from docx import Document
from docx.shared import Pt, Inches, RGBColor, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.enum.table import WD_TABLE_ALIGNMENT, WD_ALIGN_VERTICAL
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import requests, os, io

doc = Document()

# ─── Page margins ───────────────────────────────────────────────────────────
section = doc.sections[0]
section.top_margin    = Cm(2.5)
section.bottom_margin = Cm(2.5)
section.left_margin   = Cm(3.0)
section.right_margin  = Cm(2.5)

# ─── Helper: set font ────────────────────────────────────────────────────────
def set_run(run, bold=False, size=12, color=None, italic=False):
    run.bold   = bold
    run.italic = italic
    run.font.size = Pt(size)
    run.font.name = "Times New Roman"
    if color:
        run.font.color.rgb = RGBColor(*color)

def add_heading(text, level=1, color=(0,51,102)):
    p = doc.add_heading("", level=level)
    p.alignment = WD_ALIGN_PARAGRAPH.CENTER if level == 1 else WD_ALIGN_PARAGRAPH.LEFT
    run = p.runs[0] if p.runs else p.add_run()
    run.text = text
    run.font.name = "Times New Roman"
    run.font.color.rgb = RGBColor(*color)
    run.bold = True
    run.font.size = Pt(16) if level==1 else (Pt(14) if level==2 else Pt(12))
    return p

def add_para(text, bold=False, indent=False, align=WD_ALIGN_PARAGRAPH.JUSTIFY, size=12):
    p = doc.add_paragraph()
    p.alignment = align
    if indent:
        p.paragraph_format.left_indent = Cm(1)
    run = p.add_run(text)
    set_run(run, bold=bold, size=size)
    return p

def add_bullet(text, bold_prefix=None):
    p = doc.add_paragraph(style='List Bullet')
    p.alignment = WD_ALIGN_PARAGRAPH.JUSTIFY
    if bold_prefix:
        r1 = p.add_run(bold_prefix + ": ")
        set_run(r1, bold=True, size=12)
        r2 = p.add_run(text)
        set_run(r2, size=12)
    else:
        run = p.add_run(text)
        set_run(run, size=12)

def add_numbered(text, bold_prefix=None):
    p = doc.add_paragraph(style='List Number')
    p.alignment = WD_ALIGN_PARAGRAPH.JUSTIFY
    if bold_prefix:
        r1 = p.add_run(bold_prefix + ": ")
        set_run(r1, bold=True, size=12)
        r2 = p.add_run(text)
        set_run(r2, size=12)
    else:
        run = p.add_run(text)
        set_run(run, size=12)

def shading_element(fill_color):
    shd = OxmlElement('w:shd')
    shd.set(qn('w:val'), 'clear')
    shd.set(qn('w:color'), 'auto')
    shd.set(qn('w:fill'), fill_color)
    return shd

def shade_cell(cell, fill_color):
    tc_pr = cell._tc.get_or_add_tcPr()
    tc_pr.append(shading_element(fill_color))

def add_table_row(table, cells_data, header=False, shade=None):
    row = table.add_row()
    for i, data in enumerate(cells_data):
        cell = row.cells[i]
        cell.vertical_alignment = WD_ALIGN_VERTICAL.CENTER
        p = cell.paragraphs[0]
        p.alignment = WD_ALIGN_PARAGRAPH.LEFT
        run = p.add_run(str(data))
        run.bold = header
        run.font.name = "Times New Roman"
        run.font.size = Pt(11)
        if shade:
            shade_cell(cell, shade)
        elif header:
            shade_cell(cell, "003366")
            run.font.color.rgb = RGBColor(255, 255, 255)

def try_download_image(url, filename):
    try:
        r = requests.get(url, timeout=10)
        if r.status_code == 200:
            path = f"/tmp/workspace/encephalitis-case/{filename}"
            with open(path, "wb") as f:
                f.write(r.content)
            return path
    except:
        pass
    return None

# ════════════════════════════════════════════════════════════════════════════
# TITLE PAGE
# ════════════════════════════════════════════════════════════════════════════
doc.add_paragraph()
p = doc.add_paragraph()
p.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = p.add_run("RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES")
run.bold = True
run.font.name = "Times New Roman"
run.font.size = Pt(14)
run.font.color.rgb = RGBColor(0, 51, 102)

p2 = doc.add_paragraph()
p2.alignment = WD_ALIGN_PARAGRAPH.CENTER
run2 = p2.add_run("B.Sc. Nursing Programme")
run2.font.name = "Times New Roman"
run2.font.size = Pt(13)
run2.bold = True

doc.add_paragraph()
p3 = doc.add_paragraph()
p3.alignment = WD_ALIGN_PARAGRAPH.CENTER
run3 = p3.add_run("NURSING CASE PRESENTATION")
run3.bold = True
run3.font.name = "Times New Roman"
run3.font.size = Pt(22)
run3.font.color.rgb = RGBColor(0, 51, 102)

doc.add_paragraph()
p4 = doc.add_paragraph()
p4.alignment = WD_ALIGN_PARAGRAPH.CENTER
run4 = p4.add_run("ON")
run4.font.name = "Times New Roman"
run4.font.size = Pt(16)
run4.bold = True

doc.add_paragraph()
p5 = doc.add_paragraph()
p5.alignment = WD_ALIGN_PARAGRAPH.CENTER
run5 = p5.add_run("ENCEPHALITIS")
run5.bold = True
run5.font.name = "Times New Roman"
run5.font.size = Pt(28)
run5.font.color.rgb = RGBColor(192, 0, 0)

doc.add_paragraph()
doc.add_paragraph()

# Info table on title page
info_table = doc.add_table(rows=1, cols=2)
info_table.alignment = WD_TABLE_ALIGNMENT.CENTER
info_table.style = 'Table Grid'
fields = [
    ("Subject", "Medical-Surgical Nursing"),
    ("Unit", "Neurological System – Infectious Diseases"),
    ("Submitted by", "___________________________"),
    ("Register Number", "___________________________"),
    ("Year & Section", "___________________________"),
    ("College", "___________________________"),
    ("Guide/Faculty", "___________________________"),
    ("Date of Presentation", "___________________________"),
]
info_table._tbl.remove(info_table.rows[0]._tr)
for label, val in fields:
    row = info_table.add_row()
    c1, c2 = row.cells[0], row.cells[1]
    shade_cell(c1, "E8EFF7")
    r1 = c1.paragraphs[0].add_run(label)
    r1.bold = True; r1.font.name="Times New Roman"; r1.font.size=Pt(11)
    r2 = c2.paragraphs[0].add_run(val)
    r2.font.name="Times New Roman"; r2.font.size=Pt(11)

doc.add_page_break()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 1 — INTRODUCTION
# ════════════════════════════════════════════════════════════════════════════
add_heading("I. INTRODUCTION", level=1)

add_para(
    "Encephalitis is defined as a diffuse or focal inflammation of the parenchyma of the brain. "
    "It is distinct from meningitis, in which the leptomeninges are primarily involved. "
    "When both the brain parenchyma and the leptomeninges are inflamed simultaneously, the condition is termed meningoencephalitis. "
    "Encephalitis represents one of the most serious neurological emergencies encountered in clinical practice.",
    size=12
)

add_para(
    "In the United States and worldwide, approximately 50% of encephalitis cases are viral in origin and about 25% are autoimmune. "
    "The estimated incidence is 7 per 100,000 persons per year. The most common cause of fatal, sporadic encephalitis is Herpes Simplex "
    "Virus type 1 (HSV-1). In epidemic form, West Nile Virus (WNV) and Japanese Encephalitis Virus (JEV) are globally significant, "
    "particularly in South and South-East Asia.",
    size=12
)

add_para(
    "Early recognition, prompt diagnosis, and aggressive nursing and medical management are essential to prevent death and minimize "
    "permanent neurological sequelae. This case presentation follows the RGUHS B.Sc. Nursing format and addresses all components "
    "including history, physical assessment, pathophysiology, nursing diagnosis, care planning, and health education.",
    size=12
)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 2 — OBJECTIVES
# ════════════════════════════════════════════════════════════════════════════
add_heading("II. OBJECTIVES", level=1)

add_para("At the end of this case presentation, the student nurse will be able to:", bold=True)
add_numbered("Define encephalitis and differentiate it from meningitis and meningoencephalitis.")
add_numbered("Enumerate the common causes, risk factors, and pathophysiology of encephalitis.")
add_numbered("Describe the clinical manifestations of encephalitis.")
add_numbered("Explain the diagnostic investigations and their significance.")
add_numbered("Formulate nursing diagnoses based on data collected.")
add_numbered("Plan and implement individualized nursing care.")
add_numbered("Evaluate the effectiveness of nursing interventions.")
add_numbered("Provide comprehensive health education to patient and family.")
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 3 — PATIENT PROFILE / CASE HISTORY
# ════════════════════════════════════════════════════════════════════════════
add_heading("III. CASE HISTORY", level=1)

# Patient Profile Table
add_heading("3.1 Patient Profile", level=2)
pt_table = doc.add_table(rows=1, cols=4)
pt_table.style = 'Table Grid'
pt_table.alignment = WD_TABLE_ALIGNMENT.CENTER
pt_table._tbl.remove(pt_table.rows[0]._tr)

profile_data = [
    ("Patient's Name", "Mr. Ravi Kumar (Name Changed)", "Ward", "Neurology Ward – Bed 12"),
    ("Age", "28 years", "IP Number", "XXXXXXX"),
    ("Sex", "Male", "Date of Admission", "XX/XX/XXXX"),
    ("Religion", "Hindu", "Date of Presentation", "XX/XX/XXXX"),
    ("Occupation", "Farmer", "Informant", "Mother (Reliable)"),
    ("Education", "10th Standard", "Language", "Kannada"),
    ("Address", "Rural Karnataka", "Chief Complaints", "Fever, headache, seizures, confusion"),
]
for r_data in profile_data:
    row = pt_table.add_row()
    for i, val in enumerate(r_data):
        cell = row.cells[i]
        run = cell.paragraphs[0].add_run(val)
        run.font.name = "Times New Roman"
        run.font.size = Pt(11)
        if i % 2 == 0:
            run.bold = True
            shade_cell(cell, "DCE6F1")

doc.add_paragraph()

# Chief Complaints
add_heading("3.2 Chief Complaints", level=2)
add_bullet("High-grade fever for 5 days")
add_bullet("Severe throbbing headache for 4 days")
add_bullet("Vomiting (2-3 episodes/day) for 3 days")
add_bullet("Photophobia and neck stiffness for 2 days")
add_bullet("Two episodes of generalized tonic-clonic seizures on the day of admission")
add_bullet("Progressive confusion and altered sensorium since morning")
doc.add_paragraph()

# History of Present Illness
add_heading("3.3 History of Present Illness", level=2)
add_para(
    "Mr. Ravi Kumar, a 28-year-old male farmer from rural Karnataka, was apparently well until 5 days prior to admission, "
    "when he developed a sudden onset of high-grade fever (measured at 103°F at home). Fever was continuous and not associated "
    "with chills or rigors initially. After 1 day, he developed a severe bilateral throbbing headache, predominantly frontal and temporal, "
    "not relieved by analgesics.",
    size=12
)
add_para(
    "By the 3rd day, he started vomiting 2-3 times per day (projectile in nature) and became sensitive to light (photophobia). "
    "Family noted behavioral changes: irritability, restlessness, and irrelevant talk. On the day of admission (5th day of illness), "
    "he had two witnessed episodes of generalized tonic-clonic seizures, each lasting approximately 2-3 minutes, followed by post-ictal "
    "confusion. He was brought to the emergency department in an altered state of consciousness.",
    size=12
)
add_para(
    "There is no history of trauma, ear infection, or previous seizures. Patient works in paddy fields and was exposed to mosquito bites "
    "during the current harvest season. No history of travel outside Karnataka.",
    size=12
)
doc.add_paragraph()

# Past History
add_heading("3.4 Past Medical History", level=2)
add_bullet("No known history of hypertension, diabetes, or epilepsy")
add_bullet("No previous hospitalizations")
add_bullet("No history of tuberculosis or other infectious diseases")
add_bullet("Immunization status: Incomplete (no Japanese Encephalitis vaccine)")
doc.add_paragraph()

# Family History
add_heading("3.5 Family History", level=2)
add_bullet("No family history of neurological disorders or epilepsy")
add_bullet("No similar illness in household members")
doc.add_paragraph()

# Personal History
add_heading("3.6 Personal History", level=2)
add_bullet("Diet: Mixed (non-vegetarian)")
add_bullet("Sleep: Disturbed (works outdoors at dawn/dusk — high mosquito exposure)")
add_bullet("Bowel and bladder: No abnormality before admission")
add_bullet("Habits: Non-smoker, occasional alcohol")
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 4 — PHYSICAL EXAMINATION
# ════════════════════════════════════════════════════════════════════════════
add_heading("IV. PHYSICAL EXAMINATION", level=1)

add_heading("4.1 General Examination", level=2)
gen_table = doc.add_table(rows=1, cols=2)
gen_table.style = 'Table Grid'
gen_table.alignment = WD_TABLE_ALIGNMENT.LEFT
gen_table._tbl.remove(gen_table.rows[0]._tr)
add_table_row(gen_table, ["PARAMETER", "FINDING"], header=True)
gen_findings = [
    ("General Condition", "Ill-looking, confused, uncooperative"),
    ("Consciousness", "Altered (GCS: E3 V3 M5 = 11/15)"),
    ("Temperature", "103.5°F (39.7°C) — High-grade fever"),
    ("Pulse Rate", "102 beats/min, regular, good volume"),
    ("Blood Pressure", "110/70 mmHg"),
    ("Respiratory Rate", "22 breaths/min"),
    ("SpO2", "96% on room air"),
    ("Skin", "Flushed, warm, no rash"),
    ("Pallor / Icterus", "Absent"),
    ("Lymph Nodes", "Not enlarged"),
    ("Dehydration", "Mild (+)"),
    ("Height / Weight", "168 cm / 62 kg"),
]
for row_data in gen_findings:
    add_table_row(gen_table, row_data)
doc.add_paragraph()

add_heading("4.2 Systemic Examination", level=2)

# CNS
add_para("A. Central Nervous System (CNS):", bold=True)
cns_table = doc.add_table(rows=1, cols=2)
cns_table.style = 'Table Grid'
cns_table.alignment = WD_TABLE_ALIGNMENT.LEFT
cns_table._tbl.remove(cns_table.rows[0]._tr)
add_table_row(cns_table, ["CNS FINDING", "DETAILS"], header=True)
cns_data = [
    ("Level of Consciousness", "Confused and disoriented (GCS 11/15)"),
    ("Orientation", "Disoriented to time and place"),
    ("Meningeal Signs", "Neck stiffness (+), Kernig's sign (+), Brudzinski's sign (+)"),
    ("Pupils", "Equal, 4 mm, reacting to light (sluggish)"),
    ("Cranial Nerves", "Cranial nerve VI palsy suspected (right lateral gaze restriction)"),
    ("Motor System", "No focal weakness; plantar response: bilateral extensor (Babinski +)"),
    ("Reflexes", "Deep tendon reflexes hyperreflexia bilaterally"),
    ("Sensory System", "Difficult to assess (uncooperative)"),
    ("Seizures", "History of 2 GTCS (no active seizure at examination)"),
    ("Fundoscopy", "Papilloedema absent; performed by ophthalmology"),
]
for row_data in cns_data:
    add_table_row(cns_table, row_data)
doc.add_paragraph()

add_para("B. Cardiovascular System: S1 S2 heard, no murmurs. Regular rhythm.", size=12)
add_para("C. Respiratory System: Clear air entry bilaterally; no added sounds.", size=12)
add_para("D. Abdomen: Soft, non-tender, no organomegaly.", size=12)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 5 — CONCEPT OF DISEASE (REVIEW OF LITERATURE)
# ════════════════════════════════════════════════════════════════════════════
add_heading("V. REVIEW OF LITERATURE / CONCEPT OF DISEASE", level=1)

add_heading("5.1 Definition", level=2)
add_para(
    "Encephalitis is a diffuse or focal inflammation of the parenchyma (brain tissue) of the brain, "
    "arising from infectious agents or autoimmune processes. The inflammation primarily involves the brain "
    "substance rather than the leptomeninges (pia and arachnoid mater). When both meninges and parenchyma are "
    "involved, the condition is termed meningoencephalitis.",
    size=12
)
add_para(
    "Source: Goldman-Cecil Medicine, 26th Edition (2020) — Chapter 383; Harrison's Principles of Internal Medicine, 22nd Edition (2025).",
    size=10, italic_hint=True
)
doc.add_paragraph()

add_heading("5.2 Incidence and Epidemiology", level=2)
add_bullet("Global incidence: approximately 7 per 100,000 persons per year.")
add_bullet("50% of cases are viral; 25% are autoimmune; 25% are of unknown etiology.")
add_bullet("Most common cause of fatal sporadic encephalitis: Herpes Simplex Virus type 1 (HSV-1).")
add_bullet("Epidemic causes in India include Japanese Encephalitis Virus (JEV), transmitted by Culex mosquitoes — particularly in rural and agricultural areas of Uttar Pradesh, Bihar, Karnataka, and Assam.")
add_bullet("West Nile Virus (WNV) is the most common epidemic cause in the United States.")
add_bullet("Arboviral encephalitides are seasonal — peak in summer and monsoon months (July-October in India).")
doc.add_paragraph()

add_heading("5.3 Etiology / Causes", level=2)
add_para("Encephalitis can be caused by a wide range of agents:", bold=False)

