import subprocess, json, base64
from io import BytesIO
from pptx import Presentation
from pptx.util import Inches, Pt, Emu
from pptx.dml.color import RGBColor
from pptx.enum.text import PP_ALIGN, MSO_ANCHOR
from pptx.util import Inches, Pt
import requests

# ── Colour palette ────────────────────────────────────────────────────────────
TEAL_DARK   = RGBColor(0x00, 0x6E, 0x7F)   # header bars
TEAL_MID    = RGBColor(0x00, 0x99, 0xAA)   # accent
TEAL_LIGHT  = RGBColor(0xE0, 0xF5, 0xF8)   # content bg
WHITE       = RGBColor(0xFF, 0xFF, 0xFF)
DARK_TEXT   = RGBColor(0x1A, 0x1A, 0x2E)
GOLD        = RGBColor(0xF5, 0xA6, 0x23)
LIGHT_GRAY  = RGBColor(0xF4, 0xF6, 0xF9)

def hex_to_rgb(h):
    h = h.lstrip('#')
    return RGBColor(int(h[0:2],16), int(h[2:4],16), int(h[4:6],16))

prs = Presentation()
prs.slide_width  = Inches(13.333)
prs.slide_height = Inches(7.5)
blank = prs.slide_layouts[6]

def add_rect(slide, x, y, w, h, fill_rgb, alpha=None):
    shape = slide.shapes.add_shape(1, Inches(x), Inches(y), Inches(w), Inches(h))
    shape.line.fill.background()
    shape.fill.solid()
    shape.fill.fore_color.rgb = fill_rgb
    return shape

def add_text(slide, text, x, y, w, h, size=18, bold=False, color=DARK_TEXT,
             align=PP_ALIGN.LEFT, wrap=True, italic=False, valign=MSO_ANCHOR.TOP):
    tb = slide.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h))
    tf = tb.text_frame
    tf.word_wrap = wrap
    tf.vertical_anchor = valign
    tf.margin_left = Pt(2)
    tf.margin_right = Pt(2)
    tf.margin_top = Pt(2)
    tf.margin_bottom = Pt(2)
    p = tf.paragraphs[0]
    p.alignment = align
    run = p.add_run()
    run.text = text
    run.font.size = Pt(size)
    run.font.bold = bold
    run.font.italic = italic
    run.font.color.rgb = color
    return tb

def add_bullet_box(slide, items, x, y, w, h, size=15, bullet_color=TEAL_MID, text_color=DARK_TEXT, spacing=1.2):
    from pptx.oxml.ns import qn
    from lxml import etree
    tb = slide.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h))
    tf = tb.text_frame
    tf.word_wrap = True
    tf.margin_left = Pt(4)
    tf.margin_right = Pt(4)
    tf.margin_top = Pt(2)
    tf.margin_bottom = Pt(2)
    for i, item in enumerate(items):
        if i == 0:
            p = tf.paragraphs[0]
        else:
            p = tf.add_paragraph()
        p.alignment = PP_ALIGN.LEFT
        p.space_before = Pt(4)
        run = p.add_run()
        run.text = f"• {item}"
        run.font.size = Pt(size)
        run.font.color.rgb = text_color
    return tb

def download_image(url):
    try:
        r = requests.get(url, timeout=15)
        if r.status_code == 200:
            return BytesIO(r.content)
    except:
        pass
    return None

def add_image_from_url(slide, url, x, y, w, h):
    img_data = download_image(url)
    if img_data:
        slide.shapes.add_picture(img_data, Inches(x), Inches(y), Inches(w), Inches(h))
        return True
    return False

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 1 — TITLE SLIDE
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)

# Full background
add_rect(slide, 0, 0, 13.333, 7.5, TEAL_DARK)
# Lighter accent band
add_rect(slide, 0, 2.5, 13.333, 3.2, TEAL_MID)
# Bottom strip
add_rect(slide, 0, 6.5, 13.333, 1.0, hex_to_rgb('#004D5B'))

# Title
add_text(slide, "INVESTIGATION OF THYROID", 0.5, 0.3, 12.3, 1.4,
         size=42, bold=True, color=WHITE, align=PP_ALIGN.CENTER)
add_text(slide, "A Comprehensive Guide for MBBS Students", 0.5, 1.6, 12.3, 0.7,
         size=22, color=GOLD, align=PP_ALIGN.CENTER, italic=True)
# Divider line shape
shape = slide.shapes.add_shape(1, Inches(3.5), Inches(2.35), Inches(6.3), Inches(0.05))
shape.fill.solid(); shape.fill.fore_color.rgb = GOLD
shape.line.fill.background()

# Content area text
add_text(slide, "Topics Covered:", 1.0, 2.7, 11.3, 0.5, size=18, bold=True, color=WHITE, align=PP_ALIGN.CENTER)
topics = "Thyroid Physiology  •  Biochemical Tests (TSH, T3, T4)  •  Antibody Tests\nImaging (USG, Scintigraphy, CT/MRI)  •  FNAC  •  Clinical Interpretation"
add_text(slide, topics, 1.0, 3.2, 11.3, 1.2, size=16, color=TEAL_LIGHT, align=PP_ALIGN.CENTER)

add_text(slide, "Based on Scott-Brown's Otorhinolaryngology & Pye's Surgical Handicraft", 0.5, 6.6, 12.3, 0.6,
         size=12, color=GOLD, align=PP_ALIGN.CENTER, italic=True)

