#!/usr/bin/env python3
"""
Builds a single PDF: "Clinical Examination - Systems Flowcharts & Interpretation"
Flowchart images (matplotlib) + detailed interpretation tables (reportlab) per system.
"""
import matplotlib
matplotlib.use("Agg")
import matplotlib.pyplot as plt
from matplotlib.patches import FancyBboxPatch
import textwrap, os

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

OUT = "/tmp/workspace/macleod-exam-flowchart/output"
os.makedirs(OUT, exist_ok=True)

# ---------------------------------------------------------------
# 1. FLOWCHART DRAWER
# ---------------------------------------------------------------
def draw_flowchart(title, steps, fname, node_color="#2E5EAA", branch_color="#C0392B"):
    """
    steps: list of dicts:
      {"label": str, "branches": [str, str, ...]}  # branches optional, drawn to the right
    Drawn top-to-bottom, main flow centered, branches as side notes with dashed connector.
    """
    n = len(steps)
    fig_h = max(3.0, 1.55 * n + 1.2)
    fig, ax = plt.subplots(figsize=(11, fig_h))
    ax.set_xlim(0, 10)
    ax.set_ylim(0, n + 1)
    ax.axis("off")
    ax.set_title(title, fontsize=17, fontweight="bold", color="#1B2A4A", pad=14)

    box_w, box_h = 5.0, 0.9
    cx = 3.4
    ys = []
    for i, step in enumerate(steps):
        y = n - i
        ys.append(y)
        label = step["label"]
        wrapped = "\n".join(textwrap.wrap(label, 46))
        box = FancyBboxPatch((cx - box_w/2, y - box_h/2), box_w, box_h,
                              boxstyle="round,pad=0.08,rounding_size=0.12",
                              linewidth=1.4, edgecolor=node_color,
                              facecolor="#EAF1FB")
        ax.add_patch(box)
        ax.text(cx, y, wrapped, ha="center", va="center", fontsize=9.3,
                 color="#10223B", fontweight="bold" if i == 0 else "normal")

        # arrow to next
        if i < n - 1:
            ax.annotate("", xy=(cx, y - box_h/2 - 0.32), xytext=(cx, y - box_h/2),
                         arrowprops=dict(arrowstyle="-|>", color=node_color, lw=1.6))

        # branches (special tests / findings) to the right
        branches = step.get("branches", [])
        if branches:
            bx = cx + box_w/2 + 0.6
            b_gap = 0.62
            start_by = y + (len(branches)-1) * b_gap / 2
            for j, br in enumerate(branches):
                by = start_by - j * b_gap
                ax.annotate("", xy=(bx, by), xytext=(cx + box_w/2, y),
                            arrowprops=dict(arrowstyle="-", color=branch_color,
                                             lw=1.0, linestyle="dashed"))
                bw = 4.1
                wrapped_b = "\n".join(textwrap.wrap(br, 52))
                ax.text(bx + 0.08, by, wrapped_b, ha="left", va="center", fontsize=7.8,
                        color="#5C1A12",
                        bbox=dict(boxstyle="round,pad=0.3", facecolor="#FBEDEA",
                                  edgecolor=branch_color, linewidth=0.8))

    plt.tight_layout()
    path = os.path.join(OUT, fname)
    fig.savefig(path, dpi=155, bbox_inches="tight")
    plt.close(fig)
    return path

# ---------------------------------------------------------------
# 2. CONTENT DATA — one entry per system
# Each: name, flow(list of steps w/ branches), tables(list of (heading, [[col1,col2],...]))
# ---------------------------------------------------------------
SYSTEMS = []