# Etiology table
etiol_table = doc.add_table(rows=1, cols=3)
etiol_table.style = 'Table Grid'
etiol_table.alignment = WD_TABLE_ALIGNMENT.LEFT
etiol_table._tbl.remove(etiol_table.rows[0]._tr)
add_table_row(etiol_table, ["CATEGORY", "EXAMPLES", "TRANSMISSION"], header=True)
etiol_data = [
    ("Viral (Most Common)", "HSV-1, HSV-2, Varicella-Zoster, EBV, CMV, Rabies, WNV, Japanese Encephalitis, Enterovirus", "Mosquito bite, droplets, direct contact, reactivation"),
    ("Bacterial", "Listeria monocytogenes, Mycobacterium tuberculosis, Treponema pallidum (syphilis), Brucella", "Ingestion, airborne"),
    ("Fungal", "Cryptococcus neoformans (immunocompromised)", "Inhalation"),
    ("Parasitic", "Toxoplasma gondii, Plasmodium falciparum (cerebral malaria)", "Contaminated food, mosquito"),
    ("Autoimmune", "Anti-NMDA receptor encephalitis, Limbic encephalitis", "Paraneoplastic, idiopathic"),
    ("Post-infectious", "Following measles, mumps, varicella (ADEM)", "Immune-mediated after infection"),
]
for row_data in etiol_data:
    add_table_row(etiol_table, row_data)
doc.add_paragraph()

add_heading("5.4 Risk Factors", level=2)
add_bullet("Age: infants and elderly are at higher risk due to immature/weakened immunity")
add_bullet("Immunocompromised state: HIV/AIDS, organ transplant patients, cancer therapy")
add_bullet("Occupational exposure: farmers, outdoor workers in endemic areas")
add_bullet("Geographic location: rural areas, regions with Culex/Aedes mosquito vectors")
add_bullet("Season: monsoon and post-monsoon (July–October)")
add_bullet("Lack of vaccination: no JEV vaccine, no rabies post-exposure prophylaxis")
add_bullet("Contact with animals: unvaccinated dogs (rabies), birds (WNV)")
doc.add_paragraph()

add_heading("5.5 Pathophysiology", level=2)
add_para(
    "Understanding the pathophysiology of encephalitis is essential for anticipating clinical complications "
    "and planning nursing care. The sequence of events is as follows:",
    size=12
)

# Pathophysiology flow
path_table = doc.add_table(rows=1, cols=1)
path_table.style = 'Table Grid'
path_table.alignment = WD_TABLE_ALIGNMENT.CENTER
path_table._tbl.remove(path_table.rows[0]._tr)
path_steps = [
    "ENTRY OF PATHOGEN\nViral entry via mosquito bite, respiratory droplets, direct neural spread (HSV via olfactory/trigeminal nerves), or reactivation of latent virus",
    "INITIAL VIREMIA\nVirus replicates in lymphoid tissues → bloodstream → initial febrile prodrome (fever, malaise, myalgia)",
    "CNS INVASION\nVirus crosses blood-brain barrier via infected macrophages, choroid plexus, or direct axonal transport → invades neurons and glial cells",
    "INFLAMMATORY RESPONSE\nActivation of microglia and astrocytes → release of pro-inflammatory cytokines (IL-1β, TNF-α, IL-6) → cerebral inflammation",
    "CEREBRAL EDEMA\nVasodilation and increased vascular permeability → brain edema → raised intracranial pressure (ICP)",
    "NEURONAL DAMAGE\nFocal necrosis of neurons, perivascular lymphoid cuffing, microglial nodule formation → cortical and subcortical dysfunction",
    "CLINICAL MANIFESTATIONS\nFever, headache, altered sensorium, seizures, focal neurological deficits, coma",
    "OUTCOMES\nRecovery (with or without sequelae) OR death if untreated or severe",
]
for step in path_steps:
    row = path_table.add_row()
    cell = row.cells[0]
    lines = step.split('\n')
    p = cell.paragraphs[0]
    r1 = p.add_run(lines[0])
    r1.bold = True; r1.font.name = "Times New Roman"; r1.font.size = Pt(11)
    r1.font.color.rgb = RGBColor(0, 51, 102)
    if len(lines) > 1:
        r2 = p.add_run('\n' + lines[1])
        r2.font.name = "Times New Roman"; r2.font.size = Pt(11)
    shade_cell(cell, "EBF3FB")
doc.add_paragraph()

add_para(
    "Note: In Herpes Simplex Encephalitis (HSE), the virus specifically reaches the temporal lobe via the olfactory nerve or trigeminal "
    "tracts, producing hemorrhagic necrosis of the temporal lobe — a pathognomonic finding. Without treatment, mortality exceeds 70%. "
    "With IV Acyclovir (10 mg/kg every 8 hours for 14-21 days), mortality is reduced to 10-25%.",
    size=12
)
add_para("Source: Goldman-Cecil Medicine, 26th Edition — Chapter 383; Harrison's Principles of Internal Medicine, 22nd Edition, Chapter 352.", size=10)
doc.add_paragraph()

add_heading("5.6 Clinical Manifestations", level=2)

# Clinical features table
cf_table = doc.add_table(rows=1, cols=3)
cf_table.style = 'Table Grid'
cf_table.alignment = WD_TABLE_ALIGNMENT.LEFT
cf_table._tbl.remove(cf_table.rows[0]._tr)
add_table_row(cf_table, ["PHASE", "SYMPTOMS / SIGNS", "MECHANISM"], header=True)
cf_data = [
    ("Prodromal Phase\n(Days 1–3)", "Fever (38–40°C), malaise, myalgia, fatigue, sore throat, nausea, vomiting", "Systemic viremia; inflammatory cytokine release"),
    ("Meningeal Phase\n(Days 2–5)", "Severe headache, photophobia, phonophobia, neck stiffness, nausea, vomiting", "Meningeal irritation; raised ICP"),
    ("Encephalitic Phase\n(Days 3–7)", "Altered consciousness (confusion → stupor → coma), behavioral changes, irritability, disorientation, hallucinations, aphasia", "Brain parenchyma inflammation; temporal lobe involvement (HSV)"),
    ("Seizure Activity", "Focal or generalized tonic-clonic seizures; status epilepticus in severe cases", "Cortical irritability; hippocampal/limbic involvement"),
    ("Focal Deficits", "Hemiparesis, aphasia, cranial nerve palsies, cerebellar ataxia", "Focal necrosis; specific brain region involvement"),
    ("Autonomic Features", "Tachycardia, diaphoresis, labile blood pressure, temperature dysregulation", "Hypothalamic involvement; autonomic dysfunction"),
    ("Severe Features", "Deep coma, respiratory failure, papilloedema, brain herniation", "Severe cerebral edema; raised ICP"),
]
for row_data in cf_data:
    add_table_row(cf_table, row_data)
doc.add_paragraph()

add_heading("5.7 Diagnostic Investigations", level=2)

diag_table = doc.add_table(rows=1, cols=3)
diag_table.style = 'Table Grid'
diag_table.alignment = WD_TABLE_ALIGNMENT.LEFT
diag_table._tbl.remove(diag_table.rows[0]._tr)
add_table_row(diag_table, ["INVESTIGATION", "EXPECTED FINDINGS", "SIGNIFICANCE"], header=True)
diag_data = [
    ("Complete Blood Count (CBC)", "Leucocytosis (viral: normal or lymphocytosis); may show leucopenia in some viral infections", "Rule out bacterial infection; assess immune response"),
    ("Erythrocyte Sedimentation Rate (ESR)", "Elevated (20–80 mm/hr)", "Indicates inflammation; non-specific"),
    ("Blood Culture", "Usually negative in viral encephalitis", "Rules out bacteraemia"),
    ("Blood Glucose, Electrolytes, LFT, RFT", "May show hyponatraemia (SIADH)", "SIADH is a serious complication of encephalitis"),
    ("Lumbar Puncture (CSF Analysis)\n★ KEY TEST", "Pressure: elevated\nAppearance: clear or xanthochromic\nCells: 25–500 WBC/μL (predominantly lymphocytes)\nProtein: 65–150 mg/dL (elevated)\nGlucose: Normal or mildly reduced\nNo bacteria on Gram stain", "Distinguishes viral from bacterial; essential for diagnosis"),
    ("CSF PCR (HSV, CMV, EBV)", "HSV PCR positive: confirms HSV encephalitis (sensitivity 96%, specificity 99%)", "Gold standard for HSV; guides acyclovir therapy"),
    ("CSF Serology (IgM/IgG)", "West Nile/Japanese Encephalitis: IgM in CSF is diagnostic of CNS disease", "Epidemiology-specific serology"),
    ("MRI Brain (Preferred)", "HSV: T2/FLAIR hyperintensity in temporal and frontal lobes (unilateral early, bilateral late)\nJEV: bilateral thalamic hemorrhagic changes\nAutoimmune: limbic/cortical changes", "Identifies focus, extent, and nature of brain involvement"),
    ("CT Head", "Often normal early; later: edema, haemorrhagic foci in HSV", "Performed FIRST if focal deficits/coma to exclude mass lesion before LP"),
    ("EEG (Electroencephalogram)", "Diffuse slowing; temporal lobe periodic lateralized discharges (PLEDs) in HSV", "Identifies seizure activity; helps in diagnosis and monitoring"),
    ("Serum Antibodies (NMDA-R, VGKC)", "Positive in autoimmune encephalitis", "Essential when viral workup is negative"),
]
for row_data in diag_data:
    add_table_row(diag_table, row_data)
doc.add_paragraph()

add_heading("5.8 Medical Management", level=2)
add_para("Medical treatment of encephalitis is both specific (anti-viral/anti-bacterial) and supportive.", bold=False)

med_table = doc.add_table(rows=1, cols=3)
med_table.style = 'Table Grid'
med_table.alignment = WD_TABLE_ALIGNMENT.LEFT
med_table._tbl.remove(med_table.rows[0]._tr)
add_table_row(med_table, ["TREATMENT CATEGORY", "DRUG / INTERVENTION", "DOSE AND RATIONALE"], header=True)
med_data = [
    ("Specific Antiviral\n(HSV Encephalitis)", "Acyclovir IV", "10 mg/kg IV every 8 hours for 14–21 days\nReduces mortality from >70% to 10–25%"),
    ("Antiviral (CMV)", "Ganciclovir IV + Foscarnet", "For CMV encephalitis in immunocompromised"),
    ("Antibiotic Cover\n(empirical until culture report)", "Ceftriaxone + Ampicillin ± Dexamethasone", "To cover bacterial meningitis/encephalitis while awaiting results"),
    ("Anti-tubercular Therapy (ATT)", "HRZE regimen", "If TB encephalitis/TBM suspected"),
    ("Anticonvulsants", "Phenytoin IV / Levetiracetam IV", "Control of seizures; loading dose followed by maintenance"),
    ("Antipyretics", "Paracetamol 500 mg–1 g IV/oral", "Fever control; reduces metabolic demand of brain"),
    ("Corticosteroids", "Dexamethasone IV (selective use)", "Reduce cerebral edema; use with caution in viral cases"),
    ("Anti-cerebral Edema", "Mannitol 20% IV (0.25–1 g/kg)", "Osmotic diuresis; reduces raised ICP"),
    ("Immunotherapy\n(Autoimmune)", "IV Methylprednisolone / IVIG / Plasmapheresis", "First-line for anti-NMDA-R and autoimmune encephalitis"),
    ("Supportive Care", "IV Fluids, O2 therapy, nasogastric tube feed, Foley catheter, DVT prophylaxis", "Maintain homeostasis; prevent complications"),
]
for row_data in med_data:
    add_table_row(med_table, row_data)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 6 — NURSING ASSESSMENT
# ════════════════════════════════════════════════════════════════════════════
add_heading("VI. NURSING ASSESSMENT (GORDON'S FUNCTIONAL HEALTH PATTERNS)", level=1)

gordon_table = doc.add_table(rows=1, cols=2)
gordon_table.style = 'Table Grid'
gordon_table.alignment = WD_TABLE_ALIGNMENT.LEFT
gordon_table._tbl.remove(gordon_table.rows[0]._tr)
add_table_row(gordon_table, ["HEALTH PATTERN", "ASSESSMENT FINDINGS"], header=True)
gordon_data = [
    ("1. Health Perception – Health Management", "Incomplete immunization; no prior medical consultation; delayed presentation; low health literacy in family"),
    ("2. Nutritional – Metabolic", "Oral intake markedly reduced for 4 days; mild dehydration; weight 62 kg; NGT feeding may be required"),
    ("3. Elimination", "Reduced urine output (possible SIADH); unable to use toilet independently; Foley catheter inserted"),
    ("4. Activity – Exercise", "Total dependence for all activities; bedbound; GCS 11/15; risk for pressure injuries"),
    ("5. Sleep – Rest", "Severely disrupted; agitated and restless at night; altered sleep-wake cycle"),
    ("6. Cognitive – Perceptual", "Disoriented to time and place; confusion; possible aphasia; photophobia; visual hallucinations reported by family"),
    ("7. Self-perception – Self-concept", "Unable to assess fully; family expresses fear and anxiety about patient's condition and outcome"),
    ("8. Role – Relationship", "Primary breadwinner for family; wife and mother highly anxious; social isolation due to hospitalization"),
    ("9. Sexuality – Reproductive", "Not currently relevant; patient is young adult male"),
    ("10. Coping – Stress Tolerance", "Family demonstrating poor coping; asking repeatedly about prognosis; need for counseling"),
    ("11. Value – Belief", "Hindu; family may resort to faith healing; culturally appropriate communication needed"),
]
for row_data in gordon_data:
    add_table_row(gordon_table, row_data)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 7 — NURSING DIAGNOSES
# ════════════════════════════════════════════════════════════════════════════
add_heading("VII. NURSING DIAGNOSES (NANDA-I Based)", level=1)

nd_table = doc.add_table(rows=1, cols=4)
nd_table.style = 'Table Grid'
nd_table.alignment = WD_TABLE_ALIGNMENT.LEFT
nd_table._tbl.remove(nd_table.rows[0]._tr)
add_table_row(nd_table, ["No.", "NURSING DIAGNOSIS", "RELATED TO / ETIOLOGY", "AS EVIDENCED BY"], header=True)
nd_data = [
    ("1.", "Hyperthermia", "Infectious process (viral encephalitis)", "Temperature 103.5°F; flushed warm skin; tachycardia 102/min"),
    ("2.", "Acute Confusion / Disturbed Thought Process", "Cerebral inflammation and edema; raised ICP", "GCS 11/15; disorientation; inappropriate speech; behavioral changes"),
    ("3.", "Risk for Ineffective Cerebral Tissue Perfusion", "Cerebral edema; raised intracranial pressure; seizure activity", "Altered consciousness; papilloedema absent but signs of increased ICP"),
    ("4.", "Risk for Injury (Seizures)", "Seizure activity secondary to cortical irritation", "Two GTCS episodes; post-ictal confusion; uncontrolled movements"),
    ("5.", "Imbalanced Nutrition: Less Than Body Requirements", "Reduced oral intake; vomiting; impaired swallowing; altered consciousness", "Decreased food intake for 4 days; mild dehydration; weight loss"),
    ("6.", "Impaired Physical Mobility", "Altered level of consciousness; weakness; bedbound status", "Inability to ambulate or perform ADLs; total dependence for care"),
    ("7.", "Risk for Aspiration", "Impaired swallowing; reduced gag reflex; altered consciousness; NGT feeding", "GCS 11; history of vomiting; impaired protective airway reflexes"),
    ("8.", "Anxiety (Family)", "Uncertain prognosis; unfamiliar ICU environment; inadequate information", "Verbalization of fear; frequent questioning; tearfulness observed in family"),
    ("9.", "Deficient Knowledge", "New diagnosis; complex disease process; limited educational background", "Family asking repeated questions about prognosis; inability to verbalize disease process"),
    ("10.", "Risk for Impaired Skin Integrity", "Bedbound; immobility; fever and diaphoresis; malnutrition", "Bedbound status; altered nutritional status"),
]
for row_data in nd_data:
    add_table_row(nd_table, row_data)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 8 — NURSING CARE PLANS
# ════════════════════════════════════════════════════════════════════════════
add_heading("VIII. NURSING CARE PLANS", level=1)

def add_care_plan(num, diagnosis, goal, interventions_ind, interventions_col, interventions_dep, rationale_list, evaluation):
    add_heading(f"Nursing Diagnosis {num}: {diagnosis}", level=2, color=(192,0,0))
    
    cp_table = doc.add_table(rows=1, cols=2)
    cp_table.style = 'Table Grid'
    cp_table.alignment = WD_TABLE_ALIGNMENT.LEFT
    cp_table._tbl.remove(cp_table.rows[0]._tr)
    
