How to take history of COPD . Long case

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Finding Sources

Reading File

Finding Sources

Reading File

I now have comprehensive textbook content. Let me compile the full, structured long-case COPD history guide:

How to Take a History in COPD — Long Case

A complete COPD long case history is structured around the following domains. Cover each systematically before moving to examination.

1. Presenting Complaint

State the predominant symptom(s) — usually one or more of:

Breathlessness (dyspnoea)
Chronic cough
Sputum production
Wheeze
Chest tightness

2. History of Presenting Complaint (HPC)

A. Dyspnoea

The cardinal symptom. Explore in full:

Onset — Gradual over years is typical; acute onset suggests exacerbation
Duration — How long has it been present?
Progression — Slowly worsening over years (hallmark of COPD)
Exertional threshold — What activity provokes it? (climbing stairs, walking on flat, dressing, at rest?)
Orthopnoea/PND — Ask specifically; more typical of heart failure but can coexist
Quantify disability using the MRC Dyspnoea Scale:

Grade	Description
1	Breathless only with strenuous exercise
2	Short of breath when hurrying on the level or walking up a slight hill
3	Walks slower than most people of same age due to breathlessness, or has to stop for breath when walking at own pace
4	Stops for breath after walking ~100 m or after a few minutes
5	Too breathless to leave the house, or breathless when dressing/undressing

Tip: Ask about the "shopping trolley sign" — less breathless when pushing a trolley/cart than walking freely (due to tripod positioning). This is very specific for COPD.

B. Cough

Onset and duration — Chronic productive cough for ≥3 months in ≥2 consecutive years = chronic bronchitis
Character — Productive vs. dry
Time pattern — Morning cough ("morning ritual"), worse in winter
Triggers — Cold air, smoke, exercise

C. Sputum

Volume — How much per day? (teaspoon, tablespoon, egg cup)
Colour — White/grey (stable), yellow/green (infection/exacerbation), rusty (pneumococcal infection), pink frothy (pulmonary oedema — important differential)
Haemoptysis — Always ask; if present, consider lung cancer, bronchiectasis, TB. Clubbing is not a feature of COPD — its presence should prompt investigation for malignancy or pulmonary fibrosis

D. Wheeze

Persistent or episodic?
Response to bronchodilators (helps differentiate from asthma)

E. Chest Pain/Tightness

Pleuritic pain? (pneumothorax, pleurisy)
Central tightness (cor pulmonale, ischaemic heart disease)

3. Exacerbation History

Critical in COPD long cases:

Frequency — How many exacerbations per year?
Triggers — URTI, environmental, seasonal
Symptoms of exacerbation — Increased dyspnoea, increased cough, change in sputum quantity or purulence
Severity — Treated at home? GP visit? A&E? ICU?
Hospitalisations — Number, dates, whether intubated or on NIV (BiPAP)
Steroid/antibiotic courses — Home supply? "Rescue pack"?

4. Risk Factor History (Aetiology)

Smoking History — Most Important

Type — Cigarettes, cigars, pipe, shisha, e-cigarettes
Pack-year history = (cigarettes per day ÷ 20) × years smoked

e.g., 20 cigarettes/day for 30 years = 30 pack-years
Current smoker or ex-smoker — If ex, when did they stop?
Passive/secondhand smoke — Childhood exposure, occupational

Occupational Exposure

Always ask occupation(s) systematically:

Dust — Coal miners, gold miners, cotton textile workers
Fumes/chemicals — Welding, painting, agriculture
Duration of exposure — Years, intensity
Use of protective equipment (PPE)

Indoor/Biomass Fuel Exposure

Burning of wood, dung, crop residue for cooking/heating (common in low-income settings)
Poorly ventilated kitchens

Childhood History

Recurrent lower respiratory tract infections in childhood
Premature birth (poor lung development = reduced lung reserve)
Severe asthma

Environmental/Outdoor Pollution

Urban vs. rural, industrial area

Alpha-1 Antitrypsin (A1AT) Deficiency

Ask about family history of emphysema, especially in non-smokers
Young age at onset (<45 years), lower lobe predominant emphysema
Associated liver disease (cirrhosis)

5. Past Medical History

Ask specifically about:

Asthma or childhood wheeze (overlap syndrome ACOS)
Previous tuberculosis — Can cause airflow obstruction
Recurrent chest infections / bronchiectasis
Heart disease — Ischaemic heart disease, heart failure (key comorbidity and differential for dyspnoea)
Pulmonary hypertension / cor pulmonale — Ankle swelling, raised JVP
Osteoporosis — Common in COPD, worsened by steroids
Diabetes, metabolic syndrome
Lung cancer — Strong shared risk factor with smoking
Anxiety/depression — Very common comorbidity; significantly impairs quality of life

6. Drug History

Current inhalers — SABA (salbutamol), LABA (salmeterol, formoterol), LAMA (tiotropium, umeclidinium), ICS (fluticasone, budesonide), combination inhalers (LABA/LAMA, LABA/ICS, triple therapy)
Inhaler technique and compliance — Ask the patient to demonstrate
Oral medications — Theophylline, roflumilast, azithromycin prophylaxis
Long-term oral steroids — Doses, duration, side effects
Home nebulisers
Home oxygen / NIV
Medications that can worsen respiratory disease — Beta-blockers (use cardioselective if needed), NSAIDs (avoid), ACE inhibitors (cause cough — may be confused with COPD cough)
Allergy history

7. Oxygen and NIV History

Long-term oxygen therapy (LTOT) — Prescribed? Hours per day (ideally >15 hours)? Portable vs. concentrator?
Non-invasive ventilation (BiPAP/CPAP) — For hypercapnic respiratory failure
Ambulatory oxygen

8. Functional History and Quality of Life

Use the COPD Assessment Test (CAT) to quantify impact (score 0–40):

Domain	Asked
Cough frequency	Never → all the time
Sputum/phlegm	None → chest completely full
Chest tightness	None → very tight
Breathlessness on exertion	Not breathless → very breathless on one flight of stairs
Activity limitation at home	Not limited → very limited
Confidence leaving home	Confident → not confident at all
Sleep quality	Sleeps soundly → does not sleep due to lung condition
Energy levels	Lots of energy → no energy

Also ask:

Activities of daily living (ADLs) — Can they shower, dress, cook independently?
Exercise tolerance — What is the patient's current maximum walking distance?
Mobility aids — Wheelchair, rollator?
Social participation — Work, hobbies, going out

9. Social History

Smoking status (if not already asked)
Alcohol — Can affect response to infection and drug compliance
Occupation — Current or retired; occupational exposure (see above)
Housing — Stairs, heating, dampness/mould, rural vs. urban
Social support — Lives alone? Who are the carers?
Benefits/income — Disease impact on employment
Travel — Air travel (requires oxygen if PaO₂ borderline)

10. Family History

COPD or emphysema in relatives — Especially early-onset or non-smokers → suspect A1AT deficiency
Asthma — First-degree relatives
Lung cancer
Maternal tobacco use during pregnancy — Increases childhood risk

11. Systems Review (Relevant Positives/Negatives)

System	Ask About
Respiratory	Haemoptysis, pleuritic pain, snoring/OSA (overlap syndrome)
Cardiovascular	Ankle oedema (cor pulmonale), palpitations (AF common in COPD), chest pain
Neurological	Headaches on waking (CO₂ retention), confusion
Musculoskeletal	Back pain (vertebral fractures from osteoporosis/steroids), muscle weakness
Nutritional	Weight loss (sarcopenia in emphysema), anorexia
Psychiatric	Depression, anxiety (very common; affects exacerbation risk)
ENT	Chronic sinusitis, nasal polyps (asthma overlap)

12. Key Differential Diagnoses to Screen For in History

While taking the history, keep these differentials in mind and ask questions to exclude them:

Condition	Distinguishing Features in History
Asthma	Onset in childhood/young adult, episodic wheeze, atopy, family history, fully reversible
Heart failure	Orthopnoea, PND, pink frothy sputum, cardiac risk factors
Bronchiectasis	Large volumes of mucopurulent sputum daily, recurrent infections, childhood infections
TB	Night sweats, weight loss, contact history, foreign travel
Lung cancer	Haemoptysis, weight loss, hoarseness, smoking history
Pulmonary fibrosis	Dry cough, clubbing, fine crackles, autoimmune disease

13. Closing the History — Summarise the GOLD Classification Context

After the history, you should be able to stage the patient's COPD using the GOLD ABE Framework (2023 update):

Symptoms: CAT score or MRC grade
Exacerbation history: ≥2 moderate or ≥1 hospitalisation = high-risk group E
Spirometry: Confirm with FEV₁/FVC <0.7 post-bronchodilator; then GOLD 1–4 by % predicted FEV₁

GOLD Grade	FEV₁ % Predicted
1 (Mild)	≥80%
2 (Moderate)	50–79%
3 (Severe)	30–49%
4 (Very Severe)	<30%

Quick Summary Checklist for COPD Long Case History

Presenting symptoms (dyspnoea, cough, sputum, wheeze) — onset, severity, progression
MRC dyspnoea grade
CAT score questions
Exacerbation history (frequency, hospitalisations, NIV/intubation)
Smoking — pack-year history, current vs. ex-smoker
Occupational, indoor, environmental exposures
Childhood history (infections, premature birth)
Family history (A1AT, asthma, lung disease)
Past medical history (especially cardiac disease, asthma, TB)
Drug history (inhalers with compliance, oxygen, steroids)
Functional and QoL impact
Social history (living situation, support, occupation)
Systems review (cor pulmonale symptoms, depression, weight loss)
Differentials excluded by history

Sources: Goldman-Cecil Medicine, p. 2902–2921 | The Washington Manual of Medical Therapeutics, pp. 310–313 | Harrison's Principles of Internal Medicine 22E | Fishman's Pulmonary Diseases and Disorders

Create a quick reference PDF for COPD history-taking

Reading File

Running Command

ls -la /home/daytona/workspace/ 2>/dev/null && mkdir -p /home/daytona/workspace/copd-pdf

Writing File

~/copd-pdf/generate_copd_pdf.py

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

OUTPUT = "/home/daytona/workspace/copd-pdf/COPD_History_Quick_Reference.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
NAVY       = colors.HexColor("#1A3A5C")
TEAL       = colors.HexColor("#1B7A8E")
LIGHTBLUE  = colors.HexColor("#E8F4F8")
MIDBLUE    = colors.HexColor("#BEE0EA")
ORANGE     = colors.HexColor("#E67E22")
LIGHTORANGE= colors.HexColor("#FDF2E9")
RED        = colors.HexColor("#C0392B")
GREEN      = colors.HexColor("#1E8449")
LIGHTGREEN = colors.HexColor("#E9F7EF")
GREY       = colors.HexColor("#F2F3F4")
DARKGREY   = colors.HexColor("#566573")
WHITE      = colors.white
BLACK      = colors.HexColor("#1C2833")

