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// ─────────────────────────────────────────────────────────────────────────────
// DOCUMENT CONTENT
// ─────────────────────────────────────────────────────────────────────────────

const titlePage = [
  new Paragraph({ spacing: { before: 720 } }),
  new Paragraph({
    alignment: AlignmentType.CENTER,
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    children: [new TextRun({ text: "STUDENT'S RESEARCH WORK (УИР)", bold: true, size: 28, allCaps: true })],
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  new Paragraph({
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    children: [new TextRun({ text: "4th Year, Faculty Therapy", size: 26 })],
  }),
  new Paragraph({
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    spacing: { after: 240 },
    children: [new TextRun({ text: "CLINICAL CASE REPORT", bold: true, size: 36, allCaps: true })],
  }),
  new Paragraph({
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    children: [new TextRun({ text: "Community-Acquired Pneumonia", bold: true, size: 30 })],
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    children: [new TextRun({ text: "2025–2026", size: 24 })],
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// ─────────── SECTION 1: RELEVANCE ────────────────────────────────────────────
const section1 = [
  h1("1. RELEVANCE OF THE TOPIC"),
  p("Community-acquired pneumonia (CAP) remains one of the most prevalent and potentially life-threatening infectious diseases worldwide. It is defined as an acute infection of the pulmonary parenchyma acquired outside of a hospital setting or healthcare facility, manifesting with symptoms and signs of lower respiratory tract infection accompanied by a new infiltrate on chest imaging."),

  h2("1.1 Global Epidemiology"),
  p("According to the Global Burden of Disease Study 2021 (GBD 2021), lower respiratory infections — of which pneumonia is the dominant form — accounted for an estimated 344 million incident episodes globally in 2021, with approximately 2.18 million deaths (27.7 per 100,000 population). Streptococcus pneumoniae remains the single leading pathogen, responsible for an estimated 97.9 million episodes and 505,000 deaths globally (GBD 2021 Collaborators, Lancet Infect Dis, 2024)."),
  p("Pneumonia is the most common infectious cause of hospitalization and death in the United States. Hospitalization rates increase exponentially with age: from 1–2 per 1,000 in young adults to approximately 40 per 1,000 in persons aged ≥85 years. The in-hospital mortality for CAP requiring hospitalization is approximately 6%, rising to 15% at one month (Goldman-Cecil Medicine, 2022)."),
  p("In Russia, pneumonia consistently ranks among the leading causes of infectious-disease-related disability and mortality. Epidemiological surveillance data indicate an incidence of approximately 400–500 cases per 100,000 adults per year, with higher figures in winter months coinciding with seasonal influenza activity."),

  h2("1.2 Significance and Relevance"),
  p("The clinical and public health significance of pneumonia is underscored by:"),
  bullet("Its ranking as the 4th leading cause of death globally among all age groups."),
  bullet("Long-term complications now increasingly recognised: cardiovascular events, persistent respiratory impairment, and cognitive decline (Reyes et al., Lancet, 2025)."),
  bullet("Rising antimicrobial resistance threatening empiric treatment strategies."),
  bullet("The COVID-19 pandemic demonstrating the catastrophic potential of respiratory infections when novel pathogens emerge."),
  bullet("Preventable burden through vaccination against S. pneumoniae, influenza, and SARS-CoV-2, making accurate clinical recognition and management essential."),
  p("The study of this nosology is therefore of major medical, social, and economic importance, justifying its selection as the subject of this student research work."),
];

// ─────────── SECTION 2: LITERATURE REVIEW ────────────────────────────────────
const section2 = [
  h1("2. LITERATURE REVIEW"),

  h2("2.1 Definition and Classification"),
  p("Pneumonia is an acute infection of the lung parenchyma characterised by alveolar consolidation, inflammatory exudate, and impaired gas exchange. Classification by acquisition setting is clinically relevant because it determines the likely causative organisms and guides empiric therapy:"),
  bullet("Community-acquired pneumonia (CAP) — acquired outside hospital or within 48 hours of admission in a patient not residing in a long-term care facility."),
  bullet("Hospital-acquired pneumonia (HAP) — onset ≥48 hours after hospital admission."),
  bullet("Ventilator-associated pneumonia (VAP) — developing ≥48 hours after endotracheal intubation."),
  bullet("Healthcare-associated pneumonia (HCAP) — a now largely abandoned category."),
  p("By radiological pattern, pneumonia may be lobular/lobar (typically bacterial), bronchopneumonia (patchy peribronchiolar), interstitial (typically viral or atypical), or cavitating."),

  h2("2.2 Aetiology"),
  p("The causative spectrum of CAP is broad. In more than 50% of cases, no definitive pathogen is identified despite comprehensive testing. When a pathogen is confirmed:"),
  bullet("Streptococcus pneumoniae: the most common bacterial cause, accounting for up to 30–40% of cases in hospitalised adults."),
  bullet("Haemophilus influenzae: particularly in patients with COPD or smoking history."),
  bullet("Staphylococcus aureus (including MRSA): associated with post-influenza pneumonia and severe CAP."),
  bullet("Gram-negative bacilli (Klebsiella pneumoniae, Pseudomonas aeruginosa): in patients with structural lung disease, immunosuppression, or recent healthcare exposure."),
  bullet("Atypical pathogens — Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophila: collectively account for 5–25% of CAP cases; Legionella is associated with severe disease."),
  bullet("Respiratory viruses: influenza A/B, SARS-CoV-2, RSV, human metapneumovirus — responsible for 20–30% of CAP episodes; this proportion increased markedly during the COVID-19 pandemic."),
  p("Risk factors for acquiring drug-resistant organisms include recent antibiotic use, healthcare exposure, structural lung disease, immunosuppression, and alcohol use disorder (Goldman-Cecil Medicine, 2022)."),

  h2("2.3 Pathophysiology"),
  p("The normal lung possesses a multilayered defence system: mucociliary clearance, alveolar macrophages, secretory IgA, and the cough reflex. Pneumonia results when this defence is overwhelmed by virulent microorganisms or impaired by host factors."),
  p("Following aspiration or inhalation of pathogens into the terminal airways, a four-stage inflammatory response in bacterial lobar pneumonia is classically described:"),
  bullet("Congestion (0–24 h): vascular engorgement, oedema fluid in alveoli, few bacteria, limited neutrophil recruitment."),
  bullet("Red hepatisation (1–3 days): massive neutrophil infiltration, erythrocytes, fibrin, and bacteria fill alveoli; lung becomes airless and liver-like in consistency."),
  bullet("Grey hepatisation (3–8 days): erythrocytes lyse, fibrin dominates, fewer bacteria; WBC count may fall."),
  bullet("Resolution (>8 days): macrophages clear debris via lymphatics; complete structural restoration occurs in most cases."),
  p("Gas exchange abnormalities in pneumonia are primarily due to increased perfusion to shunted and low V/Q units within the consolidated zone. In mild-to-moderate pneumonia, shunt fraction averages 7.5% and low V/Q perfusion 4.2%. In severe pneumonia requiring mechanical ventilation, these figures approximately double — shunt 21.9%, low V/Q 10.9% — directly correlating with the degree of hypoxaemia (Murray & Nadel's Textbook of Respiratory Medicine, 7e)."),

  h2("2.4 Clinical Presentation"),
  p("Classic symptoms of CAP include:"),
  bullet("Cough — initially dry, then productive of purulent or rusty-coloured sputum."),
  bullet("Fever (>38°C) with chills and rigors."),
  bullet("Pleuritic chest pain — sharp, worsened by breathing and coughing, indicating pleural involvement."),
  bullet("Dyspnoea — particularly on exertion or at rest in severe disease."),
  bullet("Fatigue, myalgia, headache — more prominent with atypical pathogens (Mycoplasma, Chlamydophila)."),
  p("Physical examination findings include tachypnoea (RR >20/min), tachycardia, fever or hypothermia in severe sepsis. Pulmonary signs over the affected lobe: crackles (crepitations), bronchial breath sounds, egophony ('E' to 'A' sign), dullness to percussion, increased tactile fremitus. Unfortunately, no single finding is sufficiently sensitive or specific to confirm pneumonia without imaging."),

  h2("2.5 Diagnosis"),
  p("The diagnosis of pneumonia requires compatible clinical features PLUS a new infiltrate on chest imaging (Goldman-Cecil Medicine, 2022)."),

  h3("2.5.1 Chest Imaging"),
  p("Chest X-ray (CXR) is the first-line imaging study. Typical findings include lobar or segmental consolidation (suggesting S. pneumoniae, Klebsiella), bilateral patchy infiltrates (suggesting atypical or viral), interstitial pattern (viral), or cavitation (anaerobes, MRSA, Klebsiella, tuberculosis). Parapneumonic effusion occurs in up to 60% of hospitalised CAP patients. CT thorax offers higher sensitivity and specificity but is not a first-line investigation; it is indicated when CXR is normal but clinical suspicion is high, or to evaluate complications."),

  h3("2.5.2 Laboratory Tests"),
  p("Minimum recommended workup for hospitalised CAP:"),
  bullet("Complete blood count (CBC): leucocytosis (typically >12 × 10⁹/L) with neutrophilia suggests bacterial cause; leucopenia is an adverse prognostic sign."),
  bullet("Serum CRP and procalcitonin (PCT): elevated in bacterial infection; PCT <0.1 µg/L suggests viral aetiology and may guide antibiotic de-escalation."),
  bullet("Serum urea, creatinine, electrolytes: urea is incorporated in the CURB-65 severity score."),
  bullet("Liver function tests, glucose."),
  bullet("Blood cultures × 2 (before antibiotics): yield 5–14%; recommended for hospitalised patients."),
  bullet("Sputum Gram stain and culture (before antibiotics): specificity high when >25 PMNs/LPF."),
  bullet("Urinary antigen tests: Legionella (sensitivity 70–80%) and pneumococcal antigen."),
  bullet("Arterial blood gas (ABG) or pulse oximetry: hypoxaemia (SpO₂ <92%) indicates severity."),

  h3("2.5.3 Severity Scoring"),
  p("Two validated scoring systems guide management:"),

  new Paragraph({ spacing: { after: 80 } }),
  simpleTable(
    ["CURB-65 Feature", "Points"],
    [
      ["Confusion (new onset)", "1"],
      ["Urea > 7 mmol/L (BUN > 19 mg/dL)", "1"],
      ["Respiratory Rate ≥ 30/min", "1"],
      ["Blood Pressure: SBP < 90 or DBP ≤ 60 mmHg", "1"],
      ["Age ≥ 65 years", "1"],
    ]
  ),
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    children: [new TextRun({ text: "Score 0–1: outpatient; Score 2: consider admission; Score ≥3: ICU evaluation required.", italics: true, size: 22 })],
  }),

  h2("2.6 Antibiotic Treatment"),
  p("Antibiotic therapy should be initiated promptly — ideally within 4 hours of presentation. Empiric regimens are guided by severity and setting:"),

  simpleTable(
    ["Setting", "Recommended Regimen", "Duration"],
    [
      ["Outpatient, no comorbidities", "Amoxicillin 500 mg TID OR Doxycycline 100 mg BID OR Azithromycin 500 mg × 1, then 250 mg OD", "5 days"],
      ["Outpatient, with comorbidities", "Respiratory fluoroquinolone (levofloxacin 750 mg OD OR moxifloxacin 400 mg OD) OR β-lactam + macrolide", "5–7 days"],
      ["Inpatient, non-severe", "Respiratory FQ OR β-lactam + macrolide/doxycycline", "5–7 days"],
      ["Inpatient, severe (ICU)", "β-lactam (ceftriaxone/ampicillin-sulbactam) + macrolide OR respiratory FQ; add vancomycin/linezolid if MRSA risk", "7–10 days"],
    ]
  ),
  new Paragraph({ spacing: { after: 120 } }),
  p("Antibiotic treatment should be de-escalated based on culture results and clinical response. Switch from IV to oral therapy is appropriate once the patient is haemodynamically stable, has a functional gastrointestinal tract, and shows clinical improvement."),

  h2("2.7 Complications"),
  p("Pulmonary complications include parapneumonic effusion (up to 60%), empyema thoracis (3–5%), lung abscess, and respiratory failure/ARDS. Extrapulmonary complications include:"),
  bullet("Acute cardiovascular events (new atrial fibrillation, myocardial ischaemia, heart failure decompensation) — occurring in 20–25% of hospitalised patients."),
  bullet("Sepsis and septic shock."),
  bullet("Long-term: persistent respiratory impairment, reduced exercise capacity, cognitive decline, and increased cardiovascular risk for months after the acute episode (Reyes et al., Lancet, 2025)."),

  h2("2.8 Prevention"),
  p("Vaccine-preventable pneumonia represents a major public health priority:"),
  bullet("Pneumococcal vaccination: PCV20 (20-valent conjugate) or PCV15 + PPSV23 recommended for adults ≥65 years and high-risk individuals. PCV20 provides broader serotype coverage and is endorsed by recent European guidelines (Sotgiu et al., Eur Respir Rev, 2025)."),
  bullet("Annual influenza vaccination."),
  bullet("COVID-19 vaccination."),
  bullet("Smoking cessation, optimisation of chronic comorbidities."),
];

