#!/usr/bin/env python3
"""
MS General Surgery Exam - Structured Answers Q62-Q81
Bailey & Love 28th Edition | 15-minute exam format
"""

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

OUTPUT_PATH = "/home/daytona/workspace/surgery-exam/MS_Surgery_Exam_Q62_Q81.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
DARK_BLUE   = colors.HexColor("#1a3a5c")
MED_BLUE    = colors.HexColor("#2563a8")
LIGHT_BLUE  = colors.HexColor("#dbeafe")
ACCENT_RED  = colors.HexColor("#c0392b")
GOLD        = colors.HexColor("#d4a017")
LIGHT_GREY  = colors.HexColor("#f5f5f5")
MID_GREY    = colors.HexColor("#888888")
BLACK       = colors.black

def build_styles():
    base = getSampleStyleSheet()

    styles = {
        "cover_title": ParagraphStyle("cover_title",
            fontSize=26, leading=32, textColor=DARK_BLUE,
            fontName="Helvetica-Bold", alignment=TA_CENTER, spaceAfter=8),
        "cover_sub": ParagraphStyle("cover_sub",
            fontSize=13, leading=18, textColor=MED_BLUE,
            fontName="Helvetica", alignment=TA_CENTER, spaceAfter=6),
        "cover_note": ParagraphStyle("cover_note",
            fontSize=10, leading=14, textColor=MID_GREY,
            fontName="Helvetica-Oblique", alignment=TA_CENTER),

        "q_header": ParagraphStyle("q_header",
            fontSize=13, leading=17, textColor=colors.white,
            fontName="Helvetica-Bold", leftIndent=8, rightIndent=8,
            spaceBefore=4, spaceAfter=4),

        "section_label": ParagraphStyle("section_label",
            fontSize=9, leading=12, textColor=MED_BLUE,
            fontName="Helvetica-Bold", spaceBefore=6, spaceAfter=2,
            leftIndent=2),

        "body": ParagraphStyle("body",
            fontSize=9.5, leading=13.5, textColor=BLACK,
            fontName="Helvetica", leftIndent=6, rightIndent=4,
            spaceAfter=2, alignment=TA_JUSTIFY),

        "bullet": ParagraphStyle("bullet",
            fontSize=9.5, leading=13, textColor=BLACK,
            fontName="Helvetica", leftIndent=16, firstLineIndent=-10,
            spaceAfter=1),

        "sub_bullet": ParagraphStyle("sub_bullet",
            fontSize=9, leading=12.5, textColor=colors.HexColor("#333333"),
            fontName="Helvetica", leftIndent=28, firstLineIndent=-10,
            spaceAfter=1),

        "key_point": ParagraphStyle("key_point",
            fontSize=9.5, leading=13, textColor=ACCENT_RED,
            fontName="Helvetica-Bold", leftIndent=6, spaceAfter=1),

        "mnemonic": ParagraphStyle("mnemonic",
            fontSize=10, leading=14, textColor=DARK_BLUE,
            fontName="Helvetica-Bold", leftIndent=10, spaceAfter=2),

        "footer_note": ParagraphStyle("footer_note",
            fontSize=8, leading=11, textColor=MID_GREY,
            fontName="Helvetica-Oblique", alignment=TA_CENTER),
    }
    return styles

S = build_styles()

def q_block(num, title, year_tag, content_builder):
    """Returns a KeepTogether block for one question."""
    elements = []

    # Header bar (dark blue background via Table)
    header_text = f"Q{num}. {title}   <font color='#d4a017' size='8'>{year_tag}</font>"
    header_para = Paragraph(header_text, S["q_header"])
    header_table = Table([[header_para]], colWidths=[17.5*cm])
    header_table.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), DARK_BLUE),
        ("TOPPADDING",    (0,0), (-1,-1), 5),
        ("BOTTOMPADDING", (0,0), (-1,-1), 5),
        ("LEFTPADDING",   (0,0), (-1,-1), 8),
        ("RIGHTPADDING",  (0,0), (-1,-1), 8),
        ("ROUNDEDCORNERS", (0,0), (-1,-1), [4,4,4,4]),
    ]))
    elements.append(header_table)

    # Content
    content_builder(elements)

    elements.append(HRFlowable(width="100%", thickness=0.5,
                               color=colors.HexColor("#c0c0c0"), spaceAfter=10))
    return KeepTogether(elements)

def sec(label):
    return Paragraph(f"▶ {label}", S["section_label"])

def b(text):
    return Paragraph(f"• {text}", S["bullet"])

def sb(text):
    return Paragraph(f"– {text}", S["sub_bullet"])

def bd(text):
    return Paragraph(text, S["body"])

def kp(text):
    return Paragraph(f"★ {text}", S["key_point"])

def mn(text):
    return Paragraph(text, S["mnemonic"])

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

# ============================================================
# QUESTION DATA
# ============================================================

def build_questions(elements):

    # ── Q62 ─────────────────────────────────────────────────
    def q62(e):
        e.append(sec("DEFINITION"))
        e.append(bd("Post-operative ventilatory support = use of mechanical/assisted ventilation after surgery to maintain adequate oxygenation (PaO2 >8 kPa) and ventilation (PaCO2 4.7-6 kPa) until the patient can sustain independent respiration."))
        e.append(sp())
        e.append(sec("INDICATIONS (Mnemonic: SHARP)"))
        e.append(mn("S-H-A-R-P"))
        for x in ["S – Shock/sepsis, haemodynamic instability",
                  "H – Hypoxaemia (PaO2 <8 kPa on FiO2 >0.4), high FiO2 requirement",
                  "A – Altered consciousness (GCS <9), airway protection",
                  "R – Respiratory failure (RR >35 or <5/min, VT <5 mL/kg)",
                  "P – Prolonged major surgery (>4 h), massive blood transfusion"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("MODES OF VENTILATION"))
        tdata = [
            [Paragraph("<b>Mode</b>", S["body"]), Paragraph("<b>Description</b>", S["body"]), Paragraph("<b>Use</b>", S["body"])],
            [Paragraph("CMV/IPPV", S["body"]), Paragraph("Controlled mandatory ventilation", S["body"]), Paragraph("Fully obtunded, post-GA", S["body"])],
            [Paragraph("SIMV", S["body"]), Paragraph("Synchronised intermittent mandatory ventilation", S["body"]), Paragraph("Weaning", S["body"])],
            [Paragraph("PSV", S["body"]), Paragraph("Pressure support ventilation", S["body"]), Paragraph("Weaning, conscious pts", S["body"])],
            [Paragraph("CPAP", S["body"]), Paragraph("Continuous positive airway pressure", S["body"]), Paragraph("Non-invasive, post-op atelectasis", S["body"])],
            [Paragraph("BiPAP", S["body"]), Paragraph("Bilevel positive airway pressure", S["body"]), Paragraph("Non-invasive, COPD/obesity", S["body"])],
        ]
        t = Table(tdata, colWidths=[3*cm, 6.5*cm, 5*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), MED_BLUE),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8.5),
            ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, colors.white]),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 3),
            ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("VENTILATOR SETTINGS (Lung-protective)"))
        for x in ["Tidal volume: 6-8 mL/kg ideal body weight",
                  "PEEP: 5-8 cmH2O (recruits atelectatic alveoli)",
                  "FiO2: lowest to maintain SpO2 >94%",
                  "Respiratory rate: 12-16/min",
                  "I:E ratio: 1:2 (prolong expiration in obstructive disease)"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("WEANING CRITERIA (SMART)"))
        for x in ["Trigger: able to initiate spontaneous breaths",
                  "SpO2 >95% on FiO2 ≤0.4, PEEP ≤5",
                  "Haemodynamically stable, afebrile",
                  "Alert and co-operative, GCS recovering",
                  "Respiratory parameters: MIP > -25 cmH2O, RR <25, VT >5 mL/kg",
                  "Spontaneous Breathing Trial (SBT) x 30-120 min → if passes → extubate"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("COMPLICATIONS"))
        for x in ["VAP (Ventilator-Associated Pneumonia) - commonest",
                  "Barotrauma / volutrauma → pneumothorax",
                  "Oxygen toxicity (FiO2 >0.6 prolonged)",
                  "Haemodynamic compromise (↑intrathoracic pressure → ↓venous return)",
                  "Diaphragm atrophy, difficult weaning",
                  "Tracheal stenosis from prolonged intubation"]:
            e.append(b(x))
        e.append(kp("Key: Lung-protective ventilation (low VT 6 mL/kg) reduces ARDS mortality - ARDSNet trial"))

    elements.append(q_block(62, "Post-operative Ventilatory Support", "[2010]", q62))
    elements.append(PageBreak())

