidelines and "
 "consensus statements must summarise evidence hierarchically and clearly indicate strength of recommendations (strong versus conditional) "
 "based on quality of evidence (high, moderate, low, very low).")
])

# ─────────────────────────────────────────────────────────────────
# P35  Identifying Key Information Sources
# ─────────────────────────────────────────────────────────────────
make_doc("P35_Information_Sources.docx","P35","Others","Identifying Key Information Sources",[
("Introduction",
 "The explosion of information available to the modern physician is both an asset and a liability - access to evidence is unprecedented, "
 "yet filtering for quality and relevance is time-consuming. The physician must be skilled at identifying which sources are most reliable, "
 "current, and applicable to specific clinical questions. This requires knowledge of the hierarchy of evidence and an appreciation of the "
 "strengths and limitations of different information sources."),
("Hierarchy of Evidence",
 "Evidence is ranked by methodology: at the top are systematic reviews and meta-analyses (synthesising multiple RCTs); then RCTs (strongest "
 "study design for efficacy); then observational studies (cohort, case-control); then cross-sectional surveys and case series; at the base "
 "are expert opinion, case reports, and in vitro/animal studies. Guidelines and consensus statements are typically informed by systematic "
 "reviews and meta-analyses. However, hierarchy is context-dependent - for rare diseases or uncommon side effects, high-quality case reports "
 "may be the most informative available evidence. Preprints (manuscripts posted before peer review) are increasingly common, particularly "
 "during public health emergencies, and require careful appraisal but can provide early evidence."),
("Primary Sources",
 "Original research published in peer-reviewed journals is the primary source of evidence. Quality journals have rigorous peer review, "
 "high impact factors, and clear conflict-of-interest and methodology standards. Predatory journals accept almost any submission for a fee "
 "and lack peer review - these should be avoided. Journal impact factor is a quantitative measure of citation frequency but correlates "
 "imperfectly with individual article quality. Reading the full methods and results sections is essential - abstracts often emphasise "
 "positive findings and may misrepresent limitations."),
("Secondary Sources",
 "Narrative reviews: authoritative authors summarising a topic based on selected literature - useful for broad understanding but selective in "
 "scope and subject to author bias. Systematic reviews: structured, comprehensive searches of all available evidence with transparent inclusion "
 "criteria and methodology - far less biased than narrative reviews. Meta-analyses: statistical synthesis of data from multiple studies - "
 "provide precise estimates but are limited by quality of included studies and heterogeneity. Guidelines: recommendations developed by expert "
 "panels using systematic review of evidence - vary in quality and methodology (GRADE approach indicates strength of recommendation and quality "
 "of evidence). UpToDate and similar curated summary services: regularly updated, expertly reviewed summaries of key topics, excellent for "
 "rapid clinical reference but not substitutes for understanding underlying evidence."),
("Appraising Source Quality",
 "Key quality indicators: transparent conflict-of-interest disclosure, explicit methodology (for systematic reviews: search strategy, inclusion "
 "criteria, quality assessment tool, registration in PROSPERO), clear data presentation (distinguishing primary data from interpretation), "
 "and acknowledged limitations. Red flags: sensationalised headlines, absence of citations, industry funding without arm's-length independence, "
 "and overgeneralised conclusions from limited data. Websites from government agencies (NIH, CDC), professional societies (medical associations), "
 "and academic institutions are generally reliable; patient advocacy organisations may be biased but provide valuable patient perspectives."),
("Currency and Updating",
 "Medical knowledge evolves - yesterday's standard of care may be contradicted by today's evidence. Guidelines should be regularly updated; "
 "if a guideline is >3 years old, check for newer versions or recent trials. Journal websites, PubMed alerts, and professional societies "
 "disseminate major practice-changing trials. Social media and online communities can alert to breaking news but require critical appraisal "
 "before changing practice. The informed physician balances staying current with the efficiency of practice - not every update requires "
 "immediate practice change, but major paradigm shifts should be incorporated promptly.")