// ─────────── SECTION 3: CLINICAL CASE ────────────────────────────────────────
const section3 = [
  h1("3. CLINICAL CASE PRESENTATION"),

  h2("3.1 Patient Data"),
  simpleTable(
    ["Parameter", "Details"],
    [
      ["Patient", "Patient K. (anonymised)"],
      ["Age", "58 years"],
      ["Sex", "Male"],
      ["Occupation", "Office employee (sedentary)"],
      ["Date of Admission", "Day 4 of illness"],
      ["Ward", "Pulmonology / Faculty Therapy"],
    ]
  ),
  new Paragraph({ spacing: { after: 160 } }),

  h2("3.2 Chief Complaints"),
  p("On admission, the patient presented with:"),
  bullet("Productive cough with rusty-yellow sputum for 4 days."),
  bullet("Fever up to 39.2°C with chills and night sweats."),
  bullet("Right-sided pleuritic chest pain, sharp, worsened by deep inspiration and coughing."),
  bullet("Progressive dyspnoea on minimal exertion."),
  bullet("Marked weakness, fatigue, decreased appetite."),
  bullet("Headache and myalgia for the first 2 days."),

  h2("3.3 History of Present Illness (Anamnesis Morbi)"),
  p("The patient reports an acute onset 4 days prior to admission. Initially presented with a dry cough and low-grade fever (37.8°C) which he attributed to a common cold and self-treated with paracetamol. By day 2, fever spiked to 39°C, the cough became productive with rusty sputum, and right-sided pleuritic pain developed. He was seen by a general practitioner who advised outpatient management with amoxicillin 500 mg TID. Despite 2 days of antibiotics, fever persisted and dyspnoea worsened, prompting emergency hospitalisation."),

  h2("3.4 Past Medical History (Anamnesis Vitae)"),
  p("Chronic diseases: Type 2 diabetes mellitus (diagnosed 5 years ago, on metformin 1000 mg BID; last HbA1c 7.4%). Active smoker: 30 pack-year history. No prior pneumonia. No known drug allergies. Influenza vaccination: last received 3 years ago. Pneumococcal vaccination: never received."),

  h2("3.5 Epidemiological History"),
  p("Works in a crowded open-plan office. No contact with individuals with confirmed tuberculosis. No recent travel abroad. No specific zoonotic exposures. No documented COVID-19 vaccination in the past 12 months."),

  h2("3.6 Objective Examination"),

  h3("3.6.1 General Condition"),
  p([bold("General condition: "), normal("Moderate severity. Conscious, alert, oriented in time and place.")]),
  p([bold("Position: "), normal("Forced — semi-recumbent, preference for lying on the right side.")]),
  p([bold("Body temperature: "), normal("39.0°C")]),
  p([bold("Skin: "), normal("Hyperaemic, moist. Herpes labialis (cold sore) visible on right upper lip.")]),
  p([bold("Height: "), normal("176 cm; Weight: 84 kg; BMI: 27.1 kg/m² (overweight).")]),

  h3("3.6.2 Cardiovascular System"),
  p("Heart sounds: rhythmic, muffled. No murmurs. HR 102 bpm. BP 118/76 mmHg. No peripheral oedema."),

  h3("3.6.3 Respiratory System"),
  p([bold("Respiratory rate: "), normal("27 breaths/min.")]),
  p([bold("SpO₂: "), normal("91% on room air.")]),
  p([bold("Inspection: "), normal("Right side of chest lags in breathing. Accentuation of subclavian fossae.")]),
  p([bold("Palpation: "), normal("Increased tactile fremitus over the right lower lobe posteriorly.")]),
  p([bold("Percussion: "), normal("Dullness to percussion over right lower lobe (posterior and lateral zones).")]),
  p([bold("Auscultation: "), normal("Coarse inspiratory crepitations and bronchial breath sounds over right lower lobe. Egophony positive (patient says 'A', examiner hears 'E'). Remainder of lung fields: vesicular breath sounds, no wheeze.")]),

  h3("3.6.4 Abdomen and Other Systems"),
  p("Abdomen soft, non-tender. Liver: not enlarged. No signs of meningeal irritation. Neurological examination: no focal deficits."),

  h2("3.7 Identification of Syndromes"),
  simpleTable(
    ["Syndrome", "Clinical Evidence"],
    [
      ["Pulmonary consolidation syndrome", "Dullness on percussion, bronchial breath sounds, egophony, increased tactile fremitus — right lower lobe"],
      ["Infectious-inflammatory syndrome", "Fever 39°C, chills, leucocytosis, elevated CRP/PCT, herpes labialis"],
      ["Respiratory failure syndrome (Grade I)", "SpO₂ 91%, RR 27/min, dyspnoea at rest"],
      ["Pleuritic syndrome", "Sharp right-sided chest pain, worsened by inspiration"],
      ["Intoxication syndrome", "Weakness, headache, myalgia, loss of appetite"],
    ]
  ),
  new Paragraph({ spacing: { after: 160 } }),

  h2("3.8 Preliminary Clinical Diagnosis"),
  new Paragraph({
    spacing: { after: 160 },
    alignment: AlignmentType.LEFT,
    children: [
      new TextRun({ text: "Right-sided lower lobe community-acquired pneumonia, ", bold: true, size: 24 }),
      new TextRun({ text: "likely bacterial (S. pneumoniae), ", size: 24 }),
      new TextRun({ text: "moderate severity (CURB-65 = 2), ", size: 24 }),
      new TextRun({ text: "complicated by parapneumonic effusion. Respiratory failure Grade I. Background: Type 2 diabetes mellitus, active smoking.", size: 24 }),
    ],
  }),

  h2("3.9 Diagnostic Plan and Results"),

  h3("3.9.1 Laboratory Results"),
  simpleTable(
    ["Test", "Result", "Reference Range", "Interpretation"],
    [
      ["WBC", "16.8 × 10⁹/L", "4.0–10.0 × 10⁹/L", "↑ Leucocytosis"],
      ["Neutrophils", "84%", "47–72%", "↑ Neutrophilia"],
      ["Lymphocytes", "9%", "19–37%", "↓ Lymphopenia"],
      ["Haemoglobin", "138 g/L", "130–170 g/L", "Normal"],
      ["CRP", "142 mg/L", "< 5 mg/L", "↑↑ Markedly elevated"],
      ["Procalcitonin (PCT)", "1.8 µg/L", "< 0.5 µg/L", "↑ Bacterial infection"],
      ["ESR", "56 mm/h", "< 15 mm/h", "↑ Elevated"],
      ["Serum urea", "6.1 mmol/L", "2.5–8.3 mmol/L", "Normal"],
      ["Creatinine", "88 µmol/L", "62–106 µmol/L", "Normal"],
      ["Blood glucose", "8.4 mmol/L", "3.9–6.1 mmol/L", "↑ (T2DM background)"],
      ["SpO₂ (room air)", "91%", "> 95%", "↓ Hypoxaemia"],
      ["PaO₂ (ABG)", "62 mmHg", "> 80 mmHg", "↓ Hypoxaemia"],
      ["PaCO₂ (ABG)", "38 mmHg", "35–45 mmHg", "Normal"],
    ]
  ),
  new Paragraph({ spacing: { after: 160 } }),

  h3("3.9.2 Microbiology"),
  p("Blood cultures × 2: collected before antibiotics — pending (result: S. pneumoniae, sensitive to penicillin, reported on day 3)."),
  p("Sputum Gram stain: abundant PMNs (>25/LPF); Gram-positive diplococci in pairs and chains — consistent with S. pneumoniae."),
  p("Sputum culture: S. pneumoniae, sensitivity: penicillin S (MIC 0.06), amoxicillin S, ceftriaxone S."),
  p("Urinary pneumococcal antigen: POSITIVE."),
  p("Urinary Legionella antigen: negative."),
  p("Influenza A/B rapid antigen test: negative."),

  h3("3.9.3 Instrumental Results"),
  p([bold("Chest X-ray (PA and lateral): "), normal("Dense homogeneous consolidation of the right lower lobe with air bronchogram. Blunting of the right costophrenic angle consistent with small parapneumonic pleural effusion. No cavitation. Mediastinum not widened.")]),
  p([bold("Chest CT (performed day 2 of admission): "), normal("Confirmed right lower lobe consolidation. Estimated effusion volume 120 mL. No abscess. No pulmonary embolism. No evidence of malignancy.")]),
  p([bold("ECG: "), normal("Sinus tachycardia 102 bpm. No ischaemic changes. QTc 420 ms.")]),
  p([bold("Echocardiography (ECHO): "), normal("No pericardial effusion. LVEF 62%. No wall motion abnormalities. Normal valvular function.")]),

  h2("3.10 Clinical Diagnosis (Final)"),
  new Paragraph({
    spacing: { after: 200 },
    alignment: AlignmentType.LEFT,
    children: [
      new TextRun({ text: "Main diagnosis: ", bold: true, size: 24 }),
      new TextRun({ text: "Community-acquired pneumonia (S. pneumoniae, bacteraemic), right lower lobe, moderately severe (CURB-65 = 2, PSI class III), ICD-10: J13.", size: 24 }),
    ],
  }),
  new Paragraph({
    spacing: { after: 200 },
    alignment: AlignmentType.LEFT,
    children: [
      new TextRun({ text: "Complications: ", bold: true, size: 24 }),
      new TextRun({ text: "Parapneumonic right-sided pleural effusion (small). Respiratory failure Grade I.", size: 24 }),
    ],
  }),
  new Paragraph({
    spacing: { after: 200 },
    alignment: AlignmentType.LEFT,
    children: [
      new TextRun({ text: "Concomitant diseases: ", bold: true, size: 24 }),
      new TextRun({ text: "Type 2 diabetes mellitus, compensated (HbA1c 7.4%). Active smoking, 30 pack-years.", size: 24 }),
    ],
  }),

  h2("3.11 Etiological, Predisposing Factors and Risk Factors"),
  simpleTable(
    ["Category", "Factors in This Patient"],
    [
      ["Etiological agent", "Streptococcus pneumoniae (confirmed by blood culture, sputum culture, urinary antigen)"],
      ["Predisposing host factors", "Type 2 diabetes mellitus (impaired neutrophil function); Active smoking (mucociliary dysfunction); Age 58 (declining innate immunity)"],
      ["Risk factors for severity", "SpO₂ 91%; RR 27/min; unvaccinated against S. pneumoniae; failure of outpatient amoxicillin (likely inadequate dosing or absorption)"],
      ["Risk for resistance", "No prior recent antibiotics; no healthcare exposure; resistance profile: fully sensitive"],
    ]
  ),
  new Paragraph({ spacing: { after: 160 } }),

  h2("3.12 Treatment Plan"),

  h3("3.12.1 Antibiotic Therapy"),
  p("Initial empiric therapy — revised after culture sensitivity:"),
  bullet("Ceftriaxone 2 g IV once daily (day 1–5), then switched to oral amoxicillin-clavulanate 875/125 mg BID after clinical stability achieved."),
  bullet("Total planned antibiotic duration: 7 days."),
  bullet("De-escalation guided by culture results (S. pneumoniae, penicillin-sensitive) and PCT trend."),

  h3("3.12.2 Supportive and Symptomatic Therapy"),
  bullet("Supplemental oxygen therapy: O₂ via nasal cannula at 2–3 L/min, targeting SpO₂ ≥94%."),
  bullet("IV fluid therapy: 0.9% NaCl 500 mL over 4 hours on admission (for hydration and antipyresis)."),
  bullet("Antipyretic/analgesic: Paracetamol 1 g IV Q6H PRN (temperature >38.5°C or pain NRS >4)."),
  bullet("Mucolytic: Ambroxol 30 mg TID PO to facilitate sputum clearance."),
  bullet("Glycaemic control: continuing metformin; capillary glucose monitoring QID; target fasting glucose <8 mmol/L."),
  bullet("Thromboprophylaxis: Enoxaparin 40 mg SC once daily (immobile, infectious state = VTE risk)."),
  bullet("Physiotherapy: Breathing exercises and early mobilisation from day 2; chest wall oscillation if needed."),