    # ── Q63 ─────────────────────────────────────────────────
    def q63(e):
        e.append(sec("TRIAGE IN DISASTER"))
        e.append(bd("Triage = process of sorting casualties to maximise benefit for greatest number. Goal: Greatest good for greatest number (utilitarian principle)."))
        e.append(sp())
        e.append(sec("START TRIAGE (Simple Triage and Rapid Treatment)"))
        e.append(bd("Initial 30-second assessment - used in field triage:"))
        tdata = [
            [Paragraph("<b>Category</b>",S["body"]), Paragraph("<b>Colour</b>",S["body"]), Paragraph("<b>Criteria</b>",S["body"]), Paragraph("<b>Action</b>",S["body"])],
            [Paragraph("Immediate",S["body"]), Paragraph("RED",S["body"]), Paragraph("Life-threatening but salvageable; RR >30, cap refill >2s, altered mentation",S["body"]), Paragraph("Treat first",S["body"])],
            [Paragraph("Delayed",S["body"]), Paragraph("YELLOW",S["body"]), Paragraph("Serious but can wait; RR <30, cap refill <2s, follows commands",S["body"]), Paragraph("Treat second",S["body"])],
            [Paragraph("Minor",S["body"]), Paragraph("GREEN",S["body"]), Paragraph("'Walking wounded'; ambulatory",S["body"]), Paragraph("Self-care/defer",S["body"])],
            [Paragraph("Expectant",S["body"]), Paragraph("BLACK",S["body"]), Paragraph("Not breathing after repositioning OR survivable only with resources unavailable",S["body"]), Paragraph("Comfort only",S["body"])],
        ]
        t = Table(tdata, colWidths=[2.5*cm, 2*cm, 8.5*cm, 2.8*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), MED_BLUE),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8),
            ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, colors.white]),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 3),
            ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("SALT TRIAGE (Sort-Assess-Lifesaving-Treatment)"))
        e.append(bd("Used in mass casualty events (MCI) - modified for blast/CBRN:"))
        for x in ["Sort: global sorting - walk → wave → still",
                  "Assess: individual assessment for lifesaving interventions",
                  "Lifesaving interventions: haemorrhage control, airway opening, needle decompression, autoinjector antidote",
                  "Treatment/transport: assign category (Immediate/Delayed/Minimal/Expectant/Dead)"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("PRINCIPLES OF POLYTRAUMA MANAGEMENT"))
        e.append(mn("Mnemonic: ABCDE (ATLS Primary Survey)"))
        for x in ["A – Airway + C-spine control",
                  "B – Breathing + ventilation",
                  "C – Circulation + haemorrhage control",
                  "D – Disability (neurological: GCS, pupils, motor)",
                  "E – Exposure + Environment (undress, prevent hypothermia)"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("DAMAGE CONTROL RESUSCITATION (DCR)"))
        for x in ["Permissive hypotension: SBP 80-90 mmHg (blunt), 50-60 (TBI)",
                  "Haemostatic resuscitation: pRBC:FFP:Platelets = 1:1:1",
                  "TXA (Tranexamic acid): within 3 hours of injury - CRASH-2 trial",
                  "Limit crystalloids (<1.5 L) - avoid dilutional coagulopathy"]:
            e.append(b(x))
        e.append(kp("Key: In MCI, triage priority = RED > YELLOW > GREEN > BLACK"))

    elements.append(q_block(63, "Triage in Disaster & Principles of Polytrauma Patient (START, SALT)", "[2019]", q63))

    # ── Q64 ─────────────────────────────────────────────────
    def q64(e):
        e.append(sec("COAGULOPATHY OF TRAUMA - DEFINITION"))
        e.append(bd("Acute Traumatic Coagulopathy (ATC) / Trauma-Induced Coagulopathy (TIC): Systemic failure of haemostasis occurring within minutes of major trauma, present in ~25-35% of severely injured patients on arrival. Independent predictor of mortality (3-4x increase)."))
        e.append(sp())
        e.append(sec("LETHAL TRIAD / TRIAD OF DEATH"))
        tdata = [
            [Paragraph("<b>Component</b>",S["body"]), Paragraph("<b>Mechanism</b>",S["body"]), Paragraph("<b>Effect on coagulation</b>",S["body"])],
            [Paragraph("Hypothermia (<35°C)",S["body"]), Paragraph("↓Enzymatic activity of clotting factors; platelet dysfunction",S["body"]), Paragraph("Coagulopathy worsens",S["body"])],
            [Paragraph("Acidosis (pH <7.2)",S["body"]), Paragraph("↓Thrombin generation; fibrinogen degradation",S["body"]), Paragraph("All factors impaired",S["body"])],
            [Paragraph("Coagulopathy",S["body"]), Paragraph("Dilution, consumption, fibrinolysis",S["body"]), Paragraph("DIC-like picture",S["body"])],
        ]
        t = Table(tdata, colWidths=[4*cm, 7*cm, 5*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#7b2226")),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8.5),
            ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, colors.white]),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 3),
            ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("PATHOPHYSIOLOGY OF ATC"))
        for x in ["Tissue injury + shock → activates protein C → consumes factors V & VIII",
                  "Endothelial glycocalyx damage → thrombomodulin release → anticoagulation",
                  "Hyperfibrinolysis: tPA released → plasmin generated → clot lysis",
                  "Dilution: aggressive crystalloid resuscitation worsens coagulopathy",
                  "Platelet dysfunction + thrombocytopenia"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("DAMAGE CONTROL RESUSCITATION (DCR) - RATIONALE"))
        e.append(bd("Goal: Break the lethal triad. Applies to civilian trauma (IED blast, MVA, penetrating)."))
        for x in ["1. Permissive hypotension: Target SBP 80-90 mmHg until surgical haemostasis",
                  "2. Haemostatic resuscitation: pRBC:FFP:Platelets = 1:1:1 (massive transfusion protocol)",
                  "3. Tranexamic acid (TXA): 1g IV over 10 min then 1g over 8h - within 3h of injury",
                  "4. Avoid hypothermia: warm IV fluids, blankets, warm OR",
                  "5. Correct acidosis: restore perfusion, limit lactate",
                  "6. Fibrinogen: cryoprecipitate/fibrinogen concentrate if <1.5 g/L",
                  "7. Calcium: 10 mL 10% CaCl2 with each 4 units blood (chelation by citrate)"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("MONITORING COAGULOPATHY"))
        for x in ["Standard: PT/APTT/fibrinogen/platelet count/TEG",
                  "Viscoelastic: TEG (Thromboelastography) / ROTEM - guides component therapy",
                  "Fibrinogen threshold for FFP: PT >1.5x normal; APTT >1.5x normal"]:
            e.append(b(x))
        e.append(kp("Key: TXA within 3h reduces mortality by 15% (CRASH-2 Trial, Lancet 2010)"))

    elements.append(q_block(64, "Coagulopathy of Trauma & Damage Control Resuscitation in Civilian Trauma", "[2021]", q64))
    elements.append(PageBreak())

