const pptxgen = require("pptxgenjs");
const pres = new pptxgen();

pres.layout = "LAYOUT_WIDE";
pres.title = "Peripheral Vascular Disease - Case Presentation";
pres.author = "PG General Surgery";

// ─── PALETTE ───────────────────────────────────────────────────────────────
const C = {
  darkBg:    "0A1628",   // deep navy
  midBg:     "112240",   // slightly lighter navy
  accent:    "E63946",   // arterial red
  accentSoft:"C1121F",   // deeper red
  gold:      "F4A261",   // warm amber / highlight
  lightText: "EDF2F4",   // near-white
  subText:   "A8DADC",   // teal-gray
  white:     "FFFFFF",
  tableHdr:  "C1121F",
  tableBand: "1A2F4F",
  green:     "2DC653",
  yellow:    "FFD166",
};

// ─── HELPERS ─────────────────────────────────────────────────────────────────

function addSlideHeader(slide, title, sub) {
  // dark top bar
  slide.addShape(pres.ShapeType.rect, {
    x:0, y:0, w:13.3, h:0.85,
    fill: { color: C.accent }
  });
  slide.addText(title.toUpperCase(), {
    x:0.25, y:0.05, w:12.8, h:0.75,
    fontSize:22, bold:true, color:C.white,
    fontFace:"Calibri", align:"left", valign:"middle", margin:0
  });
  if (sub) {
    slide.addText(sub, {
      x:0.25, y:0.83, w:12.8, h:0.32,
      fontSize:11, color:C.subText, italic:true,
      fontFace:"Calibri", align:"left", valign:"middle", margin:0
    });
  }
  // bottom bar
  slide.addShape(pres.ShapeType.rect, {
    x:0, y:7.25, w:13.3, h:0.25,
    fill: { color: C.accentSoft }
  });
  slide.addText("PG General Surgery Case Presentation   |   Peripheral Vascular Disease", {
    x:0.2, y:7.26, w:12.9, h:0.2,
    fontSize:8, color:C.white, fontFace:"Calibri", align:"left", valign:"middle", margin:0
  });
}

function bulletSlide(slide, items, x, y, w, h, opts={}) {
  const rows = items.map((it, i) => {
    const isLast = i === items.length - 1;
    return {
      text: (it.indent ? "    \u25E6  " : "\u25CF  ") + it.text,
      options: {
        fontSize: opts.fontSize || 14,
        color: it.highlight ? C.gold : (it.indent ? C.subText : C.lightText),
        bold: it.bold || false,
        breakLine: !isLast,
        fontFace: "Calibri"
      }
    };
  });
  slide.addText(rows, { x, y, w, h, valign:"top", margin:4 });
}

// ─── SLIDE 1: TITLE ─────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  // decorative arc
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:4.5, h:7.5, fill:{ color:C.midBg } });
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:4.5, h:0.06, fill:{ color:C.accent } });
  // left panel text
  s.addText("CASE\nPRESENTATION", {
    x:0.2, y:0.6, w:4.1, h:2.0,
    fontSize:28, bold:true, color:C.accent, fontFace:"Calibri",
    align:"center", valign:"middle"
  });
  s.addText([
    { text: "PG General Surgery", options:{ fontSize:13, color:C.subText, breakLine:true } },
    { text: "Department of Surgery", options:{ fontSize:12, color:C.subText } }
  ], { x:0.2, y:6.8, w:4.1, h:0.6, align:"center", fontFace:"Calibri" });

  // main title
  s.addText("PERIPHERAL\nVASCULAR\nDISEASE", {
    x:5.0, y:1.0, w:7.9, h:3.5,
    fontSize:44, bold:true, color:C.lightText,
    fontFace:"Calibri", align:"left", valign:"middle"
  });
  s.addShape(pres.ShapeType.rect, { x:5.0, y:4.6, w:7.5, h:0.06, fill:{ color:C.accent } });
  s.addText("A Comprehensive Clinical Review", {
    x:5.0, y:4.7, w:7.9, h:0.5,
    fontSize:16, color:C.gold, fontFace:"Calibri", italic:true
  });
  s.addText([
    { text: "Sources: ", options:{ bold:true, color:C.gold } },
    { text: "Bailey & Love 28e  •  S. Das Manual of Clinical Surgery 13e\nSchwartz's Principles of Surgery 11e  •  Sabiston Textbook of Surgery\nCurrent Surgical Therapy 14e", options:{ color:C.subText } }
  ], { x:5.0, y:5.4, w:8.0, h:1.6, fontSize:11, fontFace:"Calibri" });
}

// ─── SLIDE 2: CASE VIGNETTE ──────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Case Vignette", "Setting the Clinical Stage");

  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.05, w:12.7, h:5.9, fill:{ color:C.midBg }, line:{ color:C.accent, pt:1.5 } });

  s.addText("PRESENTING COMPLAINT", {
    x:0.5, y:1.15, w:12.3, h:0.35,
    fontSize:12, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:2
  });
  s.addText([
    { text: "Mr. X", options:{ bold:true, color:C.gold } },
    { text: ", 58-year-old male, chronic smoker (40 pack-years), known diabetic & hypertensive,\npresents with:", options:{ color:C.lightText } }
  ], { x:0.5, y:1.55, w:12.3, h:0.75, fontSize:13, fontFace:"Calibri" });

  const complaints = [
    { text: "Pain in both calves on walking ~200 metres — relieved by rest (claudication distance: 200 m)", bold:true },
    { text: "Pain at rest in left foot for the past 3 weeks, worse at night, partially relieved by hanging the foot down" },
    { text: "Non-healing ulcer on the dorsum of left foot — present for 6 weeks" },
    { text: "Blackish discolouration of left 1st toe — noticed 2 weeks ago" },
  ];
  bulletSlide(s, complaints, 0.5, 2.3, 12.3, 2.2, { fontSize:13 });

  s.addText("RELEVANT HISTORY", {
    x:0.5, y:4.55, w:12.3, h:0.35,
    fontSize:12, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:2
  });
  const hist = [
    { text: "DM Type 2 — 12 years, on oral hypoglycaemics; Hypertension — 8 years; Smoker since age 18" },
    { text: "H/o similar but milder claudication symptoms 2 years ago — managed conservatively" },
    { text: "No h/o trauma, cardiac surgery, or previous vascular intervention" },
  ];
  bulletSlide(s, hist, 0.5, 4.95, 12.3, 1.8, { fontSize:12 });
}

// ─── SLIDE 3: DEFINITIONS & CLASSIFICATION ───────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Definitions & Classification", "Bailey & Love 28e | S. Das 13e");

  // Definition box
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.1, w:12.7, h:1.3, fill:{ color:C.midBg }, line:{ color:C.accent, pt:1.5 } });
  s.addText([
    { text: "DEFINITION  ", options:{ bold:true, color:C.gold } },
    { text: "Peripheral Vascular Disease (PVD) is a spectrum of disorders of the peripheral circulation arising from structural or functional abnormalities of the arteries, veins, or lymphatics — most commonly due to atherosclerosis causing chronic ischaemia of the lower limbs.", options:{ color:C.lightText } }
  ], { x:0.5, y:1.15, w:12.3, h:1.15, fontSize:12.5, fontFace:"Calibri", valign:"middle" });