    # Goal
    row = cp_table.add_row()
    shade_cell(row.cells[0], "003366")
    r = row.cells[0].paragraphs[0].add_run("GOAL / EXPECTED OUTCOME")
    r.bold=True; r.font.name="Times New Roman"; r.font.size=Pt(11); r.font.color.rgb=RGBColor(255,255,255)
    row.cells[1].merge(row.cells[1])
    rg = row.cells[1].paragraphs[0].add_run(goal)
    rg.font.name="Times New Roman"; rg.font.size=Pt(11)
    
    # Interventions header
    row2 = cp_table.add_row()
    shade_cell(row2.cells[0], "1F5C99")
    r2 = row2.cells[0].paragraphs[0].add_run("NURSING INTERVENTIONS")
    r2.bold=True; r2.font.name="Times New Roman"; r2.font.size=Pt(11); r2.font.color.rgb=RGBColor(255,255,255)
    shade_cell(row2.cells[1], "1F5C99")
    r3 = row2.cells[1].paragraphs[0].add_run("RATIONALE")
    r3.bold=True; r3.font.name="Times New Roman"; r3.font.size=Pt(11); r3.font.color.rgb=RGBColor(255,255,255)
    
    # Independent
    if interventions_ind:
        row_ind = cp_table.add_row()
        shade_cell(row_ind.cells[0], "DCE6F1")
        rind = row_ind.cells[0].paragraphs[0].add_run("Independent Interventions:")
        rind.bold=True; rind.font.name="Times New Roman"; rind.font.size=Pt(11)
        row_ind.cells[1].paragraphs[0].add_run("")
        for i, (intr, rat) in enumerate(zip(interventions_ind, rationale_list[:len(interventions_ind)])):
            row_i = cp_table.add_row()
            p1 = row_i.cells[0].paragraphs[0]
            r_i = p1.add_run(f"• {intr}")
            r_i.font.name="Times New Roman"; r_i.font.size=Pt(11)
            p2 = row_i.cells[1].paragraphs[0]
            r_rat = p2.add_run(rat)
            r_rat.font.name="Times New Roman"; r_rat.font.size=Pt(11)
    
    # Collaborative
    offset = len(interventions_ind)
    if interventions_col:
        row_col = cp_table.add_row()
        shade_cell(row_col.cells[0], "FFF2CC")
        rcol = row_col.cells[0].paragraphs[0].add_run("Collaborative Interventions:")
        rcol.bold=True; rcol.font.name="Times New Roman"; rcol.font.size=Pt(11)
        row_col.cells[1].paragraphs[0].add_run("")
        for intr, rat in zip(interventions_col, rationale_list[offset:offset+len(interventions_col)]):
            row_i = cp_table.add_row()
            p1 = row_i.cells[0].paragraphs[0]
            r_i = p1.add_run(f"• {intr}")
            r_i.font.name="Times New Roman"; r_i.font.size=Pt(11)
            p2 = row_i.cells[1].paragraphs[0]
            r_rat = p2.add_run(rat)
            r_rat.font.name="Times New Roman"; r_rat.font.size=Pt(11)
    
    # Dependent
    offset2 = offset + len(interventions_col)
    if interventions_dep:
        row_dep = cp_table.add_row()
        shade_cell(row_dep.cells[0], "E2EFDA")
        rdep = row_dep.cells[0].paragraphs[0].add_run("Dependent (Medical Order) Interventions:")
        rdep.bold=True; rdep.font.name="Times New Roman"; rdep.font.size=Pt(11)
        row_dep.cells[1].paragraphs[0].add_run("")
        for intr, rat in zip(interventions_dep, rationale_list[offset2:]):
            row_i = cp_table.add_row()
            p1 = row_i.cells[0].paragraphs[0]
            r_i = p1.add_run(f"• {intr}")
            r_i.font.name="Times New Roman"; r_i.font.size=Pt(11)
            p2 = row_i.cells[1].paragraphs[0]
            r_rat = p2.add_run(rat)
            r_rat.font.name="Times New Roman"; r_rat.font.size=Pt(11)
    
    # Evaluation
    row_ev = cp_table.add_row()
    shade_cell(row_ev.cells[0], "003366")
    rev = row_ev.cells[0].paragraphs[0].add_run("EVALUATION")
    rev.bold=True; rev.font.name="Times New Roman"; rev.font.size=Pt(11); rev.font.color.rgb=RGBColor(255,255,255)
    rev2 = row_ev.cells[1].paragraphs[0].add_run(evaluation)
    rev2.font.name="Times New Roman"; rev2.font.size=Pt(11)
    
    doc.add_paragraph()

# CARE PLAN 1
add_care_plan(
    "1",
    "Hyperthermia related to infectious process (viral encephalitis) as evidenced by temperature 103.5°F, tachycardia, and warm flushed skin",
    "Patient's temperature will be reduced to normal (36.5–37.5°C) within 24–48 hours and maintained throughout hospitalization.",
    [
        "Monitor temperature every 1–2 hours using axillary/rectal thermometer; record and report any further rise above 39°C immediately.",
        "Apply tepid sponging (using lukewarm water 27–30°C) to forehead, axillae, groin, and neck for 20 minutes when temperature > 38.5°C.",
        "Place ice packs (wrapped in cloth) to the groin, axillae, and neck — avoid direct skin contact.",
        "Ensure adequate ventilation in the room; use electric fan if available; avoid overcrowding.",
        "Change bed linen and patient's clothing when wet with sweat; keep the patient dry.",
        "Encourage oral/NG fluids to replace insensible losses due to fever and sweating.",
        "Monitor for signs of febrile seizures: sudden jerking movements, breath holding, rolling eyes.",
        "Document temperature, pulse, and BP on a fever chart every 4 hours.",
    ],
    [
        "Consult physician if fever does not respond to antipyretics within 1 hour.",
        "Assess blood culture results and adjust antibiotics/antivirals per sensitivity.",
        "Collaborate with ICU team for cooling blanket if fever persists above 40°C.",
    ],
    [
        "Administer IV Paracetamol (Acetaminophen) 15 mg/kg every 6 hours as ordered.",
        "Administer Acyclovir IV 10 mg/kg every 8 hours (specific antiviral therapy for HSV).",
        "Administer IV fluids as prescribed to prevent dehydration secondary to fever.",
    ],
    [
        "Frequent monitoring detects early deterioration; fever causes increased cerebral metabolic demand.",
        "Tepid sponging promotes heat loss by evaporation without causing shivering (which raises core temperature).",
        "Ice packs over major blood vessels reduce core temperature via conduction.",
        "Proper ventilation promotes radiant and convective heat loss.",
        "Wet clothing retains heat; keeping patient dry promotes comfort and heat loss.",
        "Fever increases fluid loss by approximately 10% for each 1°C rise in temperature.",
        "Early detection of seizures prevents injury and allows prompt intervention.",
        "Continuous documentation tracks fever trends and response to treatment.",
        "Persistent fever may indicate drug resistance or superinfection.",
        "Culture sensitivity guides specific antimicrobial therapy.",
        "Cooling blankets provide mechanical cooling in refractory hyperthermia.",
        "Paracetamol acts on hypothalamic thermoregulatory center to reduce fever.",
        "Acyclovir inhibits viral DNA polymerase; directly treats causative agent.",
        "IV fluids maintain circulating volume and prevent hypotensive collapse.",
    ],
    "Temperature decreased to 37.8°C within 12 hours; maintained within normal range by 48 hours. Tachycardia resolved. Goal partially/fully met."
)

# CARE PLAN 2
add_care_plan(
    "2",
    "Acute Confusion / Disturbed Thought Process related to cerebral inflammation and edema as evidenced by GCS 11/15, disorientation, and behavioral changes",
    "Patient will demonstrate improved level of consciousness (GCS ≥ 13/15) within 72 hours; will be oriented to person within 5 days.",
    [
        "Assess GCS (Glasgow Coma Scale) every 1–2 hours: record eye, verbal, and motor responses separately.",
        "Monitor pupils: size, equality, and reaction to light every 2–4 hours; report unequal or fixed pupils immediately.",
        "Maintain a calm, quiet, low-stimulus environment: dim lights, minimize noise, limit visitors.",
        "Reorient patient gently at each interaction: state your name, his name, location, and date.",
        "Keep siderails up; apply soft restraints only if patient is at risk of self-injury; never leave unattended.",
        "Position patient with head of bed elevated at 30° to reduce ICP and facilitate venous drainage.",
        "Monitor for signs of raised ICP: worsening headache, vomiting, bradycardia with hypertension (Cushing's triad), altered pupils.",
        "Maintain accurate Intake and Output chart; monitor for hyponatraemia (SIADH).",
        "Avoid clustering of nursing activities; allow rest periods between procedures.",
    ],
    [
        "Report any change in GCS of 2 or more points to physician immediately.",
        "Collaborate with neurologist for EEG monitoring if seizure activity suspected.",
        "Request ophthalmology review for fundoscopy to detect papilloedema.",
    ],
    [
        "Administer IV Mannitol 20% (0.25–0.5 g/kg) as ordered for acute raised ICP.",
        "Administer IV Dexamethasone as ordered (select cases).",
        "Administer IV Acyclovir as per schedule; do not miss doses.",
        "Administer Levetiracetam / Phenytoin IV for seizure prophylaxis/control as ordered.",
    ],
    [
        "GCS is the most reliable tool for monitoring level of consciousness in encephalitis.",
        "Pupillary changes indicate herniation or brainstem compression — a neurological emergency.",
        "Sensory stimulation increases cerebral metabolic demand and may worsen confusion.",
        "Repeated gentle reorientation maintains cognitive connections without causing agitation.",
        "Prevents patient from removing IV lines, NGT, or Foley catheter while confused.",
        "Neutral head position and 30° HOB elevation reduces ICP and promotes cerebral venous drainage.",
        "Cushing's triad (hypertension, bradycardia, irregular breathing) signals impending herniation.",
        "SIADH (dilutional hyponatraemia) worsens cerebral edema and confusion.",
        "Clustering activities increases ICP; spaced care reduces peak ICP episodes.",
        "Rapid deterioration requires urgent CT and ICP management.",
        "Sub-clinical seizures (non-convulsive status epilepticus) can worsen encephalopathy.",
        "Papilloedema confirms raised ICP and may modify management plan.",
        "Mannitol draws water osmotically from brain tissue, reducing edema and ICP.",
        "Dexamethasone reduces inflammatory cerebral edema in selective cases.",
        "Consistent antiviral dosing maintains therapeutic blood levels.",
        "Anticonvulsants prevent seizure-induced hypoxia and further brain injury.",
    ],
    "GCS improved from 11 to 13 within 72 hours. Patient able to recognize family members by day 4. Goal partially met — ongoing monitoring required."
)

# CARE PLAN 3
add_care_plan(
    "3",
    "Risk for Injury (Seizures) related to cortical irritation secondary to encephalitis",
    "Patient will remain free from seizure-related injury throughout hospitalization; seizures will be controlled within 24–48 hours.",
    [
        "Maintain seizure precautions at all times: padded siderails, padded headboard, suction machine and oxygen at bedside.",
        "Keep resuscitation tray (IV access, Diazepam/Lorazepam, airway equipment) readily available.",
        "During a seizure: do NOT restrain; protect head, turn patient to lateral decubitus position, time duration of seizure.",
        "After seizure: assess GCS, oxygen saturation, and vital signs; administer oxygen; note any new focal deficits.",
        "Remove harmful objects from the immediate environment; do not put anything in the mouth during seizure.",
        "Maintain IV line patency for emergency drug administration.",
        "Document seizure: type (focal/generalized), duration, body parts involved, post-ictal period, and recovery.",
        "Monitor serum electrolytes (Na+, K+, Ca2+, Mg2+) as hyponatraemia and hypocalcaemia lower seizure threshold.",
    ],
    [
        "Report any seizure immediately to the physician; prepare for stat IV anticonvulsant.",
        "Coordinate with neurology for continuous EEG monitoring in refractory cases.",
    ],
    [
        "Administer IV Levetiracetam / Phenytoin as loading and maintenance dose per order.",
        "In status epilepticus: Administer IV Diazepam/Lorazepam as per emergency protocol.",
        "Correct electrolyte imbalances as ordered (hyponatraemia, hypocalcaemia).",
    ],
    [
        "Environmental safety measures minimize risk of head injury, tongue bite, and aspiration during seizures.",
        "Immediate access to emergency equipment enables rapid intervention in status epilepticus.",
        "Restraining during seizure can cause fractures/dislocations; lateral position prevents aspiration.",
        "Post-ictal assessment detects new neurological deficits and hypoxia.",
        "Objects in mouth increase risk of dental trauma and airway obstruction.",
        "Patent IV line ensures immediate drug delivery during emergencies.",
        "Accurate documentation helps identify seizure patterns and response to treatment.",
        "Electrolyte imbalances are common causes of breakthrough seizures.",
        "Prompt reporting enables rapid escalation of anticonvulsant therapy.",
        "Continuous EEG detects non-convulsive status epilepticus.",
        "Levetiracetam/Phenytoin are first-line agents for encephalitis-related seizures.",
        "Benzodiazepines are first-line for active seizures/status epilepticus.",
        "Correction of metabolic causes reduces seizure frequency.",
    ],
    "No further seizure episodes after Day 1 with antiepileptic therapy. Patient remained free of injury. Goal met."
)

doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 9 — HEALTH EDUCATION
# ════════════════════════════════════════════════════════════════════════════
add_heading("IX. HEALTH EDUCATION", level=1)
add_para(
    "Health education is a critical nursing responsibility in the management of encephalitis. It is directed at the patient "
    "(when recovered), the family, and the community. Teaching sessions should be conducted in the patient's local language (Kannada), "
    "using simple terms, diagrams, and demonstrations. The RGUHS B.Sc. Nursing curriculum emphasizes a holistic approach to health "
    "education using the A-E-I-O-U model: Awareness, Education, Implementation, Observation, and Understanding.",
    size=12
)
doc.add_paragraph()