    # ── Q65 ─────────────────────────────────────────────────
    def q65(e):
        e.append(sec("INTRODUCTION"))
        e.append(bd("Head trauma = injury to scalp, skull, or brain from external force. Leading cause of trauma death (40%). Glasgow Coma Scale (GCS) = universally used neurological severity score (Teasdale & Jennett, 1974)."))
        e.append(sp())
        e.append(sec("GLASGOW COMA SCALE (GCS)"))
        tdata = [
            [Paragraph("<b>Domain</b>",S["body"]), Paragraph("<b>Response</b>",S["body"]), Paragraph("<b>Score</b>",S["body"])],
            [Paragraph("Eyes (E)",S["body"]), Paragraph("Spontaneous",S["body"]), Paragraph("4",S["body"])],
            [Paragraph("",S["body"]), Paragraph("To voice",S["body"]), Paragraph("3",S["body"])],
            [Paragraph("",S["body"]), Paragraph("To pain",S["body"]), Paragraph("2",S["body"])],
            [Paragraph("",S["body"]), Paragraph("None",S["body"]), Paragraph("1",S["body"])],
            [Paragraph("Verbal (V)",S["body"]), Paragraph("Oriented",S["body"]), Paragraph("5",S["body"])],
            [Paragraph("",S["body"]), Paragraph("Confused",S["body"]), Paragraph("4",S["body"])],
            [Paragraph("",S["body"]), Paragraph("Words only",S["body"]), Paragraph("3",S["body"])],
            [Paragraph("",S["body"]), Paragraph("Sounds only",S["body"]), Paragraph("2",S["body"])],
            [Paragraph("",S["body"]), Paragraph("None",S["body"]), Paragraph("1",S["body"])],
            [Paragraph("Motor (M)",S["body"]), Paragraph("Obeys commands",S["body"]), Paragraph("6",S["body"])],
            [Paragraph("",S["body"]), Paragraph("Localises pain",S["body"]), Paragraph("5",S["body"])],
            [Paragraph("",S["body"]), Paragraph("Withdrawal",S["body"]), Paragraph("4",S["body"])],
            [Paragraph("",S["body"]), Paragraph("Abnormal flexion (decorticate)",S["body"]), Paragraph("3",S["body"])],
            [Paragraph("",S["body"]), Paragraph("Extension (decerebrate)",S["body"]), Paragraph("2",S["body"])],
            [Paragraph("",S["body"]), Paragraph("None",S["body"]), Paragraph("1",S["body"])],
        ]
        t = Table(tdata, colWidths=[3.5*cm, 9*cm, 3*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), MED_BLUE),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8.5),
            ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, colors.white]),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 2.5),
            ("BOTTOMPADDING", (0,0), (-1,-1), 2.5),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("CLASSIFICATION BY GCS"))
        for x in ["Minor: GCS 15 (no LOC)",
                  "Mild: GCS 14-15 (with LOC)",
                  "Moderate: GCS 9-13",
                  "Severe: GCS 3-8"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("HEAD TRAUMA MANAGEMENT"))
        for x in ["Primary survey ATLS: A-B-C-D-E",
                  "C-spine immobilisation until cleared",
                  "CT brain: within 1h if GCS<13, focal deficit, suspected skull fracture, vomiting >1 episode",
                  "ICP monitoring: EVD/Camino bolt if GCS<8 + CT abnormality",
                  "Target: CPP 60-70 mmHg; ICP <20 mmHg; PaO2 >11 kPa; PaCO2 4.5-5 kPa"]:
            e.append(b(x))
        e.append(kp("Key exam fact: Motor score alone (M component) is the best predictor of outcome"))

    elements.append(q_block(65, "Head Trauma - Glasgow Coma Scale", "[2009]", q65))

    # ── Q66 ─────────────────────────────────────────────────
    def q66(e):
        e.append(sec("GCS IN ADULTS"))
        e.append(bd("Total score: 3-15. As above (E4V5M6 = 15 = normal). Severe TBI = GCS ≤8 (intubate + ventilate)."))
        e.append(sp())
        e.append(sec("GCS IN CHILDREN - PAEDIATRIC GCS (pGCS)"))
        e.append(bd("Verbal and Eye components modified for age:"))
        tdata = [
            [Paragraph("<b>Score</b>",S["body"]), Paragraph("<b>Verbal (adult)</b>",S["body"]), Paragraph("<b>Verbal (child <5y)</b>",S["body"])],
            [Paragraph("5",S["body"]), Paragraph("Oriented",S["body"]), Paragraph("Appropriate words / smiles, fixes, follows",S["body"])],
            [Paragraph("4",S["body"]), Paragraph("Confused",S["body"]), Paragraph("Cries but consolable",S["body"])],
            [Paragraph("3",S["body"]), Paragraph("Words only",S["body"]), Paragraph("Persistent crying / screaming",S["body"])],
            [Paragraph("2",S["body"]), Paragraph("Sounds only",S["body"]), Paragraph("Grunts",S["body"])],
            [Paragraph("1",S["body"]), Paragraph("None",S["body"]), Paragraph("None",S["body"])],
        ]
        t = Table(tdata, colWidths=[2*cm, 5.5*cm, 8*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), MED_BLUE),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8.5),
            ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, colors.white]),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 3),
            ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("SIGNIFICANCE OF GCS"))
        for x in ["Triage: field sorting, ICU criteria (GCS ≤8 → intubate)",
                  "Prognosis: motor score most predictive; GCS 3 at 24h = poor outcome",
                  "Serial monitoring: trend more important than single value",
                  "Surgical planning: neurosurgical intervention threshold",
                  "Medicolegal: documentation of level of consciousness"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("FALLACIES / PITFALLS of GCS"))
        for x in ["Alcohol/drug intoxication falsely lowers score",
                  "Intubated patient: verbal score recorded as 'T' or 1T",
                  "Orbital swelling: eye opening unreliable",
                  "Spinal injury: motor score falsely low",
                  "Children <2 years: verbal not assessable - use paediatric GCS",
                  "Aphasic patients: verbal score invalid",
                  "Sedated/paralysed patients: NOT assessable"]:
            e.append(b(x))
        e.append(kp("Key: GCS ≤8 = severe TBI → airway must be secured (intubate)"))

    elements.append(q_block(66, "GCS in Adults & Children - Significance & Fallacies", "[2021]", q66))
    elements.append(PageBreak())

    # ── Q67 ─────────────────────────────────────────────────
    def q67(e):
        e.append(sec("TRANSIENT LOSS OF CONSCIOUSNESS (TLOC) AFTER RTA"))
        e.append(bd("TLOC = sudden, brief, self-limited loss of consciousness followed by spontaneous complete recovery. In RTA context = concussion / mild TBI."))
        e.append(sp())
        e.append(sec("PATHOPHYSIOLOGY"))
        for x in ["Rotational/shear forces → diffuse axonal injury (DAI)",
                  "Transient neuronal dysfunction without structural damage",
                  "Altered neural transmission in the reticular activating system (RAS)",
                  "Usually seconds-minutes; prolonged TLOC (>5 min) → investigate for structural injury"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("HIGH GCS (HiGCS) - 'Talk and Die'"))
        e.append(bd("Patient initially GCS 14-15 with TLOC → apparent recovery → secondary deterioration."))
        for x in ["Lucid interval: caused by expanding extradural haematoma (EDH)",
                  "Classic: temporal bone fracture → middle meningeal artery rupture",
                  "Patient 'talks' then 'dies' if not treated",
                  "EDH: biconvex (lens-shaped) on CT - temporal/extradural space",
                  "EMERGENCY: immediate surgical evacuation (burr hole / craniotomy)"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("INVESTIGATIONS"))
        for x in ["CT brain: immediately if GCS deteriorates, focal signs, skull fracture",
                  "CT C-spine: if mechanism suggests cervical injury",
                  "Blood glucose (exclude hypoglycaemia as cause of TLOC)",
                  "ECG (cardiac cause of TLOC)",
                  "FBC/coagulation screen"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("MANAGEMENT"))
        for x in ["A-B-C-D-E resuscitation (ATLS)",
                  "C-spine immobilisation",
                  "Observe 6-12h if GCS returns to 15 and CT normal",
                  "Admit if: persistent symptoms, CT abnormality, social concerns, anticoagulant use",
                  "Neurosurgical referral: GCS deterioration, CT abnormality, focal signs",
                  "EDH: emergency burr hole/craniotomy - aim <4h from injury",
                  "Avoid: NSAIDs, anticoagulants initially"]:
            e.append(b(x))
        e.append(kp("Key: Lucid interval + temporal injury = EDH until proven otherwise"))

    elements.append(q_block(67, "Transient Loss of Consciousness Following RTA (High GCS)", "[2021/2022]", q67))

    # ── Q68 ─────────────────────────────────────────────────
    def q68(e):
        e.append(sec("CHEST TRAUMA - OVERVIEW"))
        e.append(bd("Accounts for 25% of all trauma deaths. 80% managed non-operatively. 10-15% require surgery."))
        e.append(sp())
        e.append(sec("COMPLICATIONS OF CHEST TRAUMA"))
        tdata = [
            [Paragraph("<b>Immediate (0-1h)</b>",S["body"]), Paragraph("<b>Early (1-72h)</b>",S["body"]), Paragraph("<b>Late (>72h)</b>",S["body"])],
            [Paragraph("• Tension pneumothorax\n• Massive haemothorax\n• Open pneumothorax\n• Flail chest\n• Cardiac tamponade\n• Airway obstruction",S["body"]),
             Paragraph("• Haemopneumothorax\n• Pulmonary contusion\n• Myocardial contusion\n• Diaphragm rupture\n• Oesophageal injury\n• Aortic injury",S["body"]),
             Paragraph("• Empyema\n• Missed diaphragm injury\n• ARDS\n• Bronchopleural fistula\n• Thoracic aortic pseudoaneurysm",S["body"])],
        ]
        t = Table(tdata, colWidths=[5.5*cm, 5.5*cm, 5.5*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), MED_BLUE),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8.5),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 4),
            ("BOTTOMPADDING", (0,0), (-1,-1), 4),
            ("VALIGN",     (0,0), (-1,-1), "TOP"),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("MANAGEMENT OF CHEST TRAUMA"))
        for x in ["Primary survey: A-B-C-D-E (ATLS)",
                  "High-flow O2, SpO2 monitoring, CXR (AP erect)",
                  "IVx2 large-bore + aggressive resuscitation",
                  "Tube thoracostomy (chest drain): 5th ICS, mid-axillary line",
                  "Analgesia: epidural / intercostal nerve block (essential for rib fractures)",
                  "Thoracotomy indications: initial chest drain >1500 mL OR ongoing >200-250 mL/h x3h"]:
            e.append(b(x))
        e.append(kp("Key: 6 immediately life-threatening = Airway obstruction, Tension PTX, Open PTX, Massive haemothorax, Flail chest, Cardiac tamponade (ATOMIC)"))

    elements.append(q_block(68, "Complications & Management of Chest Trauma", "[2010/2020]", q68))
    elements.append(PageBreak())