SYSTEMS.append({
"name": "1. General Examination & Vital Signs",
"flow": [
 {"label":"Introduce, consent, expose & position patient, ensure privacy/chaperone", "branches":[]},
 {"label":"General inspection: comfort, distress, build, nutrition, posture, mobility", "branches":[
    "Cachexia -> malignancy, chronic disease","Obesity -> metabolic syndrome, OSA"]},
 {"label":"Vital signs: Pulse, BP, Respiratory rate, Temperature, SpO2","branches":[
    "Tachycardia+fever -> infection/sepsis","Wide pulse pressure -> AR, thyrotoxicosis, fever",
    "Postural drop >20/10 mmHg -> orthostatic hypotension"]},
 {"label":"Hands: colour, temperature, clubbing, koilonychia, palmar erythema, tremor","branches":[
    "Clubbing -> bronchial CA, bronchiectasis, IE, cyanotic CHD, IBD, cirrhosis",
    "Koilonychia -> iron deficiency anaemia","Fine tremor -> thyrotoxicosis; flapping tremor -> CO2 retention/hepatic encephalopathy"]},
 {"label":"Face & eyes: pallor, jaundice, xanthelasma, exophthalmos, malar flush","branches":[
    "Conjunctival pallor -> anaemia","Scleral icterus -> jaundice (bilirubin >~50 umol/L)",
    "Xanthelasma -> hyperlipidaemia"]},
 {"label":"Mouth: hydration, cyanosis (central), tongue, dentition","branches":[
    "Central cyanosis -> hypoxaemia (SpO2 usually <85%)"]},
 {"label":"Neck: lymph nodes, JVP, thyroid, trachea position","branches":[
    "Raised JVP -> right heart failure, fluid overload, tamponade"]},
 {"label":"Lower limbs: oedema, temperature, varicosities, calf tenderness","branches":[
    "Pitting oedema -> cardiac/renal/hepatic failure, venous insufficiency",
    "Unilateral hot swollen calf -> DVT"]},
 {"label":"Summarise general findings before proceeding to system-specific exam","branches":[]},
],
"tables":[
 ("Key General Sign -> Interpretation", [
   ["Sign","Interpretation"],
   ["Clubbing","Lung CA, bronchiectasis, IE, cyanotic heart disease, IBD, cirrhosis"],
   ["Koilonychia","Chronic iron-deficiency anaemia"],
   ["Splinter haemorrhages","Infective endocarditis, trauma, vasculitis"],
   ["Palmar erythema","Chronic liver disease, pregnancy, thyrotoxicosis"],
   ["Central cyanosis","Hypoxaemia - cardiac/respiratory cause"],
   ["Peripheral cyanosis","Cold exposure, poor perfusion, shock"],
   ["Xanthelasma / xanthomata","Hyperlipidaemia"],
   ["Raised JVP","Right heart failure, tricuspid disease, tamponade, fluid overload"],
   ["Bilateral pitting oedema","Cardiac failure, hypoalbuminaemia, renal/hepatic disease"],
 ]),
]
})

SYSTEMS.append({
"name":"2. Cardiovascular System (CVS)",
"flow":[
 {"label":"History: chest pain, dyspnoea (exertional/orthopnoea/PND), palpitations, syncope, claudication, oedema, risk factors","branches":[]},
 {"label":"Inspection: cyanosis, malar flush, scars (sternotomy), visible pulsations, chest wall deformity","branches":[
   "Malar flush -> mitral stenosis","Midline sternotomy scar -> CABG/valve surgery"]},
 {"label":"Hands: clubbing, splinter haemorrhages, Osler's nodes, Janeway lesions, tar staining","branches":[
   "Splinters + Osler's nodes + Janeway lesions -> Infective endocarditis"]},
 {"label":"Pulse: rate, rhythm, volume, character; radial-radial & radial-femoral delay","branches":[
   "Collapsing/water-hammer pulse -> aortic regurgitation","Slow-rising pulse -> aortic stenosis",
   "Pulsus alternans -> severe LV failure","Radio-femoral delay -> coarctation of aorta",
   "Irregularly irregular -> atrial fibrillation"]},
 {"label":"Blood pressure in both arms; check for pulsus paradoxus if indicated","branches":[
   ">20 mmHg difference between arms -> aortic dissection/coarctation",
   "Pulsus paradoxus >10mmHg -> cardiac tamponade, severe asthma"]},
 {"label":"JVP: height (cm above sternal angle) & waveform, hepatojugular reflux","branches":[
   "Giant 'a' wave -> pulmonary HTN, tricuspid stenosis","Absent 'a' wave -> atrial fibrillation",
   "Large 'v' wave (giant systolic wave) -> tricuspid regurgitation",
   "Kussmaul's sign (JVP rises with inspiration) -> constrictive pericarditis/tamponade"]},
 {"label":"Precordium palpation: apex beat (location & character), heaves, thrills","branches":[
   "Tapping apex -> mitral stenosis","Heaving/sustained apex -> pressure overload (AS, HTN)",
   "Thrusting/displaced apex -> volume overload (MR, AR, dilated cardiomyopathy)",
   "Parasternal heave -> RV hypertrophy / pulmonary HTN","Palpable thrill -> loud (grade 4+) murmur"]},
 {"label":"Auscultation: mitral, tricuspid, pulmonary, aortic areas + axilla/carotids; S1,S2, added sounds, murmurs","branches":[
   "Loud S1 -> mitral stenosis; Soft S1 -> mitral regurgitation, long PR",
   "Wide split S2 -> RBBB, pulmonary stenosis; Fixed split -> ASD",
   "S3 -> heart failure/volume overload; S4 -> LVH/stiff ventricle (HTN, AS)",
   "Opening snap -> mitral stenosis; Ejection click -> bicuspid AV/PS"]},
 {"label":"Dynamic manoeuvres: sit forward+expire (aortic murmurs), left lateral position (mitral murmurs), Valsalva/squat","branches":[
   "Murmur increases with Valsalva -> HOCM; decreases -> most other murmurs",
   "Handgrip increases MR/VSD/AR murmurs"]},
 {"label":"Complete exam: lung bases for crepitations, sacral & ankle oedema, abdomen for hepatomegaly/ascites, peripheral pulses","branches":[
   "Bibasal crackles -> pulmonary oedema (LVF)","Absent peripheral pulse -> PAD/embolism"]},
],
"tables":[
 ("Murmur Pattern -> Likely Diagnosis", [
  ["Murmur","Timing / Character","Likely Diagnosis"],
  ["Ejection systolic, radiates to carotids","Crescendo-decrescendo, mid-systolic","Aortic stenosis"],
  ["Pansystolic, radiates to axilla","Blowing, apex","Mitral regurgitation"],
  ["Pansystolic, left sternal edge","Louder on inspiration","Tricuspid regurgitation"],
  ["Early diastolic, left sternal edge","Soft, sitting forward + expiration","Aortic regurgitation"],
  ["Mid-diastolic, apex, with opening snap","Rumbling, left lateral position","Mitral stenosis"],
  ["Pansystolic, left sternal edge, palpable thrill","Harsh","Ventricular septal defect"],
  ["Continuous 'machinery' murmur","Sub-clavicular","Patent ductus arteriosus"],
 ]),
 ("Pulse Character -> Interpretation",[
  ["Pulse Finding","Interpretation"],
  ["Slow-rising, low volume","Aortic stenosis"],
  ["Collapsing / water-hammer","Aortic regurgitation, PDA, high-output states"],
  ["Bisferiens (double impulse)","Mixed aortic stenosis + regurgitation"],
  ["Pulsus alternans","Severe LV systolic dysfunction"],
  ["Irregularly irregular","Atrial fibrillation"],
  ["Radio-femoral delay","Coarctation of the aorta"],
 ]),
]
})