])

# ─────────────────────────────────────────────────────────────────
# P36  Literature Searches
# ─────────────────────────────────────────────────────────────────
make_doc("P36_Literature_Searches.docx","P36","Others","Literature Searches",[
("Introduction",
 "Conducting a systematic, comprehensive literature search is essential for evidence-based practice, clinical research, and continuing "
 "education. A well-designed search strategy balances sensitivity (retrieving all relevant articles) with specificity (minimising irrelevant "
 "results). Whether searching PubMed for a clinical question, conducting a systematic review, or preparing a research proposal, the principles "
 "and techniques are similar."),
("Defining the Research Question and Search Strategy",
 "Before searching, articulate the research question using a structured framework (PICO - Population, Intervention, Comparison, Outcome). "
 "Identify keywords and Medical Subject Headings (MeSH) relevant to each component. MeSH terms are hierarchical and controlled - searching "
 "'diabetes mellitus'[MeSH] retrieves all articles indexed with that term, including articles about specific types of diabetes. Truncation "
 "(e.g. 'diabet*' retrieves diabetes, diabetic, diabetologist) expands retrieval. Phrase searching ('type 2 diabetes') improves precision. "
 "Boolean operators (AND, OR, NOT) combine terms: 'diabetes'[MeSH] AND 'heart failure'[MeSH] retrieves articles on both topics; 'diabetes'[MeSH] "
 "NOT 'type 1' retrieves diabetes literature excluding type 1 specifically."),
("Searching Multiple Databases",
 "PubMed (MEDLINE) is the largest biomedical database and is free and comprehensive. Embase indexes more European journals and drug information "
 "than MEDLINE and includes pre-prints. Web of Science and Scopus track citations and enable citation tracking (forward and backward citation "
 "searches). Google Scholar is free but includes grey literature (conference abstracts, theses) with variable quality control. Cochrane Library "
 "specialises in systematic reviews and clinical trials. For a high-quality systematic review, searching multiple databases increases the "
 "probability of identifying all relevant studies."),
("Refining Searches and Managing Results",
 "Initial searches often return too many results; filters narrow results by publication date, publication type (e.g. 'clinical trial', 'review'), "
 "language, and age/sex. Reading titles and abstracts quickly identifies obviously irrelevant articles. Citation management software (Zotero, "
 "Mendeley, EndNote) organises citations, deduplicates across databases, and generates formatted bibliographies. Hand-searching key journals and "
 "checking reference lists ('pearl growing') identifies articles missed by database searches. For systematic reviews, dual independent reviewers "
 "screen articles to reduce bias."),
("Addressing Publication Bias and Transparency",
 "Published literature is skewed toward positive results - null and negative trials are underrepresented in databases. Checking trial registries "
 "(ClinicalTrials.gov) identifies studies regardless of publication status. Funnel plots (scatter plots of trial results versus study size) "
 "identify asymmetry suggestive of publication bias. Open access to preprints and mandatory trial registration are improving transparency. "
 "Search strategy documentation and peer review of literature search methodology ensure searches are reproducible and of high quality. "
 "The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist provides standards for systematic review reporting.")