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

def S(name, **kw):
    return ParagraphStyle(name, **kw)

title_style = S("Title",
    fontName="Helvetica-Bold", fontSize=20, textColor=WHITE,
    alignment=TA_CENTER, spaceAfter=4, leading=24)

subtitle_style = S("Subtitle",
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    alignment=TA_CENTER, spaceAfter=2)

section_header = S("SecHdr",
    fontName="Helvetica-Bold", fontSize=9.5, textColor=WHITE,
    alignment=TA_LEFT, leftIndent=4, leading=13)

body = S("Body",
    fontName="Helvetica", fontSize=8.5, textColor=BLACK,
    leading=12, spaceAfter=2)

body_bold = S("BodyBold",
    fontName="Helvetica-Bold", fontSize=8.5, textColor=BLACK,
    leading=12, spaceAfter=2)

bullet = S("Bullet",
    fontName="Helvetica", fontSize=8.5, textColor=BLACK,
    leading=12, leftIndent=10, firstLineIndent=-8, spaceAfter=1.5)

bullet_bold = S("BulletBold",
    fontName="Helvetica-Bold", fontSize=8.5, textColor=NAVY,
    leading=12, leftIndent=10, firstLineIndent=-8, spaceAfter=1.5)

small = S("Small",
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    leading=10, spaceAfter=1)

small_italic = S("SmallItalic",
    fontName="Helvetica-Oblique", fontSize=7.5, textColor=DARKGREY,
    leading=10, spaceAfter=1)

table_hdr = S("TblHdr",
    fontName="Helvetica-Bold", fontSize=8, textColor=WHITE,
    alignment=TA_CENTER, leading=11)

table_cell = S("TblCell",
    fontName="Helvetica", fontSize=8, textColor=BLACK,
    leading=11)

table_cell_bold = S("TblCellBold",
    fontName="Helvetica-Bold", fontSize=8, textColor=BLACK,
    leading=11)

warn = S("Warn",
    fontName="Helvetica-BoldOblique", fontSize=8.5, textColor=RED,
    leading=12, leftIndent=8, spaceAfter=2)

tip = S("Tip",
    fontName="Helvetica-Oblique", fontSize=8, textColor=GREEN,
    leading=11, leftIndent=8, spaceAfter=2)

# ── Helper flowables ─────────────────────────────────────────────────────────

def section_box(title, bg=NAVY):
    """Coloured section header bar."""
    data = [[Paragraph(f"▌  {title}", section_header)]]
    t = Table(data, colWidths=[178*mm])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
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        ("RIGHTPADDING",  (0,0), (-1,-1), 4),
        ("ROWBACKGROUNDS",(0,0), (-1,-1), [bg]),
    ]))
    return t

def mini_box(title, bg=TEAL):
    """Smaller sub-header."""
    data = [[Paragraph(f"  {title}", S("mhdr",
        fontName="Helvetica-Bold", fontSize=8.5, textColor=WHITE,
        alignment=TA_LEFT, leading=12))]]
    t = Table(data, colWidths=[178*mm])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg),
        ("TOPPADDING",    (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ("LEFTPADDING",   (0,0), (-1,-1), 8),
        ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ]))
    return t

def sp(h=3):
    return Spacer(1, h*mm)

def hr():
    return HRFlowable(width="100%", thickness=0.5, color=MIDBLUE, spaceAfter=2)

def tbl(data, col_widths, style_extras=None, bg_header=NAVY):
    ts = [
        ("BACKGROUND",    (0,0), (-1,0), bg_header),
        ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
        ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",      (0,0), (-1,-1), 8),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, GREY]),
        ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#D5D8DC")),
        ("TOPPADDING",    (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("RIGHTPADDING",  (0,0), (-1,-1), 5),
        ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
        ("ALIGN",         (0,0), (-1,0), "CENTER"),
    ]
    if style_extras:
        ts.extend(style_extras)
    t = Table(data, colWidths=col_widths)
    t.setStyle(TableStyle(ts))
    return t

# ── Build content ─────────────────────────────────────────────────────────────

def build():
    doc = SimpleDocTemplate(
        OUTPUT,
        pagesize=A4,
        leftMargin=16*mm, rightMargin=16*mm,
        topMargin=14*mm, bottomMargin=14*mm,
        title="COPD History Quick Reference",
        author="Orris Medical"
    )

    story = []

    # ── TITLE BANNER ──────────────────────────────────────────────────────────
    banner_data = [[
        Paragraph("COPD HISTORY TAKING", title_style),
        Paragraph("Quick Reference — Long Case", subtitle_style),
    ]]
    banner = Table([[
        Paragraph("COPD HISTORY TAKING", title_style),
    ],[
        Paragraph("Quick Reference — Long Case", subtitle_style),
    ]], colWidths=[178*mm])
    banner.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), NAVY),
        ("TOPPADDING",    (0,0), (-1,-1), 8),
        ("BOTTOMPADDING", (0,0), (-1,-1), 8),
        ("LEFTPADDING",   (0,0), (-1,-1), 6),
        ("RIGHTPADDING",  (0,0), (-1,-1), 6),
    ]))
    story.append(banner)
    story.append(sp(3))

    # ── PRESENTING COMPLAINT + HPC ────────────────────────────────────────────
    story.append(section_box("1. PRESENTING COMPLAINT & HISTORY OF PRESENTING COMPLAINT"))
    story.append(sp(1))

    # Two-column layout: Dyspnoea + Cough/Sputum
    left = [
        Paragraph("<b>DYSPNOEA</b> (Cardinal Symptom)", body_bold),
        Paragraph("• Onset — gradual over years (typical) vs. acute (exacerbation)", bullet),
        Paragraph("• Duration &amp; progression", bullet),
        Paragraph("• Exertional threshold — stairs? flat ground? dressing?", bullet),
        Paragraph("• Orthopnoea / PND (suggests HF overlap)", bullet),
        Paragraph("• 'Shopping trolley sign' — less breathless pushing a cart<br/>"
                  "  <i>(tripod position, specific for COPD)</i>", bullet),
        sp(2),
        Paragraph("<b>MRC Dyspnoea Scale</b>", body_bold),
    ]
    mrc_data = [
        [Paragraph("Grade", table_hdr), Paragraph("Description", table_hdr)],
        [Paragraph("1", table_cell), Paragraph("Breathless only with strenuous exercise", table_cell)],
        [Paragraph("2", table_cell), Paragraph("Short of breath hurrying on flat or slight hill", table_cell)],
        [Paragraph("3", table_cell), Paragraph("Walks slower than peers due to breathlessness", table_cell)],
        [Paragraph("4", table_cell), Paragraph("Stops for breath after ~100 m or a few minutes", table_cell)],
        [Paragraph("5", table_cell), Paragraph("Too breathless to leave house / breathless dressing", table_cell)],
    ]
    left.append(tbl(mrc_data, [12*mm, 63*mm]))

    right = [
        Paragraph("<b>COUGH</b>", body_bold),
        Paragraph("• Onset &amp; duration — chronic ≥3 months/yr for ≥2 yrs = chronic bronchitis", bullet),
        Paragraph("• Character — productive vs. dry", bullet),
        Paragraph("• Morning cough ('morning ritual')", bullet),
        Paragraph("• Worse in winter / cold air", bullet),
        sp(2),
        Paragraph("<b>SPUTUM</b>", body_bold),
        Paragraph("• Volume per day (teaspoon / tablespoon / egg cup)", bullet),
        Paragraph("• Colour: white/grey = stable; yellow/green = infection; rust = pneumococcal; pink frothy = pulm. oedema", bullet),
        sp(2),
        Paragraph("<b>HAEMOPTYSIS</b>", body_bold),
        Paragraph(
            "⚠ Clubbing is NOT a feature of COPD. "
            "If present → investigate for lung cancer or pulmonary fibrosis.", warn),
        sp(2),
        Paragraph("<b>WHEEZE &amp; CHEST TIGHTNESS</b>", body_bold),
        Paragraph("• Wheeze — persistent or episodic? Response to bronchodilators?", bullet),
        Paragraph("• Chest tightness — pleuritic? Central? (cor pulmonale, IHD)", bullet),
    ]

    two_col = Table([[left, right]], colWidths=[89*mm, 89*mm])
    two_col.setStyle(TableStyle([
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",   (0,0), (-1,-1), 3),
        ("RIGHTPADDING",  (0,0), (-1,-1), 3),
        ("TOPPADDING",    (0,0), (-1,-1), 2),
        ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ]))
    story.append(two_col)
    story.append(sp(2))

    # ── EXACERBATION HISTORY ──────────────────────────────────────────────────
    story.append(section_box("2. EXACERBATION HISTORY", bg=TEAL))
    story.append(sp(1))
    ex_data = [
        [Paragraph("Ask About", table_hdr), Paragraph("Details", table_hdr)],
        [Paragraph("Frequency", table_cell_bold), Paragraph("How many per year?", table_cell)],
        [Paragraph("Triggers", table_cell_bold), Paragraph("URTI, environmental, seasonal", table_cell)],
        [Paragraph("Symptoms", table_cell_bold), Paragraph("↑ dyspnoea, ↑ cough, change in sputum quantity or purulence", table_cell)],
        [Paragraph("Severity", table_cell_bold), Paragraph("Treated at home? GP visit? A&amp;E? ICU admission?", table_cell)],
        [Paragraph("Hospitalisations", table_cell_bold), Paragraph("Number, dates, intubated or on NIV (BiPAP)?", table_cell)],
        [Paragraph("Rescue pack", table_cell_bold), Paragraph("Home supply of steroids/antibiotics?", table_cell)],
    ]
    story.append(tbl(ex_data, [38*mm, 140*mm], bg_header=TEAL))
    story.append(sp(2))

    # ── RISK FACTORS ──────────────────────────────────────────────────────────
    story.append(section_box("3. RISK FACTOR HISTORY (AETIOLOGY)", bg=ORANGE))
    story.append(sp(1))

    rf_left = [
        Paragraph("<b>SMOKING — Most Important</b>", body_bold),
        Paragraph("• Type: cigarettes, pipe, cigars, shisha, e-cigarettes", bullet),
        Paragraph("• <b>Pack-year = (cigs/day ÷ 20) × years smoked</b>", bullet_bold),
        Paragraph("  e.g. 20/day × 30 years = 30 pack-years", small_italic),
        Paragraph("• Current smoker or ex-smoker (when stopped?)", bullet),
        Paragraph("• Passive/secondhand smoke exposure", bullet),
        sp(2),
        Paragraph("<b>OCCUPATIONAL EXPOSURE</b>", body_bold),
        Paragraph("• Coal mining, gold mining, cotton textile dust", bullet),
        Paragraph("• Welding fumes, solvents, agricultural dust", bullet),
        Paragraph("• Duration (years), intensity, use of PPE", bullet),
        Paragraph("• Ask about ALL past occupations systematically", bullet),
    ]

    rf_right = [
        Paragraph("<b>INDOOR / BIOMASS FUEL</b>", body_bold),
        Paragraph("• Wood, dung, crop residue burning for cooking/heating", bullet),
        Paragraph("• Poorly ventilated kitchens (common in LMICs)", bullet),
        sp(2),
        Paragraph("<b>CHILDHOOD HISTORY</b>", body_bold),
        Paragraph("• Recurrent lower RTIs in childhood", bullet),
        Paragraph("• Premature birth (poor lung development)", bullet),
        Paragraph("• Severe asthma history", bullet),
        sp(2),
        Paragraph("<b>ALPHA-1 ANTITRYPSIN (A1AT) DEFICIENCY</b>", body_bold),
        Paragraph("• Family history of emphysema in non-smokers", bullet),
        Paragraph("• Onset &lt;45 years, lower-lobe predominant emphysema", bullet),
        Paragraph("• Associated liver disease (cirrhosis)", bullet),
        Paragraph("• All COPD patients should be screened at least once", bullet),
    ]

    rf_two = Table([[rf_left, rf_right]], colWidths=[89*mm, 89*mm])
    rf_two.setStyle(TableStyle([
        ("VALIGN",  (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",  (0,0), (-1,-1), 3),
        ("RIGHTPADDING", (0,0), (-1,-1), 3),
        ("TOPPADDING",   (0,0), (-1,-1), 2),
        ("BOTTOMPADDING",(0,0), (-1,-1), 2),
    ]))
    story.append(rf_two)
    story.append(sp(2))