  // Fontaine Classification table
  s.addText("FONTAINE'S CLASSIFICATION (Chronic Limb Ischaemia)", {
    x:0.3, y:2.55, w:12.7, h:0.35,
    fontSize:12, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:2
  });

  const fontaineRows = [
    ["Stage", "Clinical Features", "ABI"],
    ["Stage I", "Asymptomatic — vessel disease present but no symptoms", "> 0.9"],
    ["Stage IIa", "Mild claudication — claudication distance > 200 m", "0.7 – 0.9"],
    ["Stage IIb", "Moderate-severe claudication — distance ≤ 200 m", "0.5 – 0.7"],
    ["Stage III", "Ischaemic rest pain — nocturnal, relieved by dependency", "< 0.5"],
    ["Stage IV", "Ulceration / Gangrene — tissue loss, non-healing wounds", "< 0.3"],
  ];
  s.addTable(fontaineRows.map((row, ri) => row.map((cell, ci) => ({
    text: cell,
    options: {
      bold: ri === 0,
      color: ri === 0 ? C.white : (ri >= 4 ? C.gold : C.lightText),
      fill: ri === 0 ? C.tableHdr : (ri % 2 === 0 ? C.tableBand : C.midBg),
      align: ci === 0 ? "center" : "left",
      fontSize: ri === 0 ? 12 : 11,
      fontFace:"Calibri"
    }
  }))), { x:0.3, y:2.95, w:12.7, colW:[1.5, 8.5, 2.7], rowH:0.42, border:{ type:"solid", color:"334466", pt:0.5 } });

  s.addText("Rutherford Classification also widely used (Categories 0–6, Classes I–III) — correlates with Fontaine stages", {
    x:0.3, y:5.75, w:12.7, h:0.35,
    fontSize:10.5, color:C.subText, italic:true, fontFace:"Calibri"
  });

  // TASC II note
  s.addShape(pres.ShapeType.rect, { x:0.3, y:6.15, w:12.7, h:0.85, fill:{ color:"1A2F4F" }, line:{ color:C.gold, pt:1 } });
  s.addText([
    { text: "TASC II Classification", options:{ bold:true, color:C.gold } },
    { text: " — Classifies lesions A–D based on morphology for endovascular vs. surgical decision making:\n", options:{ color:C.lightText } },
    { text: "Type A: single stenosis <3 cm → best for PTA | Type D: extensive disease → surgery preferred", options:{ color:C.subText, italic:true } }
  ], { x:0.5, y:6.18, w:12.3, h:0.8, fontSize:11, fontFace:"Calibri", valign:"middle" });
}

// ─── SLIDE 4: AETIOLOGY & RISK FACTORS ──────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Aetiology & Risk Factors", "Schwartz 11e | Bailey & Love 28e");

  // Left column
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.1, w:6.1, h:5.9, fill:{ color:C.midBg }, line:{ color:C.accent, pt:1 } });
  s.addText("CAUSES OF PVD", {
    x:0.5, y:1.15, w:5.7, h:0.38, fontSize:13, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:2
  });
  const causes = [
    { text: "OCCLUSIVE (commonest)", bold:true, highlight:true },
    { text: "Atherosclerosis — most common cause (>90%)", indent:true },
    { text: "Thromboangiitis obliterans (Buerger's disease)", indent:true },
    { text: "Arterial embolism (acute)", indent:true },
    { text: "Acute-on-chronic thrombosis", indent:true },
    { text: "INFLAMMATORY / VASCULITIS", bold:true, highlight:true },
    { text: "Takayasu's arteritis", indent:true },
    { text: "Temporal (giant cell) arteritis", indent:true },
    { text: "Polyarteritis nodosa, SLE, RA", indent:true },
    { text: "FUNCTIONAL / VASOSPASTIC", bold:true, highlight:true },
    { text: "Raynaud's disease / syndrome", indent:true },
    { text: "Acrocyanosis, livedo reticularis", indent:true },
    { text: "OTHER", bold:true, highlight:true },
    { text: "Popliteal entrapment, cystic adventitial disease", indent:true },
    { text: "Cervical rib / thoracic outlet syndrome", indent:true },
  ];
  bulletSlide(s, causes, 0.5, 1.6, 5.7, 5.2, { fontSize:11.5 });

  // Right column
  s.addShape(pres.ShapeType.rect, { x:6.9, y:1.1, w:6.1, h:5.9, fill:{ color:C.midBg }, line:{ color:C.gold, pt:1 } });
  s.addText("RISK FACTORS (Atherosclerosis)", {
    x:7.1, y:1.15, w:5.7, h:0.38, fontSize:13, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:2
  });

  const riskRows = [
    ["NON-MODIFIABLE", ""],
    ["Age >50 years", "Male gender"],
    ["Family history", "Race (higher in S. Asians)"],
    ["MODIFIABLE", ""],
    ["Cigarette smoking*", "Diabetes mellitus*"],
    ["Hypertension", "Hyperlipidaemia"],
    ["Obesity / sedentary", "Hypercoagulable states"],
    ["Homocysteinaemia", "CKD / Renal disease"],
  ];
  s.addTable(riskRows.map((row, ri) => row.map((cell) => ({
    text: cell,
    options: {
      bold: (cell === "NON-MODIFIABLE" || cell === "MODIFIABLE"),
      color: (cell === "NON-MODIFIABLE" || cell === "MODIFIABLE") ? C.white : C.lightText,
      fill: (cell === "NON-MODIFIABLE" || cell === "MODIFIABLE") ? C.accentSoft : (ri % 2 === 0 ? C.tableBand : C.midBg),
      fontSize:11.5, fontFace:"Calibri"
    }
  }))), { x:6.9, y:1.6, w:6.1, colW:[3.05, 3.05], rowH:0.42, border:{ type:"solid", color:"334466", pt:0.5 } });

  s.addShape(pres.ShapeType.rect, { x:6.9, y:5.5, w:6.1, h:1.3, fill:{ color:"1A2F4F" }, line:{ color:C.accent, pt:1 } });
  s.addText([
    { text: "* SMOKING", options:{ bold:true, color:C.accent } },
    { text: " is the single most important risk factor — 3–4× increased risk of PVD\n", options:{ color:C.lightText } },
    { text: "* DIABETES", options:{ bold:true, color:C.accent } },
    { text: " causes distal small vessel disease predominantly — below-knee vessels\nABI may be falsely elevated in diabetes due to calcified incompressible vessels", options:{ color:C.subText } }
  ], { x:7.1, y:5.55, w:5.7, h:1.2, fontSize:11, fontFace:"Calibri", valign:"top" });
}

// ─── SLIDE 5: PATHOPHYSIOLOGY ────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Pathophysiology", "Robbins Pathology | Schwartz 11e | Sabiston");

  s.addText("ATHEROSCLEROSIS — THE UNDERLYING MECHANISM", {
    x:0.3, y:1.0, w:12.7, h:0.35,
    fontSize:12, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:2
  });

  // Flow diagram boxes
  const steps = [
    { label: "1. Endothelial Injury", detail: "Turbulent flow at\nbifurcations, smoking,\nDM, HTN → injury" },
    { label: "2. Lipid Deposition", detail: "LDL enters intima\nOxidised LDL triggers\ninflammatory cascade" },
    { label: "3. Foam Cells", detail: "Macrophages ingest\nox-LDL → foam cells\n→ fatty streaks" },
    { label: "4. Fibrous Plaque", detail: "SMC proliferation\nCollagen deposition\nFibrous cap forms" },
    { label: "5. Calcification", detail: "Complex plaque with\ncalcium, necrotic core\n→ stenosis/occlusion" },
  ];
  steps.forEach((step, i) => {
    const x = 0.3 + i * 2.5;
    s.addShape(pres.ShapeType.rect, { x, y:1.5, w:2.3, h:1.8, fill:{ color:C.midBg }, line:{ color:C.accent, pt:1.5 } });
    s.addText(step.label, { x, y:1.5, w:2.3, h:0.5, fontSize:11, bold:true, color:C.gold, fontFace:"Calibri", align:"center", valign:"middle" });
    s.addText(step.detail, { x, y:2.0, w:2.3, h:1.3, fontSize:10, color:C.lightText, fontFace:"Calibri", align:"center", valign:"top" });
    if (i < 4) {
      s.addText("→", { x: x+2.3, y:2.1, w:0.2, h:0.6, fontSize:18, color:C.accent, align:"center", valign:"middle", fontFace:"Calibri" });
    }
  });

  s.addText("CONSEQUENCES OF ARTERIAL OCCLUSION", {
    x:0.3, y:3.55, w:12.7, h:0.35,
    fontSize:12, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:2
  });