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 2 — THYROID PHYSIOLOGY & HPT AXIS
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)
add_rect(slide, 0, 0, 13.333, 7.5, LIGHT_GRAY)
add_rect(slide, 0, 0, 13.333, 1.1, TEAL_DARK)
add_text(slide, "THYROID PHYSIOLOGY — HPT Axis & Hormone Synthesis", 0.3, 0.15, 12.7, 0.8,
         size=26, bold=True, color=WHITE, align=PP_ALIGN.LEFT)

# Left column
add_rect(slide, 0.3, 1.25, 5.8, 5.9, WHITE)
add_text(slide, "Hypothalamic-Pituitary-Thyroid (HPT) Axis", 0.4, 1.3, 5.6, 0.5,
         size=16, bold=True, color=TEAL_DARK)
hpt_points = [
    "Hypothalamus → TRH (Thyrotropin-Releasing Hormone)",
    "Anterior Pituitary → TSH (Thyroid-Stimulating Hormone)",
    "Thyroid gland → T3 (Triiodothyronine) + T4 (Thyroxine)",
    "Negative feedback: T3/T4 inhibit TRH & TSH",
    "TSH shows log-linear inverse relation to FT4",
    "TSH is the MOST SENSITIVE test for thyroid dysfunction"
]
add_bullet_box(slide, hpt_points, 0.4, 1.85, 5.6, 3.5, size=14)

add_text(slide, "Normal Reference Ranges", 0.4, 5.4, 5.6, 0.4, size=15, bold=True, color=TEAL_DARK)
add_bullet_box(slide, [
    "TSH: 0.4 – 4.5 mIU/L",
    "Free T4 (FT4): 9 – 25 pmol/L",
    "Free T3 (FT3): 3.5 – 7.8 pmol/L",
    "Total T4: 60 – 160 nmol/L",
    "Total T3: 1.2 – 2.9 nmol/L"
], 0.4, 5.85, 5.6, 1.3, size=13, text_color=DARK_TEXT)

# Right column — image
add_rect(slide, 6.4, 1.25, 6.6, 5.9, WHITE)
add_text(slide, "HPT Axis — Normal vs Critical Illness", 6.5, 1.3, 6.4, 0.5,
         size=15, bold=True, color=TEAL_DARK)
added = add_image_from_url(slide,
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_00f638808512b7f8be8d91134e573dbda3092b285ba987b05f18a41a9e261bd6.jpg",
    6.5, 1.85, 6.2, 5.0)
if not added:
    add_text(slide, "[HPT Axis Diagram]", 6.5, 1.85, 6.2, 5.0, size=14, color=TEAL_MID, align=PP_ALIGN.CENTER)

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 3 — TSH: THE FIRST-LINE TEST
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)
add_rect(slide, 0, 0, 13.333, 7.5, LIGHT_GRAY)
add_rect(slide, 0, 0, 13.333, 1.1, TEAL_DARK)
add_text(slide, "TSH — The First-Line Test for Thyroid Dysfunction", 0.3, 0.15, 12.7, 0.8,
         size=26, bold=True, color=WHITE)

# TSH box
add_rect(slide, 0.3, 1.25, 8.0, 5.9, WHITE)
add_text(slide, "Why TSH is the Best Screening Test", 0.5, 1.3, 7.6, 0.5, size=16, bold=True, color=TEAL_DARK)
add_bullet_box(slide, [
    "Sandwich immunoassay using two monoclonal antibodies",
    "Detects TSH levels as low as 0.01 mIU/L (3rd generation)",
    "Log-linear inverse relationship with FT4 → highly sensitive",
    "Best single test to detect primary thyroid dysfunction",
    "TSH alone sufficient as first-line; measure FT4 only if TSH abnormal"
], 0.5, 1.85, 7.6, 2.0, size=14)

add_text(slide, "Factors That Affect TSH Levels (Box 60.1)", 0.5, 3.9, 7.6, 0.45, size=15, bold=True, color=TEAL_DARK)
add_bullet_box(slide, [
    "Inversely proportional to FT3/FT4 levels",
    "Non-thyroidal illness & psychiatric disorders → TSH ↓",
    "Pregnancy (1st trimester): hCG effect → TSH ↓",
    "Pituitary/hypothalamic disease → TSH ↓",
    "Drugs: dopamine, somatostatin, high-dose glucocorticoids → TSH ↓",
    "Assay artefacts: heterophilic antibody interference"
], 0.5, 4.4, 7.6, 2.5, size=13)

# Side box
add_rect(slide, 8.6, 1.25, 4.4, 2.8, TEAL_MID)
add_text(slide, "TSH Interpretation", 8.7, 1.3, 4.2, 0.45, size=15, bold=True, color=WHITE)
interp = [
    ("↑ TSH + ↓ FT4", "Primary Hypothyroidism"),
    ("↑ TSH + Normal FT4", "Subclinical Hypothyroidism"),
    ("↓ TSH + ↑ FT4", "Primary Hyperthyroidism"),
    ("↓ TSH + Normal FT4", "Subclinical Hyperthyroidism"),
    ("↓ TSH + ↓ FT4", "Secondary Hypothyroidism"),
]
y = 1.85
for lab, dx in interp:
    add_text(slide, f"• {lab}:", 8.7, y, 2.1, 0.38, size=11.5, bold=True, color=WHITE)
    add_text(slide, dx, 10.7, y, 2.2, 0.38, size=11.5, color=WHITE)
    y += 0.42

add_rect(slide, 8.6, 4.25, 4.4, 2.9, hex_to_rgb('#E8F8FB'))
add_text(slide, "Key Clinical Points", 8.7, 4.3, 4.2, 0.45, size=14, bold=True, color=TEAL_DARK)
add_bullet_box(slide, [
    "Measure TSH 2 months after any dose change",
    "Annual TSH monitoring once stable",
    "In secondary hypothyroidism: use FT4 (not TSH) to monitor",
    "Target FT4: upper third of reference range"
], 8.7, 4.8, 4.2, 2.2, size=12)