SYSTEMS.append({
"name":"3. Respiratory System",
"flow":[
 {"label":"History: cough, sputum (colour/volume), haemoptysis, dyspnoea, wheeze, pleuritic pain, smoking/occupational exposure","branches":[]},
 {"label":"General inspection: respiratory distress, RR & pattern, accessory muscle use, cyanosis, audible wheeze/stridor","branches":[
   "Stridor -> upper airway obstruction","Pursed-lip breathing -> COPD"]},
 {"label":"Hands & face: clubbing, CO2 flap (asterixis), tar staining, Horner's syndrome, cyanosis","branches":[
   "Clubbing -> bronchial CA, bronchiectasis, fibrosing lung disease, empyema",
   "CO2 retention flap + bounding pulse -> hypercapnia",
   "Horner's syndrome -> Pancoast tumour"]},
 {"label":"Neck: lymphadenopathy (esp. supraclavicular/Virchow's node), trachea deviation, JVP","branches":[
   "Trachea deviated away from lesion -> tension pneumothorax/large effusion",
   "Trachea deviated towards lesion -> collapse/fibrosis"]},
 {"label":"Chest inspection: shape (barrel, pectus), symmetry of movement, scars, chest wall deformity","branches":[
   "Barrel chest -> hyperinflation/COPD","Asymmetrical expansion -> pathology on the reduced side"]},
 {"label":"Palpation: tracheal position, chest expansion (front & back), tactile vocal fremitus, apex beat","branches":[
   "Reduced expansion unilateral -> effusion, pneumothorax, collapse, consolidation"]},
 {"label":"Percussion: comparing both sides, all lung zones, note resonance","branches":[
   "Stony dull -> pleural effusion","Dull -> consolidation/collapse",
   "Hyperresonant -> pneumothorax, emphysema"]},
 {"label":"Auscultation: breath sounds (vesicular vs bronchial), added sounds, vocal resonance","branches":[
   "Bronchial breathing -> consolidation with patent airway",
   "Fine end-inspiratory crackles -> pulmonary fibrosis/pulmonary oedema",
   "Coarse crackles -> bronchiectasis, infection",
   "Wheeze (expiratory) -> asthma/COPD/airway narrowing",
   "Pleural rub -> pleurisy"]},
 {"label":"Special tests: whispering pectoriloquy, egophony, if indicated","branches":[
   "Positive whispering pectoriloquy -> consolidation"]},
 {"label":"Complete: peripheral oedema (cor pulmonale), peak flow/spirometry if available","branches":[]},
],
"tables":[
 ("Percussion & Auscultation Pattern -> Diagnosis",[
  ["Percussion","Breath sounds","Vocal resonance","Diagnosis"],
  ["Stony dull","Absent/reduced","Reduced","Pleural effusion"],
  ["Dull","Bronchial, crackles","Increased (aegophony)","Consolidation (pneumonia)"],
  ["Hyperresonant","Reduced/absent","Reduced","Pneumothorax"],
  ["Dull, trachea shifted toward lesion","Reduced","Reduced","Lobar collapse"],
  ["Resonant","Fine end-inspiratory crackles","Normal","Pulmonary fibrosis"],
  ["Resonant","Wheeze, prolonged expiration","Normal","Asthma / COPD"],
  ["Normal/hyperresonant","Coarse crackles, clear w/ cough","Normal","Bronchiectasis"],
 ]),
]
})