    # ── PAST MEDICAL HISTORY ──────────────────────────────────────────────────
    story.append(section_box("4. PAST MEDICAL HISTORY"))
    story.append(sp(1))

    pmh_data = [
        [Paragraph("Condition", table_hdr), Paragraph("Why It Matters", table_hdr)],
        [Paragraph("Asthma / childhood wheeze", table_cell_bold), Paragraph("ACOS (Asthma-COPD Overlap Syndrome)", table_cell)],
        [Paragraph("Tuberculosis", table_cell_bold), Paragraph("Can cause airflow obstruction", table_cell)],
        [Paragraph("Recurrent chest infections / bronchiectasis", table_cell_bold), Paragraph("Differential; concurrent condition", table_cell)],
        [Paragraph("Heart failure / IHD", table_cell_bold), Paragraph("Key comorbidity and differential for dyspnoea", table_cell)],
        [Paragraph("Pulmonary hypertension / cor pulmonale", table_cell_bold), Paragraph("Ankle swelling, raised JVP, RVF signs", table_cell)],
        [Paragraph("Osteoporosis", table_cell_bold), Paragraph("Common in COPD; worsened by steroids", table_cell)],
        [Paragraph("Lung cancer", table_cell_bold), Paragraph("Shared smoking risk factor; haemoptysis", table_cell)],
        [Paragraph("Anxiety / depression", table_cell_bold), Paragraph("Very common; impairs QoL, ↑ exacerbation risk", table_cell)],
    ]
    story.append(tbl(pmh_data, [72*mm, 106*mm]))
    story.append(sp(2))

    # ── DRUG HISTORY ──────────────────────────────────────────────────────────
    story.append(section_box("5. DRUG HISTORY", bg=TEAL))
    story.append(sp(1))

    dh_left = [
        Paragraph("<b>INHALERS (ask patient to demonstrate technique)</b>", body_bold),
        Paragraph("• SABA — salbutamol, terbutaline", bullet),
        Paragraph("• LABA — salmeterol, formoterol, indacaterol", bullet),
        Paragraph("• LAMA — tiotropium, umeclidinium, glycopyrronium", bullet),
        Paragraph("• ICS — fluticasone, budesonide, beclomethasone", bullet),
        Paragraph("• Combinations: LABA/LAMA, LABA/ICS, Triple therapy", bullet),
        Paragraph("• Compliance and frequency of use", bullet),
        sp(2),
        Paragraph("<b>OTHER RESPIRATORY DRUGS</b>", body_bold),
        Paragraph("• Theophylline, roflumilast, azithromycin prophylaxis", bullet),
        Paragraph("• Oral steroids — dose, duration, side effects", bullet),
        Paragraph("• Home nebulisers", bullet),
    ]

    dh_right = [
        Paragraph("<b>OXYGEN &amp; NIV</b>", body_bold),
        Paragraph("• LTOT: prescribed? Hours/day (goal &gt;15h)?", bullet),
        Paragraph("• Portable O₂ vs. concentrator", bullet),
        Paragraph("• NIV (BiPAP) — for hypercapnic respiratory failure", bullet),
        Paragraph("• Ambulatory oxygen", bullet),
        sp(2),
        Paragraph("<b>DRUGS THAT WORSEN RESPIRATORY DISEASE</b>", body_bold),
        Paragraph("⚠ Beta-blockers — use cardioselective if required", warn),
        Paragraph("⚠ NSAIDs — avoid if possible", warn),
        Paragraph("⚠ ACE inhibitors — cause cough (may mimic COPD cough)", warn),
        sp(2),
        Paragraph("<b>ALLERGIES</b>", body_bold),
        Paragraph("• Drug name + type of reaction", bullet),
    ]

    dh_two = Table([[dh_left, dh_right]], colWidths=[89*mm, 89*mm])
    dh_two.setStyle(TableStyle([
        ("VALIGN",  (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",  (0,0), (-1,-1), 3),
        ("RIGHTPADDING", (0,0), (-1,-1), 3),
    ]))
    story.append(dh_two)
    story.append(sp(2))

    # ── SOCIAL HISTORY + FUNCTIONAL ───────────────────────────────────────────
    story.append(section_box("6. SOCIAL &amp; FUNCTIONAL HISTORY", bg=colors.HexColor("#6C3483")))
    story.append(sp(1))

    soc_left = [
        Paragraph("<b>SOCIAL HISTORY</b>", body_bold),
        Paragraph("• Smoking (if not already asked)", bullet),
        Paragraph("• Alcohol intake", bullet),
        Paragraph("• Current / past occupation (exposure history)", bullet),
        Paragraph("• Housing — stairs, heating, dampness/mould", bullet),
        Paragraph("• Social support — lives alone? Who are the carers?", bullet),
        Paragraph("• Employment impact / disability benefits", bullet),
        Paragraph("• Air travel — needs oxygen assessment if PaO₂ borderline", bullet),
    ]

    soc_right = [
        Paragraph("<b>FUNCTIONAL IMPACT (QoL)</b>", body_bold),
        Paragraph("• ADLs — can patient shower, dress, cook independently?", bullet),
        Paragraph("• Maximum walking distance", bullet),
        Paragraph("• Mobility aids (rollator, wheelchair)", bullet),
        Paragraph("• Hobbies, work, social participation", bullet),
        sp(2),
        Paragraph("<b>CAT SCORE DOMAINS (0–40)</b>", body_bold),
        Paragraph("Cough | Sputum | Chest tightness | Breathlessness | Activity at home | Confidence leaving home | Sleep | Energy", small),
        Paragraph("Score ≥10 = significant impact on QoL", small_italic),
    ]

    soc_two = Table([[soc_left, soc_right]], colWidths=[89*mm, 89*mm])
    soc_two.setStyle(TableStyle([
        ("VALIGN",  (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",  (0,0), (-1,-1), 3),
        ("RIGHTPADDING", (0,0), (-1,-1), 3),
    ]))
    story.append(soc_two)
    story.append(sp(2))

    # ── FAMILY HISTORY + SYSTEMS ──────────────────────────────────────────────
    fam_sys_left = [
        section_box("7. FAMILY HISTORY", bg=colors.HexColor("#1E8449")),
        sp(1),
        Paragraph("• COPD or emphysema — especially early-onset / non-smokers", bullet),
        Paragraph("  → Suspect <b>A1AT deficiency</b>", bullet),
        Paragraph("• Asthma (first-degree relatives)", bullet),
        Paragraph("• Lung cancer", bullet),
        Paragraph("• Maternal tobacco use during pregnancy", bullet),
    ]

    fam_sys_right = [
        section_box("8. SYSTEMS REVIEW", bg=colors.HexColor("#1E8449")),
        sp(1),
        Paragraph("• <b>CVS:</b> Ankle oedema (cor pulmonale), palpitations (AF), chest pain", bullet),
        Paragraph("• <b>Neuro:</b> Morning headaches, confusion (CO₂ retention)", bullet),
        Paragraph("• <b>MSK:</b> Back pain (vertebral fractures / steroids), muscle weakness", bullet),
        Paragraph("• <b>Nutrition:</b> Weight loss, anorexia (sarcopenia in emphysema)", bullet),
        Paragraph("• <b>Psych:</b> Depression, anxiety (very common in COPD)", bullet),
        Paragraph("• <b>ENT:</b> Chronic sinusitis, nasal polyps (asthma overlap)", bullet),
        Paragraph("• <b>Sleep:</b> Snoring / OSA (obesity-hypoventilation overlap)", bullet),
    ]

    fam_sys = Table([[fam_sys_left, fam_sys_right]], colWidths=[89*mm, 89*mm])
    fam_sys.setStyle(TableStyle([
        ("VALIGN",  (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",  (0,0), (-1,-1), 0),
        ("RIGHTPADDING", (0,0), (-1,-1), 3),
        ("TOPPADDING",   (0,0), (-1,-1), 0),
        ("BOTTOMPADDING",(0,0), (-1,-1), 0),
    ]))
    story.append(fam_sys)
    story.append(sp(3))

    # ── DIFFERENTIALS ─────────────────────────────────────────────────────────
    story.append(section_box("9. KEY DIFFERENTIALS TO EXCLUDE IN HISTORY", bg=RED))
    story.append(sp(1))
    diff_data = [
        [Paragraph("Condition", table_hdr), Paragraph("Distinguishing History Features", table_hdr)],
        [Paragraph("Asthma", table_cell_bold), Paragraph("Young onset, episodic wheeze, atopy, family history, fully reversible, responds well to ICS", table_cell)],
        [Paragraph("Heart Failure", table_cell_bold), Paragraph("Orthopnoea, PND, pink frothy sputum, cardiac risk factors, bilateral ankle oedema", table_cell)],
        [Paragraph("Bronchiectasis", table_cell_bold), Paragraph("Large volumes of mucopurulent sputum daily, recurrent infections, childhood lung disease", table_cell)],
        [Paragraph("Tuberculosis", table_cell_bold), Paragraph("Night sweats, weight loss, haemoptysis, contact history, foreign travel/endemic area", table_cell)],
        [Paragraph("Lung Cancer", table_cell_bold), Paragraph("Haemoptysis, significant weight loss, hoarseness, new finger clubbing, heavy smoker", table_cell)],
        [Paragraph("Pulmonary Fibrosis", table_cell_bold), Paragraph("Dry cough, clubbing, fine velcro crackles, autoimmune disease, occupational exposure (birds)", table_cell)],
    ]
    story.append(tbl(diff_data, [38*mm, 140*mm], bg_header=RED))
    story.append(sp(3))

    # ── GOLD STAGING REMINDER ─────────────────────────────────────────────────
    story.append(section_box("10. GOLD STAGING REMINDER (Confirm with Spirometry)", bg=ORANGE))
    story.append(sp(1))

    gold_left = [
        Paragraph("<b>GOLD SPIROMETRIC GRADES</b>", body_bold),
        Paragraph("(Post-bronchodilator FEV₁/FVC &lt;0.7)", small),
        sp(1),
    ]
    gold_grade_data = [
        [Paragraph("Grade", table_hdr), Paragraph("Severity", table_hdr), Paragraph("FEV₁ % Predicted", table_hdr)],
        [Paragraph("1", table_cell), Paragraph("Mild", table_cell), Paragraph("≥ 80%", table_cell)],
        [Paragraph("2", table_cell), Paragraph("Moderate", table_cell), Paragraph("50–79%", table_cell)],
        [Paragraph("3", table_cell), Paragraph("Severe", table_cell), Paragraph("30–49%", table_cell)],
        [Paragraph("4", table_cell), Paragraph("Very Severe", table_cell), Paragraph("< 30%", table_cell)],
    ]
    gold_left.append(tbl(gold_grade_data, [15*mm, 30*mm, 40*mm], bg_header=ORANGE))

    gold_right = [
        Paragraph("<b>GOLD ABE GROUPS (2023)</b>", body_bold),
        Paragraph("(Symptoms + Exacerbation Risk)", small),
        sp(1),
    ]
    gold_grp_data = [
        [Paragraph("Group", table_hdr), Paragraph("Criteria", table_hdr)],
        [Paragraph("A", table_cell), Paragraph("0–1 moderate exacerbations, no hospitalisation; low symptoms (CAT &lt;10)", table_cell)],
        [Paragraph("B", table_cell), Paragraph("0–1 moderate exacerbations, no hospitalisation; high symptoms (CAT ≥10)", table_cell)],
        [Paragraph("E", table_cell), Paragraph("≥2 moderate exacerbations OR ≥1 hospitalisation (regardless of symptoms)", table_cell)],
    ]
    gold_right.append(tbl(gold_grp_data, [12*mm, 75*mm], bg_header=ORANGE))

    gold_two = Table([[gold_left, gold_right]], colWidths=[89*mm, 89*mm])
    gold_two.setStyle(TableStyle([
        ("VALIGN",  (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",  (0,0), (-1,-1), 3),
        ("RIGHTPADDING", (0,0), (-1,-1), 3),
    ]))
    story.append(gold_two)
    story.append(sp(3))