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 4 — FT3 & FT4 MEASUREMENTS
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)
add_rect(slide, 0, 0, 13.333, 7.5, LIGHT_GRAY)
add_rect(slide, 0, 0, 13.333, 1.1, TEAL_DARK)
add_text(slide, "Measurement of Free T3 & Free T4", 0.3, 0.15, 12.7, 0.8,
         size=26, bold=True, color=WHITE)

# Left box — FT4
add_rect(slide, 0.3, 1.25, 6.0, 5.9, WHITE)
add_text(slide, "Free T4 (FT4)", 0.5, 1.3, 5.6, 0.5, size=18, bold=True, color=TEAL_DARK)
add_bullet_box(slide, [
    "Over 99% of T3 & T4 is bound (to TBG, albumin, pre-albumin)",
    "Only FREE fraction is biologically active",
    "Measured by immunoassay — eliminates binding protein artefacts",
    "Primary test when TSH is abnormal",
    "Used to monitor levothyroxine in secondary hypothyroidism",
    "Anomalous results if inconsistent with TSH → measure TOTAL T4"
], 0.5, 1.85, 5.6, 2.8, size=14)

add_text(slide, "Factors Affecting FT3/FT4 (Box 60.2)", 0.5, 4.75, 5.6, 0.45, size=14, bold=True, color=TEAL_DARK)
add_bullet_box(slide, [
    "Non-thyroidal illness → ↓ FT3 (sick euthyroid syndrome)",
    "NSAIDs, furosemide, phenytoin, carbamazepine, heparin",
    "Oestrogens → ↑ TBG → ↑ total T4 (but FT4 normal)"
], 0.5, 5.25, 5.6, 1.8, size=13)

# Right box — FT3
add_rect(slide, 6.6, 1.25, 6.4, 5.9, WHITE)
add_text(slide, "Free T3 (FT3) — When to Measure", 6.8, 1.3, 6.0, 0.5, size=18, bold=True, color=TEAL_DARK)

add_rect(slide, 6.7, 1.9, 6.1, 0.5, TEAL_MID)
add_text(slide, "INDICATED in:", 6.8, 1.92, 5.8, 0.4, size=14, bold=True, color=WHITE)
add_bullet_box(slide, [
    "T3-toxicosis: TSH suppressed + FT4 still NORMAL (earliest thyrotoxicosis)",
    "Patient on propylthiouracil (PTU) — impairs T4 → T3 conversion",
    "Patient on amiodarone — impairs T4 → T3 conversion",
    "Confirms overt thyrotoxicosis when FT4 borderline"
], 6.8, 2.45, 6.0, 2.1, size=14)

add_rect(slide, 6.7, 4.6, 6.1, 0.5, RGBColor(0xC0, 0x39, 0x2B))
add_text(slide, "NOT INDICATED in:", 6.8, 4.62, 5.8, 0.4, size=14, bold=True, color=WHITE)
add_bullet_box(slide, [
    "Diagnosis of hypothyroidism",
    "FT3 remains normal until very late in hypothyroidism",
    "Despite ↓ FT4 and ↑ TSH, FT3 can still be normal"
], 6.8, 5.15, 6.0, 1.8, size=14, text_color=RGBColor(0x7B, 0x24, 0x1C))

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 5 — THYROID ANTIBODIES
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)
add_rect(slide, 0, 0, 13.333, 7.5, LIGHT_GRAY)
add_rect(slide, 0, 0, 13.333, 1.1, TEAL_DARK)
add_text(slide, "Thyroid Antibody Tests", 0.3, 0.15, 12.7, 0.8, size=26, bold=True, color=WHITE)

# Three columns
col_data = [
    {
        "title": "Anti-TPO Antibodies",
        "subtitle": "(Anti-Thyroid Peroxidase)",
        "points": [
            "Most sensitive antibody test",
            "Positive in >90% Hashimoto's thyroiditis",
            "Positive in 70-80% Graves' disease",
            "Indicates autoimmune thyroid disease",
            "High titre → risk of hypothyroidism",
            "Used in subclinical hypothyroidism workup"
        ],
        "color": TEAL_DARK
    },
    {
        "title": "Anti-Tg Antibodies",
        "subtitle": "(Anti-Thyroglobulin)",
        "points": [
            "Less specific than Anti-TPO",
            "Positive in Hashimoto's thyroiditis",
            "Interferes with thyroglobulin measurement",
            "Important in differentiated thyroid cancer follow-up",
            "High titres can give false-low Tg levels",
            "Order alongside Tg in cancer surveillance"
        ],
        "color": TEAL_MID
    },
    {
        "title": "TRAb / TSH-RAb",
        "subtitle": "(TSH Receptor Antibodies)",
        "points": [
            "Pathognomonic for Graves' disease",
            "Stimulating type (TSAb) → hyperthyroidism",
            "Blocking type → hypothyroidism (rare)",
            "Predicts neonatal thyrotoxicosis in pregnancy",
            "Guides decision on anti-thyroid drug withdrawal",
            "High titre = relapse risk after stopping ATD"
        ],
        "color": hex_to_rgb('#2E86AB')
    }
]