SYSTEMS.append({
"name":"4. Gastrointestinal System / Abdomen",
"flow":[
 {"label":"History: pain (site, character, radiation), vomiting, bowel habit, jaundice, weight loss, appetite, GI bleeding","branches":[]},
 {"label":"General inspection: nutritional status, jaundice, pallor, hydration, stigmata of chronic liver disease","branches":[
   "Spider naevi, gynaecomastia, palmar erythema, caput medusae -> chronic liver disease"]},
 {"label":"Position patient supine, expose abdomen (nipples to knees), inspect abdomen","branches":[
   "Distension -> the 5 F's: Fat, Fluid, Flatus, Faeces, Fetus",
   "Visible peristalsis -> intestinal obstruction","Caput medusae -> portal hypertension",
   "Striae, scars, stomas, visible masses"]},
 {"label":"Light palpation of all 9 regions -> tenderness, guarding, rigidity","branches":[
   "Involuntary guarding/rigidity -> peritonitis",
   "Rebound tenderness -> peritoneal irritation"]},
 {"label":"Deep palpation: organomegaly - liver, spleen, kidneys (bimanual/ballottement), masses","branches":[
   "Hepatomegaly -> cirrhosis, malignancy, heart failure, infiltration",
   "Splenomegaly -> portal HTN, haematological disease, infection",
   "Ballotable mass -> renal in origin"]},
 {"label":"Percussion: liver span, splenic dullness, shifting dullness for ascites, bladder","branches":[
   "Shifting dullness / fluid thrill -> ascites","Liver span >12-15cm -> hepatomegaly"]},
 {"label":"Auscultation: bowel sounds, bruits (aortic, renal, hepatic)","branches":[
   "Absent bowel sounds -> ileus/peritonitis","High-pitched tinkling -> mechanical obstruction",
   "Bruit over liver -> hepatocellular carcinoma/AV malformation"]},
 {"label":"Special/provocative tests as indicated by history","branches":[
   "Murphy's sign positive -> acute cholecystitis",
   "McBurney's point tenderness + Rovsing's sign -> acute appendicitis",
   "Psoas sign / obturator sign positive -> appendicitis (retrocaecal/pelvic)",
   "Fluid thrill / shifting dullness -> ascites",
   "Cullen's/Grey-Turner's sign -> haemorrhagic pancreatitis"]},
 {"label":"Complete exam: hernial orifices, external genitalia, digital rectal examination","branches":[
   "DRE mass/blood -> colorectal malignancy, haemorrhoids, fissure"]},
],
"tables":[
 ("Special Sign / Test -> Interpretation",[
  ["Sign / Test","How elicited","Interpretation"],
  ["Murphy's sign","Pain + inspiratory arrest on RUQ palpation during inspiration","Acute cholecystitis"],
  ["Rovsing's sign","LIF palpation causes pain in RIF","Acute appendicitis"],
  ["Psoas sign","Pain on hip extension / flexion against resistance","Retrocaecal appendicitis"],
  ["Obturator sign","Pain on internal rotation of flexed hip","Pelvic appendicitis"],
  ["Shifting dullness","Dullness moves with position change","Ascites"],
  ["Fluid thrill","Ripple felt on tapping opposite flank","Large volume ascites"],
  ["Cullen's sign","Periumbilical bruising","Haemorrhagic/necrotising pancreatitis"],
  ["Grey-Turner's sign","Flank bruising","Haemorrhagic/necrotising pancreatitis"],
  ["Courvoisier's law","Palpable painless gallbladder + jaundice","Pancreatic head / biliary malignancy (not gallstones)"],
 ]),
]
})

