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

OUTPUT_PATH = "/tmp/workspace/patient-examination/Approach_to_Patient_General_Examination.pdf"

# ─── Page layout ───────────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT_PATH,
    pagesize=A4,
    topMargin=2*cm, bottomMargin=2*cm,
    leftMargin=2.2*cm, rightMargin=2.2*cm,
    title="Approach to the Patient & General Examination",
    author="Orris Medical Reference",
    subject="Clinical Medicine"
)

# ─── Colour palette ────────────────────────────────────────────────────────────
DARK_BLUE   = colors.HexColor("#1A3A5C")
MID_BLUE    = colors.HexColor("#2E6DA4")
LIGHT_BLUE  = colors.HexColor("#D6E8F7")
ACCENT      = colors.HexColor("#E8A020")
LIGHT_GRAY  = colors.HexColor("#F5F5F5")
MED_GRAY    = colors.HexColor("#CCCCCC")
TEXT_COLOR  = colors.HexColor("#1A1A1A")
WHITE       = colors.white

# ─── Styles ────────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

cover_title = ParagraphStyle(
    "CoverTitle", fontSize=28, leading=34, textColor=WHITE,
    fontName="Helvetica-Bold", alignment=TA_CENTER, spaceAfter=10
)
cover_sub = ParagraphStyle(
    "CoverSub", fontSize=15, leading=20, textColor=colors.HexColor("#C8DCEF"),
    fontName="Helvetica", alignment=TA_CENTER, spaceAfter=6
)
cover_ref = ParagraphStyle(
    "CoverRef", fontSize=9, leading=13, textColor=colors.HexColor("#A0C0E0"),
    fontName="Helvetica-Oblique", alignment=TA_CENTER
)

h1 = ParagraphStyle(
    "H1", fontSize=16, leading=20, textColor=WHITE,
    fontName="Helvetica-Bold", alignment=TA_LEFT,
    spaceBefore=14, spaceAfter=4, leftIndent=0
)
h2 = ParagraphStyle(
    "H2", fontSize=13, leading=17, textColor=DARK_BLUE,
    fontName="Helvetica-Bold", alignment=TA_LEFT,
    spaceBefore=12, spaceAfter=4
)
h3 = ParagraphStyle(
    "H3", fontSize=11, leading=15, textColor=MID_BLUE,
    fontName="Helvetica-Bold", alignment=TA_LEFT,
    spaceBefore=8, spaceAfter=3
)
body = ParagraphStyle(
    "Body", fontSize=10, leading=15, textColor=TEXT_COLOR,
    fontName="Helvetica", alignment=TA_JUSTIFY,
    spaceBefore=3, spaceAfter=3
)
bullet_style = ParagraphStyle(
    "Bullet", fontSize=10, leading=14, textColor=TEXT_COLOR,
    fontName="Helvetica", alignment=TA_LEFT,
    leftIndent=14, spaceBefore=2, spaceAfter=2,
    bulletIndent=4
)
note_style = ParagraphStyle(
    "Note", fontSize=9, leading=13, textColor=colors.HexColor("#4A4A4A"),
    fontName="Helvetica-Oblique", alignment=TA_LEFT,
    leftIndent=10, spaceBefore=2, spaceAfter=2
)
caption_style = ParagraphStyle(
    "Caption", fontSize=8, leading=11, textColor=MID_BLUE,
    fontName="Helvetica-Bold", alignment=TA_CENTER, spaceAfter=4
)

# ─── Helper: section banner ────────────────────────────────────────────────────
def section_banner(text):
    tbl = Table([[Paragraph(text, h1)]], colWidths=[doc.width])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0, 0), (-1, -1), DARK_BLUE),
        ("TOPPADDING",    (0, 0), (-1, -1), 8),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 8),
        ("LEFTPADDING",   (0, 0), (-1, -1), 12),
        ("RIGHTPADDING",  (0, 0), (-1, -1), 12),
        ("ROUNDEDCORNERS", [4, 4, 4, 4]),
    ]))
    return tbl

def info_box(text, bg=LIGHT_BLUE, border=MID_BLUE):
    tbl = Table([[Paragraph(text, body)]], colWidths=[doc.width])
    tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0, 0), (-1, -1), bg),
        ("BOX",           (0, 0), (-1, -1), 1.2, border),
        ("TOPPADDING",    (0, 0), (-1, -1), 8),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 8),
        ("LEFTPADDING",   (0, 0), (-1, -1), 12),
        ("RIGHTPADDING",  (0, 0), (-1, -1), 12),
    ]))
    return tbl

def accent_box(title, rows):
    """Two-column key-value highlight box."""
    data = [[Paragraph(f"<b>{k}</b>", body), Paragraph(v, body)] for k, v in rows]
    col_w = [doc.width * 0.35, doc.width * 0.65]
    tbl = Table(data, colWidths=col_w)
    tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0, 0), (0, -1), LIGHT_BLUE),
        ("BACKGROUND",    (1, 0), (1, -1), colors.HexColor("#FAFCFF")),
        ("ROWBACKGROUNDS", (0, 0), (-1, -1), [LIGHT_BLUE, colors.HexColor("#EAF3FC")]),
        ("BOX",           (0, 0), (-1, -1), 1, MID_BLUE),
        ("INNERGRID",     (0, 0), (-1, -1), 0.5, MED_GRAY),
        ("TOPPADDING",    (0, 0), (-1, -1), 5),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
        ("LEFTPADDING",   (0, 0), (-1, -1), 8),
        ("RIGHTPADDING",  (0, 0), (-1, -1), 8),
        ("VALIGN",        (0, 0), (-1, -1), "TOP"),
    ]))
    return tbl

def two_col_table(data, header_row=None):
    col_w = [doc.width * 0.35, doc.width * 0.65]
    rows = []
    if header_row:
        rows.append([Paragraph(f"<b>{h}</b>", body) for h in header_row])
    for k, v in data:
        rows.append([Paragraph(f"<b>{k}</b>", body), Paragraph(v, body)])
    tbl = Table(rows, colWidths=col_w)
    style_cmds = [
        ("BOX",       (0, 0), (-1, -1), 1, MID_BLUE),
        ("INNERGRID", (0, 0), (-1, -1), 0.5, MED_GRAY),
        ("TOPPADDING",    (0, 0), (-1, -1), 5),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
        ("LEFTPADDING",   (0, 0), (-1, -1), 8),
        ("RIGHTPADDING",  (0, 0), (-1, -1), 8),
        ("VALIGN",    (0, 0), (-1, -1), "TOP"),
    ]
    if header_row:
        style_cmds += [
            ("BACKGROUND",  (0, 0), (-1, 0), DARK_BLUE),
            ("TEXTCOLOR",   (0, 0), (-1, 0), WHITE),
            ("FONTNAME",    (0, 0), (-1, 0), "Helvetica-Bold"),
        ]
    else:
        style_cmds += [("ROWBACKGROUNDS", (0, 0), (-1, -1), [LIGHT_BLUE, WHITE])]
    tbl.setStyle(TableStyle(style_cmds))
    return tbl

def bullets(items):
    return [Paragraph(f"• {item}", bullet_style) for item in items]

def hr():
    return HRFlowable(width="100%", thickness=1.2, color=MID_BLUE, spaceAfter=6, spaceBefore=6)

# ─── COVER PAGE ────────────────────────────────────────────────────────────────
def cover_page():
    elems = []
    # top colour block
    cover_data = [[
        Paragraph("APPROACH TO THE PATIENT", cover_title),
        Paragraph("&amp; GENERAL EXAMINATION", cover_title),
        Spacer(1, 0.4*cm),
        Paragraph("A Comprehensive Clinical Reference", cover_sub),
        Spacer(1, 0.3*cm),
        Paragraph("Based on Goldman-Cecil Medicine · Fuster &amp; Hurst's The Heart · Bailey &amp; Love's Surgery · S. Das Manual on Clinical Surgery · Neuroanatomy Through Clinical Cases", cover_ref),
        Spacer(1, 0.5*cm),
        Paragraph("Orris Medical Reference  |  July 2026", cover_ref),
    ]]
    cover_tbl = Table(cover_data, colWidths=[doc.width])
    cover_tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0, 0), (-1, -1), DARK_BLUE),
        ("TOPPADDING",    (0, 0), (-1, -1), 28),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 28),
        ("LEFTPADDING",   (0, 0), (-1, -1), 24),
        ("RIGHTPADDING",  (0, 0), (-1, -1), 24),
    ]))
    elems.append(Spacer(1, 2*cm))
    elems.append(cover_tbl)
    elems.append(Spacer(1, 1*cm))

    # TOC box
    toc_items = [
        ("1.", "Approach to the Patient — Principles"),
        ("2.", "History Taking — Structure & Components"),
        ("3.", "General Appearance & First Impression"),
        ("4.", "Vital Signs — Temperature, Pulse, BP, RR, SpO₂"),
        ("5.", "Systematic General Examination Head to Toe"),
        ("6.", "Examination of Hands, Nails & Peripheral Circulation"),
        ("7.", "Examination of the Head & Neck"),
        ("8.", "Chest & Cardiovascular Examination Overview"),
        ("9.", "Abdominal Examination Overview"),
        ("10.", "Neurological General Examination"),
        ("11.", "Lymph Nodes, Skin & Musculoskeletal Assessment"),
        ("12.", "Assessment, Differential Diagnosis & Plan"),
        ("13.", "Special Populations & Key Clinical Pearls"),
    ]
    toc_data = [[Paragraph(f"<b>{n}</b>", body), Paragraph(desc, body)] for n, desc in toc_items]
    toc_tbl = Table(toc_data, colWidths=[doc.width * 0.1, doc.width * 0.9])
    toc_tbl.setStyle(TableStyle([
        ("ROWBACKGROUNDS", (0, 0), (-1, -1), [LIGHT_BLUE, WHITE]),
        ("BOX",       (0, 0), (-1, -1), 1, MID_BLUE),
        ("INNERGRID", (0, 0), (-1, -1), 0.3, MED_GRAY),
        ("TOPPADDING",    (0, 0), (-1, -1), 4),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 4),
        ("LEFTPADDING",   (0, 0), (-1, -1), 8),
        ("RIGHTPADDING",  (0, 0), (-1, -1), 8),
    ]))

    toc_header = Table([[Paragraph("<b>TABLE OF CONTENTS</b>", ParagraphStyle("TOCHead",
        fontSize=12, fontName="Helvetica-Bold", textColor=WHITE, alignment=TA_CENTER))]],
        colWidths=[doc.width])
    toc_header.setStyle(TableStyle([
        ("BACKGROUND",    (0, 0), (-1, -1), MID_BLUE),
        ("TOPPADDING",    (0, 0), (-1, -1), 7),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 7),
    ]))
    elems.append(toc_header)
    elems.append(toc_tbl)
    elems.append(PageBreak())
    return elems

# ─── CONTENT ───────────────────────────────────────────────────────────────────
story = []
story += cover_page()

# ═══ SECTION 1: APPROACH TO THE PATIENT — PRINCIPLES ══════════════════════════
story.append(section_banner("1. APPROACH TO THE PATIENT — PRINCIPLES"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "The clinical encounter is the foundation of medical practice. Every clinician must develop a "
    "systematic, reproducible approach to each patient — one that is thorough, empathetic, and "
    "efficient. The goal is to gather sufficient information through history, examination, and "
    "investigations to reach a diagnosis and formulate a management plan.",
    body
))
story.append(Spacer(1, 0.2*cm))
story.append(info_box(
    "<b>Core Principle (Goldman-Cecil Medicine):</b> \"Care of the patient is guided by integration "
    "of the chief complaint, history, vital signs, and findings on physical examination. Physicians "
    "should be keenly aware of a patient's vital signs, because they are important markers of "
    "clinical stability.\""
))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("The Five Pillars of Patient Assessment", h2))
pillar_data = [
    ("Chief Complaint", "The primary symptom or reason for the patient's presentation, stated in their own words."),
    ("History", "A structured account of the present illness, past medical/surgical history, medications, allergies, family & social history."),
    ("Vital Signs", "Temperature, pulse, blood pressure, respiratory rate, oxygen saturation — objective markers of physiologic stability."),
    ("Physical Examination", "A systematic head-to-toe inspection, palpation, percussion, and auscultation."),
    ("Assessment & Plan", "Integration of all data into a diagnosis (or differential) and a management strategy."),
]
story.append(two_col_table(pillar_data, header_row=["Pillar", "Description"]))
story.append(Spacer(1, 0.4*cm))

story.append(Paragraph("Key Principles from Fuster & Hurst's The Heart (15th Ed.)", h3))
story.append(Paragraph(
    "Each clinician needs to develop his or her own stepwise approach to the cardiovascular "
    "examination — and by extension, all physical examinations. The initial history should be "
    "taken with the patient fully dressed to allow a one-to-one relationship to be built. "
    "For a comprehensive physical examination, the patient must be undressed with an appropriate "
    "gown. An examination should <b>never</b> be done by placing the stethoscope under a shirt or "
    "blouse; full inspection of the chest and extremities is always necessary.",
    body
))
story.append(Spacer(1, 0.5*cm))