x_starts = [0.3, 4.6, 8.9]
for i, col in enumerate(col_data):
    x = x_starts[i]
    add_rect(slide, x, 1.25, 4.0, 5.9, WHITE)
    add_rect(slide, x, 1.25, 4.0, 0.8, col["color"])
    add_text(slide, col["title"], x+0.15, 1.3, 3.7, 0.42, size=16, bold=True, color=WHITE)
    add_text(slide, col["subtitle"], x+0.15, 1.72, 3.7, 0.28, size=11, color=TEAL_LIGHT, italic=True)
    add_bullet_box(slide, col["points"], x+0.15, 2.15, 3.7, 4.7, size=13)

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 6 — OTHER BIOCHEMICAL TESTS
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)
add_rect(slide, 0, 0, 13.333, 7.5, LIGHT_GRAY)
add_rect(slide, 0, 0, 13.333, 1.1, TEAL_DARK)
add_text(slide, "Other Biochemical & Special Tests", 0.3, 0.15, 12.7, 0.8, size=26, bold=True, color=WHITE)

# Row 1
boxes = [
    {"title": "Serum Thyroglobulin (Tg)", "pts": [
        "Produced only by thyroid follicular cells",
        "NOT useful for initial diagnosis",
        "Tumour marker in differentiated thyroid ca",
        "Post-thyroidectomy: undetectable Tg = remission",
        "Rising Tg → recurrence/metastasis",
        "Interfered by anti-Tg antibodies"
    ]},
    {"title": "Serum Calcitonin", "pts": [
        "Produced by parafollicular C-cells",
        "Elevated in medullary thyroid carcinoma (MTC)",
        "Useful for diagnosis & post-op monitoring of MTC",
        "Screen in MEN 2A/2B families",
        "Pentagastrin stimulation test used historically"
    ]},
    {"title": "TRH Stimulation Test", "pts": [
        "IV TRH given → TSH measured at 20 & 60 min",
        "Normal: TSH rises ≥2 mIU/L",
        "Blunted/absent rise → hyperthyroidism",
        "Exaggerated rise → primary hypothyroidism",
        "Largely replaced by sensitive TSH assays",
        "Still used when TSH is borderline"
    ]},
    {"title": "Other Biochemical Markers", "pts": [
        "Serum calcium: ↑ in 15-20% thyrotoxicosis",
        "Liver enzymes: may be elevated in thyrotoxicosis",
        "Cholesterol: ↑ in hypothyroidism",
        "Anaemia: may occur in both hypo & hyperthyroidism",
        "CPK: elevated in hypothyroid myopathy",
        "Prolactin: elevated in severe hypothyroidism"
    ]},
]

positions = [(0.3, 1.25), (3.55, 1.25), (6.8, 1.25), (10.05, 1.25)]
for i, (box, (x, y)) in enumerate(zip(boxes, positions)):
    add_rect(slide, x, y, 3.0, 5.9, WHITE)
    add_rect(slide, x, y, 3.0, 0.55, TEAL_MID)
    add_text(slide, box["title"], x+0.1, y+0.05, 2.8, 0.45, size=13, bold=True, color=WHITE)
    add_bullet_box(slide, box["pts"], x+0.1, y+0.65, 2.8, 5.0, size=12)

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 7 — THYROID ULTRASOUND
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)
add_rect(slide, 0, 0, 13.333, 7.5, LIGHT_GRAY)
add_rect(slide, 0, 0, 13.333, 1.1, TEAL_DARK)
add_text(slide, "Thyroid Ultrasonography (USG)", 0.3, 0.15, 12.7, 0.8, size=26, bold=True, color=WHITE)

add_rect(slide, 0.3, 1.25, 5.8, 5.9, WHITE)
add_text(slide, "Technique & Clinical Uses", 0.5, 1.3, 5.4, 0.5, size=16, bold=True, color=TEAL_DARK)
add_bullet_box(slide, [
    "High-frequency (7.5–15 MHz) B-mode imaging",
    "FIRST-LINE imaging for thyroid nodules",
    "Distinguishes solid vs cystic lesions",
    "Detects multifocal disease when only single swelling apparent clinically",
    "Guides FNAC — increases accuracy of biopsy",
    "Assesses vascularity (Doppler): diffuse ↑ flow in Graves' disease",
    "Measures thyroid volume (goitre assessment)"
], 0.5, 1.9, 5.4, 3.4, size=14)

add_text(slide, "TI-RADS Features (Suspicious for Malignancy)", 0.5, 5.35, 5.4, 0.45, size=14, bold=True, color=TEAL_DARK)
add_bullet_box(slide, [
    "Hypoechoic solid nodule",
    "Microcalcifications (punctate echogenic foci)",
    "Irregular/ill-defined margins",
    "Taller-than-wide orientation",
    "Incomplete peripheral rim of calcification"
], 0.5, 5.85, 5.4, 1.5, size=13)