SYSTEMS.append({
"name":"5. Nervous System (CNS)",
"flow":[
 {"label":"History: headache, weakness, sensory change, seizures, vision/speech change, LOC, function/ADLs","branches":[]},
 {"label":"Higher mental function: consciousness (GCS), orientation, memory, speech/language, praxis","branches":[
   "GCS <8 -> severe impairment, consider airway protection",
   "Expressive aphasia -> Broca's area; Receptive aphasia -> Wernicke's area"]},
 {"label":"Cranial nerves I-XII systematically","branches":[
   "CN II-IV,VI: visual fields, pupils (direct/consensual/RAPD), eye movements, fundoscopy",
   "CN V,VII: facial sensation & movement - UMN (forehead spared) vs LMN (forehead affected) facial palsy",
   "CN VIII: hearing, Rinne/Weber","CN IX,X: palate/gag/swallow","CN XI: shoulder shrug/SCM",
   "CN XII: tongue - deviates towards side of LMN lesion"]},
 {"label":"Motor system: inspection (wasting, fasciculations, abnormal posture), tone, power (MRC 0-5), reflexes, plantar response","branches":[
   "Increased tone + hyperreflexia + upgoing plantar (Babinski +) -> UMN lesion",
   "Reduced tone + wasting + fasciculations + hyporeflexia -> LMN lesion",
   "MRC power grading: 0 none,1 flicker,2 movement w/o gravity,3 against gravity,4 against resistance,5 normal"]},
 {"label":"Sensory system: pain/temperature (spinothalamic), vibration/proprioception (dorsal column), light touch, dermatomal mapping","branches":[
   "Dissociated sensory loss (pain/temp lost, vibration intact) -> spinothalamic tract lesion (e.g. syringomyelia)",
   "Glove & stocking sensory loss -> peripheral neuropathy"]},
 {"label":"Cerebellar signs: nystagmus, dysarthria (staccato speech), finger-nose test, dysdiadochokinesia, heel-shin test","branches":[
   "DANISH: Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonia -> cerebellar syndrome"]},
 {"label":"Gait & stance: Romberg's test, tandem gait, casual gait observation","branches":[
   "Romberg's positive (falls with eyes closed) -> sensory ataxia/dorsal column loss",
   "Wide-based ataxic gait -> cerebellar disease",
   "Shuffling, festinant gait -> Parkinsonism",
   "High-stepping gait -> foot drop/peripheral neuropathy"]},
 {"label":"Meningeal signs if indicated","branches":[
   "Kernig's sign positive (pain/resistance on knee extension with hip flexed) -> meningeal irritation",
   "Brudzinski's sign positive (neck flexion causes hip/knee flexion) -> meningitis"]},
],
"tables":[
 ("UMN vs LMN Lesion — Key Differences",[
  ["Feature","UMN lesion","LMN lesion"],
  ["Tone","Increased (spasticity)","Decreased (flaccid)"],
  ["Power","Weak, pyramidal pattern","Weak, focal/segmental"],
  ["Reflexes","Exaggerated/hyperreflexia","Diminished/absent"],
  ["Plantar response","Extensor (Babinski positive)","Flexor/absent"],
  ["Wasting/fasciculation","Absent (or late, disuse)","Present, early"],
 ]),
 ("Reflex Level (root/nerve) — quick reference",[
  ["Reflex","Root/Level"],
  ["Biceps","C5/C6"],
  ["Supinator (brachioradialis)","C5/C6"],
  ["Triceps","C7/C8"],
  ["Knee (patellar)","L3/L4"],
  ["Ankle","S1/S2"],
  ["Plantar (Babinski)","S1 / corticospinal integrity"],
 ]),
]
})