  // Two columns
  s.addShape(pres.ShapeType.rect, { x:0.3, y:4.0, w:6.1, h:3.2, fill:{ color:C.midBg }, line:{ color:C.accent, pt:1 } });
  s.addText("Haemodynamic Effects", {
    x:0.5, y:4.05, w:5.7, h:0.35, fontSize:12, bold:true, color:C.accent, fontFace:"Calibri"
  });
  const haemo = [
    { text: "Stenosis >50% → significant pressure gradient" },
    { text: "Critical stenosis >75% → resting ischaemia" },
    { text: "ABI (ABPI) falls below 1.0 — diagnostic" },
    { text: "Collateral vessels develop (Profunda femoris → popliteal)" },
    { text: "Reactive hyperaemia impaired (Buerger's sign)" },
  ];
  bulletSlide(s, haemo, 0.5, 4.45, 5.7, 2.5, { fontSize:11.5 });

  s.addShape(pres.ShapeType.rect, { x:6.9, y:4.0, w:6.1, h:3.2, fill:{ color:C.midBg }, line:{ color:C.gold, pt:1 } });
  s.addText("Tissue Consequences", {
    x:7.1, y:4.05, w:5.7, h:0.35, fontSize:12, bold:true, color:C.gold, fontFace:"Calibri"
  });
  const tissue = [
    { text: "Anaerobic metabolism → lactic acid → claudication pain" },
    { text: "Oxygen demand exceeds supply at rest → rest pain" },
    { text: "Skin & subcutaneous tissue most vulnerable" },
    { text: "Muscle loses bulk → wasting, weakness" },
    { text: "Neuropathy (in DM) masks pain → silent ischaemia" },
    { text: "Ulceration → infection → gangrene (dry or wet)" },
  ];
  bulletSlide(s, tissue, 7.1, 4.45, 5.7, 2.5, { fontSize:11.5 });
}

// ─── SLIDE 6: CLINICAL FEATURES ──────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Clinical Features — History & Symptoms", "S. Das 13e | Bailey & Love 28e");

  // Symptoms table
  s.addText("CARDINAL SYMPTOMS OF CHRONIC LIMB ISCHAEMIA", {
    x:0.3, y:1.0, w:12.7, h:0.35,
    fontSize:12, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:2
  });

  const sympRows = [
    ["Symptom", "Description", "Stage"],
    ["Intermittent Claudication", "Muscle pain / cramping on walking; relieved by rest in <5 min; reproducible at same distance", "IIa–IIb"],
    ["Rest Pain", "Burning/aching in foot & toes; worse at night (lying down); relieved by dependency (hanging foot down) — Buerger's dependency test", "III"],
    ["Non-healing Ulcers", "Punched-out arterial ulcers on pressure areas — toes, heel, malleoli; painful (unlike venous)", "IV"],
    ["Gangrene", "Dry gangrene (mummification) or Wet gangrene (infection); blackened, demarcated tissue", "IV"],
    ["Impotence (males)", "Leriche syndrome: aorto-iliac occlusion — bilateral claudication + absent femoral pulses + impotence", "Special"],
  ];
  s.addTable(sympRows.map((row, ri) => row.map((cell, ci) => ({
    text: cell,
    options: {
      bold: ri === 0,
      color: ri === 0 ? C.white : (ci === 2 ? C.gold : C.lightText),
      fill: ri === 0 ? C.tableHdr : (ri % 2 === 0 ? C.tableBand : C.midBg),
      fontSize: ri === 0 ? 12 : 11,
      fontFace:"Calibri",
      align: ci === 2 ? "center" : "left"
    }
  }))), { x:0.3, y:1.4, w:12.7, colW:[2.8, 7.7, 2.2], rowH:0.48, border:{ type:"solid", color:"334466", pt:0.5 } });

  // Important viva point
  s.addShape(pres.ShapeType.rect, { x:0.3, y:4.95, w:12.7, h:1.4, fill:{ color:"1A2F4F" }, line:{ color:C.gold, pt:1.5 } });
  s.addText([
    { text: "VIVA POINT — Claudication vs. Rest Pain vs. Other Leg Pain:\n", options:{ bold:true, color:C.gold } },
    { text: "Claudication — walking ◈ | Venous claudication — worse on standing, requires elevation for relief ◈ | Neurogenic claudication — flexing spine (leaning forward on trolley) relieves pain ◈ | Rest pain — worse supine, relieved by dependency in arterial disease", options:{ color:C.lightText } }
  ], { x:0.5, y:5.0, w:12.3, h:1.3, fontSize:11.5, fontFace:"Calibri", valign:"top" });

  s.addText("Leriche Syndrome (Aorto-iliac occlusion): Bilateral claudication buttock/thigh + absent femoral pulses + impotence", {
    x:0.3, y:6.45, w:12.7, h:0.45,
    fontSize:11.5, color:C.accent, bold:true, fontFace:"Calibri", italic:true
  });
}

// ─── SLIDE 7: CLINICAL EXAMINATION ───────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Clinical Examination — Signs", "S. Das 13e | Bailey & Love 28e");

  // Left column: Inspection
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.1, w:4.0, h:5.85, fill:{ color:C.midBg }, line:{ color:C.accent, pt:1 } });
  s.addText("INSPECTION", {
    x:0.5, y:1.15, w:3.6, h:0.38, fontSize:12, bold:true, color:C.accent, fontFace:"Calibri", charSpacing:2
  });
  const inspection = [
    { text: "Colour: pallor / cyanosis / blackening" },
    { text: "Skin: shiny, hairless, dry skin" },
    { text: "Trophic changes: thickened nails" },
    { text: "Muscle wasting of calf & thigh" },
    { text: "Ulceration: site, base, edge" },
    { text: "Gangrene: wet vs dry, extent" },
    { text: "Venous guttering (veins collapse)" },
    { text: "Buerger's angle (normal >45°)" },
    { text: "Capillary refilling — slow or absent" },
    { text: "Colour change on elevation (pallor) and dependency (dusky redness)" },
  ];
  bulletSlide(s, inspection, 0.5, 1.6, 3.6, 5.2, { fontSize:11 });

  // Middle column: Palpation
  s.addShape(pres.ShapeType.rect, { x:4.7, y:1.1, w:4.0, h:5.85, fill:{ color:C.midBg }, line:{ color:C.gold, pt:1 } });
  s.addText("PALPATION", {
    x:4.9, y:1.15, w:3.6, h:0.38, fontSize:12, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:2
  });
  const palpation = [
    { text: "Temperature — cold limb (dorsum of hand)" },
    { text: "Capillary refilling — >2 sec abnormal" },
    { text: "PULSES — systematically:" },
    { text: "Femoral: below midinguinal point", indent:true },
    { text: "Popliteal: knee flexed 40°, firm pressure", indent:true },
    { text: "Post. tibial: behind medial malleolus", indent:true },
    { text: "Dorsalis pedis: lat to EHL tendon*", indent:true },
    { text: "(*absent in 10% of normal population)", indent:true },
    { text: "Tenderness of calf muscles" },
    { text: "Bruit palpable as thrill" },
    { text: "Pulsatile mass → aneurysm" },
  ];
  bulletSlide(s, palpation, 4.9, 1.6, 3.6, 5.2, { fontSize:11 });