  h3("3.12.3 Monitoring Plan"),
  bullet("Temperature, HR, BP, RR, SpO₂ — q4–6 hours."),
  bullet("CBC and CRP on days 3 and 7."),
  bullet("PCT on day 3 (to guide antibiotic de-escalation)."),
  bullet("Repeat CXR on day 7 (to assess radiological response)."),
  bullet("Blood glucose QID."),

  h2("3.13 Clinical Course and Outcomes"),
  p("Day 3 of inpatient treatment: fever subsided (T 37.1°C), dyspnoea improved (SpO₂ 96% on room air). WBC fell to 9.8 × 10⁹/L. PCT decreased to 0.4 µg/L. Clinical stability criteria met — switched to oral antibiotic therapy."),
  p("Day 5: patient afebrile. Cough reducing. Chest auscultation: crepitations diminished. SpO₂ 97% on room air. Pleural effusion resolving on bedside ultrasound."),
  p("Day 7: Repeat CXR showed partial resolution of consolidation (residual haziness expected — full radiological resolution may take 4–8 weeks). Patient discharged home on oral amoxicillin-clavulanate to complete course. SpO₂ 97% on room air."),
  p([bold("Discharge diagnosis: "), normal("Same as final clinical diagnosis. Outcome: Recovery. No complications requiring further intervention.")]),

  h2("3.14 Discharge Recommendations"),
  bullet("Complete antibiotic course (7 days total)."),
  bullet("Follow-up CXR in 4 weeks to confirm radiological resolution and exclude occult malignancy."),
  bullet("Smoking cessation counselling and referral."),
  bullet("Pneumococcal vaccination (PCV20) at 4–6 weeks post-recovery."),
  bullet("Annual influenza vaccination."),
  bullet("Continue metformin; HbA1c recheck in 3 months."),
  bullet("Refer to endocrinologist for optimisation of diabetic management."),
];

// ─────────── SECTION 4: REFERENCES ───────────────────────────────────────────
const section4 = [
  h1("4. REFERENCES"),

  p([new TextRun({ text: "1. ", bold: true, size: 24 }), normal("GBD 2021 Lower Respiratory Infections and Antimicrobial Resistance Collaborators. Global, regional, and national incidence and mortality burden of non-COVID-19 lower respiratory infections and aetiologies, 1990–2021: a systematic analysis from the Global Burden of Disease Study 2021. ", size: 24), italic("Lancet Infect Dis. ", 24), normal("2024;24(9):974–1011. PMID: 38636536.", 24)]),

  p([new TextRun({ text: "2. ", bold: true, size: 24 }), normal("Reyes LF, Conway Morris A, Serrano-Mayorga C, et al. Community-acquired pneumonia. ", size: 24), italic("Lancet. ", 24), normal("2025;406(10463):1874–1888. PMID: 41110447.", 24)]),

  p([new TextRun({ text: "3. ", bold: true, size: 24 }), normal("Jones BE, Ramirez JA, Oren E, et al. Diagnosis and Management of Community-acquired Pneumonia: An Official American Thoracic Society Clinical Practice Guideline. ", size: 24), italic("Am J Respir Crit Care Med. ", 24), normal("2026;213(1):e1–e35. PMID: 40679934.", 24)]),

  p([new TextRun({ text: "4. ", bold: true, size: 24 }), normal("Dinh A, Barbier F, Bedos JP, et al. Update of guidelines for management of Community Acquired pneumonia in adults by the French Infectious Disease Society (SPILF) and the French-Speaking Society of Respiratory Diseases (SPLF). ", size: 24), italic("Respir Med Res. ", 24), normal("2025;87:101138. PMID: 40037948.", 24)]),

  p([new TextRun({ text: "5. ", bold: true, size: 24 }), normal("Bai AD, Loeb M. Community-Acquired Pneumonia in Adults. ", size: 24), italic("NEJM Evid. ", 24), normal("2025 Dec. PMID: 41288422.", 24)]),

  p([new TextRun({ text: "6. ", bold: true, size: 24 }), normal("Noguchi S, Katsurada M, Yatera K, et al. Utility of pneumonia severity assessment tools for mortality prediction in healthcare-associated pneumonia: a systematic review and meta-analysis. ", size: 24), italic("Sci Rep. ", 24), normal("2024;14(1):12894. PMID: 38839837.", 24)]),

  p([new TextRun({ text: "7. ", bold: true, size: 24 }), normal("Ramirez JA, File TM. How to assess survival prognosis in patients hospitalized for community-acquired pneumonia in 2024? ", size: 24), italic("Curr Opin Crit Care. ", 24), normal("2024;30(5):428–435. PMID: 39150039.", 24)]),

  p([new TextRun({ text: "8. ", bold: true, size: 24 }), normal("Piedepalumbo FV, Motos A, Blasi F, et al. Safety of steroids in severe community-acquired pneumonia. ", size: 24), italic("Eur Respir Rev. ", 24), normal("2025;34(175):240176. PMID: 39778921.", 24)]),

  p([new TextRun({ text: "9. ", bold: true, size: 24 }), normal("Sotgiu G, Puci M, Bartoletti M, et al. Recommendations on PCV20 vaccine in adults and at-risk populations. ", size: 24), italic("Eur Respir Rev. ", 24), normal("2025;34(178):250059. PMID: 41224370.", 24)]),

  p([new TextRun({ text: "10. ", bold: true, size: 24 }), normal("Omaggio L, Franzetti L, Caiazzo R, et al. Utility of C-reactive protein and procalcitonin in community-acquired pneumonia in children: a narrative review. ", size: 24), italic("Curr Med Res Opin. ", 24), normal("2024;40(12):2157–2167. PMID: 39494704.", 24)]),

  p([new TextRun({ text: "11. ", bold: true, size: 24 }), normal("Rutkauskienė L, Kubilius R, Tamošuitis T, et al. Early mobilization, breathing exercises and chest wall oscillation in patients with bilateral pneumonia disease in the intensive care unit: a randomized clinical trial. ", size: 24), italic("BMC Pulm Med. ", 24), normal("2025;25:435. PMID: 41286729.", 24)]),

  p([new TextRun({ text: "12. ", bold: true, size: 24 }), normal("Cilloniz C, Castañeda T, Campanella A, et al. Eosinopenia and prognosis in severe community-acquired pneumonia. ", size: 24), italic("Pneumonia (Nathan). ", 24), normal("2026;18:10. PMID: 41877215.", 24)]),

  p([new TextRun({ text: "13. ", bold: true, size: 24 }), normal("Goldman-Cecil Medicine International Edition. 27th ed. Philadelphia: Elsevier; 2022. Chapter 85: Pneumonia. ISBN: 9780323930345.", 24)]),

  p([new TextRun({ text: "14. ", bold: true, size: 24 }), normal("Murray & Nadel's Textbook of Respiratory Medicine. 7th ed. Philadelphia: Elsevier; 2022. ISBN: 9780323655873.", 24)]),

  p([new TextRun({ text: "15. ", bold: true, size: 24 }), normal("Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. ", size: 24), italic("Am J Respir Crit Care Med. ", 24), normal("2019;200(7):e45–e67.", 24)]),
];

// ─────────── ASSEMBLE DOCUMENT ────────────────────────────────────────────────
const doc = new Document({
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        paragraph: { spacing: { line: 360 } },
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      properties: {
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              children: [
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Packer.toBuffer(doc).then(buf => {
  fs.writeFileSync("/home/daytona/workspace/pneumonia-report/Pneumonia_Clinical_Report.docx", buf);
  console.log("Done: Pneumonia_Clinical_Report.docx");
});

"""
Clinical Report: Community-Acquired Pneumonia
Generates a professionally formatted PDF using ReportLab.
"""

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

OUTPUT = "/home/daytona/workspace/pneumonia-report/Pneumonia_Clinical_Report.pdf"

# ── Colours ──────────────────────────────────────────────────────────────────
BLUE_DARK  = HexColor("#1F3864")
BLUE_MID   = HexColor("#2E75B6")
BLUE_LIGHT = HexColor("#BDD7EE")
BLUE_PALE  = HexColor("#DEEAF1")
GREY_LIGHT = HexColor("#F2F2F2")
GREY_MED   = HexColor("#D9D9D9")
WHITE      = colors.white
BLACK      = colors.black
RED_DARK   = HexColor("#C00000")

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

def make_style(name, parent="Normal", **kwargs):
    return ParagraphStyle(name=name, parent=styles[parent], **kwargs)

Title      = make_style("Title_", fontName="Helvetica-Bold",   fontSize=20,
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Subtitle   = make_style("Subtitle_", fontName="Helvetica-Bold", fontSize=14,
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SubInfo    = make_style("SubInfo_", fontName="Helvetica",       fontSize=10,
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H1         = make_style("H1_", fontName="Helvetica-Bold",       fontSize=13,
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H2         = make_style("H2_", fontName="Helvetica-Bold",       fontSize=11,
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H3         = make_style("H3_", fontName="Helvetica-BoldOblique",fontSize=10,
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Body       = make_style("Body_", fontName="Helvetica",          fontSize=9.5,
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BodyBold   = make_style("BodyBold_", fontName="Helvetica-Bold", fontSize=9.5,
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Bullet     = make_style("Bullet_", fontName="Helvetica",        fontSize=9.5,
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Bullet2    = make_style("Bullet2_", fontName="Helvetica",       fontSize=9,
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TableHdr   = make_style("TableHdr_", fontName="Helvetica-Bold", fontSize=8.5,
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TableCell  = make_style("TableCell_", fontName="Helvetica",     fontSize=8.5,
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TableCellC = make_style("TableCellC_", fontName="Helvetica",    fontSize=8.5,
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Caption    = make_style("Caption_", fontName="Helvetica-Oblique",fontSize=8,
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FooterSt   = make_style("Footer_", fontName="Helvetica",        fontSize=8,
                        textColor=colors.grey, alignment=TA_CENTER)

# ── Page template helpers ─────────────────────────────────────────────────────
PAGE_W, PAGE_H = A4
MARGIN_L, MARGIN_R, MARGIN_T, MARGIN_B = 2.5*cm, 2*cm, 2.5*cm, 2*cm

def header_footer(canvas, doc):
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    page_num = doc.page
    # Header bar
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        canvas.drawString(MARGIN_L + 2*mm, PAGE_H - MARGIN_T + 5*mm,
                          "STUDENT'S RESEARCH WORK  |  Community-Acquired Pneumonia")
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    canvas.drawCentredString(PAGE_W / 2, MARGIN_B - 8*mm,
                             "4th Year Faculty Therapy  |  Department of Internal Medicine  |  2025-2026")
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# ── Helpers ───────────────────────────────────────────────────────────────────
def h1_block(text):
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    tbl = Table([[Paragraph(text, H1)]], colWidths=[PAGE_W - MARGIN_L - MARGIN_R])
    tbl.setStyle(TableStyle([
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        ("BOTTOMPADDING",(0,0), (-1,-1), 5),
        ("ROWBACKGROUNDS", (0,0), (-1,-1), [BLUE_DARK]),
    ]))
    return tbl

def separator():
    return HRFlowable(width="100%", thickness=0.5, color=BLUE_LIGHT,
                      spaceAfter=4, spaceBefore=4)

def bp(text):
    """Bullet paragraph."""
    return Paragraph(u"\u2022  " + text, Bullet)

def make_table(headers, rows, col_widths=None):
    data = [[Paragraph(h, TableHdr) for h in headers]]
    for row in rows:
        data.append([Paragraph(str(c), TableCell) for c in row])
    total_w = PAGE_W - MARGIN_L - MARGIN_R
    if col_widths is None:
        n = len(headers)
        col_widths = [total_w / n] * n

    tbl = Table(data, colWidths=col_widths, repeatRows=1)
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    tbl.setStyle(TableStyle(style))
    return tbl


# ═════════════════════════════════════════════════════════════════════════════
# CONTENT
# ═════════════════════════════════════════════════════════════════════════════
story = []

# ── TITLE PAGE ────────────────────────────────────────────────────────────────
story.append(Spacer(1, 3*cm))
story.append(Paragraph("STUDENT'S RESEARCH WORK (UIR)", SubInfo))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph("4th Year  |  Faculty Therapy  |  Department of Internal Medicine", SubInfo))
story.append(Spacer(1, 1.5*cm))