])

# ─────────────────────────────────────────────────────────────────
# P37  Information Management
# ─────────────────────────────────────────────────────────────────
make_doc("P37_Information_Management.docx","P37","Others","Information Management",[
("Introduction",
 "Clinicians are inundated with information - clinical guidelines, new journal articles, patient data, laboratory results, imaging reports - yet "
 "must synthesise this into actionable clinical decisions rapidly and accurately. Effective information management involves organisational "
 "systems, digital tools, and cognitive strategies that prevent information overload and support timely, safe decision-making."),
("Clinical Data Organisation and EHR Management",
 "Electronic health records (EHRs) consolidate patient data but can be overwhelming if poorly organised. Systematic review of the chart should "
 "follow a structured approach: demographics and identifiers, active problems, allergies and adverse reactions, current medications, relevant "
 "prior history and procedures, and current results. Problem lists should be kept up-to-date and accurate - obsolete items should be marked "
 "resolved and removed. Regularly sorting by active/inactive, surgical history, family history reduces time spent searching. Customisation of "
 "the EHR interface to the clinician's workflow (most frequently accessed data in prominent positions) improves efficiency."),
("Personal Knowledge Management",
 "Physicians accumulate vast amounts of medical knowledge throughout training and practice - managing this personal knowledge base supports "
 "continuing education and evidence-based practice. Strategies include: maintaining a reading/journal club schedule with colleagues (peer "
 "learning); creating personal notes/summaries of key articles or guidelines for rapid reference; using decision-support tools and reference "
 "apps (drug formularies, calculators, diagnostic aids); and participating in case conferences that formalise reflection on complex cases. "
 "Some clinicians maintain a 'learning portfolio' - documented examples of learning events, reflecting on what was learned and how it will be "
 "applied."),
("Patient-Specific Information and Shared Decision-Making",
 "As patients increasingly access their own health information online and participate in care decisions, physicians must be skilled at "
 "synthesising patient-specific data into an understandable narrative. Timely communication of results (preferably in plain language summaries) "
 "avoids patient anxiety from unexplained abnormalities. Shared decision-making tools - simple written or visual guides to treatment options "
 "and their pros/cons - help patients and clinicians align on priorities. Patient portals enable asynchronous communication and reduce phone "
 "tag. Documenting patient preferences and shared decisions in the medical record supports care continuity."),
("Population-Level Information and Quality Improvement",
 "Aggregating de-identified patient data enables population health management - identifying high-risk patients, measuring care quality metrics, "
 "tracking outcomes, and testing improvement interventions. Dashboards and reports provide real-time feedback on performance. Feedback loops "
 "are more effective when reported to frontline clinicians quickly and in a non-punitive manner. Data governance - clear policies on data "
 "access, security, and use - is essential to protect patient privacy while enabling improvement. Information management at scale requires "
 "informatics expertise and infrastructure; increasingly, health systems employ data scientists and analysts to support clinical teams.")
])

# ─────────────────────────────────────────────────────────────────
# P38  Managing Multiple Problems Simultaneously
# ─────────────────────────────────────────────────────────────────
make_doc("P38_Multiple_Problems.docx","P38","Others","Managing Multiple Problems Simultaneously",[
("Introduction",
 "Internal medicine practice frequently involves patients with multiple concurrent conditions - comorbidity is the norm rather than the "
 "exception, particularly in elderly populations. Polypharmacy, drug-drug interactions, and competing treatment priorities complicate management. "
 "The physician must synthesise information across multiple disease domains, coordinate specialist recommendations, and prioritise interventions "
 "to maximise benefit while minimising harm and burden on the patient."),
("Prioritising and Sequencing Management",
 "When multiple problems compete for attention, explicit prioritisation prevents omissions and wasted effort. The hierarchy typically places "
 "life-threatening or time-sensitive conditions at the top (acute MI, sepsis, acute stroke) and chronic stable conditions lower. Other "
 "considerations: patient preferences and values (an elderly patient with advanced dementia and limited life expectancy may prioritise "
 "symptom control over aggressive cardiovascular risk reduction), disease trajectory and prognosis, and anticipated life expectancy (aggressive "
 "glycaemic control in a patient with limited life expectancy from metastatic cancer is less relevant than symptom management). Documentation "
 "of the problem list, with prioritisation and planned interventions for each, supports communication across the team."),
("Drug Interactions and Polypharmacy Deprescribing",
 "Polypharmacy (typically >5 medications, though context matters) increases risk of adverse drug interactions, medication errors, and adverse "
 "events. A medication reconciliation process at each encounter identifies duplicates, omissions, and interactions. Drug-drug interactions may be "
 "synergistic (additive harm, e.g. NSAIDs + ACEi + diuretics = acute kidney injury 'triple whammy'), pharmacokinetic (affecting drug metabolism "
 "or elimination, e.g. statins + gemfibrozil), or pharmacodynamic (affecting the same physiological system, e.g. multiple anticoagulants). "