# ═══ SECTION 2: HISTORY TAKING ══════════════════════════════════════════════
story.append(section_banner("2. HISTORY TAKING — STRUCTURE & COMPONENTS"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "A thorough history is the single most important diagnostic tool. Studies show that in the "
    "majority of cases, a diagnosis can be made from history alone. The history must be systematic, "
    "complete, and documented in a standard order.",
    body
))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("A. Identifying Data & Chief Complaint", h2))
story.append(Paragraph(
    "Begin every history with identifying data: patient's name, age, sex, occupation, "
    "and source of referral. The chief complaint (CC) is the main symptom in the patient's own "
    "words, e.g., 'chest pain for 2 hours.' Always record its duration.",
    body
))

story.append(Paragraph("B. History of Present Illness (HPI) — SOCRATES Framework", h2))
socrates_data = [
    ("S — Site",         "Where is the problem? Does it radiate anywhere?"),
    ("O — Onset",        "When did it start? Was onset sudden or gradual?"),
    ("C — Character",    "What is the quality? (Sharp, dull, burning, colicky, throbbing)"),
    ("R — Radiation",    "Does it spread? (E.g., angina radiating to the left arm/jaw)"),
    ("A — Associations", "Associated symptoms? (Nausea, sweating, dyspnoea, etc.)"),
    ("T — Time course",  "Constant or intermittent? Getting better or worse?"),
    ("E — Exacerbating/Relieving", "What makes it worse or better? (Exercise, rest, food, position)"),
    ("S — Severity",     "Score 1–10. How does it affect daily activities?"),
]
story.append(two_col_table(socrates_data, header_row=["Component", "Key Questions"]))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("C. Past Medical & Surgical History (PMH/PSH)", h2))
story += bullets([
    "Previous illnesses, hospitalisations, operations, procedures",
    "Childhood illnesses (rheumatic fever, measles, pertussis)",
    "Trauma, accidents",
    "Obstetric history in women (G×P×, complications, menstrual history)",
    "Psychiatric history"
])

story.append(Paragraph("D. Medications & Allergies", h2))
story += bullets([
    "Current medications: name, dose, frequency, duration, compliance",
    "Over-the-counter drugs, herbal/complementary medicines",
    "Drug allergies: document the reaction type (rash, anaphylaxis, intolerance)",
    "Vaccinations and immunisation history"
])

story.append(Paragraph("E. Family History", h2))
story += bullets([
    "First-degree relatives: parents, siblings, children",
    "Heritable conditions: coronary artery disease, diabetes, hypertension, cancer, stroke",
    "Genetic disorders, consanguinity in some populations",
    "Note age and cause of death of parents if deceased"
])

story.append(Paragraph("F. Social & Personal History", h2))
story += bullets([
    "Smoking: pack-year history (packs/day × years)",
    "Alcohol: units per week; CAGE questionnaire if indicated",
    "Recreational/illicit drug use (non-judgmentally)",
    "Occupation and occupational exposures (asbestos, silica, radiation)",
    "Marital/relationship status, living conditions, social support",
    "Travel history (tropical infections, endemic diseases)",
    "Sexual history (orientation, partners, protected sex, STI screening)",
    "Military service history (exposures, injuries, PTSD risk)"
])

story.append(Spacer(1, 0.3*cm))
story.append(info_box(
    "<b>Clinical Pearl:</b> The social history often unlocks diagnoses that the rest of the history "
    "misses. Occupation, travel, and substance use are frequently under-elicited. The [CDC "
    "guidelines] recommend routinely collecting sexual orientation and gender identity "
    "data to improve care equity."
))
story.append(Spacer(1, 0.5*cm))

# ═══ SECTION 3: GENERAL APPEARANCE ══════════════════════════════════════════
story.append(section_banner("3. GENERAL APPEARANCE & FIRST IMPRESSION"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "Before touching the patient, spend 30–60 seconds observing their overall appearance. "
    "This 'end-of-bed' assessment can yield critical diagnostic information instantly.",
    body
))
story.append(Spacer(1, 0.2*cm))
story.append(info_box(
    "<b>Goldman-Cecil Medicine:</b> \"Clinicians should never forget that the most important vital sign "
    "is what the patient looks like; general appearance is a sign that guides the intensity and "
    "urgency of the evaluation.\""
))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("End-of-Bed Observations", h2))
appear_data = [
    ("Level of consciousness", "Alert, drowsy, confused, stuporous, comatose (use GCS)"),
    ("Distress / discomfort",  "Acute distress, pain grimacing, laboured breathing, agitation"),
    ("Body habitus",           "Obese, cachectic, well-nourished; BMI estimation; muscular wasting"),
    ("Posture",                "Sitting forward (cardiac tamponade, pericarditis, COPD), writhing (colic), rigid (peritonitis)"),
    ("Skin colour",            "Pale (anaemia/shock), jaundiced, cyanosed, flushed, ashen, mottled"),
    ("Dysmorphic features",    "Syndromic features: Marfan, Turner, Down, Cushing — may guide diagnosis immediately"),
    ("Age vs appearance",      "Does the patient look older than stated age? (Chronic disease, lifestyle, neglect)"),
    ("Hygiene & dress",        "Self-neglect may suggest psychiatric illness, dementia, or social deprivation"),
    ("Assistive devices",      "Wheelchair, walking aids, oxygen, hearing aids, glasses"),
    ("Affect & mood",          "Anxious, depressed, flat, irritable — psychiatric assessment prompt"),
]
story.append(two_col_table(appear_data, header_row=["Observation", "Clinical Significance"]))
story.append(Spacer(1, 0.5*cm))

# ═══ SECTION 4: VITAL SIGNS ══════════════════════════════════════════════════
story.append(section_banner("4. VITAL SIGNS"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "The five key vital signs are temperature, pulse, blood pressure, respiratory rate, and oxygen "
    "saturation (pulse oximetry). They are objective, reproducible markers of physiologic stability. "
    "Each should be measured accurately and documented at every clinical encounter.",
    body
))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("A. Temperature", h2))
temp_data = [
    ("Normal range",        "36.1 – 37.2 °C (97 – 99 °F) orally; rectally ~0.5°C higher"),
    ("Fever (pyrexia)",     ">38.0 °C — infection (bacterial, viral, fungal), inflammatory, malignancy, drugs"),
    ("Hyperpyrexia",        ">40°C — severe sepsis, heatstroke, malignant hyperthermia, neuroleptic malignant syndrome"),
    ("Hypothermia",         "<35°C — exposure, hypothyroidism, sepsis (especially elderly), alcohol intoxication"),
    ("Methods",             "Oral (most common), rectal (most accurate), tympanic, axillary (least accurate), temporal"),
    ("Fever patterns",      "Continuous (lobar pneumonia), intermittent (malaria), remittent (typhoid), hectic/septic (abscess)"),
]
story.append(two_col_table(temp_data))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("B. Pulse", h2))
pulse_data = [
    ("Normal rate",         "60–100 bpm (adults); higher in children, infants"),
    ("Tachycardia",         ">100 bpm — fever, pain, anxiety, anaemia, heart failure, hyperthyroidism, shock"),
    ("Bradycardia",         "<60 bpm — athletes, vagal tone, heart block, hypothyroidism, raised ICP (Cushing reflex), beta-blockers"),
    ("Rhythm",              "Regular or irregular? If irregular — is it regularly irregular (2° heart block) or irregularly irregular (AF)?"),
    ("Volume",              "Full/bounding (fever, AR, PDA, CO₂ retention) vs. weak/thready (shock, dehydration, AS)"),
    ("Character",           "Slow-rising (AS), collapsing (AR, PDA), bisferiens (mixed AS+AR), pulsus alternans (LVF), paradoxus (cardiac tamponade, severe asthma)"),
    ("Rate variability",    "Pulsus paradoxus: >10 mmHg fall in SBP on inspiration — tamponade, severe asthma/COPD"),
    ("Radial-femoral delay","Coarctation of aorta — always check in young hypertensives"),
]
story.append(two_col_table(pulse_data))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("C. Blood Pressure", h2))
bp_data = [
    ("Normal",              "Systolic 90–120 mmHg; Diastolic 60–80 mmHg"),
    ("Prehypertension",     "120–139/80–89 mmHg — lifestyle modification advised"),
    ("Stage 1 HTN",         "140–159/90–99 mmHg"),
    ("Stage 2 HTN",         "≥160/≥100 mmHg"),
    ("Hypertensive urgency","≥180/≥120 mmHg without end-organ damage"),
    ("Hypertensive emergency","≥180/≥120 mmHg WITH end-organ damage (brain, heart, kidneys, eyes)"),
    ("Hypotension",         "<90/60 mmHg — septic, cardiogenic, hypovolaemic, neurogenic, anaphylactic shock"),
    ("Measurement",         "Both arms routinely — >10 mmHg difference suggests subclavian stenosis or aortic dissection"),
    ("Postural BP",         "Lying→standing — fall >20 mmHg systolic or >10 mmHg diastolic = orthostatic hypotension"),
    ("Pulse pressure",      "SBP - DBP; widened (>60) in AR, atherosclerosis; narrowed (<25) in AS, tamponade, shock"),
]
story.append(two_col_table(bp_data))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("D. Respiratory Rate", h2))
rr_data = [
    ("Normal",      "12–20 breaths/min (adults)"),
    ("Tachypnoea",  ">20 — pneumonia, PE, heart failure, metabolic acidosis, pain, anxiety"),
    ("Bradypnoea",  "<12 — opioid overdose, raised ICP, metabolic alkalosis, hypothyroidism"),
    ("Patterns",    "Cheyne-Stokes (CCF, uraemia, raised ICP), Kussmaul (metabolic acidosis), Biot's (raised ICP)"),
    ("Note",        "RR is the most sensitive early indicator of deterioration — often under-recorded. Count for a full 60 seconds."),
]
story.append(two_col_table(rr_data))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("E. Oxygen Saturation (SpO₂)", h2))
spo2_data = [
    ("Normal",          "≥95% on room air (94–98% acceptable range)"),
    ("Mild hypoxia",    "90–94% — supplemental oxygen, investigate cause"),
    ("Moderate hypoxia","85–89% — high-flow oxygen, close monitoring"),
    ("Severe hypoxia",  "<85% — life-threatening, may need respiratory support"),
    ("Limitation",      "Unreliable in carbon monoxide poisoning (CO-oximetry required); inaccurate in poor perfusion, nail polish, dark pigmentation"),
    ("Fifth vital sign","Now considered standard alongside T, P, BP, RR in all clinical settings"),
]
story.append(two_col_table(spo2_data))
story.append(Spacer(1, 0.3*cm))

story.append(info_box(
    "<b>Additional Metrics to Record:</b> Height and weight → BMI (kg/m²). BMI <18.5 = underweight; "
    "18.5–24.9 = normal; 25–29.9 = overweight; ≥30 = obese. Waist circumference (metabolic risk). "
    "In elective settings, always record BMI."
))
story.append(Spacer(1, 0.5*cm))

# ═══ SECTION 5: SYSTEMATIC GENERAL EXAMINATION ═══════════════════════════════
story.append(section_banner("5. SYSTEMATIC GENERAL EXAMINATION — HEAD TO TOE"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "The physical examination proceeds systematically from head to toe. This ensures no region "
    "is missed. The four techniques — inspection, palpation, percussion, auscultation (IPPA) — "
    "are applied in order to each region, except the abdomen where auscultation precedes palpation.",
    body
))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("Sequence of a Complete Physical Examination", h2))
seq_data = [
    ("1", "General appearance, nutritional status, hydration, mental state"),
    ("2", "Vital signs (T, P, BP, RR, SpO₂, height, weight, BMI)"),
    ("3", "Hands, nails, peripheral circulation, radial pulse"),
    ("4", "Head — scalp, face, eyes (PERLA, fundi), ears, nose, mouth/teeth, throat"),
    ("5", "Neck — thyroid, trachea, carotids, JVP, lymph nodes"),
    ("6", "Chest — respiratory system (inspection, palpation, percussion, auscultation)"),
    ("7", "Cardiovascular — precordium (inspection, palpation, auscultation)"),
    ("8", "Abdomen — inspection, auscultation, palpation (light then deep), percussion"),
    ("9", "Genitalia, hernial orifices, per rectal/vaginal examination if indicated"),
    ("10","Extremities — upper and lower, oedema, peripheral pulses, joints"),
    ("11","Neurological examination — cranial nerves, motor, sensory, reflexes, coordination, gait"),
    ("12","Musculoskeletal — joints, spine, muscles"),
    ("13","Dermatological — skin, hair, nails — systematic survey"),
    ("14","Lymph nodes — all groups"),
]
seq_table_data = [[Paragraph(f"<b>Step {n}</b>", body), Paragraph(desc, body)] for n, desc in seq_data]
seq_tbl = Table(seq_table_data, colWidths=[doc.width * 0.18, doc.width * 0.82])
seq_tbl.setStyle(TableStyle([
    ("ROWBACKGROUNDS", (0, 0), (-1, -1), [LIGHT_BLUE, WHITE]),
    ("BOX",       (0, 0), (-1, -1), 1, MID_BLUE),
    ("INNERGRID", (0, 0), (-1, -1), 0.4, MED_GRAY),
    ("TOPPADDING",    (0, 0), (-1, -1), 4),
    ("BOTTOMPADDING", (0, 0), (-1, -1), 4),
    ("LEFTPADDING",   (0, 0), (-1, -1), 8),
    ("RIGHTPADDING",  (0, 0), (-1, -1), 8),
    ("VALIGN",    (0, 0), (-1, -1), "TOP"),
]))
story.append(seq_tbl)
story.append(Spacer(1, 0.5*cm))

# ═══ SECTION 6: HANDS, NAILS & PERIPHERAL CIRCULATION ═══════════════════════
story.append(section_banner("6. HANDS, NAILS & PERIPHERAL CIRCULATION"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "Examination of the hands takes only 30 seconds but yields enormous diagnostic information. "
    "Shaking a patient's hand gives a simultaneous frailty assessment, tissue perfusion estimate, "
    "myotonia screen, and temperature assessment.",
    body
))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("Nail Signs", h2))
nail_data = [
    ("Clubbing",            "Grade I–IV. Causes: bronchogenic carcinoma, suppurative lung disease (abscess, bronchiectasis), cyanotic CHD, infective endocarditis, IBD, cirrhosis, mesothelioma"),
    ("Koilonychia",         "Spoon-shaped nails — iron deficiency anaemia (chronic, severe)"),
    ("Leuconychia",         "White nails — hypoalbuminaemia (chronic liver disease, nephrotic syndrome, malnutrition)"),
    ("Terry's nails",       "White proximally, pink distally — liver cirrhosis, CCF, diabetes"),
    ("Splinter haemorrhages","Longitudinal brown-red lines — infective endocarditis (distal splinters are often traumatic)"),
    ("Onycholysis",         "Nail lifting from bed — hyperthyroidism (Plummer's nails), psoriasis, trauma, fungal infection"),
    ("Beau's lines",        "Transverse grooves — periods of severe systemic illness, nutritional deficiency, chemotherapy"),
    ("Mees' lines",         "White transverse bands — arsenic poisoning, renal failure, chemotherapy"),
    ("Cyanosis (peripheral)","Blue discolouration of nails — vasospasm, cold exposure, peripheral vascular disease"),
    ("Pitting",             "Small pits — psoriasis, alopecia areata"),
]
story.append(two_col_table(nail_data, header_row=["Sign", "Causes / Significance"]))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("Hand Signs", h2))
hand_data = [
    ("Pallor of palmar creases", "Haemoglobin <7–8 g/dL — significant anaemia"),
    ("Palmar erythema",         "Chronic liver disease, pregnancy, RA, hyperthyroidism, idiopathic"),
    ("Dupuytren's contracture", "Fibrosis of palmar fascia — liver cirrhosis (alcohol), diabetes, trauma, genetic"),
    ("Tremor",                  "Resting (Parkinson's), intention (cerebellar), postural (essential tremor, thyrotoxicosis)"),
    ("Wasting of thenar eminence","Carpal tunnel syndrome (median nerve), T1 root lesion"),
    ("Wasting of hypothenar",   "Ulnar nerve palsy, C8/T1 root lesion, syringomyelia"),
    ("Heberden's nodes",        "DIP joint osteophytes — primary osteoarthritis"),
    ("Bouchard's nodes",        "PIP joint osteophytes — osteoarthritis"),
    ("Osler's nodes",           "Painful nodules on fingertips — infective endocarditis (immune complex)"),
    ("Janeway lesions",         "Non-tender haemorrhagic macules on palms/soles — infective endocarditis (septic emboli)"),
    ("Xanthomata",              "Cholesterol deposits — hypercholesterolaemia, familial hyperlipidaemia"),
]
story.append(two_col_table(hand_data))
story.append(Spacer(1, 0.5*cm))

