const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Lumbar Canal Stenosis - Case Presentation";
pres.author = "PAHS";

// Color palette: deep navy dominant, teal accent, white text
const C = {
  navy:    "0A1E3C",
  navyMid: "122850",
  teal:    "0C7B93",
  tealLt:  "1A9BB4",
  gold:    "E8A020",
  white:   "FFFFFF",
  light:   "EAF4F8",
  gray:    "6B7280",
  darkTxt: "1A2B4A",
  red:     "C0392B",
  green:   "1A7A4A",
};

// ── HELPER: add a slide header bar ────────────────────────────────────────────
function addHeader(slide, title, subtitle) {
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 1.05, fill: { color: C.navy } });
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 1.05, w: 10, h: 0.07, fill: { color: C.teal } });
  slide.addText(title, { x: 0.35, y: 0.12, w: 8.5, h: 0.55, fontSize: 22, bold: true, color: C.white, fontFace: "Calibri", margin: 0 });
  if (subtitle) {
    slide.addText(subtitle, { x: 0.35, y: 0.63, w: 9, h: 0.35, fontSize: 12, color: C.tealLt, fontFace: "Calibri", margin: 0, italic: true });
  }
}

// ── HELPER: footer ─────────────────────────────────────────────────────────────
function addFooter(slide, pageNum, total) {
  slide.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.35, w: 10, h: 0.275, fill: { color: C.navyMid } });
  slide.addText("PAHS  |  Department of Neurosurgery / Orthopaedics", { x: 0.3, y: 5.36, w: 7, h: 0.25, fontSize: 8.5, color: C.tealLt, fontFace: "Calibri", margin: 0 });
  slide.addText(`${pageNum} / ${total}`, { x: 8.8, y: 5.36, w: 1, h: 0.25, fontSize: 8.5, color: C.tealLt, fontFace: "Calibri", align: "right", margin: 0 });
}

// ══ SLIDE 1 — TITLE ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  // Full dark background
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.navy } });
  // Decorative accent left bar
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.25, h: 5.625, fill: { color: C.teal } });
  // Gold accent stripe
  s.addShape(pres.shapes.RECTANGLE, { x: 0.25, y: 1.8, w: 9.75, h: 0.06, fill: { color: C.gold } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.25, y: 3.7, w: 9.75, h: 0.06, fill: { color: C.gold } });

  s.addText("CASE PRESENTATION", { x: 1, y: 0.5, w: 8, h: 0.5, fontSize: 13, color: C.tealLt, fontFace: "Calibri", align: "center", charSpacing: 5 });
  s.addText("Lumbar Canal Stenosis", { x: 0.8, y: 1.1, w: 8.4, h: 1.35, fontSize: 36, bold: true, color: C.white, fontFace: "Calibri", align: "center" });
  s.addText("Neurogenic Claudication  •  Diagnosis  •  Management", { x: 0.8, y: 2.1, w: 8.4, h: 0.5, fontSize: 14, color: C.gold, fontFace: "Calibri", align: "center" });

  s.addText([
    { text: "Presented at:  ", options: { bold: false } },
    { text: "Pokhara Academy of Health Sciences (PAHS)", options: { bold: true } },
  ], { x: 1, y: 3.9, w: 8, h: 0.45, fontSize: 14, color: C.white, fontFace: "Calibri", align: "center" });

  s.addText("Department of Neurosurgery / Orthopaedic Surgery", { x: 1, y: 4.35, w: 8, h: 0.3, fontSize: 11, color: C.tealLt, fontFace: "Calibri", align: "center" });
  s.addText("July 2026", { x: 1, y: 4.7, w: 8, h: 0.3, fontSize: 10, color: C.gray, fontFace: "Calibri", align: "center" });
}

// ══ SLIDE 2 — PATIENT DETAILS ═════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.light } });
  addHeader(s, "Patient Profile", "Case Presentation — Lumbar Canal Stenosis");
  addFooter(s, 2, 14);

  // Info card
  const card = { fill: { color: C.white }, shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.1 } };
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.4, y: 1.25, w: 4.2, h: 3.85, ...card, rectRadius: 0.12 });
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 4.9, y: 1.25, w: 4.7, h: 3.85, ...card, rectRadius: 0.12 });

  s.addText("Demographics", { x: 0.6, y: 1.4, w: 3.8, h: 0.4, fontSize: 13, bold: true, color: C.navy, fontFace: "Calibri" });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.6, y: 1.8, w: 3.8, h: 0.04, fill: { color: C.teal } });

  const dem = [
    ["Name", "Mr. R.B. Shrestha (anonymised)"],
    ["Age / Sex", "62 years / Male"],
    ["Occupation", "Retired farmer"],
    ["Address", "Kaski, Gandaki Province"],
    ["BMI", "26.4 kg/m²"],
    ["Presented to", "OPD, PAHS, Pokhara"],
  ];
  dem.forEach(([k, v], i) => {
    s.addText([{ text: k + ":  ", options: { bold: true, color: C.navy } }, { text: v, options: { color: C.darkTxt } }],
      { x: 0.65, y: 1.95 + i * 0.48, w: 3.8, h: 0.42, fontSize: 11, fontFace: "Calibri" });
  });

  s.addText("Presenting Complaints", { x: 5.1, y: 1.4, w: 4.3, h: 0.4, fontSize: 13, bold: true, color: C.navy, fontFace: "Calibri" });
  s.addShape(pres.shapes.RECTANGLE, { x: 5.1, y: 1.8, w: 4.3, h: 0.04, fill: { color: C.teal } });

  const comp = [
    "Bilateral lower limb pain radiating to calves  ×  8 months",
    "Numbness and tingling in both legs  ×  6 months",
    "Progressive difficulty walking > 200 m  ×  4 months",
    "Low back pain — dull, aching  ×  2 years",
    "Relief on sitting / leaning forward",
    "No bowel or bladder dysfunction",
  ];
  s.addText(comp.map((t, i) => ({
    text: "•  " + t,
    options: { breakLine: i < comp.length - 1, color: C.darkTxt }
  })), { x: 5.1, y: 1.95, w: 4.3, h: 3.0, fontSize: 10.5, fontFace: "Calibri", valign: "top" });
}

// ══ SLIDE 3 — HISTORY ════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.light } });
  addHeader(s, "History", "Past Medical, Drug, Family & Social History");
  addFooter(s, 3, 14);

  const cols = [
    {
      label: "Past Medical History",
      items: ["Type 2 Diabetes Mellitus — 5 yrs", "Hypertension — 8 yrs", "No prior spinal surgery", "No TB / malignancy"],
    },
    {
      label: "Drug History",
      items: ["Metformin 500 mg BD", "Amlodipine 5 mg OD", "NSAIDs — occasional", "No anticoagulants"],
    },
    {
      label: "Family History",
      items: ["Father — low back pain", "No hereditary skeletal disorder", "No malignancy in family"],
    },
    {
      label: "Social History",
      items: ["Non-smoker, non-alcoholic", "Retired farmer", "Sedentary lifestyle for 3 yrs", "Lives in hilly terrain"],
    },
  ];

  cols.forEach((col, i) => {
    const x = 0.3 + i * 2.38;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y: 1.25, w: 2.2, h: 4.0, fill: { color: C.white }, shadow: { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.08 }, rectRadius: 0.1 });
    s.addShape(pres.shapes.RECTANGLE, { x, y: 1.25, w: 2.2, h: 0.45, fill: { color: C.teal } });
    s.addText(col.label, { x: x + 0.08, y: 1.28, w: 2.05, h: 0.4, fontSize: 10, bold: true, color: C.white, fontFace: "Calibri" });
    s.addText(col.items.map((t, j) => ({
      text: "• " + t,
      options: { breakLine: j < col.items.length - 1, color: C.darkTxt }
    })), { x: x + 0.1, y: 1.8, w: 2.0, h: 3.2, fontSize: 10, fontFace: "Calibri", valign: "top" });
  });
}

// ══ SLIDE 4 — EXAMINATION ════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.light } });
  addHeader(s, "Physical Examination", "General, Spine & Neurological Findings");
  addFooter(s, 4, 14);

  // General
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.3, y: 1.25, w: 9.4, h: 0.7, fill: { color: C.navy }, rectRadius: 0.08 });
  s.addText([
    { text: "General:  ", options: { bold: true, color: C.gold } },
    { text: "Conscious, oriented, mildly obese.  ", options: { color: C.white } },
    { text: "Vitals:  ", options: { bold: true, color: C.gold } },
    { text: "BP 142/88 mmHg, PR 80/min, SpO₂ 98%", options: { color: C.white } },
  ], { x: 0.5, y: 1.3, w: 9.0, h: 0.55, fontSize: 11, fontFace: "Calibri" });

  const sections = [
    {
      title: "Spine Examination",
      rows: [
        ["Gait", "Stooped, wide-based — 'shopping cart sign'"],
        ["Lumbar ROM", "Flexion — reduced; Extension — markedly restricted"],
        ["Tenderness", "Paravertebral tenderness L3-L5"],
        ["SLR", "Negative bilaterally"],
        ["Spurling's", "Negative"],
      ],
    },
    {
      title: "Neurological Examination",
      rows: [
        ["Power", "L4/L5/S1 myotomes — 4/5 bilaterally"],
        ["Sensation", "Reduced light touch — L4, L5 dermatomes bilaterally"],
        ["Reflexes", "Knee jerk — normal; Ankle jerk — reduced bilaterally"],
        ["Clonus / Babinski", "Absent — upper motor neuron signs absent"],
        ["Bladder/Bowel", "Normal — no cauda equina syndrome"],
      ],
    },
  ];

  sections.forEach((sec, i) => {
    const x = 0.3 + i * 4.85;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y: 2.1, w: 4.6, h: 3.1, fill: { color: C.white }, shadow: { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.1 }, rectRadius: 0.1 });
    s.addShape(pres.shapes.RECTANGLE, { x, y: 2.1, w: 4.6, h: 0.4, fill: { color: C.navyMid } });
    s.addText(sec.title, { x: x + 0.12, y: 2.13, w: 4.3, h: 0.35, fontSize: 11.5, bold: true, color: C.white, fontFace: "Calibri" });
    sec.rows.forEach(([k, v], j) => {
      const bg = j % 2 === 0 ? "F0F7FA" : C.white;
      s.addShape(pres.shapes.RECTANGLE, { x, y: 2.5 + j * 0.52, w: 4.6, h: 0.52, fill: { color: bg } });
      s.addText(k, { x: x + 0.1, y: 2.5 + j * 0.52, w: 1.35, h: 0.52, fontSize: 9.5, bold: true, color: C.navy, fontFace: "Calibri" });
      s.addText(v, { x: x + 1.45, y: 2.5 + j * 0.52, w: 3.05, h: 0.52, fontSize: 9.5, color: C.darkTxt, fontFace: "Calibri" });
    });
  });
}