    # ── Q69 ─────────────────────────────────────────────────
    def q69(e):
        e.append(sec("THE 'DANGEROUS DOZEN' OF THORACIC TRAUMA"))
        e.append(sec("GROUP 1: 6 IMMEDIATELY LIFE-THREATENING (ATOMIC)"))
        tdata = [
            [Paragraph("<b>#</b>",S["body"]), Paragraph("<b>Condition</b>",S["body"]), Paragraph("<b>Signs</b>",S["body"]), Paragraph("<b>Immediate Rx</b>",S["body"])],
            [Paragraph("1",S["body"]), Paragraph("Airway obstruction",S["body"]), Paragraph("Stridor, paradoxical breathing",S["body"]), Paragraph("Intubate/surgical airway",S["body"])],
            [Paragraph("2",S["body"]), Paragraph("Tension pneumothorax",S["body"]), Paragraph("↑JVP, tracheal deviation, absent breath sounds, hypotension",S["body"]), Paragraph("Needle decompression 2nd ICS MCL → chest drain",S["body"])],
            [Paragraph("3",S["body"]), Paragraph("Open ('sucking') pneumothorax",S["body"]), Paragraph("Chest wall defect, air movement through wound",S["body"]), Paragraph("3-sided occlusive dressing → chest drain",S["body"])],
            [Paragraph("4",S["body"]), Paragraph("Massive haemothorax",S["body"]), Paragraph(">1500 mL blood, dull percussion, shock",S["body"]), Paragraph("Chest drain → thoracotomy if ongoing",S["body"])],
            [Paragraph("5",S["body"]), Paragraph("Flail chest",S["body"]), Paragraph("Paradoxical chest movement, crepitus ≥3 consecutive ribs",S["body"]), Paragraph("O2, analgesia, IPPV if severe",S["body"])],
            [Paragraph("6",S["body"]), Paragraph("Cardiac tamponade",S["body"]), Paragraph("Beck's triad: ↓BP + ↑JVP + muffled heart sounds",S["body"]), Paragraph("Pericardiocentesis → thoracotomy",S["body"])],
        ]
        t = Table(tdata, colWidths=[0.7*cm, 3.8*cm, 6.5*cm, 5.5*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), colors.HexColor("#7b2226")),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8),
            ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, colors.white]),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 3),
            ("BOTTOMPADDING", (0,0), (-1,-1), 3),
            ("VALIGN", (0,0), (-1,-1), "TOP"),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("GROUP 2: 6 POTENTIALLY LIFE-THREATENING"))
        for x in ["7. Pulmonary contusion - CXR may be normal initially; ARDS risk",
                  "8. Myocardial contusion - ECG changes (ST, arrhythmia); troponin rise",
                  "9. Aortic disruption - widened mediastinum on CXR; CT angio diagnostic",
                  "10. Diaphragm rupture - nasogastric tube in chest on CXR",
                  "11. Oesophageal rupture - Hamman's sign, mediastinitis, high mortality",
                  "12. Tracheobronchial injury - persistent air leak despite chest drain"]:
            e.append(b(x))
        e.append(kp("Key: Tension PTX = CLINICAL diagnosis. Do NOT wait for CXR. Treat immediately."))

    elements.append(q_block(69, "The 'Dangerous Dozen' of Thoracic Trauma - Management of Immediately Life-Threatening Conditions", "[2021]", q69))

    # ── Q70 ─────────────────────────────────────────────────
    def q70(e):
        e.append(sec("DEFINITION"))
        e.append(bd("Flail chest = fracture of ≥3 consecutive ribs in ≥2 places creating a free-floating (flail) chest wall segment that moves paradoxically (inward on inspiration, outward on expiration)."))
        e.append(sp())
        e.append(sec("PHYSIOLOGICAL CHANGES"))
        for x in ["Paradoxical movement → ineffective ventilation → hypoxia",
                  "Underlying pulmonary contusion: most important determinant of morbidity",
                  "Pain → splinting → atelectasis → pneumonia",
                  "Pendellüft: air shifts between lungs worsening hypoxia (historical concept)",
                  "Respiratory failure: ↑work of breathing → respiratory muscle fatigue"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("TYPES"))
        for x in ["Anterior flail: involves sternum/parasternal ribs - associated with cardiac injury",
                  "Lateral flail: most common; ribs fractured in lateral/posterior segments",
                  "Posterior flail: rare; muscle splinting reduces paradox"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("MANAGEMENT"))
        e.append(mn("Mnemonic: OPAIPE"))
        for x in ["O – Oxygen: high-flow, target SpO2 >95%",
                  "P – Pain control: epidural analgesia (GOLD STANDARD) / intercostal nerve block / IV opioids",
                  "A – Airway + ventilation: IPPV if SpO2 <90% despite O2, or RR >30, or fatigue",
                  "I – ICU admission for monitoring",
                  "P – Physiotherapy: chest physiotherapy, incentive spirometry",
                  "E – Rib fixation (surgical stabilisation): VATS / open for anterior flail chest"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("ANTERIOR FLAIL CHEST - SPECIFIC MANAGEMENT"))
        for x in ["Involves sternum; paradox more severe",
                  "Sternal fracture: evaluate for cardiac contusion (ECG, troponin, echo)",
                  "Surgical rib fixation (ORIF with plates) shown to reduce ICU days and ventilator time",
                  "Indications for surgical fixation: failure to wean from ventilator, open chest trauma, thoracotomy for other reason"]:
            e.append(b(x))
        e.append(kp("Key: Pulmonary contusion (not the flail segment) causes hypoxia. Epidural = best analgesia."))

    elements.append(q_block(70, "Flail Chest - Physiological Changes, Types & Management", "[2009/2015]", q70))
    elements.append(PageBreak())

    # ── Q71 ─────────────────────────────────────────────────
    def q71(e):
        e.append(sec("DEFINITIONS"))
        e.append(bd("Haemopneumothorax = simultaneous presence of blood (haemothorax) AND air (pneumothorax) in the pleural cavity. Common in chest trauma (rib fractures, penetrating injuries)."))
        e.append(sp())
        e.append(sec("HAEMOTHORAX - CLASSIFICATION"))
        for x in ["Small (<300 mL): may resolve spontaneously",
                  "Moderate (300-1500 mL): drain required",
                  "Massive (>1500 mL OR >200 mL/h x3h): thoracotomy"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("SIGNS"))
        for x in ["Dull percussion (haemothorax) + absent breath sounds",
                  "Trachea: deviated away (if tension component)",
                  "Shock: haemorrhagic (massive haemothorax)",
                  "CXR: unilateral opacification + fluid level"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("MANAGEMENT"))
        for x in ["Resuscitation: IV access x2, bloods (crossmatch), fluid resuscitation",
                  "Chest drain: large-bore (28-32 Fr) - 5th ICS mid-axillary line",
                  "Water-seal drainage + underwater seal bottle",
                  "Haemothorax VATS evacuation: if clotted haemothorax (within 3-7 days)",
                  "Thoracotomy: initial drain >1500 mL OR ongoing >200-250 mL/h x 3h",
                  "Pneumothorax component: same chest drain manages both",
                  "Empyema prevention: antibiotics + early drainage of clotted blood"]:
            e.append(b(x))
        e.append(kp("Key: Single large-bore chest drain is first-line for haemopneumothorax"))

    elements.append(q_block(71, "Haemopneumothorax", "[2007]", q71))