SYSTEMS.append({
"name":"6. Musculoskeletal System (GALS + Regional Joint Exam)",
"flow":[
 {"label":"History/screening questions: any pain/stiffness in joints, muscles, back; any difficulty dressing/climbing stairs","branches":[]},
 {"label":"GAIT: observe walking - symmetry, smoothness, arm swing, ability to turn","branches":[
   "Antalgic gait -> pain avoidance","Trendelenburg gait -> hip abductor weakness"]},
 {"label":"ARMS: inspect hands/arms, 'put hands behind head', grip strength, fine motor (pincer grip), squeeze MCPs","branches":[
   "Painful MCP squeeze -> inflammatory arthritis (e.g. RA)"]},
 {"label":"LEGS: inspect for swelling/deformity, passive hip/knee flexion & internal rotation, patellar tap, squeeze MTPs","branches":[
   "Patellar tap positive -> knee effusion","Painful MTP squeeze -> inflammatory arthropathy"]},
 {"label":"SPINE: inspect from behind & side (scoliosis, kyphosis, lordosis), lateral flexion, Schober's test for lumbar flexion","branches":[
   "Reduced Schober's (<5cm expansion) -> ankylosing spondylitis / reduced lumbar mobility"]},
 {"label":"If abnormality found on screen -> proceed to REGIONAL joint exam: Look, Feel, Move (active/passive), Special tests, Function","branches":[]},
 {"label":"Shoulder: painful arc, empty can test (supraspinatus), Hawkins-Kennedy (impingement)","branches":[
   "Painful arc 60-120° -> subacromial impingement/rotator cuff pathology"]},
 {"label":"Knee: McMurray's test (meniscus), Lachman's/anterior drawer (ACL), varus/valgus stress (collateral ligaments)","branches":[
   "McMurray's click+pain -> meniscal tear","Lachman's laxity -> ACL rupture"]},
 {"label":"Hip: Trendelenburg's test, Thomas's test (fixed flexion deformity), FABER/Patrick's test","branches":[
   "Trendelenburg positive (pelvis drops on standing on affected leg) -> abductor weakness/hip pathology"]},
 {"label":"Wrist/Hand: Tinel's & Phalen's tests (carpal tunnel), Finkelstein's test (De Quervain's tenosynovitis)","branches":[
   "Positive Tinel's/Phalen's -> carpal tunnel syndrome (median nerve compression)"]},
 {"label":"Spine (regional): straight leg raise (sciatic nerve stretch), femoral stretch test","branches":[
   "Positive SLR <30-70° reproducing leg pain -> lumbar disc herniation/sciatica"]},
],
"tables":[
 ("Special Orthopaedic Tests -> Interpretation",[
  ["Test","Joint","Positive Finding -> Diagnosis"],
  ["McMurray's test","Knee","Click/pain on rotation -> meniscal tear"],
  ["Lachman's test","Knee","Excess anterior translation -> ACL rupture"],
  ["Anterior/Posterior drawer","Knee","Laxity -> ACL / PCL injury"],
  ["Trendelenburg's test","Hip","Pelvis drops on unaffected side -> hip abductor weakness"],
  ["Thomas's test","Hip","Inability to flatten lumbar spine -> fixed flexion deformity"],
  ["FABER/Patrick's test","Hip/SI joint","Groin pain -> hip pathology; posterior pain -> SI joint"],
  ["Empty can test","Shoulder","Weakness/pain -> supraspinatus tear"],
  ["Hawkins-Kennedy test","Shoulder","Pain on internal rotation of flexed shoulder -> impingement"],
  ["Tinel's / Phalen's test","Wrist","Tingling in median distribution -> carpal tunnel syndrome"],
  ["Finkelstein's test","Wrist/Thumb","Pain on ulnar deviation with thumb flexed -> De Quervain's tenosynovitis"],
  ["Straight leg raise","Lumbar spine","Reproduces radicular leg pain -> disc herniation/sciatica"],
  ["Schober's test","Lumbar spine","<5cm expansion on flexion -> ankylosing spondylitis"],
 ]),
]
})

SYSTEMS.append({
"name":"7. Renal & Genitourinary System",
"flow":[
 {"label":"History: dysuria, frequency, haematuria, loin pain, oliguria/polyuria, oedema, LUTS","branches":[]},
 {"label":"General: pallor (anaemia of CKD), oedema, uraemic fetor, excoriations (pruritus), hydration status, BP","branches":[
   "Uraemic fetor + drowsiness -> advanced renal failure"]},
 {"label":"Abdomen: inspect flanks for fullness/scars (transplant/nephrectomy/dialysis access), palpate kidneys bimanually (ballot)","branches":[
   "Ballotable enlarged kidney(s) -> polycystic kidney disease, hydronephrosis, tumour"]},
 {"label":"Percuss for renal angle tenderness; percuss bladder for distension; auscultate for renal artery bruits","branches":[
   "Renal angle tenderness -> pyelonephritis/renal calculus",
   "Renal artery bruit -> renal artery stenosis (renovascular hypertension)",
   "Palpable/percussible bladder above symphysis -> urinary retention"]},
 {"label":"External genitalia and, if indicated, digital rectal exam (prostate) / pelvic exam","branches":[
   "Enlarged firm/nodular prostate -> prostate cancer; smooth enlarged -> BPH"]},
 {"label":"Check for AV fistula/dialysis access, vascular access lines if on dialysis; assess fluid status/oedema","branches":[]},
],
"tables":[
 ("Key Renal Signs -> Interpretation",[
  ["Sign","Interpretation"],
  ["Ballotable kidney(s), bilateral","Polycystic kidney disease"],
  ["Renal angle tenderness + fever","Acute pyelonephritis"],
  ["Distended bladder, dull to percussion","Urinary retention"],
  ["Renal bruit","Renal artery stenosis"],
  ["Uraemic fetor, pruritus, pallor","Chronic kidney disease"],
 ]),
]
})