// ══ SLIDE 5 — PATHOPHYSIOLOGY ════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.light } });
  addHeader(s, "Pathophysiology", "Mechanism of Lumbar Canal Stenosis");
  addFooter(s, 5, 14);

  // Central diagram boxes
  const steps = [
    { label: "Disc\nDegeneration\n& Narrowing", x: 4.0, y: 1.3, accent: C.teal },
    { label: "Osteophyte\nFormation", x: 1.2, y: 2.2, accent: C.navyMid },
    { label: "Facet Joint\nHypertrophy", x: 6.8, y: 2.2, accent: C.navyMid },
    { label: "Ligamentum\nFlavum\nThickening", x: 0.3, y: 3.5, accent: C.tealLt },
    { label: "Spondylo-\nlisthesis", x: 3.0, y: 3.8, accent: C.tealLt },
    { label: "Congenital\nSmall Canal", x: 5.8, y: 3.8, accent: C.tealLt },
    { label: "Reduced\nCross-sectional\nArea of Canal", x: 3.7, y: 2.5, accent: C.gold },
  ];

  // Draw the "result" box prominently
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 2.8, y: 4.55, w: 4.5, h: 0.7, fill: { color: C.red }, rectRadius: 0.08 });
  s.addText("Nerve Root Compression  →  Neurogenic Claudication", { x: 2.9, y: 4.58, w: 4.3, h: 0.6, fontSize: 11.5, bold: true, color: C.white, fontFace: "Calibri", align: "center" });

  steps.forEach((st) => {
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: st.x, y: st.y, w: 2.0, h: 0.75, fill: { color: st.accent }, rectRadius: 0.08 });
    s.addText(st.label, { x: st.x + 0.05, y: st.y + 0.02, w: 1.9, h: 0.72, fontSize: 9, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
  });

  // Central connector arrow text
  s.addText("↓ Canal Narrowing ↓", { x: 3.5, y: 3.25, w: 3.0, h: 0.4, fontSize: 11, bold: true, color: C.navy, fontFace: "Calibri", align: "center" });
}

// ══ SLIDE 6 — CLASSIFICATION ══════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.light } });
  addHeader(s, "Classification of Lumbar Canal Stenosis", "Anatomical & Etiological Types");
  addFooter(s, 6, 14);

  const types = [
    {
      title: "Central Stenosis",
      desc: "Thecal sac compression — posterior to posterior longitudinal ligament, anterior to ligamentum flavum. Absolute stenosis: cross-sectional area < 100 mm² or AP diameter < 10 mm.",
      color: C.navy,
    },
    {
      title: "Lateral Recess / Subarticular Stenosis",
      desc: "Entry zone stenosis — nerve root compression at the subarticular recess. Most common cause of radiculopathy in elderly. Pain in dermatomal distribution.",
      color: C.teal,
    },
    {
      title: "Foraminal Stenosis",
      desc: "Nerve root compression within the neural foramen. Osteophytes + disc bulge narrow the exit zone. Often causes unilateral radiculopathy.",
      color: C.tealLt,
    },
  ];

  const etiol = [
    { label: "Congenital", sub: "Idiopathic short pedicles, Achondroplasia, Morquio syndrome" },
    { label: "Degenerative (MC)", sub: "Disc degeneration, Osteophytes, Facet hypertrophy, Ligamentum flavum buckling" },
    { label: "Spondylolisthesis", sub: "Degenerative or isthmic — further exacerbates canal narrowing" },
    { label: "Iatrogenic", sub: "Post-laminectomy instability, post-fusion adjacent segment" },
    { label: "Metabolic", sub: "Paget disease, Acromegaly, Fluorosis, Ankylosing spondylitis" },
  ];

  types.forEach((t, i) => {
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.3 + i * 3.25, y: 1.25, w: 3.05, h: 2.0, fill: { color: t.color }, rectRadius: 0.1 });
    s.addText(t.title, { x: 0.4 + i * 3.25, y: 1.3, w: 2.85, h: 0.4, fontSize: 11, bold: true, color: C.white, fontFace: "Calibri" });
    s.addText(t.desc, { x: 0.4 + i * 3.25, y: 1.72, w: 2.85, h: 1.45, fontSize: 9, color: C.white, fontFace: "Calibri" });
  });

  s.addText("Etiological Classification", { x: 0.3, y: 3.35, w: 5, h: 0.35, fontSize: 12, bold: true, color: C.navy, fontFace: "Calibri" });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.3, y: 3.68, w: 9.4, h: 0.04, fill: { color: C.teal } });

  etiol.forEach((e, i) => {
    const x = 0.3 + (i % 3) * 3.2;
    const y = 3.8 + Math.floor(i / 3) * 0.62;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w: 3.0, h: 0.55, fill: { color: C.navyMid }, rectRadius: 0.07 });
    s.addText([{ text: e.label + ":  ", options: { bold: true, color: C.gold } }, { text: e.sub, options: { color: C.white } }],
      { x: x + 0.1, y: y + 0.04, w: 2.8, h: 0.47, fontSize: 8.5, fontFace: "Calibri", valign: "middle" });
  });
}

// ══ SLIDE 7 — CLINICAL FEATURES ══════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.light } });
  addHeader(s, "Clinical Features", "Symptoms & Signs of Lumbar Canal Stenosis");
  addFooter(s, 7, 14);

  // Left: symptoms
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 0.3, y: 1.25, w: 4.55, h: 3.9, fill: { color: C.white }, shadow: { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.1 }, rectRadius: 0.1 });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.3, y: 1.25, w: 4.55, h: 0.42, fill: { color: C.navy } });
  s.addText("Symptoms", { x: 0.45, y: 1.28, w: 4.3, h: 0.36, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri" });

  const symp = [
    "Neurogenic intermittent claudication (hallmark)",
    "Low back pain — dull, insidious onset",
    "Bilateral leg pain: buttock → thigh → calf",
    "Paresthesia / numbness in lower limbs",
    "Pain worsened by extension, walking, standing",
    "Relief with sitting, flexion ('shopping cart sign')",
    "Cycling possible without symptoms",
    "Rarely: leg weakness, cauda equina syndrome",
  ];
  s.addText(symp.map((t, i) => ({
    text: "•  " + t,
    options: { breakLine: i < symp.length - 1, color: i === 0 ? C.teal : C.darkTxt, bold: i === 0 }
  })), { x: 0.45, y: 1.75, w: 4.3, h: 3.3, fontSize: 10, fontFace: "Calibri", valign: "top" });

  // Right: signs
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x: 5.15, y: 1.25, w: 4.55, h: 3.9, fill: { color: C.white }, shadow: { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.1 }, rectRadius: 0.1 });
  s.addShape(pres.shapes.RECTANGLE, { x: 5.15, y: 1.25, w: 4.55, h: 0.42, fill: { color: C.navy } });
  s.addText("Signs", { x: 5.3, y: 1.28, w: 4.3, h: 0.36, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri" });

  const signs = [
    "Wide-based, stooped gait",
    "Reduced lumbar extension",
    "Paravertebral muscle spasm / tenderness",
    "Objective neurological deficits in < 50%",
    "Reduced ankle jerks (S1 compression)",
    "SLR — usually negative (vs disc prolapse)",
    "Normal peripheral pulses (vs vascular claudication)",
    "Abnormal Romberg test — if severe",
    "Post-exercise neurological signs helpful",
  ];
  s.addText(signs.map((t, i) => ({
    text: "•  " + t,
    options: { breakLine: i < signs.length - 1, color: C.darkTxt }
  })), { x: 5.3, y: 1.75, w: 4.3, h: 3.3, fontSize: 10, fontFace: "Calibri", valign: "top" });
}

// ══ SLIDE 8 — DIFFERENTIAL DIAGNOSIS ═════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.light } });
  addHeader(s, "Differential Diagnosis", "Key Conditions to Distinguish");
  addFooter(s, 8, 14);

  const rows = [
    ["Condition", "Claudication type", "Pulses", "Posture relief", "SLR", "Key differentiator"],
    ["Lumbar Canal Stenosis", "Neurogenic (proximal→distal)", "Normal", "Flexion/sitting", "Negative", "Shopping cart sign; MRI canal stenosis"],
    ["Vascular Claudication", "Vascular (distal→proximal)", "Reduced/absent", "Standing still", "Negative", "ABI < 0.9; Doppler study"],
    ["Lumbar Disc Prolapse", "Radiculopathy", "Normal", "Variable", "Positive", "Younger age; single dermatomal pain"],
    ["Diabetic Peripheral Neuropathy", "Burning/stocking-glove", "Normal", "No change", "Negative", "Symmetrical distal; NCS abnormal"],
    ["Hip OA", "Groin/anterior thigh", "Normal", "Rest", "Negative", "FABER test positive; hip X-ray changes"],
    ["Cauda Equina Syndrome", "Bilateral radiculopathy", "Normal", "No relief", "Variable", "Bowel/bladder dysfunction — EMERGENCY"],
  ];

  const colW = [2.3, 1.7, 0.9, 1.2, 0.7, 3.0];
  const colX = [0.15, 2.45, 4.15, 5.05, 6.25, 6.95];

  rows.forEach((row, ri) => {
    const y = 1.3 + ri * 0.62;
    const isHeader = ri === 0;
    const isLCS = ri === 1;
    const bg = isHeader ? C.navy : isLCS ? "E0F4FA" : ri % 2 === 0 ? "F5F9FC" : C.white;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.15, y, w: 9.7, h: 0.6, fill: { color: bg } });
    row.forEach((cell, ci) => {
      s.addText(cell, {
        x: colX[ci] + 0.05, y: y + 0.04, w: colW[ci] - 0.1, h: 0.52,
        fontSize: isHeader ? 9 : 8.5,
        bold: isHeader || (ri > 0 && ci === 0),
        color: isHeader ? C.white : ci === 0 && isLCS ? C.teal : C.darkTxt,
        fontFace: "Calibri",
        valign: "middle",
      });
    });
  });
}