# ═══ SECTION 7: HEAD & NECK ══════════════════════════════════════════════════
story.append(section_banner("7. HEAD & NECK EXAMINATION"))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("Eyes", h2))
eye_data = [
    ("Conjunctival pallor",    "Anaemia — pull down lower lid; pale pink/white mucosa"),
    ("Scleral icterus",        "Jaundice — bilirubin >35 µmol/L; best seen in natural light"),
    ("Corneal arcus",          "Lipid ring — hyperlipidaemia in <45 years; normal in elderly"),
    ("Xanthelasmata",          "Yellow plaques at inner canthi — hyperlipidaemia"),
    ("Proptosis/exophthalmos", "Hyperthyroidism (Graves'), retro-orbital tumour"),
    ("Ptosis",                 "CN III palsy (with dilated pupil), Horner's (with miosis), myasthenia gravis (fatigable)"),
    ("Kayser-Fleischer rings", "Copper deposits in Descemet's membrane — Wilson's disease"),
    ("Pupils",                 "PERLA (pupils equal, round, reactive to light and accommodation). Anisocoria, fixed dilated, pinpoint"),
    ("Fundoscopy",             "Papilloedema (raised ICP), hypertensive retinopathy (AV nipping, haemorrhages), diabetic retinopathy"),
]
story.append(two_col_table(eye_data))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("Face & Mouth", h2))
face_data = [
    ("Moon face",           "Cushing's syndrome — round plethoric face, acne, hirsutism"),
    ("Malar flush",         "Mitral stenosis — bilateral reddish-cyanotic cheeks"),
    ("Butterfly rash",      "SLE — erythematous rash across cheeks and nose bridge, sparing nasolabial folds"),
    ("Acromegalic facies",  "Protruding jaw, large nose, coarse features, widely spaced teeth — GH excess"),
    ("Myxoedematous facies","Periorbital puffiness, thick dry skin, hoarse voice, sparse lateral eyebrows — hypothyroidism"),
    ("Central cyanosis",    "Bluish discolouration of lips and tongue — cardiorespiratory failure, Hb <5 g/dL of deoxygenated blood"),
    ("Angular cheilosis",   "Iron deficiency, B₂ deficiency, ill-fitting dentures"),
    ("Mouth/teeth",         "Dental caries/infection — source of bacteraemia; gum disease; oral candidiasis (immunosuppression)"),
]
story.append(two_col_table(face_data))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("Neck", h2))
neck_data = [
    ("JVP",                 "Jugular venous pressure — internal jugular at 45°. Normal <3 cm above sternal angle. Elevated in CCF, SVCO, pericardial disease, TR"),
    ("Tracheal position",   "Central vs. deviated — trachea deviates away from tension pneumothorax, towards collapse/fibrosis"),
    ("Thyroid",             "Size, consistency, nodularity, tenderness, bruit, lymphadenopathy, dysphagia, tracheal compression"),
    ("Carotid pulse",       "Rate, character, bruits (→ carotid artery disease)"),
    ("Cervical LN",         "Anterior/posterior triangle; supraclavicular (Virchow's node — left = GI malignancy, right = lung/mediastinal)"),
]
story.append(two_col_table(neck_data))
story.append(Spacer(1, 0.5*cm))

# ═══ SECTION 8: CHEST & CARDIOVASCULAR ═══════════════════════════════════════
story.append(section_banner("8. CHEST & CARDIOVASCULAR EXAMINATION OVERVIEW"))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("Stepwise Cardiovascular Examination (Fuster & Hurst's The Heart)", h2))
cardio_data = [
    ("Sitting — Step 1",  "General inspection including dental examination (source of endocarditis)"),
    ("Sitting — Step 2",  "Shake hands → palpate radial pulse; inspect nail beds (clubbing, cyanosis, splinters)"),
    ("Sitting — Step 3",  "Manual blood pressure both arms (>10 mmHg difference is significant)"),
    ("Sitting — Step 4",  "Inspect chest and lower extremities — skin, scars, deformity"),
    ("Sitting — Step 5",  "Palpation + auscultation of carotids — upstroke character, bruits"),
    ("Sitting — Step 6",  "Palpation of chest — PMI, heaves, thrills"),
    ("Sitting — Step 7",  "Lung examination — percussion + auscultation (crackles in CCF/pneumonia, wheeze in COPD/asthma)"),
    ("Sitting — Step 8",  "Auscultation of precordium with diaphragm: upper sternal border → right upper sternal → down to apex"),
    ("Sitting→Supine",    "Estimate central venous pressure via JVP; may need to lower head of bed"),
    ("Supine — Step 10",  "Inspect precordium — apex beat position, visible heave"),
    ("Supine — Step 11",  "Palpate apical impulse + right ventricular heave"),
    ("Supine — Step 12",  "Auscultate with diaphragm: apex → sternal border → left upper border → right upper sternal"),
    ("Left lateral decubitus","Palpate and auscultate apex with bell — mitral stenosis rumble best heard here"),
    ("Remaining exam",    "Liver size (hepatomegaly in CCF), ascites, ankle/sacral oedema, vascular exam of legs"),
]
story.append(two_col_table(cardio_data, header_row=["Position / Step", "Examination Element"]))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("Respiratory Examination Highlights", h2))
resp_data = [
    ("Inspection",   "Respiratory rate, pattern, depth; use of accessory muscles; chest shape (barrel = hyperinflation), asymmetry, scars; tracheal position; pursed-lip breathing"),
    ("Palpation",    "Chest expansion (normal = symmetric, ≥5 cm); tactile vocal fremitus (increased = consolidation; decreased = effusion/pneumothorax)"),
    ("Percussion",   "Resonant (normal), dull (consolidation, effusion, collapse), hyper-resonant (pneumothorax, emphysema)"),
    ("Auscultation", "Breath sounds: vesicular (normal), bronchial (consolidation, above effusion). Added sounds: crackles (fine=fibrosis/LVF, coarse=secretions), wheeze (airway narrowing), pleural rub"),
]
story.append(two_col_table(resp_data))
story.append(Spacer(1, 0.5*cm))

# ═══ SECTION 9: ABDOMINAL EXAMINATION ════════════════════════════════════════
story.append(section_banner("9. ABDOMINAL EXAMINATION OVERVIEW"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "The patient should be lying flat with hips and knees extended (pillow if needed) with the "
    "abdomen adequately exposed from xiphisternum to inguinal ligaments. For palpation, flex "
    "hips and knees to relax abdominal muscles. (Bailey & Love's Surgery, 28th Ed.)",
    body
))
story.append(Spacer(1, 0.2*cm))

abd_data = [
    ("Inspection",
     "Weight loss, dehydration, pedal oedema, anaemia, jaundice, abnormal pigmentation. "
     "Scars, distension, visible peristalsis, dilated veins (caput medusae in portal HTN), "
     "pulsatile mass, visible hernias. "
     "Grey Turner's sign = flank bruising (retroperitoneal haemorrhage — pancreatitis, AAA). "
     "Cullen's sign = periumbilical bruising (pancreatitis, ruptured ectopic, liver trauma)."),
    ("Auscultation",
     "Before palpation. Normal bowel sounds q5–15 seconds. "
     "Absent = paralytic ileus, peritonitis. "
     "Tinkling/high-pitched = mechanical obstruction. "
     "Arterial bruits = renal artery stenosis (renal bruits), AAA."),
    ("Palpation — Light",
     "Superficial palpation with warm hands, watching the face. "
     "Tenderness, guarding (voluntary/involuntary), rebound tenderness (peritonism). "
     "Start away from the area of pain."),
    ("Palpation — Deep",
     "Organomegaly: liver (measure in cm below costal margin), spleen (Traube's space, left lateral decubitus), kidneys (bimanual ballottement). "
     "Identify masses: location, size, shape, consistency, surface, mobility, pulsatility, transillumination."),
    ("Percussion",
     "Liver span (6–12 cm). "
     "Splenomegaly (dull in Traube's space). "
     "Shifting dullness + fluid thrill = ascites (≥1.5L for shifting dullness). "
     "Suprapubic dullness = bladder distension."),
    ("Hernial orifices",
     "Inguinal (medial = direct, lateral = indirect), femoral (below and lateral to pubic tubercle), umbilical, incisional scars. "
     "Ask patient to cough; check for reducibility, auscultate if suspected bowel."),
    ("PR examination",
     "Rectal mass, haemorrhoids, prostate size/consistency, cervix, peritoneal deposits ('shelf'). "
     "Observe stool on glove: blood, mucus, melaena."),
]
story.append(two_col_table(abd_data, header_row=["Technique", "Key Findings"]))
story.append(Spacer(1, 0.5*cm))

# ═══ SECTION 10: NEUROLOGICAL GENERAL EXAMINATION ═══════════════════════════
story.append(section_banner("10. NEUROLOGICAL GENERAL EXAMINATION"))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph(
    "The neurological examination proceeds systematically. Localization is the cornerstone — "
    "identifying where in the nervous system the lesion is, before considering what it is. "
    "(Neuroanatomy Through Clinical Cases, 3rd Ed.)",
    body
))
story.append(Spacer(1, 0.2*cm))

neuro_data = [
    ("Mental State",        "Consciousness (GCS/AVPU), orientation (time, place, person), memory (short/long term), language, affect, higher functions — MMSE/MoCA if indicated"),
    ("Cranial Nerves I–XII","CN I: smell. CN II: acuity, fields, fundi, RAPD. CN III/IV/VI: eye movements, pupils. CN V: facial sensation + jaw. CN VII: facial muscles. CN VIII: hearing, Rinne/Weber. CN IX/X: palate, gag. CN XI: trapezius/SCM. CN XII: tongue (wasting, fasciculations, deviation)"),
    ("Motor System",        "Tone (normal/spastic/rigid/flaccid), power (MRC 0–5 scale), bulk (wasting, hypertrophy), involuntary movements (tremor, fasciculations, chorea, athetosis)"),
    ("Reflexes",            "DTRs: biceps C5, triceps C7, supinator C6, knee L3-4, ankle S1. Plantar response (upgoing=UMN). Reinforcement (Jendrassik). Clonus. Primitive reflexes (frontal lobe)"),
    ("Sensation",           "Light touch, pinprick, temperature, vibration (128 Hz tuning fork), proprioception (joint position sense), two-point discrimination, stereognosis, graphaesthesia"),
    ("Coordination",        "Finger-nose test (dysmetria, intention tremor), heel-shin, rapid alternating movements (dysdiadochokinesis), Romberg's test"),
    ("Gait",                "Observe: stride, base, arm swing, turning. Hemiplegic, spastic (scissors), steppage (foot drop), ataxic (broad-based), parkinsonian (shuffling, festinant, reduced arm swing), apraxic (dementia)"),
    ("Signs of meningism",  "Neck stiffness, Kernig's sign (knee extension from 90° flexion), Brudzinski's sign — bacterial meningitis, SAH, meningeal carcinomatosis"),
]
story.append(two_col_table(neuro_data, header_row=["Component", "Assessment"]))
story.append(Spacer(1, 0.5*cm))

# ═══ SECTION 11: LYMPH NODES, SKIN, MSK ══════════════════════════════════════
story.append(section_banner("11. LYMPH NODES, SKIN & MUSCULOSKELETAL ASSESSMENT"))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("Lymph Node Examination", h2))
ln_data = [
    ("Cervical groups",   "Submental, submandibular, anterior/posterior cervical chains, preauricular, postauricular, occipital, supraclavicular"),
    ("Axillary groups",   "Anterior (pectoral), posterior (subscapular), lateral, medial (brachial), apical — examine with arm supported"),
    ("Inguinal groups",   "Horizontal (superficial inguinal), vertical"),
    ("Other groups",      "Epitrochlear (forearm/hand infections, secondary syphilis), popliteal (rare)"),
    ("Palpation features","Size, shape, consistency (hard=malignant; rubbery=lymphoma; soft=reactive), surface, tenderness, fixation, matting, overlying skin"),
    ("Virchow's node",    "Left supraclavicular lymphadenopathy — Troisier's sign — GI malignancy (especially gastric). Right supraclavicular — lung, mediastinum"),
    ("Causes of generalised LN", "Infections (EBV, HIV, TB, brucella), haematological malignancy (CLL, lymphoma), SLE, sarcoidosis, drugs"),
]
story.append(two_col_table(ln_data, header_row=["Region/Feature", "Details"]))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("Key Dermatological Signs in General Examination", h2))
derm_data = [
    ("Jaundice",            "Skin + sclera yellow → pre-hepatic (haemolysis), hepatic (liver disease), post-hepatic (biliary obstruction)"),
    ("Pallor",              "Anaemia, shock, vasoconstriction — assess conjunctivae, palms, mucous membranes"),
    ("Central cyanosis",    "Lips, tongue, buccal mucosa — right-to-left shunts, severe respiratory failure"),
    ("Peripheral cyanosis", "Fingers, toes, nose, ears — vasoconstriction, Raynaud's, peripheral vascular disease"),
    ("Spider naevi",        ">5 in distribution of SVC (face, neck, upper arms, trunk) — chronic liver disease; also seen in pregnancy"),
    ("Purpura/petechiae",   "Non-blanching — thrombocytopaenia, meningococcaemia, vasculitis, DIC, Henoch-Schönlein purpura"),
    ("Oedema",              "Pedal/ankle oedema: CCF, hypoalbuminaemia (nephrotic/hepatic), venous insufficiency, lymphoedema, drug-induced. Sacral oedema in bed-bound patients"),
    ("Rashes",              "Distribution, character (macular, papular, vesicular, pustular, plaques), blanching — document carefully"),
    ("Hyperpigmentation",   "Addison's disease (buccal mucosa, pressure areas, scars), haemochromatosis (bronzing), primary biliary cholangitis"),
    ("Striae",              "Silver (old) or purple/red (active — Cushing's/rapid weight change)"),
]
story.append(two_col_table(derm_data))
story.append(Spacer(1, 0.5*cm))