  // Right column: Special Tests
  s.addShape(pres.ShapeType.rect, { x:9.1, y:1.1, w:3.9, h:5.85, fill:{ color:C.midBg }, line:{ color:C.subText, pt:1 } });
  s.addText("SPECIAL TESTS", {
    x:9.2, y:1.15, w:3.5, h:0.38, fontSize:12, bold:true, color:C.subText, fontFace:"Calibri", charSpacing:2
  });
  const special = [
    { text: "BUERGER'S TEST:", bold:true, highlight:true },
    { text: "Raise leg: pallor at angle of ischaemia (<15° = critical)", indent:true },
    { text: "Hang leg down: reactive hyperaemia (guttered veins refill >15s → ischaemia)", indent:true },
    { text: "ADSON'S TEST:", bold:true, highlight:true },
    { text: "+ve in cervical rib: radial pulse obliterated on deep inspiration + turning head", indent:true },
    { text: "ALLEN'S TEST:", bold:true, highlight:true },
    { text: "For radial/ulnar artery patency", indent:true },
    { text: "CAPILLARY RETURN:", bold:true, highlight:true },
    { text: "Blanch nail bed — return >2 sec = abnormal", indent:true },
    { text: "AUSCULTATION:", bold:true, highlight:true },
    { text: "Bruits over aorta, iliacs, femorals — turbulence at stenosis", indent:true },
  ];
  bulletSlide(s, special, 9.2, 1.6, 3.6, 5.2, { fontSize:10.5 });
}

// ─── SLIDE 8: BUERGER'S ANGLE & BUERGER'S DISEASE ────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Buerger's Test & Buerger's Disease", "S. Das 13e | Bailey & Love 28e | Schwartz 11e");

  // Left: Buerger's test
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.1, w:6.1, h:5.9, fill:{ color:C.midBg }, line:{ color:C.accent, pt:1.5 } });
  s.addText("BUERGER'S TEST (Angle of Ischaemia)", {
    x:0.5, y:1.15, w:5.7, h:0.4, fontSize:13, bold:true, color:C.gold, fontFace:"Calibri"
  });
  const buergerTest = [
    { text: "ELEVATION PHASE:", bold:true, highlight:true },
    { text: "Patient supine, leg raised slowly", indent:true },
    { text: "Angle at which limb becomes pale = Buerger's angle", indent:true },
    { text: "Normal: pallor never occurs up to 90°", indent:true },
    { text: "Mild ischaemia: pallor at 45–60°", indent:true },
    { text: "Severe ischaemia: pallor at <20° (critical ischaemia)", indent:true },
    { text: "DEPENDENCY PHASE:", bold:true, highlight:true },
    { text: "After elevation, leg hung down", indent:true },
    { text: "Normal: veins refill in <5 seconds", indent:true },
    { text: "Ischaemic: guttered veins refill in >15 sec; reactive hyperaemia (brick-red colour) — pathognomonic", indent:true },
    { text: "SIGNIFICANCE:", bold:true, highlight:true },
    { text: "Buerger's angle <15° = critical ischaemia = urgent intervention", indent:true },
    { text: "Helps assess severity before ABI measurement", indent:true },
  ];
  bulletSlide(s, buergerTest, 0.5, 1.6, 5.7, 5.2, { fontSize:11 });

  // Right: Buerger's Disease
  s.addShape(pres.ShapeType.rect, { x:6.9, y:1.1, w:6.1, h:5.9, fill:{ color:C.midBg }, line:{ color:C.gold, pt:1.5 } });
  s.addText("BUERGER'S DISEASE (Thromboangiitis Obliterans)", {
    x:7.1, y:1.15, w:5.7, h:0.4, fontSize:12.5, bold:true, color:C.gold, fontFace:"Calibri"
  });
  const buergersDisease = [
    { text: "DEFINITION:", bold:true, highlight:true },
    { text: "Non-atherosclerotic, segmental, inflammatory disease affecting small-medium arteries AND veins of upper & lower limbs", indent:true },
    { text: "EPIDEMIOLOGY:", bold:true, highlight:true },
    { text: "Young males (20–40 years), heavy smoker, no cardiovascular risk factors", indent:true },
    { text: "More common in Middle East, Southeast Asia, Indian subcontinent", indent:true },
    { text: "PATHOLOGY:", bold:true, highlight:true },
    { text: "Inflammatory occlusive thrombus — highly cellular (unlike atherosclerosis)", indent:true },
    { text: "Both arteries AND veins involved (migratory thrombophlebitis)", indent:true },
    { text: "CLINICAL FEATURES:", bold:true, highlight:true },
    { text: "Distal claudication: arch of foot, forearm", indent:true },
    { text: "Raynaud's phenomenon; Superficial thrombophlebitis", indent:true },
    { text: "Rest pain → digital gangrene → amputation", indent:true },
    { text: "TREATMENT:", bold:true, highlight:true },
    { text: "Complete smoking cessation (absolute must) — arrests disease", indent:true },
    { text: "Prostaglandins (PGE1/Iloprost) for severe ischaemia", indent:true },
    { text: "Sympathectomy: useful in early vasospasm stage", indent:true },
    { text: "Amputation if gangrene — at digital level if possible", indent:true },
  ];
  bulletSlide(s, buergersDisease, 7.1, 1.6, 5.7, 5.2, { fontSize:11 });
}

// ─── SLIDE 9: INVESTIGATIONS ─────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Investigations", "S. Das 13e | Bailey & Love 28e | Sabiston");

  s.addText("ANKLE-BRACHIAL PRESSURE INDEX (ABPI / ABI) — THE MOST IMPORTANT BEDSIDE TEST", {
    x:0.3, y:1.0, w:12.7, h:0.38,
    fontSize:11.5, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:1
  });

  const abiRows = [
    ["ABI Value", "Interpretation", "Clinical Correlation"],
    ["> 1.3", "Non-compressible vessels", "DM / CKD — vessels calcified (falsely high)"],
    ["0.9 – 1.3", "Normal", "No significant PAD"],
    ["0.7 – 0.9", "Mild PAD", "Claudication at >200m (Fontaine IIa)"],
    ["0.5 – 0.7", "Moderate PAD", "Claudication at <200m (Fontaine IIb)"],
    ["0.3 – 0.5", "Severe PAD", "Rest pain present (Fontaine III)"],
    ["< 0.3", "Critical ischaemia", "Ulceration / gangrene (Fontaine IV)"],
  ];
  s.addTable(abiRows.map((row, ri) => row.map((cell, ci) => ({
    text: cell,
    options: {
      bold: ri === 0 || ri >= 5,
      color: ri === 0 ? C.white : (ri >= 5 ? C.gold : C.lightText),
      fill: ri === 0 ? C.tableHdr : (ri % 2 === 0 ? C.tableBand : C.midBg),
      fontSize: ri === 0 ? 11.5 : 11,
      fontFace:"Calibri",
      align: ci === 0 ? "center" : "left"
    }
  }))), { x:0.3, y:1.45, w:12.7, colW:[2.0, 3.0, 7.7], rowH:0.42, border:{ type:"solid", color:"334466", pt:0.5 } });