// ══ SLIDE 9 — INVESTIGATIONS ═════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.light } });
  addHeader(s, "Investigations", "Imaging & Electrophysiological Studies");
  addFooter(s, 9, 14);

  const invest = [
    {
      title: "X-Ray Lumbosacral Spine (AP/Lateral)",
      pts: [
        "First-line, inexpensive",
        "Interspace narrowing, facet joint degenerative changes",
        "Spondylolisthesis on lateral view",
        "Medially placed facets, flattened lordosis",
        "Cannot directly visualize neural compression",
      ],
      color: C.navyMid,
    },
    {
      title: "MRI Lumbar Spine (Study of Choice)",
      pts: [
        "Best for soft tissue: ligamentum flavum hypertrophy, disc bulge",
        "Sagittal relationships — spondylolisthesis, canal dimensions",
        "Rules out tumour, infection, fracture",
        "T2 axial: demonstrates trefoil canal ('Mickey Mouse' sign)",
        "No radiation; superior for surgical planning",
      ],
      color: C.teal,
    },
    {
      title: "CT Myelogram / CT Scan",
      pts: [
        "Best for bone detail: osteophytes, foraminal stenosis",
        "Distinguishes disc from osteophyte in neural foramen",
        "Used when MRI is contraindicated (pacemaker, metal implants)",
        "CT myelogram — gold standard if MRI inconclusive",
      ],
      color: C.tealLt,
    },
  ];

  invest.forEach((inv, i) => {
    const x = 0.25 + i * 3.25;
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    s.addText(inv.title, { x: x + 0.1, y: 1.32, w: 2.9, h: 0.55, fontSize: 10, bold: true, color: C.white, fontFace: "Calibri" });
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  });

  // EMG/NCS note
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    { x: 0.4, y: 4.95, w: 9.1, h: 0.45, fontSize: 9.5, fontFace: "Calibri" });
}

// ══ SLIDE 10 — INVESTIGATIONS (PATIENT-SPECIFIC) ══════════════════════════════
{
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  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.light } });
  addHeader(s, "Investigations — This Patient", "Mr. R.B. Shrestha, 62M");
  addFooter(s, 10, 14);

  const labs = [
    ["CBC", "Hb 13.2 g/dL, TLC 8,200, Platelets 210,000"],
    ["FBS / HbA1c", "FBS 142 mg/dL, HbA1c 7.8%"],
    ["RFT / LFT", "Creatinine 1.0 mg/dL, Normal LFT"],
    ["ABI (bilateral)", "0.95 Right, 0.94 Left — Normal (vascular claudication excluded)"],
    ["X-Ray LS Spine", "Disc space narrowing L4-L5, L5-S1; degenerative osteophytes; Grade I spondylolisthesis L4 over L5"],
    ["MRI Lumbar Spine", "Severe canal stenosis L4-L5 with ligamentum flavum hypertrophy + disc bulge; moderate at L3-L4; bilateral foraminal stenosis L5-S1"],
    ["NCS / EMG", "Bilateral L4, L5 radiculopathy confirmed; peripheral neuropathy excluded"],
  ];

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  s.addText("MRI Diagnosis: Severe multi-level lumbar canal stenosis — L3-L4, L4-L5 (worst), L5-S1", { x: 0.4, y: 5.24, w: 9.1, h: 0.3, fontSize: 9.5, bold: true, color: C.navy, fontFace: "Calibri" });
}

// ══ SLIDE 11 — MANAGEMENT PLAN ════════════════════════════════════════════════
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  addFooter(s, 11, 14);

  // Non-op
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  s.addShape(pres.shapes.RECTANGLE, { x: 0.3, y: 1.25, w: 4.5, h: 0.48, fill: { color: C.teal } });
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  const nonOp = [
    "Rest, activity modification",
    "NSAIDs — short-term analgesia",
    "Williams flexion exercises",
    "Weight reduction",
    "Lumbar epidural steroid injections — short-term benefit; variable in controlled trials",
    "Transforaminal nerve root block — if specific root identified",
    "Physiotherapy: core strengthening, aquatic therapy",
    "Cane / walking aid for stooped posture",
    "Interspinous process device (e.g. X-STOP) — frail elderly, Grade I–II stenosis",
  ];
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    text: "•  " + t,
    options: { breakLine: i < nonOp.length - 1, color: C.white }
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  // Op
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  s.addText("Surgical Indications:", { x: 5.35, y: 1.82, w: 4.2, h: 0.3, fontSize: 10, bold: true, color: C.navy, fontFace: "Calibri" });
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    "Intractable leg pain despite 6 wks conservative therapy",
    "Progressive motor weakness",
    "Bowel / bladder dysfunction (urgent decompression)",
    "Unacceptably impaired quality of life",
  ];
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  s.addText("Surgical Techniques:", { x: 5.35, y: 3.32, w: 4.2, h: 0.3, fontSize: 10, bold: true, color: C.navy, fontFace: "Calibri" });
  const surgTech = [
    "Wide laminectomy + partial medial facetectomy (standard)",
    "Minimally invasive laminectomy (1–2 level disease)",
    "Fusion — if instability: spondylolisthesis, degenerative scoliosis, post-surgical instability",
    "SPORT trial: surgery superior to conservative at 4-yr follow-up for SF-36 and ODI",
  ];
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}

// ══ SLIDE 12 — MANAGEMENT — THIS PATIENT ══════════════════════════════════════
{
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  addHeader(s, "Management — This Patient", "Mr. R.B. Shrestha: Planned Approach at PAHS");
  addFooter(s, 12, 14);

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      phase: "Phase 1 — Optimisation",
      color: C.teal,
      items: [
        "Diabetic control: HbA1c < 7.5% before surgery",
        "Blood pressure control: target < 130/80 mmHg",
        "Pre-operative physiotherapy: flexion exercises",
        "Analgesics: Pregabalin 75 mg BD + NSAID short-course",
        "Patient counselled regarding surgical risks and benefit",
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      phase: "Phase 2 — Surgical Plan",
      color: C.navy,
      items: [
        "Procedure: L4-L5 decompressive laminectomy ± L3-L4",
        "Partial medial facetectomy (bilateral)",
        "Foraminotomy at L5-S1 bilaterally",
        "Fusion at L4-L5 given Grade I spondylolisthesis",
        "Anaesthesia: Spinal / General — anaesthesia team review",
        "Intra-op neuromonitoring: SSEP/MEP if available",
      ],
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      phase: "Phase 3 — Post-Op Care",
      color: C.tealLt,
      items: [
        "Early mobilisation: Day 1 post-op with walker",
        "DVT prophylaxis: LMWH + compression stockings",
        "Wound care, antibiotics 24 hrs perioperative",
        "Physiotherapy: strengthening exercises from week 2",
        "Neurological assessment daily in ward",
        "OPD follow-up: 2 weeks, 6 weeks, 3 months, 1 year",
      ],
    },
  ];

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}

// ══ SLIDE 13 — PROGNOSIS / DISCUSSION ════════════════════════════════════════
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  addHeader(s, "Prognosis & Discussion", "Outcomes and Key Learning Points");
  addFooter(s, 13, 14);

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  s.addText("Prognosis", { x: 0.45, y: 1.28, w: 4.3, h: 0.38, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri" });

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    "Many patients have stable or slowly progressive symptoms for years",
    "Spontaneous regression may occur in some",
    "SPORT trial (4-yr): surgical patients significantly better QoL, less pain, better function vs non-operative",
    "Residual foraminal stenosis is commonest cause of persistent post-op pain",
    "Fusion adds no incremental benefit for pure decompression (evidence 2022-2024)",
    "Diabetic patients at higher risk of wound complications and slower neurological recovery",
    "Long-term: 20–30% re-operation rate at 10 years for adjacent segment disease",
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  s.addShape(pres.shapes.RECTANGLE, { x: 5.2, y: 1.25, w: 4.5, h: 0.44, fill: { color: C.gold } });
  s.addText("Key Learning Points", { x: 5.35, y: 1.28, w: 4.2, h: 0.38, fontSize: 12, bold: true, color: C.navy, fontFace: "Calibri" });

  const kl = [
    "Always exclude vascular claudication — ABI is cheap and effective",
    "'Shopping cart sign' is highly specific for neurogenic claudication",
    "MRI is investigation of choice — do not rely on X-ray alone",
    "EMG/NCS confirms radiculopathy and guides surgical level selection",
    "Surgery > conservative at 4 years — but conservative first in stable patients",
    "Optimise comorbidities (DM, HTN) before elective spinal surgery",
    "Cauda equina syndrome = surgical EMERGENCY — do not delay > 24–48 hrs",
    "Interspinous devices offer a minimally invasive option for selected frail patients",
  ];
  s.addText(kl.map((t, i) => ({
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}

// ══ SLIDE 14 — THANK YOU ══════════════════════════════════════════════════════
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  s.addText("Questions & Discussion", { x: 1, y: 1.75, w: 8, h: 0.55, fontSize: 18, color: C.tealLt, fontFace: "Calibri", align: "center" });

  s.addText("Pokhara Academy of Health Sciences (PAHS)", { x: 1, y: 3.55, w: 8, h: 0.45, fontSize: 15, bold: true, color: C.white, fontFace: "Calibri", align: "center" });
  s.addText("Department of Neurosurgery / Orthopaedic Surgery", { x: 1, y: 4.0, w: 8, h: 0.35, fontSize: 12, color: C.tealLt, fontFace: "Calibri", align: "center" });
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  s.addText("References: Bradley & Daroff's Neurology in Clinical Practice | Miller's Review of Orthopaedics 9E | Harrison's Principles 22E | Firestein & Kelley's Textbook of Rheumatology", {
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// ── WRITE FILE ─────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/lumbar-stenosis-pahs/Lumbar_Canal_Stenosis_PAHS.pptx" })
  .then(() => console.log("Done: Lumbar_Canal_Stenosis_PAHS.pptx created"))
  .catch(err => { console.error(err); process.exit(1); });

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Lumbar Canal Stenosis - Case Presentation - PAHS";

// ─── PALETTE ────────────────────────────────────────────────────────────────
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const TOTAL = 22;