    # ── Q72 ─────────────────────────────────────────────────
    def q72(e):
        e.append(sec("DEFINITION"))
        e.append(bd("Underwater seal drain (UWSD) / intercostal drainage = tube in pleural space with distal end submerged under water, creating a one-way valve allowing air/fluid out but not back in."))
        e.append(sp())
        e.append(sec("COMPONENTS"))
        for x in ["Chest tube: 20-32 Fr (small = air; large = blood/fluid)",
                  "Underwater seal bottle: water level 2-3 cm submerged",
                  "Collection chamber: measures output",
                  "Suction port: can apply -20 cmH2O suction if needed",
                  "Triple-bottle system or commercial Pleur-evac unit"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("INSERTION TECHNIQUE"))
        for x in ["Position: supine or 45° with arm raised",
                  "Site: 5th ICS, anterior mid-axillary line (safe triangle)",
                  "Anaesthesia: local infiltration down to pleura",
                  "Blunt dissection over upper border of rib (avoid neurovascular bundle below)",
                  "Finger check in pleural space → insert tube directed posterosuperiorly",
                  "Connect to underwater seal, confirm swinging/bubbling"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("MONITORING"))
        for x in ["Swinging: respiratory variation confirms correct placement",
                  "Bubbling: air leak present",
                  "Cessation of swinging: lung re-expanded OR tube blocked/kinked",
                  "Output: record hourly; replace blood if >200 mL/h",
                  "CXR: confirm position + lung re-expansion"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("REMOVAL"))
        for x in ["Criteria: lung fully re-expanded on CXR + no air leak x24h + output <100-150 mL/24h",
                  "Method: remove at end-expiration or peak inspiration (Valsalva) → immediate occlusion",
                  "Purse-string suture or direct pressure + sterile dressing"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("COMPLICATIONS"))
        for x in ["Malposition: intraparenchymal, subdiaphragmatic, subcutaneous",
                  "Blocked tube: kinking, clotted blood",
                  "Empyema: from prolonged drainage (prophylactic antibiotics debate)",
                  "Lung laceration, re-expansion pulmonary oedema"]:
            e.append(b(x))
        e.append(kp("Key: Never clamp a bubbling chest drain (risk of tension pneumothorax)"))

    elements.append(q_block(72, "Underwater Seal Drainage", "[2021]", q72))
    elements.append(PageBreak())

    # ── Q73 ─────────────────────────────────────────────────
    def q73(e):
        e.append(sec("DEFINITION"))
        e.append(bd("NOMAT (Non-Operative Management of Abdominal Trauma) = non-surgical approach to manage solid organ injuries in haemodynamically stable blunt trauma patients."))
        e.append(sp())
        e.append(sec("SOLID ORGANS COMMONLY INJURED IN BLUNT TRAUMA"))
        tdata = [
            [Paragraph("<b>Organ</b>",S["body"]), Paragraph("<b>Frequency</b>",S["body"]), Paragraph("<b>NOMAT success rate</b>",S["body"])],
            [Paragraph("Spleen",S["body"]), Paragraph("Most common (40-55%)",S["body"]), Paragraph("~85-95% (children), ~65-75% (adults)",S["body"])],
            [Paragraph("Liver",S["body"]), Paragraph("2nd most common (35-45%)",S["body"]), Paragraph("~85-90%",S["body"])],
            [Paragraph("Kidney",S["body"]), Paragraph("~10%",S["body"]), Paragraph("~95% (Grade I-III)",S["body"])],
            [Paragraph("Pancreas",S["body"]), Paragraph("Rare (3-12%)",S["body"]), Paragraph("~50-80% (depends on duct)",S["body"])],
        ]
        t = Table(tdata, colWidths=[3*cm, 5*cm, 7*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), MED_BLUE),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8.5),
            ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, colors.white]),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 3),
            ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("PRE-HOSPITAL CARE & INITIAL ASSESSMENT"))
        for x in ["Scene: control external haemorrhage (tourniquet/pressure), immobilise spine",
                  "ABCDE, IV access, fluids (restricted crystalloid), monitoring",
                  "Transport to Level 1 trauma centre",
                  "FAST (Focused Assessment with Sonography in Trauma): bedside, detect free fluid",
                  "CT abdomen/pelvis with IV contrast: gold standard for staging (haemodynamically stable)"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("CRITERIA FOR NOMAT"))
        for x in ["Haemodynamic stability (systolic >90 mmHg without ongoing pressor/transfusion requirement)",
                  "No peritonism on examination",
                  "CT staging: Grade I-III (low grade) injury",
                  "No associated hollow viscus injury, diaphragm rupture",
                  "Availability of ICU/HDU, OR backup, experienced surgical team"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("NOMAT PROTOCOL"))
        for x in ["ICU/HDU admission, serial abdominal examinations (2-4 hourly)",
                  "Serial Hb, haematocrit q4-6h",
                  "Angioembolisation: if active contrast blush on CT (spleen/liver Grade III-IV)",
                  "Bed rest: 24-48h for lower grade; longer for higher grade",
                  "Conversion to operative management if: haemodynamic deterioration, peritonism, Hb drop >2 g/dL, transfusion >4 units"]:
            e.append(b(x))
        e.append(kp("Key: NOMAT requires haemodynamic STABILITY. Any deterioration = laparotomy."))

    elements.append(q_block(73, "NOMAT - Non-Operative Management of Solid Organ Injuries (Blunt Abdominal Trauma)", "[2021]", q73))

    # ── Q74 ─────────────────────────────────────────────────
    def q74(e):
        e.append(sec("MOST COMMON INTRA-ABDOMINAL ORGAN IN BLUNT TRAUMA"))
        e.append(bd("SPLEEN = most commonly injured solid organ in blunt abdominal trauma (40-55% of solid organ injuries)."))
        e.append(sp())
        e.append(sec("MECHANISM"))
        for x in ["Direct blow to left lower chest/upper abdomen",
                  "Deceleration injury: spleen tears at vascular pedicle",
                  "Associated with left rib fractures (9-11) + left pneumothorax"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("AAST SPLENIC INJURY SCALE"))
        tdata = [
            [Paragraph("<b>Grade</b>",S["body"]), Paragraph("<b>Description</b>",S["body"]), Paragraph("<b>Management</b>",S["body"])],
            [Paragraph("I",S["body"]), Paragraph("Subcapsular haematoma <10%; capsular tear <1 cm deep",S["body"]), Paragraph("NOMAT",S["body"])],
            [Paragraph("II",S["body"]), Paragraph("Subcapsular 10-50%; laceration 1-3 cm",S["body"]), Paragraph("NOMAT",S["body"])],
            [Paragraph("III",S["body"]), Paragraph("Subcapsular >50% / expanding; laceration >3 cm; devascularised <25%",S["body"]), Paragraph("NOMAT ± angioembolisation",S["body"])],
            [Paragraph("IV",S["body"]), Paragraph("Laceration involving segmental/hilar vessels; devascularised >25%",S["body"]), Paragraph("Angioembolisation vs splenectomy",S["body"])],
            [Paragraph("V",S["body"]), Paragraph("Shattered spleen; hilar devascularisation",S["body"]), Paragraph("Splenectomy",S["body"])],
        ]
        t = Table(tdata, colWidths=[1.5*cm, 9*cm, 5*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), MED_BLUE),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8.5),
            ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, colors.white]),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 3),
            ("BOTTOMPADDING", (0,0), (-1,-1), 3),
            ("VALIGN", (0,0), (-1,-1), "TOP"),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("MANAGEMENT"))
        for x in ["NOMAT: haemodynamically stable + Grade I-III → monitor in ICU",
                  "Angioembolisation: active blush on CT Grade III-IV → TAE (transcatheter arterial embolisation)",
                  "Splenorrhaphy: repair if accessible and controllable (packing, suture, mesh wrap)",
                  "Splenectomy: massive injury, haemodynamic instability, Grade V",
                  "Post-splenectomy: vaccinate (Pneumococcus, Meningococcus, HiB) + daily penicillin prophylaxis x2 years"]:
            e.append(b(x))
        e.append(kp("Key: OPSI (Overwhelming Post-Splenectomy Infection) - lifelong risk, prevent with vaccination"))

    elements.append(q_block(74, "Most Common Intra-Abdominal Surgery - Splenic Injury & Splenic Injury Scale", "[2021]", q74))
    elements.append(PageBreak())