  // Other investigations
  s.addText("OTHER KEY INVESTIGATIONS", {
    x:0.3, y:4.55, w:12.7, h:0.38,
    fontSize:11.5, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:2
  });

  s.addTable([
    ["Investigation", "Findings / Purpose"],
    ["Duplex Ultrasound (DUS)", "First-line imaging: stenosis location, velocity, peak systolic velocity ratio >2 = significant stenosis"],
    ["CT Angiography (CTA)", "Gold standard non-invasive — full arterial road map for surgical planning; rapid, widely available"],
    ["MR Angiography (MRA)", "No radiation; useful in renal impairment; overestimates stenosis"],
    ["Digital Subtraction Angiography (DSA)", "Gold standard invasive; done before endovascular treatment; gives therapeutic option simultaneously"],
    ["Toe Brachial Index (TBI)", "Useful in DM (ABI unreliable); <0.7 = abnormal; <0.15 = critical ischaemia"],
    ["Bloods: FBC, RFT, LFT, lipids, HbA1c, coag", "Assess comorbidities, renal function before contrast; surgical fitness"],
    ["ECG + Echo + Cardiac stress test", "Perioperative cardiac risk assessment — essential before major vascular surgery"],
  ].map((row, ri) => row.map((cell) => ({
    text: cell,
    options: {
      bold: ri === 0,
      color: ri === 0 ? C.white : C.lightText,
      fill: ri === 0 ? C.tableHdr : (ri % 2 === 0 ? C.tableBand : C.midBg),
      fontSize: ri === 0 ? 11 : 10.5,
      fontFace:"Calibri"
    }
  }))), { x:0.3, y:5.0, w:12.7, colW:[4.0, 8.7], rowH:0.35, border:{ type:"solid", color:"334466", pt:0.5 } });
}

// ─── SLIDE 10: ACUTE LIMB ISCHAEMIA ──────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Acute Limb Ischaemia", "Bailey & Love 28e | S. Das 13e | Schwartz 11e");

  // 6 Ps
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.1, w:12.7, h:1.6, fill:{ color:C.midBg }, line:{ color:C.accent, pt:2 } });
  s.addText("THE 6 Ps OF ACUTE LIMB ISCHAEMIA", {
    x:0.5, y:1.15, w:12.3, h:0.38, fontSize:13, bold:true, color:C.accent, fontFace:"Calibri", charSpacing:2
  });

  const ps = ["Pain", "Pallor", "Pulselessness", "Paraesthesia", "Paralysis", "Perishing with cold"];
  ps.forEach((p, i) => {
    const x = 0.5 + i * 2.1;
    s.addShape(pres.ShapeType.rect, { x, y:1.6, w:1.9, h:0.9, fill:{ color:C.accentSoft }, line:{ color:C.gold, pt:1 } });
    s.addText(p, { x, y:1.6, w:1.9, h:0.9, fontSize:11.5, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
  });

  s.addText("Neurological symptoms (paraesthesia/paralysis) indicate irreversible ischaemia is imminent — surgical emergency", {
    x:0.3, y:2.62, w:12.7, h:0.38, fontSize:11, color:C.gold, italic:true, fontFace:"Calibri"
  });

  // Embolus vs Thrombosis table
  s.addText("EMBOLUS vs. THROMBOSIS — KEY DISTINCTION (Viva Favourite!)", {
    x:0.3, y:3.1, w:12.7, h:0.38, fontSize:12, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:2
  });

  s.addTable([
    ["Feature", "Arterial Embolism", "Acute-on-Chronic Thrombosis"],
    ["Onset", "Sudden, acute (<1 hr)", "Gradual (hours-days)"],
    ["Prior symptoms", "None — no claudication", "H/o claudication present"],
    ["Contralateral limb", "Normal pulses", "Absent/reduced pulses"],
    ["Cardiac history", "AF, MI, Valvular disease", "Atherosclerosis risk factors"],
    ["Limb viability", "Severely threatened (no collaterals)", "Less severe (collaterals present)"],
    ["Angiography", "Sharp cut-off, no collaterals", "Irregular, collaterals present"],
    ["Treatment", "Embolectomy (Fogarty catheter)", "Thrombolysis / bypass first"],
  ].map((row, ri) => row.map((cell, ci) => ({
    text: cell,
    options: {
      bold: ri === 0 || ci === 0,
      color: ri === 0 ? C.white : (ci === 0 ? C.gold : C.lightText),
      fill: ri === 0 ? C.tableHdr : (ci === 0 ? "1A2F4F" : (ri % 2 === 0 ? C.tableBand : C.midBg)),
      fontSize: ri === 0 ? 11.5 : 11,
      fontFace:"Calibri"
    }
  }))), { x:0.3, y:3.55, w:12.7, colW:[2.8, 5.0, 4.9], rowH:0.38, border:{ type:"solid", color:"334466", pt:0.5 } });

  // Rutherford ALI
  s.addShape(pres.ShapeType.rect, { x:0.3, y:6.65, w:12.7, h:0.6, fill:{ color:"1A2F4F" }, line:{ color:C.accent, pt:1 } });
  s.addText([
    { text: "RUTHERFORD CLASSIFICATION of ALI: ", options:{ bold:true, color:C.gold } },
    { text: "Class I — Viable (no immediate threat) | Class IIa — Marginally threatened | Class IIb — Immediately threatened (motor loss) | Class III — Irreversible (major tissue loss inevitable) → primary amputation", options:{ color:C.lightText } }
  ], { x:0.5, y:6.68, w:12.3, h:0.55, fontSize:10.5, fontFace:"Calibri", valign:"middle" });
}

// ─── SLIDE 11: MANAGEMENT — MEDICAL / ENDOVASCULAR ───────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Management — Medical & Endovascular", "Sabiston | Schwartz 11e | Bailey & Love 28e");

  // Medical Management
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.1, w:5.9, h:5.9, fill:{ color:C.midBg }, line:{ color:C.accent, pt:1 } });
  s.addText("MEDICAL MANAGEMENT (Claudication)", {
    x:0.5, y:1.15, w:5.5, h:0.4, fontSize:12, bold:true, color:C.accent, fontFace:"Calibri"
  });
  const medical = [
    { text: "RISK FACTOR MODIFICATION:", bold:true, highlight:true },
    { text: "Smoking cessation — most important single intervention", indent:true },
    { text: "Tight glycaemic control (HbA1c <7%)", indent:true },
    { text: "Blood pressure control (<130/80 mmHg)", indent:true },
    { text: "Statins — target LDL <70 mg/dL; pleiotropic effects", indent:true },
    { text: "ANTIPLATELET THERAPY:", bold:true, highlight:true },
    { text: "Aspirin 75–150 mg/day OR Clopidogrel 75 mg/day", indent:true },
    { text: "Dual antiplatelet post-intervention", indent:true },
    { text: "EXERCISE REHABILITATION:", bold:true, highlight:true },
    { text: "Supervised walking programme — 30–60 min, 3x/week", indent:true },
    { text: "Increases claudication distance by 100–150%", indent:true },
    { text: "PHARMACOLOGICAL:", bold:true, highlight:true },
    { text: "Cilostazol (phosphodiesterase inhibitor) — improves claudication distance", indent:true },
    { text: "Naftidrofuryl oxalate — alternative to cilostazol", indent:true },
    { text: "Prostaglandins (PGE1/Iloprost) — critical ischaemia", indent:true },
    { text: "Anticoagulation (warfarin / LMWH) post-bypass", indent:true },
  ];
  bulletSlide(s, medical, 0.5, 1.6, 5.5, 5.2, { fontSize:10.5 });