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ══════════════════════════════════════════════════════════════════════════════
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// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 — PATIENT PROFILE
// ══════════════════════════════════════════════════════════════════════════════
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    ["Bed No.","33 / 34"],["Date of Admission","2083/3/15 (BS)"],
    ["Diagnosis (Provisional)","Lumbar Canal Stenosis L4-L5, L5-S1"],
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    "Pain: Ache over low back, dull aching, radiating to LEFT leg",
    "Pain aggravated on movement",
    "Pain present throughout the day — severe",
    "Past h/o admission for low back pain at another centre",
    "MRI done previously (films not available)",
  ];
  bullets(s,cc,5.22,1.68,4.35,2.5,9.5);
  s.addShape(pres.shapes.RECTANGLE,{x:5.1,y:4.2,w:4.6,h:0.04,fill:{color:C.gold}});
  s.addText("X-Ray: L-S Spine Flexion/Extension views (2026-07-09, PoAHS WRH)",{x:5.22,y:4.27,w:4.35,h:0.32,fontSize:8.5,italic:true,color:C.navy,fontFace:"Calibri"});
  s.addText("MRI Lumbar Spine: Axial T2 series (Gurung 44YRS/F — 30-Jun-2026, PoAHS WRH)",{x:5.22,y:4.58,w:4.35,h:0.32,fontSize:8.5,italic:true,color:C.navy,fontFace:"Calibri"});
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 — HISTORY TAKING FINDINGS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Findings of History Taking","Detailed Clinical History"); ftr(s,3,TOTAL);
  const boxes=[
    {label:"Pain History",color:C.navy,x:0.3,y:1.18,w:3.0,items:[
      "Site: Low back → left leg (radiculopathy)",
      "Character: Dull aching, constant",
      "Radiation: Down left leg (L5/S1 dermatomal)",
      "Aggravating: Movement, prolonged standing",
      "Relieving: Rest, sitting, forward flexion",
      "Duration: 5 years, worsening",
      "Severity: Severe — affects daily activities",
    ]},
    {label:"Past History",color:C.teal,x:3.6,y:1.18,w:3.0,items:[
      "Previous admission at another centre for back pain",
      "MRI done previously (films not available)",
      "No prior spinal surgery",
      "No known comorbidities documented",
      "No history of trauma/injury",
    ]},
    {label:"Personal & Social History",color:C.purple,x:6.9,y:1.18,w:2.8,items:[
      "Age: 44 years, Female",
      "Married (marital status: documented)",
      "Occupation: Not documented",
      "Resides: Pokhara area",
      "No addiction history documented",
    ]},
  ];
  boxes.forEach(b=>{
    card(s,b.x,b.y,b.w,4.05);
    cardHdr(s,b.x,b.y,b.w,b.color,b.label);
    bullets(s,b.items,b.x+0.1,b.y+0.5,b.w-0.2,3.45,9,C.dark);
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 — PHYSICAL EXAMINATION FINDINGS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Findings of Physical Examination","O/E — Documented in PAHS Admission Record"); ftr(s,4,TOTAL);

  // General
  s.addShape(pres.shapes.ROUNDED_RECTANGLE,{x:0.3,y:1.18,w:9.4,h:0.65,fill:{color:C.navy},rectRadius:0.08});
  s.addText([
    {text:"O/E of Back:  ",options:{bold:true,color:C.gold}},
    {text:"Skin intact   ",options:{color:C.white}},
    {text:"Swelling ⊖   ",options:{color:C.white}},
    {text:"Tenderness ⊖   ",options:{color:C.white}},
    {text:"   ROM:  ",options:{bold:true,color:C.gold}},
    {text:"Extension restricted (pain↑)",options:{color:C.white}},
  ],{x:0.5,y:1.22,w:9.0,h:0.56,fontSize:11,fontFace:"Calibri"});

  // Neurological table
  s.addText("Neurological Examination:",{x:0.3,y:1.95,w:5,h:0.3,fontSize:11,bold:true,color:C.navy,fontFace:"Calibri"});
  const neuroRows=[
    ["Level","Motor (M)","Sensation (S)","Reflex","Side"],
    ["L2","5/5","5/5","—","Bilateral"],
    ["L3","5/5","5/5","—","Bilateral"],
    ["L4","5/5 (Rt) / 5/5 (Lt)","5/5","Knee ++ (2/2)","Bilateral"],
    ["L5","5/5 (Rt) / 4/5 (Lt)","Reduced Lt","—","Left deficit"],
    ["S1","5/5 (Rt) / 4/5 (Lt)","Reduced Lt","Ankle + (1/2 Lt)","Left deficit"],
  ];
  const colX2=[0.3,1.85,3.3,4.7,5.9];
  const colW2=[1.55,1.45,1.4,1.2,1.3];
  neuroRows.forEach((row,ri)=>{
    const y=2.28+ri*0.5;
    const isH=ri===0;
    const isLeft=ri>=4;
    s.addShape(pres.shapes.RECTANGLE,{x:0.3,y,w:7.3,h:0.48,fill:{color:isH?C.navy:isLeft?"FFF3E0":ri%2===0?"EBF5FB":C.white}});
    row.forEach((cell,ci)=>{
      s.addText(cell,{x:colX2[ci]+0.05,y:y+0.04,w:colW2[ci]-0.1,h:0.4,
        fontSize:isH?9:9,bold:isH||ci===0,color:isH?C.white:isLeft&&ci>1?C.orange:C.dark,fontFace:"Calibri",valign:"middle"});
    });
  });

  // Right panel
  card(s,7.75,1.95,2.0,3.2);
  cardHdr(s,7.75,1.95,2.0,C.teal,"Other Findings");
  const other=["SLR: Not documented","Gait: Not documented","Vital signs: Stable","Bladder: Normal","Bowel: Normal","Sensation: Reduced L5-S1 (Lt)"];
  bullets(s,other,7.85,2.43,1.8,2.6,8.5,C.dark);

  s.addShape(pres.shapes.ROUNDED_RECTANGLE,{x:0.3,y:5.08,w:7.3,h:0.24,fill:{color:"FFF3E0"},rectRadius:0.05});
  s.addText("Left-sided weakness at L5/S1 myotomes and reduced ankle jerk confirmed on admission",
    {x:0.4,y:5.09,w:7.1,h:0.22,fontSize:8.5,bold:true,color:C.orange,fontFace:"Calibri"});
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 — ANATOMY & PHYSIOLOGY
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Anatomy & Physiology of the Lumbar Spine","Structural Basis for Understanding Canal Stenosis"); ftr(s,5,TOTAL);

  card(s,0.3,1.18,4.6,4.05);
  cardHdr(s,0.3,1.18,4.6,C.navy,"Lumbar Vertebral Structure");
  const anat=[
    "5 lumbar vertebrae (L1–L5) — largest & strongest",
    "Each vertebra: body + neural arch enclosing spinal canal",
    "Intervertebral disc: annulus fibrosus (outer) + nucleus pulposus (inner shock absorber)",
    "Facet joints (apophyseal): posterior articulation — guide movement",
    "Ligamentum flavum: connects laminae, borders canal posteriorly",
    "Anterior & posterior longitudinal ligaments: stabilise vertebral column",
    "Cauda equina: bundle of lumbar & sacral nerve roots — occupies lower spinal canal",
    "Lateral recess: furrow along inner pedicle — common site of root entrapment",
    "Neural foramina: exit zones for spinal nerve roots",
  ];
  bullets(s,anat,0.42,1.68,4.38,3.46,9,C.dark);

  card(s,5.2,1.18,4.5,4.05);
  cardHdr(s,5.2,1.18,4.5,C.teal,"Physiology of Spinal Canal Function");
  const phys=[
    "Normal AP diameter of lumbar canal: 15–27 mm",
    "Normal cross-sectional area: 150–250 mm²",
    "Absolute stenosis: area < 100 mm² or AP < 10 mm",
    "CSF cushions nerve roots within the thecal sac",
    "Nerve roots require adequate blood supply — vulnerable to ischemia",
    "Extension narrows canal (ligamentum flavum buckles inward)",
    "Flexion widens canal — explains posture-related symptom relief",
    "Aging: disc dehydration → loss of height → facet subluxation → canal narrowing",
    "Venous congestion + arterial insufficiency of nerve roots → neurogenic claudication",
  ];
  bullets(s,phys,5.32,1.68,4.28,3.46,9,C.dark);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 — DISEASE INTRODUCTION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Lumbar Canal Stenosis — Introduction","Definition, Classification & Overview"); ftr(s,6,TOTAL);

  s.addShape(pres.shapes.ROUNDED_RECTANGLE,{x:0.3,y:1.18,w:9.4,h:1.15,fill:{color:C.navy},rectRadius:0.1});
  s.addText([
    {text:"Definition:  ",options:{bold:true,color:C.gold,fontSize:12}},
    {text:"Lumbar canal stenosis (LCS) is narrowing of the lumbar spinal canal, lateral recesses, or neural foramina producing nerve root compression, root ischemia, and a variable syndrome of back and leg pain. It results from subnormal cross-sectional area of the spinal canal due to varied anatomical changes.",options:{color:C.white,fontSize:10.5}},
  ],{x:0.5,y:1.22,w:9.0,h:1.0,fontFace:"Calibri"});

  const types=[
    {t:"Central Stenosis",d:"Thecal sac compression. Posterior to PLL, anterior to ligamentum flavum. Area < 100 mm² or AP < 10 mm. More common in men at L3-L5.",c:C.navy},
    {t:"Lateral Recess / Subarticular Stenosis",d:"Entry zone stenosis — nerve root compressed at subarticular recess. Commonest cause of radiculopathy in elderly.",c:C.teal},
    {t:"Foraminal Stenosis",d:"Nerve root compressed within exit zone (neural foramen). Osteophytes + disc bulge. Causes unilateral dermatomal radiculopathy.",c:C.purple},
  ];
  types.forEach((t,i)=>{
    card(s,0.3+i*3.23,2.5,3.05,2.7);
    s.addShape(pres.shapes.RECTANGLE,{x:0.3+i*3.23,y:2.5,w:3.05,h:0.42,fill:{color:t.c}});
    s.addText(t.t,{x:0.4+i*3.23,y:2.53,w:2.85,h:0.36,fontSize:9.5,bold:true,color:C.white,fontFace:"Calibri"});
    s.addText(t.d,{x:0.4+i*3.23,y:3.0,w:2.85,h:2.1,fontSize:9,color:C.dark,fontFace:"Calibri"});
  });

  s.addText("Source: Bradley & Daroff's Neurology in Clinical Practice | Miller's Review of Orthopaedics 9E",
    {x:0.3,y:5.18,w:9.4,h:0.2,fontSize:7.5,italic:true,color:C.gray,fontFace:"Calibri"});
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 — EPIDEMIOLOGY
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Epidemiology","Prevalence, Demographics & Burden of Disease"); ftr(s,7,TOTAL);

  const stats=[
    {val:"12–21%",label:"Prevalence in older adults",color:C.navy},
    {val:"60s–70s",label:"Peak age of onset",color:C.teal},
    {val:"♂ > ♀",label:"Men more affected (central stenosis)",color:C.purple},
    {val:"~44 yrs",label:"Our patient — early onset due to degenerative changes",color:C.orange},
  ];
  stats.forEach((st,i)=>{
    s.addShape(pres.shapes.ROUNDED_RECTANGLE,{x:0.3+i*2.43,y:1.25,w:2.3,h:1.7,fill:{color:st.color},rectRadius:0.1});
    s.addText(st.val,{x:0.3+i*2.43+0.1,y:1.35,w:2.1,h:0.75,fontSize:26,bold:true,color:C.white,fontFace:"Calibri",align:"center"});
    s.addText(st.label,{x:0.3+i*2.43+0.1,y:2.1,w:2.1,h:0.75,fontSize:9,color:C.white,fontFace:"Calibri",align:"center"});
  });