    # ── Q75 ─────────────────────────────────────────────────
    def q75(e):
        e.append(sec("CLINICAL SCENARIO"))
        e.append(bd("Blunt abdominal trauma with haemodynamic shock = surgical emergency. Requires rapid, systematic evaluation and immediate intervention."))
        e.append(sp())
        e.append(sec("IMMEDIATE ASSESSMENT (ATLS Protocol)"))
        for x in ["A: Secure airway (intubate if GCS <8)",
                  "B: Oxygen, ventilate",
                  "C: IV x2 large bore, blood type & crossmatch, MTP (massive transfusion protocol)",
                  "D: Disability - GCS, pupils",
                  "E: Expose - inspect abdomen (bruising, distension, guarding)"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("BEDSIDE INVESTIGATIONS (while resuscitating)"))
        for x in ["FAST scan: free fluid in Morrison's pouch, perihepatic, perisplenic, pelvis",
                  "Diagnostic Peritoneal Lavage (DPL): if FAST equivocal, >100,000 RBC/mL = positive",
                  "CXR + Pelvis X-ray: exclude haemothorax, pelvic fracture",
                  "ABG: lactate (perfusion marker), base deficit"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("MANAGEMENT ALGORITHM"))
        e.append(mn("Shocked + FAST positive → Emergency Laparotomy"))
        for x in ["Haemodynamic control: 1:1:1 pRBC:FFP:Platelets, TXA",
                  "Damage Control Laparotomy (DCL):",
                  "   → Pack all 4 quadrants to control haemorrhage",
                  "   → Identify and control bleeding source",
                  "   → Temporary abdominal closure (Bogota bag / VAC)",
                  "   → Transfer to ICU: correct hypothermia, acidosis, coagulopathy",
                  "   → Definitive repair: planned relook at 24-48h",
                  "Pelvic fracture: pelvic binder + external fixation + angioembolisation"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("DAMAGE CONTROL SURGERY PRINCIPLES"))
        for x in ["Phase 1: abbreviated laparotomy (control of haemorrhage + contamination only)",
                  "Phase 2: ICU resuscitation (reverse lethal triad)",
                  "Phase 3: definitive surgery when physiology corrected (24-72h)"]:
            e.append(b(x))
        e.append(kp("Key: Shocked patient = don't delay for CT. FAST positive + shock = immediate laparotomy."))

    elements.append(q_block(75, "Management of Blunt Trauma Abdomen in Shock", "[2020]", q75))

    # ── Q76 ─────────────────────────────────────────────────
    def q76(e):
        e.append(sec("DIAGNOSTIC MODALITIES IN BLUNT ABDOMINAL TRAUMA"))
        tdata = [
            [Paragraph("<b>Investigation</b>",S["body"]), Paragraph("<b>Indication</b>",S["body"]), Paragraph("<b>Advantages</b>",S["body"]), Paragraph("<b>Limitations</b>",S["body"])],
            [Paragraph("FAST Ultrasound",S["body"]), Paragraph("Bedside, 1st line, haemodynamically unstable",S["body"]), Paragraph("Fast, portable, no radiation, repeatable",S["body"]), Paragraph("Operator-dependent, misses hollow viscus/retroperitoneal",S["body"])],
            [Paragraph("CT Abdomen (IV contrast)",S["body"]), Paragraph("GOLD STANDARD - haemodynamically stable",S["body"]), Paragraph("Defines organ injury, grade, active blush, retroperitoneal",S["body"]), Paragraph("Radiation, contrast risk, time, transport",S["body"])],
            [Paragraph("DPL (Diagnostic Peritoneal Lavage)",S["body"]), Paragraph("FAST equivocal, no CT available",S["body"]), Paragraph("High sensitivity (98%)",S["body"]), Paragraph("Invasive, non-specific, does not grade injury",S["body"])],
            [Paragraph("X-Ray (CXR + Pelvis)",S["body"]), Paragraph("Primary survey adjunct",S["body"]), Paragraph("Rapid, identifies pneumothorax, pelvis #",S["body"]), Paragraph("Limited abdominal info",S["body"])],
            [Paragraph("Diagnostic Laparoscopy",S["body"]), Paragraph("Equivocal clinical/imaging findings",S["body"]), Paragraph("Therapeutic + diagnostic",S["body"]), Paragraph("Requires GA, misses retroperitoneal",S["body"])],
            [Paragraph("CECT Angiography",S["body"]), Paragraph("Active contrast extravasation seen on CT",S["body"]), Paragraph("Diagnostic + therapeutic (embolisation)",S["body"]), Paragraph("Specialist centre required",S["body"])],
        ]
        t = Table(tdata, colWidths=[3.5*cm, 4*cm, 4.5*cm, 4.5*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), MED_BLUE),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8),
            ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, colors.white]),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 3),
            ("BOTTOMPADDING", (0,0), (-1,-1), 3),
            ("VALIGN", (0,0), (-1,-1), "TOP"),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("DPL CRITERIA (Positive)"))
        for x in [">10 mL blood on initial aspiration",
                  "Lavage fluid in chest drain/Foley (organ perforation)",
                  "RBC >100,000/mL (blunt) or >10,000/mL (penetrating)",
                  "WBC >500/mL",
                  "Bile, bacteria, food fibres"]:
            e.append(b(x))
        e.append(kp("Key: CT abdomen with IV contrast = gold standard if patient is stable"))

    elements.append(q_block(76, "Diagnostic Modalities in Blunt Abdominal Trauma", "[2016]", q76))
    elements.append(PageBreak())

    # ── Q77 ─────────────────────────────────────────────────
    def q77(e):
        e.append(sec("APPROACHES TO LAPAROTOMY IN BLUNT ABDOMINAL TRAUMA"))
        e.append(sec("INCISION"))
        for x in ["Long midline laparotomy: from xiphoid to pubic symphysis",
                  "Allows full access to all abdominal quadrants",
                  "Can be extended into median sternotomy if needed"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("INDICATIONS FOR LAPAROTOMY (MANDATORY)"))
        for x in ["Haemodynamic instability with FAST positive free fluid",
                  "Peritonitis on examination",
                  "Evisceration",
                  "Impalement injury",
                  "Diaphragm rupture on imaging",
                  "Free air on X-ray/CT (hollow viscus injury)",
                  "Gunshot wound traversing peritoneal cavity",
                  "Positive DPL",
                  "Failure of NOMAT (haemodynamic deterioration, peritonism, falling Hb)"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("RELATIVE INDICATIONS (SELECTIVE)"))
        for x in ["Persistent tachycardia without other cause",
                  "Unexplained blood transfusion requirement",
                  "Grade IV-V solid organ injury on CT"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("DAMAGE CONTROL LAPAROTOMY SEQUENCE"))
        for x in ["Enter abdomen: pack all 4 quadrants immediately",
                  "Control haemorrhage: pressure, clamping, ligation, packing",
                  "Control contamination: bowel clamps, not anastomosis",
                  "Assess injury burden: systematic exploration",
                  "Temporary closure: Bogota bag / Opsite sandwich / ABThera VAC",
                  "ICU: correct triad",
                  "Planned relook: 24-48h for definitive repair"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("SPECIFIC ORGAN APPROACHES"))
        for x in ["Liver: Pringle manoeuvre (portal hepatis clamp), packing, argon beam",
                  "Spleen: lienorenal ligament division, medial rotation",
                  "Kidney: Mattox manoeuvre (left-sided retroperitoneal exposure)",
                  "Aorta: supracoeliac aortic control at hiatus",
                  "Bowel: resect + staple ends, no primary anastomosis in damage control"]:
            e.append(b(x))
        e.append(kp("Key: Damage control laparotomy = abbreviated surgery to control haemorrhage + contamination ONLY"))

    elements.append(q_block(77, "Approaches & Indications for Laparotomy in Blunt Abdominal Trauma", "[ ]", q77))