# Right — image
add_rect(slide, 6.4, 1.25, 6.6, 5.9, WHITE)
add_text(slide, "Ultrasound — Thyroid Nodule (TI-RADS 4B)", 6.5, 1.3, 6.3, 0.5,
         size=14, bold=True, color=TEAL_DARK)
add_image_from_url(slide,
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_5a9ae0a22ec899ef678f79affb868337f139abbed0676fd858f93a10c19ab3c0.jpg",
    6.5, 1.85, 6.2, 4.9)
add_image_from_url(slide,
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_5a9ae0a22ec899ef678f79affb868337f139abbed0676fd858f93a10c19ab3c0.jpg",
    6.5, 1.85, 6.2, 4.9)

# Try primary URL
img1 = download_image("https://cdn.orris.care/cdss_images/pmc_clinical_VQA_5a9ae0a22ec899ef678f78effb868337f139abbed0676fd858f93a10c19ab3c0.jpg")
if img1:
    slide.shapes.add_picture(img1, Inches(6.5), Inches(1.85), Inches(6.2), Inches(4.9))
else:
    add_text(slide, "[Thyroid Ultrasound Image]", 6.5, 1.85, 6.2, 4.9, size=14, color=TEAL_MID, align=PP_ALIGN.CENTER)

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 8 — THYROID SCINTIGRAPHY
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)
add_rect(slide, 0, 0, 13.333, 7.5, LIGHT_GRAY)
add_rect(slide, 0, 0, 13.333, 1.1, TEAL_DARK)
add_text(slide, "Thyroid Scintigraphy (Radionuclide Scan)", 0.3, 0.15, 12.7, 0.8,
         size=26, bold=True, color=WHITE)

# Left
add_rect(slide, 0.3, 1.25, 6.2, 5.9, WHITE)
add_text(slide, "Isotopes Used", 0.5, 1.3, 5.8, 0.45, size=16, bold=True, color=TEAL_DARK)
add_bullet_box(slide, [
    "99mTc-Pertechnetate — most common, low radiation, rapid imaging",
    "131I-Radioiodine — functional imaging, also used for therapy",
    "123I — less radiation than 131I, better imaging"
], 0.5, 1.8, 5.8, 1.2, size=14)

add_text(slide, "Information Provided", 0.5, 3.05, 5.8, 0.4, size=15, bold=True, color=TEAL_DARK)
add_bullet_box(slide, [
    "Measures avidity of isotope uptake (gland function)",
    "Pattern of uptake: diffuse / focal / suppressed"
], 0.5, 3.5, 5.8, 0.9, size=14)

add_text(slide, "Hot vs Cold Nodule", 0.5, 4.5, 5.8, 0.45, size=15, bold=True, color=TEAL_DARK)

# Table-like boxes
add_rect(slide, 0.5, 5.0, 2.7, 0.45, TEAL_MID)
add_text(slide, "HOT Nodule", 0.55, 5.02, 2.6, 0.4, size=13, bold=True, color=WHITE, align=PP_ALIGN.CENTER)
add_rect(slide, 3.3, 5.0, 2.9, 0.45, RGBColor(0xC0, 0x39, 0x2B))
add_text(slide, "COLD Nodule", 3.35, 5.02, 2.8, 0.4, size=13, bold=True, color=WHITE, align=PP_ALIGN.CENTER)

add_bullet_box(slide, [
    "↑ tracer uptake",
    "Autonomous function",
    "Toxic adenoma",
    "Almost always BENIGN"
], 0.5, 5.5, 2.7, 1.6, size=12)
add_bullet_box(slide, [
    "↓ tracer uptake",
    "Non-functioning tissue",
    "Cyst, adenoma, carcinoma, thyroiditis",
    "Up to 10% are MALIGNANT"
], 3.3, 5.5, 2.9, 1.6, size=12)

# Right — image
add_rect(slide, 6.8, 1.25, 6.2, 5.9, WHITE)
add_text(slide, "99mTc Pertechnetate Scan — Hot Nodule (Left Lobe)", 6.9, 1.3, 6.0, 0.5,
         size=13, bold=True, color=TEAL_DARK)
img2 = download_image("https://cdn.orris.care/cdss_images/roco_radiology_ROCO_16747_1766646999875.png")
if img2:
    slide.shapes.add_picture(img2, Inches(6.9), Inches(1.85), Inches(5.9), Inches(5.1))
else:
    add_text(slide, "[Thyroid Scintigraphy Scan]", 6.9, 1.85, 5.9, 5.1, size=14, color=TEAL_MID, align=PP_ALIGN.CENTER)