 "Deprescribing - the systematic withdrawal of medications no longer beneficial or harmful - is increasingly important, particularly in elderly "
 "patients. Deprescribing algorithms and tools (e.g. Beers Criteria for potentially inappropriate medications in older adults) guide selection "
 "of candidates for discontinuation."),
("Specialist Input and Coordination",
 "Patients with multiple conditions often see multiple specialists; coordination prevents fragmentation and conflicting recommendations. The "
 "primary care physician or internist often serves as the 'conductor,' synthesising specialist recommendations and ensuring coherent, patient-centred "
 "care. Communication from specialist to primary team should be timely and should explicitly state: the diagnosis, findings, recommended "
 "interventions, and any follow-up plans or monitoring needed. Bidirectional communication ensures the primary team can feed back information "
 "about medication tolerability, adherence challenges, or patient values that might affect implementation."),
("Patient Burden and Shared Decision-Making in Multimorbidity",
 "Treatment burden - the cumulative workload of managing multiple conditions - is often overlooked but profoundly affects patient quality of "
 "life and adherence. A patient with diabetes, hypertension, and COPD may have >10 medications, four appointments per month, and frequent "
 "blood tests - clearly unsustainable long-term. Shared decision-making should explicitly address: which conditions are most important to the "
 "patient, what outcomes matter most (longevity, functional independence, symptom control, avoiding hospitalisation), and how can burdensome "
 "treatments be simplified or discontinued without harm. Setting realistic, modest goals ('lower your blood pressure a bit') rather than "
 "aggressive targets often improves adherence and satisfaction. Integration of palliative care principles - even in non-terminal illness - "
 "supports quality of life alongside disease management.")
])

# ─────────────────────────────────────────────────────────────────
# P39  Assessing Risks, Benefits, and Costs of Treatment Options
# ─────────────────────────────────────────────────────────────────
make_doc("P39_Risks_Benefits_Costs.docx","P39","Others","Assessing Risks, Benefits, and Costs of Treatment Options",[
("Introduction",
 "Every clinical decision involves trade-offs between potential benefits and harms, and increasingly, consideration of cost-effectiveness. "
 "The physician must be skilled at identifying and quantifying risks and benefits specific to individual patients, communicating probabilities "
 "in understandable ways, and engaging patients in preference-based decision-making that weighs these factors against the patient's values."),
("Quantifying Benefits and Harms",
 "Efficacy and safety data come from clinical trials, observational studies, and real-world registry data. Key metrics: Number Needed to Treat "
 "(NNT - the number of patients who must receive the treatment for one to benefit) and Number Needed to Harm (NNH - the number treated for one "
 "to experience the harm). For example, an antihypertensive with NNT=100 and NNH=1000 is clearly beneficial; NNT=500 with NNH=50 raises "
 "concerns. Absolute risk reduction (ARR) and relative risk reduction (RRR) differ substantially - a therapy reducing risk from 20% to 10% "
 "represents a 50% RRR but only 10% ARR, and conveys very different clinical significance. Cumulative data over time matters - prophylactic "
 "interventions accumulate benefits and harms over years; understanding the timeframe is essential (risk reduction of 0.1% per year compounds "
 "over decades)."),
("Individual Patient Risk Assessment",
 "Population-based trial data must be contextualised for individual patients. Risk calculators (e.g. ASCVD risk calculator for cardiovascular "
 "events, FRACTURE risk for osteoporosis) personalise estimates based on age, sex, and relevant risk factors. A patient's risk of bleeding on "
 "anticoagulation depends on comorbidities and prior bleeding history, not just the drug. Baseline risk fundamentally alters the risk-benefit "
 "ratio - a therapy with an NNH of 50 is concerning at low baseline risk but acceptable at high baseline risk. Genetic or phenotypic factors "
 "(CYP450 polymorphisms, beta-thalassemia trait, G6PD deficiency) predict individual drug metabolism and adverse effects."),
("Cost-Effectiveness and Resource Allocation",
 "Cost-effectiveness analysis compares the ratio of cost to outcome (quality-adjusted life years, QALY, or disability-adjusted life years, DALY). "
 "A threshold of $50,000-100,000 per QALY gained is often used to judge whether an intervention represents good value. Expensive drugs targeting "
 "rare diseases may have high cost per QALY; widespread preventive interventions may have low cost per QALY. Out-of-pocket costs to patients are "
 "relevant for adherence - a patient may rationally prefer a cheaper, slightly less effective alternative if the cost of the optimal drug is "
 "prohibitive. In resource-limited settings, opportunity costs (the benefit foregone by allocating resources to one intervention over another) "
 "are starkly relevant."),
("Shared Decision-Making and Communication",
 "The physician should present options alongside risks and benefits in balanced language, without steering toward a predetermined choice (unless "
 "the evidence overwhelmingly favours one option). Visual aids - infographics, Normalised Absolute Risk Increase (NARI) graphs - help patients "
 "grasp probability and magnitude. Exploring the patient's values ('What's most important to you - living longer, avoiding side effects, or "
 "maintaining independence?') guides what benefits and harms are most salient. Revisiting decisions periodically is important, as patient "
 "values and circumstances change. Documentation of the shared decision-making process demonstrates patient-centred, evidence-based care.")