    # ── Q78 ─────────────────────────────────────────────────
    def q78(e):
        e.append(sec("AAST LIVER INJURY SCALE"))
        tdata = [
            [Paragraph("<b>Grade</b>",S["body"]), Paragraph("<b>Description</b>",S["body"]), Paragraph("<b>Management</b>",S["body"])],
            [Paragraph("I",S["body"]), Paragraph("Haematoma <10% surface; Laceration <1 cm",S["body"]), Paragraph("NOMAT",S["body"])],
            [Paragraph("II",S["body"]), Paragraph("Haematoma 10-50%; Laceration 1-3 cm, <10 cm length",S["body"]), Paragraph("NOMAT",S["body"])],
            [Paragraph("III",S["body"]), Paragraph("Haematoma >50%; Laceration >3 cm deep",S["body"]), Paragraph("NOMAT ± angioembolisation",S["body"])],
            [Paragraph("IV",S["body"]), Paragraph("Parenchymal disruption 25-75% of lobe",S["body"]), Paragraph("Angioembolisation vs surgery",S["body"])],
            [Paragraph("V",S["body"]), Paragraph("Parenchymal disruption >75% lobe; juxtahepatic vein injury",S["body"]), Paragraph("Surgery (packing + DCL)",S["body"])],
            [Paragraph("VI",S["body"]), Paragraph("Hepatic avulsion",S["body"]), Paragraph("Lethal; packing/hepatectomy",S["body"])],
        ]
        t = Table(tdata, colWidths=[1.5*cm, 9.5*cm, 4.5*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), MED_BLUE),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8.5),
            ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, colors.white]),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 3),
            ("BOTTOMPADDING", (0,0), (-1,-1), 3),
            ("VALIGN", (0,0), (-1,-1), "TOP"),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("MANAGEMENT ALGORITHM - LIVER INJURY WITH ACTIVE BLEED"))
        for x in ["Haemodynamically STABLE: CT scan → grade injury → NOMAT ± angioembolisation",
                  "Haemodynamically UNSTABLE: emergency laparotomy",
                  "Intraoperative control: Pringle manoeuvre (clamp hepatoduodenal ligament)",
                  "Surgical techniques: 4P approach - Pressure, Pringle, Plug (balloon), Pack",
                  "Packing: 4 packs per lobe → temporary closure → ICU",
                  "Angioembolisation: IR-guided TAE for active contrast blush (Grade III-IV)",
                  "Biliary complications: bile leak → ERCP + stent or drain",
                  "Definitive repair at relook: suture, fibrin glue, omentoplasty, hepatectomy (rare)"]:
            e.append(b(x))
        e.append(kp("Key: Pringle manoeuvre (hepatoduodenal ligament clamping) = primary intraoperative haemostasis. Can clamp 15-20 min intermittently."))

    elements.append(q_block(78, "Grades of Liver Injury & Management Algorithm with Active Bleeding", "[ ]", q78))
    elements.append(PageBreak())

    # ── Q79 ─────────────────────────────────────────────────
    def q79(e):
        e.append(sec("DUODENAL INJURIES - OVERVIEW"))
        e.append(bd("Rare (3-5% of abdominal trauma). Most from penetrating trauma (70%). Blunt: steering wheel, seatbelt, handlebar injuries. Often associated with pancreatic injury."))
        e.append(sp())
        e.append(sec("AAST DUODENAL INJURY SCALE"))
        tdata = [
            [Paragraph("<b>Grade</b>",S["body"]), Paragraph("<b>Description</b>",S["body"]), Paragraph("<b>Management</b>",S["body"])],
            [Paragraph("I",S["body"]), Paragraph("Haematoma: single portion; Laceration: partial thickness, no perforation",S["body"]), Paragraph("Conservative (NGT, TPN)",S["body"])],
            [Paragraph("II",S["body"]), Paragraph("Haematoma: >1 portion; Laceration: <50% circumference disruption",S["body"]), Paragraph("Primary repair",S["body"])],
            [Paragraph("III",S["body"]), Paragraph("Laceration: D2: 50-75%; D1,D3,D4: 50-100%",S["body"]), Paragraph("Primary repair + pyloric exclusion",S["body"])],
            [Paragraph("IV",S["body"]), Paragraph("Laceration: D2: >75%; involves ampulla/CBD",S["body"]), Paragraph("Complex repair / Whipple's",S["body"])],
            [Paragraph("V",S["body"]), Paragraph("Massive disruption of duodenopancreatic complex; devascularisation",S["body"]), Paragraph("Damage control/Whipple's",S["body"])],
        ]
        t = Table(tdata, colWidths=[1.5*cm, 8.5*cm, 5.5*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), MED_BLUE),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8.5),
            ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, colors.white]),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 3),
            ("BOTTOMPADDING", (0,0), (-1,-1), 3),
            ("VALIGN", (0,0), (-1,-1), "TOP"),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("MANAGEMENT"))
        for x in ["Grade I: nasogastric decompression, TPN - haematoma resolves in 7-14 days",
                  "Grade II-III: primary repair in 2 layers ± decompression",
                  "Pyloric exclusion: staple pylorus + gastrojejunostomy to divert flow away from repair",
                  "Grade IV-V: pancreaticoduodenectomy (Whipple's) - rarely in acute setting",
                  "Always drain: closed suction drain near repair",
                  "Duodenostomy tube: feeding"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("DIAGNOSIS (KEY POINT - difficult)"))
        for x in ["CT scan: retroperitoneal air, fluid, duodenal wall thickening",
                  "Water-soluble contrast swallow: leak detection",
                  "Often delayed diagnosis → increased mortality"]:
            e.append(b(x))
        e.append(kp("Key: Duodenal haematoma in children - exclude NAI (Non-Accidental Injury)"))

    elements.append(q_block(79, "Duodenal Injuries (Traumatic) - Grades & Management", "[2015/2021/2014]", q79))

    # ── Q80 ─────────────────────────────────────────────────
    def q80(e):
        e.append(sec("TRAUMATIC PANCREATIC INJURY - OVERVIEW"))
        e.append(bd("Uncommon but high mortality (10-30%). Blunt: steering wheel, handlebar (classic), direct blow to epigastrium. Pancreas fixed at L1-L2 against spine = vulnerable to crushing. Most injuries involve body/neck (most common site)."))
        e.append(sp())
        e.append(sec("AAST PANCREATIC INJURY SCALE"))
        tdata = [
            [Paragraph("<b>Grade</b>",S["body"]), Paragraph("<b>Description</b>",S["body"]), Paragraph("<b>Management</b>",S["body"])],
            [Paragraph("I",S["body"]), Paragraph("Minor contusion/laceration, no duct injury",S["body"]), Paragraph("Closed drainage",S["body"])],
            [Paragraph("II",S["body"]), Paragraph("Major contusion/laceration, no duct injury",S["body"]), Paragraph("Closed drainage",S["body"])],
            [Paragraph("III",S["body"]), Paragraph("Distal transection OR parenchymal injury + duct injury",S["body"]), Paragraph("Distal pancreatectomy ± splenectomy",S["body"])],
            [Paragraph("IV",S["body"]), Paragraph("Proximal transection involving ampulla",S["body"]), Paragraph("Drainage ± complex repair",S["body"])],
            [Paragraph("V",S["body"]), Paragraph("Massive disruption of pancreatic head",S["body"]), Paragraph("Damage control → pancreaticoduodenectomy",S["body"])],
        ]
        t = Table(tdata, colWidths=[1.5*cm, 8.5*cm, 5.5*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), MED_BLUE),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8.5),
            ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, colors.white]),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 3),
            ("BOTTOMPADDING", (0,0), (-1,-1), 3),
            ("VALIGN", (0,0), (-1,-1), "TOP"),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("MANAGEMENT ALGORITHM (2021)"))
        for x in ["Diagnosis: CT with IV contrast (main duct injury), serum amylase/lipase (insensitive early), MRCP/ERCP",
                  "Grade I-II: closed suction drainage alone (most resolve)",
                  "Grade III (distal duct injury): distal pancreatectomy ± splenectomy",
                  "Grade IV-V: damage control (pack + drain) → planned reconstruction at 24-72h",
                  "ERCP + stenting: for ductal disruption if patient stable (Grade III-IV)",
                  "Whipple's (pancreaticoduodenectomy): only for stable patient with irreparable head injury",
                  "KEY PRINCIPLE: Conservative surgery; always drain; avoid Whipple's acutely"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("COMPLICATIONS"))
        for x in ["Pancreatic fistula: most common (Grade A-C, ISGPF criteria)",
                  "Pseudocyst: collection of amylase-rich fluid",
                  "Pancreatitis, abscess, haemorrhage"]:
            e.append(b(x))
        e.append(kp("Key: Duct integrity determines management. CT cannot reliably show duct injury - use MRCP/ERCP."))

    elements.append(q_block(80, "Classify Pancreatic Trauma & Management Algorithm for Traumatic Pancreatic Injury", "[2021]", q80))
    elements.append(PageBreak())