  card(s,0.3,3.1,4.6,2.1);
  cardHdr(s,0.3,3.1,4.6,C.navy,"Global Epidemiology");
  bullets(s,[
    "Estimated prevalence 12–21% in adults > 60 yrs (Symptom to Diagnosis, 4E)",
    "Most common cause of spinal surgery in adults > 65 years",
    "Incidence rising with global ageing population",
    "Rarely symptomatic before age 40 (unless congenital)",
    "Congenital stenosis: short pedicles — symptomatic earlier (as in this 44-yr-old)",
    "Degenerative LCS: insidious onset over years of disc degeneration",
  ],0.42,3.58,4.38,1.55,8.8,C.dark);

  card(s,5.2,3.1,4.5,2.1);
  cardHdr(s,5.2,3.1,4.5,C.teal,"Nepal / Local Context");
  bullets(s,[
    "PAHS WRH Pokhara: orthopaedic unit manages significant LCS burden",
    "Hilly terrain + manual labour → higher incidence of degenerative spine disease",
    "Female patients: osteoporosis-related disc collapse adds to stenosis risk",
    "Early age of presentation (this patient: 44F) not uncommon in Nepal",
    "Limited MRI access at primary level leads to delayed diagnosis",
    "TLIF (fusion surgery) now available at PAHS WRH",
  ],5.32,3.58,4.28,1.55,8.8,C.dark);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 — CAUSES & RISK FACTORS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Causes & Risk Factors","Etiological Classification of Lumbar Canal Stenosis"); ftr(s,8,TOTAL);

  const causes=[
    {title:"Congenital / Developmental",color:C.purple,x:0.3,y:1.18,w:2.95,items:[
      "Idiopathic — congenitally short pedicles","Achondroplasia","Morquio syndrome","Down syndrome",
    ]},
    {title:"Degenerative (Most Common)",color:C.navy,x:3.55,y:1.18,w:2.95,items:[
      "Disc degeneration & bulging (as in this patient)","Osteophyte formation","Facet joint osteoarthritis + hypertrophy","Ligamentum flavum buckling/hypertrophy","Degenerative spondylolisthesis",
    ]},
    {title:"Iatrogenic / Post-surgical",color:C.teal,x:6.8,y:1.18,w:2.9,items:[
      "Post-laminectomy scarring","Adjacent segment disease after fusion","Post-discectomy instability",
    ]},
  ];
  causes.forEach(b=>{
    card(s,b.x,b.y,b.w,2.35);
    cardHdr(s,b.x,b.y,b.w,b.color,b.title);
    bullets(s,b.items,b.x+0.1,b.y+0.5,b.w-0.2,1.75,8.5,C.dark);
  });

  card(s,0.3,3.72,9.4,1.52);
  s.addShape(pres.shapes.RECTANGLE,{x:0.3,y:3.72,w:9.4,h:0.42,fill:{color:C.orange}});
  s.addText("Risk Factors",{x:0.42,y:3.75,w:9.1,h:0.35,fontSize:11,bold:true,color:C.white,fontFace:"Calibri"});
  const rf=[
    "Advanced age (>60 yrs)","Female sex (osteoporosis)","Obesity (BMI >25)","Heavy physical labour",
    "Genetic predisposition","Sedentary lifestyle","Previous spinal surgery","Scoliosis/spondylolisthesis",
  ];
  const perRow=4;
  rf.forEach((r,i)=>{
    const col=i%perRow; const row=Math.floor(i/perRow);
    const x=0.42+col*2.35; const y=4.22+row*0.42;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE,{x,y,w:2.2,h:0.36,fill:{color:"FFF3E0"},rectRadius:0.06});
    s.addText("⚠ "+r,{x:x+0.06,y:y+0.04,w:2.1,h:0.28,fontSize:8.5,color:C.orange,fontFace:"Calibri",bold:false});
  });
  // mark patient's risk factors
  s.addText("★ This patient: Female 44yrs, degenerative LCS — multiple risk factors present",
    {x:0.3,y:5.2,w:9.4,h:0.2,fontSize:8,italic:true,color:C.navy,fontFace:"Calibri",bold:true});
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 — PATHOPHYSIOLOGY
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Pathophysiology","Mechanism of Symptom Production in Lumbar Canal Stenosis"); ftr(s,9,TOTAL);

  const steps=[
    {label:"Disc Degeneration\n& Narrowing",x:3.9,y:1.25,c:C.navy},
    {label:"Osteophyte\nFormation",x:0.8,y:1.95,c:C.teal},
    {label:"Facet Joint\nHypertrophy",x:7.0,y:1.95,c:C.teal},
    {label:"Lig. Flavum\nBuckling/Hypertrophy",x:0.3,y:3.05,c:C.purple},
    {label:"Spondylolisthesis",x:3.1,y:3.4,c:C.purple},
    {label:"Congenital\nSmall Canal",x:5.9,y:3.4,c:C.purple},
  ];
  steps.forEach(st=>{
    s.addShape(pres.shapes.ROUNDED_RECTANGLE,{x:st.x,y:st.y,w:2.1,h:0.72,fill:{color:st.c},rectRadius:0.08});
    s.addText(st.label,{x:st.x+0.07,y:st.y+0.04,w:1.96,h:0.64,fontSize:8.5,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
  });

  s.addShape(pres.shapes.ROUNDED_RECTANGLE,{x:3.5,y:2.85,w:3.0,h:0.55,fill:{color:C.gold},rectRadius:0.08});
  s.addText("↓ Cross-Sectional Area of Canal",{x:3.6,y:2.88,w:2.8,h:0.48,fontSize:10,bold:true,color:C.navy,fontFace:"Calibri",align:"center"});

  s.addShape(pres.shapes.ROUNDED_RECTANGLE,{x:3.2,y:4.0,w:3.6,h:0.6,fill:{color:C.tealLt},rectRadius:0.08});
  s.addText("Nerve Root Compression / Ischemia",{x:3.3,y:4.03,w:3.4,h:0.54,fontSize:10.5,bold:true,color:C.white,fontFace:"Calibri",align:"center"});

  s.addShape(pres.shapes.ROUNDED_RECTANGLE,{x:2.5,y:4.74,w:5.0,h:0.56,fill:{color:C.red},rectRadius:0.08});
  s.addText("Neurogenic Claudication + Radiculopathy + Low Back Pain",{x:2.6,y:4.77,w:4.8,h:0.5,fontSize:10,bold:true,color:C.white,fontFace:"Calibri",align:"center"});

  s.addShape(pres.shapes.RECTANGLE,{x:7.3,y:1.18,w:2.5,h:3.95,fill:{color:C.navyMid}});
  s.addText("Why flexion helps:",{x:7.38,y:1.24,w:2.35,h:0.3,fontSize:9.5,bold:true,color:C.gold,fontFace:"Calibri"});
  bullets(s,[
    "Extension: lig. flavum buckles in → canal narrows further → pain ↑",
    "Flexion: lig. flavum stretches out → canal opens → pain ↓",
    "Explains 'shopping cart sign'",
    "Cycling: flexed posture → no symptoms",
  ],7.38,1.56,2.35,2.5,8.5,C.white);
  s.addText("Venous congestion + arterial insufficiency of nerve roots → ischemia during walking → claudication",
    {x:7.38,y:4.05,w:2.35,h:0.9,fontSize:8,color:C.tealLt,fontFace:"Calibri",italic:true});
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 — CLINICAL FEATURES
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Clinical Features","Symptoms & Signs — General & This Patient"); ftr(s,10,TOTAL);

  card(s,0.3,1.18,4.55,4.05); cardHdr(s,0.3,1.18,4.55,C.navy,"General Clinical Features");
  const symp=[
    "Neurogenic intermittent claudication (HALLMARK)",
    "Low back pain — dull, insidious, constant",
    "Bilateral or unilateral leg pain: buttock → thigh → calf",
    "Paresthesia / numbness in lower limbs",
    "Pain worsened by extension, walking, prolonged standing",
    "Relief with sitting, forward flexion ('shopping cart sign')",
    "Can bicycle without symptoms (unlike vascular claudication)",
    "Wide-based, stooped gait",
    "Reduced ankle jerks (S1 compression)",
    "SLR usually negative",
    "Rare: cauda equina syndrome (emergency)",
  ];
  s.addText(symp.map((t,i)=>({
    text:"•  "+t,
    options:{breakLine:i<symp.length-1,color:i===0?C.teal:C.dark,bold:i===0,fontSize:i===0?9.5:9}
  })),{x:0.42,y:1.68,w:4.3,h:3.46,fontFace:"Calibri",valign:"top"});

  card(s,5.15,1.18,4.55,4.05); cardHdr(s,5.15,1.18,4.55,C.teal,"This Patient — Kumari Gurung 44F");
  const patSymp=[
    "Low back pain × 5 years (on/off)",
    "Dull aching pain radiating to LEFT leg",
    "Aggravated on movement",
    "Present throughout the day — severe",
    "Motor weakness: L5 (4/5 Lt), S1 (4/5 Lt)",
    "Reduced ankle jerk — left side (1/2)",
    "L5/S1 dermatomal sensory loss — left",
    "L5-S1 foraminal stenosis confirmed on MRI",
    "Radiculopathy confirmed on admission",
    "No bowel/bladder dysfunction documented",
  ];
  s.addText(patSymp.map((t,i)=>({
    text:"★  "+t,
    options:{breakLine:i<patSymp.length-1,color:i>=4&&i<=6?C.orange:C.dark,bold:i>=4&&i<=6}
  })),{x:5.27,y:1.68,w:4.3,h:3.46,fontSize:9.5,fontFace:"Calibri",valign:"top"});
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 11 — IMAGING FINDINGS (X-RAY + MRI)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Imaging Findings — Patient: Kumari Gurung 44F","X-Ray L-S Spine + MRI Lumbar Spine, PAHS WRH Pokhara"); ftr(s,11,TOTAL);

  card(s,0.3,1.18,4.55,4.05); cardHdr(s,0.3,1.18,4.55,C.navy,"X-Ray L-S Spine (2026-07-09)");
  const xrFind=[
    "Views: AP and Lateral — Flexion (F) and Extension (E) dynamic views",
    "Preservation of lumbar lordosis — mild straightening present",
    "Intervertebral disc space narrowing: L4-L5 and L5-S1",
    "Mild anterior osteophyte formation at vertebral endplates",
    "Mild lumbar spondylosis (degenerative wear and tear)",
    "No gross spondylolisthesis on plain film",
    "Bowel gas obscures some bony detail",
    "Vertebral body heights preserved — no acute fracture",
    "Dynamic views ordered to assess segmental instability",
    "Patient: KUMARI GURUNG, 44Y/F — PoAHS WRH Pokhara",
  ];
  bullets(s,xrFind,0.42,1.68,4.3,3.46,9,C.dark);