# ═══ SECTION 12: ASSESSMENT, DIFFERENTIAL & PLAN ═════════════════════════════
story.append(section_banner("12. ASSESSMENT, DIFFERENTIAL DIAGNOSIS & PLAN"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "After completing the history and examination, the clinician synthesises all findings into "
    "a structured Assessment and Plan. This is the clinical reasoning step — moving from data "
    "collection to diagnosis and management.",
    body
))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("Structure of Assessment", h2))
story.append(Paragraph(
    "<b>Step 1 — Summary formulation:</b> A 1–2 sentence summary encapsulating the patient's key clinical "
    "features and most likely diagnosis.",
    body
))
story.append(Paragraph(
    "<i>Example: \"This is a 53-year-old man with cardiac risk factors of hypertension and family "
    "history of coronary artery disease who presents with substernal chest pain and EKG changes "
    "suggestive of anterolateral wall myocardial infarction.\"</i>",
    note_style
))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "<b>Step 2 — Differential diagnosis:</b> List alternative diagnoses in order of likelihood. "
    "Use the mnemonic VINDICATE or a systems-based approach.",
    body
))
story.append(Paragraph(
    "<b>Step 3 — Problem list:</b> Break down all active problems.",
    body
))
story.append(Paragraph(
    "<b>Step 4 — Management plan:</b> For each problem, outline investigations, treatments, "
    "monitoring, referrals, and patient education.",
    body
))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("Neurological Differential Diagnosis — Arrowhead Approach", h2))
story.append(Paragraph(
    "In neurology, the assessment is first anatomical (localization), then aetiological. "
    "Use the mnemonic <b>VITAMIN C(D)</b> for the neurological differential:",
    body
))
vitamin_data = [
    ("V — Vascular",        "Stroke, TIA, haemorrhage, vasculitis, venous thrombosis"),
    ("I — Infectious",      "Meningitis, encephalitis, abscess, HIV, PML, neurosyphilis"),
    ("T — Traumatic/Toxic", "Head injury, spinal cord injury, metabolic encephalopathy, drugs/alcohol"),
    ("A — Autoimmune",      "MS, NMO, anti-NMDAR encephalitis, Guillain-Barré, myasthenia gravis, vasculitis"),
    ("M — Metabolic",       "Hepatic/renal encephalopathy, hypoglycaemia, electrolyte disorders, thiamine deficiency"),
    ("I — Idiopathic",      "Epilepsy, Parkinson's disease, essential tremor"),
    ("N — Neoplastic",      "Primary brain tumour, metastases, paraneoplastic syndromes, meningeal carcinomatosis"),
    ("C — Congenital",      "Malformations, neurocutaneous syndromes (NF1/2, TSC, Sturge-Weber)"),
    ("D — Degenerative",    "Alzheimer's, frontotemporal dementia, motor neurone disease, Huntington's, MSA"),
]
story.append(two_col_table(vitamin_data, header_row=["Category", "Examples"]))
story.append(Spacer(1, 0.5*cm))

# ═══ SECTION 13: SPECIAL POPULATIONS & CLINICAL PEARLS ═══════════════════════
story.append(section_banner("13. SPECIAL POPULATIONS & KEY CLINICAL PEARLS"))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("Special Populations", h2))
pop_data = [
    ("Paediatric",      "Adjust normal ranges for age (HR, BP, RR). Use PEWS score for deterioration. Assess growth parameters, developmental milestones, immunisation status, safeguarding concerns"),
    ("Geriatric",       "Polypharmacy (>5 medications — increased interaction risk). Atypical presentations of common diseases. Falls, cognitive decline, functional status (ADLs/IADLs), nutritional screening, pressure sores, urinary incontinence"),
    ("Pregnant",        "Physiological changes: HR+10–15 bpm, BP drops in 2nd trimester, RR may increase. Avoid supine position in late pregnancy (aortocaval compression). Fundal height, foetal heart sounds, presentation, engagement"),
    ("Immunocompromised","Atypical/absent fever, minimal examination signs despite severe infection. Low threshold for investigation. Screen for opportunistic infections (PCP, CMV, fungal)"),
    ("Renal/hepatic impairment", "Drug dosing adjustments mandatory. Monitor for encephalopathy (hepatic), uraemia (renal). Fluid balance critically important"),
    ("Psychiatric/alcohol/drug","Non-judgmental approach. Cognitive assessment. Withdrawal risk scoring (CIWA for alcohol). Nutritional status, infectious disease screening (HIV, Hep B/C), safeguarding"),
]
story.append(two_col_table(pop_data, header_row=["Population", "Special Considerations"]))
story.append(Spacer(1, 0.3*cm))

story.append(Paragraph("Key Clinical Pearls", h2))
pearls = [
    "The history gives the diagnosis in 70–80% of cases. Time invested in history is never wasted.",
    "Vital signs are the most sensitive early indicators of deterioration — respiratory rate especially. Always count the RR for a full 60 seconds.",
    "Never examine through clothing. Proper exposure is non-negotiable for a thorough examination.",
    "Always examine the other limb, the contralateral lymph nodes, and adjacent structures before diagnosing a localised lesion.",
    "In any patient with a swelling suspected to be malignant, metastatic sites must be systematically assessed — chest (cough, haemoptysis), liver, abdomen (peritoneal), bones (spine, pelvis, skull). (S. Das, Manual on Clinical Surgery)",
    "Lymph node enlargement always requires examination of all lymph node groups to identify the cause.",
    "Grey Turner's sign and Cullen's sign indicate retroperitoneal/intra-abdominal haemorrhage — early recognition can be life-saving.",
    "A 'positive shaking hands' examination gives frailty assessment, tone, temperature, pulse, and bilateral BP asymmetry simultaneously.",
    "Virchow's node (left supraclavicular lymphadenopathy) is a red flag for intra-abdominal or thoracic malignancy — never ignore it.",
    "Document all findings clearly: positive AND pertinent negative findings both contribute to the clinical picture and medicolegal record.",
    "In elderly patients, always assess functional status alongside clinical examination — a patient's ability to perform ADLs often predicts outcome better than lab values.",
    "Pain is sometimes considered the 'sixth vital sign' — always assess and document it."
]
for pearl in pearls:
    story.append(Paragraph(f"★  {pearl}", bullet_style))
    story.append(Spacer(1, 0.1*cm))

story.append(Spacer(1, 0.4*cm))
story.append(hr())

# ─── References ───────────────────────────────────────────────────────────────
story.append(Paragraph("References & Sources", h2))
refs = [
    "Goldman L, Cooney KA (eds). Goldman-Cecil Medicine International Edition, 2-Volume Set. 26th ed. Elsevier, 2023.",
    "Fuster V, Harrington RA, Narula J, Eapen ZJ (eds). Fuster and Hurst's The Heart. 15th ed. McGraw-Hill, 2022.",
    "Williams NS, O'Connell PR, McCaskie AW (eds). Bailey and Love's Short Practice of Surgery. 28th ed. CRC Press/Taylor & Francis, 2023.",
    "Das S. A Manual on Clinical Surgery. 13th ed. Dr S Das, 2020.",
    "Blumenfeld H. Neuroanatomy Through Clinical Cases. 3rd ed. Sinauer/Oxford University Press, 2021.",
    "Bradley WG, Daroff RB et al. Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Elsevier, 2022.",
]
for ref in refs:
    story.append(Paragraph(f"• {ref}", note_style))

story.append(Spacer(1, 0.5*cm))

# ─── Footer note ──────────────────────────────────────────────────────────────
footer_box_data = [[Paragraph(
    "<b>Disclaimer:</b> This document is compiled from authoritative medical textbooks for "
    "educational purposes only. It does not constitute clinical advice. Clinical decisions must "
    "be made by qualified healthcare professionals taking into account the individual patient's "
    "full clinical context.",
    ParagraphStyle("FooterNote", fontSize=8, leading=12, textColor=colors.HexColor("#555555"),
                   fontName="Helvetica-Oblique", alignment=TA_LEFT)
)]]
footer_tbl = Table(footer_box_data, colWidths=[doc.width])
footer_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0, 0), (-1, -1), LIGHT_GRAY),
    ("BOX",           (0, 0), (-1, -1), 0.8, MED_GRAY),
    ("TOPPADDING",    (0, 0), (-1, -1), 8),
    ("BOTTOMPADDING", (0, 0), (-1, -1), 8),
    ("LEFTPADDING",   (0, 0), (-1, -1), 10),
    ("RIGHTPADDING",  (0, 0), (-1, -1), 10),
]))
story.append(footer_tbl)

# ─── Build ─────────────────────────────────────────────────────────────────────
doc.build(story)
print(f"PDF successfully created: {OUTPUT_PATH}")

import json, base64
from io import BytesIO
from pptx import Presentation
from pptx.util import Inches, Pt, Emu
from pptx.dml.color import RGBColor
from pptx.enum.text import PP_ALIGN
from pptx.util import Inches, Pt, Cm
import copy

# ── load images ──────────────────────────────────────────────────────────────
with open("/tmp/workspace/systemic-exam-ppt/images.json") as f:
    IMG_DATA = json.load(f)

URLS = [
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_81a5258f41299fc026cdf9329d826db5021038ce217a8ba40b41ef74f19a0820.jpg",   # 0 clubbing bilateral
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_7579570ccbf69e539c1688067de9e7782bde674c80d7db0396fd9542082cf1f7.jpg",   # 1 chest auscultation
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_b862e31b5c8b51ce6dc1fbafd8916cd21f449fca24d6b0fc8443445b8157a825.jpg",   # 2 JVP neck
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_468b985e1b329f8d924765ab81ffabbb95ce1caf122a71672abd10ccff33359c.jpg",   # 3 CXR pneumonia consolidation
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_478d74974a93434c9f097dc4a7e5833344fb1b6eb3b2cd4c88eb794f28bea401.jpg",   # 4 hepatosplenomegaly abdomen
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_2cf74e492f1faa3f2caf6656da1935e09de76884443d31f5d670e78065869e70.jpg",   # 5 knee jerk reflex
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_4d033b199c9c19d09d67819c668ad35a525c5ec78b6ea4044b05d3219def06c2.jpg",   # 6 Babinski plantar
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_6c2816087b6f8412fa2c06fbe6aa1639544fb615bf5fd9dab7406a72ac304aaf.jpg",   # 7 scleral icterus
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_e034bc783baface3d65666b0a8ae0dc9aa43e261f01230d774b0b743d7202a29.jpg",   # 8 liver disease signs
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_a5aa1577a309b773aa904acf5993f3f7cab2b262bc0571b2b34fc3412c419fb7.jpg",   # 9 auscultation supine
]

def img_stream(idx):
    for item in IMG_DATA:
        if item["url"] == URLS[idx] and item.get("base64"):
            raw = base64.b64decode(item["base64"].split(",")[-1])
            return BytesIO(raw)
    return None

# ── colour palette ────────────────────────────────────────────────────────────
DARK_BLUE   = RGBColor(0x1A, 0x3A, 0x5C)
MID_BLUE    = RGBColor(0x2E, 0x6D, 0xA4)
TEAL        = RGBColor(0x00, 0x7B, 0x83)
GREEN       = RGBColor(0x1E, 0x7A, 0x3E)
ORANGE      = RGBColor(0xE0, 0x6C, 0x00)
PURPLE      = RGBColor(0x5B, 0x2D, 0x8E)
RED         = RGBColor(0xC0, 0x20, 0x20)
LIGHT_BLUE  = RGBColor(0xD6, 0xE8, 0xF7)
LIGHT_GREEN = RGBColor(0xD6, 0xF0, 0xE0)
LIGHT_TEAL  = RGBColor(0xD0, 0xF0, 0xF4)
LIGHT_ORANGE= RGBColor(0xFD, 0xEE, 0xD8)
LIGHT_PURPLE= RGBColor(0xEEE0FF)
WHITE       = RGBColor(0xFF, 0xFF, 0xFF)
NEAR_WHITE  = RGBColor(0xF8, 0xF8, 0xF8)
GRAY        = RGBColor(0x66, 0x66, 0x66)
DARK_GRAY   = RGBColor(0x33, 0x33, 0x33)
ACCENT_GOLD = RGBColor(0xE8, 0xA0, 0x20)

# ── presentation setup ────────────────────────────────────────────────────────
prs = Presentation()
prs.slide_width  = Inches(13.33)
prs.slide_height = Inches(7.5)
W = prs.slide_width
H = prs.slide_height
BLANK = prs.slide_layouts[6]   # completely blank

