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'