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 9 — FNAC
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)
add_rect(slide, 0, 0, 13.333, 7.5, LIGHT_GRAY)
add_rect(slide, 0, 0, 13.333, 1.1, TEAL_DARK)
add_text(slide, "Fine Needle Aspiration Cytology (FNAC)", 0.3, 0.15, 12.7, 0.8,
         size=26, bold=True, color=WHITE)

add_rect(slide, 0.3, 1.25, 5.8, 5.9, WHITE)
add_text(slide, "Indications & Technique", 0.5, 1.3, 5.4, 0.45, size=16, bold=True, color=TEAL_DARK)
add_bullet_box(slide, [
    "Gold standard to evaluate thyroid nodule for malignancy",
    "Indications: solitary nodule, suspicious USG features, cold nodule on scan",
    "23-25 gauge needle; USG-guided for accuracy",
    "Material smeared, fixed and stained (Pap or H&E)",
    "Sample adequacy: ≥6 groups of follicular cells per slide"
], 0.5, 1.8, 5.4, 2.2, size=14)

add_text(slide, "Bethesda Classification", 0.5, 4.05, 5.4, 0.45, size=15, bold=True, color=TEAL_DARK)
bethesda = [
    ("I", "Non-diagnostic / Unsatisfactory", "Repeat FNAC"),
    ("II", "Benign", "Clinical follow-up"),
    ("III", "Atypia of Undetermined Significance", "Repeat FNAC / molecular"),
    ("IV", "Follicular Neoplasm", "Diagnostic lobectomy"),
    ("V", "Suspicious for Malignancy", "Near-total thyroidectomy"),
    ("VI", "Malignant", "Total thyroidectomy"),
]
y = 4.55
for cat, desc, mgmt in bethesda:
    add_rect(slide, 0.5, y, 0.4, 0.38, TEAL_DARK)
    add_text(slide, cat, 0.5, y+0.01, 0.4, 0.36, size=11, bold=True, color=WHITE, align=PP_ALIGN.CENTER)
    add_text(slide, desc, 0.95, y, 3.0, 0.38, size=11, color=DARK_TEXT)
    add_text(slide, mgmt, 3.98, y, 2.0, 0.38, size=10, color=TEAL_MID, italic=True)
    y += 0.4

# Right — images
add_rect(slide, 6.4, 1.25, 6.6, 5.9, WHITE)
add_text(slide, "USG-Guided FNAC + Cytology", 6.5, 1.3, 6.3, 0.45, size=14, bold=True, color=TEAL_DARK)
img3 = download_image("https://cdn.orris.care/cdss_images/pmc_clinical_VQA_64be58c7c920c7ef8e3955f9bcd00af39833566458ef67badeaa037940faf9ee.jpg")
if img3:
    slide.shapes.add_picture(img3, Inches(6.5), Inches(1.85), Inches(6.2), Inches(2.7))
img4 = download_image("https://cdn.orris.care/cdss_images/Pathology_1760052506580_9aaa2ee8-a930-4ed3-8a86-7ff26ed89543.jpg")
if img4:
    slide.shapes.add_picture(img4, Inches(6.5), Inches(4.65), Inches(6.2), Inches(2.35))

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 10 — CT, MRI & OTHER IMAGING
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)
add_rect(slide, 0, 0, 13.333, 7.5, LIGHT_GRAY)
add_rect(slide, 0, 0, 13.333, 1.1, TEAL_DARK)
add_text(slide, "CT Scan, MRI & Other Investigations", 0.3, 0.15, 12.7, 0.8,
         size=26, bold=True, color=WHITE)

panels = [
    {"title": "CT Scan of Neck", "color": TEAL_DARK, "pts": [
        "Not first-line for thyroid evaluation",
        "Best for: retrosternal goitre extent",
        "Assesses tracheal compression/deviation",
        "Lymph node mapping before surgery",
        "Detects calcification (dystrophic/psammomatous)",
        "Contrast may be delayed if ¹³¹I planned (iodine load)"
    ]},
    {"title": "MRI of Neck", "color": TEAL_MID, "pts": [
        "Superior soft tissue contrast vs CT",
        "No ionizing radiation",
        "Invasive thyroid cancer: vessel/nerve involvement",
        "Better characterization of retrosternal extension",
        "MRI-guided biopsy in difficult locations",
        "Not routine for nodule evaluation"
    ]},
    {"title": "PET-CT (FDG)", "color": hex_to_rgb('#8E44AD'), "pts": [
        "18F-FDG for poorly differentiated thyroid ca",
        "Used when RAI scan negative but Tg rising",
        "Identifies dedifferentiated/aggressive metastases",
        "Incidental thyroid uptake on PET → FNAC recommended",
        "Not routine in initial workup"
    ]},
    {"title": "Chest X-Ray / Barium Swallow", "color": hex_to_rgb('#2E86AB'), "pts": [
        "CXR: tracheal deviation, calcification in goitre",
        "Retrosternal extension on CXR (AP + Lateral)",
        "Barium swallow: oesophageal compression",
        "Useful when advanced imaging not available",
        "Historical role now largely replaced by CT"
    ]},
]

xs = [0.3, 3.55, 6.8, 10.05]
for i, (panel, x) in enumerate(zip(panels, xs)):
    add_rect(slide, x, 1.25, 3.0, 5.9, WHITE)
    add_rect(slide, x, 1.25, 3.0, 0.6, panel["color"])
    add_text(slide, panel["title"], x+0.1, 1.3, 2.8, 0.5, size=14, bold=True, color=WHITE)
    add_bullet_box(slide, panel["pts"], x+0.1, 1.95, 2.8, 5.0, size=12)

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 11 — CLINICAL APPROACH / ALGORITHM
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)
add_rect(slide, 0, 0, 13.333, 7.5, LIGHT_GRAY)
add_rect(slide, 0, 0, 13.333, 1.1, TEAL_DARK)
add_text(slide, "Clinical Approach to Thyroid Investigation", 0.3, 0.15, 12.7, 0.8,
         size=26, bold=True, color=WHITE)