    # ── CHECKLIST ─────────────────────────────────────────────────────────────
    story.append(section_box("QUICK CHECKLIST", bg=colors.HexColor("#2C3E50")))
    story.append(sp(1))

    checks = [
        ("Presenting symptoms", "Dyspnoea, cough, sputum, wheeze — onset, severity, progression"),
        ("MRC Grade", "Quantify exertional breathlessness (1–5)"),
        ("Exacerbation history", "Frequency, hospitalisations, NIV, rescue packs"),
        ("Smoking", "Pack-year history, current vs. ex-smoker"),
        ("Occupational / indoor / environmental exposure", "All jobs, biomass fuels, PPE"),
        ("Childhood history", "Recurrent RTIs, premature birth"),
        ("Family history", "A1AT, asthma, lung disease, maternal smoking"),
        ("Past medical history", "Cardiac disease, asthma, TB, depression"),
        ("Drug history", "Inhalers with technique, oxygen, steroids, harmful drugs"),
        ("Functional impact / QoL", "ADLs, walking distance, CAT score"),
        ("Social history", "Housing, support, employment, travel"),
        ("Systems review", "Cor pulmonale, CO₂ retention, weight loss, mood"),
        ("Differentials excluded", "Asthma, HF, bronchiectasis, TB, lung cancer, PF"),
    ]

    check_data = [[
        Paragraph("✓", S("chk", fontName="Helvetica-Bold", fontSize=9,
                         textColor=GREEN, alignment=TA_CENTER, leading=11)),
        Paragraph(f"<b>{c[0]}</b>", table_cell_bold),
        Paragraph(c[1], table_cell),
    ] for c in checks]
    check_data.insert(0, [
        Paragraph("", table_hdr),
        Paragraph("Domain", table_hdr),
        Paragraph("Key Points", table_hdr),
    ])
    chk_tbl = Table(check_data, colWidths=[7*mm, 55*mm, 116*mm])
    chk_tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), colors.HexColor("#2C3E50")),
        ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
        ("FONTNAME",      (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",      (0,0), (-1,-1), 8),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [LIGHTGREEN, WHITE]),
        ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#D5D8DC")),
        ("TOPPADDING",    (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
        ("ALIGN",         (0,0), (-1,-1), "LEFT"),
    ]))
    story.append(chk_tbl)
    story.append(sp(3))

    # ── FOOTER ────────────────────────────────────────────────────────────────
    footer_data = [[
        Paragraph(
            "<i>Sources: Goldman-Cecil Medicine | Washington Manual of Medical Therapeutics | "
            "Harrison's Principles of Internal Medicine 22E | Fishman's Pulmonary Diseases &amp; Disorders | "
            "GOLD 2023 Guidelines</i>",
            S("ftr", fontName="Helvetica-Oblique", fontSize=7, textColor=DARKGREY,
              alignment=TA_CENTER, leading=10)
        )
    ]]
    footer = Table(footer_data, colWidths=[178*mm])
    footer.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), GREY),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 6),
    ]))
    story.append(footer)

    doc.build(story)
    print(f"PDF created: {OUTPUT}")

build()

Running Command

cd /home/daytona/workspace/copd-pdf && python generate_copd_pdf.py 2>&1

Running Command

ls -lh /home/daytona/workspace/copd-pdf/COPD_History_Quick_Reference.pdf

Your PDF is ready:

COPD History Quick Reference

PDF Document · PDF

The single-page A4 quick reference includes:

Section	Contents
1. HPC	Dyspnoea (MRC scale table), cough, sputum, wheeze, haemoptysis warning
2. Exacerbation History	Frequency, triggers, severity, hospitalisations, NIV/intubation
3. Risk Factors	Pack-year formula, occupational exposure, biomass fuel, A1AT deficiency
4. Past Medical History	Key comorbidities and why each matters
5. Drug History	Inhaler classes, O₂/NIV, harmful drugs (beta-blockers, NSAIDs, ACEi)
6. Social & Functional	ADLs, CAT score domains, housing, support
7–8. Family & Systems Review	A1AT flags, cor pulmonale, CO₂ retention, depression
9. Differentials	Asthma, HF, bronchiectasis, TB, lung cancer, PF with distinguishing features
10. GOLD Staging	GOLD 1–4 (FEV₁) + ABE groups (2023)
Checklist	13-point visual checklist for the exam

How will i exclude cor pulmonale

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I now have all the content needed. Here is the comprehensive answer:

Excluding Cor Pulmonale in a COPD Long Case

Cor pulmonale = right ventricular hypertrophy/failure caused by pulmonary hypertension secondary to lung disease. In COPD, it develops via chronic alveolar hypoxia → pulmonary vasoconstriction → vascular remodeling → ↑ pulmonary vascular resistance → RV pressure overload → RV failure.

You exclude (or confirm) it across three levels: history → examination → investigations.

1. HISTORY — Symptoms That Suggest Cor Pulmonale

Ask specifically:

Symptom	How to Ask
Ankle swelling	"Have you noticed swelling of your ankles or legs?" "Is it worse at the end of the day?"
Progressive dyspnoea	Disproportionate breathlessness beyond what the COPD severity would explain
Fatigue / exercise intolerance	Low-output RV failure causes profound fatigue
Presyncope / syncope	From reduced cardiac output; suggests severe PH
Abdominal distension / discomfort	Hepatic congestion from elevated right atrial pressure
Anorexia / nausea	Gut congestion
Palpitations	AF and supraventricular arrhythmias are common (right atrial enlargement + hypoxaemia + bronchodilators)

Key point: Peripheral oedema in COPD patients is poorly correlated with resting right atrial pressure — it may also reflect RAAS activation from hypoxia, not just RV failure. Do not use ankle swelling alone to confirm or exclude cor pulmonale.

2. EXAMINATION — Signs to Look For

Vital Signs

SpO₂ — Hypoxia (SpO₂ <88%) is the main driver; chronic hypoxia must be present
Tachycardia — RV compensation / hypoxia / arrhythmia
Cyanosis — Central (lips/tongue) from hypoxia; peripheral (extremities) from low cardiac output

JVP (Jugular Venous Pressure)

Elevated JVP — the single most reliable bedside sign of raised right atrial pressure
Look for prominent 'a' wave (RVH, decreased RV compliance)
Look for prominent 'v' wave + pulsatile liver → tricuspid regurgitation (TR), a complication of longstanding cor pulmonale

Precordial Examination

Parasternal heave — RV hypertrophy (hand over left sternal edge)
Loud P₂ — Pulmonary hypertension (listen at pulmonary area 2nd ICS left)
Right ventricular S₃ — RV failure
TR murmur — Pansystolic at left sternal edge, louder on inspiration (Carvallo's sign)

Abdomen

Hepatomegaly — tender, pulsatile (if TR present)
Ascites — late sign of severe RHF

Peripheries

Pitting ankle/leg oedema — bilateral, pitting, dependent
Look up to the sacrum (if patient is bed-bound)

Signs you would NOT expect in simple COPD but suggest cor pulmonale:

Raised JVP
Parasternal heave
Loud P₂
TR murmur
Hepatomegaly + pulsatile liver

3. INVESTIGATIONS — How to Confirm/Exclude

Bedside

Test	Cor Pulmonale Finding
SpO₂ / ABG	PaO₂ <8 kPa (60 mmHg), PaCO₂ ↑ (late), respiratory acidosis
ECG	Right axis deviation, P pulmonale (tall peaked P in II >2.5 mm), RVH (dominant R in V1, deep S in V5/V6), RBBB, S₁Q₃T₃ pattern

Bloods

Test	Finding
FBC	Polycythaemia (Hb ↑) — compensatory response to chronic hypoxia
U&E	May show diuretic effects; hyponatraemia in severe failure
BNP / NT-proBNP	Elevated in RV failure
LFTs	Raised in hepatic congestion (↑ ALP, bilirubin)
Venous bicarbonate	↑ suggests chronic CO₂ retention

Imaging

Modality	Finding
Chest X-ray	Prominent pulmonary arteries (>16 mm right descending PA), enlarged hilar vessels, RV enlargement (obliteration of retrosternal space on lateral), peripheral pruning of vessels
ECG-gated CXR (PA)	Cardiomegaly with RV dominance
Echocardiogram (Key investigation)	RV enlargement + hypertrophy, elevated tricuspid regurgitant jet velocity (TRJV >2.8 m/s suggests PH), septal flattening/D-shaped LV in systole, estimated RVSP >35 mmHg
Cardiac MRI	Gold standard for RV volume/function; used when echo is inconclusive

Definitive Diagnosis

Right heart catheterisation (RHC) — the gold standard; demonstrates mean pulmonary artery pressure (mPAP) ≥25 mmHg at rest (or ≥20 mmHg by updated ESC criteria 2022). Required when echocardiogram is inconclusive or before specific PAH-targeted therapy.

Summary: Practical Approach in Long Case

History: Ankle oedema, worsening dyspnoea, syncope, abdominal distension
    ↓
Examination: Elevated JVP, parasternal heave, loud P₂, TR murmur,
             hepatomegaly, pitting oedema
    ↓
ECG: Right axis deviation, P pulmonale, RVH pattern
    ↓
CXR: Prominent pulmonary arteries, RV enlargement
    ↓
Echo: RV hypertrophy, TRJV, estimated RVSP
    ↓
ABG: Confirm hypoxia/hypercapnia (the primary driver)
    ↓
RHC (if needed): mPAP ≥20–25 mmHg = confirmed

Important caveat: Physical findings of venous engorgement and RV hypertrophy are late signs — by the time they are clinically obvious, significant PH is already established. Echocardiography is the most practical non-invasive tool and should be performed early in any COPD patient with unexplained worsening dyspnoea or oedema.