# Subheadings for health education
add_heading("9.1 Health Education to the Patient and Family", level=2)

he_table = doc.add_table(rows=1, cols=3)
he_table.style = 'Table Grid'
he_table.alignment = WD_TABLE_ALIGNMENT.LEFT
he_table._tbl.remove(he_table.rows[0]._tr)
add_table_row(he_table, ["TOPIC", "KEY TEACHING POINTS", "METHOD"], header=True)
he_data = [
    (
        "About the Disease",
        "• Encephalitis is an infection/inflammation of brain tissue\n"
        "• It is NOT contagious person-to-person (viral types)\n"
        "• Common cause in India: Japanese Encephalitis via mosquito bites\n"
        "• Early treatment is essential to prevent brain damage\n"
        "• Full recovery may take weeks to months; some residual effects possible",
        "Verbal explanation with simple diagrams"
    ),
    (
        "Medication Compliance",
        "• Explain importance of completing full course of IV Acyclovir\n"
        "• Do NOT stop antiepileptic drugs (AEDs) without doctor's advice\n"
        "• Side effects of drugs: nausea, rash, kidney problems with acyclovir — report immediately\n"
        "• Take medications at exact times prescribed\n"
        "• Keep follow-up appointments for medication review",
        "Verbal + demonstration + written leaflet"
    ),
    (
        "Mosquito Prevention\n(Vector Control)",
        "• Use mosquito nets (bed nets — preferably insecticide-treated nets / ITNs)\n"
        "• Apply mosquito repellent (DEET-based) on exposed skin before outdoor activity\n"
        "• Wear full-sleeved clothing and long trousers at dawn and dusk\n"
        "• Eliminate mosquito breeding sites: empty stagnant water from pots, tyres, coolers, drums\n"
        "• Use mosquito coils/mats indoors\n"
        "• Install wire mesh on windows and doors",
        "Demonstration + pamphlets + community video"
    ),
    (
        "Vaccination",
        "• Japanese Encephalitis Vaccine (JE-VAX / SA14-14-2): highly recommended for all persons in endemic areas\n"
        "• Given at 9 months and 16–24 months under National Immunization Programme\n"
        "• Adults working in endemic areas should receive vaccine\n"
        "• Rabies pre-exposure prophylaxis for animal handlers\n"
        "• Influenza and varicella vaccines reduce risk of viral encephalitis in vulnerable groups",
        "Counseling; referral to PHC for vaccination"
    ),
    (
        "Personal Hygiene",
        "• Wash hands frequently with soap and water (prevents enterovirus spread)\n"
        "• Do not consume unpasteurized milk or raw meat (reduces risk of listeria, tick-borne encephalitis)\n"
        "• Avoid contact with sick animals; report animal bites immediately\n"
        "• Avoid sharing utensils, towels, or personal items",
        "Demonstration"
    ),
    (
        "Seizure First Aid\n(Family Education)",
        "• Do NOT put spoon, finger, or any object in the mouth\n"
        "• Do NOT hold or restrain the patient during seizure\n"
        "• Turn patient to the SIDE (lateral/recovery position) to prevent aspiration\n"
        "• Protect head from hard surfaces; clear surrounding area\n"
        "• Time the seizure; call emergency if > 5 minutes (status epilepticus)\n"
        "• After seizure: keep patient calm; do not offer food/water immediately",
        "Demonstration with mannequin or illustration"
    ),
    (
        "Signs of Relapse /\nWhen to Return to Hospital",
        "• Return IMMEDIATELY for: sudden high fever, severe headache, confusion, seizures, difficulty speaking, weakness of limbs\n"
        "• Report: rash, neck stiffness, extreme drowsiness\n"
        "• Do not delay — encephalitis can worsen rapidly\n"
        "• Keep emergency contact number of treating hospital\n"
        "• Regular outpatient follow-up every 2 weeks for first 3 months after discharge",
        "Verbal + written emergency card"
    ),
    (
        "Rehabilitation and Recovery",
        "• Recovery from encephalitis may be prolonged (weeks to months)\n"
        "• Speech therapy, physiotherapy, and occupational therapy may be required\n"
        "• Cognitive and behavioral changes (memory problems, personality changes) may occur — family counseling essential\n"
        "• Encourage gradual return to activities; avoid strenuous work initially\n"
        "• Adequate nutrition (high protein, high calorie) supports brain recovery\n"
        "• Family support groups and community health worker involvement recommended",
        "Counseling + written discharge summary"
    ),
    (
        "Environmental / Community Sanitation",
        "• Participate in community fogging campaigns for mosquito control\n"
        "• Report clusters of fever/neurological illness in the village to ASHAs/ANMs\n"
        "• Drain stagnant water near homes, paddy fields, piggeries (JEV reservoir)\n"
        "• Government scheme: Rashtriya Bal Swasthya Karyakram (RBSK) for child neurological surveillance\n"
        "• Cooperate with health department during disease surveillance",
        "Community meeting; IEC materials"
    ),
]
for row_data in he_data:
    add_table_row(he_table, row_data)
doc.add_paragraph()

add_heading("9.2 Discharge Planning", level=2)
discharge_data = [
    ("Medications", "Prescribe oral Acyclovir / AEDs with written schedule; explain names, doses, timing, and side effects"),
    ("Diet", "High protein, high calorie, soft diet; adequate hydration (2–3 liters/day unless contraindicated)"),
    ("Activity", "Rest adequately; gradual return to activities; no driving until seizure-free for 6 months (as per medical advice)"),
    ("Follow-up", "OPD review in 1 week, 2 weeks, 1 month, 3 months; bring all medications and reports"),
    ("Physiotherapy", "Referral if any motor weakness or coordination difficulty"),
    ("Speech Therapy", "Referral for aphasia or swallowing difficulties"),
    ("Psychological Support", "Counseling for patient and family regarding behavioral/cognitive changes post-encephalitis"),
    ("Vaccination", "Ensure JE vaccination for family members in endemic areas; update all pending immunizations"),
    ("Emergency Contact", "Provide hospital emergency number; instruct to come immediately if any new neurological symptoms"),
]
dis_table = doc.add_table(rows=1, cols=2)
dis_table.style = 'Table Grid'
dis_table.alignment = WD_TABLE_ALIGNMENT.LEFT
dis_table._tbl.remove(dis_table.rows[0]._tr)
add_table_row(dis_table, ["AREA", "DISCHARGE INSTRUCTIONS"], header=True)
for row_data in discharge_data:
    add_table_row(dis_table, row_data)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 10 — COMPLICATIONS
# ════════════════════════════════════════════════════════════════════════════
add_heading("X. COMPLICATIONS OF ENCEPHALITIS", level=1)

comp_table = doc.add_table(rows=1, cols=3)
comp_table.style = 'Table Grid'
comp_table.alignment = WD_TABLE_ALIGNMENT.LEFT
comp_table._tbl.remove(comp_table.rows[0]._tr)
add_table_row(comp_table, ["COMPLICATION", "MECHANISM", "NURSING/MEDICAL INTERVENTION"], header=True)
comp_data = [
    ("Status Epilepticus", "Prolonged seizure activity; persistent cortical irritation", "IV Diazepam → IV Phenytoin/Levetiracetam; airway management; ICU"),
    ("Raised Intracranial Pressure (ICP)", "Cerebral edema; CSF obstruction", "Mannitol, head elevation, hyperventilation, decompressive surgery if needed"),
    ("SIADH (Syndrome of Inappropriate ADH)", "Hypothalamic-pituitary involvement; dysregulation of ADH secretion", "Fluid restriction; hypertonic saline if severe; daily electrolytes"),
    ("Respiratory Failure", "Brainstem involvement; aspiration pneumonia; neuromuscular weakness", "O2 therapy; mechanical ventilation (ICU); chest physiotherapy"),
    ("Aspiration Pneumonia", "Impaired gag reflex; reduced consciousness; vomiting", "NG tube feeding; semi-recumbent position; chest physio; antibiotics"),
    ("Brain Herniation", "Uncontrolled ICP; temporal lobe swelling causing uncal herniation", "Emergency CT; mannitol; decompressive craniectomy"),
    ("Deep Vein Thrombosis (DVT)", "Immobility; hypercoagulable state in infection", "LMWH prophylaxis; compression stockings; passive exercises"),
    ("Pressure Ulcers", "Immobility; poor nutrition; moisture from fever/sweating", "2-hourly turning; pressure-relieving mattress; skin care protocol"),
    ("Neurological Sequelae\n(long-term)", "Residual neuronal damage: memory impairment, personality changes, epilepsy, motor deficits", "Rehabilitation; speech and physiotherapy; AEDs; family counseling"),
    ("Death", "Uncontrolled brain herniation; multi-organ failure; respiratory arrest", "ICU care; family counseling on prognosis; palliative support if needed"),
]
for row_data in comp_data:
    add_table_row(comp_table, row_data)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 11 — EVALUATION AND PROGNOSIS
# ════════════════════════════════════════════════════════════════════════════
add_heading("XI. EVALUATION OF NURSING CARE", level=1)

eval_table = doc.add_table(rows=1, cols=3)
eval_table.style = 'Table Grid'
eval_table.alignment = WD_TABLE_ALIGNMENT.LEFT
eval_table._tbl.remove(eval_table.rows[0]._tr)
add_table_row(eval_table, ["NURSING DIAGNOSIS", "EXPECTED OUTCOME", "EVALUATION STATUS"], header=True)
eval_data = [
    ("Hyperthermia", "Temperature ≤ 37.5°C within 48 hours", "Goal Met — Temperature 37.2°C by Day 2"),
    ("Acute Confusion", "GCS ≥ 13 within 72 hours", "Goal Partially Met — GCS 13 by Day 4"),
    ("Risk for Injury (Seizures)", "No seizure-related injury", "Goal Met — No injury; seizures controlled"),
    ("Imbalanced Nutrition", "Adequate intake via NGT; stable weight", "Goal Partially Met — NGT feeding maintained"),
    ("Impaired Mobility", "Prevent pressure injuries; maintain ROM", "Goal Met — No pressure ulcers; passive ROM performed daily"),
    ("Risk for Aspiration", "No aspiration events", "Goal Met — No aspiration noted"),
    ("Family Anxiety", "Family demonstrates reduced anxiety; verbalizes understanding", "Goal Partially Met — Counseling ongoing"),
    ("Deficient Knowledge", "Family verbalizes mosquito prevention and medication compliance", "Goal Met — Health education successfully completed"),
]
for row_data in eval_data:
    add_table_row(eval_table, row_data)
doc.add_paragraph()

add_heading("Prognosis:", level=2)
add_bullet("Untreated HSV encephalitis: mortality > 70%; < 10% return to baseline function.")
add_bullet("With IV Acyclovir: mortality reduced to 10–25%; 40–55% resume activities of daily living.")
add_bullet("Japanese Encephalitis: mortality 20–30%; 30–50% survivors have significant neurological sequelae.")
add_bullet("Autoimmune encephalitis (anti-NMDA-R): good prognosis with immunotherapy; 80% improve.")
add_bullet("Prognostic factors: age (elderly/infants worse), GCS on admission, time to treatment, causative agent.")
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 12 — CONCLUSION
# ════════════════════════════════════════════════════════════════════════════
add_heading("XII. CONCLUSION", level=1)
add_para(
    "Encephalitis is a life-threatening neurological emergency that demands rapid assessment, prompt investigation, and "
    "immediate institution of antiviral therapy and supportive care. The nurse plays a central role in: continuous neurological "
    "monitoring, prevention and management of complications such as raised ICP and status epilepticus, maintaining airway safety, "
    "providing nutritional support, and delivering comprehensive health education to patients and families.",
    size=12
)
add_para(
    "This case of Mr. Ravi Kumar illustrates the typical presentation of viral (likely Japanese) encephalitis in a young male "
    "from a rural agricultural background during the monsoon season. Through evidence-based nursing care guided by the nursing "
    "process (Assessment, Diagnosis, Planning, Implementation, Evaluation), nursing outcomes were progressively achieved.",
    size=12
)
add_para(
    "Community-level interventions — including vaccination against JEV, vector control, and public health education — are "
    "equally essential to reduce the burden of encephalitis in endemic areas of India.",
    size=12
)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# SECTION 13 — REFERENCES
# ════════════════════════════════════════════════════════════════════════════
add_heading("XIII. REFERENCES", level=1)

refs = [
    "Goldman L, Cooney KA (Eds.). Goldman-Cecil Medicine, 26th Edition. Elsevier, 2020. Chapter 383: Encephalitis.",
    "Loscalzo J, et al. Harrison's Principles of Internal Medicine, 22nd Edition. McGraw-Hill, 2025. Chapter 352: Arboviral Encephalitides.",
    "Hinkle JL, Cheever KH. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th Edition. Wolters Kluwer, 2022.",
    "Black JM, Hawks JH. Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 8th Edition. Elsevier, 2019.",
    "Carpenito-Moyet LJ. Nursing Diagnosis: Application to Clinical Practice, 16th Edition. Wolters Kluwer, 2019.",
    "Porth CM. Essentials of Pathophysiology: Concepts of Altered Health States, 4th Edition. Wolters Kluwer, 2015.",
    "Sherris & Ryan's Medical Microbiology, 8th Edition. McGraw-Hill, 2022. Chapter: Viral Infections of the CNS.",
    "World Health Organization (WHO). Japanese Encephalitis Fact Sheet. WHO, 2019. Available at: www.who.int",
    "National Vector Borne Disease Control Programme (NVBDCP), Government of India. Japanese Encephalitis Control Programme Guidelines, 2021.",
    "RGUHS B.Sc. Nursing Curriculum and Examination Regulations, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka.",
]
for i, ref in enumerate(refs, 1):
    p = doc.add_paragraph()
    p.alignment = WD_ALIGN_PARAGRAPH.JUSTIFY
    p.paragraph_format.left_indent = Cm(1.5)
    p.paragraph_format.first_line_indent = Cm(-1.5)
    run = p.add_run(f"{i}. {ref}")
    run.font.name = "Times New Roman"
    run.font.size = Pt(11)

doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# SAVE
# ════════════════════════════════════════════════════════════════════════════
output_path = "/tmp/workspace/encephalitis-case/Encephalitis_Nursing_Case_Presentation_RGUHS.docx"
doc.save(output_path)
print(f"Document saved: {output_path}")

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/encephalitis-case/create_case.py'

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

doc = Document()

# ─── Page margins ────────────────────────────────────────────────────────────
section = doc.sections[0]
section.top_margin    = Cm(2.5)
section.bottom_margin = Cm(2.5)
section.left_margin   = Cm(3.0)
section.right_margin  = Cm(2.5)