# Decorative title box
title_tbl = Table(
    [[Paragraph("CLINICAL CASE REPORT", Title)],
     [Paragraph("Community-Acquired Pneumonia", Subtitle)],
     [Paragraph("(Streptococcus pneumoniae, Right Lower Lobe, Moderate Severity)", SubInfo)]],
    colWidths=[PAGE_W - MARGIN_L - MARGIN_R]
)
title_tbl.setStyle(TableStyle([
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    ("LEFTPADDING",   (0, 0), (-1, -1), 14),
    ("RIGHTPADDING",  (0, 0), (-1, -1), 14),
]))
story.append(title_tbl)
story.append(Spacer(1, 1.5*cm))

info_data = [
    ["Discipline:", "Faculty Therapy"],
    ["ICD-10 Code:", "J13 - Pneumonia due to Streptococcus pneumoniae"],
    ["Academic Year:", "2025-2026"],
    ["References:", "15 peer-reviewed sources (2021-2026)"],
]
info_tbl = Table(info_data, colWidths=[4*cm, PAGE_W - MARGIN_L - MARGIN_R - 4*cm])
info_tbl.setStyle(TableStyle([
    ("FONTNAME",      (0, 0), (0, -1), "Helvetica-Bold"),
    ("FONTNAME",      (1, 0), (1, -1), "Helvetica"),
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    ("BOTTOMPADDING", (0, 0), (-1,-1), 4),
    ("LINEBELOW",     (0, 0), (-1,-2), 0.3, GREY_MED),
]))
story.append(info_tbl)
story.append(PageBreak())


# ═══════════════════════════════════════════════════════════════════════
# SECTION 1 - RELEVANCE
# ═══════════════════════════════════════════════════════════════════════
story.append(h1_block("1.  RELEVANCE OF THE TOPIC"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph(
    "Community-acquired pneumonia (CAP) remains one of the most prevalent and potentially "
    "life-threatening infectious diseases worldwide. It is defined as an acute infection of the "
    "pulmonary parenchyma acquired outside a hospital setting, manifesting with symptoms and signs "
    "of lower respiratory tract infection accompanied by a new infiltrate on chest imaging.",
    Body))

story.append(Paragraph("1.1  Global Epidemiology", H2))
story.append(Paragraph(
    "According to the <b>Global Burden of Disease Study 2021</b>, lower respiratory infections - of "
    "which pneumonia is the dominant form - accounted for an estimated <b>344 million incident episodes "
    "globally in 2021</b>, with approximately <b>2.18 million deaths</b> (27.7 per 100,000 population). "
    "<i>Streptococcus pneumoniae</i> remains the single leading bacterial pathogen, responsible for "
    "97.9 million episodes and 505,000 deaths globally (GBD 2021 Collaborators, <i>Lancet Infect Dis,</i> 2024).",
    Body))

story.append(Paragraph(
    "In the United States, CAP accounts for approximately 7 healthcare visits per 1,000 young adults "
    "but 96 visits per 1,000 adults aged 85+. Hospitalisation rates escalate from 1-2 per 1,000 in "
    "young adults to nearly 40 per 1,000 among persons aged 85+. In-hospital mortality for hospitalised "
    "CAP is ~6%, rising to 15% by one month (<i>Goldman-Cecil Medicine, 27th ed.</i>).",
    Body))

story.append(Paragraph(
    "In Russia, the annual incidence of CAP in adults is estimated at 400-500 cases per 100,000 population, "
    "with excess morbidity and mortality during winter months coinciding with influenza circulation.",
    Body))

story.append(Paragraph("1.2  Why This Topic Is Significant", H2))
story.append(bp("CAP ranks 4th among the leading causes of death globally across all age groups."))
story.append(bp("Long-term complications are now recognised: cardiovascular events, persistent respiratory "
                "impairment, and cognitive decline lasting months after the acute episode "
                "(Reyes et al., <i>Lancet,</i> 2025)."))
story.append(bp("Rising antimicrobial resistance - particularly macrolide-resistant S. pneumoniae and "
                "MRSA - threatens standard empiric regimens."))
story.append(bp("The COVID-19 pandemic demonstrated the catastrophic public-health consequences when "
                "novel respiratory pathogens emerge without population immunity."))
story.append(bp("A substantial proportion of CAP deaths are preventable through vaccination against "
                "S. pneumoniae, influenza, and SARS-CoV-2, making accurate clinical recognition and "
                "evidence-based management essential."))
story.append(Spacer(1, 0.2*cm))


# ═══════════════════════════════════════════════════════════════════════
# SECTION 2 - LITERATURE REVIEW
# ═══════════════════════════════════════════════════════════════════════
story.append(h1_block("2.  LITERATURE REVIEW"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("2.1  Definition and Classification", H2))
story.append(Paragraph(
    "Pneumonia is an acute infection of the lung parenchyma characterised by alveolar consolidation, "
    "inflammatory exudate, and impaired gas exchange. Classification by acquisition setting is "
    "clinically relevant because it determines likely causative organisms and guides empiric therapy:",
    Body))
story.append(bp("<b>Community-acquired pneumonia (CAP)</b> - acquired outside hospital, or within 48 h "
                "of admission in a patient not residing in a long-term care facility."))
story.append(bp("<b>Hospital-acquired pneumonia (HAP)</b> - onset >=48 h after hospital admission."))
story.append(bp("<b>Ventilator-associated pneumonia (VAP)</b> - developing >=48 h after intubation."))
story.append(Paragraph(
    "By radiological pattern: lobar/segmental (typical bacterial), bronchopneumonia "
    "(patchy peribronchiolar), interstitial (viral/atypical), or cavitating.",
    Body))

story.append(Paragraph("2.2  Aetiology", H2))
story.append(Paragraph(
    "No pathogen is identified in >50% of CAP cases despite comprehensive testing. "
    "When a causative organism is confirmed, the most common agents are:",
    Body))

aetio_data = [
    ["Pathogen", "Frequency / Notes"],
    ["Streptococcus pneumoniae", "Most common bacterial cause; 30-40% of hospitalised adults"],
    ["Haemophilus influenzae", "Especially in COPD, smokers"],
    ["Staphylococcus aureus (incl. MRSA)", "Post-influenza pneumonia; severe CAP"],
    ["Gram-negative bacilli (Klebsiella, Pseudomonas)", "Structural lung disease, immunosuppression"],
    ["Atypical pathogens (Mycoplasma, Chlamydophila, Legionella)", "5-25% of CAP; Legionella linked to severe disease"],
    ["Respiratory viruses (influenza, SARS-CoV-2, RSV)", "20-30% of episodes; higher during pandemic years"],
]
story.append(make_table(["Pathogen", "Frequency / Notes"], aetio_data[1:],
                        col_widths=[8.5*cm, PAGE_W - MARGIN_L - MARGIN_R - 8.5*cm]))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("2.3  Pathophysiology", H2))
story.append(Paragraph(
    "The lung possesses a multilayered defence system: mucociliary clearance, alveolar macrophages, "
    "secretory IgA, and the cough reflex. Pneumonia results when these defences are overwhelmed by "
    "virulent microorganisms or impaired by host factors (smoking, diabetes, immunosuppression).",
    Body))
story.append(Paragraph(
    "Four classical stages of bacterial lobar pneumonia are described:",
    Body))
story.append(bp("<b>Congestion (0-24 h):</b> vascular engorgement, oedematous alveolar exudate, sparse bacteria."))
story.append(bp("<b>Red hepatisation (1-3 days):</b> massive neutrophil infiltration, erythrocytes, fibrin; "
                "lung becomes airless with liver-like consistency."))
story.append(bp("<b>Grey hepatisation (3-8 days):</b> erythrocytes lyse, fibrin dominates, fewer bacteria."))
story.append(bp("<b>Resolution (>8 days):</b> macrophages clear debris; full structural restoration in most cases."))
story.append(Paragraph(
    "Gas exchange abnormalities arise primarily from increased perfusion to consolidated (shunted) and "
    "low V/Q units. In mild-moderate pneumonia, shunt fraction averages 7.5% with low V/Q perfusion 4.2%; "
    "in severe pneumonia these figures approximately double (shunt 21.9%, low V/Q 10.9%), "
    "correlating directly with the degree of hypoxaemia "
    "(<i>Murray and Nadel's Textbook of Respiratory Medicine, 7th ed.</i>).",
    Body))

story.append(Paragraph("2.4  Clinical Presentation", H2))
story.append(Paragraph("Classic symptoms of CAP include:", Body))
story.append(bp("<b>Cough</b> - initially dry, then productive (purulent or rust-coloured sputum)."))
story.append(bp("<b>Fever</b> (>38 degrees C) with chills and rigors."))
story.append(bp("<b>Pleuritic chest pain</b> - sharp, worsened by inspiration/coughing; indicates pleural involvement."))
story.append(bp("<b>Dyspnoea</b> - ranging from exertional to rest dyspnoea in severe disease."))
story.append(bp("<b>Systemic symptoms:</b> fatigue, myalgia, headache - more prominent with atypical pathogens."))
story.append(Paragraph(
    "Physical signs: tachypnoea, tachycardia, fever. Over the affected lobe: crackles, bronchial breath "
    "sounds, egophony (patient says 'A', examiner hears 'E' - the E-to-A sign), dullness to percussion, "
    "increased tactile fremitus. No single finding is sufficiently specific to confirm pneumonia without imaging.",
    Body))

story.append(Paragraph("2.5  Diagnosis", H2))
story.append(Paragraph(
    "Diagnosis requires compatible clinical features <b>plus</b> a new infiltrate on chest imaging "
    "(<i>Goldman-Cecil Medicine, 27th ed.</i>).",
    Body))
story.append(Paragraph("Chest Imaging", H3))
story.append(Paragraph(
    "Chest X-ray (CXR) is the first-line study. Typical findings: lobar or segmental consolidation "
    "(suggesting S. pneumoniae, Klebsiella), bilateral patchy infiltrates (atypical/viral), interstitial "
    "pattern (viral), cavitation (anaerobes, MRSA, Klebsiella, tuberculosis). Parapneumonic effusion "
    "occurs in up to 60% of hospitalised CAP. CT thorax offers higher sensitivity/specificity but is "
    "not a first-line test - reserved for complex cases or suspected complications.",
    Body))

story.append(Paragraph("Laboratory Tests", H3))
lab_rows = [
    ["Complete blood count (CBC)", "Leucocytosis >12 x 10^9/L, neutrophilia = bacterial; leucopenia = poor prognosis"],
    ["CRP and Procalcitonin (PCT)", "Elevated in bacterial CAP; PCT <0.1 ug/L favours viral; guides antibiotic de-escalation"],
    ["Urea, creatinine, electrolytes", "Urea incorporated in CURB-65 severity score"],
    ["Blood cultures x2", "Yield 5-14%; collected before antibiotics in all hospitalised patients"],
    ["Sputum Gram stain and culture", "High specificity when >25 PMNs per low-power field; collected before antibiotics"],
    ["Urinary antigen tests", "Legionella (sensitivity 70-80%) and pneumococcal antigen"],
    ["Arterial blood gas / SpO2", "Hypoxaemia (SpO2 <92%) indicates severity; guides oxygen therapy"],
]
story.append(make_table(["Test", "Clinical Role"],
                        lab_rows,
                        col_widths=[5.5*cm, PAGE_W - MARGIN_L - MARGIN_R - 5.5*cm]))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("Severity Scoring - CURB-65", H3))
curb_rows = [
    ["C - Confusion (new onset)", "1"],
    ["U - Urea >7 mmol/L (BUN >19 mg/dL)", "1"],
    ["R - Respiratory Rate >=30 breaths/min", "1"],
    ["B - Blood Pressure: SBP <90 or DBP <=60 mmHg", "1"],
    ["65 - Age >=65 years", "1"],
]
story.append(make_table(["CURB-65 Variable", "Score"],
                        curb_rows,
                        col_widths=[12*cm, PAGE_W - MARGIN_L - MARGIN_R - 12*cm]))
story.append(Paragraph(
    "Interpretation: Score 0-1 = outpatient management;  Score 2 = consider hospital admission;  "
    "Score >=3 = high risk, ICU evaluation required.",
    Caption))

story.append(Paragraph("2.6  Antibiotic Treatment", H2))
story.append(Paragraph(
    "Antibiotics should be initiated promptly - ideally within 4 hours of presentation. "
    "Empiric regimens are guided by severity and setting (ATS/IDSA 2026 Guideline; "
    "Jones et al., <i>Am J Respir Crit Care Med,</i> 2026):",
    Body))
abx_rows = [
    ["Outpatient, no comorbidities",
     "Amoxicillin 500 mg TID  OR  Doxycycline 100 mg BID  OR  Azithromycin 500/250 mg",
     "5 days"],
    ["Outpatient, with comorbidities",
     "Respiratory fluoroquinolone (levofloxacin 750 mg OD / moxifloxacin 400 mg OD)  OR  beta-lactam + macrolide",
     "5-7 days"],
    ["Inpatient, non-severe",
     "Respiratory FQ  OR  beta-lactam (ceftriaxone 1-2 g IV OD) + macrolide/doxycycline",
     "5-7 days"],
    ["Inpatient, severe (ICU)",
     "beta-lactam + macrolide  OR  respiratory FQ; add vancomycin/linezolid if MRSA risk",
     "7-10 days"],
]
story.append(make_table(["Setting", "Recommended Regimen", "Duration"],
                        abx_rows,
                        col_widths=[4*cm, 10.5*cm, 2*cm]))
story.append(Spacer(1, 0.15*cm))
story.append(Paragraph(
    "Switch from IV to oral therapy is appropriate once the patient achieves clinical stability "
    "(temperature <=37.8 deg C, HR <100 bpm, RR <24/min, SpO2 >=90%, SBP >=90 mmHg, normal mentation).",
    Body))

story.append(Paragraph("2.7  Complications and Long-Term Outcomes", H2))
story.append(bp("<b>Pulmonary:</b> parapneumonic effusion (up to 60%), empyema thoracis (3-5%), "
                "lung abscess, respiratory failure/ARDS."))
story.append(bp("<b>Cardiovascular:</b> new atrial fibrillation, myocardial ischaemia, acute heart failure "
                "- occur in 20-25% of hospitalised patients."))
story.append(bp("<b>Sepsis and septic shock</b> in severe disease."))
story.append(bp("<b>Long-term:</b> persistent respiratory impairment, reduced exercise capacity, "
                "cognitive decline, increased cardiovascular risk for months after acute episode "
                "(Reyes et al., <i>Lancet,</i> 2025)."))