Sources: Fuster & Hurst's The Heart 15th Ed., pp. 1773–1777 | Fishman's Pulmonary Diseases & Disorders, p. 734

Can u make reference pdf of history taking of hepatitis, CKD

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Writing File

~/copd-pdf/generate_hep_ckd_pdf.py

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

OUTPUT = "/home/daytona/workspace/copd-pdf/Hepatitis_CKD_History_Quick_Reference.pdf"

# ── Palette ──────────────────────────────────────────────────────────────────
NAVY      = colors.HexColor("#1A3A5C")
TEAL      = colors.HexColor("#117A65")
AMBER     = colors.HexColor("#B7770D")
RED       = colors.HexColor("#922B21")
PURPLE    = colors.HexColor("#6C3483")
BLUE2     = colors.HexColor("#1A5276")
GREEN     = colors.HexColor("#1E8449")
DARKGREY  = colors.HexColor("#566573")
GREY      = colors.HexColor("#F2F3F4")
LIGHTGREY = colors.HexColor("#FDFEFE")
MIDGREY   = colors.HexColor("#D5D8DC")
WHITE     = colors.white
BLACK     = colors.HexColor("#1C2833")
LIGHTYELLOW = colors.HexColor("#FEF9E7")
LIGHTBLUE = colors.HexColor("#EAF2FF")
LIGHTRED  = colors.HexColor("#FDEDEC")
LIGHTGREEN= colors.HexColor("#E9F7EF")

PW = 178 * mm  # usable page width

# ── Style factory ────────────────────────────────────────────────────────────
def S(name, **kw):
    return ParagraphStyle(name, **kw)

title_s   = S("T", fontName="Helvetica-Bold",   fontSize=18, textColor=WHITE,  alignment=TA_CENTER, leading=22)
sub_s     = S("Su", fontName="Helvetica",        fontSize=9,  textColor=colors.HexColor("#AED6F1"), alignment=TA_CENTER, leading=12)
sechdr_s  = S("SH", fontName="Helvetica-Bold",   fontSize=9.5,textColor=WHITE,  alignment=TA_LEFT, leading=13)
body_s    = S("B",  fontName="Helvetica",         fontSize=8.5,textColor=BLACK,  leading=12, spaceAfter=2)
bold_s    = S("BB", fontName="Helvetica-Bold",    fontSize=8.5,textColor=BLACK,  leading=12, spaceAfter=2)
bul_s     = S("Bu", fontName="Helvetica",         fontSize=8.5,textColor=BLACK,  leading=12, leftIndent=10, firstLineIndent=-8, spaceAfter=1.5)
buld_s    = S("Bd", fontName="Helvetica-Bold",    fontSize=8.5,textColor=NAVY,   leading=12, leftIndent=10, firstLineIndent=-8, spaceAfter=1.5)
warn_s    = S("W",  fontName="Helvetica-BoldOblique", fontSize=8.5, textColor=RED, leading=12, leftIndent=8, spaceAfter=2)
tip_s     = S("Ti", fontName="Helvetica-Oblique", fontSize=8,  textColor=TEAL,  leading=11, leftIndent=8, spaceAfter=2)
small_s   = S("Sm", fontName="Helvetica",         fontSize=7.5,textColor=DARKGREY, leading=10, spaceAfter=1)
smit_s    = S("Si", fontName="Helvetica-Oblique", fontSize=7.5,textColor=DARKGREY, leading=10, spaceAfter=1)
th_s      = S("Th", fontName="Helvetica-Bold",    fontSize=8,  textColor=WHITE,  alignment=TA_CENTER, leading=11)
tc_s      = S("Tc", fontName="Helvetica",         fontSize=8,  textColor=BLACK,  leading=11)
tcb_s     = S("Tcb",fontName="Helvetica-Bold",    fontSize=8,  textColor=BLACK,  leading=11)
ftr_s     = S("Ft", fontName="Helvetica-Oblique", fontSize=7,  textColor=DARKGREY, alignment=TA_CENTER, leading=10)

# ── Helpers ───────────────────────────────────────────────────────────────────
def sp(h=3):
    return Spacer(1, h*mm)

def sec(title, bg=NAVY):
    d = [[Paragraph(f"▌  {title}", sechdr_s)]]
    t = Table(d, colWidths=[PW])
    t.setStyle(TableStyle([
        ("BACKGROUND",    (0,0),(-1,-1), bg),
        ("TOPPADDING",    (0,0),(-1,-1), 4),
        ("BOTTOMPADDING", (0,0),(-1,-1), 4),
        ("LEFTPADDING",   (0,0),(-1,-1), 6),
        ("RIGHTPADDING",  (0,0),(-1,-1), 4),
    ]))
    return t

def tbl(data, cw, bg=NAVY, extra=None):
    ts = [
        ("BACKGROUND",    (0,0),(-1,0), bg),
        ("TEXTCOLOR",     (0,0),(-1,0), WHITE),
        ("FONTNAME",      (0,0),(-1,0), "Helvetica-Bold"),
        ("FONTSIZE",      (0,0),(-1,-1), 8),
        ("ROWBACKGROUNDS",(0,1),(-1,-1), [WHITE, GREY]),
        ("GRID",          (0,0),(-1,-1), 0.4, MIDGREY),
        ("TOPPADDING",    (0,0),(-1,-1), 3),
        ("BOTTOMPADDING", (0,0),(-1,-1), 3),
        ("LEFTPADDING",   (0,0),(-1,-1), 5),
        ("RIGHTPADDING",  (0,0),(-1,-1), 5),
        ("VALIGN",        (0,0),(-1,-1), "MIDDLE"),
        ("ALIGN",         (0,0),(-1,0),  "CENTER"),
    ]
    if extra:
        ts.extend(extra)
    t = Table(data, colWidths=cw)
    t.setStyle(TableStyle(ts))
    return t

def two_col(left_items, right_items, lw=89, rw=89):
    t = Table([[left_items, right_items]], colWidths=[lw*mm, rw*mm])
    t.setStyle(TableStyle([
        ("VALIGN",        (0,0),(-1,-1), "TOP"),
        ("LEFTPADDING",   (0,0),(-1,-1), 3),
        ("RIGHTPADDING",  (0,0),(-1,-1), 3),
        ("TOPPADDING",    (0,0),(-1,-1), 2),
        ("BOTTOMPADDING", (0,0),(-1,-1), 2),
    ]))
    return t

def banner(main, sub, bg):
    t = Table([[Paragraph(main, title_s)], [Paragraph(sub, sub_s)]], colWidths=[PW])
    t.setStyle(TableStyle([
        ("BACKGROUND",    (0,0),(-1,-1), bg),
        ("TOPPADDING",    (0,0),(-1,-1), 8),
        ("BOTTOMPADDING", (0,0),(-1,-1), 8),
        ("LEFTPADDING",   (0,0),(-1,-1), 6),
    ]))
    return t

def checklist_table(rows, bg_hdr=colors.HexColor("#2C3E50"), row_colors=None):
    data = [[Paragraph("✓", S("c", fontName="Helvetica-Bold", fontSize=9, textColor=GREEN, alignment=TA_CENTER, leading=11)),
             Paragraph("Domain", th_s),
             Paragraph("Key Points", th_s)]]
    for r in rows:
        data.append([
            Paragraph("□", S("cb", fontName="Helvetica-Bold", fontSize=9, textColor=DARKGREY, alignment=TA_CENTER, leading=11)),
            Paragraph(f"<b>{r[0]}</b>", tcb_s),
            Paragraph(r[1], tc_s),
        ])
    rc = row_colors or [LIGHTGREEN, WHITE]
    t = Table(data, colWidths=[7*mm, 55*mm, 116*mm])
    t.setStyle(TableStyle([
        ("BACKGROUND",    (0,0),(-1,0), bg_hdr),
        ("TEXTCOLOR",     (0,0),(-1,0), WHITE),
        ("FONTNAME",      (0,0),(-1,0), "Helvetica-Bold"),
        ("FONTSIZE",      (0,0),(-1,-1), 8),
        ("ROWBACKGROUNDS",(0,1),(-1,-1), rc),
        ("GRID",          (0,0),(-1,-1), 0.4, MIDGREY),
        ("TOPPADDING",    (0,0),(-1,-1), 3),
        ("BOTTOMPADDING", (0,0),(-1,-1), 3),
        ("LEFTPADDING",   (0,0),(-1,-1), 5),
        ("VALIGN",        (0,0),(-1,-1), "MIDDLE"),
    ]))
    return t

# ════════════════════════════════════════════════════════════════════════════
# BUILD
# ════════════════════════════════════════════════════════════════════════════
def build():
    doc = SimpleDocTemplate(
        OUTPUT, pagesize=A4,
        leftMargin=16*mm, rightMargin=16*mm,
        topMargin=14*mm, bottomMargin=14*mm,
        title="Hepatitis & CKD History Quick Reference",
        author="Orris Medical"
    )
    story = []

    # ════════════════════════════════════════════════════════════════════════
    # PAGE 1 — HEPATITIS
    # ════════════════════════════════════════════════════════════════════════
    story.append(banner(
        "HEPATITIS — HISTORY TAKING",
        "Quick Reference — Long Case   |   Acute & Chronic Hepatitis (A/B/C/D/E + Autoimmune + Alcoholic)",
        colors.HexColor("#6E2C00")
    ))
    story.append(sp(2))

    # ── 1. Presenting Complaint ──────────────────────────────────────────────
    story.append(sec("1. PRESENTING COMPLAINT", bg=colors.HexColor("#6E2C00")))
    story.append(sp(1))
    story.append(Paragraph(
        "Common presenting symptoms: <b>jaundice</b>, fatigue, right-upper-quadrant (RUQ) pain, "
        "nausea/vomiting, anorexia, dark urine, pale stools, pruritus, abdominal distension. "
        "Many patients are <b>asymptomatic</b> and diagnosed incidentally on LFTs.",
        body_s))
    story.append(sp(2))

    # ── 2. HPC ───────────────────────────────────────────────────────────────
    story.append(sec("2. HISTORY OF PRESENTING COMPLAINT", bg=colors.HexColor("#873600")))
    story.append(sp(1))

    hpc_left = [
        Paragraph("<b>JAUNDICE</b>", bold_s),
        Paragraph("• Onset — sudden (acute hepatitis) vs. gradual (chronic/cirrhosis)", bul_s),
        Paragraph("• Duration and progression", bul_s),
        Paragraph("• Fluctuating (haemolytic/Gilbert's) vs. persistent", bul_s),
        Paragraph("• Associated dark urine + pale stools (cholestatic pattern)", bul_s),
        Paragraph("• Pruritus — suggests cholestasis (biliary obstruction or PBC)", bul_s),
        sp(2),
        Paragraph("<b>PAIN</b>", bold_s),
        Paragraph("• RUQ/epigastric — dull ache = hepatitis; sharp/colicky = biliary", bul_s),
        Paragraph("• Onset, radiation (to right shoulder = biliary)", bul_s),
        Paragraph("• Relation to food (biliary colic)", bul_s),
        sp(2),
        Paragraph("<b>SYSTEMIC SYMPTOMS</b>", bold_s),
        Paragraph("• Fatigue, malaise (often presenting complaint in chronic hepatitis)", bul_s),
        Paragraph("• Anorexia, nausea, vomiting, weight loss", bul_s),
        Paragraph("• Fever, arthralgia, rash — prodrome of Hep A/B", bul_s),
        Paragraph("• Low-grade fever vs. rigors (suggests cholangitis)", bul_s),
    ]

    hpc_right = [
        Paragraph("<b>COMPLICATIONS / ADVANCED DISEASE</b>", bold_s),
        Paragraph("• Abdominal distension — ascites (portal hypertension / liver failure)", bul_s),
        Paragraph("• Haematemesis / melaena — oesophageal varices", bul_s),
        Paragraph("• Easy bruising / prolonged bleeding — coagulopathy", bul_s),
        Paragraph("• Confusion / drowsiness / sleep inversion — hepatic encephalopathy", bul_s),
        Paragraph("• Ankle swelling — hypoalbuminaemia or portal HTN", bul_s),
        sp(2),
        Paragraph("<b>SPECIFIC TO ACUTE HEPATITIS</b>", bold_s),
        Paragraph("• Pre-icteric phase: flu-like illness 1–2 weeks before jaundice", bul_s),
        Paragraph("• Icteric phase: jaundice, dark urine, pale stools, RUQ discomfort", bul_s),
        Paragraph("• Resolution vs. fulminant hepatic failure (encephalopathy, coagulopathy)", bul_s),
        sp(2),
        Paragraph("<b>SPECIFIC TO CHRONIC HEPATITIS</b>", bold_s),
        Paragraph("• Insidious fatigue, vague RUQ discomfort for months–years", bul_s),
        Paragraph("• Features of cirrhosis: gynecomastia, testicular atrophy, spider naevi", bul_s),
        Paragraph("• Hepatocellular carcinoma screen: weight loss, worsening RUQ pain", bul_s),
    ]

    story.append(two_col(hpc_left, hpc_right))
    story.append(sp(2))