  card(s,5.15,1.18,4.55,4.05); cardHdr(s,5.15,1.18,4.55,C.teal,"MRI Lumbar Spine — T2 Axial (30-Jun-2026)");
  const mriFind=[
    "Scan: Axial T2-weighted series, L3-L4 to L5-S1 levels",
    "L4-L5: Broad-based posterior disc bulge/herniation",
    "Disc material extends posteriorly → indents thecal sac",
    "Mild-to-moderate central canal stenosis at L4-L5",
    "Ligamentum flavum hypertrophy — contributes to posterior compression",
    "Bilateral lateral recess narrowing — traversing nerve roots crowded",
    "Potential compression/impingement of traversing roots at L4-L5",
    "L5-S1: Foraminal stenosis with nerve root entrapment",
    "Upper levels (L3-L4): Canal relatively patent — cauda equina visible",
    "Findings consistent with: Lumbar Canal Stenosis L4-L5, L5-S1",
  ];
  bullets(s,mriFind,5.27,1.68,4.3,3.46,9,C.dark);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 12 — DIAGNOSTIC MEASURES
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Diagnostic Measures","Investigations for Lumbar Canal Stenosis"); ftr(s,12,TOTAL);

  const diag=[
    {title:"X-Ray L-S Spine (AP/Lateral/Dynamic)",color:C.navy,items:[
      "First-line, low cost, widely available",
      "Disc space narrowing, osteophytes, spondylolisthesis",
      "Flexion/extension views: segmental instability",
      "Cannot show soft tissue or neural compression directly",
    ]},
    {title:"MRI Lumbar Spine (Study of Choice)",color:C.teal,items:[
      "Best for soft tissue: lig. flavum, disc, neural elements",
      "T2 axial: cross-sectional area of canal",
      "Sagittal: spondylolisthesis, multilevel disease",
      "T2 'Mickey Mouse' / trefoil canal sign",
      "Distinguishes disc from tumour/infection",
    ]},
    {title:"CT Scan / CT Myelogram",color:C.purple,items:[
      "Best bone detail: osteophytes, foraminal stenosis",
      "CT myelogram: gold standard if MRI contraindicated",
      "Axial CT: trefoil canal morphology",
      "Distinguishes disc from calcified osteophyte",
    ]},
    {title:"EMG / NCS",color:C.orange,items:[
      "Confirms radiculopathy — level and severity",
      "Differentiates radiculopathy from peripheral neuropathy",
      "Guides surgical level selection",
      "Variable sensitivity — examiner-dependent",
    ]},
    {title:"Laboratory Investigations",color:C.green,items:[
      "CBC, CRP, ESR — rule out infection/malignancy",
      "Blood glucose / HbA1c — rule out neuropathy",
      "Pre-operative workup: CBC, RFT, LFT, coagulation",
      "Blood group and cross-match before surgery",
    ]},
    {title:"This Patient's Workup",color:C.red,items:[
      "X-Ray: L-S Spine AP/Lateral/Flexion — Done ✓",
      "MRI: Axial T2 lumbar spine — Done ✓",
      "Pre-op investigations completed",
      "EMG/NCS: Neurological findings on clinical exam",
    ]},
  ];
  diag.forEach((d,i)=>{
    const col=i%3; const row=Math.floor(i/3);
    const x=0.3+col*3.23; const y=1.25+row*2.05;
    card(s,x,y,3.05,1.95);
    s.addShape(pres.shapes.RECTANGLE,{x,y,w:3.05,h:0.4,fill:{color:d.color}});
    s.addText(d.title,{x:x+0.08,y:y+0.04,w:2.9,h:0.34,fontSize:8.5,bold:true,color:C.white,fontFace:"Calibri"});
    bullets(s,d.items,x+0.1,y+0.47,2.88,1.4,8.3,C.dark);
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 13 — MEDICAL MANAGEMENT
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Medical (Non-Operative) Management","Conservative Treatment of Lumbar Canal Stenosis"); ftr(s,13,TOTAL);

  card(s,0.3,1.18,4.55,4.05); cardHdr(s,0.3,1.18,4.55,C.navy,"Pharmacological Management");
  const pharma=[
    "NSAIDs (Ketorolac, Ibuprofen) — analgesic + anti-inflammatory",
    "Paracetamol (PCM) — safe baseline analgesia",
    "Corticosteroids (Dexamethasone, Betamethasone) — reduce nerve root oedema",
    "Neuropathic agents: Pregabalin (Pregex-M Forte) — nerve pain",
    "Opioid analgesics: Tramadol — moderate-severe pain, short-term",
    "Proton pump inhibitors: Pantoprazole — gastroprotection with NSAIDs",
    "Laxatives: Duphalac (Lactulose) — prevent constipation with opioids",
    "Epidural steroid injections — short-term benefit (variable in trials)",
    "Transforaminal nerve root block — if specific root identified",
  ];
  bullets(s,pharma,0.42,1.68,4.3,3.46,9,C.dark);

  card(s,5.15,1.18,4.55,4.05); cardHdr(s,5.15,1.18,4.55,C.teal,"Non-Pharmacological Management");
  const nonph=[
    "REST & Activity modification — avoid aggravating positions",
    "Physiotherapy: Williams flexion exercises — core strengthening",
    "Aquatic/hydrotherapy — reduces axial loading on spine",
    "Weight reduction — reduces mechanical stress",
    "TENS (Transcutaneous Electrical Nerve Stimulation)",
    "Hot/cold packs — muscle relaxation",
    "Lumbar support / brace — limited evidence, short-term only",
    "Cane / walking aid — stooped posture assistance",
    "Patient education: posture, body mechanics, lifestyle",
    "Interspinous process device (X-STOP): frail elderly — local anesthetic option",
  ];
  bullets(s,nonph,5.27,1.68,4.3,3.46,9,C.dark);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 14 — DRUG CHART (PATIENT SPECIFIC)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Drug Administration Chart — Kumari Gurung","Ward: Ortho  |  Bed: 33/34  |  PAHS WRH Pokhara  |  Dates: 3/15 to 3/21"); ftr(s,14,TOTAL);

  const drugs=[
    {drug:"Inj. PCM (Paracetamol) 1 gm","route":"IV","freq":"QID","start":"D1 (3/15)","end":"D7 (3/21)","note":"Baseline analgesic — safe, effective"},
    {drug:"Inj. Ketorol (Ketorolac) 30 mg","route":"IV","freq":"TDS","start":"D1 (3/15)","end":"D6 (3/20)","note":"NSAID — anti-inflammatory; STOPPED D6"},
    {drug:"Inj. Dexona (Dexamethasone) 8 mg","route":"IV","freq":"TDS","start":"D1 (3/15)","end":"D7 (3/21)","note":"Reduces nerve root oedema"},
    {drug:"T. Pregex-M Forte 75/1500 mcg (Pregabalin/Mecobalamin)","route":"PO","freq":"OD","start":"D1 (3/15)","end":"D7 (3/21)","note":"Neuropathic pain + nerve healing"},
    {drug:"Inj. Tramadol 100 mg","route":"IV","freq":"PRN","start":"D5, D7","end":"As needed","note":"Opioid — breakthrough severe pain"},
    {drug:"Inj. Deca (Dexamethasone) 4 mg","route":"IM","freq":"TDS","start":"D2 (3/16)","end":"D7","note":"Post-op steroid cover"},
    {drug:"Inj. Betnesol (Betamethasone) 8 mg","route":"IV","freq":"SOS","start":"D7","end":"SOS","note":"Potent steroid — as needed"},
    {drug:"Syp. Duphalac 10 mL (Lactulose)","route":"PO","freq":"BD","start":"D2 (3/16)","end":"D7","note":"Laxative — prevents opioid constipation"},
    {drug:"Tab. Pan-D (Pantoprazole 40 mg)","route":"PO","freq":"OD","start":"D2 (3/16)","end":"D7","note":"Gastroprotection with NSAIDs/steroids"},
  ];

  const headers=["Drug / Dose","Route","Freq.","Start","End","Rationale"];
  const colX3=[0.25,3.8,4.55,5.2,6.3,7.25]; const colW3=[3.55,0.75,0.65,1.1,0.95,2.55];
  // header row
  s.addShape(pres.shapes.RECTANGLE,{x:0.25,y:1.18,w:9.5,h:0.42,fill:{color:C.navy}});
  headers.forEach((h,i)=>s.addText(h,{x:colX3[i]+0.05,y:1.2,w:colW3[i]-0.1,h:0.38,fontSize:9,bold:true,color:C.white,fontFace:"Calibri",valign:"middle"}));

  drugs.forEach((d,i)=>{
    const y=1.6+i*0.42;
    const bg2=i%2===0?"EBF5FB":C.white;
    s.addShape(pres.shapes.RECTANGLE,{x:0.25,y,w:9.5,h:0.42,fill:{color:bg2}});
    const vals=[d.drug,d.route,d.freq,d.start,d.end,d.note];
    vals.forEach((v,ci)=>{
      s.addText(v,{x:colX3[ci]+0.05,y:y+0.03,w:colW3[ci]-0.1,h:0.36,
        fontSize:ci===0?8.5:8.2,bold:ci===0,color:C.dark,fontFace:"Calibri",valign:"middle"});
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 15 — SURGICAL MANAGEMENT (GENERAL)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Surgical Management","Indications, Techniques & TLIF Procedure"); ftr(s,15,TOTAL);

  card(s,0.3,1.18,4.55,4.05); cardHdr(s,0.3,1.18,4.55,C.navy,"Indications for Surgery");
  const ind=[
    "Intractable leg pain / radiculopathy despite ≥6 weeks conservative therapy",
    "Progressive motor weakness (as in this patient: L5/S1 weakness left)",
    "Bowel or bladder dysfunction — URGENT decompression within 24-48 hrs",
    "Unacceptably impaired quality of life",
    "Positive imaging + clinical correlation",
    "Degenerative spondylolisthesis with instability — fusion indicated",
  ];
  bullets(s,ind,0.42,1.68,4.3,3.46,9.5,C.dark);

  card(s,5.15,1.18,4.55,4.05); cardHdr(s,5.15,1.18,4.55,C.teal,"Surgical Options");
  const surgopts=[
    "Decompressive Laminectomy ± partial medial facetectomy (standard)",
    "Minimally invasive laminectomy (1-2 level disease)",
    "Foraminotomy — lateral recess / foraminal stenosis",
    "TLIF (Transforaminal Lumbar Interbody Fusion) — gold standard for stenosis + instability",
    "PLIF (Posterior Lumbar Interbody Fusion) — bilateral access",
    "Interspinous process device (X-STOP) — frail patients",
    "Fusion indications: spondylolisthesis, instability, degenerative scoliosis, >50% facetectomy",
    "SPORT Trial (4-yr): surgery > conservative — better pain, function, QoL",
    "Fusion does NOT add benefit for pure decompression (2022-2024 evidence)",
  ];
  bullets(s,surgopts,5.27,1.68,4.3,3.46,9,C.dark);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 16 — OPERATIVE PROCEDURE (PATIENT SPECIFIC)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Operative Procedure — Kumari Gurung, 44F","Operation: Decompression with TLIF at L4-L5  |  PAHS WRH  |  Date: 2083/3/26"); ftr(s,16,TOTAL);