  // Endovascular
  s.addShape(pres.ShapeType.rect, { x:6.6, y:1.1, w:6.4, h:5.9, fill:{ color:C.midBg }, line:{ color:C.gold, pt:1 } });
  s.addText("ENDOVASCULAR TREATMENT", {
    x:6.8, y:1.15, w:6.0, h:0.4, fontSize:12, bold:true, color:C.gold, fontFace:"Calibri"
  });
  const endo = [
    { text: "INDICATIONS:", bold:true, highlight:true },
    { text: "Lifestyle-limiting claudication + failed conservative", indent:true },
    { text: "Critical limb ischaemia (rest pain/ulceration)", indent:true },
    { text: "TASC A/B lesions — endovascular preferred", indent:true },
    { text: "PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY (PTA):", bold:true, highlight:true },
    { text: "Balloon dilatation of stenosis or short occlusion", indent:true },
    { text: "Best results: iliac > femoral > popliteal", indent:true },
    { text: "STENTING:", bold:true, highlight:true },
    { text: "Balloon-expandable (iliac) or self-expanding (SFA)", indent:true },
    { text: "Drug-eluting stents / stent grafts — reduce restenosis", indent:true },
    { text: "THROMBOLYSIS:", bold:true, highlight:true },
    { text: "Catheter-directed tPA for acute thrombus (<14 days)", indent:true },
    { text: "Uncovers underlying stenosis for definitive treatment", indent:true },
    { text: "CI: recent stroke, active bleed, recent surgery", indent:true },
    { text: "NEWER TECHNIQUES:", bold:true, highlight:true },
    { text: "Atherectomy (rotational/laser) | Drug-coated balloons", indent:true },
    { text: "EVAR for aneurysmal disease", indent:true },
  ];
  bulletSlide(s, endo, 6.8, 1.6, 6.0, 5.2, { fontSize:10.5 });
}

// ─── SLIDE 12: SURGICAL MANAGEMENT ───────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Surgical Management", "Bailey & Love 28e | Schwartz 11e | S. Das 13e");

  // Reconstructive procedures
  s.addText("RECONSTRUCTIVE / BYPASS PROCEDURES", {
    x:0.3, y:1.0, w:12.7, h:0.38, fontSize:12, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:2
  });

  s.addTable([
    ["Procedure", "Indication / Level", "Conduit / Technique"],
    ["Aorto-bifemoral bypass", "Aorto-iliac occlusion (Leriche)", "Dacron bifurcation graft — gold standard"],
    ["Ilio-femoral bypass", "Unilateral iliac occlusion", "PTFE / Dacron graft"],
    ["Femoro-popliteal bypass", "SFA occlusion — above / below knee", "Long saphenous vein (preferred) or PTFE"],
    ["Femoro-distal bypass", "Tibio-peroneal disease (CLI)", "Reversed saphenous vein — best patency"],
    ["Embolectomy (Fogarty)", "Acute limb ischaemia — embolus", "Fogarty balloon catheter via femoral artery"],
    ["Endarterectomy", "Short localised disease — iliac / CFA", "Remove intima + plaque, patch angioplasty"],
    ["Extra-anatomic bypass", "Bilateral iliac disease, unfit patient", "Axillo-femoral / femoro-femoral crossover"],
  ].map((row, ri) => row.map((cell, ci) => ({
    text: cell,
    options: {
      bold: ri === 0,
      color: ri === 0 ? C.white : (ci === 0 ? C.gold : C.lightText),
      fill: ri === 0 ? C.tableHdr : (ri % 2 === 0 ? C.tableBand : C.midBg),
      fontSize: ri === 0 ? 11.5 : 11,
      fontFace:"Calibri"
    }
  }))), { x:0.3, y:1.45, w:12.7, colW:[3.5, 4.5, 4.7], rowH:0.42, border:{ type:"solid", color:"334466", pt:0.5 } });

  // Amputation
  s.addShape(pres.ShapeType.rect, { x:0.3, y:4.6, w:6.1, h:2.65, fill:{ color:C.midBg }, line:{ color:C.accent, pt:1.5 } });
  s.addText("AMPUTATION", {
    x:0.5, y:4.65, w:5.7, h:0.38, fontSize:12, bold:true, color:C.accent, fontFace:"Calibri"
  });
  const amputation = [
    { text: "INDICATIONS: non-salvageable limb, failed bypass, irreversible ischaemia, extensive wet gangrene" },
    { text: "LEVELS: digit → ray → transmetatarsal → Syme's → below-knee (BKA) → above-knee (AKA)" },
    { text: "BKA preferred over AKA: better prosthetic rehabilitation; energy expenditure lower" },
    { text: "AKA if: flexion contracture, failed BKA, knee joint involvement" },
    { text: "Rule: amputate through viable tissue — healing depends on adequate blood supply" },
  ];
  bulletSlide(s, amputation, 0.5, 5.1, 5.7, 2.0, { fontSize:11 });

  // Sympathectomy
  s.addShape(pres.ShapeType.rect, { x:6.9, y:4.6, w:6.1, h:2.65, fill:{ color:C.midBg }, line:{ color:C.gold, pt:1.5 } });
  s.addText("SYMPATHECTOMY", {
    x:7.1, y:4.65, w:5.7, h:0.38, fontSize:12, bold:true, color:C.gold, fontFace:"Calibri"
  });
  const sympath = [
    { text: "LUMBAR SYMPATHECTOMY: best for inoperable distal disease, rest pain, Buerger's disease (early), Raynaud's" },
    { text: "Mechanism: removes vasospasm, improves skin/subcutaneous circulation; NOT useful for muscle claudication" },
    { text: "METHODS: surgical (L2–L4 ganglia) or chemical (phenol injection) or laparoscopic" },
    { text: "CERVICAL sympathectomy: for upper limb vasospasm / hyperhidrosis" },
    { text: "Contraindicated in: fixed organic stenosis with no vasospasm component" },
  ];
  bulletSlide(s, sympath, 7.1, 5.1, 5.7, 2.0, { fontSize:11 });
}

// ─── SLIDE 13: GANGRENE ───────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Gangrene — Types, Differences & Management", "S. Das 13e | Bailey & Love 28e");

  s.addTable([
    ["Feature", "Dry Gangrene", "Wet Gangrene", "Gas Gangrene"],
    ["Definition", "Coagulative necrosis — arterial ischaemia without infection", "Ischaemia + superimposed bacterial infection", "Clostridium infection with gas production"],
    ["Mechanism", "Mummification — tissue dries and shrivels", "Putrefaction — liquefaction necrosis", "Toxin-mediated myonecrosis"],
    ["Smell", "Absent (no bacteria)", "Foul-smelling putrefaction", "Sweet, mousy odour"],
    ["Colour", "Black, mummified, shrunken", "Black/green, swollen, moist", "Bronze/grey, crepitus on palpation"],
    ["Demarcation", "Clear line of demarcation (wait)", "Spreading — no clear demarcation", "Rapid spreading — no demarcation"],
    ["Systemic signs", "Minimal — patient relatively well", "Severe: fever, toxaemia, septic shock", "Severe toxaemia — rapidly fatal if untreated"],
    ["Treatment", "Conservative → elective amputation", "Emergency debridement + IV antibiotics + amputation", "Hyperbaric O2 + wide excision + penicillin"],
  ].map((row, ri) => row.map((cell, ci) => ({
    text: cell,
    options: {
      bold: ri === 0 || ci === 0,
      color: ri === 0 ? C.white : (ci === 0 ? C.gold : C.lightText),
      fill: ri === 0 ? C.tableHdr : (ci === 0 ? "1A2F4F" : (ri % 2 === 0 ? C.tableBand : C.midBg)),
      fontSize: ri === 0 ? 11 : 10.5,
      fontFace:"Calibri"
    }
  }))), { x:0.3, y:1.1, w:12.7, colW:[2.4, 3.3, 3.7, 3.3], rowH:0.5, border:{ type:"solid", color:"334466", pt:0.5 } });