])

# ─────────────────────────────────────────────────────────────────
# P40  Involving Patients in Decision-Making
# ─────────────────────────────────────────────────────────────────
make_doc("P40_Patient_Decision_Making.docx","P40","Others","Involving Patients in Decision-Making",[
("Introduction",
 "Patient involvement in healthcare decisions - shared decision-making (SDM) - is both an ethical imperative (respecting autonomy) and a "
 "practical necessity for improving outcomes. Patients have preferences, values, and contextual knowledge about their own lives that the "
 "physician lacks. SDM integrates clinical expertise with patient values and preferences to arrive at decisions that are both evidence-based "
 "and aligned with what matters most to the individual."),
("The Shared Decision-Making Process",
 "SDM follows a structured but flexible process: (1) Establish partnership - frame the decision as collaborative rather than physician-directed. "
 "(2) Discuss the problem - ensure mutual understanding of the condition, its likely course without intervention, and why a decision is needed. "
 "(3) Present options - describe each alternative (including watchful waiting/no intervention) with evidence on risks and benefits. (4) Discuss "
 "patient preferences - explore values, life circumstances, family considerations, and prior experiences that shape preferences ('What concerns "
 "you most about this condition? What would be unacceptable to you?'). (5) Make a decision together - support the patient in deciding based on "
 "their informed preference. (6) Follow-up and revisit - check that the decision is being implemented and revisit if circumstances change."),
("Barriers and Enablers to SDM",
 "Barriers include time constraints (SDM takes longer than physician directive advice), patient reluctance to participate (some prefer physician "
 "direction, particularly in acute illness or in cultures with hierarchical doctor-patient models), and clinician discomfort with uncertainty or "
 "with ceding decision authority. Enablers include decision support tools and patient education materials (reduce the workload of SDM and improve "
 "patient understanding), training in SDM communication for clinicians, and health system support (time allocation for SDM, electronic tools "
 "integrated into the EHR, measurement of SDM as a quality metric)."),
("Specific Scenarios",
 "SDM is particularly important for preference-sensitive decisions with no clearly superior option (e.g. surveillance versus immediate treatment "
 "for localised prostate cancer; conservative versus aggressive management of asymptomatic carotid stenosis). In acute life-threatening illness "
 "(sepsis, MI), SDM may be constrained by time and urgency, but values discussions should occur as soon as acute stabilisation allows. Chronic "
 "disease management revisits decisions repeatedly - an elderly patient may accept intensive antihypertensive therapy at age 65 but reasonably "
 "prefer deprescribing at age 85. Advance directives and values-based planning for potential future incapacity respect autonomy even if "
 "conversation is not possible at the critical moment."),
("Evidence and Outcomes",
 "Research shows SDM improves patient knowledge, reduces decisional conflict, and increases adherence to agreed decisions. Surprisingly, SDM does "
 "not prolong encounters substantially if structured effectively. Documentation should reflect that SDM occurred and what was decided, supporting "
 "continuity if the patient sees another clinician. Ultimately, SDM is not about the physician 'selling' a predetermined option but about arriving "
 "at a decision that both the clinician and patient believe is right for that individual at that time.")