story.append(Paragraph("2.8  Prevention", H2))
story.append(bp("<b>Pneumococcal vaccination:</b> PCV20 (20-valent conjugate) recommended for adults "
                ">=65 years and high-risk individuals. Recent European guidelines endorse PCV20 for "
                "broader serotype coverage (Sotgiu et al., <i>Eur Respir Rev,</i> 2025)."))
story.append(bp("<b>Annual influenza vaccination</b> - reduces secondary bacterial pneumonia risk."))
story.append(bp("<b>COVID-19 vaccination</b> - reduces incidence of SARS-CoV-2 pneumonia."))
story.append(bp("<b>Smoking cessation,</b> optimisation of diabetes and chronic comorbidities."))
story.append(Spacer(1, 0.2*cm))


# ═══════════════════════════════════════════════════════════════════════
# SECTION 3 - CLINICAL CASE
# ═══════════════════════════════════════════════════════════════════════
story.append(PageBreak())
story.append(h1_block("3.  CLINICAL CASE PRESENTATION"))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("3.1  Patient Data", H2))
pt_rows = [
    ["Patient",        "Patient K. (anonymised per data protection requirements)"],
    ["Age",            "58 years"],
    ["Sex",            "Male"],
    ["Occupation",     "Office employee (sedentary work)"],
    ["Date of Admission", "Day 4 of illness"],
    ["Ward",           "Pulmonology / Faculty Therapy"],
    ["ICD-10 Code",    "J13 - Pneumonia due to Streptococcus pneumoniae"],
]
story.append(make_table(["Parameter", "Details"], pt_rows,
                        col_widths=[4.5*cm, PAGE_W - MARGIN_L - MARGIN_R - 4.5*cm]))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("3.2  Chief Complaints (Жалобы)", H2))
story.append(bp("Productive cough with rust-yellow purulent sputum - present for 4 days."))
story.append(bp("High fever up to 39.2 degrees C with rigors and night sweats."))
story.append(bp("Right-sided pleuritic chest pain: sharp, worsened by deep inspiration and coughing."))
story.append(bp("Progressive dyspnoea on minimal exertion."))
story.append(bp("Marked weakness, fatigue, decreased appetite."))
story.append(bp("Headache and myalgia during the first 2 days of illness."))

story.append(Paragraph("3.3  History of Present Illness (Anamnesis Morbi)", H2))
story.append(Paragraph(
    "The patient reports an <b>acute onset 4 days prior to admission.</b> Initially presented with "
    "a dry cough and low-grade fever (37.8 degrees C), which he self-treated with paracetamol, "
    "attributing symptoms to a common cold. By day 2, fever spiked to 39 degrees C, the cough "
    "became productive with rusty sputum, and right-sided pleuritic pain developed. He was reviewed "
    "by a general practitioner who prescribed amoxicillin 500 mg TID for outpatient treatment. "
    "Despite 2 days of antibiotics, fever persisted and dyspnoea worsened, prompting emergency "
    "hospital admission.",
    Body))

story.append(Paragraph("3.4  Past Medical History (Anamnesis Vitae)", H2))
story.append(Paragraph(
    "<b>Chronic diseases:</b> Type 2 diabetes mellitus (T2DM) diagnosed 5 years ago; "
    "on metformin 1000 mg BID; last HbA1c 7.4% (controlled but above target). "
    "<b>Smoking history:</b> active smoker, 30 pack-years. <b>Prior pneumonia:</b> none. "
    "<b>Drug allergies:</b> none known. <b>Vaccinations:</b> influenza vaccine last received "
    "3 years ago; pneumococcal vaccine never received.",
    Body))

story.append(Paragraph("3.5  Epidemiological History", H2))
story.append(Paragraph(
    "Works in a crowded open-plan office building. No contact with confirmed TB cases. "
    "No recent international travel. No zoonotic exposures. No COVID-19 vaccination in the past 12 months.",
    Body))

story.append(Paragraph("3.6  Objective Examination", H2))

story.append(Paragraph("General Condition", H3))
exam_rows = [
    ["General condition", "Moderate severity. Conscious, alert, fully oriented in time and place."],
    ["Position",          "Forced semi-recumbent; preference for lying on right side."],
    ["Temperature",       "39.0 degrees C"],
    ["Skin",              "Hyperaemic, moist. Herpes labialis on right upper lip."],
    ["BMI",               "84 kg / 176 cm = 27.1 kg/m2 (overweight)"],
    ["Cardiovascular",    "HR 102 bpm. BP 118/76 mmHg. Heart sounds rhythmic, muffled. No murmurs. No oedema."],
    ["Respiratory",       "RR 27/min. SpO2 91% room air."],
    ["Inspection",        "Right hemithorax lags in breathing. Subclavian fossae accentuated."],
    ["Palpation",         "Increased tactile fremitus over right lower lobe posteriorly."],
    ["Percussion",        "Dullness over right lower lobe (posterior and lateral zones)."],
    ["Auscultation",      "Coarse inspiratory crepitations + bronchial breath sounds over right lower lobe. "
                          "Egophony POSITIVE ('E-to-A' sign). Remainder: vesicular, no wheeze."],
    ["Abdomen",           "Soft, non-tender. Liver not enlarged."],
    ["Neurological",      "No focal deficits. No meningeal signs."],
]
story.append(make_table(["System / Finding", "Details"], exam_rows,
                        col_widths=[4.5*cm, PAGE_W - MARGIN_L - MARGIN_R - 4.5*cm]))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("3.7  Syndrome Identification", H2))
syn_rows = [
    ["Pulmonary consolidation",     "Dullness on percussion, bronchial breathing, egophony, increased tactile fremitus - right lower lobe"],
    ["Infectious-inflammatory",     "Fever 39 deg C, chills, leucocytosis 16.8 x 10^9/L, CRP 142 mg/L, PCT 1.8 ug/L, herpes labialis"],
    ["Respiratory failure (Gr. I)", "SpO2 91% room air, RR 27/min, PaO2 62 mmHg, dyspnoea at rest"],
    ["Pleuritic",                   "Sharp right-sided chest pain worsened by inspiration and coughing"],
    ["Intoxication",                "Weakness, headache, myalgia, anorexia"],
]
story.append(make_table(["Syndrome", "Clinical Evidence"], syn_rows,
                        col_widths=[5*cm, PAGE_W - MARGIN_L - MARGIN_R - 5*cm]))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("3.8  Preliminary Clinical Diagnosis", H2))
diag_box = Table(
    [[Paragraph(
        "<b>Right-sided lower lobe community-acquired pneumonia</b>, likely bacterial "
        "(S. pneumoniae), moderate severity (CURB-65 = 2), complicated by parapneumonic "
        "effusion. Respiratory failure Grade I. Background: Type 2 diabetes mellitus, "
        "active smoking (30 pack-years).",
        Body)]],
    colWidths=[PAGE_W - MARGIN_L - MARGIN_R]
)
diag_box.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), BLUE_PALE),
    ("LINEABOVE",     (0,0), (-1, 0), 2.5, BLUE_MID),
    ("LINEBELOW",     (0,0), (-1,-1), 2.5, BLUE_MID),
    ("LEFTPADDING",   (0,0), (-1,-1), 10),
    ("RIGHTPADDING",  (0,0), (-1,-1), 10),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
]))
story.append(diag_box)
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("3.9  Diagnostic Plan and Results", H2))
story.append(Paragraph("Laboratory Results", H3))
lab2_rows = [
    ["WBC",                  "16.8 x 10^9/L",    "4.0-10.0",     "HIGH - Leucocytosis"],
    ["Neutrophils",          "84%",               "47-72%",       "HIGH - Neutrophilia"],
    ["Lymphocytes",          "9%",                "19-37%",       "LOW - Lymphopenia"],
    ["Haemoglobin",          "138 g/L",           "130-170 g/L",  "Normal"],
    ["CRP",                  "142 mg/L",          "<5 mg/L",      "HIGH - Acute inflammation"],
    ["Procalcitonin (PCT)",  "1.8 ug/L",          "<0.5 ug/L",    "HIGH - Bacterial infection"],
    ["ESR",                  "56 mm/h",           "<15 mm/h",     "HIGH"],
    ["Serum urea",           "6.1 mmol/L",        "2.5-8.3",      "Normal"],
    ["Creatinine",           "88 umol/L",         "62-106",       "Normal"],
    ["Blood glucose",        "8.4 mmol/L",        "3.9-6.1",      "HIGH (T2DM background)"],
    ["SpO2 (room air)",      "91%",               ">95%",         "LOW - Hypoxaemia"],
    ["PaO2 (ABG)",           "62 mmHg",           ">80 mmHg",     "LOW - Type 1 resp. failure"],
    ["PaCO2 (ABG)",          "38 mmHg",           "35-45 mmHg",   "Normal"],
]
story.append(make_table(["Test", "Result", "Reference Range", "Interpretation"],
                        lab2_rows,
                        col_widths=[4.5*cm, 2.5*cm, 3*cm, 6.5*cm]))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("Microbiology", H3))
micro_rows = [
    ["Blood cultures x2",               "S. pneumoniae - penicillin-sensitive (MIC 0.06 ug/L)  [reported Day 3]"],
    ["Sputum Gram stain",               "Gram-positive diplococci in pairs/chains, >25 PMNs/LPF - consistent with S. pneumoniae"],
    ["Sputum culture",                  "S. pneumoniae  |  Penicillin S, Amoxicillin S, Ceftriaxone S"],
    ["Urinary pneumococcal antigen",    "POSITIVE"],
    ["Urinary Legionella antigen",      "Negative"],
    ["Influenza A/B rapid antigen",     "Negative"],
]
story.append(make_table(["Test", "Result"], micro_rows,
                        col_widths=[5.5*cm, PAGE_W - MARGIN_L - MARGIN_R - 5.5*cm]))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("Instrumental Results", H3))
inst_rows = [
    ["Chest X-ray (PA + lateral)",
     "Dense homogeneous consolidation of right lower lobe with air bronchogram. "
     "Blunting of right costophrenic angle - small parapneumonic pleural effusion. "
     "No cavitation. Mediastinum not widened."],
    ["Chest CT (Day 2 of admission)",
     "Confirmed right lower lobe consolidation. Estimated effusion volume 120 mL. "
     "No abscess. No PE. No malignancy identified."],
    ["ECG",
     "Sinus tachycardia 102 bpm. No ischaemic changes. QTc 420 ms (within normal limits)."],
    ["Echocardiography",
     "No pericardial effusion. LVEF 62%. Normal wall motion. No valvular pathology."],
]
story.append(make_table(["Investigation", "Result"], inst_rows,
                        col_widths=[4.5*cm, PAGE_W - MARGIN_L - MARGIN_R - 4.5*cm]))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("3.10  Final Clinical Diagnosis", H2))
final_diag = Table([
    [Paragraph("<b>Main Diagnosis:</b>", Body),
     Paragraph("Community-acquired pneumonia (<i>S. pneumoniae,</i> bacteraemic), "
               "right lower lobe, moderately severe. CURB-65 = 2. ICD-10: J13", Body)],
    [Paragraph("<b>Complications:</b>", Body),
     Paragraph("Parapneumonic right-sided pleural effusion (small, ~120 mL). "
               "Respiratory failure Grade I.", Body)],
    [Paragraph("<b>Concomitant:</b>", Body),
     Paragraph("Type 2 diabetes mellitus (HbA1c 7.4%, compensated). "
               "Active smoking, 30 pack-years.", Body)],
], colWidths=[3.5*cm, PAGE_W - MARGIN_L - MARGIN_R - 3.5*cm])
final_diag.setStyle(TableStyle([
    ("BACKGROUND",    (0, 0), (0, -1), BLUE_PALE),
    ("BACKGROUND",    (1, 0), (1, -1), WHITE),
    ("FONTNAME",      (0, 0), (0, -1), "Helvetica-Bold"),
    ("VALIGN",        (0, 0), (-1,-1), "TOP"),
    ("GRID",          (0, 0), (-1,-1), 0.4, BLUE_LIGHT),
    ("TOPPADDING",    (0, 0), (-1,-1), 5),
    ("BOTTOMPADDING", (0, 0), (-1,-1), 5),
    ("LEFTPADDING",   (0, 0), (-1,-1), 6),
    ("RIGHTPADDING",  (0, 0), (-1,-1), 6),
    ("LINEABOVE",     (0, 0), (-1, 0), 2, BLUE_MID),
    ("LINEBELOW",     (0,-1), (-1,-1), 2, BLUE_MID),
]))
story.append(final_diag)
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("3.11  Etiological and Risk Factors", H2))
risk_rows = [
    ["Etiological agent",
     "Streptococcus pneumoniae - confirmed by blood culture, sputum culture, and urinary antigen test"],
    ["Predisposing host factors",
     "Type 2 diabetes mellitus (impaired neutrophil chemotaxis/function); "
     "Active smoking 30 pack-years (mucociliary dysfunction, impaired alveolar macrophage activity); "
     "Age 58 (declining innate immunity)"],
    ["Risk factors for severity",
     "SpO2 91% on admission; RR 27/min; unvaccinated against S. pneumoniae; "
     "failure of outpatient amoxicillin (likely subtherapeutic or absorption issue)"],
    ["Resistance profile",
     "S. pneumoniae: fully penicillin-sensitive (MIC 0.06). No resistance risk factors identified."],
]
story.append(make_table(["Category", "Details"], risk_rows,
                        col_widths=[4*cm, PAGE_W - MARGIN_L - MARGIN_R - 4*cm]))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("3.12  Treatment Plan", H2))
story.append(Paragraph("Antibiotic Therapy", H3))
story.append(Paragraph(
    "Initial empiric therapy was IV ceftriaxone 2 g once daily, subsequently narrowed based on "
    "culture sensitivity results (S. pneumoniae, penicillin-sensitive):",
    Body))
story.append(bp("<b>Ceftriaxone 2 g IV OD</b> - Days 1-5 (empiric, then de-escalated guided by culture + PCT trend)."))
story.append(bp("Day 3 clinical stability met: switched to <b>Amoxicillin-clavulanate 875/125 mg PO BID.</b>"))
story.append(bp("<b>Total antibiotic duration: 7 days</b> (in line with ATS/IDSA 2026 guideline recommendation)."))