  // Types of ulcers
  s.addText("ARTERIAL vs. VENOUS vs. NEUROPATHIC ULCER — KEY COMPARISON", {
    x:0.3, y:5.4, w:12.7, h:0.38, fontSize:12, bold:true, color:C.gold, fontFace:"Calibri", charSpacing:1
  });

  s.addTable([
    ["Feature", "Arterial Ulcer", "Venous Ulcer", "Neuropathic Ulcer"],
    ["Site", "Tips of toes, heels, malleoli (pressure)", "Gaiter area (above medial malleolus)", "Pressure points: heel, metatarsal heads"],
    ["Pain", "Very painful (ischaemic)", "Mild to moderate", "Painless (anaesthetic)"],
    ["Edge", "Punched-out, well-defined", "Sloping, irregular", "Punched-out, callus rim"],
    ["Base", "Pale, necrotic, no granulation", "Pink granulation tissue", "Deep, may reach bone"],
    ["Surrounding", "Cold, pallor, hairless skin", "Pigmentation, lipodermatosclerosis", "Warm, deformed foot (Charcot)"],
  ].map((row, ri) => row.map((cell, ci) => ({
    text: cell,
    options: {
      bold: ri === 0 || ci === 0,
      color: ri === 0 ? C.white : (ci === 0 ? C.gold : C.lightText),
      fill: ri === 0 ? C.tableHdr : (ci === 0 ? "1A2F4F" : (ri % 2 === 0 ? C.tableBand : C.midBg)),
      fontSize: ri === 0 ? 11 : 10.5,
      fontFace:"Calibri"
    }
  }))), { x:0.3, y:5.85, w:12.7, colW:[2.1, 3.5, 3.7, 3.4], rowH:0.34, border:{ type:"solid", color:"334466", pt:0.5 } });
}

// ─── SLIDE 14: RAYNAUD'S + THORACIC OUTLET ────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Raynaud's Phenomenon & Thoracic Outlet Syndrome", "Bailey & Love 28e | S. Das 13e");

  // Raynaud's
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.1, w:6.1, h:5.9, fill:{ color:C.midBg }, line:{ color:C.accent, pt:1 } });
  s.addText("RAYNAUD'S PHENOMENON", {
    x:0.5, y:1.15, w:5.7, h:0.4, fontSize:13, bold:true, color:C.gold, fontFace:"Calibri"
  });
  const raynaud = [
    { text: "DEFINITION: Episodic digital vasospasm triggered by cold/stress — triphasic colour change" },
    { text: "TRIPHASIC COLOUR CHANGE:", bold:true, highlight:true },
    { text: "WHITE (pallor): arterial vasospasm → digital ischaemia", indent:true },
    { text: "BLUE (cyanosis): venous stasis, slow flow, deoxygenation", indent:true },
    { text: "RED (rubor): reactive hyperaemia on rewarming", indent:true },
    { text: "RAYNAUD'S DISEASE (Primary):", bold:true, highlight:true },
    { text: "Idiopathic; young women; bilateral; no tissue loss; benign", indent:true },
    { text: "RAYNAUD'S SYNDROME (Secondary):", bold:true, highlight:true },
    { text: "Associated with: SLE, RA, scleroderma, CREST syndrome, Buerger's disease, vibration white finger, cervical rib", indent:true },
    { text: "TREATMENT:", bold:true, highlight:true },
    { text: "Avoid cold; heated gloves; stop smoking", indent:true },
    { text: "CCBs (Nifedipine) — first line drug", indent:true },
    { text: "Prostaglandins (Iloprost) — severe cases", indent:true },
    { text: "Sympathectomy: cervical (hands), lumbar (feet) — short-lived benefit", indent:true },
    { text: "Treat underlying cause in secondary disease", indent:true },
  ];
  bulletSlide(s, raynaud, 0.5, 1.6, 5.7, 5.2, { fontSize:11 });

  // TOS + Cervical Rib
  s.addShape(pres.ShapeType.rect, { x:6.9, y:1.1, w:6.1, h:5.9, fill:{ color:C.midBg }, line:{ color:C.gold, pt:1 } });
  s.addText("THORACIC OUTLET SYNDROME & CERVICAL RIB", {
    x:7.1, y:1.15, w:5.7, h:0.4, fontSize:12, bold:true, color:C.gold, fontFace:"Calibri"
  });
  const tos = [
    { text: "CERVICAL RIB:", bold:true, highlight:true },
    { text: "Accessory rib arising from C7 vertebra", indent:true },
    { text: "Compresses subclavian artery / brachial plexus", indent:true },
    { text: "ADSON'S TEST:", bold:true, highlight:true },
    { text: "Deep inspiration + head rotation to affected side → radial pulse obliterated", indent:true },
    { text: "CLINICAL FEATURES:", bold:true, highlight:true },
    { text: "Upper limb claudication on exertion", indent:true },
    { text: "Neurological: C8/T1 distribution — medial arm/hand", indent:true },
    { text: "Wasting of thenar / hypothenar muscles", indent:true },
    { text: "Subclavian artery: post-stenotic dilation → thrombus → distal embolism", indent:true },
    { text: "Arterial: pallor, coldness, Raynaud's, digital ischaemia", indent:true },
    { text: "INVESTIGATIONS:", bold:true, highlight:true },
    { text: "CXR / Cervical spine X-ray — cervical rib visible", indent:true },
    { text: "Duplex / Angiography — subclavian compression", indent:true },
    { text: "TREATMENT:", bold:true, highlight:true },
    { text: "Physiotherapy (minor cases) → surgical excision of rib + scalenectomy", indent:true },
    { text: "Subclavian reconstruction if post-stenotic aneurysm", indent:true },
  ];
  bulletSlide(s, tos, 7.1, 1.6, 5.7, 5.2, { fontSize:11 });
}

// ─── SLIDE 15: VIVA QUESTIONS ─────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "High-Yield Viva Questions & Answers", "PG Surgery Examination Prep");

  const vivas = [
    { q: "Q1. What is critical limb ischaemia?", a: "Rest pain >2 weeks + ABI <0.5 OR ankle pressure <50 mmHg OR toe pressure <30 mmHg OR tissue loss (ulcer/gangrene) — requires urgent revascularisation" },
    { q: "Q2. What is the Fontaine classification?", a: "Stage I: Asymptomatic | IIa: Claudication >200m | IIb: <200m | III: Rest pain | IV: Ulcer/gangrene" },
    { q: "Q3. How do you differentiate embolism from thrombosis?", a: "Embolism: sudden, no prior claudication, normal contralateral limb, cardiac source (AF/MI), sharp angio cut-off. Thrombosis: gradual, h/o claudication, bilateral disease, collaterals on angio" },
    { q: "Q4. What is Leriche syndrome?", a: "Aorto-iliac occlusion: triad of bilateral hip/thigh/buttock claudication + absent femoral pulses + impotence in males" },
    { q: "Q5. Best conduit for femoropopliteal bypass?", a: "Long saphenous vein (reversed or in-situ) — best patency. PTFE acceptable above-knee when vein unavailable" },
    { q: "Q6. When is sympathectomy indicated?", a: "Inoperable distal PVD, rest pain, Buerger's disease (vasospasm phase), Raynaud's, hyperhidrosis. Not useful for claudication (muscle ischaemia)" },
    { q: "Q7. ABI falsely high in diabetes — why?", a: "Medial calcification makes tibial arteries non-compressible. Use toe-brachial index (TBI) instead — <0.7 abnormal" },
    { q: "Q8. Fogarty catheter — describe the procedure", a: "Groin incision, expose CFA; transverse arteriotomy; catheter passed distal & proximal to clot, balloon inflated, withdrawn — clot extracted; angiogram to confirm; heparin systemically" },
  ];

  let yPos = 1.08;
  vivas.forEach((item, i) => {
    const row = Math.floor(i/2);
    const col = i % 2;
    const x = col === 0 ? 0.3 : 6.85;
    const y = 1.08 + row * 1.52;
    s.addShape(pres.ShapeType.rect, { x, y, w:6.15, h:1.42, fill:{ color:C.midBg }, line:{ color: i%2===0 ? C.accent : C.gold, pt:1 } });
    s.addText([
      { text: item.q + "\n", options:{ bold:true, color:C.gold, fontSize:10.5 } },
      { text: item.a, options:{ color:C.lightText, fontSize:10 } }
    ], { x: x+0.15, y: y+0.05, w:5.85, h:1.3, fontFace:"Calibri", valign:"top" });
  });
}