])

# ─────────────────────────────────────────────────────────────────
# P41  Selecting Specific Drugs Within Classes
# ─────────────────────────────────────────────────────────────────
make_doc("P41_Drug_Selection.docx","P41","Others","Selecting Specific Drugs Within Classes",[
("Introduction",
 "Drugs within the same therapeutic class (e.g. ACE inhibitors, statins, antiplatelets) share a mechanism but differ in potency, pharmacokinetics, "
 "side effect profile, drug interactions, cost, and availability. Selecting the right drug for a specific patient requires understanding these "
 "differences and individualising choice based on patient factors, co-medications, renal/hepatic function, and tolerability."),
("General Principles of Drug Selection",
 "Efficacy within a class is often similar - for a given indication, all ACE inhibitors lower blood pressure, all statins lower cholesterol - "
 "but magnitude of effect may differ at equivalent doses. Potency differs - fosinopril and lisinopril are not equipotent. Pharmacokinetics "
 "(absorption, distribution, metabolism, elimination) determine frequency of dosing, time to steady-state, and need for dose adjustment in "
 "organ dysfunction. Side effect profiles vary - lisinopril commonly causes a dry cough; fosinopril causes bronchitis in some patients; "
 "valsartan does not. Drug interactions vary - simvastatin interacts extensively with CYP3A4 inhibitors; pravastatin does not. Cost and "
 "availability influence selection, particularly in resource-limited settings."),
("Drug Selection in Renal and Hepatic Impairment",
 "Renal function (estimated GFR) governs elimination of many drugs; dose reduction or alternative selection is needed in renal impairment to "
 "prevent accumulation and toxicity. ACE inhibitors and ARBs are relatively contraindicated in advanced CKD with hyperkalaemia; thiazide "
 "diuretics are ineffective in eGFR <30. Hepatic metabolism determines clearance of many drugs - cirrhosis necessitates dose reduction or "
 "alternative selection to prevent toxicity. Prodrugs (requiring hepatic conversion to active form) are ineffective or dangerous in severe "
 "hepatic disease. Dialysable drugs may require supplemental dosing post-dialysis."),
("Drug Interactions and Patient Factors",
 "Patients on multiple medications require screening for drug interactions. Significant interactions involve CYP450 enzymes - inducers (rifampicin, "
 "phenytoin) increase metabolism of co-medications; inhibitors (ketoconazole, erythromycin, ritonavir) decrease metabolism. Transporter interactions "
 "(P-glycoprotein, OATP) affect bioavailability. Pharmacodynamic interactions (additive or opposing effects on the same pathway) are equally "
 "important - NSAIDs reduce antihypertensive effect of ACE inhibitors. Patient factors - age (elderly often require dose reduction), genetics "
 "(CYP2D6 polymorphisms affecting codeine metabolism), comorbidities, and concomitant disease - inform drug selection."),
("Drug Tolerability and Adherence",
 "If two drugs are equally efficacious, the one with better tolerability and fewer side effects should be chosen, as adherence improves with "
 "fewer side effects. Dry cough from ACE inhibitors causes some patients to stop; offering an ARB may restore adherence. Complex regimens "
 "(multiple daily doses) are associated with worse adherence; once-daily formulations are preferred when available. Cost and stigma also affect "
 "adherence. Regular follow-up assesses tolerability; if side effects occur, switching to an alternative within the class or a different class "
 "with similar efficacy may restore adherence. Deprescribing underutilised drugs (started for an indication that no longer applies, or at a dose "
 "higher than needed) simplifies regimens and reduces burden.")