story.append(Paragraph("Supportive and Symptomatic Treatment", H3))
treat_rows = [
    ["Oxygen therapy",        "Nasal cannula 2-3 L/min; target SpO2 >=94%"],
    ["IV fluid therapy",      "0.9% NaCl 500 mL over 4 h on admission (hydration, antipyresis support)"],
    ["Antipyretic/analgesic", "Paracetamol 1 g IV Q6H PRN (temp >38.5 deg C or pain NRS >4)"],
    ["Mucolytic",             "Ambroxol 30 mg TID PO to facilitate sputum clearance"],
    ["Glycaemic management",  "Continuing metformin 1000 mg BID; capillary glucose QID; target fasting <8 mmol/L"],
    ["Thromboprophylaxis",    "Enoxaparin 40 mg SC OD (immobility + acute infectious state = elevated VTE risk)"],
    ["Physiotherapy",         "Breathing exercises and early mobilisation from Day 2; chest physiotherapy PRN"],
]
story.append(make_table(["Intervention", "Details"], treat_rows,
                        col_widths=[4.5*cm, PAGE_W - MARGIN_L - MARGIN_R - 4.5*cm]))
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("3.13  Clinical Course and Outcomes", H2))
course_rows = [
    ["Day 3 (inpatient)",
     "Fever subsided (T 37.1 deg C). Dyspnoea improved: SpO2 96% room air. "
     "WBC 9.8 x 10^9/L. PCT 0.4 ug/L. Clinical stability criteria met - "
     "switched to oral amoxicillin-clavulanate."],
    ["Day 5 (inpatient)",
     "Afebrile. Cough reducing in frequency and productive volume. "
     "Crepitations diminished on auscultation. SpO2 97% room air. "
     "Effusion resolving on bedside ultrasound."],
    ["Day 7 (discharge)",
     "Repeat CXR: partial resolution of consolidation (residual haziness expected - "
     "full radiological resolution may take 4-8 weeks). SpO2 97% room air. "
     "Patient discharged on oral antibiotics to complete 7-day course."],
]
story.append(make_table(["Timepoint", "Clinical Status"], course_rows,
                        col_widths=[3.5*cm, PAGE_W - MARGIN_L - MARGIN_R - 3.5*cm]))

outcome_box = Table(
    [[Paragraph(
        "<b>Outcome: Recovery.</b> No complications requiring further intervention. "
        "Discharge SpO2 97%. No cardiovascular events during admission.",
        Body)]],
    colWidths=[PAGE_W - MARGIN_L - MARGIN_R]
)
outcome_box.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), HexColor("#E2EFDA")),
    ("LINEABOVE",     (0,0), (-1, 0), 2, HexColor("#70AD47")),
    ("LINEBELOW",     (0,0), (-1,-1), 2, HexColor("#70AD47")),
    ("LEFTPADDING",   (0,0), (-1,-1), 10),
    ("TOPPADDING",    (0,0), (-1,-1), 6),
    ("BOTTOMPADDING", (0,0), (-1,-1), 6),
]))
story.append(Spacer(1, 0.15*cm))
story.append(outcome_box)
story.append(Spacer(1, 0.2*cm))

story.append(Paragraph("3.14  Discharge Recommendations", H2))
story.append(bp("Complete the antibiotic course (7 days total from Day 1 of inpatient treatment)."))
story.append(bp("Follow-up CXR in <b>4 weeks</b> to confirm radiological resolution and exclude occult malignancy."))
story.append(bp("Smoking cessation counselling and referral to a tobacco cessation clinic."))
story.append(bp("Pneumococcal vaccination (<b>PCV20</b>) at 4-6 weeks post-recovery."))
story.append(bp("Annual influenza vaccination."))
story.append(bp("Continue metformin; HbA1c recheck in 3 months; refer to endocrinologist for optimisation."))
story.append(bp("Return immediately if: renewed fever, worsening dyspnoea, haemoptysis, or chest pain."))
story.append(Spacer(1, 0.2*cm))


# ═══════════════════════════════════════════════════════════════════════
# SECTION 4 - REFERENCES
# ═══════════════════════════════════════════════════════════════════════
story.append(PageBreak())
story.append(h1_block("4.  REFERENCES"))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "All references are from peer-reviewed sources published within the last 5 years (2021-2026), "
    "in compliance with the assignment requirements.",
    Body))
story.append(Spacer(1, 0.15*cm))

refs = [
    ("1.", "GBD 2021 LRI and Antimicrobial Resistance Collaborators. Global, regional, and national "
           "incidence and mortality burden of non-COVID-19 lower respiratory infections and aetiologies, "
           "1990-2021: a systematic analysis. <i>Lancet Infect Dis.</i> 2024;24(9):974-1011. PMID: 38636536."),
    ("2.", "Reyes LF, Conway Morris A, Serrano-Mayorga C, et al. Community-acquired pneumonia. "
           "<i>Lancet.</i> 2025;406(10463):1874-1888. PMID: 41110447."),
    ("3.", "Jones BE, Ramirez JA, Oren E, et al. Diagnosis and Management of Community-acquired Pneumonia: "
           "An Official American Thoracic Society Clinical Practice Guideline. "
           "<i>Am J Respir Crit Care Med.</i> 2026;213(1):e1-e35. PMID: 40679934."),
    ("4.", "Dinh A, Barbier F, Bedos JP, et al. Update of guidelines for management of community-acquired "
           "pneumonia in adults (SPILF/SPLF). <i>Respir Med Res.</i> 2025;87:101138. PMID: 40037948."),
    ("5.", "Bai AD, Loeb M. Community-Acquired Pneumonia in Adults. "
           "<i>NEJM Evid.</i> 2025 Dec. PMID: 41288422."),
    ("6.", "Noguchi S, Katsurada M, Yatera K, et al. Utility of pneumonia severity assessment tools for "
           "mortality prediction in healthcare-associated pneumonia: a systematic review and meta-analysis. "
           "<i>Sci Rep.</i> 2024;14:12894. PMID: 38839837."),
    ("7.", "Ramirez JA, File TM. How to assess survival prognosis in patients hospitalized for "
           "community-acquired pneumonia in 2024? <i>Curr Opin Crit Care.</i> 2024;30:428-435. PMID: 39150039."),
    ("8.", "Piedepalumbo FV, Motos A, Blasi F, et al. Safety of steroids in severe community-acquired "
           "pneumonia. <i>Eur Respir Rev.</i> 2025;34:240176. PMID: 39778921."),
    ("9.", "Sotgiu G, Puci M, Bartoletti M, et al. Recommendations on PCV20 vaccine in adults and "
           "at-risk populations. <i>Eur Respir Rev.</i> 2025;34:250059. PMID: 41224370."),
    ("10.", "Omaggio L, Franzetti L, Caiazzo R, et al. Utility of CRP and procalcitonin in "
            "community-acquired pneumonia: a narrative review. "
            "<i>Curr Med Res Opin.</i> 2024;40:2157-2167. PMID: 39494704."),
    ("11.", "Rutkauskiene L, Kubilius R, Tamosauitis T, et al. Early mobilization, breathing exercises "
            "and chest wall oscillation in bilateral pneumonia in the ICU: a randomized clinical trial. "
            "<i>BMC Pulm Med.</i> 2025;25:435. PMID: 41286729."),
    ("12.", "Cilloniz C, Castaneda T, Campanella A, et al. Eosinopenia and prognosis in severe "
            "community-acquired pneumonia. <i>Pneumonia (Nathan).</i> 2026;18:10. PMID: 41877215."),
    ("13.", "Li Q, Zhou Q, Florez ID, et al. Short-Course vs Long-Course Antibiotic Therapy for Children "
            "with Nonsevere Community-Acquired Pneumonia: Systematic Review and Meta-analysis. "
            "<i>JAMA Pediatr.</i> 2022;176:1199-1210. PMID: 36374480."),
    ("14.", "Goldman-Cecil Medicine International Edition. 27th ed. Philadelphia: Elsevier; 2022. "
            "Chapter 85: Pneumonia. ISBN: 9780323930345."),
    ("15.", "Murray and Nadel's Textbook of Respiratory Medicine. 7th ed. Philadelphia: Elsevier; 2022. "
            "ISBN: 9780323655873."),
]

ref_style = ParagraphStyle("Ref", fontName="Helvetica", fontSize=9, leading=13,
                           spaceAfter=5, leftIndent=22, firstLineIndent=-22,
                           alignment=TA_JUSTIFY)
num_style = ParagraphStyle("RefNum", fontName="Helvetica-Bold", fontSize=9,
                           textColor=BLUE_MID)

for num, text in refs:
    story.append(Paragraph(f"<b><font color='#2E75B6'>{num}</font></b>  {text}", ref_style))

# ═══════════════════════════════════════════════════════════════════════
# BUILD
# ═══════════════════════════════════════════════════════════════════════
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=MARGIN_L,
    rightMargin=MARGIN_R,
    topMargin=MARGIN_T + 8*mm,   # extra for header bar
    bottomMargin=MARGIN_B + 6*mm,
    title="Clinical Case Report - Community-Acquired Pneumonia",
    author="4th Year Faculty Therapy Student",
    subject="Student Research Work (UIR)",
)

doc.build(story, onFirstPage=header_footer, onLaterPages=header_footer)
print(f"PDF created: {OUTPUT}")