# ─── Helpers ─────────────────────────────────────────────────────────────────
def shade_cell(cell, fill_color):
    tcp = cell._tc.get_or_add_tcPr()
    shd = OxmlElement('w:shd')
    shd.set(qn('w:val'), 'clear')
    shd.set(qn('w:color'), 'auto')
    shd.set(qn('w:fill'), fill_color)
    tcp.append(shd)

def set_col_width(table, col_idx, width_cm):
    for row in table.rows:
        row.cells[col_idx].width = Cm(width_cm)

def hdr_row(table, *labels, shade="003366"):
    row = table.add_row()
    for i, label in enumerate(labels):
        cell = row.cells[i]
        shade_cell(cell, shade)
        r = cell.paragraphs[0].add_run(label)
        r.bold = True
        r.font.name = "Times New Roman"
        r.font.size = Pt(11)
        r.font.color.rgb = RGBColor(255, 255, 255)

def data_row(table, *values, alt=False):
    row = table.add_row()
    for i, val in enumerate(values):
        cell = row.cells[i]
        cell.vertical_alignment = WD_ALIGN_VERTICAL.CENTER
        if alt and i % 2 == 0:
            shade_cell(cell, "DCE6F1")
        p = cell.paragraphs[0]
        p.alignment = WD_ALIGN_PARAGRAPH.LEFT
        r = p.add_run(str(val))
        r.font.name = "Times New Roman"
        r.font.size = Pt(11)
        if alt and i % 2 == 0:
            r.bold = True

def make_table(cols):
    t = doc.add_table(rows=0, cols=cols)
    t.style = 'Table Grid'
    t.alignment = WD_TABLE_ALIGNMENT.LEFT
    return t

def h1(text, color=(0,51,102)):
    p = doc.add_heading("", level=1)
    p.alignment = WD_ALIGN_PARAGRAPH.CENTER
    run = p.runs[0] if p.runs else p.add_run()
    run.text = text
    run.font.name = "Times New Roman"
    run.font.color.rgb = RGBColor(*color)
    run.bold = True
    run.font.size = Pt(15)
    return p

def h2(text, color=(0,51,102)):
    p = doc.add_heading("", level=2)
    p.alignment = WD_ALIGN_PARAGRAPH.LEFT
    run = p.runs[0] if p.runs else p.add_run()
    run.text = text
    run.font.name = "Times New Roman"
    run.font.color.rgb = RGBColor(*color)
    run.bold = True
    run.font.size = Pt(13)
    return p

def para(text, size=12, bold=False, align=WD_ALIGN_PARAGRAPH.JUSTIFY):
    p = doc.add_paragraph()
    p.alignment = align
    r = p.add_run(text)
    r.font.name = "Times New Roman"
    r.font.size = Pt(size)
    r.bold = bold
    return p

def bullet(text, prefix=None):
    p = doc.add_paragraph(style='List Bullet')
    p.alignment = WD_ALIGN_PARAGRAPH.JUSTIFY
    if prefix:
        r1 = p.add_run(prefix + ": ")
        r1.bold = True; r1.font.name = "Times New Roman"; r1.font.size = Pt(12)
        r2 = p.add_run(text)
        r2.font.name = "Times New Roman"; r2.font.size = Pt(12)
    else:
        r = p.add_run(text)
        r.font.name = "Times New Roman"; r.font.size = Pt(12)

def numbered(text, prefix=None):
    p = doc.add_paragraph(style='List Number')
    p.alignment = WD_ALIGN_PARAGRAPH.JUSTIFY
    if prefix:
        r1 = p.add_run(prefix + ": ")
        r1.bold = True; r1.font.name = "Times New Roman"; r1.font.size = Pt(12)
        r2 = p.add_run(text)
        r2.font.name = "Times New Roman"; r2.font.size = Pt(12)
    else:
        r = p.add_run(text)
        r.font.name = "Times New Roman"; r.font.size = Pt(12)

def sp():
    doc.add_paragraph()

# ═══════════════════════════════════════════════════════════════════════════
# TITLE PAGE
# ═══════════════════════════════════════════════════════════════════════════
sp()
for line, sz, bold, clr in [
    ("RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES", 14, True, (0,51,102)),
    ("B.Sc. Nursing Programme – Child Health Nursing", 13, True, (0,51,102)),
    ("", 12, False, (0,0,0)),
    ("NURSING CASE PRESENTATION", 20, True, (0,51,102)),
    ("ON", 14, True, (0,0,0)),
    ("", 12, False, (0,0,0)),
    ("ENCEPHALITIS IN CHILDREN", 26, True, (192,0,0)),
    ("(Paediatric Encephalitis)", 16, True, (0,51,102)),
]:
    p = doc.add_paragraph()
    p.alignment = WD_ALIGN_PARAGRAPH.CENTER
    r = p.add_run(line)
    r.bold = bold; r.font.name = "Times New Roman"
    r.font.size = Pt(sz); r.font.color.rgb = RGBColor(*clr)

sp(); sp()

info_t = make_table(2)
for label, val in [
    ("Subject", "Child Health Nursing"),
    ("Unit", "Neurological Disorders in Children"),
    ("Submitted by", "___________________________"),
    ("Register Number", "___________________________"),
    ("Year / Semester", "___________________________"),
    ("Name of College", "___________________________"),
    ("Guide / Clinical Faculty", "___________________________"),
    ("Date of Presentation", "___________________________"),
]:
    row = info_t.add_row()
    shade_cell(row.cells[0], "E8EFF7")
    r1 = row.cells[0].paragraphs[0].add_run(label)
    r1.bold = True; r1.font.name = "Times New Roman"; r1.font.size = Pt(11)
    r2 = row.cells[1].paragraphs[0].add_run(val)
    r2.font.name = "Times New Roman"; r2.font.size = Pt(11)

doc.add_page_break()

# ═══════════════════════════════════════════════════════════════════════════
# I. INTRODUCTION
# ═══════════════════════════════════════════════════════════════════════════
h1("I. INTRODUCTION")
para(
    "Encephalitis is one of the most serious neurological emergencies in paediatric practice. "
    "It is defined as inflammation of the brain parenchyma, most commonly caused by viral agents, "
    "resulting in altered consciousness, seizures, and focal neurological deficits in affected children. "
    "Children — especially those under 15 years of age — are disproportionately affected, and in India, "
    "Japanese Encephalitis Virus (JEV) is the single most important cause of epidemic encephalitis in children, "
    "particularly in rural agricultural states such as Karnataka, Uttar Pradesh, Bihar, West Bengal, and Assam."
)
para(
    "Japanese Encephalitis (JE) is transmitted by Culex mosquitoes and carries a mortality rate of 20-30% in children; "
    "30-50% of survivors suffer permanent neurological disability including cognitive impairment, motor deficits, "
    "epilepsy, and behavioural changes. Beyond JE, Herpes Simplex Virus (HSV-2) is the most common cause of "
    "neonatal encephalitis, while enteroviruses cause epidemic viral encephalitis in school-age children during summer."
)
para(
    "The nurse caring for a child with encephalitis must possess strong skills in paediatric neurological assessment, "
    "seizure management, family communication, and developmental care. This case presentation follows the RGUHS "
    "B.Sc. Nursing Child Health Nursing format and applies the nursing process comprehensively to a paediatric case."
)
sp()

# ═══════════════════════════════════════════════════════════════════════════
# II. OBJECTIVES
# ═══════════════════════════════════════════════════════════════════════════
h1("II. OBJECTIVES")
para("At the end of this case presentation, the student nurse will be able to:", bold=True)
numbered("Define and classify encephalitis with specific reference to paediatric age group.")
numbered("Enumerate the common causes and risk factors of encephalitis in children in India.")
numbered("Describe the pathophysiology of paediatric encephalitis.")
numbered("Enumerate the clinical manifestations of encephalitis with age-specific variations.")
numbered("Explain the diagnostic investigations and interpret their findings.")
numbered("Formulate nursing diagnoses based on the child's presenting problems.")
numbered("Plan and implement individualized nursing care for the child with encephalitis.")
numbered("Evaluate the effectiveness of nursing care and modify the care plan accordingly.")
numbered("Provide age-appropriate health education to the child and family.")
numbered("Identify complications and apply preventive nursing measures.")
sp()

# ═══════════════════════════════════════════════════════════════════════════
# III. CASE HISTORY
# ═══════════════════════════════════════════════════════════════════════════
h1("III. CASE HISTORY")

h2("3.1 Patient Profile")
pt = make_table(4)
hdr_row(pt, "PARAMETER", "DETAILS", "PARAMETER", "DETAILS")
pt_rows = [
    ("Patient's Name", "Master Arjun S. (Name Changed)", "IP Number", "XXXXXXXX"),
    ("Age", "6 years", "Ward / Bed", "Paediatric Neurology – Bed 5"),
    ("Sex", "Male", "Date of Admission", "XX/XX/XXXX"),
    ("Religion", "Hindu", "Date of Presentation", "XX/XX/XXXX"),
    ("Father's Name", "Mr. Suresh S.", "Mother's Name", "Mrs. Kavitha S."),
    ("Address", "Village, Mandya Dist., Karnataka", "Informant", "Mother (Reliable)"),
    ("Birth Order", "1st child", "Immunization Status", "Incomplete — No JE vaccine"),
    ("Chief Complaints", "Fever, headache, vomiting,\nseizures, altered sensorium", "Mode of Admission", "Emergency (ambulance)"),
]
for r in pt_rows:
    row = pt.add_row()
    for i, val in enumerate(r):
        c = row.cells[i]
        if i % 2 == 0:
            shade_cell(c, "DCE6F1")
        rv = c.paragraphs[0].add_run(val)
        rv.font.name = "Times New Roman"; rv.font.size = Pt(11)
        if i % 2 == 0:
            rv.bold = True
sp()

h2("3.2 Chief Complaints")
bullet("High-grade fever for 4 days (measured at 104°F at home)")
bullet("Severe headache and crying inconsolably for 3 days")
bullet("Vomiting 3-4 times per day for 2 days (projectile, non-bilious)")
bullet("Photophobia and refusal to open eyes since yesterday")
bullet("Two episodes of generalized tonic-clonic seizures on the morning of admission")
bullet("Progressive drowsiness and inability to recognize parents since this morning")
sp()

h2("3.3 History of Present Illness")
para(
    "Master Arjun, a 6-year-old male child from a rural village in Mandya district, Karnataka, was apparently "
    "healthy until 4 days prior to admission. His illness began with sudden onset of high-grade fever (104°F), "
    "associated with loss of appetite and irritability. His mother gave him Paracetamol syrup at home with "
    "partial relief. By day 2, severe headache developed; the child cried inconsolably and was more irritable than usual."
)
para(
    "From day 3, he started vomiting 3-4 times per day (projectile, not related to feeds), and became "
    "sensitive to light — he kept his eyes closed and cried on exposure to light. On the morning of admission (day 4), "
    "he had two witnessed generalized tonic-clonic seizure episodes at home, each lasting about 2 minutes, "
    "with upward rolling of eyes, stiffening of limbs, and frothing from mouth. After the seizures, he became "
    "unresponsive and could not recognize his parents. He was rushed to the district hospital and then referred to "
    "the paediatric neurology unit."
)
para(
    "Epidemiological history: The child lives near paddy and sugarcane fields in Mandya district. The family "
    "reports increased mosquito activity in recent weeks following monsoon. A neighbour's child was recently "
    "admitted to hospital with similar symptoms. No history of trauma, animal bite, or foreign travel. "
    "Immunization was incomplete — the child had not received the Japanese Encephalitis vaccine."
)
sp()

h2("3.4 Antenatal and Birth History")
bullet("Antenatal period: Uneventful; born at term by normal vaginal delivery")
bullet("Birth weight: 3.1 kg; APGAR score: 8/10 at 1 min, 9/10 at 5 min")
bullet("No significant neonatal illness; no history of neonatal seizures")
bullet("Developmental milestones: Age-appropriate (walked at 13 months, spoke 2-word sentences at 2 years)")
sp()

h2("3.5 Past Medical History")
bullet("No previous hospitalizations or major illnesses")
bullet("No history of epilepsy, febrile convulsions, or neurological disorders")
bullet("No known drug allergies")
sp()

h2("3.6 Family History")
bullet("No history of epilepsy or inherited neurological disorders in family")
bullet("Neighbour's child with similar febrile encephalitis illness — possible cluster")
bullet("No family history of tuberculosis or immunodeficiency")
sp()

h2("3.7 Nutritional and Immunization History")
t_imm = make_table(3)
hdr_row(t_imm, "VACCINE", "RECOMMENDED AGE", "STATUS")
imm_data = [
    ("BCG", "At birth", "Given"),
    ("OPV 0, 1, 2, 3 + Booster", "Birth, 6, 10, 14 wks + 16-24 months", "Given"),
    ("DPT 1, 2, 3 + Booster", "6, 10, 14 wks + 16-24 months", "Given"),
    ("Hepatitis B (3 doses)", "Birth, 6, 14 weeks", "Given"),
    ("Measles / MMR", "9 months, 15-18 months", "Given"),
    ("Vitamin A supplementation", "9 months onward", "Given"),
    ("Japanese Encephalitis (JE)", "9-12 months + booster at 16-24 months", "NOT GIVEN — MISSED"),
    ("Typhoid", "2 years onward", "Not given"),
]
for row_d in imm_data:
    row = t_imm.add_row()
    for i, val in enumerate(row_d):
        c = row.cells[i]
        rv = c.paragraphs[0].add_run(val)
        rv.font.name = "Times New Roman"; rv.font.size = Pt(11)
        if val in ("NOT GIVEN — MISSED",):
            rv.bold = True; rv.font.color.rgb = RGBColor(192, 0, 0)
sp()

# ═══════════════════════════════════════════════════════════════════════════
# IV. PHYSICAL EXAMINATION
# ═══════════════════════════════════════════════════════════════════════════
h1("IV. PHYSICAL EXAMINATION")

h2("4.1 General Examination")
gen_t = make_table(2)
hdr_row(gen_t, "PARAMETER", "FINDING")
gen_data = [
    ("General Condition", "Ill-looking, drowsy, moaning, uncooperative"),
    ("Level of Consciousness", "Altered — Modified GCS: E2 V2 M4 = 8/15 (Paediatric GCS)"),
    ("Temperature", "104°F (40°C) — High-grade fever"),
    ("Heart Rate", "118 beats/min (tachycardia; normal for age: 80-100/min)"),
    ("Respiratory Rate", "28 breaths/min (tachypnoea; normal: 20-24/min)"),
    ("Blood Pressure", "90/60 mmHg (low-normal for age)"),
    ("SpO2", "94% on room air → improved to 99% on 4L/min O2"),
    ("Weight", "18 kg (appropriate for 6-year-old)"),
    ("Pallor", "Mild (+); no jaundice, no cyanosis"),
    ("Skin", "Flushed, warm, no petechiae or purpuric rash"),
    ("Lymph Nodes", "Not palpable"),
    ("Nutritional Status", "Moderate (grade I malnutrition)"),
]
for d in gen_data:
    data_row(gen_t, *d)
sp()

h2("4.2 Systemic Examination")
para("A. Central Nervous System (CNS):", bold=True)
cns_t = make_table(2)
hdr_row(cns_t, "CNS FINDING", "DETAILS")
cns_data = [
    ("Level of Consciousness", "Altered; drowsy → stuporous; responds to painful stimuli only"),
    ("Paediatric Glasgow Coma Scale (PGCS)", "Eye Opening: 2 (to pain); Verbal: 2 (moaning); Motor: 4 (flexion) = 8/15"),
    ("Fontanelle (not applicable — 6yrs)", "Anterior fontanelle closed (normal for age)"),
    ("Meningeal Signs", "Neck stiffness (+); Kernig's sign (+); Brudzinski's sign (+)"),
    ("Pupils", "Both equal, 3 mm, sluggishly reactive to light"),
    ("Cranial Nerves", "VI nerve palsy suspected — limited left lateral gaze"),
    ("Motor System", "Hypotonia; bilateral extensor plantar response (Babinski's sign +)"),
    ("Deep Tendon Reflexes", "Exaggerated bilaterally"),
    ("Seizures", "Two GTCS before admission; no active seizure on examination"),
    ("Fundoscopy", "Normal (no papilloedema on initial assessment)"),
]
for d in cns_data:
    data_row(cns_t, *d)
sp()
para("B. Cardiovascular System: S1 S2 heard, tachycardia, no murmur.", size=12)
para("C. Respiratory System: Tachypnoea; bilateral air entry clear; no added sounds. O2 supplement given.", size=12)
para("D. Abdomen: Soft, non-tender, no hepatosplenomegaly.", size=12)
para("E. Anthropometry: Weight 18 kg; Height 110 cm; BMI 14.9 (slightly underweight).", size=12)
sp()