SYSTEMS.append({
"name":"8. Endocrine System (Thyroid & Diabetes-focused)",
"flow":[
 {"label":"History: weight change, heat/cold intolerance, tremor, palpitations, bowel habit, menstrual change, polyuria/polydipsia","branches":[]},
 {"label":"General: tremor, sweating, hair/skin texture, weight, affect/anxiety, proximal myopathy","branches":[
   "Fine tremor+sweaty warm skin -> hyperthyroidism","Dry skin+bradycardia+slow relaxing reflexes -> hypothyroidism"]},
 {"label":"Eyes: exophthalmos/proptosis, lid retraction, lid lag, ophthalmoplegia","branches":[
   "Exophthalmos + lid lag -> Graves' disease"]},
 {"label":"Neck/Thyroid: inspect (swelling, moves with swallowing/tongue protrusion), palpate from behind (size, consistency, nodules, tenderness, mobility, thrill), percuss for retrosternal extension, auscultate for bruit","branches":[
   "Diffuse smooth goitre + bruit -> Graves' disease",
   "Single hard irregular nodule + lymphadenopathy -> thyroid malignancy",
   "Tender goitre -> subacute (De Quervain's) thyroiditis"]},
 {"label":"Reflexes: assess relaxation phase (ankle jerk)","branches":[
   "Slow-relaxing ('hung-up') reflexes -> hypothyroidism","Brisk reflexes -> hyperthyroidism"]},
 {"label":"Diabetes-focused exam: feet (inspection, monofilament/vibration sensation, pulses, ulcers), fundoscopy for retinopathy, injection sites","branches":[
   "Loss of monofilament/vibration sensation -> peripheral neuropathy - at risk foot",
   "Absent foot pulses -> peripheral arterial disease",
   "Dot-blot haemorrhages/exudates/neovascularisation on fundoscopy -> diabetic retinopathy"]},
],
"tables":[
 ("Thyroid Exam Findings -> Interpretation",[
  ["Finding","Interpretation"],
  ["Diffuse goitre + bruit + exophthalmos","Graves' disease"],
  ["Tender diffuse goitre, post-viral","Subacute (De Quervain's) thyroiditis"],
  ["Firm irregular nodule + cervical nodes","Thyroid carcinoma - refer urgently"],
  ["Multiple nodules, longstanding","Multinodular goitre"],
  ["Slow-relaxing ankle jerk + bradycardia","Hypothyroidism"],
 ]),
]
})

SYSTEMS.append({
"name":"9. Eye Examination",
"flow":[
 {"label":"History: visual loss/blur, pain, redness, diplopia, photophobia, flashes/floaters, trauma","branches":[]},
 {"label":"Visual acuity: Snellen chart each eye (with glasses/pinhole)","branches":[
   "Improves with pinhole -> refractive error"]},
 {"label":"Visual fields by confrontation","branches":[
   "Bitemporal hemianopia -> optic chiasm lesion (pituitary tumour)",
   "Homonymous hemianopia -> post-chiasmal lesion (stroke)"]},
 {"label":"External inspection: lids, conjunctiva, sclera, cornea, pupil size/shape/symmetry","branches":[
   "Ciliary injection + small pupil -> uveitis/acute angle closure needs urgent referral"]},
 {"label":"Pupils: direct & consensual light reflex, swinging light test for RAPD, accommodation","branches":[
   "Relative afferent pupillary defect -> optic nerve pathology (e.g. optic neuritis)"]},
 {"label":"Eye movements (CN III, IV, VI) - H-pattern, look for nystagmus/diplopia","branches":[
   "Ptosis+dilated pupil+down-and-out eye -> CN III palsy"]},
 {"label":"Fundoscopy: red reflex, optic disc, vessels, macula, periphery","branches":[
   "Papilloedema (blurred disc margins, swollen) -> raised ICP",
   "Cotton wool spots, flame haemorrhages -> hypertensive/diabetic retinopathy",
   "Cupped disc -> glaucoma"]},
],
"tables":[
 ("Eye Findings -> Interpretation",[
  ["Finding","Interpretation"],
  ["RAPD (Marcus Gunn pupil)","Optic nerve disease (e.g. optic neuritis)"],
  ["Papilloedema","Raised intracranial pressure"],
  ["Bitemporal hemianopia","Optic chiasm compression (pituitary adenoma)"],
  ["Cupped optic disc","Glaucoma"],
  ["Dot-blot haemorrhages, hard exudates","Diabetic retinopathy"],
 ]),
]
})