// ─── SLIDE 16: MORE VIVA QUESTIONS ────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "High-Yield Viva Questions — Continued", "PG Surgery Examination Prep");

  const vivas2 = [
    { q: "Q9. Features of Buerger's disease vs. atherosclerosis", a: "Buerger's: young (20-40y), male, heavy smoker, no CV risk factors, involves distal small vessels AND veins, migratory thrombophlebitis, no calcium on angio. Atherosclerosis: older, proximal disease, CV risk factors" },
    { q: "Q10. What is the ankle-brachial pressure index and how to measure?", a: "ABPI = ankle systolic BP ÷ brachial systolic BP. Measured with hand-held Doppler. Normal >0.9. <0.5 = severe. >1.3 = calcified vessels (DM). Resting + post-exercise (treadmill) increases sensitivity" },
    { q: "Q11. What investigations before vascular surgery?", a: "FBC, U&E, LFT, coag screen, HbA1c, lipid profile, ECG, echo, cardiac stress test (if high risk), CXR, duplex USS, CT angiography, chest x-ray, PFTs if indicated" },
    { q: "Q12. Indications for amputation in PVD?", a: "Irreversible ischaemia (Rutherford III), failed/not feasible revascularisation, extensive tissue loss/wet gangrene, sepsis threatening life, intractable rest pain with no option, Buerger's with digital gangrene" },
    { q: "Q13. Types of bypass graft materials?", a: "Autologous vein (LSV — gold standard), PTFE (above-knee acceptable), Dacron (aortic/iliac), Cryopreserved vein, Human umbilical vein. Vein > PTFE for below-knee and all infra-inguinal bypasses" },
    { q: "Q14. Complications of vascular surgery?", a: "General: MI, stroke, renal failure, DVT/PE. Local: graft thrombosis, infection, anastomotic leak, false aneurysm, lymphocele, nerve injury, reperfusion injury, compartment syndrome post-embolectomy" },
    { q: "Q15. What is reperfusion injury?", a: "After revascularisation, restoration of blood flow → xanthine oxidase-generated free radicals, inflammatory mediators → cell death, oedema, compartment syndrome, myoglobinuria → AKI. Managed with fasciotomy, hydration, bicarbonate" },
    { q: "Q16. What is Leriche's symptom complex vs Fontaine staging?", a: "Leriche: clinical syndrome of aorto-iliac occlusion (the 3 features). Fontaine: grading severity of any chronic lower limb ischaemia I–IV. They address different aspects of PVD" },
  ];

  vivas2.forEach((item, i) => {
    const col = i % 2;
    const row = Math.floor(i/2);
    const x = col === 0 ? 0.3 : 6.85;
    const y = 1.08 + row * 1.52;
    s.addShape(pres.ShapeType.rect, { x, y, w:6.15, h:1.42, fill:{ color:C.midBg }, line:{ color: col===0 ? C.accent : C.gold, pt:1 } });
    s.addText([
      { text: item.q + "\n", options:{ bold:true, color:C.gold, fontSize:10.5 } },
      { text: item.a, options:{ color:C.lightText, fontSize:10 } }
    ], { x: x+0.15, y: y+0.05, w:5.85, h:1.3, fontFace:"Calibri", valign:"top" });
  });
}

// ─── SLIDE 17: SUMMARY / KEY POINTS ──────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  addSlideHeader(s, "Summary — Key Take-Home Points", "For the Examiner's Corner");

  const keyPoints = [
    { text: "PVD most commonly = atherosclerosis; Buerger's = young male smoker with distal + venous involvement", bold:true, highlight:true },
    { text: "Fontaine I→IV: asymptomatic → claudication → rest pain → gangrene/ulcer (correlate with ABI values)" },
    { text: "6 Ps of ALI: Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Perishing cold — paralysis = emergency" },
    { text: "ABI: <0.9 = PAD; <0.5 = severe; >1.3 = calcified (DM) — use TBI in diabetes" },
    { text: "Embolism: acute, cardiac source, sharp cut-off, no collaterals → Fogarty embolectomy" },
    { text: "Thrombosis: subacute, atherosclerosis background, collaterals → thrombolysis / bypass" },
    { text: "Gold standard bypass conduit = long saphenous vein; Dacron for aortic work; PTFE above-knee" },
    { text: "Leriche syndrome: aorto-iliac occlusion → bilateral claudication + absent femorals + impotence" },
    { text: "Buerger's angle <15° = critical ischaemia; Dependency test: reactive hyperaemia >15s = significant" },
    { text: "Sympathectomy: useful for vasospasm/distal disease — NOT muscle claudication" },
    { text: "Dry gangrene: await demarcation → elective amputation | Wet gangrene: emergency debridement + amputation" },
    { text: "Pre-op work-up: cardiac assessment mandatory — PVD + CAD frequently coexist (same aetiology)" },
  ];
  bulletSlide(s, keyPoints, 0.5, 1.15, 12.3, 6.0, { fontSize:12 });
}

// ─── SLIDE 18: REFERENCES ─────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.darkBg } });
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:0.85, fill:{ color:C.accentSoft } });
  s.addText("REFERENCES & SOURCES", {
    x:0.25, y:0.05, w:12.8, h:0.75,
    fontSize:22, bold:true, color:C.white, fontFace:"Calibri", align:"left", valign:"middle", margin:0
  });
  s.addShape(pres.ShapeType.rect, { x:0, y:7.25, w:13.3, h:0.25, fill:{ color:C.accentSoft } });

  const refs = [
    "1.  Norman S. Williams, Christopher J.K. Bulstrode, P. Ronan O'Connell. Bailey & Love's Short Practice of Surgery, 28th Edition. CRC Press, 2023. — Chapter 61: Peripheral Vascular Disease",
    "2.  S. Das. A Manual on Clinical Surgery, 13th Edition. — Chapter 6: Peripheral Vascular Disease, Pg. 88–105",
    "3.  F. Charles Brunicardi et al. Schwartz's Principles of Surgery, 11th Edition. McGraw-Hill, 2019. — Chapter 23: Arterial Disease",
    "4.  Courtney M. Townsend et al. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 21st Edition. Elsevier, 2022.",
    "5.  John L. Cameron, Andrew M. Cameron. Current Surgical Therapy, 14th Edition. Elsevier, 2023.",
    "6.  Mulholland & Greenfield's Surgery: Scientific Principles and Practice, 7th Edition. Wolters Kluwer, 2022.",
    "7.  Kumar V, Abbas AK, Aster JC. Robbins & Cotran Pathologic Basis of Disease, 10th Edition. Chapter 11: Blood Vessels",
    "8.  Norgren L, Hiatt WR, Dormandy JA et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33 Suppl 1:S1-75.",
  ];

  refs.forEach((ref, i) => {
    s.addText(ref, {
      x:0.5, y: 1.1 + i * 0.75,
      w:12.3, h:0.65,
      fontSize:11, color: i % 2 === 0 ? C.lightText : C.subText,
      fontFace:"Calibri", valign:"top"
    });
  });
}

// ─── WRITE FILE ───────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/pvd-presentation/PVD_Case_Presentation_PG_Surgery.pptx" })
  .then(() => console.log("PPT created successfully!"))
  .catch(e => console.error("Error:", e));