# ── helpers ───────────────────────────────────────────────────────────────────
def add_rect(slide, l, t, w, h, fill=None, line=None, line_w=Pt(0)):
    shape = slide.shapes.add_shape(1, l, t, w, h)  # MSO_SHAPE_TYPE.RECTANGLE=1
    shape.line.fill.background()
    if fill:
        shape.fill.solid()
        shape.fill.fore_color.rgb = fill
    else:
        shape.fill.background()
    if line:
        shape.line.color.rgb = line
        shape.line.width = line_w
    else:
        shape.line.fill.background()
    return shape

def add_text(slide, text, l, t, w, h, size=18, bold=False, color=DARK_GRAY,
             align=PP_ALIGN.LEFT, wrap=True, italic=False):
    txBox = slide.shapes.add_textbox(l, t, w, h)
    tf = txBox.text_frame
    tf.word_wrap = wrap
    p = tf.paragraphs[0]
    p.alignment = align
    run = p.add_run()
    run.text = text
    run.font.size = Pt(size)
    run.font.bold = bold
    run.font.italic = italic
    run.font.color.rgb = color
    return txBox

def add_text_para(slide, lines, l, t, w, h, size=13, bold_first=False,
                  color=DARK_GRAY, line_color=None, spacing=1.15):
    """lines = list of (text, bold, color_override) tuples or plain strings"""
    txBox = slide.shapes.add_textbox(l, t, w, h)
    tf = txBox.text_frame
    tf.word_wrap = True
    for i, item in enumerate(lines):
        if i == 0:
            p = tf.paragraphs[0]
        else:
            p = tf.add_paragraph()
        if isinstance(item, str):
            text, bld, col = item, (bold_first and i == 0), color
        else:
            text, bld, col = item[0], item[1], item[2] if len(item) > 2 else color
        p.alignment = PP_ALIGN.LEFT
        run = p.add_run()
        run.text = text
        run.font.size = Pt(size)
        run.font.bold = bld
        run.font.color.rgb = col
    return txBox

def section_header(slide, title, subtitle, bg_color, icon=""):
    """Full-width section header bar at top"""
    add_rect(slide, 0, 0, W, Inches(1.5), fill=bg_color)
    add_rect(slide, 0, Inches(1.5), W, Inches(6.0), fill=NEAR_WHITE)
    # accent left bar
    add_rect(slide, 0, 0, Inches(0.12), Inches(1.5), fill=ACCENT_GOLD)
    # title
    add_text(slide, f"{icon}  {title}", Inches(0.25), Inches(0.1),
             Inches(10), Inches(0.9), size=32, bold=True, color=WHITE)
    if subtitle:
        add_text(slide, subtitle, Inches(0.25), Inches(0.95),
                 Inches(12), Inches(0.45), size=14, color=RGBColor(0xC8, 0xDC, 0xEF))

def img_on_slide(slide, idx, l, t, w, h):
    s = img_stream(idx)
    if s:
        slide.shapes.add_picture(s, l, t, width=w, height=h)

def colored_bullet_box(slide, title, items, l, t, w, h, hdr_color, bullet_color,
                       title_size=15, item_size=12):
    """Box with coloured header + bullet items"""
    add_rect(slide, l, t, w, Inches(0.38), fill=hdr_color)
    add_text(slide, title, l + Inches(0.1), t + Inches(0.02),
             w - Inches(0.2), Inches(0.34), size=title_size, bold=True, color=WHITE)
    add_rect(slide, l, t + Inches(0.38), w, h - Inches(0.38),
             fill=WHITE, line=hdr_color, line_w=Pt(1.2))
    item_h = (h - Inches(0.38)) / max(len(items), 1)
    for i, item in enumerate(items):
        # bullet dot
        dot = slide.shapes.add_shape(9, l + Inches(0.12),
                                      t + Inches(0.38) + int(i * item_h) + Inches(0.09),
                                      Inches(0.12), Inches(0.12))
        dot.fill.solid(); dot.fill.fore_color.rgb = bullet_color
        dot.line.fill.background()
        add_text(slide, item,
                 l + Inches(0.3), t + Inches(0.38) + int(i * item_h) + Inches(0.03),
                 w - Inches(0.38), item_h - Inches(0.06),
                 size=item_size, color=DARK_GRAY)

def table_slide(slide, headers, rows, l, t, w, h, hdr_color, alt_color):
    """Draw a simple table"""
    n_cols = len(headers)
    n_rows = len(rows)
    col_w = w // n_cols
    row_h = h // (n_rows + 1)
    # header row
    for ci, hdr in enumerate(headers):
        add_rect(slide, l + ci*col_w, t, col_w, row_h, fill=hdr_color)
        add_text(slide, hdr, l + ci*col_w + Inches(0.08), t + Inches(0.04),
                 col_w - Inches(0.16), row_h - Inches(0.08),
                 size=12, bold=True, color=WHITE, align=PP_ALIGN.CENTER)
    # data rows
    for ri, row in enumerate(rows):
        bg = alt_color if ri % 2 == 0 else WHITE
        for ci, cell in enumerate(row):
            add_rect(slide, l + ci*col_w, t + (ri+1)*row_h, col_w, row_h,
                     fill=bg, line=hdr_color, line_w=Pt(0.5))
            add_text(slide, cell,
                     l + ci*col_w + Inches(0.08), t + (ri+1)*row_h + Inches(0.03),
                     col_w - Inches(0.16), row_h - Inches(0.06),
                     size=11, color=DARK_GRAY)

def flow_box(slide, text, l, t, w, h, fill, text_color=WHITE, size=12, bold=True):
    add_rect(slide, l, t, w, h, fill=fill)
    add_text(slide, text, l+Inches(0.08), t+Inches(0.06),
             w-Inches(0.16), h-Inches(0.12), size=size, bold=bold,
             color=text_color, align=PP_ALIGN.CENTER)

def arrow_right(slide, l, t, h_center):
    """Draw a right-pointing arrow"""
    arr = slide.shapes.add_shape(13, l, h_center - Inches(0.12),
                                  Inches(0.3), Inches(0.24))  # right arrow
    arr.fill.solid(); arr.fill.fore_color.rgb = GRAY
    arr.line.fill.background()

def arrow_down(slide, l_center, t, height=Inches(0.3)):
    arr = slide.shapes.add_shape(131, l_center - Inches(0.12), t,
                                   Inches(0.24), height)
    arr.fill.solid(); arr.fill.fore_color.rgb = GRAY
    arr.line.fill.background()

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 1 — TITLE
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
add_rect(s, 0, 0, W, H, fill=DARK_BLUE)
add_rect(s, 0, 0, Inches(0.18), H, fill=ACCENT_GOLD)
add_rect(s, Inches(0.18), Inches(4.8), W - Inches(0.18), Inches(2.7),
         fill=RGBColor(0x0E, 0x24, 0x3A))

add_text(s, "SYSTEMIC EXAMINATION", Inches(0.5), Inches(0.9),
         Inches(12), Inches(1.3), size=44, bold=True, color=WHITE,
         align=PP_ALIGN.LEFT)
add_text(s, "OF THE PATIENT", Inches(0.5), Inches(2.1),
         Inches(12), Inches(1.0), size=44, bold=True, color=ACCENT_GOLD,
         align=PP_ALIGN.LEFT)
add_text(s, "A Comprehensive Clinical Reference  |  Respiratory  ·  Cardiovascular  ·  Abdominal  ·  Neurological  ·  Musculoskeletal",
         Inches(0.5), Inches(3.3), Inches(12), Inches(0.5),
         size=14, color=RGBColor(0xC8, 0xDC, 0xEF))
add_rect(s, Inches(0.5), Inches(3.9), Inches(3.5), Inches(0.05), fill=ACCENT_GOLD)

# System icons row
systems = [("🫁", "Respiratory"), ("❤️", "Cardiovascular"), ("🫃", "Abdominal"),
           ("🧠", "Neurological"), ("🦴", "Musculoskeletal")]
for i, (icon, label) in enumerate(systems):
    bx = Inches(0.5) + i * Inches(2.45)
    add_rect(s, bx, Inches(4.95), Inches(2.3), Inches(1.3),
             fill=RGBColor(0x20, 0x4A, 0x70))
    add_text(s, icon, bx, Inches(5.0), Inches(2.3), Inches(0.55),
             size=24, align=PP_ALIGN.CENTER, color=WHITE)
    add_text(s, label, bx, Inches(5.55), Inches(2.3), Inches(0.55),
             size=13, bold=True, color=WHITE, align=PP_ALIGN.CENTER)

add_text(s, "Orris Medical Reference  |  July 2026",
         Inches(0.5), Inches(7.0), Inches(6), Inches(0.35),
         size=10, color=GRAY, italic=True)

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 2 — OVERVIEW / APPROACH FLOWCHART
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Overview: Approach to Systemic Examination",
               "IPPA applied to each system — Inspection · Palpation · Percussion · Auscultation", DARK_BLUE)

add_text(s, "Sequential Head-to-Toe Examination Flowchart",
         Inches(0.3), Inches(1.65), Inches(12.7), Inches(0.38),
         size=15, bold=True, color=DARK_BLUE)

# Flowchart — 5 steps across
steps = [
    ("1\nGENERAL\nINSPECTION", TEAL),
    ("2\nRESPIRATORY\nSYSTEM", MID_BLUE),
    ("3\nCARDIO-\nVASCULAR", RED),
    ("4\nABDOMEN &\nGI SYSTEM", GREEN),
    ("5\nNEURO-\nLOGICAL", PURPLE),
]
for i, (label, col) in enumerate(steps):
    bx = Inches(0.3) + i * Inches(2.57)
    add_rect(s, bx, Inches(2.1), Inches(2.3), Inches(1.0), fill=col)
    add_text(s, label, bx, Inches(2.15), Inches(2.3), Inches(0.9),
             size=12, bold=True, color=WHITE, align=PP_ALIGN.CENTER)
    if i < 4:
        arrow_right(s, bx + Inches(2.3), 0, Inches(2.6))

# Second row
steps2 = [
    ("6\nMUSCULO-\nSKELETAL", ORANGE),
    ("7\nSKIN &\nDERMATOLOGY", RGBColor(0x7B, 0x3F, 0x00)),
    ("8\nLYMPH\nNODES", RGBColor(0x5A, 0x5A, 0xAA)),
    ("9\nASSESSMENT\n& PLAN", DARK_BLUE),
]
for i, (label, col) in enumerate(steps2):
    bx = Inches(0.3) + i * Inches(3.25)
    add_rect(s, bx, Inches(3.6), Inches(2.9), Inches(0.9), fill=col)
    add_text(s, label, bx, Inches(3.65), Inches(2.9), Inches(0.8),
             size=12, bold=True, color=WHITE, align=PP_ALIGN.CENTER)

# IPPA reminder box
add_rect(s, Inches(0.3), Inches(4.65), Inches(12.7), Inches(0.55),
         fill=LIGHT_BLUE, line=MID_BLUE, line_w=Pt(1.5))
add_text(s, "📋  For EVERY system apply:   I — Inspection   →   P — Palpation   →   P — Percussion   →   A — Auscultation",
         Inches(0.5), Inches(4.7), Inches(12.3), Inches(0.45),
         size=14, bold=True, color=DARK_BLUE, align=PP_ALIGN.CENTER)

add_rect(s, Inches(0.3), Inches(5.35), Inches(12.7), Inches(0.55),
         fill=RGBColor(0xFF, 0xF3, 0xD6), line=ORANGE, line_w=Pt(1.5))
add_text(s, "⚠️  EXCEPTION — Abdomen:   I — Inspection   →   A — Auscultation   →   P — Palpation   →   P — Percussion",
         Inches(0.5), Inches(5.4), Inches(12.3), Inches(0.45),
         size=13, bold=True, color=ORANGE, align=PP_ALIGN.CENTER)

# key principle
add_rect(s, Inches(0.3), Inches(6.05), Inches(12.7), Inches(0.9),
         fill=NEAR_WHITE, line=TEAL, line_w=Pt(1))
add_text(s, '"The examination always follows the history and is focused on the patient\'s specific problem. '
            'Proper exposure is non-negotiable — never examine through clothing."',
         Inches(0.5), Inches(6.1), Inches(12.3), Inches(0.8),
         size=12, italic=True, color=GRAY)

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 3 — RESPIRATORY: INSPECTION
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Respiratory System — Inspection", "Step 1 of IPPA", TEAL)

# Left column — inspection checklist
colored_bullet_box(s, "🔍 Inspection — What to Look For",
    ["Rate, rhythm, depth of breathing",
     "Use of accessory muscles (SCM, scalenes, intercostals)",
     "Chest shape: barrel chest (COPD/emphysema), pigeon chest (pectus carinatum)",
     "Chest wall asymmetry — one side moves less",
     "Surgical scars (thoracotomy, VATS, drains)",
     "Tracheal position (deviated away = tension PTx; toward = collapse)",
     "Pursed-lip breathing (COPD)",
     "Nasal flaring, intercostal recession (children)",
     "Cyanosis — peripheral (nails/lips) vs central (tongue)"],
    Inches(0.3), Inches(1.65), Inches(5.5), Inches(4.4),
    TEAL, TEAL)

# Breathing patterns box
colored_bullet_box(s, "🌊 Abnormal Breathing Patterns",
    ["Cheyne-Stokes — crescendo-decrescendo cycles → CCF, uraemia, raised ICP",
     "Kussmaul — deep, laboured, rapid → metabolic acidosis (DKA)",
     "Biot's — irregular cycles with apnoeas → raised ICP, brainstem lesion",
     "Apnoeustic — prolonged inspiratory hold → pontine damage",
     "Sighing — anxiety, hyperventilation syndrome"],
    Inches(0.3), Inches(6.1), Inches(5.5), Inches(1.3),
    RGBColor(0x00, 0x5F, 0x73), RGBColor(0x00, 0x5F, 0x73), title_size=13, item_size=10)

# Right — real image of clubbing
img_on_slide(s, 0, Inches(6.05), Inches(1.65), Inches(4.0), Inches(2.7))
add_rect(s, Inches(6.05), Inches(4.35), Inches(4.0), Inches(0.35),
         fill=TEAL)
add_text(s, "Fig 1. Bilateral digital clubbing — drumstick appearance, loss of Lovibond angle",
         Inches(6.1), Inches(4.37), Inches(3.9), Inches(0.32),
         size=9, color=WHITE, italic=True)

# Clubbing grades table
add_text(s, "Grading of Clubbing", Inches(6.05), Inches(4.8),
         Inches(7.0), Inches(0.32), size=13, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Grade", "Features"],
    [["I", "Softening & fluctuation of nail bed"],
     ["II", "Loss of Lovibond angle (>180°)"],
     ["III", "Drumstick appearance of distal phalanx"],
     ["IV", "Hypertrophic osteoarthropathy (periosteal new bone)"]],
    Inches(6.05), Inches(5.15), Inches(7.0), Inches(1.8),
    TEAL, LIGHT_TEAL)