# ═══════════════════════════════════════════════════════════════════════════
# V. REVIEW OF LITERATURE
# ═══════════════════════════════════════════════════════════════════════════
h1("V. REVIEW OF LITERATURE / CONCEPT OF DISEASE")

h2("5.1 Definition")
para(
    "Encephalitis is defined as a diffuse or focal inflammation of the parenchyma (substance) of the brain, "
    "characterized by evidence of brain dysfunction (altered consciousness, behavioural change, or focal neurological "
    "deficit). In children, the definition by the International Encephalitis Consortium (2013) requires: altered "
    "mental status for at least 24 hours, plus at least two of the following — fever, new-onset seizures, new focal "
    "neurological findings, CSF pleocytosis, or MRI/EEG changes consistent with encephalitis."
)
para("Source: Goldman-Cecil Medicine, 26th Ed., Chapter 383; Harrison's Principles of Internal Medicine, 22nd Ed., Chapter 352.", size=10)
sp()

h2("5.2 Classification of Encephalitis")
cl_t = make_table(3)
hdr_row(cl_t, "CLASSIFICATION", "TYPE", "EXAMPLES")
cl_data = [
    ("By Cause", "Infectious (Viral)", "HSV-1/2, JEV, Enterovirus, EBV, CMV, Rabies, Influenza"),
    ("", "Infectious (Bacterial)", "Listeria, TB, Brucella, Rickettsiae"),
    ("", "Parasitic", "Toxoplasma, Plasmodium falciparum (cerebral malaria)"),
    ("", "Autoimmune / Post-infectious", "Anti-NMDAR encephalitis, ADEM (post-measles, post-varicella)"),
    ("By Age", "Neonatal (0-28 days)", "HSV-2, CMV, Group B Streptococcus"),
    ("", "Infant (1-12 months)", "Enterovirus, HSV-1, HHV-6"),
    ("", "Child (1-15 years)", "JEV (India), Enterovirus 71, Mumps, Nipah virus"),
    ("", "Adolescent", "EBV, autoimmune (NMDAR), HSV-1"),
    ("By Onset", "Acute (<2 weeks)", "Viral, bacterial"),
    ("", "Subacute (2-6 weeks)", "TB, autoimmune"),
    ("", "Chronic (>6 weeks)", "HIV, SSPE (measles), PML"),
]
for d in cl_data:
    row = cl_t.add_row()
    for i, val in enumerate(d):
        rv = row.cells[i].paragraphs[0].add_run(val)
        rv.font.name = "Times New Roman"; rv.font.size = Pt(11)
        if i == 0 and val:
            rv.bold = True
sp()

h2("5.3 Aetiology — Causes in Paediatric Age Group (India)")
et_t = make_table(3)
hdr_row(et_t, "CAUSATIVE AGENT", "AGE GROUP MOST AFFECTED", "KEY FEATURE IN INDIA")
et_data = [
    ("Japanese Encephalitis Virus (JEV)", "1-15 years (peak 5-10 years)", "Most common epidemic encephalitis in India; Culex mosquito vector; associated with piggeries and paddy fields"),
    ("Herpes Simplex Virus Type 2 (HSV-2)", "Neonates (0-28 days)", "Acquired during delivery; disseminated or CNS disease; IV Acyclovir life-saving"),
    ("Herpes Simplex Virus Type 1 (HSV-1)", "All ages, particularly >3 months", "Most common sporadic fatal encephalitis; temporal lobe involvement"),
    ("Enterovirus (EV-71, EV-A16)", "6 months – 5 years", "Hand-Foot-Mouth Disease epidemics; brainstem encephalitis; poor prognosis"),
    ("Measles (SSPE)", "5-15 years", "Subacute Sclerosing Panencephalitis — delayed complication years after measles; preventable by MMR vaccine"),
    ("Nipah Virus", "Any age; outbreaks in Kerala, WB", "Zoonosis (bats/pigs); CFR up to 80%; no specific therapy"),
    ("Rabies", "Any age; children common victims", "Almost always fatal; due to dog bites; preventable by vaccination"),
    ("Mycobacterium tuberculosis", "Any age; common in malnourished", "TB meningoencephalitis; subacute onset; basal exudate on MRI"),
]
for d in et_data:
    data_row(et_t, *d)
sp()

h2("5.4 Pathophysiology")
para("The pathophysiology of paediatric encephalitis follows the sequence below. Children are particularly vulnerable because of:", bold=False)
bullet("Immature blood-brain barrier (especially in neonates and infants)")
bullet("Developing immune system with limited ability to mount local CNS immune response")
bullet("Greater brain plasticity — but also greater vulnerability to seizure-induced damage (lower seizure threshold)")
bullet("Incomplete myelination in young children — greater susceptibility to diffuse axonal injury")
sp()

path_t = make_table(1)
path_steps = [
    ("ENTRY OF PATHOGEN", "Mosquito bite (JEV), respiratory route, vertical transmission (HSV-2 neonatal), reactivation of latent virus"),
    ("VIREMIA / BACTEREMIA", "Virus replicates in lymphoid tissue and vascular endothelium → enters bloodstream → Febrile prodrome (fever, malaise, irritability in child)"),
    ("CNS INVASION", "Virus crosses blood-brain barrier: via infected macrophages, choroid plexus, or olfactory/trigeminal routes → invades neurons and glial cells"),
    ("NEURO-INFLAMMATION", "Activation of microglia → pro-inflammatory cytokines (IL-1β, TNF-α, IL-6) → cerebral inflammation and vasculitis"),
    ("CEREBRAL OEDEMA", "Disruption of blood-brain barrier → cytotoxic + vasogenic oedema → raised intracranial pressure (ICP)"),
    ("NEURONAL NECROSIS", "Focal or diffuse necrosis of neurons; perivascular lymphocytic infiltration; microglial nodule formation"),
    ("CLINICAL EFFECTS", "Fever, seizures, altered sensorium, focal deficits (age-specific: infants → bulging fontanelle; children → headache, photophobia, behavioral change)"),
    ("OUTCOMES", "Recovery (complete or with sequelae) OR death in untreated/severe disease"),
]
for title, desc in path_steps:
    row = path_t.add_row()
    cell = row.cells[0]
    shade_cell(cell, "EBF3FB")
    p = cell.paragraphs[0]
    r1 = p.add_run(f"{title}: ")
    r1.bold = True; r1.font.name = "Times New Roman"; r1.font.size = Pt(11)
    r1.font.color.rgb = RGBColor(0, 51, 102)
    r2 = p.add_run(desc)
    r2.font.name = "Times New Roman"; r2.font.size = Pt(11)
sp()

h2("5.5 Clinical Manifestations — Age-Specific Features")
cm_t = make_table(4)
hdr_row(cm_t, "FEATURE", "NEONATES (0-28 days)", "INFANTS (1-12 months)", "CHILDREN (1-15 years)")
cm_data = [
    ("Fever", "May be absent or hypothermia", "High-grade (>38.5°C); irritability", "Abrupt high-grade fever (39-40°C)"),
    ("Fontanelle", "Bulging anterior fontanelle", "Bulging / tense fontanelle", "Closed (not applicable)"),
    ("Headache", "Cannot report", "Inconsolable cry (high-pitched)", "Severe throbbing headache"),
    ("Photophobia", "Blepharospasm", "Turns face away from light", "Classical photophobia; eye closure"),
    ("Neck Stiffness", "May be absent (50%)", "Opisthotonos; neck stiffness", "Kernig's sign +; Brudzinski's sign +"),
    ("Seizures", "Subtle (lip smacking, cycling); focal clonic", "Febrile seizures → prolonged/focal", "GTCS; focal seizures; status epilepticus"),
    ("Consciousness", "Lethargy, poor feeding, apnoea", "Drowsiness, irritability, stupor", "Confusion → disorientation → coma"),
    ("Behavioural Change", "Not applicable", "Excessive crying, loss of milestones", "Aggression, hallucinations, personality change"),
    ("Vomiting", "Common", "Projectile vomiting", "Projectile vomiting with headache"),
    ("Focal Deficits", "Rare except HSV (focal seizures)", "Rare; hemiparesis if focal disease", "Hemiparesis, aphasia, ataxia, diplopia"),
    ("Rash", "Vesicular rash in HSV neonatal", "Vesicular rash (HSV/VZV)", "Usually absent; rash suggests VZV/enterovirus"),
]
for d in cm_data:
    data_row(cm_t, *d)
sp()

h2("5.6 Diagnostic Investigations")
diag_t = make_table(3)
hdr_row(diag_t, "INVESTIGATION", "EXPECTED FINDINGS IN VIRAL ENCEPHALITIS", "CLINICAL SIGNIFICANCE")
diag_data = [
    ("Complete Blood Count", "Normal or lymphocytosis (viral)\nLeukopenia in some arboviruses\nElevated ESR", "Rules out bacterial infection; monitors immune status"),
    ("Blood Culture & Sensitivity", "Usually sterile in viral cases", "Excludes septicaemia and bacterial meningoencephalitis"),
    ("Blood Glucose & Electrolytes", "May show hyponatraemia (SIADH)\nHypoglycaemia in neonates", "SIADH complication; hypoglycaemia worsens brain injury"),
    ("Renal & Liver Function Tests", "Usually normal; monitor on Acyclovir (nephrotoxic)", "Baseline and monitoring for drug toxicity"),
    ("Lumbar Puncture — CSF Analysis\n(KEY TEST — after CT if focal signs)", "Opening Pressure: Elevated\nAppearance: Clear / colourless\nWBC: 10-500 cells (lymphocytic pleocytosis)\nProtein: 65-150 mg/dL (elevated)\nGlucose: Normal (>60% of blood glucose)\nGram stain: Negative", "Distinguishes viral from bacterial meningitis; guides empirical therapy"),
    ("CSF PCR (HSV, JEV, CMV, EV)", "HSV PCR +ve: sensitivity 96%, specificity 99%\nJEV IgM in CSF: diagnostic of CNS JE\nEnterovirus PCR +ve", "Gold standard for specific viral diagnosis; directs antiviral choice"),
    ("Serology (IgM/IgG)", "JEV IgM in blood or CSF: +ve within 4-7 days\nHSV antibody titres", "Epidemiologically important; confirms arboviral cause"),
    ("MRI Brain (PREFERRED)", "JEV: bilateral thalamic T2 hyperintensity (+ haemorrhage)\nHSV: temporal lobe FLAIR/T2 hyperintensity\nADEM: multifocal white matter lesions", "Identifies specific virus; shows extent of brain involvement; prognostic"),
    ("CT Head (FIRST if focal deficit/coma)", "May be normal early; later: oedema, haemorrhage\nRequired BEFORE LP if focal signs or papilloedema", "Excludes mass lesion; detects herniation risk before LP"),
    ("EEG (Electroencephalogram)", "Diffuse slow-wave activity\nPLEDs (periodic lateralised epileptiform discharges) in HSV\nSpike-and-wave in seizures", "Detects seizure activity (including sub-clinical NCSE); monitors treatment"),
    ("Nasopharyngeal/Throat Swab", "For enterovirus culture/PCR in summer outbreaks", "Identifies enteroviral aetiology"),
    ("Blood Ammonia + Metabolic Screen", "In infants: rule out metabolic encephalopathy", "Metabolic causes must be excluded in neonates/infants"),
]
for d in diag_data:
    data_row(diag_t, *d)
sp()

h2("5.7 Medical Management")
med_t = make_table(3)
hdr_row(med_t, "TREATMENT", "DRUG / INTERVENTION", "PAEDIATRIC DOSE / NOTE")
med_data = [
    ("Specific Antiviral\n(HSV Encephalitis)", "IV Acyclovir", "Neonate: 20 mg/kg IV q8h x 21 days\nChild >3 months: 10-15 mg/kg IV q8h x 14-21 days\nMost important intervention — do not delay"),
    ("Antibiotic (Empirical cover)", "IV Ceftriaxone + IV Ampicillin", "Until bacterial meningitis/Listeria ruled out\nCeftriaxone: 100 mg/kg/day in 2 divided doses"),
    ("Anti-tubercular (if TB suspected)", "HRZE (4-drug ATT regimen)", "If clinical/CSF picture suggests TBM"),
    ("Anticonvulsants — Acute Seizure", "IV Lorazepam / IV Diazepam", "Lorazepam 0.05-0.1 mg/kg IV (max 4 mg)\nDiazepam 0.2-0.5 mg/kg IV or 0.5 mg/kg PR — first line"),
    ("Anticonvulsants — Maintenance", "IV/Oral Phenobarbitone\nOr IV Levetiracetam\nOr IV Phenytoin", "Phenobarbitone: 5 mg/kg/day\nLevetiracetam: 20-60 mg/kg/day in 2 doses\nPhenytoini: 5-8 mg/kg/day"),
    ("Antipyretic", "Paracetamol Suspension / IV", "10-15 mg/kg/dose every 4-6 hours; not to exceed 5 doses/day"),
    ("Anti-cerebral Oedema", "Mannitol 20% IV", "0.25-0.5 g/kg IV over 20-30 min; repeat q4-6h as needed"),
    ("Corticosteroids (selective)", "IV Dexamethasone", "For significant cerebral oedema and TB meningoencephalitis; avoid in uncomplicated viral encephalitis"),
    ("Immunotherapy (Autoimmune)", "IV Methylprednisolone / IVIG / Plasmapheresis", "1st line in anti-NMDA-R encephalitis and ADEM:\nMethylprednisolone 30 mg/kg/day x 5 days\nIVIG 2 g/kg over 2-5 days"),
    ("Oxygen Therapy", "Nasal prongs / Mask / Mechanical ventilation", "Maintain SpO2 >95%; intubate if GCS <8 or respiratory failure"),
    ("Nutritional Support", "IV fluids + Nasogastric (NG) tube feeding", "Restrict fluids to 2/3 maintenance if SIADH; monitor serum Na+\nNG feeds: 60-70% estimated energy requirement initially"),
    ("DVT Prophylaxis", "Passive limb exercises + position change", "Pharmacological prophylaxis usually not used in children"),
]
for d in med_data:
    data_row(med_t, *d)
sp()

# ═══════════════════════════════════════════════════════════════════════════
# VI. NURSING ASSESSMENT
# ═══════════════════════════════════════════════════════════════════════════
h1("VI. NURSING ASSESSMENT")

h2("6.1 Paediatric Neurological Assessment Tools")
na_t = make_table(2)
hdr_row(na_t, "ASSESSMENT TOOL", "FINDINGS IN THIS CHILD")
na_data = [
    ("Paediatric Glasgow Coma Scale (PGCS)", "E2 (opens eyes to pain) + V2 (moaning) + M4 (flexion response) = 8/15\nSevere impairment (normal = 15)"),
    ("AVPU Scale", "P — responds to Pain only (A=Alert, V=Voice, P=Pain, U=Unresponsive)"),
    ("Paediatric Early Warning Score (PEWS)", "High risk score — HR 118, RR 28, SpO2 94%, consciousness altered"),
    ("Seizure Assessment", "Type: GTCS; Duration: ~2 min each; Frequency: 2 episodes; Post-ictal: confusion; Trigger: fever"),
    ("Pain Assessment (FLACC Scale)", "FLACC Score: 7/10 (Face 2, Legs 1, Activity 2, Cry 1, Consolability 1)"),
    ("Nutritional Status (IAP criteria)", "Grade I mild malnutrition; poor oral intake for 4 days; at risk for refeeding syndrome"),
    ("Developmental Assessment", "Pre-morbidly age-appropriate; risk for regression; cognitive/motor sequelae possible"),
]
for d in na_data:
    data_row(na_t, *d)
sp()

h2("6.2 Gordon's Functional Health Patterns — Paediatric Application")
gf_t = make_table(2)
hdr_row(gf_t, "HEALTH PATTERN", "ASSESSMENT IN CHILD / FAMILY")
gf_data = [
    ("1. Health Perception", "Family had incomplete immunization; delayed hospital presentation; poor awareness of JE vaccine"),
    ("2. Nutritional-Metabolic", "No oral intake for 2 days; vomiting; weight 18 kg (slightly underweight); requires NG tube feeding"),
    ("3. Elimination", "No urine output for last 6 hrs; Foley catheter inserted; risk of SIADH; bowel assessment pending"),
    ("4. Activity-Exercise", "Completely dependent; bedridden; risk of pressure sore, contractures, and aspiration"),
    ("5. Sleep-Rest", "Severely disturbed; drowsy during day; agitated at night (reversal of sleep-wake cycle)"),
    ("6. Cognitive-Perceptual", "Altered consciousness GCS 8/15; photophobia; cannot communicate; seizure activity"),
    ("7. Self-Perception", "Not assessable in acute phase; family extremely anxious and distressed"),
    ("8. Role-Relationship", "Father is daily wage worker; mother is homemaker; family highly dependent on NGO/PHC support"),
    ("9. Sexuality-Reproductive", "Not applicable for 6-year-old child"),
    ("10. Coping-Stress Tolerance", "Parents in shock; mother crying; father asking about outcome; need for consistent family support"),
    ("11. Value-Belief", "Hindu family; may consider faith healing; nurse should address concerns with empathy and evidence"),
]
for d in gf_data:
    data_row(gf_t, *d)
sp()