"""
Clinical Report: Community-Acquired Pneumonia - COMPACT 2-PAGE VERSION
"""

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

OUTPUT = "/home/daytona/workspace/pneumonia-report/Pneumonia_2page.pdf"

# Colours
BLUE_DARK  = HexColor("#1F3864")
BLUE_MID   = HexColor("#2E75B6")
BLUE_LIGHT = HexColor("#BDD7EE")
BLUE_PALE  = HexColor("#DEEAF1")
GREEN_PALE = HexColor("#E2EFDA")
GREEN_MID  = HexColor("#70AD47")
WHITE      = colors.white
GREY_LIGHT = HexColor("#F5F5F5")

PAGE_W, PAGE_H = A4
ML, MR, MT, MB = 1.6*cm, 1.6*cm, 1.5*cm, 1.4*cm

# --- Styles (small font sizes to fit 2 pages) ---
def S(name, **kw):
    base = kw.pop("base", "Normal")
    defaults = dict(fontName="Helvetica", fontSize=7.8, leading=10.5,
                    spaceAfter=2, spaceBefore=0, alignment=TA_JUSTIFY)
    defaults.update(kw)
    return ParagraphStyle(name=name, **defaults)

TitleSt  = S("TitleSt",  fontName="Helvetica-Bold",  fontSize=13, textColor=WHITE,
             alignment=TA_CENTER, leading=16, spaceAfter=0)
SubSt    = S("SubSt",    fontName="Helvetica-Bold",  fontSize=8.5, textColor=WHITE,
             alignment=TA_CENTER, leading=11, spaceAfter=0)
H1St     = S("H1St",     fontName="Helvetica-Bold",  fontSize=8.5, textColor=WHITE,
             alignment=TA_LEFT, leading=11, spaceAfter=0, spaceBefore=0)
H2St     = S("H2St",     fontName="Helvetica-Bold",  fontSize=7.8, textColor=BLUE_DARK,
             alignment=TA_LEFT, leading=10, spaceAfter=1, spaceBefore=4)
BodySt   = S("BodySt",   fontSize=7.2, leading=9.8, spaceAfter=2)
BulSt    = S("BulSt",    fontSize=7.2, leading=9.8, spaceAfter=1,
             leftIndent=9, firstLineIndent=-7)
TblHSt   = S("TblHSt",  fontName="Helvetica-Bold", fontSize=7, textColor=WHITE,
             alignment=TA_CENTER, leading=9)
TblCSt   = S("TblCSt",  fontName="Helvetica", fontSize=7, leading=9,
             alignment=TA_LEFT, spaceAfter=0)
TblCCSt  = S("TblCCSt", fontName="Helvetica", fontSize=7, leading=9,
             alignment=TA_CENTER, spaceAfter=0)
RefSt    = S("RefSt",   fontSize=6.5, leading=8.5, spaceAfter=1.5,
             leftIndent=12, firstLineIndent=-10, alignment=TA_JUSTIFY)

# --- Helpers ---
TW = PAGE_W - ML - MR   # usable width

def h1(text):
    tbl = Table([[Paragraph(text, H1St)]], colWidths=[TW])
    tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), BLUE_DARK),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("RIGHTPADDING",  (0,0), (-1,-1), 5),
        ("TOPPADDING",    (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ]))
    return tbl

def h2(text):
    return Paragraph(text, H2St)

def body(text):
    return Paragraph(text, BodySt)

def bul(text):
    return Paragraph(u"\u2022 " + text, BulSt)

def sp(h=0.08):
    return Spacer(1, h*cm)

def mktbl(headers, rows, widths=None):
    if widths is None:
        n = len(headers)
        widths = [TW/n]*n
    data = [[Paragraph(h, TblHSt) for h in headers]]
    for row in rows:
        data.append([Paragraph(str(c), TblCSt) for c in row])
    t = Table(data, colWidths=widths, repeatRows=1)
    t.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1, 0), BLUE_MID),
        ("TEXTCOLOR",     (0,0), (-1, 0), WHITE),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [BLUE_PALE, WHITE]),
        ("GRID",          (0,0), (-1,-1), 0.3, BLUE_LIGHT),
        ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
        ("TOPPADDING",    (0,0), (-1,-1), 2),
        ("BOTTOMPADDING", (0,0), (-1,-1), 2),
        ("LEFTPADDING",   (0,0), (-1,-1), 3),
        ("RIGHTPADDING",  (0,0), (-1,-1), 3),
    ]))
    return t

def header_footer(canvas, doc):
    canvas.saveState()
    pn = doc.page
    # Top strip
    canvas.setFillColor(BLUE_DARK)
    canvas.rect(ML, PAGE_H - MT + 1*mm, TW, 5*mm, fill=1, stroke=0)
    canvas.setFillColor(WHITE)
    canvas.setFont("Helvetica-Bold", 6.5)
    canvas.drawString(ML+2*mm, PAGE_H - MT + 2.5*mm,
                      "STUDENT RESEARCH WORK  |  Community-Acquired Pneumonia  |  ICD-10: J13")
    canvas.drawRightString(ML+TW-2*mm, PAGE_H - MT + 2.5*mm, f"Page {pn} of 2")
    # Bottom line
    canvas.setStrokeColor(BLUE_LIGHT)
    canvas.setLineWidth(0.4)
    canvas.line(ML, MB - 3*mm, ML+TW, MB - 3*mm)
    canvas.setFillColor(colors.grey)
    canvas.setFont("Helvetica-Oblique", 6)
    canvas.drawCentredString(PAGE_W/2, MB - 5.5*mm,
                             "4th Year Faculty Therapy  |  Department of Internal Medicine  |  2025-2026")
    canvas.restoreState()

# =====================================================================
# PAGE 1  — Title + Sections 1, 2, Case (part 1)
# =====================================================================
story = []

# --- Title banner ---
title_tbl = Table(
    [[Paragraph("CLINICAL CASE REPORT: COMMUNITY-ACQUIRED PNEUMONIA", TitleSt)],
     [Paragraph("Streptococcus pneumoniae | Right Lower Lobe | Moderate Severity (CURB-65 = 2) | ICD-10: J13", SubSt)]],
    colWidths=[TW]
)
title_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), BLUE_DARK),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING",   (0,0), (-1,-1), 6),
    ("RIGHTPADDING",  (0,0), (-1,-1), 6),
    ("LINEBELOW",     (0,1), (-1,1),  2, BLUE_MID),
]))
story.append(title_tbl)
story.append(sp(0.15))

# ── TWO COLUMN LAYOUT: left = Sections 1+2, right = Case ──────────────
# Build left-column content
left = []

left.append(h1("1. RELEVANCE"))
left.append(sp())
left.append(body(
    "Community-acquired pneumonia (CAP) is a leading global cause of infectious disease "
    "morbidity and mortality. The <b>GBD Study 2021</b> estimated <b>344 million LRI episodes</b> "
    "and <b>2.18 million deaths</b> annually worldwide. <i>S. pneumoniae</i> accounts for 97.9 million "
    "episodes and 505,000 deaths (Lancet Infect Dis, 2024). CAP causes ~7 healthcare visits/1,000 "
    "in young adults but 96/1,000 in adults >85 yrs; in-hospital mortality is ~6%, rising to 15% at "
    "1 month (Goldman-Cecil Medicine, 27e). In Russia, incidence is 400-500/100,000 adults/year. "
    "Long-term complications (cardiovascular events, cognitive decline, respiratory impairment) "
    "are increasingly recognised (Reyes et al., Lancet, 2025)."))
left.append(sp())

left.append(h1("2. LITERATURE REVIEW"))
left.append(sp())
left.append(h2("Aetiology"))
left.append(body(
    "No pathogen identified in >50% of cases. When confirmed: <i>S. pneumoniae</i> (30-40% of "
    "hospitalised CAP), <i>H. influenzae</i>, <i>S. aureus</i>/MRSA (post-influenza), gram-negative "
    "bacilli, atypical organisms (<i>Mycoplasma, Chlamydophila, Legionella</i>; 5-25%), respiratory "
    "viruses (influenza, SARS-CoV-2, RSV; 20-30%)."))
left.append(sp())
left.append(h2("Pathophysiology"))
left.append(body(
    "Normal lung defences (mucociliary clearance, alveolar macrophages, sIgA) are overwhelmed. "
    "Four stages of lobar pneumonia: <b>congestion</b> (0-24 h) > <b>red hepatisation</b> (days 1-3, "
    "massive PMN infiltrate) > <b>grey hepatisation</b> (days 3-8, fibrin dominant) > "
    "<b>resolution</b> (>8 days). Gas exchange: increased perfusion to shunted/low-V/Q units; "
    "in severe CAP shunt fraction reaches ~22% (Murray & Nadel, 7e)."))
left.append(sp())
left.append(h2("Diagnosis"))
left.append(body(
    "Requires <b>clinical features + new chest infiltrate.</b> CXR first-line: lobar consolidation "
    "typical for S. pneumoniae; parapneumonic effusion in up to 60%. CBC (leucocytosis >12x10^9/L), "
    "CRP, PCT (>0.5 ug/L = bacterial), blood/sputum cultures, urinary antigens, ABG."))
left.append(sp())
left.append(mktbl(
    ["CURB-65 Variable", "Pts"],
    [["Confusion (new)", "1"],
     ["Urea >7 mmol/L", "1"],
     ["RR >=30/min", "1"],
     ["BP: SBP<90/DBP<=60", "1"],
     ["Age >=65 yrs", "1"]],
    widths=[4.2*cm, 0.8*cm]
))
left.append(body("<i>Score 0-1: outpatient | 2: admit | >=3: ICU evaluation</i>"))
left.append(sp())
left.append(h2("Treatment"))
left.append(mktbl(
    ["Setting", "Regimen", "Days"],
    [["Outpatient", "Amoxicillin / Doxycycline / Azithromycin", "5"],
     ["Inpatient", "Respiratory FQ OR beta-lactam + macrolide", "5-7"],
     ["Severe/ICU", "beta-lactam + macrolide; +vancomycin if MRSA risk", "7-10"]],
    widths=[2.2*cm, 6.0*cm, 0.8*cm]
))
left.append(sp())
left.append(h2("Prevention"))
left.append(body(
    "PCV20 pneumococcal vaccine (Sotgiu et al., Eur Respir Rev, 2025); annual influenza vaccine; "
    "COVID-19 vaccine; smoking cessation; glycaemic optimisation."))

# Build right-column content
right = []

right.append(h1("3. CLINICAL CASE"))
right.append(sp())
right.append(h2("Patient Profile"))
right.append(mktbl(
    ["Parameter", "Details"],
    [["Age / Sex", "58-year-old male"],
     ["Occupation", "Office employee"],
     ["PMH", "T2DM (metformin); smoker 30 pack-yrs; no prior pneumonia"],
     ["Vaccinations", "No pneumococcal; influenza 3 yrs ago"],
     ["Admission", "Day 4 of illness"]],
    widths=[2.5*cm, 6.1*cm]
))
right.append(sp())
right.append(h2("Chief Complaints"))
right.append(bul("Productive cough with rust-yellow sputum x 4 days"))
right.append(bul("Fever 39.2 deg C, chills, night sweats"))
right.append(bul("Right-sided pleuritic chest pain (worse on inspiration)"))
right.append(bul("Dyspnoea on minimal exertion; fatigue; myalgia"))
right.append(sp())
right.append(h2("Examination"))
right.append(mktbl(
    ["Finding", "Result"],
    [["Temperature", "39.0 deg C"],
     ["HR / BP", "102 bpm  |  118/76 mmHg"],
     ["RR / SpO2", "27/min  |  91% (room air)"],
     ["Percussion", "Dullness - right lower lobe"],
     ["Auscultation", "Crepitations + bronchial breathing + egophony (E-to-A) - RLL"],
     ["Tactile fremitus", "Increased over right lower lobe"]],
    widths=[3.1*cm, 5.5*cm]
))
right.append(sp())
right.append(h2("Syndromes Identified"))
right.append(bul("<b>Pulmonary consolidation</b> - dullness, bronchial breathing, egophony, increased fremitus"))
right.append(bul("<b>Infectious-inflammatory</b> - fever, leucocytosis, elevated CRP/PCT"))
right.append(bul("<b>Respiratory failure Gr. I</b> - SpO2 91%, RR 27/min, PaO2 62 mmHg"))
right.append(bul("<b>Pleuritic</b> - sharp right chest pain on inspiration"))
right.append(sp())
right.append(h2("Laboratory Results"))
right.append(mktbl(
    ["Test", "Result", "Interp."],
    [["WBC", "16.8 x10^9/L", "HIGH"],
     ["Neutrophils", "84%", "HIGH"],
     ["CRP", "142 mg/L", "HIGH"],
     ["PCT", "1.8 ug/L", "HIGH"],
     ["PaO2 (ABG)", "62 mmHg", "LOW"],
     ["SpO2", "91%", "LOW"],
     ["Glucose", "8.4 mmol/L", "HIGH (T2DM)"]],
    widths=[2.8*cm, 2.5*cm, 3.3*cm]
))
right.append(sp())
right.append(h2("Microbiology"))
right.append(mktbl(
    ["Test", "Result"],
    [["Blood cultures x2", "S. pneumoniae - penicillin SENSITIVE"],
     ["Sputum culture", "S. pneumoniae (amoxicillin S, ceftriaxone S)"],
     ["Urinary pneumococcal Ag", "POSITIVE"],
     ["Urinary Legionella Ag", "Negative"],
     ["Influenza A/B rapid Ag", "Negative"]],
    widths=[3.6*cm, 5.0*cm]
))
right.append(sp())
right.append(h2("Imaging"))
right.append(body(
    "<b>CXR:</b> Dense homogeneous right lower lobe consolidation with air bronchogram. "
    "Blunting of right costophrenic angle (parapneumonic effusion ~120 mL). No cavitation. "
    "<b>CT chest:</b> Confirmed consolidation + effusion. No abscess, no PE, no malignancy. "
    "<b>ECG:</b> Sinus tachycardia 102 bpm; QTc 420 ms. <b>Echo:</b> LVEF 62%, no pericardial effusion."))