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 4 — RESPIRATORY: PALPATION, PERCUSSION & AUSCULTATION
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Respiratory System — Palpation, Percussion & Auscultation",
               "Steps 2, 3 & 4 of IPPA", TEAL)

# Palpation
colored_bullet_box(s, "✋ Palpation",
    ["Tracheal position — index finger in suprasternal notch",
     "Chest expansion — hands on lower chest; normal ≥5 cm",
     "Tactile vocal fremitus — say '99'; increased = consolidation; decreased = effusion/PTx",
     "Apex beat — helps identify cardiac vs. respiratory pathology"],
    Inches(0.3), Inches(1.65), Inches(4.2), Inches(1.9), TEAL, TEAL, item_size=11)

# Percussion notes table
add_text(s, "🥁 Percussion Notes",
         Inches(0.3), Inches(3.65), Inches(4.2), Inches(0.32),
         size=13, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Note", "Cause"],
    [["Resonant", "Normal lung"],
     ["Hyper-resonant", "Pneumothorax, emphysema"],
     ["Dull", "Consolidation, collapse, mass"],
     ["Stony dull", "Pleural effusion"],
     ["Tympanic", "Gas-filled cavity (pneumothorax)"]],
    Inches(0.3), Inches(4.0), Inches(4.2), Inches(2.6),
    TEAL, LIGHT_TEAL)

# Right side — CXR image
img_on_slide(s, 3, Inches(4.7), Inches(1.65), Inches(3.6), Inches(2.7))
add_rect(s, Inches(4.7), Inches(4.35), Inches(3.6), Inches(0.3), fill=TEAL)
add_text(s, "Fig 2. CXR: Left lower lobe consolidation + blunted costophrenic angle (effusion)",
         Inches(4.75), Inches(4.37), Inches(3.5), Inches(0.28), size=9, color=WHITE, italic=True)

# Auscultation
colored_bullet_box(s, "🔊 Auscultation — Breath Sounds & Added Sounds",
    ["Vesicular (normal) — soft, low-pitched, inspiration > expiration",
     "Bronchial — harsh, high-pitched, expiration ≥ inspiration → consolidation above effusion",
     "Diminished/absent — effusion, pneumothorax, obesity, collapse",
     "Fine crackles — pulmonary fibrosis, LVF (end-inspiratory)",
     "Coarse crackles — bronchiectasis, secretions (cleared by coughing)",
     "Wheeze (polyphonic) — diffuse airflow obstruction (asthma, COPD)",
     "Wheeze (monophonic fixed) — partial obstruction (tumour, foreign body)",
     "Pleural rub — pleuritis (low-pitched, leathery creaking, both phases)"],
    Inches(4.7), Inches(4.75), Inches(8.3), Inches(2.6),
    RGBColor(0x00, 0x5F, 0x73), RGBColor(0x00, 0x5F, 0x73), item_size=11)

# Auscultation image
img_on_slide(s, 1, Inches(0.3), Inches(6.6), Inches(4.2), Inches(0.8))

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 5 — CARDIOVASCULAR: INSPECTION + PERIPHERAL SIGNS
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Cardiovascular System — Inspection & Peripheral Signs",
               "Fuster & Hurst's The Heart, 15th Ed.", RED)

# Left col
colored_bullet_box(s, "👁 General Inspection",
    ["Breathlessness at rest / on exertion",
     "Central cyanosis — lips, tongue (R→L shunts, severe cardiorespiratory failure)",
     "Pallor — anaemia contributing to CCF",
     "Malar flush (bilateral reddish-cyanotic cheeks) — mitral stenosis",
     "Xanthelasmata / corneal arcus — hyperlipidaemia, CAD risk",
     "Syndromic features: Marfan (tall, arachnodactyly), Turner, Down, Noonan"],
    Inches(0.3), Inches(1.65), Inches(5.5), Inches(2.5), RED, RED, item_size=11)

colored_bullet_box(s, "✋ Hands & Peripheral Signs",
    ["Clubbing → cyanotic CHD, infective endocarditis",
     "Splinter haemorrhages → infective endocarditis (distal = often traumatic)",
     "Osler's nodes (painful) → IE — immune complex deposition",
     "Janeway lesions (painless) → IE — septic emboli",
     "Peripheral cyanosis → Raynaud's, PVD, low output states",
     "Koilonychia (spoon nails) → iron deficiency → CCF risk factor"],
    Inches(0.3), Inches(4.3), Inches(5.5), Inches(2.4), RGBColor(0x8B, 0x00, 0x00), RGBColor(0x8B, 0x00, 0x00), item_size=11)

# JVP image + description
img_on_slide(s, 2, Inches(6.0), Inches(1.65), Inches(4.0), Inches(2.8))
add_rect(s, Inches(6.0), Inches(4.45), Inches(4.0), Inches(0.32), fill=RED)
add_text(s, "Fig 3. JVP assessment: patient at 45°, head rotated left, IJV pulsation marked",
         Inches(6.05), Inches(4.47), Inches(3.9), Inches(0.28), size=9, color=WHITE, italic=True)

# JVP table
add_text(s, "Jugular Venous Pressure (JVP) — Key Points",
         Inches(6.0), Inches(4.85), Inches(7.1), Inches(0.3),
         size=13, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Feature", "Details"],
    [["Normal", "< 3 cm above sternal angle at 45°"],
     ["Elevated JVP", "CCF, SVCO, TR, pericardial effusion, constrictive pericarditis"],
     ["Kussmaul's sign", "JVP rises on inspiration → constrictive pericarditis, RV failure"],
     ["Waveforms", "a = atrial contraction; c = tricuspid closure; v = venous filling"],
     ["Cannon a-waves", "Complete heart block (AV dissociation)"]],
    Inches(6.0), Inches(5.18), Inches(7.1), Inches(2.1),
    RED, RGBColor(0xFF, 0xEE, 0xEE))

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 6 — CARDIOVASCULAR: PULSE, PALPATION & AUSCULTATION
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Cardiovascular System — Pulse, Palpation & Auscultation",
               "Stepwise approach from Fuster & Hurst's The Heart, 15th Ed.", RED)

# Pulse characters table
add_text(s, "Pulse Characters & Their Clinical Significance",
         Inches(0.3), Inches(1.65), Inches(7.5), Inches(0.32),
         size=14, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Pulse Character", "Cause"],
    [["Slow-rising, low-amplitude", "Aortic stenosis"],
     ["Collapsing / water-hammer", "Aortic regurgitation, PDA, thyrotoxicosis, fever"],
     ["Bisferiens (double peak)", "Mixed AS + AR, HOCM"],
     ["Pulsus alternans", "Severe LV failure"],
     ["Pulsus paradoxus (>10 mmHg)", "Cardiac tamponade, severe asthma"],
     ["Pulsus parvus et tardus", "Aortic stenosis (small and slow)"],
     ["Radial-femoral delay", "Coarctation of aorta"]],
    Inches(0.3), Inches(2.0), Inches(6.5), Inches(2.8),
    RED, RGBColor(0xFF, 0xF0, 0xF0))

# Palpation
colored_bullet_box(s, "✋ Precordial Palpation",
    ["Apex beat — normally 5th ICS, MCL; displaced = LV enlargement",
     "Heaving apex — pressure overload (AS, HTN)",
     "Tapping apex — palpable S1 in mitral stenosis",
     "Parasternal heave (left) — RV hypertrophy/enlargement",
     "Thrills — palpable murmurs (grade 4+); systolic thrill at base = AS/PS"],
    Inches(0.3), Inches(4.95), Inches(6.5), Inches(2.4), RED, RED, item_size=11)

# Auscultation areas
add_text(s, "🔊 Auscultation Areas",
         Inches(7.0), Inches(1.65), Inches(6.0), Inches(0.32),
         size=14, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Area", "Location", "Best Hears"],
    [["Aortic (A2)", "2nd ICS, right sternal border", "Aortic valve sounds"],
     ["Pulmonary (P2)", "2nd ICS, left sternal border", "Pulmonary valve, S2 split"],
     ["Tricuspid (T)", "Lower left sternal border", "Tricuspid murmurs"],
     ["Mitral (M)", "Apex (5th ICS, MCL)", "Mitral murmurs"],
     ["Erb's Point", "3rd ICS, left sternal border", "AR diastolic murmur"]],
    Inches(7.0), Inches(2.0), Inches(6.1), Inches(2.2),
    RED, RGBColor(0xFF, 0xF0, 0xF0))

colored_bullet_box(s, "Heart Sounds & Murmurs",
    ["S1 (lub) — MV + TV closure; loud in MS, soft in MR/AS",
     "S2 (dub) — AV + PV closure; split widens on inspiration",
     "Fixed split S2 — ASD",
     "S3 (ventricular gallop) — CCF, MR, VSD (bell at apex)",
     "S4 (atrial gallop) — stiff ventricle, HTN, HOCM",
     "Pansystolic murmur — MR, TR, VSD",
     "Ejection systolic — AS, PS, flow murmur",
     "Early diastolic — AR (decrescendo), PR",
     "Mid-diastolic — MS (rumble at apex with bell, left lateral position)"],
    Inches(7.0), Inches(4.3), Inches(6.1), Inches(3.1),
    RGBColor(0x8B, 0x00, 0x00), RGBColor(0x8B, 0x00, 0x00), item_size=10)

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 7 — ABDOMINAL EXAMINATION: INSPECTION & AUSCULTATION
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Abdominal Examination — Inspection & Auscultation",
               "Bailey & Love's Short Practice of Surgery, 28th Ed.", GREEN)

# Patient position
add_rect(s, Inches(0.3), Inches(1.65), Inches(12.7), Inches(0.55),
         fill=LIGHT_GREEN, line=GREEN, line_w=Pt(1.5))
add_text(s, "Patient Position:  Lying flat, arms by sides, hips/knees extended (pillow if needed). Expose from xiphisternum → inguinal ligaments."
            "  For palpation: flex hips & knees to relax abdominal wall muscles.",
         Inches(0.5), Inches(1.68), Inches(12.3), Inches(0.48),
         size=12, bold=False, color=GREEN)

# Inspection left col
colored_bullet_box(s, "👁 Inspection — End of Bed & Close Inspection",
    ["Body habitus: cachectic (malignancy/malabsorption), obese",
     "Skin: jaundice, spider naevi (≥5 = liver disease), caput medusae (portal HTN)",
     "Scars: laparotomy, laparoscopic ports, stoma sites",
     "Distension: 5 Fs — Fat, Fluid, Flatus, Faeces, Foetus (+ Filthy big tumour)",
     "Visible peristalsis — pyloric stenosis (gastric), SBO",
     "Pulsatile epigastric mass — abdominal aortic aneurysm",
     "Dilated veins (caput medusae) — flow away from umbilicus",
     "Stoma — ileostomy (spout, RIF), colostomy (flush, LIF)",
     "Hernias — umbilical, incisional, inguinal (ask to cough)"],
    Inches(0.3), Inches(2.3), Inches(6.0), Inches(4.1), GREEN, GREEN, item_size=11)

# Right side: special signs + image
img_on_slide(s, 4, Inches(6.5), Inches(2.3), Inches(4.0), Inches(2.7))
add_rect(s, Inches(6.5), Inches(5.0), Inches(4.0), Inches(0.32), fill=GREEN)
add_text(s, "Fig 4. Hepatosplenomegaly with skin markings — EBV infectious mononucleosis",
         Inches(6.55), Inches(5.02), Inches(3.9), Inches(0.28), size=9, color=WHITE, italic=True)

colored_bullet_box(s, "⚠️ Emergency Abdominal Signs",
    ["Grey Turner's sign — flank bruising → retroperitoneal haemorrhage (pancreatitis, AAA)",
     "Cullen's sign — periumbilical bruising → intra-abdominal bleed (pancreatitis, ruptured ectopic)",
     "Visible peristalsis with distension → mechanical obstruction"],
    Inches(6.5), Inches(5.4), Inches(6.5), Inches(1.15),
    RED, RED, item_size=11, title_size=13)

colored_bullet_box(s, "🔊 Auscultation (Before Palpation!)",
    ["Normal bowel sounds: intermittent gurgles q5–15 sec",
     "Absent (>2 min silence): paralytic ileus, peritonitis, post-op",
     "Tinkling / high-pitched rushes: mechanical bowel obstruction",
     "Renal bruit (paraumbilical): renal artery stenosis",
     "Aortic bruit (midline): AAA or atherosclerosis",
     "Hepatic bruit: hepatocellular carcinoma, alcoholic hepatitis"],
    Inches(0.3), Inches(6.45), Inches(6.0), Inches(1.0),
    RGBColor(0x00, 0x6B, 0x3C), RGBColor(0x00, 0x6B, 0x3C), item_size=10, title_size=12)

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 8 — ABDOMINAL EXAMINATION: PALPATION & PERCUSSION
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Abdominal Examination — Palpation & Percussion",
               "Bailey & Love's Short Practice of Surgery, 28th Ed.", GREEN)

# Light palpation
colored_bullet_box(s, "✋ Light Palpation",
    ["Warm hands; watch face, not hands",
     "Start in the RIF (away from pain); 9 regions systematically",
     "Tenderness — site, severity (1–10)",
     "Guarding — voluntary (muscle tensing) vs involuntary (peritonism)",
     "Rebound tenderness — pain worse on release → peritoneal irritation",
     "Rigidity — board-like = generalised peritonitis"],
    Inches(0.3), Inches(1.65), Inches(4.5), Inches(2.4), GREEN, GREEN, item_size=11)

# Deep palpation
colored_bullet_box(s, "✋ Deep Palpation — Organomegaly",
    ["Liver: start RIF, move toward RUQ on inspiration; measure cm below costal margin",
     "Spleen: start RIF, move toward LUQ; left lateral decubitus position if needed",
     "Kidneys: bimanual ballottement, lower poles (right lower than left)",
     "Aorta: pulsatile, expansile midline mass → AAA",
     "Bladder: suprapubic dull mass → retention",
     "Murphy's sign: arrest of inspiration on palpating gallbladder → acute cholecystitis"],
    Inches(0.3), Inches(4.15), Inches(4.5), Inches(2.6), RGBColor(0x00, 0x6B, 0x3C),
    RGBColor(0x00, 0x6B, 0x3C), item_size=11)