# ═══════════════════════════════════════════════════════════════════════════
# VII. NURSING DIAGNOSES
# ═══════════════════════════════════════════════════════════════════════════
h1("VII. NURSING DIAGNOSES (NANDA-I Based — Paediatric)")
nd_t = make_table(4)
hdr_row(nd_t, "No.", "NURSING DIAGNOSIS", "RELATED TO", "AS EVIDENCED BY")
nd_data = [
    ("1.", "Hyperthermia", "Infectious process (viral encephalitis — JEV)", "Temperature 104°F; tachycardia HR 118; flushed warm skin"),
    ("2.", "Ineffective Cerebral Tissue Perfusion (Risk)", "Cerebral oedema; raised ICP; seizure activity", "PGCS 8/15; altered sensorium; tachycardia; drowsiness"),
    ("3.", "Acute Confusion / Altered Thought Process", "Brain parenchyma inflammation; cerebral oedema", "PGCS 8/15; disorientation; non-recognition of parents; moaning"),
    ("4.", "Risk for Injury (Seizures)", "Cortical irritation due to encephalitis; lowered seizure threshold in child", "Two GTCS episodes; hyperthermia; CSF pleocytosis"),
    ("5.", "Ineffective Airway Clearance", "Impaired cough reflex; altered consciousness; secretion accumulation", "SpO2 94% on room air; tachypnoea RR 28/min; drowsiness"),
    ("6.", "Imbalanced Nutrition: Less Than Body Requirements", "Vomiting; inability to feed orally; increased metabolic demand", "No oral intake for 2 days; weight borderline low; vomiting x3-4/day"),
    ("7.", "Risk for Aspiration", "Impaired swallowing reflex; reduced consciousness; NG tube feeding", "PGCS 8/15; absent gag reflex; vomiting episodes"),
    ("8.", "Impaired Skin Integrity (Risk)", "Immobility; fever and diaphoresis; poor nutrition", "Bedridden; altered nutrition; diaphoresis"),
    ("9.", "Anxiety (Parental)", "Uncertain prognosis; unfamiliar hospital environment; child's critical condition", "Parental verbalization of fear; crying; repeated questions about prognosis"),
    ("10.", "Deficient Knowledge (Family)", "Lack of awareness of JE vaccine; vector prevention; disease process", "Missed JE vaccination; no mosquito protection measures at home"),
    ("11.", "Delayed Growth and Development (Risk)", "Neurological insult during critical developmental period", "Acute encephalitis at age 6; potential for cognitive, motor, speech sequelae"),
]
for d in nd_data:
    data_row(nd_t, *d)
sp()

# ═══════════════════════════════════════════════════════════════════════════
# VIII. NURSING CARE PLANS
# ═══════════════════════════════════════════════════════════════════════════
h1("VIII. NURSING CARE PLANS")

def care_plan(num, diag, goal, ind_i, col_i, dep_i, rationale, evaluation):
    h2(f"Nursing Diagnosis {num}: {diag}", color=(192,0,0))
    cp_t = make_table(2)
    # Goal row
    row_g = cp_t.add_row()
    shade_cell(row_g.cells[0], "003366")
    rg = row_g.cells[0].paragraphs[0].add_run("GOAL / EXPECTED OUTCOME")
    rg.bold=True; rg.font.name="Times New Roman"; rg.font.size=Pt(11); rg.font.color.rgb=RGBColor(255,255,255)
    rgg = row_g.cells[1].paragraphs[0].add_run(goal)
    rgg.font.name="Times New Roman"; rgg.font.size=Pt(11)
    # Headers
    row_h = cp_t.add_row()
    shade_cell(row_h.cells[0], "1F5C99")
    rh1 = row_h.cells[0].paragraphs[0].add_run("NURSING INTERVENTIONS")
    rh1.bold=True; rh1.font.name="Times New Roman"; rh1.font.size=Pt(11); rh1.font.color.rgb=RGBColor(255,255,255)
    shade_cell(row_h.cells[1], "1F5C99")
    rh2 = row_h.cells[1].paragraphs[0].add_run("RATIONALE")
    rh2.bold=True; rh2.font.name="Times New Roman"; rh2.font.size=Pt(11); rh2.font.color.rgb=RGBColor(255,255,255)
    rat_idx = 0
    for cat_label, items, shade_c in [("Independent Interventions", ind_i, "DCE6F1"),
                                       ("Collaborative Interventions", col_i, "FFF2CC"),
                                       ("Dependent (Medical Order) Interventions", dep_i, "E2EFDA")]:
        if items:
            row_cat = cp_t.add_row()
            shade_cell(row_cat.cells[0], shade_c)
            rc = row_cat.cells[0].paragraphs[0].add_run(cat_label + ":")
            rc.bold=True; rc.font.name="Times New Roman"; rc.font.size=Pt(11)
            row_cat.cells[1].paragraphs[0].add_run("")
            for item in items:
                r_item = cp_t.add_row()
                ri = r_item.cells[0].paragraphs[0].add_run(f"• {item}")
                ri.font.name="Times New Roman"; ri.font.size=Pt(11)
                rat_text = rationale[rat_idx] if rat_idx < len(rationale) else ""
                rrat = r_item.cells[1].paragraphs[0].add_run(rat_text)
                rrat.font.name="Times New Roman"; rrat.font.size=Pt(11)
                rat_idx += 1
    # Evaluation
    row_ev = cp_t.add_row()
    shade_cell(row_ev.cells[0], "003366")
    rev = row_ev.cells[0].paragraphs[0].add_run("EVALUATION")
    rev.bold=True; rev.font.name="Times New Roman"; rev.font.size=Pt(11); rev.font.color.rgb=RGBColor(255,255,255)
    rev2 = row_ev.cells[1].paragraphs[0].add_run(evaluation)
    rev2.font.name="Times New Roman"; rev2.font.size=Pt(11)
    sp()

# CARE PLAN 1 — HYPERTHERMIA
care_plan(
    "1",
    "Hyperthermia related to viral infectious process (JEV encephalitis) as evidenced by temperature 104°F, tachycardia, and flushed skin",
    "Child's temperature will be reduced to normal (36.5–37.5°C) within 24-48 hours and maintained. Tachycardia will resolve.",
    [
        "Monitor temperature every 1-2 hours; record on temperature chart; notify doctor if >40°C or <36°C.",
        "Apply tepid sponging using lukewarm water (27-30°C) to forehead, axillae, groin for 15-20 min when temp >38.5°C; avoid cold water.",
        "Place cool, moist cloths on forehead; apply ice pack (wrapped in cloth) to groin and axillae.",
        "Remove excess clothing and blankets; use a single cotton sheet.",
        "Ensure adequate ventilation; use a fan if available; avoid overcrowding.",
        "Maintain strict fluid balance chart every hour; monitor for signs of dehydration.",
        "Monitor for febrile seizures: observe for stiffening, jerking, eye deviation; activate seizure protocol if it occurs.",
        "Position child in lateral (recovery) position if vomiting to prevent aspiration.",
    ],
    [
        "Consult paediatrician if temperature does not respond within 1 hour of antipyretics.",
        "Collaborate with dietitian for adequate caloric and fluid intake when oral feeds resume.",
    ],
    [
        "Administer Paracetamol 10-15 mg/kg/dose oral/IV q4-6h as ordered; not >5 doses/day.",
        "Administer IV Acyclovir 10-15 mg/kg q8h (specific antiviral — controls causative virus).",
        "Administer IV fluids as prescribed; monitor for SIADH (restrict fluids to 2/3 maintenance if Na+ falls).",
    ],
    [
        "Frequent temperature monitoring detects deterioration early; fever increases cerebral metabolic demand by 10% per °C.",
        "Tepid sponging promotes heat dissipation by evaporation; cold water causes vasoconstriction and shivering — counterproductive.",
        "Cooling major blood vessel areas (groin, axillae) reduces core temperature rapidly.",
        "Minimal clothing promotes radiant heat loss from skin surface.",
        "Ventilation promotes convective heat loss; reduces room temperature.",
        "Fever increases insensible fluid losses; dehydration worsens cerebral hypoperfusion.",
        "Children with encephalitis have a low seizure threshold; fever is a common trigger for febrile seizures.",
        "Lateral position drains oral secretions; reduces aspiration risk during vomiting.",
        "Paracetamol acts on hypothalamic thermostat to reset temperature setpoint downward.",
        "Acyclovir inhibits viral DNA polymerase; reduces viral replication and systemic inflammatory response.",
        "IV fluids maintain circulating volume; SIADH monitoring prevents dilutional hyponatraemia.",
    ],
    "Temperature reduced to 37.8°C within 12 hours; maintained at 37.2°C by 48 hours. Tachycardia resolved. Goal MET."
)

# CARE PLAN 2 — RISK FOR INJURY (SEIZURES)
care_plan(
    "2",
    "Risk for Injury related to seizure activity secondary to cortical irritation from encephalitis",
    "Child will remain free from seizure-related injury throughout hospitalisation. Seizures will be controlled within 24-48 hours of anticonvulsant therapy.",
    [
        "Maintain seizure precautions: padded cot rails, padded headboard, suction machine and oxygen at bedside at all times.",
        "Keep resuscitation tray (IV access, Diazepam injection, Lorazepam, airway adjuncts) READY at the bedside.",
        "During seizure: DO NOT restrain; protect head; turn child to lateral position; time duration; note type and body parts affected.",
        "Post-seizure: assess PGCS, SpO2, pupils, vital signs; administer O2; note any new focal deficits.",
        "Remove IV cannula caps, hard toys, or objects near the child; ensure cot sides are up at all times.",
        "Monitor serum electrolytes (Na+, K+, Ca2+, Mg2+) every 12-24 hours — electrolyte imbalances lower seizure threshold.",
        "Document seizure accurately: onset time, type, duration, body parts involved, post-ictal recovery, and triggers.",
        "Educate parents: do not put fingers or objects in mouth during seizure; remain calm and call for nurse immediately.",
        "Monitor for status epilepticus (seizure >5 minutes or two seizures without recovery) — a neurological emergency.",
    ],
    [
        "Report any new seizure to paediatrician immediately; prepare for IV anticonvulsant orders.",
        "Coordinate with neurology for continuous EEG monitoring if seizures difficult to control.",
        "Request electrolyte correction order from physician if serum Na+ <130 mEq/L or Ca2+ low.",
    ],
    [
        "Administer IV Lorazepam 0.05-0.1 mg/kg (first-line for active seizure) as ordered; repeat once if needed.",
        "Administer IV Phenobarbitone / Levetiracetam as maintenance anticonvulsant per prescription.",
        "Administer IV Mannitol 20% (0.25-0.5 g/kg) for acute raised ICP if ordered.",
        "Correct electrolyte imbalances as prescribed (IV NaCl for hyponatraemia; IV Calcium gluconate if hypocalcaemia).",
    ],
    [
        "Padded cot sides prevent head injury; oxygen and suction at bedside enable immediate post-seizure management.",
        "Immediate access to emergency drugs and airway equipment enables rapid intervention in status epilepticus.",
        "Restraining causes fractures and dislocations; lateral position drains secretions and prevents aspiration.",
        "Post-ictal assessment detects new focal deficits, hypoxia, or aspiration.",
        "Hard objects cause dental and skin injuries during convulsive movements.",
        "Hyponatraemia (SIADH), hypocalcaemia, and hypomagnesaemia all lower the seizure threshold in children.",
        "Accurate seizure documentation helps identify patterns and guides anticonvulsant adjustment.",
        "Parental education reduces panic and prevents harmful manoeuvres (tongue depressors, restraint).",
        "Status epilepticus causes excitotoxic brain injury if not terminated within 30 minutes.",
        "Prompt reporting enables rapid dose escalation.",
        "Continuous EEG detects non-convulsive status epilepticus (NCSE) — common in encephalitis.",
        "Hyponatraemia from SIADH is a frequent cause of breakthrough seizures in encephalitis.",
        "Lorazepam/Diazepam enhance GABA inhibitory neurotransmission — first-line for acute seizure termination.",
        "Phenobarbitone/Levetiracetam provide sustained seizure protection.",
        "Mannitol reduces ICP by osmotic dehydration of brain tissue.",
        "Electrolyte correction removes metabolic triggers of seizure recurrence.",
    ],
    "No seizure-related injury occurred. Seizure-free by Day 2 with anticonvulsant therapy. Goal MET."
)

# CARE PLAN 3 — PARENTAL ANXIETY
care_plan(
    "3",
    "Anxiety (Parental) related to child's critical condition and uncertain prognosis as evidenced by crying, repeated questioning, and expressed fear",
    "Parents will demonstrate reduced anxiety by Day 2; will be able to verbalize understanding of child's condition and participate in care by Day 3.",
    [
        "Establish therapeutic relationship: introduce yourself by name; maintain eye contact; speak in Kannada (local language); show genuine empathy.",
        "Assess level of parental anxiety using verbal and non-verbal cues; acknowledge and validate their feelings.",
        "Provide clear, honest, and age-appropriate information about the child's condition, investigations, and treatment plan.",
        "Explain ICU/ward routines, visiting hours, and what to expect during treatment.",
        "Allow parents to stay with child for maximum time possible; encourage them to talk to and touch the child.",
        "Teach parents simple comfort measures: how to wipe the child's face, oral care, holding the hand.",
        "Avoid medical jargon; use simple analogies; repeat information patiently as anxiety impairs retention.",
        "Provide a quiet space for parents to rest and grieve; refer to hospital chaplain/social worker if needed.",
    ],
    [
        "Arrange a family meeting with the paediatric neurologist for detailed discussion of prognosis.",
        "Refer to hospital medical social worker for financial and emotional support.",
        "Connect family with parent support groups if available.",
    ],
    [
        "No specific drug orders; emotional support is a primary nursing intervention.",
    ],
    [
        "A therapeutic relationship based on trust reduces anxiety and improves compliance with care.",
        "Acknowledging feelings validates the parents' experience and reduces isolation.",
        "Lack of information is the primary driver of anxiety in parents of hospitalised children.",
        "Familiarity with routines reduces unpredictability — a major source of parental stress in ICU.",
        "Parental presence is therapeutic for the child; reduces stress hormones; promotes recovery.",
        "Participation in care empowers parents and reduces helplessness.",
        "Anxiety interferes with information processing; repetition and plain language improve comprehension.",
        "Bereavement support is essential if prognosis is poor; prevents complicated grief.",
        "Medical team input clarifies clinical questions beyond the nurse's scope.",
        "Social worker addresses financial burden of hospitalisation, a major stressor for rural families.",
        "Peer support from other parents reduces isolation.",
        "Human connection and empathetic listening are the most effective anxiolytics.",
    ],
    "Parents verbalized reduced anxiety by Day 2. Actively participated in child's care (oral hygiene, limb exercises) by Day 3. Goal MET."
)
sp()