SYSTEMS.append({
"name":"10. ENT (Ear, Nose, Throat) Examination",
"flow":[
 {"label":"History: hearing loss, otalgia, discharge, tinnitus, vertigo, nasal obstruction/discharge, sore throat, hoarseness","branches":[]},
 {"label":"Ear: inspect pinna & post-auricular area, otoscopy - canal, tympanic membrane","branches":[
   "Bulging red TM -> acute otitis media","Retracted/perforated TM -> chronic otitis media"]},
 {"label":"Hearing tests: whisper test, tuning fork - Rinne's and Weber's tests","branches":[
   "Rinne negative (BC>AC) affected ear -> conductive hearing loss",
   "Weber lateralises to affected ear -> conductive loss; to unaffected ear -> sensorineural loss"]},
 {"label":"Nose: external inspection, anterior rhinoscopy (septum, turbinates, discharge/polyps)","branches":[
   "Deviated septum -> structural obstruction","Pale boggy turbinates -> allergic rhinitis"]},
 {"label":"Throat/Oral cavity: lips, teeth, tongue, oropharynx, tonsils, palate movement","branches":[
   "Exudative tonsillar enlargement + fever -> tonsillitis (bacterial/viral)",
   "Unilateral tonsillar bulge + uvula deviation -> peritonsillar abscess (quinsy)"]},
 {"label":"Neck: cervical lymph nodes, salivary glands, thyroid, laryngeal palpation","branches":[]},
],
"tables":[
 ("Rinne & Weber Test Interpretation",[
  ["Test result","Interpretation"],
  ["Rinne: AC>BC (normal) bilaterally, Weber midline","Normal hearing"],
  ["Rinne: BC>AC in affected ear, Weber lateralises to affected ear","Conductive hearing loss"],
  ["Rinne: AC>BC in affected ear (reduced), Weber lateralises to unaffected ear","Sensorineural hearing loss"],
 ]),
]
})

SYSTEMS.append({
"name":"11. Skin (Dermatological) Examination",
"flow":[
 {"label":"History: onset, duration, distribution, itch/pain, evolution, triggers, systemic symptoms","branches":[]},
 {"label":"Inspect whole skin, hair, nails in good light; note distribution pattern (flexor/extensor, sun-exposed, dermatomal)","branches":[
   "Dermatomal vesicular rash -> Herpes zoster","Symmetrical extensor rash -> psoriasis"]},
 {"label":"Describe primary lesion: macule, papule, plaque, vesicle, bulla, pustule, nodule, wheal","branches":[]},
 {"label":"Describe secondary changes: scale, crust, excoriation, lichenification, ulceration, scarring","branches":[]},
 {"label":"Palpate: texture, temperature, tenderness, blanching (glass test for purpura/petechiae)","branches":[
   "Non-blanching rash -> vasculitis/purpura/meningococcaemia - urgent"]},
 {"label":"For pigmented lesion use ABCDE rule +/- dermatoscopy","branches":[
   "Asymmetry, Border irregularity, Colour variation, Diameter>6mm, Evolving -> suspicious for melanoma"]},
 {"label":"Examine mucous membranes, palms/soles, and regional lymph nodes if malignancy/infection suspected","branches":[]},
],
"tables":[
 ("ABCDE Rule for Pigmented Lesions",[
  ["Feature","Concerning finding"],
  ["Asymmetry","Two halves of the lesion do not match"],
  ["Border","Irregular, notched or blurred edges"],
  ["Colour","Multiple colours / uneven pigmentation"],
  ["Diameter","Greater than 6 mm"],
  ["Evolution","Change in size, shape, colour or symptoms over time"],
 ]),
]
})

SYSTEMS.append({
"name":"12. Breast Examination",
"flow":[
 {"label":"History: lump, pain, nipple discharge/change, skin change, family history, menstrual/menopausal status","branches":[]},
 {"label":"Inspection: sitting, arms at sides, then raised, then hands on hips (pectoral contraction) - symmetry, skin, nipple","branches":[
   "Peau d'orange skin -> lymphatic obstruction from underlying carcinoma",
   "Nipple retraction/deviation -> underlying malignancy"]},
 {"label":"Palpation: patient supine, systematic quadrant-by-quadrant (or spiral) palpation of both breasts and nipple","branches":[
   "Hard, irregular, fixed, painless lump -> carcinoma until proven otherwise",
   "Smooth, mobile, well-defined lump in young woman -> fibroadenoma",
   "Tender, fluctuant, cyclical lump -> fibrocystic change/cyst"]},
 {"label":"Palpate axillary and supraclavicular lymph nodes","branches":[
   "Firm, matted, fixed axillary nodes -> metastatic spread"]},
 {"label":"Check for nipple discharge (express gently if history suggests) and note character","branches":[
   "Bloody discharge -> intraductal papilloma or carcinoma",
   "Milky discharge (non-lactating) -> hyperprolactinaemia"]},
],
"tables":[
 ("Breast Lump Characteristics -> Likely Diagnosis",[
  ["Characteristics","Likely Diagnosis"],
  ["Hard, irregular, fixed, painless","Carcinoma"],
  ["Smooth, mobile, well-circumscribed, young patient","Fibroadenoma"],
  ["Tender, fluctuant, size varies with cycle","Breast cyst / fibrocystic disease"],
  ["Painful, warm, erythematous, fluctuant, lactating","Breast abscess/mastitis"],
 ]),
]
})

print(f"Loaded {len(SYSTEMS)} systems")

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/macleod-exam-flowchart/build.py'

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/macleod-exam-flowchart/build.py'