# Percussion
colored_bullet_box(s, "🥁 Percussion",
    ["Liver span: 6–12 cm (dull); increased = hepatomegaly",
     "Traube's space (L): tympanic normally; dull = splenomegaly",
     "Shifting dullness: >1.5 L ascites needed; dullness shifts with position",
     "Fluid thrill: large ascites; tap one flank, feel thrill on other",
     "Suprapubic dullness: full bladder, ovarian cyst, gravid uterus"],
    Inches(0.3), Inches(6.85), Inches(4.5), Inches(0.55),
    TEAL, TEAL, item_size=9, title_size=11)

# Mass characteristics table
add_text(s, "Palpable Mass — Descriptors to Record",
         Inches(5.0), Inches(1.65), Inches(8.1), Inches(0.3),
         size=13, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Feature", "Options"],
    [["Site", "Which region? (RUQ, LUQ, RIF, LIF, epigastric, umbilical, suprapubic, flanks)"],
     ["Size & Shape", "Measure in cm; oval, round, irregular"],
     ["Surface", "Smooth (simple cyst, kidney), irregular/nodular (malignancy, hydatid)"],
     ["Consistency", "Soft, firm, hard (malignancy, fibrosis), fluctuant (cystic/abscess)"],
     ["Tenderness", "Tender (inflammatory/ischaemic), non-tender (malignancy often)"],
     ["Mobility", "Mobile (benign), fixed (malignancy, retroperitoneal)"],
     ["Pulsatility", "Transmitted (anterior mass) vs expansile (AAA)"],
     ["Transillumination", "Lights up = cystic (lipoma, hydrocele, ovarian cyst)"]],
    Inches(5.0), Inches(2.0), Inches(8.1), Inches(3.3),
    GREEN, LIGHT_GREEN)

# Hepatosplenomegaly causes
add_text(s, "Causes of Hepatosplenomegaly",
         Inches(5.0), Inches(5.4), Inches(8.1), Inches(0.3),
         size=13, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Hepatomegaly Causes", "Splenomegaly Causes"],
    [["Viral hepatitis (A,B,C,E), EBV, CMV", "Portal hypertension (cirrhosis, Budd-Chiari)"],
     ["Cirrhosis (early), fatty liver (NAFLD)", "Haematological: lymphoma, CML, thalassaemia"],
     ["CCF (congestive hepatomegaly)", "Infection: malaria, kala-azar, EBV, typhoid"],
     ["Metastases, HCC, liver abscess", "Autoimmune: RA (Felty's), SLE, sarcoidosis"]],
    Inches(5.0), Inches(5.75), Inches(8.1), Inches(1.65),
    GREEN, LIGHT_GREEN)

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 9 — NEUROLOGICAL EXAMINATION: OVERVIEW & CRANIAL NERVES
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Neurological Examination — Overview & Cranial Nerves",
               "Neuroanatomy Through Clinical Cases, 3rd Ed.", PURPLE)

# Sequence box
add_rect(s, Inches(0.3), Inches(1.65), Inches(12.7), Inches(0.45),
         fill=LIGHT_PURPLE, line=PURPLE, line_w=Pt(1.5))
add_text(s, "Neurological Exam Sequence:  Mental State  →  Cranial Nerves I–XII  →  Motor  →  Sensation  →  Reflexes  →  Coordination  →  Gait",
         Inches(0.5), Inches(1.68), Inches(12.3), Inches(0.4),
         size=13, bold=True, color=PURPLE, align=PP_ALIGN.CENTER)

# Cranial nerves table
add_text(s, "Cranial Nerves — Function & Test",
         Inches(0.3), Inches(2.2), Inches(8.5), Inches(0.32),
         size=14, bold=True, color=DARK_BLUE)
table_slide(s,
    ["CN", "Name", "Function", "Bedside Test"],
    [["I", "Olfactory", "Smell", "Identify coffee/vanilla (each nostril)"],
     ["II", "Optic", "Vision", "Acuity, fields, RAPD, fundoscopy"],
     ["III/IV/VI", "Oculomotor/Trochlear/Abducens", "Eye movements, pupil", "H-pattern, pupil reactions"],
     ["V", "Trigeminal", "Facial sensation, jaw", "Light touch 3 divisions; jaw jerk"],
     ["VII", "Facial", "Facial muscles", "Raise brows, close eyes, show teeth"],
     ["VIII", "Vestibulocochlear", "Hearing, balance", "Rinne, Weber; watch for nystagmus"],
     ["IX/X", "Glossopharyngeal/Vagus", "Palate, gag, speech", "Say 'Ahh'; palate rise symmetrical"],
     ["XI", "Accessory", "SCM, trapezius", "Head turn against resistance"],
     ["XII", "Hypoglossal", "Tongue", "Protrude tongue — deviates to side of lesion"]],
    Inches(0.3), Inches(2.55), Inches(8.5), Inches(4.0),
    PURPLE, LIGHT_PURPLE)

# Mental state column
colored_bullet_box(s, "🧠 Mental State Examination",
    ["Consciousness: GCS (E+V+M, max 15)",
     "Orientation: time, place, person",
     "Registration & recall (3-object memory)",
     "Attention (serial 7s, WORLD backwards)",
     "Language: fluency, naming, comprehension, repetition",
     "MMSE (<24/30) or MoCA (<26/30) for formal screening",
     "Affect and mood assessment"],
    Inches(8.9), Inches(1.65), Inches(4.1), Inches(3.4), PURPLE, PURPLE, item_size=11)

# HEENT diagram
colored_bullet_box(s, "⚠️ Signs of Meningism",
    ["Neck stiffness — resistance to passive flexion",
     "Kernig's sign — flex hip 90°, extend knee → pain/resistance",
     "Brudzinski's sign — flex neck → hips flex involuntarily",
     "Causes: bacterial meningitis, SAH, meningeal carcinomatosis"],
    Inches(8.9), Inches(5.15), Inches(4.1), Inches(2.15), RED, RED, item_size=11)

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 10 — NEUROLOGICAL: MOTOR, REFLEXES & COORDINATION
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Neurological Examination — Motor, Reflexes & Coordination",
               "Adams & Victor's Principles of Neurology, 12th Ed.", PURPLE)

# Motor table
add_text(s, "Motor Examination", Inches(0.3), Inches(1.65), Inches(6.0), Inches(0.3),
         size=14, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Component", "Method", "Findings"],
    [["Tone", "Passive flexion/extension of joints", "Spasticity (UMN), rigidity (extrapyramidal), flaccidity (LMN)"],
     ["Power", "MRC 0–5 scale against resistance", "Proximal (myopathy), distal (neuropathy), pattern (UMN vs LMN)"],
     ["Bulk", "Visual & tactile assessment", "Wasting (LMN/disuse/myopathy), hypertrophy (Duchenne pseudohypertrophy)"],
     ["Involuntary movements", "Observation at rest & action", "Tremor, fasciculations, chorea, athetosis, ballismus, myoclonus"]],
    Inches(0.3), Inches(2.0), Inches(6.0), Inches(2.2),
    PURPLE, LIGHT_PURPLE)

# Reflexes table
add_text(s, "Deep Tendon Reflexes", Inches(0.3), Inches(4.3), Inches(6.0), Inches(0.3),
         size=14, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Reflex", "Root", "Grading"],
    [["Biceps", "C5, C6", "0 = absent; 1+ = diminished; 2+ = normal"],
     ["Supinator (brachioradialis)", "C6", "3+ = brisk; 4+ = clonus"],
     ["Triceps", "C7", "Decreased = LMN / peripheral neuropathy"],
     ["Knee (patellar)", "L3, L4", "Increased = UMN lesion above that segment"],
     ["Ankle (Achilles)", "S1", "Reinforcement (Jendrassik) if absent initially"]],
    Inches(0.3), Inches(4.65), Inches(6.0), Inches(2.1),
    PURPLE, LIGHT_PURPLE)

# Reflex image
img_on_slide(s, 5, Inches(6.5), Inches(1.65), Inches(3.3), Inches(2.3))
add_rect(s, Inches(6.5), Inches(3.95), Inches(3.3), Inches(0.3), fill=PURPLE)
add_text(s, "Fig 5. Knee jerk (L3–L4) with Jendrassik manoeuvre",
         Inches(6.55), Inches(3.97), Inches(3.2), Inches(0.28), size=9, color=WHITE, italic=True)

# Babinski image
img_on_slide(s, 6, Inches(9.9), Inches(1.65), Inches(3.1), Inches(2.3))
add_rect(s, Inches(9.9), Inches(3.95), Inches(3.1), Inches(0.3), fill=PURPLE)
add_text(s, "Fig 6. Babinski sign — upgoing plantar = UMN lesion",
         Inches(9.95), Inches(3.97), Inches(3.0), Inches(0.28), size=9, color=WHITE, italic=True)

# UMN vs LMN
add_text(s, "UMN vs LMN — Distinguishing Features",
         Inches(6.5), Inches(4.35), Inches(6.5), Inches(0.3),
         size=13, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Feature", "UMN Lesion", "LMN Lesion"],
    [["Tone", "Increased (spasticity)", "Decreased (flaccid)"],
     ["Power", "Decreased (pyramidal distribution)", "Decreased (at level of lesion)"],
     ["Reflexes", "Brisk / clonus", "Absent / diminished"],
     ["Plantar", "Upgoing (Babinski +ve)", "Downgoing / absent"],
     ["Wasting", "Mild (disuse)", "Marked (denervation)"],
     ["Fasciculations", "Absent", "Present"]],
    Inches(6.5), Inches(4.68), Inches(6.5), Inches(2.65),
    PURPLE, LIGHT_PURPLE)

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 11 — NEUROLOGICAL: SENSATION, COORDINATION & GAIT
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Neurological Examination — Sensation, Coordination & Gait",
               "Neuroanatomy Through Clinical Cases, 3rd Ed.", PURPLE)

# Sensation
colored_bullet_box(s, "🖐 Sensory Examination",
    ["Light touch — cotton wool; test each dermatome systematically",
     "Pinprick (pain) — Neurotip; distal→proximal to find level",
     "Temperature — cold tuning fork or hot/cold tubes",
     "Vibration — 128 Hz tuning fork; start distally (great toe → malleolus → knee)",
     "Proprioception (joint position sense) — up/down movement of distal phalanx",
     "Two-point discrimination — fingertip normal ≤5 mm; dorsal hand ≤20 mm",
     "Graphaesthesia — number drawn on palm (cortical/parietal lobe function)",
     "Stereognosis — identify object by touch alone (cortical function)"],
    Inches(0.3), Inches(1.65), Inches(5.8), Inches(3.5), PURPLE, PURPLE, item_size=11)

# Sensory loss patterns
add_text(s, "Sensory Loss Patterns", Inches(0.3), Inches(5.25), Inches(5.8), Inches(0.3),
         size=13, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Pattern", "Lesion Level"],
    [["Glove & stocking", "Peripheral neuropathy (diabetes, B12, alcohol)"],
     ["Hemibody loss", "Thalamus, internal capsule, cortex"],
     ["Level (sensory level)", "Spinal cord lesion — below level affected"],
     ["Dissociated (pain/temp)", "Spinothalamic — hemisection (Brown-Séquard)"],
     ["Dermatomal", "Root (radiculopathy) or ganglion (herpes zoster)"]],
    Inches(0.3), Inches(5.58), Inches(5.8), Inches(1.85),
    PURPLE, LIGHT_PURPLE)

# Coordination
colored_bullet_box(s, "🎯 Coordination (Cerebellar Function)",
    ["Finger-nose test — dysmetria (overshoot), intention tremor",
     "Heel-shin test — ataxic, unable to run heel smoothly",
     "Rapid alternating movements — dysdiadochokinesia",
     "Romberg test — eyes closed: sways = posterior column / vestibular disease",
     "DANISH mnemonic: Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Slurred speech (dysarthria), Hypotonia"],
    Inches(6.2), Inches(1.65), Inches(6.9), Inches(2.8), TEAL, TEAL, item_size=11)

# Gait types
add_text(s, "Gait Abnormalities & Their Causes",
         Inches(6.2), Inches(4.55), Inches(6.9), Inches(0.3),
         size=14, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Gait Type", "Features", "Cause"],
    [["Hemiplegic", "Arm flexed, leg circumducts", "Contralateral UMN (stroke)"],
     ["Scissor", "Stiff crossing legs", "Bilateral UMN (CP, MS)"],
     ["Steppage", "High-lift, foot slap", "Foot drop (L4/5, peroneal N.)"],
     ["Ataxic / broad-based", "Wide base, unstable", "Cerebellar disease"],
     ["Parkinsonian", "Shuffling, festinant, reduced arm swing, stooped", "Parkinson's / Parkinsonism"],
     ["Apraxic", "'Stuck to floor', wide base", "Frontal lobe, NPH"],
     ["Antalgic", "Limp, reduced stance phase", "Pain (osteoarthritis, fracture)"]],
    Inches(6.2), Inches(4.88), Inches(6.9), Inches(2.55),
    PURPLE, LIGHT_PURPLE)

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 12 — MUSCULOSKELETAL EXAMINATION
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Musculoskeletal Examination",
               "Rheumatology, 2-Volume Set (2022, Elsevier)", ORANGE)

# GALS screen
colored_bullet_box(s, "🦴 GALS Screen (Gait, Arms, Legs, Spine)",
    ["Ask 3 screening questions: any pain/stiffness? any swelling? any difficulty with stairs/dressing?",
     "GAIT — observe walking: symmetry, stride, arm swing, turning",
     "ARMS — hands outstretched (deformity, wasting); make fist; touch each finger to thumb",
     "LEGS — squat; inspect knees; passive ROM of hip (flexion, internal rotation)",
     "SPINE — lateral flexion of cervical spine; lumbar forward flexion (finger-floor distance)"],
    Inches(0.3), Inches(1.65), Inches(5.8), Inches(2.6), ORANGE, ORANGE, item_size=11)