# Algorithm box
add_rect(slide, 0.3, 1.25, 12.7, 5.9, WHITE)
add_text(slide, "STEP-WISE APPROACH", 0.5, 1.35, 12.3, 0.45, size=17, bold=True,
         color=TEAL_DARK, align=PP_ALIGN.CENTER)

steps = [
    ("STEP 1", "History & Physical Examination",
     "Symptoms of hyper/hypothyroidism, goitre, nodule, family history, medications, prior neck radiation"),
    ("STEP 2", "First-Line Biochemical: TSH",
     "Normal TSH → unlikely primary thyroid disease | Abnormal TSH → proceed to Step 3"),
    ("STEP 3", "Second-Line: FT4 ± FT3",
     "FT4 confirms degree of dysfunction | FT3 only if T3-toxicosis suspected or on PTU/amiodarone"),
    ("STEP 4", "Antibody Testing",
     "Autoimmune suspected → Anti-TPO, Anti-Tg, TRAb | Graves' disease: TRAb | Hashimoto: Anti-TPO"),
    ("STEP 5", "Imaging: Ultrasound",
     "All palpable nodules → USG | Characterize nodule (TI-RADS) | Guide FNAC if needed"),
    ("STEP 6", "Scintigraphy / FNAC",
     "Thyrotoxicosis with nodule → Scan first | Cold nodule → FNAC | TI-RADS 4/5 → FNAC regardless"),
    ("STEP 7", "Advanced Imaging / Molecular Testing",
     "CT/MRI for retrosternal goitre, malignant invasion | Bethesda III-IV: consider molecular markers"),
]

y = 1.9
colors = [TEAL_DARK, TEAL_MID, hex_to_rgb('#2E86AB'), hex_to_rgb('#8E44AD'),
          hex_to_rgb('#16A085'), hex_to_rgb('#D35400'), hex_to_rgb('#C0392B')]
for i, (step, title, detail) in enumerate(steps):
    add_rect(slide, 0.5, y, 1.1, 0.62, colors[i])
    add_text(slide, step, 0.52, y+0.05, 1.06, 0.52, size=11, bold=True, color=WHITE, align=PP_ALIGN.CENTER)
    add_rect(slide, 1.65, y, 3.3, 0.62, RGBColor(0xF0, 0xF8, 0xFA))
    add_text(slide, title, 1.72, y+0.05, 3.1, 0.52, size=12, bold=True, color=TEAL_DARK)
    add_text(slide, detail, 5.1, y+0.07, 7.8, 0.52, size=11.5, color=DARK_TEXT)
    y += 0.73

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 12 — SPECIAL SITUATIONS
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)
add_rect(slide, 0, 0, 13.333, 7.5, LIGHT_GRAY)
add_rect(slide, 0, 0, 13.333, 1.1, TEAL_DARK)
add_text(slide, "Special Clinical Situations", 0.3, 0.15, 12.7, 0.8, size=26, bold=True, color=WHITE)

situations = [
    {"title": "Pregnancy", "color": hex_to_rgb('#16A085'), "pts": [
        "Use trimester-specific TSH ranges",
        "1st trimester TSH: 0.1–2.5 mIU/L",
        "2nd trimester TSH: 0.2–3.0 mIU/L",
        "3rd trimester TSH: 0.3–3.0 mIU/L",
        "hCG stimulates thyroid → lower TSH in 1st trimester",
        "Screen all women planning pregnancy",
        "High TRAb in mother → neonatal thyrotoxicosis risk"
    ]},
    {"title": "Non-Thyroidal Illness (Sick Euthyroid)", "color": hex_to_rgb('#D35400'), "pts": [
        "Systemic illness → ↓ T3 (reduced T4→T3 conversion)",
        "FT4 may be low or normal",
        "TSH typically low but may be inappropriately normal",
        "Do NOT treat unless overt dysfunction confirmed",
        "Repeat TFTs after recovery from acute illness",
        "Low rT3 helps distinguish from true hypothyroidism"
    ]},
    {"title": "Thyroid Cancer Monitoring", "color": hex_to_rgb('#8E44AD'), "pts": [
        "Post-thyroidectomy: Thyroglobulin (Tg) as tumour marker",
        "Tg undetectable = remission; rising = recurrence",
        "Anti-Tg antibodies interfere → monitor trends",
        "TSH suppression therapy in high-risk DTC",
        "131I whole body scan after withdrawal or rhTSH",
        "Annual neck USG for surveillance"
    ]},
    {"title": "Subclinical Thyroid Disease", "color": hex_to_rgb('#2C3E50'), "pts": [
        "Subclinical Hypothyroidism: ↑TSH + normal FT4",
        "Treat if TSH >10, symptoms, or pregnancy",
        "Subclinical Hyperthyroidism: ↓TSH + normal FT3/FT4",
        "Treat if TSH <0.1, cardiac disease, osteoporosis risk",
        "Repeat TFTs in 3–6 months before treating",
        "Identify underlying cause before therapy"
    ]},
]

xs = [0.3, 3.55, 6.8, 10.05]
for panel, x in zip(situations, xs):
    add_rect(slide, x, 1.25, 3.0, 5.9, WHITE)
    add_rect(slide, x, 1.25, 3.0, 0.6, panel["color"])
    add_text(slide, panel["title"], x+0.1, 1.3, 2.8, 0.5, size=13, bold=True, color=WHITE)
    add_bullet_box(slide, panel["pts"], x+0.1, 1.95, 2.8, 5.0, size=12)