# ═══════════════════════════════════════════════════════════════════════════
# IX. HEALTH EDUCATION
# ═══════════════════════════════════════════════════════════════════════════
h1("IX. HEALTH EDUCATION")
para(
    "Health education in paediatric encephalitis is directed at three levels: (1) the immediate family of the child, "
    "(2) the community (village level), and (3) the child (when recovered — age-appropriate teaching). "
    "Teaching must be conducted in the local language (Kannada), using simple illustrations, demonstrations, and return demonstrations. "
    "The RGUHS curriculum emphasizes empowering families to prevent recurrence and recognize danger signs."
)
sp()

h2("9.1 Health Teaching — Family Education Table")
he_t = make_table(3)
hdr_row(he_t, "TOPIC", "KEY TEACHING POINTS", "TEACHING METHOD")
he_data = [
    (
        "Understanding the Disease",
        "• Encephalitis = swelling/infection of the brain tissue\n"
        "• In India, Japanese Encephalitis is the most common cause in children\n"
        "• Spread by Culex mosquito bites — NOT from person to person\n"
        "• Symptoms: high fever + headache + vomiting + seizures + unconsciousness\n"
        "• It is NOT like ordinary fever — it can be fatal; go to hospital IMMEDIATELY",
        "Verbal explanation; simple diagram of brain and mosquito"
    ),
    (
        "Japanese Encephalitis Vaccine\n(JE Vaccine) — MOST IMPORTANT",
        "• JE vaccine is FREE under National Immunization Programme (NIP)\n"
        "• Two doses: at 9-12 months AND booster at 16-24 months\n"
        "• If your child has NOT received it — go to the nearest PHC/Sub-Centre TODAY\n"
        "• Vaccine prevents JE in 98-99% of vaccinated children\n"
        "• Siblings and other village children should also be vaccinated\n"
        "• JE vaccine is available at Govt. hospitals free of cost",
        "Immunization card demonstration; referral slip to PHC"
    ),
    (
        "Mosquito Bite Prevention\n(Vector Control)",
        "• Use insecticide-treated bed nets (ITNs) for all children — every night\n"
        "• Apply mosquito repellent (DEET or neem-based) on exposed skin before sunset\n"
        "• Dress children in full-sleeved shirts and long trousers from dusk to dawn\n"
        "• Install wire mesh on windows and doors\n"
        "• Drain stagnant water (pots, tyres, coolers, drums, flower pots) every week\n"
        "• Culex mosquitoes breed in paddy fields, drains, and ponds near piggeries\n"
        "• Keep pigs (JEV reservoir) away from human dwellings — especially at dusk",
        "Demonstration with mosquito net; poster showing breeding sites"
    ),
    (
        "Seizure First Aid\n(Critical for Family)",
        "• If your child has a fit/seizure:\n"
        "  - Stay CALM; do NOT panic\n"
        "  - Lay child on the GROUND/FLOOR (not on bed — risk of falling)\n"
        "  - Turn child to the SIDE (recovery position) — prevents choking on vomit\n"
        "  - Protect the HEAD — put soft cloth under head\n"
        "  - Do NOT put finger, spoon, or cloth in the mouth — DANGEROUS\n"
        "  - Do NOT hold or restrain the child during seizure\n"
        "  - Time the seizure: if >5 minutes → call ambulance/go to hospital NOW\n"
        "  - After seizure: keep child lying down; allow to rest; do not give food/water",
        "Live demonstration using doll; role-play with parents"
    ),
    (
        "Warning Signs — When to Return to Hospital",
        "• Come to hospital IMMEDIATELY for:\n"
        "  - Sudden high fever (>102°F)\n"
        "  - Severe headache (child cries holding head)\n"
        "  - Repeated vomiting\n"
        "  - Neck stiffness or child refuses to lower chin\n"
        "  - Seizures / fits\n"
        "  - Unusual drowsiness or cannot be woken up\n"
        "  - Child stops recognizing family members\n"
        "  - Weakness in any limb\n"
        "• Don't wait at home; delay worsens outcome",
        "Written emergency card in Kannada; verbal emphasis"
    ),
    (
        "Medication Compliance\n(After Discharge)",
        "• Give oral Acyclovir / AEDs (antiepileptic drugs) EXACTLY as prescribed\n"
        "• Do NOT stop anti-epileptic medicines without the doctor's permission\n"
        "• Give medicines at same time every day — set a phone alarm\n"
        "• If vomiting after medicine: inform doctor before skipping dose\n"
        "• Side effects to watch: skin rash, excessive drowsiness → report to doctor",
        "Pill organiser demonstration; written medication schedule"
    ),
    (
        "Nutrition and Recovery",
        "• Give high-protein, high-calorie, soft foods: dal, khichdi, curd, egg, banana\n"
        "• Small, frequent meals (6 times/day) better than 3 large meals\n"
        "• Adequate fluids: minimum 1.5 litres/day (water, coconut water, ORS if needed)\n"
        "• Brain recovery requires good nutrition — do not restrict food\n"
        "• Continue breastfeeding for infants (if applicable)\n"
        "• Monitor weight weekly after discharge",
        "Diet chart in Kannada; food demonstration"
    ),
    (
        "Rehabilitation / Follow-up",
        "• Brain recovery after encephalitis may take months\n"
        "• Your child may have: memory problems, behavioural changes, weakness, speech difficulty — all are treatable\n"
        "• Physiotherapy: daily passive and active exercises for weak limbs\n"
        "• Speech therapy: if speech is affected\n"
        "• Follow-up OPD: 1 week, 1 month, 3 months, 6 months, 1 year after discharge\n"
        "• Child should return to school gradually — inform teacher about condition\n"
        "• RBSK (Rashtriya Bal Swasthya Karyakram) — free child health screening through Govt.",
        "Physiotherapy demonstration; written follow-up card"
    ),
    (
        "Child's Mental Health",
        "• Children with encephalitis may develop fear, nightmares, or behavioural changes after recovery\n"
        "• Be patient and understanding — recovery takes time\n"
        "• Re-establish normal routine gradually (school, play, meals)\n"
        "• Praise child for small achievements during recovery\n"
        "• If persistent behaviour problems: consult child psychiatrist / developmental paediatrician\n"
        "• Siblings at home may feel neglected — include them in recovery activities",
        "Counselling; family meeting"
    ),
    (
        "Environmental and Community Actions",
        "• Report fever + seizure illness in the village to ASHA / ANM immediately\n"
        "• Participate in Govt. anti-mosquito campaigns (fogging, larval control)\n"
        "• Ensure ALL children in village receive JE vaccine\n"
        "• Use covered water storage containers; empty all water-storing vessels weekly\n"
        "• Village panchayat: advocate for drainage cleaning and mosquito control\n"
        "• Avoid keeping pigs near houses; if keeping pigs, vaccinate animals against JEV",
        "Community meeting; IEC (Information-Education-Communication) materials"
    ),
]
for d in he_data:
    data_row(he_t, *d)
sp()

h2("9.2 Discharge Planning")
dis_t = make_table(2)
hdr_row(dis_t, "DISCHARGE AREA", "INSTRUCTIONS")
dis_data = [
    ("Medications", "Written schedule: drug name, dose, time, duration; AED must not be stopped without doctor advice"),
    ("Diet", "High protein, high calorie, soft foods; small frequent meals; minimum 1.5 L fluids/day"),
    ("Activity", "Rest adequately; gradual return to play; no vigorous physical activity for 4 weeks"),
    ("School", "Can return to school after 4-6 weeks with medical clearance; inform class teacher"),
    ("Follow-up", "OPD: 1 week, 1 month, 3 months, 6 months, 1 year; bring medicines and immunization card"),
    ("Physiotherapy", "Referral if motor weakness or coordination problems"),
    ("Speech Therapy", "Referral if speech/language delay noted"),
    ("Developmental Review", "Paediatric neurodevelopmental assessment at 3 months and 1 year post-discharge"),
    ("JE Vaccination", "Ensure child and all siblings receive complete JE vaccination; obtain from PHC free of cost"),
    ("Emergency Contact", "Hospital paediatric emergency number provided; instructions on when to present immediately"),
    ("Social Support", "Medical social worker contact for financial assistance; ASHA linkage for home visits"),
]
for d in dis_data:
    data_row(dis_t, *d)
sp()

# ═══════════════════════════════════════════════════════════════════════════
# X. COMPLICATIONS
# ═══════════════════════════════════════════════════════════════════════════
h1("X. COMPLICATIONS OF PAEDIATRIC ENCEPHALITIS")
comp_t = make_table(3)
hdr_row(comp_t, "COMPLICATION", "MECHANISM", "NURSING / MEDICAL INTERVENTION")
comp_data = [
    ("Status Epilepticus", "Prolonged seizure >5 min; most feared acute complication in children", "IV Lorazepam → Phenobarbitone → RSI + intubation; call resuscitation team"),
    ("Raised Intracranial Pressure", "Cerebral oedema; CSF outflow obstruction", "Head elevation 30°; IV Mannitol; CT monitoring; neurosurgery consult"),
    ("SIADH (Dilutional Hyponatraemia)", "Hypothalamic dysfunction; inappropriate ADH secretion", "Fluid restriction (2/3 maintenance); hypertonic saline if Na+ <120; monitor Na+ every 6-8 hrs"),
    ("Aspiration Pneumonia", "Impaired gag reflex; vomiting; reduced consciousness", "NG tube feeding; semi-recumbent; chest physio; antibiotics if pneumonia"),
    ("Respiratory Failure", "Brainstem involvement; aspiration; neuromuscular depression", "O2 therapy; bag-valve-mask; mechanical ventilation in PICU"),
    ("Cerebral Herniation", "Uncontrolled ICP causing uncal / tonsillar herniation", "Emergency CT; IV Mannitol; hyperventilation; decompressive craniectomy"),
    ("Pressure Ulcers", "Prolonged immobility; poor nutrition; fever + diaphoresis", "2-hourly position change; foam mattress; skin inspection 4-hourly; nutrition"),
    ("Neurological Sequelae\n(Short-term)", "Residual cognitive impairment, behavioural changes, epilepsy", "Anticonvulsants; cognitive rehabilitation; counselling; school integration support"),
    ("Neurological Sequelae\n(Long-term)", "JEV: 30-50% survivors have motor/cognitive/behavioural disability; SSPE: progressive and fatal", "Multidisciplinary rehabilitation; RBSK enrolment; educational support; family counselling"),
    ("Death", "Uncontrolled brain herniation; multi-organ failure; status epilepticus", "PICU intensive care; family support; palliative care counselling if needed"),
]
for d in comp_data:
    data_row(comp_t, *d)
sp()

# ═══════════════════════════════════════════════════════════════════════════
# XI. EVALUATION
# ═══════════════════════════════════════════════════════════════════════════
h1("XI. EVALUATION OF NURSING CARE")
ev_t = make_table(3)
hdr_row(ev_t, "NURSING DIAGNOSIS", "EXPECTED OUTCOME", "EVALUATION STATUS")
ev_data = [
    ("Hyperthermia", "Temperature ≤ 37.5°C within 48 hours", "Goal MET — Temperature 37.2°C by Day 2"),
    ("Risk for Seizure Injury", "No injury from seizures; seizures controlled", "Goal MET — No injury; seizure-free from Day 2"),
    ("Acute Confusion", "PGCS ≥ 12 within 72 hours", "Goal Partially Met — PGCS 11 by Day 4"),
    ("Ineffective Airway Clearance", "SpO2 >95% maintained; no aspiration", "Goal Met — SpO2 99% on O2; no aspiration"),
    ("Imbalanced Nutrition", "Adequate NG feed; stable weight", "Goal Partially Met — NG feeds established"),
    ("Risk for Impaired Skin Integrity", "No pressure ulcers", "Goal Met — Skin intact throughout"),
    ("Parental Anxiety", "Parents verbalize reduced anxiety; participate in care", "Goal Met — Parents actively assisting care by Day 3"),
    ("Deficient Knowledge (Family)", "Family verbalizes JE vaccine importance; mosquito prevention", "Goal Met — Health education completed; JE vaccine referral given"),
    ("Risk for Developmental Delay", "Child enrolled in neurodevelopmental follow-up", "Goal Met — Referral made at discharge"),
]
for d in ev_data:
    data_row(ev_t, *d)
sp()

h2("Prognosis")
bullet("Japanese Encephalitis in children: mortality 20-30%; 30-50% survivors have significant neurological sequelae.")
bullet("HSV-2 neonatal encephalitis without treatment: mortality >80%; with Acyclovir: reduced significantly.")
bullet("Autoimmune encephalitis (anti-NMDA-R): 80% improvement with immunotherapy — best prognosis.")
bullet("SSPE (Subacute Sclerosing Panencephalitis): uniformly fatal; preventable by MMR vaccination.")
bullet("Enteroviral encephalitis (EV-71 brainstem encephalitis): mortality 15-25% in severe cases.")
bullet("Key prognostic factors: age (infants worst prognosis), GCS on admission, time to treatment initiation, causative agent.")
sp()

# ═══════════════════════════════════════════════════════════════════════════
# XII. CONCLUSION
# ═══════════════════════════════════════════════════════════════════════════
h1("XII. CONCLUSION")
para(
    "Paediatric encephalitis is one of the most serious and potentially devastating neurological emergencies in child health nursing. "
    "Master Arjun's case represents a typical presentation of Japanese Encephalitis in a young school-age child from rural Karnataka — "
    "a scenario encountered frequently in paediatric wards during the monsoon and post-monsoon season."
)
para(
    "The nurse's role is multidimensional: meticulous neurological monitoring using the Paediatric GCS, expert seizure management, "
    "maintaining airway safety and oxygenation, preventing complications such as SIADH and aspiration, providing developmental care, "
    "and being the primary communicator with a distressed family. Through the systematic application of the nursing process "
    "(Assessment, Diagnosis, Planning, Implementation, and Evaluation), nursing care was optimized for this child."
)
para(
    "The most powerful tool against paediatric encephalitis, however, remains PREVENTION — through universal JE vaccination, "
    "community vector control, and empowered families who recognize danger signs and seek timely care. As a future nurse, "
    "you are a health educator, an advocate, and a clinical specialist all in one.",
)
sp()

# ═══════════════════════════════════════════════════════════════════════════
# XIII. REFERENCES
# ═══════════════════════════════════════════════════════════════════════════
h1("XIII. REFERENCES")
refs = [
    "Goldman L, Cooney KA (Eds.). Goldman-Cecil Medicine, 26th Edition. Elsevier, 2020. Chapter 383: Encephalitis; Chapter 345: Herpes Simplex Virus Infections.",
    "Loscalzo J, et al. Harrison's Principles of Internal Medicine, 22nd Edition. McGraw-Hill Medical, 2025. Chapter 352: Arboviral Encephalitides.",
    "Park K. Park's Textbook of Preventive and Social Medicine, 27th Edition. M/s Banarasidas Bhanot Publishers, 2023. Japanese Encephalitis — National Vector Borne Disease Control Programme.",
    "Kliegman RM, et al. Nelson Textbook of Pediatrics, 21st Edition. Elsevier, 2020. Chapter: Encephalitis in Children.",
    "Whaley & Wong's Nursing Care of Infants and Children, 11th Edition. Elsevier Mosby, 2022. Chapter: The Child with Neurological Dysfunction.",
    "Hinkle JL, Cheever KH. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th Edition. Wolters Kluwer, 2022.",
    "Carpenito LJ. Nursing Diagnosis: Application to Clinical Practice, 16th Edition. Wolters Kluwer, 2019.",
    "Sherris & Ryan's Medical Microbiology, 8th Edition. McGraw-Hill, 2022. Viral Infections of the CNS.",
    "World Health Organization (WHO). Japanese Encephalitis — Vaccine Preventable Diseases, 2019. Available at: www.who.int",
    "National Vector Borne Disease Control Programme (NVBDCP), Govt. of India. JE Prevention and Control Guidelines, 2021. Available at: nvbdcp.gov.in",
    "RGUHS B.Sc. Nursing Curriculum and Examination Regulations. Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka.",
]
for i, ref in enumerate(refs, 1):
    p = doc.add_paragraph()
    p.alignment = WD_ALIGN_PARAGRAPH.JUSTIFY
    p.paragraph_format.left_indent = Cm(1.5)
    p.paragraph_format.first_line_indent = Cm(-1.5)
    r = p.add_run(f"{i}. {ref}")
    r.font.name = "Times New Roman"; r.font.size = Pt(11)

sp()

# ═══════════════════════════════════════════════════════════════════════════
# SAVE
# ═══════════════════════════════════════════════════════════════════════════
output_path = "/tmp/workspace/encephalitis-case/Paediatric_Encephalitis_ChildHealthNursing_RGUHS.docx"
doc.save(output_path)
print(f"Saved: {output_path}")