# Joint examination sequence
colored_bullet_box(s, "🔄 Joint Examination — LOOK, FEEL, MOVE",
    ["LOOK: deformity, swelling, erythema, muscle wasting, scars, psoriatic plaques",
     "FEEL: warmth (dorsum of hand), tenderness (site — joint line vs peri-articular), crepitus, effusion (patellar tap, bulge sign)",
     "MOVE (Active first, then Passive): record ROM in degrees; note pain, instability, end-feel",
     "SPECIAL TESTS: Lachman (ACL), McMurray (meniscus), Finkelstein (De Quervain's), Phalen's (CTS)"],
    Inches(0.3), Inches(4.4), Inches(5.8), Inches(2.0), RGBColor(0xC0, 0x50, 0x00),
    RGBColor(0xC0, 0x50, 0x00), item_size=11)

# Hand in RA and OA
add_text(s, "Hand Deformity Patterns",
         Inches(0.3), Inches(6.5), Inches(5.8), Inches(0.3),
         size=13, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Deformity", "Condition"],
    [["Ulnar deviation + MCP swelling", "Rheumatoid arthritis"],
     ["Swan-neck / Boutonnière deformity", "Rheumatoid arthritis"],
     ["Heberden's (DIP) + Bouchard's (PIP) nodes", "Osteoarthritis"],
     ["Tophaceous nodules (chalk-white)", "Chronic tophaceous gout"]],
    Inches(0.3), Inches(6.85), Inches(5.8), Inches(0.58),
    ORANGE, LIGHT_ORANGE)

# Systemic signs of rheumatological disease
add_text(s, "Systemic Rheumatological Signs",
         Inches(6.2), Inches(1.65), Inches(6.9), Inches(0.3),
         size=14, bold=True, color=DARK_BLUE)
table_slide(s,
    ["System", "Sign", "Condition"],
    [["Skin", "Butterfly rash, Gottron's papules, sclerodactyly", "SLE, DM/PM, SSc"],
     ["Eyes", "Dry eyes/mouth (sicca), episcleritis, uveitis", "Sjögren's, RA, AS"],
     ["Nails", "Pitting, onycholysis, nail-fold infarcts", "Psoriatic arthritis, SSc"],
     ["Lungs", "Fibrosis, pleuritis, effusion", "RA, SLE, SSc, PM"],
     ["Kidneys", "Proteinuria, haematuria, HTN", "SLE nephritis, vasculitis"],
     ["Heart", "Pericarditis, Libman-Sacks endocarditis", "SLE, RA"],
     ["Neurology", "Mononeuritis multiplex, CNS vasculitis", "RA, SLE, PAN"]],
    Inches(6.2), Inches(2.0), Inches(6.9), Inches(3.1),
    ORANGE, LIGHT_ORANGE)

# Spine
colored_bullet_box(s, "🔲 Spine Examination",
    ["Cervical: range of motion (flexion, extension, lateral flexion, rotation); Spurling's test (foraminal compression)",
     "Thoracic: kyphosis (osteoporosis, ankylosing spondylitis), scoliosis, local tenderness",
     "Lumbar: Schober's test (AS — mark L4-S1, 10 cm up; should expand to ≥15 cm on forward flexion)",
     "SLR (straight leg raise) → <70° with sciatica = L4/5/S1 radiculopathy",
     "Femoral stretch test → anterior thigh pain = L2/3/4 radiculopathy"],
    Inches(6.2), Inches(5.2), Inches(6.9), Inches(2.2), RGBColor(0xC0, 0x50, 0x00),
    RGBColor(0xC0, 0x50, 0x00), item_size=11)

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 13 — SKIN & ABDOMINAL SIGNS WITH REAL IMAGES
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Key Clinical Signs — Dermatological & Abdominal",
               "Fitzpatrick's Dermatology · Bailey & Love's Surgery", RGBColor(0x7B, 0x3F, 0x00))

HDR = RGBColor(0x7B, 0x3F, 0x00)
LGHT = RGBColor(0xFD, 0xF3, 0xE7)

# Real images row
img_on_slide(s, 7, Inches(0.3), Inches(1.65), Inches(4.0), Inches(2.7))
add_rect(s, Inches(0.3), Inches(4.35), Inches(4.0), Inches(0.32), fill=HDR)
add_text(s, "Fig 7. Scleral icterus (bilirubin >35 µmol/L) — before & after treatment",
         Inches(0.35), Inches(4.37), Inches(3.9), Inches(0.28), size=9, color=WHITE, italic=True)

img_on_slide(s, 8, Inches(4.5), Inches(1.65), Inches(4.5), Inches(2.7))
add_rect(s, Inches(4.5), Inches(4.35), Inches(4.5), Inches(0.32), fill=HDR)
add_text(s, "Fig 8. Multiple stigmata of chronic liver disease: icterus, gynecomastia, spider naevi, prurigo nodularis, xanthelasma",
         Inches(4.55), Inches(4.37), Inches(4.4), Inches(0.28), size=9, color=WHITE, italic=True)

img_on_slide(s, 9, Inches(9.2), Inches(1.65), Inches(3.9), Inches(2.7))
add_rect(s, Inches(9.2), Inches(4.35), Inches(3.9), Inches(0.32), fill=HDR)
add_text(s, "Fig 9. Cardiac auscultation — supine position with stethoscope diaphragm on precordium",
         Inches(9.25), Inches(4.37), Inches(3.8), Inches(0.28), size=9, color=WHITE, italic=True)

# Jaundice classification
add_text(s, "Jaundice — Classification & Causes",
         Inches(0.3), Inches(4.8), Inches(6.0), Inches(0.3),
         size=13, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Type", "Bilirubin", "Causes"],
    [["Pre-hepatic", "Unconjugated ↑", "Haemolysis (sickle cell, spherocytosis, G6PD, malaria)"],
     ["Hepatic", "Both ↑", "Viral hepatitis, alcoholic hepatitis, cirrhosis, drugs"],
     ["Post-hepatic", "Conjugated ↑", "Gallstones, cholangiocarcinoma, pancreatic head Ca, PSC"]],
    Inches(0.3), Inches(5.13), Inches(6.0), Inches(1.4),
    HDR, LGHT)

# Liver disease signs
add_text(s, "Stigmata of Chronic Liver Disease",
         Inches(6.5), Inches(4.8), Inches(6.5), Inches(0.3),
         size=13, bold=True, color=DARK_BLUE)
table_slide(s,
    ["Sign", "Location", "Significance"],
    [["Spider naevi (>5)", "SVC distribution — face, arms, trunk", "Oestrogen excess — CLD"],
     ["Palmar erythema", "Thenar/hypothenar mottling", "CLD, pregnancy, RA"],
     ["Leukonychia", "White nails", "Hypoalbuminaemia"],
     ["Dupuytren's contracture", "Palmar fascia fibrosis", "Alcoholic CLD"],
     ["Gynaecomastia", "Male breast tissue", "Oestrogen excess"],
     ["Caput medusae", "Dilated periumbilical veins", "Portal hypertension"],
     ["Ascites", "Abdominal distension + shifting dullness", "Portal HTN + hypoalbuminaemia"],
     ["Fetor hepaticus", "Sweet-musty breath", "Severe hepatic failure"]],
    Inches(6.5), Inches(5.13), Inches(6.5), Inches(2.3),
    HDR, LGHT)

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 14 — DIFFERENTIAL DIAGNOSIS FLOWCHART
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Clinical Reasoning — Differential Diagnosis Framework",
               "Goldman-Cecil Medicine, 26th Ed.", DARK_BLUE)

add_text(s, "VITAMIN C(D) Mnemonic for Neurological DDx",
         Inches(0.3), Inches(1.65), Inches(6.5), Inches(0.32),
         size=14, bold=True, color=DARK_BLUE)
vitamin_items = [
    ("V — Vascular", "Stroke, TIA, haemorrhage, vasculitis, venous sinus thrombosis", MID_BLUE),
    ("I — Infectious", "Meningitis, encephalitis, abscess, HIV, PML, neurosyphilis, prions", TEAL),
    ("T — Toxic/Traumatic", "Head injury, drugs, alcohol, CO poisoning, metabolic encephalopathy", ORANGE),
    ("A — Autoimmune", "MS, NMO, anti-NMDAR encephalitis, Guillain-Barré, MG, vasculitis", PURPLE),
    ("M — Metabolic", "Hypoglycaemia, uraemia, hepatic failure, thyroid/adrenal, electrolytes", GREEN),
    ("I — Idiopathic", "Epilepsy, Parkinson's disease, essential tremor, functional neurological disorder", MID_BLUE),
    ("N — Neoplastic", "Primary tumour, metastases, paraneoplastic syndromes, meningeal carcinomatosis", RED),
    ("C — Congenital", "Malformations, NF1/2, TSC, Sturge-Weber syndrome", RGBColor(0x5A, 0x5A, 0xAA)),
    ("D — Degenerative", "Alzheimer's, FTD, MND, Huntington's, MSA, PSP, DLB", RGBColor(0x7B, 0x3F, 0x00)),
]
for i, (cat, detail, col) in enumerate(vitamin_items):
    row = i % 3
    col_n = i // 3
    bx = Inches(0.3) + col_n * Inches(4.4)
    by = Inches(2.1) + row * Inches(1.4)
    add_rect(s, bx, by, Inches(4.1), Inches(0.38), fill=col)
    add_text(s, cat, bx + Inches(0.1), by + Inches(0.04),
             Inches(3.9), Inches(0.3), size=13, bold=True, color=WHITE)
    add_rect(s, bx, by + Inches(0.38), Inches(4.1), Inches(1.0),
             fill=WHITE, line=col, line_w=Pt(1))
    add_text(s, detail, bx + Inches(0.1), by + Inches(0.42),
             Inches(3.9), Inches(0.95), size=10, color=DARK_GRAY)

# Assessment structure
add_text(s, "Structured Assessment & Plan",
         Inches(13.5 * 0.69), Inches(1.65), Inches(4.1), Inches(0.32),
         size=14, bold=True, color=DARK_BLUE)
steps_plan = [
    ("1. Summary\nFormulation", "1–2 sentence summary of age, key features, likely diagnosis", DARK_BLUE),
    ("2. Differential\nDiagnosis", "List in order of probability; consider common > rare; dangerous > benign", MID_BLUE),
    ("3. Investigations", "Bloods, imaging, special tests — justify each investigation", TEAL),
    ("4. Management", "Problem-based: medications, procedures, referrals, monitoring", GREEN),
    ("5. Patient\nEducation", "Explain diagnosis, prognosis, lifestyle, follow-up", ORANGE),
]
for i, (title, detail, col) in enumerate(steps_plan):
    by = Inches(2.1) + i * Inches(0.97)
    flow_box(s, title, Inches(9.25), by, Inches(1.6), Inches(0.75), col)
    add_rect(s, Inches(10.85), by, Inches(2.3), Inches(0.75),
             fill=WHITE, line=col, line_w=Pt(0.8))
    add_text(s, detail, Inches(10.95), by + Inches(0.05),
             Inches(2.1), Inches(0.65), size=9, color=DARK_GRAY)

# ═════════════════════════════════════════════════════════════════════════════
# SLIDE 15 — REFERENCES & KEY CLINICAL PEARLS
# ═════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(BLANK)
section_header(s, "Key Clinical Pearls & References", "", DARK_BLUE)

pearls = [
    ("👁", "Always expose the patient properly — never examine through clothing. Observation begins the moment you see the patient.", MID_BLUE),
    ("💬", "History gives the diagnosis in 70–80% of cases. Invest time in it — the examination confirms it.", TEAL),
    ("🫁", "Respiratory rate is the most sensitive early sign of deterioration. Count it for a full 60 seconds.", GREEN),
    ("❤️", "Shaking hands gives 5 pieces of information simultaneously: tone, temperature, peripheral perfusion, pulse, and bilateral BP asymmetry.", RED),
    ("🫃", "In abdominal examination, AUSCULTATE before palpating — palpation stimulates bowel sounds artificially.", ORANGE),
    ("🧠", "In neurology, always localise before aetiologising — where is the lesion? Then: what is the lesion?", PURPLE),
    ("⚠️", "Grey Turner's + Cullen's signs = retroperitoneal/intra-abdominal haemorrhage. Virchow's node = intra-abdominal malignancy. Never miss them.", RGBColor(0xC0, 0x20, 0x20)),
    ("🦴", "In MSK: LOOK, FEEL, MOVE — in that order. Always compare with the contralateral side.", ORANGE),
    ("📝", "Document BOTH positive findings AND pertinent negatives — both contribute to the clinical picture and medicolegal record.", DARK_BLUE),
    ("🌡️", "The most important vital sign is what the patient looks like. General appearance guides urgency more than any single number. — Goldman-Cecil Medicine", MID_BLUE),
]
for i, (icon, pearl, col) in enumerate(pearls):
    row = i % 5
    col_n = i // 5
    bx = Inches(0.3) + col_n * Inches(6.4)
    by = Inches(1.65) + row * Inches(1.07)
    add_rect(s, bx, by, Inches(0.45), Inches(0.9), fill=col)
    add_text(s, icon, bx, by + Inches(0.18), Inches(0.45), Inches(0.5),
             size=18, align=PP_ALIGN.CENTER, color=WHITE)
    add_rect(s, bx + Inches(0.45), by, Inches(5.7), Inches(0.9),
             fill=WHITE, line=col, line_w=Pt(0.8))
    add_text(s, pearl, bx + Inches(0.55), by + Inches(0.05),
             Inches(5.5), Inches(0.82), size=11, color=DARK_GRAY)

# References
add_rect(s, Inches(0.3), Inches(7.1), Inches(12.7), Inches(0.32),
         fill=DARK_BLUE)
refs = "Sources: Goldman-Cecil Medicine 26e  ·  Fuster & Hurst's The Heart 15e  ·  Bailey & Love's Surgery 28e  ·  S. Das Manual on Clinical Surgery 13e  ·  Neuroanatomy Through Clinical Cases 3e  ·  Rheumatology 2022 Elsevier"
add_text(s, refs, Inches(0.4), Inches(7.12), Inches(12.5), Inches(0.28),
         size=8, color=RGBColor(0xC8, 0xDC, 0xEF), italic=True, align=PP_ALIGN.CENTER)

# ── save ──────────────────────────────────────────────────────────────────────
OUT = "/tmp/workspace/systemic-exam-ppt/Systemic_Examination_of_Patient.pptx"
prs.save(OUT)
print(f"Saved: {OUT}")
import os
print(f"Size: {os.path.getsize(OUT)//1024} KB  |  Slides: 15")

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/systemic-exam-ppt/build_ppt.py'