])

# ─────────────────────────────────────────────────────────────────
# P42  Rational Use of Drugs
# ─────────────────────────────────────────────────────────────────
make_doc("P42_Rational_Drug_Use.docx","P42","Others","Rational Use of Drugs",[
("Introduction",
 "Rational use of medicines - prescribing, dispensing, and using medicines appropriately for the individual patient - is fundamental to effective "
 "and safe healthcare. The WHO defines rational use as: 'patients receive medications appropriate to their clinical needs, in doses that meet their "
 "individual requirements, for an adequate duration, at the lowest cost to them and their community.' Conversely, irrational use includes "
 "overprescribing, underprescribing, inappropriate selection, and overuse of antibiotics and other drugs that accelerate resistance."),
("Assessing the Need for Medication",
 "Before prescribing, clearly establish the indication - what problem will the medication address? Medications should be prescribed for diagnoses "
 "confirmed (not on suspicion or to 'see if it works'). Ask: Is this medication evidence-supported for this indication? Does the patient have "
 "contraindications? Is non-pharmacological management sufficient? Sometimes reassurance, exercise, dietary modification, or time are more "
 "appropriate than medication. Periodic deprescribing of chronically prescribed medications - particularly in stable conditions or when efficacy "
 "is unclear - reduces unnecessary polypharmacy."),
("Right Drug, Right Dose, Right Route, Right Time, Right Duration",
 "Prescribing should specify: (1) the exact drug name (brand and generic), (2) the dose appropriate to the individual (considering age, renal/hepatic "
 "function, co-medications), (3) the route (oral, IV, IM, etc.), (4) the frequency and total daily dose, (5) the duration of therapy (finite courses "
 "of antibiotics; long-term for chronic disease). A 'right duration' is often overlooked - antibiotics should be of finite duration, not stopped "
 "prematurely when symptoms resolve; maintenance antidepressants should continue at least 9-12 months to prevent relapse. Dosing must be individualised "
 "- fixed-dose regimens appropriate for population averages are inappropriate for extremes of age, weight, or organ function."),
("Antibiotic Stewardship and Resistance",
 "Irrational antibiotic use drives the global crisis of antimicrobial resistance (AMR). Rational use includes: (1) Use antibiotics only for bacterial "
 "infections (not viral); (2) Culture when possible before starting (reduces empiricism); (3) Choose narrow-spectrum agents covering likely pathogens, "
 "avoiding broad-spectrum empiricism unless critically ill; (4) De-escalate after culture results (if empiric third-generation cephalosporin but "
 "culture shows susceptible E. coli, switch to ceftriaxone monotherapy); (5) Avoid combination therapy unless synergy is proven; (6) Use appropriate "
 "duration (7-10 days for most community infections; shorter courses increasingly supported for select conditions); (7) Educate patients - antibiotics "
 "do not treat viral colds/cough, completion of course even if feeling better, and not sharing/stockpiling. Audit resistance patterns locally and "
 "provide feedback to prescribers."),
("Cost-Effectiveness and Generic Equivalence",
 "Generic medications (chemically equivalent to brand-name drugs) are substantially cheaper and should be preferred when available. Prescribing "
 "expensive brand names without clinical justification wastes resources and reduces access for others. Cost-effectiveness analysis guides which "
 "medications justify their expense for the population or individual. Fixed-dose combinations (e.g. lisinopril/hydrochlorothiazide) can simplify "
 "regimens and improve adherence but should not sacrifice individualisation. Electronic prescribing systems with formulary guidance and interruptive "
 "alerts for high-cost, low-value interventions support rational prescribing at the point of care."),
("Medication Safety and Adverse Effects",
 "Rational prescribers actively monitor for adverse effects and adjust or discontinue medications causing harm. Adverse drug reaction reports should "
 "be submitted to pharmacovigilance systems, supporting post-marketing safety surveillance. Patient education on medication side effects and when to "
 "contact the clinician improves early recognition and reporting. Medication reconciliation at each encounter identifies duplicates and omissions. "
 "Ultimately, rational drug use is a professional ethical obligation - medications are powerful tools that benefit patients but can cause substantial "
 "harm when used irrationally or carelessly.")
])

print("\nPart 4 (P30-P42, Others): DONE")

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 "vulnerable moments, expecting that trust to be respected and that the physician will act in their best interests.")
("Core Principles of Medical Professionalism",'

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