    # ── 3. Risk Factors / Aetiology ──────────────────────────────────────────
    story.append(sec("3. RISK FACTOR HISTORY — AETIOLOGY", bg=AMBER))
    story.append(sp(1))

    rf_data = [
        [Paragraph("Type", th_s), Paragraph("Route", th_s), Paragraph("Key Risk Factors to Ask", th_s)],
        [Paragraph("Hep A", tcb_s), Paragraph("Faeco-oral", tc_s),
         Paragraph("Travel to endemic areas, contaminated food/water, raw seafood, poor sanitation", tc_s)],
        [Paragraph("Hep B", tcb_s), Paragraph("Parenteral / sexual / vertical", tc_s),
         Paragraph("IV drug use (shared needles), unprotected sex, multiple partners, blood transfusion pre-1990s, tattoos/piercings, healthcare worker, born to HBsAg+ mother, needlestick", tc_s)],
        [Paragraph("Hep C", tcb_s), Paragraph("Parenteral (mainly)", tc_s),
         Paragraph("IV drug use (most common), blood transfusion pre-1992, haemodialysis, tattoos, needlestick, sexual contact (lower risk)", tc_s)],
        [Paragraph("Hep D", tcb_s), Paragraph("Parenteral (requires HBV)", tc_s),
         Paragraph("Co-infection or superinfection with HBV; same risk factors as Hep B", tc_s)],
        [Paragraph("Hep E", tcb_s), Paragraph("Faeco-oral", tc_s),
         Paragraph("Travel to South/East Asia, Central America, Africa; undercooked pork; immunosuppressed patients (chronic HEV)", tc_s)],
        [Paragraph("Alcoholic", tcb_s), Paragraph("Toxin", tc_s),
         Paragraph("Alcohol intake: units/week, duration, type; CAGE/AUDIT score; binge pattern", tc_s)],
        [Paragraph("Autoimmune", tcb_s), Paragraph("Autoimmune", tc_s),
         Paragraph("Female sex, personal/family history of autoimmune disease (thyroid, IBD, T1DM, SLE)", tc_s)],
        [Paragraph("NASH/MASH", tcb_s), Paragraph("Metabolic", tc_s),
         Paragraph("Obesity, T2DM, hyperlipidaemia, metabolic syndrome, rapid weight loss, TPN", tc_s)],
        [Paragraph("Drug-induced", tcb_s), Paragraph("Hepatotoxin", tc_s),
         Paragraph("All drugs incl. OTC, herbal/supplements, paracetamol dose, isoniazid, methotrexate, statins, antiepileptics, antiretrovirals", tc_s)],
        [Paragraph("Genetic", tcb_s), Paragraph("Inherited", tc_s),
         Paragraph("Haemochromatosis (Irish/Northern European, joint pain, diabetes, skin bronzing), Wilson's disease (young patient, neuropsychiatric), A1AT deficiency", tc_s)],
    ]
    story.append(tbl(rf_data, [16*mm, 40*mm, 122*mm], bg=AMBER))
    story.append(sp(1))
    story.append(Paragraph(
        "⚠ Always ask: <b>alcohol history</b> (quantify in units/week), <b>full drug history including herbals</b>, "
        "<b>sexual history</b>, <b>IV drug use</b> (non-judgmentally), <b>travel history</b>, <b>tattoos/piercings</b>, "
        "<b>blood products received</b> (when, where).",
        warn_s))
    story.append(sp(2))

    # ── 4. Past Medical History ──────────────────────────────────────────────
    story.append(sec("4. PAST MEDICAL HISTORY", bg=BLUE2))
    story.append(sp(1))
    pmh_left = [
        Paragraph("<b>Liver disease history</b>", bold_s),
        Paragraph("• Previous jaundice (post-op, in pregnancy, childhood)", bul_s),
        Paragraph("• Prior hepatitis diagnosis — acute or chronic", bul_s),
        Paragraph("• Cirrhosis, portal hypertension, varices, ascites", bul_s),
        Paragraph("• Liver biopsy — when, result?", bul_s),
        Paragraph("• Hepatocellular carcinoma", bul_s),
        sp(2),
        Paragraph("<b>Metabolic / systemic</b>", bold_s),
        Paragraph("• Diabetes mellitus, obesity, hyperlipidaemia (NASH risk)", bul_s),
        Paragraph("• Autoimmune conditions (AIH, IBD, thyroid disease)", bul_s),
        Paragraph("• Coeliac disease (abnormal LFTs)", bul_s),
    ]
    pmh_right = [
        Paragraph("<b>Surgical / procedural history</b>", bold_s),
        Paragraph("• Cholecystectomy, biliary surgery (biliary stricture)", bul_s),
        Paragraph("• Blood transfusions — pre-1992 (HCV risk)", bul_s),
        Paragraph("• Organ transplant (immunosuppression → chronic HBV/HCV)", bul_s),
        Paragraph("• Haemodialysis history (HCV risk)", bul_s),
        sp(2),
        Paragraph("<b>HIV status</b>", bold_s),
        Paragraph("• HIV co-infection accelerates HBV/HCV progression to cirrhosis", bul_s),
        Paragraph("• Antiretroviral therapy can cause hepatotoxicity", bul_s),
    ]
    story.append(two_col(pmh_left, pmh_right))
    story.append(sp(2))

    # ── 5. Drug History ──────────────────────────────────────────────────────
    story.append(sec("5. DRUG HISTORY", bg=PURPLE))
    story.append(sp(1))
    story.append(Paragraph(
        "List <b>all medications</b> — prescribed, OTC, herbal, and illicit. Ask about dose and duration. "
        "Common hepatotoxic agents include:",
        body_s))
    drug_data = [
        [Paragraph("Category", th_s), Paragraph("Examples", th_s), Paragraph("Pattern", th_s)],
        [Paragraph("Analgesics", tc_s), Paragraph("Paracetamol (↑ dose), NSAIDs", tc_s), Paragraph("Hepatocellular", tc_s)],
        [Paragraph("Antibiotics", tc_s), Paragraph("Flucloxacillin, co-amoxiclav, isoniazid, nitrofurantoin", tc_s), Paragraph("Hepatocellular / cholestatic", tc_s)],
        [Paragraph("Statins", tc_s), Paragraph("All statins", tc_s), Paragraph("Hepatocellular (usually mild)", tc_s)],
        [Paragraph("Antiepileptics", tc_s), Paragraph("Phenytoin, sodium valproate, carbamazepine", tc_s), Paragraph("Hepatocellular", tc_s)],
        [Paragraph("Chemotherapy", tc_s), Paragraph("Methotrexate, azathioprine", tc_s), Paragraph("Fibrosis / hepatocellular", tc_s)],
        [Paragraph("Herbal/supplements", tc_s), Paragraph("Kava, comfrey, green tea extract", tc_s), Paragraph("Variable — often underreported", tc_s)],
        [Paragraph("Alcohol", tc_s), Paragraph("Ethanol", tc_s), Paragraph("Steatosis → hepatitis → cirrhosis", tc_s)],
    ]
    story.append(tbl(drug_data, [30*mm, 74*mm, 74*mm], bg=PURPLE))
    story.append(sp(2))

    # ── 6. Social, Family, Systems ───────────────────────────────────────────
    soc_fam_left = [
        sec("6. SOCIAL HISTORY", bg=TEAL),
        sp(1),
        Paragraph("• <b>Alcohol</b> — units/week, years, type; CAGE/AUDIT score", bul_s),
        Paragraph("• <b>IV drug use</b> — past or present, sharing needles", bul_s),
        Paragraph("• <b>Sexual history</b> — partners, unprotected intercourse, MSM", bul_s),
        Paragraph("• <b>Travel</b> — endemic regions for Hep A/E (South Asia, Africa)", bul_s),
        Paragraph("• <b>Tattoos/piercings</b> — where, sterile technique?", bul_s),
        Paragraph("• <b>Occupation</b> — healthcare worker (needlestick risk)", bul_s),
        Paragraph("• <b>Immigration background</b> — HBV endemic countries (SE Asia, Sub-Saharan Africa)", bul_s),
        Paragraph("• <b>Household contacts</b> — HBV/HCV infected family members?", bul_s),
        Paragraph("• <b>Vaccination history</b> — Hep A / Hep B vaccinated?", bul_s),
    ]
    soc_fam_right = [
        sec("7. FAMILY HISTORY", bg=TEAL),
        sp(1),
        Paragraph("• Liver disease, cirrhosis, liver cancer", bul_s),
        Paragraph("• <b>Haemochromatosis</b> — Northern European ancestry; joint/cardiac disease", bul_s),
        Paragraph("• <b>Wilson's disease</b> — young patient, neurological symptoms", bul_s),
        Paragraph("• <b>A1AT deficiency</b> — emphysema + liver disease", bul_s),
        Paragraph("• Autoimmune diseases in family (AIH risk)", bul_s),
        sp(1),
        sec("8. SYSTEMS REVIEW", bg=GREEN),
        sp(1),
        Paragraph("• <b>GI:</b> Abdominal pain, change in bowel habit, melaena/haematemesis", bul_s),
        Paragraph("• <b>Neuro:</b> Confusion, personality change, sleep inversion → encephalopathy", bul_s),
        Paragraph("• <b>MSK:</b> Joint pains (Hep B prodrome, haemochromatosis)", bul_s),
        Paragraph("• <b>Skin:</b> Jaundice, spider naevi, palmar erythema, leuconychia, purpura", bul_s),
        Paragraph("• <b>Endocrine:</b> Gynaecomastia, loss of body hair, menstrual irregularity", bul_s),
        Paragraph("• <b>Renal:</b> Oedema (hypoalbuminaemia), hepatorenal syndrome", bul_s),
    ]
    story.append(two_col(soc_fam_left, soc_fam_right, lw=88, rw=90))
    story.append(sp(2))

    # ── Differentials ─────────────────────────────────────────────────────────
    story.append(sec("9. KEY DIFFERENTIALS TO EXCLUDE", bg=RED))
    story.append(sp(1))
    diff_data = [
        [Paragraph("Diagnosis", th_s), Paragraph("Distinguishing History Features", th_s)],
        [Paragraph("Biliary obstruction (stone/cancer)", tcb_s), Paragraph("Colicky RUQ pain radiating to shoulder, fluctuating jaundice, pale stools/dark urine, itching, weight loss (cancer)", tc_s)],
        [Paragraph("Alcoholic hepatitis", tcb_s), Paragraph("Heavy alcohol intake, recent binge, fever, tender hepatomegaly, coagulopathy", tc_s)],
        [Paragraph("Non-alcoholic steatohepatitis", tcb_s), Paragraph("Obesity, T2DM, metabolic syndrome, no/minimal alcohol, incidental LFT rise", tc_s)],
        [Paragraph("Haemolytic jaundice", tcb_s), Paragraph("Family history, anaemia, dark urine without pale stools, fluctuating, no hepatic symptoms", tc_s)],
        [Paragraph("Hepatocellular carcinoma", tcb_s), Paragraph("Background cirrhosis, weight loss, worsening ascites, ↑ AFP, RUQ mass", tc_s)],
        [Paragraph("Primary biliary cholangitis", tcb_s), Paragraph("Middle-aged woman, severe pruritus, fatigue, autoimmune disease, AMA positive", tc_s)],
    ]
    story.append(tbl(diff_data, [50*mm, 128*mm], bg=RED))
    story.append(sp(2))