  // Op details box
  s.addShape(pres.shapes.ROUNDED_RECTANGLE,{x:0.3,y:1.18,w:9.4,h:0.65,fill:{color:C.navy},rectRadius:0.08});
  const opDetails=[
    {k:"Reg. No.:",v:"431841"},{k:"Pre-op Dx:",v:"LCS L4-L5, L5-S1"},{k:"Post-op Dx:",v:"L4-L5 with TLIF"},
    {k:"Procedure:",v:"Decompression + TLIF"},{k:"Anaesthesia:",v:"GA"},{k:"Surgeons:",v:"Dr. SGD, Dr. MS, Dr. ST | Asst: Dr. NY"}
  ];
  const opW=[1.2,1.7,1.7,2.0,1.4,3.0]; let ox=0.35;
  opDetails.forEach((od,i)=>{
    s.addText([{text:od.k+" ",options:{bold:true,color:C.gold,fontSize:8}},{text:od.v,options:{color:C.white,fontSize:8}}],
      {x:ox,y:1.22,w:opW[i],h:0.56,fontFace:"Calibri"});
    ox+=opW[i];
  });

  card(s,0.3,1.95,9.4,3.28); cardHdr(s,0.3,1.95,9.4,C.teal,"Step-by-Step Operative Procedure");
  const steps=[
    "1. Patient placed in PRONE position on operating table",
    "2. Painting and draping performed under aseptic technique",
    "3. Midline incision made over lower back at level of L4-L5",
    "4. Paravertebral muscles pushed and split (paraspinal approach)",
    "5. L4-L5 level confirmed under C-Arm (intraoperative fluoroscopy)",
    "6. Pedicle screws inserted into pedicles at L4-L5 bilaterally; rod placed on RIGHT side",
    "7. 2nd pedicle screw distractor kept on LEFT side",
    "8. Laminectomy performed and facet joint removed (decompression)",
    "9. Disc removal done at L4-L5 level (discectomy)",
    "10. Bone graft placed with No. 12 bullet cage (TLIF cage — interbody fusion)",
    "11. Pedicle distractor removed; rod placed on LEFT side (bilateral rod-screw construct)",
    "12. Lavage performed; Vancomycin powder applied (infection prophylaxis)",
  ];
  // 2 columns
  const half=Math.ceil(steps.length/2);
  steps.slice(0,half).forEach((st,i)=>{
    const even=i%2===0;
    s.addShape(pres.shapes.RECTANGLE,{x:0.3,y:2.42+i*0.42,w:4.65,h:0.41,fill:{color:even?"EBF5FB":C.white}});
    s.addText(st,{x:0.4,y:2.44+i*0.42,w:4.5,h:0.37,fontSize:8.5,color:C.dark,fontFace:"Calibri",valign:"middle"});
  });
  steps.slice(half).forEach((st,i)=>{
    const even=i%2===0;
    s.addShape(pres.shapes.RECTANGLE,{x:5.05,y:2.42+i*0.42,w:4.65,h:0.41,fill:{color:even?"EBF5FB":C.white}});
    s.addText(st,{x:5.15,y:2.44+i*0.42,w:4.5,h:0.37,fontSize:8.5,color:C.dark,fontFace:"Calibri",valign:"middle"});
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 17 — NURSING MANAGEMENT
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Nursing Management","Pre-operative, Intra-operative & Post-operative Care"); ftr(s,17,TOTAL);

  const phases=[
    {phase:"Pre-operative Nursing Care",color:C.navy,x:0.25,y:1.18,w:3.1,items:[
      "Complete nursing assessment & documentation",
      "Vital signs monitoring: BP, PR, Temp, SpO₂",
      "Patient identification and allergy verification",
      "Consent verification and patient education",
      "NBM (nil by mouth) ≥6 hrs before surgery",
      "IV access: establish wide-bore IV line",
      "Pre-op medications administered as ordered",
      "Skin preparation: antiseptic wash",
      "Bladder catheterization if required",
      "Bowel preparation if ordered",
    ]},
    {phase:"Intra-operative Nursing Care",color:C.teal,x:3.58,y:1.18,w:3.1,items:[
      "Maintain sterile field throughout procedure",
      "Patient positioning: prone — protect pressure points",
      "Padding: knees, ankles, chest, face (prone)",
      "Eye care: prevent corneal abrasion in prone",
      "Instrument and sponge count (before, during, after)",
      "Assist with C-arm fluoroscopy setup",
      "Record all implants: pedicle screws, cage size, rods",
      "Irrigation preparation: normal saline lavage",
      "Vancomycin powder preparation and delivery",
      "Monitor blood loss — coordinate with anaesthetist",
    ]},
    {phase:"Post-operative Nursing Care",color:C.purple,x:6.9,y:1.18,w:2.85,items:[
      "Hourly neuro check: motor & sensory",
      "Vital signs every 15-30 min initially",
      "Wound: inspect drain output, dressing",
      "DVT prophylaxis: LMWH + stockings",
      "Pain assessment & analgesia (VAS scale)",
      "Urinary output monitoring (catheter care)",
      "Early mobilization: Day 1 with walker",
      "Log-roll technique for position changes",
      "Patient education: no bending, twisting",
      "Diet: progress from sips to normal",
    ]},
  ];
  phases.forEach(ph=>{
    card(s,ph.x,ph.y,ph.w,4.05);
    cardHdr(s,ph.x,ph.y,ph.w,ph.color,ph.phase);
    bullets(s,ph.items,ph.x+0.1,ph.y+0.5,ph.w-0.2,3.45,8.2,C.dark);
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 18 — NURSING DIAGNOSES
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Nursing Diagnoses & Care Plans","NANDA-Based — Kumari Gurung, 44F, Post-TLIF"); ftr(s,18,TOTAL);

  const ndx=[
    {nd:"1. Acute/Chronic Pain",rel:"Related to: nerve root compression, surgical trauma",man:"Administer analgesics (PCM, Ketorolac, Tramadol) as ordered; positioning — semi-Fowler or log-roll; assess pain VAS q4h; non-pharmacological: heat/cold pack",c:C.red},
    {nd:"2. Impaired Physical Mobility",rel:"Related to: neurological deficit, post-surgical pain",man:"Assisted ambulation Day 1 with walker; log-roll technique; physiotherapy referral; range of motion exercises; DVT prophylaxis",c:C.navy},
    {nd:"3. Anxiety / Fear",rel:"Related to: diagnosis, surgical procedure, uncertain outcome",man:"Therapeutic communication; explain all procedures; involve patient in care plan; reassure regarding surgery outcomes",c:C.purple},
    {nd:"4. Risk for Surgical Site Infection",rel:"Related to: invasive spinal surgery, implant insertion",man:"Wound inspection daily; strict aseptic dressing changes; Vancomycin powder used intra-op; monitor temp/WBC; isolate if needed",c:C.orange},
    {nd:"5. Constipation",rel:"Related to: opioid medications (Tramadol), decreased mobility",man:"Duphalac syrup BD as prescribed; adequate fluid intake; fibre-rich diet; early ambulation",c:C.green},
    {nd:"6. Knowledge Deficit",rel:"Related to: disease process, post-op care, activity restrictions",man:"Patient education: activity restrictions × 6 wks; log-rolling; no bending/twisting; follow-up schedule; signs to report",c:C.teal},
  ];

  ndx.forEach((n,i)=>{
    const col=i%2; const row=Math.floor(i/2);
    const x=0.25+col*4.95; const y=1.25+row*1.4;
    card(s,x,y,4.75,1.32);
    s.addShape(pres.shapes.RECTANGLE,{x,y,w:4.75,h:0.35,fill:{color:n.c}});
    s.addText(n.nd,{x:x+0.08,y:y+0.04,w:4.6,h:0.28,fontSize:9.5,bold:true,color:C.white,fontFace:"Calibri"});
    s.addText([{text:"AEB: ",options:{bold:true,color:n.c}},{text:n.rel,options:{color:C.dark}}],
      {x:x+0.08,y:y+0.4,w:4.6,h:0.28,fontSize:8.5,fontFace:"Calibri"});
    s.addText([{text:"Intervention: ",options:{bold:true,color:C.navy}},{text:n.man,options:{color:C.dark}}],
      {x:x+0.08,y:y+0.68,w:4.6,h:0.55,fontSize:8,fontFace:"Calibri"});
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 19 — NURSING THEORY (OREM'S SELF-CARE DEFICIT)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Nursing Theory Application","Dorothea Orem's Self-Care Deficit Theory — Applied to Kumari Gurung"); ftr(s,19,TOTAL);

  s.addShape(pres.shapes.ROUNDED_RECTANGLE,{x:0.3,y:1.18,w:9.4,h:0.82,fill:{color:C.navy},rectRadius:0.08});
  s.addText([
    {text:"Theory: ",options:{bold:true,color:C.gold}},
    {text:"Dorothea Orem's Self-Care Deficit Nursing Theory (SCDNT) proposes that individuals have the capacity to perform self-care activities to maintain health. When a SELF-CARE DEFICIT exists — where the individual cannot meet their own self-care needs — nursing care is required. Three nursing systems are used: Wholly Compensatory, Partly Compensatory, and Supportive-Educative.",options:{color:C.white}},
  ],{x:0.45,y:1.22,w:9.1,h:0.74,fontSize:9.5,fontFace:"Calibri"});