    # ── Q81 ─────────────────────────────────────────────────
    def q81(e):
        e.append(sec("DEFINITION"))
        e.append(bd("Pancreaticoduodenal injury = combined injury to pancreatic head and duodenum (usually Grade IV-V pancreas + Grade III-V duodenum). High mortality (40-60%). Rare but catastrophic."))
        e.append(sp())
        e.append(sec("MECHANISM"))
        for x in ["High-energy blunt: steering wheel, handlebar - crushing pancreatic head against L1-L2 spine",
                  "Penetrating: gunshot wounds through epigastrium",
                  "Associated injuries: IVC, portal vein, superior mesenteric vessels, CBD"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("DIAGNOSIS"))
        for x in ["CT abdomen/pelvis with IV contrast: retroperitoneal air, fluid, duct disruption",
                  "MRCP: duct integrity assessment",
                  "Intraoperative cholangiogram: CBD injury",
                  "Serum amylase: elevated but non-specific"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("MANAGEMENT (Bailey & Love Principles)"))
        e.append(mn("Principles: Damage Control First"))
        for x in ["Damage control: packing + external drainage + temporary closure",
                  "ICU: resuscitate, correct coagulopathy/hypothermia/acidosis",
                  "Planned relook at 24-48h for definitive repair"]:
            e.append(b(x))
        e.append(sp())
        e.append(sec("DEFINITIVE SURGICAL OPTIONS"))
        tdata = [
            [Paragraph("<b>Procedure</b>",S["body"]), Paragraph("<b>Indication</b>",S["body"]), Paragraph("<b>Notes</b>",S["body"])],
            [Paragraph("Primary duodenal repair + drainage",S["body"]), Paragraph("Grade I-II duodenum + Grade I-II pancreas",S["body"]), Paragraph("Simplest; low mortality",S["body"])],
            [Paragraph("Pyloric exclusion + Gastrojejunostomy",S["body"]), Paragraph("Grade II-III duodenum",S["body"]), Paragraph("Diverts bile/pancreatic juice from repair",S["body"])],
            [Paragraph("Triple tube decompression (Berne)",S["body"]), Paragraph("Duodenal repairs",S["body"]), Paragraph("Gastrostomy + duodenostomy + jejunostomy",S["body"])],
            [Paragraph("Pancreaticoduodenectomy (Whipple's)",S["body"]), Paragraph("Irreparable pancreatic head + duodenum (Grade IV-V)",S["body"]), Paragraph("Only in stable patient - high mortality if emergent",S["body"])],
            [Paragraph("Duodenal diverticulisation",S["body"]), Paragraph("Complex duodenal injury",S["body"]), Paragraph("Antrectomy + Billroth II + tube duodenostomy",S["body"])],
        ]
        t = Table(tdata, colWidths=[4.5*cm, 5.5*cm, 5.5*cm])
        t.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,0), MED_BLUE),
            ("TEXTCOLOR",  (0,0), (-1,0), colors.white),
            ("FONTNAME",   (0,0), (-1,0), "Helvetica-Bold"),
            ("FONTSIZE",   (0,0), (-1,-1), 8.5),
            ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_GREY, colors.white]),
            ("GRID",       (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING", (0,0), (-1,-1), 3),
            ("BOTTOMPADDING", (0,0), (-1,-1), 3),
            ("VALIGN", (0,0), (-1,-1), "TOP"),
        ]))
        e.append(t)
        e.append(sp())
        e.append(sec("COMPLICATIONS"))
        for x in ["Duodenal fistula: most feared; >15-20% in complex repairs",
                  "Pancreatic fistula: common",
                  "Intraabdominal abscess, sepsis, haemorrhage",
                  "Delayed gastric emptying after Whipple's",
                  "Jaundice if CBD not repaired"]:
            e.append(b(x))
        e.append(kp("Key: Pyloric exclusion = most widely used procedure for complex duodenal injuries (protects repair site)"))

    elements.append(q_block(81, "Management of Pancreaticoduodenal Injury", "[2007/2025]", q81))


# ============================================================
# COVER PAGE
# ============================================================
def build_cover():
    elems = []
    elems.append(Spacer(1, 2.5*cm))
    elems.append(Paragraph("MS General Surgery", S["cover_title"]))
    elems.append(Paragraph("Structured Exam Answers — Questions 62 to 81", S["cover_sub"]))
    elems.append(Spacer(1, 0.4*cm))
    elems.append(HRFlowable(width="70%", thickness=2, color=GOLD, spaceAfter=16))
    elems.append(Paragraph("TRAUMA SECTION", ParagraphStyle("ts", fontSize=15, fontName="Helvetica-Bold",
                textColor=DARK_BLUE, alignment=TA_CENTER, spaceAfter=8)))
    elems.append(Spacer(1, 0.3*cm))

    topics = [
        ("Q62", "Post-operative Ventilatory Support"),
        ("Q63", "Triage in Disaster — START & SALT | Polytrauma"),
        ("Q64", "Coagulopathy of Trauma & Damage Control Resuscitation"),
        ("Q65", "Head Trauma & Glasgow Coma Scale"),
        ("Q66", "GCS in Adults & Children — Significance & Fallacies"),
        ("Q67", "Transient Loss of Consciousness After RTA (High GCS)"),
        ("Q68", "Complications & Management of Chest Trauma"),
        ("Q69", "The 'Dangerous Dozen' of Thoracic Trauma"),
        ("Q70", "Flail Chest — Types, Physiology & Management"),
        ("Q71", "Haemopneumothorax"),
        ("Q72", "Underwater Seal Drainage"),
        ("Q73", "NOMAT — Non-Operative Management of Solid Organ Injuries"),
        ("Q74", "Most Common Intra-Abdominal Injury — Spleen & Grading Scale"),
        ("Q75", "Management of Blunt Abdominal Trauma in Shock"),
        ("Q76", "Diagnostic Modalities in Blunt Abdominal Trauma"),
        ("Q77", "Approaches & Indications for Laparotomy"),
        ("Q78", "Grades of Liver Injury & Management with Active Bleed"),
        ("Q79", "Traumatic Duodenal Injuries — Grades & Management"),
        ("Q80", "Traumatic Pancreatic Injury — Classification & Algorithm"),
        ("Q81", "Management of Pancreaticoduodenal Injury"),
    ]
    tdata = []
    for q, t in topics:
        tdata.append([Paragraph(q, ParagraphStyle("ql", fontSize=9, fontName="Helvetica-Bold",
                      textColor=DARK_BLUE)),
                      Paragraph(t, ParagraphStyle("tl", fontSize=9, fontName="Helvetica",
                      textColor=BLACK))])
    t = Table(tdata, colWidths=[2*cm, 13*cm])
    t.setStyle(TableStyle([
        ("ROWBACKGROUNDS", (0,0), (-1,-1), [LIGHT_BLUE, colors.white]),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 8),
        ("GRID",          (0,0), (-1,-1), 0.3, colors.HexColor("#c0c0c0")),
    ]))
    elems.append(t)
    elems.append(Spacer(1, 1*cm))
    elems.append(HRFlowable(width="70%", thickness=1, color=GOLD, spaceAfter=8))
    elems.append(Paragraph("Source: Bailey & Love's Short Practice of Surgery, 28th Edition",
                            S["cover_note"]))
    elems.append(Paragraph("Designed for 15-minute exam answers | Key scoring points highlighted",
                            S["cover_note"]))
    elems.append(Paragraph("MS General Surgery Examination Format", S["cover_note"]))
    elems.append(PageBreak())
    return elems


# ============================================================
# PAGE TEMPLATES
# ============================================================
def add_page_number(canvas, doc):
    canvas.saveState()
    canvas.setFont("Helvetica", 8)
    canvas.setFillColor(MID_GREY)
    page_num = canvas.getPageNumber()
    canvas.drawCentredString(A4[0]/2, 1.2*cm,
        f"MS Surgery Exam — Q62-Q81 | Bailey & Love 28e    |    Page {page_num}")
    canvas.setStrokeColor(colors.HexColor("#d4a017"))
    canvas.setLineWidth(0.5)
    canvas.line(2*cm, 1.5*cm, A4[0]-2*cm, 1.5*cm)
    canvas.restoreState()


# ============================================================
# MAIN
# ============================================================
def main():
    doc = SimpleDocTemplate(
        OUTPUT_PATH,
        pagesize=A4,
        rightMargin=1.8*cm,
        leftMargin=1.8*cm,
        topMargin=1.8*cm,
        bottomMargin=2*cm,
        title="MS Surgery Exam Answers Q62-Q81",
        author="Bailey & Love 28e",
    )

    story = []
    story.extend(build_cover())

    build_questions(story)

    doc.build(story, onFirstPage=add_page_number, onLaterPages=add_page_number)
    print(f"PDF generated: {OUTPUT_PATH}")

if __name__ == "__main__":
    main()