    # ── Checklist ─────────────────────────────────────────────────────────────
    story.append(sec("HEPATITIS HISTORY CHECKLIST", bg=colors.HexColor("#2C3E50")))
    story.append(sp(1))
    hep_checks = [
        ("Presenting symptom", "Jaundice, fatigue, RUQ pain, dark urine, pale stools, pruritus"),
        ("Onset & course", "Acute vs. chronic; complications (encephalopathy, variceal bleed, ascites)"),
        ("Viral risk factors", "IV drug use, sexual history, blood products, tattoos, travel, needlestick"),
        ("Alcohol history", "Units/week, years drinking, CAGE/AUDIT score"),
        ("Drug & herbal history", "All medications including OTC, herbal, supplements — dose & duration"),
        ("Metabolic risk", "Obesity, T2DM, hyperlipidaemia, metabolic syndrome (NASH)"),
        ("Autoimmune screen", "Personal/family autoimmune disease history"),
        ("Genetic causes", "Family history of haemochromatosis, Wilson's, A1AT"),
        ("Past medical history", "Previous jaundice, liver disease, biliary surgery, HIV, dialysis"),
        ("Family history", "Liver disease, genetic disorders, HBV/HCV in household"),
        ("Vaccination history", "Hep A and B vaccination status"),
        ("Systems review", "Encephalopathy, GI bleeding, skin signs, renal, musculoskeletal"),
        ("Differentials excluded", "Biliary obstruction, haemolysis, HCC, PBC, alcoholic hepatitis"),
    ]
    story.append(checklist_table(hep_checks, bg_hdr=colors.HexColor("#6E2C00"), row_colors=[LIGHTYELLOW, WHITE]))
    story.append(sp(2))

    # ════════════════════════════════════════════════════════════════════════
    # PAGE BREAK → CKD
    # ════════════════════════════════════════════════════════════════════════
    story.append(PageBreak())

    story.append(banner(
        "CHRONIC KIDNEY DISEASE (CKD) — HISTORY TAKING",
        "Quick Reference — Long Case   |   CKD Stages 1–5 Including ESRD / Renal Replacement Therapy",
        colors.HexColor("#154360")
    ))
    story.append(sp(2))

    # ── 1. Presenting Complaint ───────────────────────────────────────────────
    story.append(sec("1. PRESENTING COMPLAINT", bg=colors.HexColor("#154360")))
    story.append(sp(1))
    story.append(Paragraph(
        "CKD is often <b>asymptomatic until late stages</b> — many patients are diagnosed incidentally on blood tests. "
        "Pain in the renal region and reduced urine output are <b>NOT</b> typical features of CKD. "
        "When symptoms do occur, they reflect the uraemic syndrome.",
        body_s))
    story.append(Paragraph(
        "⚠ Ask specifically: Was this an incidental finding? Or were there symptoms prompting testing?",
        warn_s))
    story.append(sp(2))

    # ── 2. HPC ───────────────────────────────────────────────────────────────
    story.append(sec("2. HISTORY OF PRESENTING COMPLAINT — URAEMIC SYNDROME", bg=colors.HexColor("#1A5276")))
    story.append(sp(1))

    uraemic_data = [
        [Paragraph("System", th_s), Paragraph("Symptoms to Ask About", th_s), Paragraph("Notes", th_s)],
        [Paragraph("General", tcb_s), Paragraph("Fatigue, malaise, weakness, weight loss, anorexia", tc_s), Paragraph("Often earliest symptoms; non-specific", tc_s)],
        [Paragraph("GI", tcb_s), Paragraph("Nausea, vomiting, hiccups, metallic taste in mouth, anorexia", tc_s), Paragraph("Uraemic gastritis and gastroparesis", tc_s)],
        [Paragraph("Neurological", tcb_s), Paragraph("Confusion, drowsiness, asterixis, seizures (severe); restless legs at night; muscle cramps", tc_s), Paragraph("Uraemic encephalopathy; peripheral neuropathy", tc_s)],
        [Paragraph("Cardiovascular", tcb_s), Paragraph("Breathlessness, orthopnoea, ankle swelling, chest pain", tc_s), Paragraph("Fluid overload, LVH, pericarditis (friction rub)", tc_s)],
        [Paragraph("Haematological", tcb_s), Paragraph("Pallor, fatigue, dyspnoea on exertion, easy bruising/bleeding", tc_s), Paragraph("Normochromic normocytic anaemia (↓EPO); platelet dysfunction", tc_s)],
        [Paragraph("Skin", tcb_s), Paragraph("Pruritus (generalised, severe), sallow/yellow-brown skin", tc_s), Paragraph("Uraemic frost (very late, rare now); calcium-phosphate deposition", tc_s)],
        [Paragraph("Bone/MSK", tcb_s), Paragraph("Bone pain, fractures, muscle weakness, proximal myopathy", tc_s), Paragraph("Renal osteodystrophy (↓vit D, ↑PTH, ↑phosphate)", tc_s)],
        [Paragraph("Urological", tcb_s), Paragraph("Nocturia (early; loss of concentrating ability), oliguria, haematuria, frothy urine (proteinuria)", tc_s), Paragraph("Haematuria → glomerulonephritis, cancer, stones", tc_s)],
        [Paragraph("Sleep / psych", tcb_s), Paragraph("Restless leg syndrome, insomnia, depression, cognitive impairment", tc_s), Paragraph("Very common; QoL impact", tc_s)],
    ]
    story.append(tbl(uraemic_data, [28*mm, 88*mm, 62*mm], bg=colors.HexColor("#1A5276")))
    story.append(sp(2))

    # ── 3. Risk Factors / Aetiology ──────────────────────────────────────────
    story.append(sec("3. RISK FACTOR HISTORY — CAUSES OF CKD", bg=AMBER))
    story.append(sp(1))

    ckd_cause_left = [
        Paragraph("<b>MOST COMMON CAUSES (ask first)</b>", bold_s),
        Paragraph("• <b>Diabetes mellitus</b> — type, duration, glycaemic control (HbA1c), proteinuria onset, diabetic retinopathy (marker of nephropathy)", bul_s),
        Paragraph("• <b>Hypertension</b> — duration, BP control, medications; may cause OR be caused by CKD", bul_s),
        Paragraph("• <b>Glomerulonephritis</b> — haematuria, proteinuria, nephrotic/nephritic syndrome, previous biopsy", bul_s),
        Paragraph("• <b>Renovascular disease</b> — atherosclerotic risk factors, flash pulmonary oedema, resistant hypertension", bul_s),
        sp(2),
        Paragraph("<b>OBSTRUCTIVE / STRUCTURAL</b>", bold_s),
        Paragraph("• BPH / prostate cancer — hesitancy, nocturia, poor flow", bul_s),
        Paragraph("• Recurrent renal calculi — previous stones, haematuria, colicky pain, metabolic causes", bul_s),
        Paragraph("• Recurrent UTIs / reflux nephropathy", bul_s),
        Paragraph("• Congenital — horseshoe kidney, duplex system", bul_s),
    ]

    ckd_cause_right = [
        Paragraph("<b>SYSTEMIC DISEASES</b>", bold_s),
        Paragraph("• SLE / vasculitis — arthralgia, rash, pleuritis, sinusitis, haemoptysis", bul_s),
        Paragraph("• Amyloidosis — chronic inflammatory disease, myeloma, weight loss", bul_s),
        Paragraph("• Multiple myeloma — back pain, anaemia, hypercalcaemia (age >40 + unexplained CKD)", bul_s),
        Paragraph("• Sickle cell disease — sickling crises, chronic haemolysis", bul_s),
        sp(2),
        Paragraph("<b>HEREDITARY</b>", bold_s),
        Paragraph("• <b>Polycystic kidney disease (ADPKD)</b> — family history, loin pain, hypertension, haematuria, liver cysts, cerebral aneurysm", bul_s),
        Paragraph("• <b>Alport's syndrome</b> — haematuria, sensorineural deafness, ocular defects, family history", bul_s),
        Paragraph("• <b>Fabry's disease</b> — neuropathic pain, angiokeratomas, cardiac disease", bul_s),
        sp(2),
        Paragraph("<b>NEPHROTOXIC EXPOSURE</b>", bold_s),
        Paragraph("• NSAIDs, COX-2 inhibitors (chronic use)", bul_s),
        Paragraph("• Contrast nephropathy history", bul_s),
        Paragraph("• Lithium — therapeutic levels, duration", bul_s),
        Paragraph("• Heavy metals (lead, cadmium) — occupational", bul_s),
        Paragraph("• Previous cisplatin / aminoglycoside use", bul_s),
        Paragraph("• Aristolochic acid (herbal medicines)", bul_s),
    ]
    story.append(two_col(ckd_cause_left, ckd_cause_right))
    story.append(sp(2))

    # ── 4. Past Medical History ──────────────────────────────────────────────
    story.append(sec("4. PAST MEDICAL HISTORY", bg=BLUE2))
    story.append(sp(1))
    pmh2_data = [
        [Paragraph("Condition", th_s), Paragraph("Why It Matters", th_s)],
        [Paragraph("Diabetes mellitus", tcb_s), Paragraph("Most common cause of CKD in developed world; check duration, complications, glycaemic control", tc_s)],
        [Paragraph("Hypertension", tcb_s), Paragraph("Cause and consequence of CKD; control critical to slow progression", tc_s)],
        [Paragraph("Cardiovascular disease", tcb_s), Paragraph("IHD, heart failure, stroke — major comorbidity and cause of death in CKD", tc_s)],
        [Paragraph("Previous AKI", tcb_s), Paragraph("Risk factor for CKD; prior AKI episodes, cause, severity, recovery", tc_s)],
        [Paragraph("Urological history", tcb_s), Paragraph("Stones, UTIs, BPH, reflux, haematuria, previous operations", tc_s)],
        [Paragraph("Preeclampsia", tcb_s), Paragraph("CKD risk factor; also haematuria / proteinuria in pregnancy", tc_s)],
        [Paragraph("Hepatitis B / C / HIV", tcb_s), Paragraph("Membranous/MPGN nephropathy; immunosuppression affects management", tc_s)],
        [Paragraph("Gout", tcb_s), Paragraph("Urate nephropathy; shares risk factors with CKD", tc_s)],
    ]
    story.append(tbl(pmh2_data, [45*mm, 133*mm], bg=BLUE2))
    story.append(sp(2))