  const systems=[
    {sys:"Wholly Compensatory System",time:"IMMEDIATE POST-OP (Day 0-1)",c:C.red,items:[
      "Patient cannot perform self-care independently",
      "Nurse performs ALL care: hygiene, positioning, feeding",
      "Log-roll technique for bed turns every 2 hours",
      "Catheter care, wound monitoring, vital signs",
      "Administer all medications as prescribed",
      "Patient: Kumari Gurung — Day 0 post-TLIF, prone to supine transfer",
    ]},
    {sys:"Partly Compensatory System",time:"EARLY RECOVERY (Day 1-3)",c:C.teal,items:[
      "Patient begins to participate in own care",
      "Nurse assists with ambulation (walker support)",
      "Patient washes face, feeds self — nurse assists bathing",
      "Patient takes oral medications independently",
      "Nurse monitors neurological status, wound",
      "Patient: Day 1-3 post-TLIF — mobilising with physiotherapist",
    ]},
    {sys:"Supportive-Educative System",time:"DISCHARGE PLANNING (Day 4-7)",c:C.green,items:[
      "Patient largely independent — needs guidance",
      "Education: activity restrictions × 6 weeks",
      "No bending, twisting, lifting > 5 kg",
      "Follow-up: 2 wks, 6 wks, 3 months, 1 year",
      "Wound care, when to seek help (fever, weakness, bladder change)",
      "Patient: Kumari Gurung — discharge planning, home exercises",
    ]},
  ];
  systems.forEach((sys,i)=>{
    card(s,0.25+i*3.25,2.12,3.1,3.08);
    s.addShape(pres.shapes.RECTANGLE,{x:0.25+i*3.25,y:2.12,w:3.1,h:0.55,fill:{color:sys.c}});
    s.addText(sys.sys,{x:0.35+i*3.25,y:2.15,w:2.9,h:0.3,fontSize:9.5,bold:true,color:C.white,fontFace:"Calibri"});
    s.addText(sys.time,{x:0.35+i*3.25,y:2.44,w:2.9,h:0.22,fontSize:7.5,color:C.white,fontFace:"Calibri",italic:true});
    bullets(s,sys.items,0.35+i*3.25,2.73,2.9,2.4,8.3,C.dark);
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 20 — DAILY PROGRESS REPORT (D1–D4)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Daily Progress Report — Kumari Gurung, 44F","Ward: Ortho | Bed 33/34 | PAHS WRH | Post-TLIF L4-L5"); ftr(s,20,TOTAL);

  const days=[
    {day:"Day 1 (3/15)\nPre-op / Admission",bg:"E8F5FF",col:C.navy,notes:[
      "Admitted to Ortho Ward, Bed 34","Vital signs stable: BP / PR / Temp / SpO₂ WNL",
      "Provisional Dx: LCS L4-L5, L5-S1","IV access established",
      "Inj. PCM 1gm IV QID started","Inj. Ketorol 30mg IV TDS started",
      "Inj. Dexona 8mg IV TDS started","T. Pregex-M Forte 75/1500mcg OD started",
      "Pain management initiated","MRI and X-Ray reviewed",
      "Neurology: L5 motor 4/5 Lt, S1 4/5 Lt, ankle jerk ↓ Lt",
    ]},
    {day:"Day 2 (3/16)\nPre-op preparation",bg:"E8FFF0",col:C.green,notes:[
      "Patient stable, pain partially controlled (VAS 6/10)",
      "Syp. Duphalac 10mL BD added (constipation prophylaxis)",
      "Tab. Pan-D 40mg OD added (gastroprotection)",
      "Inj. Deca 4mg IM TDS added",
      "Inj. Betnesol 8mg IV SOS added",
      "Pre-operative consent obtained","Surgical team discussed plan: TLIF L4-L5",
      "Patient and family counselled regarding surgery",
      "Pre-op bloods and cross-match sent","NBM instruction given",
    ]},
    {day:"Day 3 (3/17)\nPost-op Day 1",bg:"FFF8E8",col:C.orange,notes:[
      "TLIF L4-L5 performed under GA — procedure completed",
      "Patient shifted to ward post-recovery","Vital signs: monitored q15-30 min",
      "Wound: drain in-situ, output monitored","Neuro check hourly",
      "Catheter in situ — urinary output monitored","NBM → sips of water",
      "Physiotherapy: early mobilisation plan",
      "All medications continued as per chart","VAS pain: 7/10 — managed with Tramadol PRN",
      "DVT prophylaxis initiated",
    ]},
    {day:"Day 4 (3/18)\nPost-op Day 2",bg:"F5E8FF",col:C.purple,notes:[
      "Patient mobilised with walker + physiotherapist",
      "VAS pain: 5/10 — improving","Diet: oral tolerated — progressed",
      "Catheter removed — voiding independently",
      "Neuro: L5 motor improving, sensation slowly recovering",
      "Wound: dry and intact, no signs of infection",
      "Drain output reducing","Medications continued",
      "Patient education commenced: activity restrictions, posture",
      "Family counselled regarding home care",
    ]},
  ];

  days.forEach((d,i)=>{
    const x=0.25+i*2.45;
    card(s,x,1.18,2.3,4.05);
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    s.addText(d.day,{x:x+0.07,y:1.2,w:2.16,h:0.52,fontSize:9,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
    s.addText(d.notes.map((n,j)=>({text:"•  "+n,options:{breakLine:j<d.notes.length-1,color:C.dark}})),
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  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 21 — DAILY PROGRESS D5–D7 + DISCHARGE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); bg(s); hdr(s,"Daily Progress Report — Days 5-7 & Discharge Plan","Kumari Gurung, 44F | Post-TLIF Recovery Continued"); ftr(s,21,TOTAL);

  const days2=[
    {day:"Day 5 (3/19)\nPost-op Day 3",col:C.teal,notes:[
      "Ambulating with walker — 50m in corridor",
      "VAS pain: 4/10 — controlled on Pregabalin + PCM",
      "Inj. Tramadol given PRN (breakthrough pain at 2pm)",
      "Wound: sutures intact, minimal serous discharge",
      "Inj. Ketorol continuing — to be stopped D6",
      "Physiotherapy: flexion exercises initiated (gentle)",
      "Appetite improved — normal diet tolerated",
      "Neuro: sensory slowly improving — encouraging",
    ]},
    {day:"Day 6 (3/20)\nPost-op Day 4",col:C.navy,notes:[
      "Inj. Ketorol STOPPED (Day 6 per drug chart)",
      "Pain well controlled — VAS 3/10",
      "Mobilising independently with walker",
      "Wound: clean, dry, no erythema or discharge",
      "Drain removed (if not already)",
      "Patient educated: wound care, warning signs",
      "Discharge planning initiated",
      "OPD follow-up scheduled: 2 weeks post-discharge",
    ]},
    {day:"Day 7 (3/21)\nDischarge Day",col:C.green,notes:[
      "Patient stable — fit for discharge",
      "VAS pain: 2-3/10 on oral medications",
      "Inj. Betnesol given as SOS (per chart)",
      "Discharge medications: Pregabalin, PCM oral",
      "Discharge summary prepared",
      "Written instructions given to patient & family",
      "Activity restriction: no bending × 6 weeks",
      "Follow-up: 2 wks wound check, 6 wks X-ray",
    ]},
  ];

  days2.forEach((d,i)=>{
    card(s,0.25+i*3.25,1.18,3.1,3.3);
    s.addShape(pres.shapes.RECTANGLE,{x:0.25+i*3.25,y:1.18,w:3.1,h:0.45,fill:{color:d.col}});
    s.addText(d.day,{x:0.35+i*3.25,y:1.21,w:2.9,h:0.4,fontSize:10,bold:true,color:C.white,fontFace:"Calibri",align:"center"});
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  card(s,0.25,4.6,9.5,0.78);
  s.addShape(pres.shapes.RECTANGLE,{x:0.25,y:4.6,w:9.5,h:0.42,fill:{color:C.gold}});
  s.addText("Discharge Plan & Follow-Up",{x:0.38,y:4.63,w:9.2,h:0.35,fontSize:11,bold:true,color:C.navy,fontFace:"Calibri"});
  s.addText("2 weeks: Wound suture removal + wound check  |  6 weeks: X-Ray L-S spine + clinical review  |  3 months: Neurological assessment + physiotherapy review  |  1 year: Follow-up imaging if required  |  Advised: Pregabalin + Mecobalamin continued orally",
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}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 22 — CONCLUSION + REFERENCES
// ══════════════════════════════════════════════════════════════════════════════
{
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  s.addShape(pres.shapes.RECTANGLE,{x:0.28,y:2.1,w:9.44,h:0.07,fill:{color:C.gold}});
  s.addShape(pres.shapes.RECTANGLE,{x:0.28,y:3.65,w:9.44,h:0.07,fill:{color:C.gold}});

  s.addText("Thank You",{x:0.8,y:0.4,w:8.4,h:1.2,fontSize:44,bold:true,color:C.white,fontFace:"Calibri",align:"center"});
  s.addText("Questions & Discussion Welcome",{x:1,y:1.55,w:8,h:0.4,fontSize:16,color:C.tealLt,fontFace:"Calibri",align:"center"});

  const kp=[
    "Kumari Gurung, 44F — Rare early-onset LCS — L4-L5 (worst), L5-S1",
    "Presented with 5-yr h/o LBP + left radiculopathy + L5/S1 motor weakness",
    "MRI confirmed central canal stenosis + bilateral lateral recess narrowing",
    "Underwent: Decompression + TLIF L4-L5 under GA — PAHS WRH 2083/3/26",
    "7-day drug chart: PCM, Ketorol, Dexona, Pregabalin, Tramadol PRN",
    "Nursing theory: Orem's SCDNT — Wholly → Partly → Supportive-Educative",
    "Discharged Day 7 — Follow-up scheduled at 2 wks, 6 wks, 3 months",
  ];
  s.addText(kp.map((t,i)=>({text:"•  "+t,options:{breakLine:i<kp.length-1,color:i<=3?C.gold:C.tealLt,fontSize:9.5}})),
    {x:1,y:2.25,w:8,h:1.3,fontFace:"Calibri"});

  s.addText("Pokhara Academy of Health Sciences (PAHS)  |  Western Regional Hospital",{x:1,y:3.8,w:8,h:0.3,fontSize:12,bold:true,color:C.white,fontFace:"Calibri",align:"center"});
  s.addText("Department of Orthopaedic Surgery  |  Ramghat-10, Pokhara, Gandaki Province, Nepal",{x:1,y:4.12,w:8,h:0.28,fontSize:10,color:C.tealLt,fontFace:"Calibri",align:"center"});
  s.addText("References: Bradley & Daroff's Neurology in Clinical Practice | Miller's Review of Orthopaedics 9E | Harrison's Principles 22E | Adams & Victor's Neurology 12E | Firestein & Kelley's Textbook of Rheumatology | Campbell's Operative Orthopaedics 15E",
    {x:0.4,y:4.5,w:9.2,h:0.5,fontSize:7,color:C.gray,fontFace:"Calibri",align:"center",italic:true});
}

// ─── WRITE ────────────────────────────────────────────────────────────────────
pres.writeFile({fileName:"/home/daytona/workspace/lumbar-stenosis-pahs/LCS_PAHS_Kumari_Gurung.pptx"})
  .then(()=>console.log("Done: LCS_PAHS_Kumari_Gurung.pptx"))
  .catch(e=>{console.error(e);process.exit(1);});