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 13 — SUMMARY TABLE
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)
add_rect(slide, 0, 0, 13.333, 7.5, LIGHT_GRAY)
add_rect(slide, 0, 0, 13.333, 1.1, TEAL_DARK)
add_text(slide, "Summary: Investigation of Thyroid at a Glance", 0.3, 0.15, 12.7, 0.8,
         size=26, bold=True, color=WHITE)

add_rect(slide, 0.3, 1.25, 12.7, 5.9, WHITE)

# Table header
headers = ["Investigation", "What It Measures", "Key Use", "MBBS Pearl"]
col_ws = [2.5, 3.2, 3.5, 3.2]
xs = [0.4, 2.95, 6.2, 9.75]
header_y = 1.35
for hdr, x, w in zip(headers, xs, col_ws):
    add_rect(slide, x, header_y, w-0.05, 0.45, TEAL_DARK)
    add_text(slide, hdr, x+0.05, header_y+0.04, w-0.15, 0.37, size=13, bold=True,
             color=WHITE, align=PP_ALIGN.CENTER)

rows = [
    ("TSH", "Pituitary response to thyroid hormones", "Best single screening test", "First test to order"),
    ("Free T4", "Active thyroxine level", "Confirm & quantify dysfunction", "Measure if TSH abnormal"),
    ("Free T3", "Active triiodothyronine", "Diagnose T3-toxicosis", "Not for hypothyroidism Dx"),
    ("Anti-TPO", "Thyroid autoimmunity", "Hashimoto's / Graves' diagnosis", "Most sensitive Ab test"),
    ("TRAb", "TSH receptor antibodies", "Confirm Graves' disease", "Neonatal risk predictor"),
    ("Thyroglobulin", "Residual thyroid tissue", "Post-thyroid ca monitoring", "Tumour marker only"),
    ("USG", "Nodule morphology", "First imaging for nodules", "Guide FNAC"),
    ("Scintigraphy", "Uptake & function", "Hot vs cold nodule", "Cold = up to 10% malignant"),
    ("FNAC", "Cytology", "Definitive nodule assessment", "Bethesda system"),
    ("CT/MRI", "Anatomy & extent", "Retrosternal/invasive disease", "Not routine for nodules"),
]

row_colors = [LIGHT_GRAY, WHITE]
y = 1.85
for i, row in enumerate(rows):
    bg = row_colors[i % 2]
    for j, (cell, x, w) in enumerate(zip(row, xs, col_ws)):
        add_rect(slide, x, y, w-0.05, 0.48, bg)
        add_text(slide, cell, x+0.05, y+0.04, w-0.15, 0.40,
                 size=11.5, bold=(j==0), color=DARK_TEXT if j>0 else TEAL_DARK)
    y += 0.49

# ─────────────────────────────────────────────────────────────────────────────
# SLIDE 14 — THANK YOU / REFERENCES
# ─────────────────────────────────────────────────────────────────────────────
slide = prs.slides.add_slide(blank)
add_rect(slide, 0, 0, 13.333, 7.5, TEAL_DARK)
add_rect(slide, 0, 2.6, 13.333, 2.5, TEAL_MID)
add_rect(slide, 0, 6.5, 13.333, 1.0, hex_to_rgb('#004D5B'))

add_text(slide, "Thank You", 0.5, 0.5, 12.3, 1.4, size=52, bold=True,
         color=WHITE, align=PP_ALIGN.CENTER)
add_text(slide, "Key Takeaways", 0.5, 2.7, 12.3, 0.5, size=20, bold=True,
         color=WHITE, align=PP_ALIGN.CENTER)
takeaways = "TSH is the most sensitive first-line test  •  Always confirm abnormal TSH with FT4  •  FT3 only for T3-toxicosis\n" \
            "Anti-TPO for autoimmune thyroid disease  •  USG is first-line imaging  •  FNAC = Bethesda system\n" \
            "Cold nodule: up to 10% malignancy risk  •  Tg is a tumour marker post-thyroidectomy"
add_text(slide, takeaways, 0.5, 3.25, 12.3, 1.3, size=15, color=WHITE, align=PP_ALIGN.CENTER)

add_text(slide, "References", 0.5, 4.75, 12.3, 0.4, size=16, bold=True,
         color=GOLD, align=PP_ALIGN.LEFT)
refs = [
    "1. Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol 1 — Chapter 60: Investigation of Thyroid",
    "2. Pye's Surgical Handicraft, 22nd Ed — Chapter 22: Thyroid",
    "3. Harper's Illustrated Biochemistry, 32nd Ed — Thyroid Function Tests",
    "4. Goodman & Gilman's Pharmacological Basis of Therapeutics — Thyroid & Anti-thyroid Drugs",
]
y = 5.25
for ref in refs:
    add_text(slide, ref, 0.6, y, 12.0, 0.35, size=11, color=TEAL_LIGHT, italic=True)
    y += 0.35

# ─────────────────────────────────────────────────────────────────────────────
# SAVE
# ─────────────────────────────────────────────────────────────────────────────
out_path = "/tmp/workspace/thyroid-pptx/Investigation_of_Thyroid_MBBS.pptx"
prs.save(out_path)
print(f"Saved: {out_path}")
print(f"Slides: {len(prs.slides)}")

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/thyroid-pptx/build_pptx.py'