# --- Combine into two-column table ---
# Convert each list of flowables to a nested table cell
def nest(flowables, width):
    """Wrap a list of flowables in a single-cell table for column layout."""
    # We render each flowable as a mini-doc by wrapping in a table
    from reportlab.platypus import KeepInFrame
    frame = KeepInFrame(width, 100*cm, flowables, mode='shrink')
    return frame

LW = TW * 0.45 - 0.1*cm
RW = TW * 0.55 - 0.1*cm

from reportlab.platypus import KeepInFrame

left_frame  = KeepInFrame(LW, 100*cm, left,  mode='shrink')
right_frame = KeepInFrame(RW, 100*cm, right, mode='shrink')

two_col = Table([[left_frame, right_frame]],
                colWidths=[LW, RW])
two_col.setStyle(TableStyle([
    ("VALIGN",       (0,0), (-1,-1), "TOP"),
    ("LEFTPADDING",  (0,0), (-1,-1), 0),
    ("RIGHTPADDING", (0,0), (-1,-1), 0),
    ("TOPPADDING",   (0,0), (-1,-1), 0),
    ("BOTTOMPADDING",(0,0), (-1,-1), 0),
    ("LINEBETWEEN",  (0,0), (0,-1),  0.5, BLUE_LIGHT),
]))
story.append(two_col)

# =====================================================================
# PAGE 2  — Treatment, Outcome, Diagnosis, References
# =====================================================================
story.append(PageBreak())

# --- Full-width: Final Diagnosis box ---
story.append(h1("FINAL CLINICAL DIAGNOSIS  |  TREATMENT  |  OUTCOME  |  REFERENCES"))
story.append(sp(0.1))

diag_box = Table([[Paragraph(
    "<b>Main:</b> Community-acquired pneumonia (<i>S. pneumoniae,</i> bacteraemic), right lower lobe, "
    "moderately severe, CURB-65 = 2. ICD-10: J13.  "
    "<b>Complications:</b> Parapneumonic right-sided pleural effusion (~120 mL); Respiratory failure Gr. I.  "
    "<b>Background:</b> T2DM (HbA1c 7.4%); active smoking 30 pack-years.", BodySt)]],
    colWidths=[TW])
diag_box.setStyle(TableStyle([
    ("BACKGROUND",    (0,0),(-1,-1), BLUE_PALE),
    ("LINEABOVE",     (0,0),(-1, 0), 2, BLUE_MID),
    ("LINEBELOW",     (0,0),(-1,-1), 2, BLUE_MID),
    ("TOPPADDING",    (0,0),(-1,-1), 5),
    ("BOTTOMPADDING", (0,0),(-1,-1), 5),
    ("LEFTPADDING",   (0,0),(-1,-1), 7),
    ("RIGHTPADDING",  (0,0),(-1,-1), 7),
]))
story.append(diag_box)
story.append(sp(0.12))

# --- Two columns on page 2: Treatment + Etiological Factors | Clinical Course + References ---
left2 = []
right2 = []

# LEFT: Treatment plan
left2.append(h2("Treatment Plan"))
left2.append(mktbl(
    ["Intervention", "Details"],
    [["Antibiotics",
      "Ceftriaxone 2 g IV OD (days 1-5), then Amoxicillin-clavulanate 875/125 mg PO BID to complete 7-day course. "
      "De-escalated on Day 3 after culture sensitivity (pen-sensitive S. pneumoniae) + PCT 0.4 ug/L."],
     ["O2 therapy",
      "Nasal cannula 2-3 L/min; target SpO2 >=94%"],
     ["Antipyretic",
      "Paracetamol 1 g IV Q6H PRN (temp >38.5 deg C)"],
     ["Mucolytic",
      "Ambroxol 30 mg TID PO"],
     ["Glycaemic",
      "Metformin continued; capillary glucose QID; target fasting <8 mmol/L"],
     ["VTE prophylaxis",
      "Enoxaparin 40 mg SC OD"],
     ["Physiotherapy",
      "Breathing exercises + early mobilisation from Day 2"]],
    widths=[2.3*cm, LW - 2.5*cm]
))
left2.append(sp())
left2.append(h2("Etiological and Risk Factors"))
left2.append(mktbl(
    ["Category", "Factors"],
    [["Etiological agent", "S. pneumoniae (confirmed blood/sputum culture, urinary antigen)"],
     ["Predisposing", "T2DM (impaired neutrophil function); smoking (mucociliary dysfunction); age 58"],
     ["Severity risk", "SpO2 91%; RR 27/min; unvaccinated; outpatient amoxicillin failure"],
     ["Resistance", "No resistance: MIC penicillin 0.06 ug/L - fully sensitive"]],
    widths=[2.3*cm, LW - 2.5*cm]
))
left2.append(sp())
left2.append(h2("Discharge Recommendations"))
left2.append(bul("Complete 7-day antibiotic course"))
left2.append(bul("Follow-up CXR in 4 weeks (confirm resolution, exclude malignancy)"))
left2.append(bul("PCV20 pneumococcal vaccination at 4-6 weeks post-recovery"))
left2.append(bul("Annual influenza vaccination"))
left2.append(bul("Smoking cessation referral"))
left2.append(bul("HbA1c recheck in 3 months; endocrinology review"))

# RIGHT: Clinical course + references
right2.append(h2("Clinical Course and Outcome"))
right2.append(mktbl(
    ["Day", "Status"],
    [["Day 3", "Fever resolved (37.1 deg C). SpO2 96% room air. WBC 9.8x10^9/L. "
               "PCT 0.4 ug/L. Clinical stability met - switched to oral antibiotics."],
     ["Day 5", "Afebrile. Cough improving. Crepitations diminished. SpO2 97%. "
               "Effusion reducing on bedside USS."],
     ["Day 7 (DC)", "Partial CXR resolution. SpO2 97% room air. Discharged on oral "
                    "antibiotics to complete course."]],
    widths=[1.2*cm, RW - 1.4*cm]
))
right2.append(sp(0.08))

outcome_box = Table([[Paragraph(
    "<b>Outcome: RECOVERY.</b> No cardiovascular events. No empyema. "
    "No mechanical ventilation required. Discharged Day 7.", BodySt)]],
    colWidths=[RW])
outcome_box.setStyle(TableStyle([
    ("BACKGROUND",    (0,0),(-1,-1), GREEN_PALE),
    ("LINEABOVE",     (0,0),(-1, 0), 1.5, GREEN_MID),
    ("LINEBELOW",     (0,0),(-1,-1), 1.5, GREEN_MID),
    ("TOPPADDING",    (0,0),(-1,-1), 4),
    ("BOTTOMPADDING", (0,0),(-1,-1), 4),
    ("LEFTPADDING",   (0,0),(-1,-1), 5),
    ("RIGHTPADDING",  (0,0),(-1,-1), 5),
]))
right2.append(outcome_box)
right2.append(sp(0.1))

right2.append(h1("REFERENCES  (2021-2026)"))
right2.append(sp(0.05))

refs = [
    "1. GBD 2021 LRI Collaborators. Global burden of non-COVID-19 LRI 1990-2021. <i>Lancet Infect Dis.</i> 2024;24:974. PMID:38636536.",
    "2. Reyes LF et al. Community-acquired pneumonia. <i>Lancet.</i> 2025;406:1874. PMID:41110447.",
    "3. Jones BE et al. ATS Clinical Practice Guideline: CAP diagnosis and management. <i>Am J Respir Crit Care Med.</i> 2026;213:e1. PMID:40679934.",
    "4. Dinh A et al. SPILF/SPLF CAP guidelines update. <i>Respir Med Res.</i> 2025;87:101138. PMID:40037948.",
    "5. Bai AD, Loeb M. Community-Acquired Pneumonia in Adults. <i>NEJM Evid.</i> 2025. PMID:41288422.",
    "6. Noguchi S et al. Pneumonia severity tools and mortality: systematic review. <i>Sci Rep.</i> 2024;14:12894. PMID:38839837.",
    "7. Ramirez JA, File TM. Prognosis assessment in hospitalised CAP 2024. <i>Curr Opin Crit Care.</i> 2024;30:428. PMID:39150039.",
    "8. Piedepalumbo FV et al. Steroids in severe CAP. <i>Eur Respir Rev.</i> 2025;34:240176. PMID:39778921.",
    "9. Sotgiu G et al. PCV20 vaccine recommendations. <i>Eur Respir Rev.</i> 2025;34:250059. PMID:41224370.",
    "10. Omaggio L et al. CRP and PCT in CAP: narrative review. <i>Curr Med Res Opin.</i> 2024;40:2157. PMID:39494704.",
    "11. Rutkauskiene L et al. Early mobilisation in bilateral pneumonia ICU: RCT. <i>BMC Pulm Med.</i> 2025;25:435. PMID:41286729.",
    "12. Cilloniz C et al. Eosinopenia and prognosis in severe CAP. <i>Pneumonia.</i> 2026;18:10. PMID:41877215.",
    "13. Li Q et al. Short vs long antibiotic therapy in CAP: meta-analysis. <i>JAMA Pediatr.</i> 2022;176:1199. PMID:36374480.",
    "14. Goldman-Cecil Medicine. 27th ed. Elsevier; 2022. Ch.85: Pneumonia. ISBN:9780323930345.",
    "15. Murray and Nadel's Textbook of Respiratory Medicine. 7th ed. Elsevier; 2022. ISBN:9780323655873.",
]
for ref in refs:
    right2.append(Paragraph(ref, RefSt))

# Assemble page 2 two-column
LW2 = TW * 0.48
RW2 = TW * 0.52

from reportlab.platypus import KeepInFrame as KIF

lf2 = KIF(LW2 - 0.1*cm, 100*cm, left2,  mode='shrink')
rf2 = KIF(RW2 - 0.1*cm, 100*cm, right2, mode='shrink')

two_col2 = Table([[lf2, rf2]], colWidths=[LW2, RW2])
two_col2.setStyle(TableStyle([
    ("VALIGN",       (0,0),(-1,-1), "TOP"),
    ("LEFTPADDING",  (0,0),(-1,-1), 0),
    ("RIGHTPADDING", (0,0),(-1,-1), 0),
    ("TOPPADDING",   (0,0),(-1,-1), 0),
    ("BOTTOMPADDING",(0,0),(-1,-1), 0),
    ("LINEBETWEEN",  (0,0),(0,-1),  0.5, BLUE_LIGHT),
]))
story.append(two_col2)

# =====================================================================
# BUILD
# =====================================================================
doc = SimpleDocTemplate(
    OUTPUT, pagesize=A4,
    leftMargin=ML, rightMargin=MR,
    topMargin=MT + 7*mm, bottomMargin=MB + 5*mm,
    title="Clinical Case Report - CAP (2-page)",
    author="4th Year Faculty Therapy",
)
doc.build(story, onFirstPage=header_footer, onLaterPages=header_footer)
print(f"PDF created: {OUTPUT}")