    # ── 5. Drug History ──────────────────────────────────────────────────────
    story.append(sec("5. DRUG HISTORY — NEPHROTOXIC AGENTS & RENAL DOSING", bg=PURPLE))
    story.append(sp(1))
    ckd_drug_left = [
        Paragraph("<b>NEPHROTOXIC DRUGS TO IDENTIFY</b>", bold_s),
        Paragraph("• NSAIDs (ibuprofen, diclofenac) — chronic use", bul_s),
        Paragraph("• COX-2 inhibitors", bul_s),
        Paragraph("• Lithium — check levels and duration", bul_s),
        Paragraph("• Calcineurin inhibitors (ciclosporin, tacrolimus)", bul_s),
        Paragraph("• Aminoglycosides — past IV courses", bul_s),
        Paragraph("• Contrast agents — previous AKI after imaging?", bul_s),
        Paragraph("• Proton pump inhibitors — interstitial nephritis", bul_s),
        Paragraph("• Phosphate-containing bowel preps", bul_s),
        Paragraph("• Herbal medicines (aristolochic acid)", bul_s),
    ]
    ckd_drug_right = [
        Paragraph("<b>CURRENT MEDICATIONS FOR CKD</b>", bold_s),
        Paragraph("• ACE inhibitor / ARB — renoprotective; dose?", bul_s),
        Paragraph("• <b>SGLT2 inhibitor</b> — dapagliflozin, empagliflozin (renoprotective in DKD)", bul_s),
        Paragraph("• Diuretics — loop (furosemide), thiazide", bul_s),
        Paragraph("• Phosphate binders — sevelamer, calcium carbonate", bul_s),
        Paragraph("• Vitamin D analogues — alfacalcidol, calcitriol", bul_s),
        Paragraph("• EPO / ESAs — darbepoetin, erythropoietin", bul_s),
        Paragraph("• Antihypertensives — target BP &lt;130/80 in CKD+proteinuria", bul_s),
        Paragraph("• Bicarbonate supplementation — for metabolic acidosis", bul_s),
        Paragraph("• Allopurinol — for hyperuricaemia", bul_s),
    ]
    story.append(two_col(ckd_drug_left, ckd_drug_right))
    story.append(sp(2))

    # ── 6. RRT History ───────────────────────────────────────────────────────
    story.append(sec("6. RENAL REPLACEMENT THERAPY (RRT) HISTORY — IF APPLICABLE", bg=colors.HexColor("#117A65")))
    story.append(sp(1))
    rrt_left = [
        Paragraph("<b>DIALYSIS</b>", bold_s),
        Paragraph("• Type: Haemodialysis (HD) or Peritoneal dialysis (PD)", bul_s),
        Paragraph("• HD: frequency (3×/week), duration, unit or home-based", bul_s),
        Paragraph("• Access: arteriovenous fistula (AVF), tunnelled line, PD catheter", bul_s),
        Paragraph("• Complications: infections, access failure, hypotension on HD", bul_s),
        Paragraph("• Adequacy: Kt/V, fluid removal, residual renal function", bul_s),
    ]
    rrt_right = [
        Paragraph("<b>TRANSPLANT</b>", bold_s),
        Paragraph("• Date, donor (living/deceased), type of match", bul_s),
        Paragraph("• Current immunosuppression: tacrolimus, mycophenolate, prednisolone", bul_s),
        Paragraph("• Rejection episodes — acute or chronic", bul_s),
        Paragraph("• Complications: infections, malignancy, calcineurin toxicity", bul_s),
        Paragraph("• Current eGFR of transplant kidney", bul_s),
        Paragraph("• Listed for re-transplant?", bul_s),
    ]
    story.append(two_col(rrt_left, rrt_right))
    story.append(sp(2))

    # ── 7. Social + Family + Systems ─────────────────────────────────────────
    soc2_left = [
        sec("7. SOCIAL HISTORY", bg=TEAL),
        sp(1),
        Paragraph("• Occupation — nephrotoxic exposures (lead, cadmium, solvents)", bul_s),
        Paragraph("• Diet — high protein, salt, potassium, phosphate intake", bul_s),
        Paragraph("• Fluid intake and management", bul_s),
        Paragraph("• Smoking — accelerates CKD progression and CVD risk", bul_s),
        Paragraph("• Alcohol — NSAID + alcohol = nephrotoxic combination", bul_s),
        Paragraph("• Exercise tolerance and functional status", bul_s),
        Paragraph("• Transport to dialysis unit (if on HD)", bul_s),
        Paragraph("• Social support / carer involvement", bul_s),
        Paragraph("• Employment impact / disability", bul_s),
    ]
    soc2_right = [
        sec("8. FAMILY HISTORY", bg=TEAL),
        sp(1),
        Paragraph("• CKD in family members — same or different cause", bul_s),
        Paragraph("• <b>ADPKD</b> — autosomal dominant; ask about each parent", bul_s),
        Paragraph("• <b>Alport's syndrome</b> — X-linked; family deafness/haematuria", bul_s),
        Paragraph("• Diabetes, hypertension in family (risk factors)", bul_s),
        Paragraph("• Shared environmental nephrotoxin exposure", bul_s),
        sp(1),
        sec("9. SYSTEMS REVIEW", bg=GREEN),
        sp(1),
        Paragraph("• <b>CVS:</b> IHD, LVH, pericarditis (friction rub = uraemia), AF", bul_s),
        Paragraph("• <b>Neuro:</b> Peripheral neuropathy, restless legs, encephalopathy", bul_s),
        Paragraph("• <b>Eyes:</b> Diabetic retinopathy, hypertensive retinopathy", bul_s),
        Paragraph("• <b>Bone:</b> Fractures, bone pain (renal osteodystrophy)", bul_s),
        Paragraph("• <b>Psych:</b> Depression, cognitive impairment (very common)", bul_s),
        Paragraph("• <b>Sexual:</b> Erectile dysfunction, menstrual irregularity (uraemia)", bul_s),
    ]
    story.append(two_col(soc2_left, soc2_right, lw=88, rw=90))
    story.append(sp(2))

    # ── CKD Staging Reminder ─────────────────────────────────────────────────
    story.append(sec("10. CKD STAGING — KDIGO 2024 (eGFR + Albuminuria)", bg=AMBER))
    story.append(sp(1))
    ckd_stage_data = [
        [Paragraph("Stage", th_s), Paragraph("eGFR (mL/min/1.73m²)", th_s), Paragraph("Severity", th_s)],
        [Paragraph("G1", tc_s), Paragraph("≥ 90", tc_s), Paragraph("Normal or high (kidney damage markers present)", tc_s)],
        [Paragraph("G2", tc_s), Paragraph("60–89", tc_s), Paragraph("Mildly decreased", tc_s)],
        [Paragraph("G3a", tc_s), Paragraph("45–59", tc_s), Paragraph("Mildly to moderately decreased", tc_s)],
        [Paragraph("G3b", tc_s), Paragraph("30–44", tc_s), Paragraph("Moderately to severely decreased", tc_s)],
        [Paragraph("G4", tc_s), Paragraph("15–29", tc_s), Paragraph("Severely decreased — prepare for RRT", tc_s)],
        [Paragraph("G5", tc_s), Paragraph("< 15", tc_s), Paragraph("Kidney failure (ESRD) — RRT or conservative management", tc_s)],
    ]
    story.append(tbl(ckd_stage_data, [13*mm, 50*mm, 115*mm], bg=AMBER))
    story.append(sp(1))
    story.append(Paragraph(
        "Albuminuria categories: A1 &lt;30 mg/g (normal–mildly increased), A2 30–300 mg/g (moderately increased), "
        "A3 &gt;300 mg/g (severely increased). Higher albuminuria = faster progression. "
        "Combine G and A categories for full staging (e.g. G3bA2).",
        smit_s))
    story.append(sp(2))

    # ── CKD Checklist ─────────────────────────────────────────────────────────
    story.append(sec("CKD HISTORY CHECKLIST", bg=colors.HexColor("#2C3E50")))
    story.append(sp(1))
    ckd_checks = [
        ("Presenting complaint", "Incidental vs. symptomatic; uraemic symptoms: fatigue, nausea, pruritus, restless legs"),
        ("Uraemic syndrome review", "GI, neuro, CVS, haematological, skin, bone, urological, sleep symptoms"),
        ("Cause of CKD", "Diabetes, hypertension, GN, renovascular, obstructive, hereditary, systemic disease"),
        ("Nephrotoxic drug history", "NSAIDs, lithium, contrast, aminoglycosides, herbal medicines"),
        ("Current CKD medications", "ACEi/ARB, SGLT2i, diuretics, phosphate binders, EPO, vitamin D"),
        ("Past medical history", "Diabetes, hypertension, AKI, urological, preeclampsia, cardiovascular"),
        ("RRT history", "Type of dialysis (HD/PD), access, frequency; transplant history and immunosuppression"),
        ("Family history", "ADPKD, Alport's, diabetes, hypertension, shared toxin exposure"),
        ("Social history", "Occupation, diet, smoking, fluid management, transport to dialysis"),
        ("Systems review", "CVS (IHD, pericarditis), eyes (retinopathy), neuro (neuropathy), bone, psych"),
        ("CKD staging", "eGFR value, albuminuria category — G and A staging"),
        ("Differentials", "AKI vs. CKD, obstructive uropathy, myeloma (age >35 with unexplained CKD + anaemia)"),
    ]
    story.append(checklist_table(ckd_checks, bg_hdr=colors.HexColor("#154360"), row_colors=[LIGHTBLUE, WHITE]))
    story.append(sp(3))

    # ── Footer ────────────────────────────────────────────────────────────────
    footer_d = [[Paragraph(
        "<i>Sources: Harrison's Principles of Internal Medicine 22E | Barash Clinical Anesthesia 9e | "
        "Sleisenger &amp; Fordtran's GI and Liver Disease | Goldman-Cecil Medicine | "
        "Tietz Textbook of Laboratory Medicine | KDIGO CKD Guidelines 2024</i>",
        ftr_s)]]
    footer = Table(footer_d, colWidths=[PW])
    footer.setStyle(TableStyle([
        ("BACKGROUND",    (0,0),(-1,-1), GREY),
        ("TOPPADDING",    (0,0),(-1,-1), 4),
        ("BOTTOMPADDING", (0,0),(-1,-1), 4),
        ("LEFTPADDING",   (0,0),(-1,-1), 6),
    ]))
    story.append(footer)

    doc.build(story)
    print(f"PDF created: {OUTPUT}")

build()

Running Command

cd /home/daytona/workspace/copd-pdf && python generate_hep_ckd_pdf.py 2>&1

Running Command

ls -lh /home/daytona/workspace/copd-pdf/

Your 2-page PDF is ready:

Hepatitis CKD History Quick Reference

PDF Document · PDF

Page 1 — Hepatitis (burnt orange theme)

Section	Contents
Presenting Complaint	Jaundice, fatigue, RUQ pain, dark urine, pale stools, pruritus
HPC	Acute vs. chronic features, complications (encephalopathy, varices, ascites)
Risk Factor Table	Hep A/B/C/D/E, alcoholic, autoimmune, NASH, drug-induced, genetic — routes & specific risk factors
Past Medical History	Previous jaundice, biliary surgery, blood products, HIV, dialysis
Drug History Table	Hepatotoxic drug classes with patterns (hepatocellular/cholestatic)
Social, Family, Systems	Alcohol CAGE/AUDIT, IV drug use, sexual history, travel, vaccination, family genetic causes
Differentials	Biliary obstruction, haemolysis, HCC, PBC, alcoholic hepatitis with distinguishing features
Checklist	13-point exam checklist

Page 2 — CKD (navy/blue theme)

Section	Contents
Uraemic Syndrome Table	All systems — GI, neuro, CVS, haematological, skin, bone, urological, sleep
Causes of CKD	DM, HTN, GN, ADPKD, Alport's, SLE, myeloma, obstructive, nephrotoxins
Past Medical History	Diabetes, hypertension, AKI, cardiovascular, preeclampsia
Drug History	Nephrotoxic drugs + current CKD medications (SGLT2i, ACEi, EPO, phosphate binders)
RRT History	Haemodialysis, peritoneal dialysis, transplant sections
Social, Family, Systems	Diet, fluid, occupation, ADPKD/Alport's family history
KDIGO Staging	G1–G5 eGFR table + albuminuria A1–A3 explanation
Checklist	12-point exam checklist

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