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

doc = SimpleDocTemplate(
    "/tmp/workspace/varicose-veins-pdf/Varicose_Veins_Significance.pdf",
    pagesize=A4,
    rightMargin=2*cm, leftMargin=2*cm,
    topMargin=2.2*cm, bottomMargin=2.2*cm
)

styles = getSampleStyleSheet()

# Custom styles
TITLE = ParagraphStyle('TITLE', parent=styles['Title'],
    fontSize=20, textColor=colors.HexColor('#1a237e'),
    spaceAfter=6, spaceBefore=0, alignment=TA_CENTER, fontName='Helvetica-Bold')

SUBTITLE = ParagraphStyle('SUBTITLE', parent=styles['Normal'],
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    spaceAfter=10, spaceBefore=0, alignment=TA_CENTER, fontName='Helvetica-Oblique')

SECTION_HEADER = ParagraphStyle('SECTION_HEADER', parent=styles['Heading1'],
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SUBSECTION_HEADER = ParagraphStyle('SUBSECTION_HEADER', parent=styles['Heading2'],
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    fontName='Helvetica-Bold',
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ITEM_HEADER = ParagraphStyle('ITEM_HEADER', parent=styles['Normal'],
    fontSize=11, textColor=colors.HexColor('#b71c1c'),
    spaceAfter=2, spaceBefore=6, fontName='Helvetica-Bold')

BODY = ParagraphStyle('BODY', parent=styles['Normal'],
    fontSize=9.5, textColor=colors.HexColor('#212121'),
    spaceAfter=4, spaceBefore=0, leading=14,
    fontName='Helvetica', alignment=TA_JUSTIFY, leftIndent=8)

NOTE = ParagraphStyle('NOTE', parent=styles['Normal'],
    fontSize=9, textColor=colors.HexColor('#4a148c'),
    spaceAfter=4, spaceBefore=2, fontName='Helvetica-Oblique', leftIndent=8)

BULLET = ParagraphStyle('BULLET', parent=styles['Normal'],
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story = []

# ── TITLE PAGE ─────────────────────────────────────────────────────────────
story.append(Spacer(1, 1.5*cm))
story.append(Paragraph("VARICOSE VEINS", TITLE))
story.append(Paragraph("Long Case History & Examination", TITLE))
story.append(Spacer(1, 0.3*cm))
story.append(HRFlowable(width="100%", thickness=3, color=colors.HexColor('#1a237e')))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph("Significance of Every History and Examination Finding", SUBTITLE))
story.append(Paragraph("According to Das's Manual of Clinical Surgery & Rajamahendran's Surgical Principles", SUBTITLE))
story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor('#90a4ae')))
story.append(Spacer(1, 2*cm))

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    story.append(Spacer(1, 0.2*cm))

def subsection(title):
    story.append(Paragraph(title, SUBSECTION_HEADER))

def item(title, body, note=None):
    story.append(Paragraph(f"▶ {title}", ITEM_HEADER))
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        story.append(Paragraph(body, BODY))
    if note:
        story.append(Paragraph(f"Examiner's Note: {note}", NOTE))
    story.append(Spacer(1, 0.1*cm))

# ════════════════════════════════════════════════════
# 1. CHIEF COMPLAINTS
# ════════════════════════════════════════════════════
section("1. CHIEF COMPLAINTS — WHY ASKED & SIGNIFICANCE")

item("Multiple Swellings / Dilated Tortuous Veins in the Lower Limb",
     "The primary presenting feature of varicose veins. Tortuous, dilated, elongated superficial veins result from incompetent valves in the great saphenous vein (GSV), small saphenous vein (SSV), or their tributaries. "
     "Asking the duration establishes chronicity. Varicosities starting below the knee and progressing upward suggest perforator incompetence. Those involving the medial aspect indicate GSV system; lateral/posterior involvement indicates SSV system. "
     "This helps classify the extent and guides surgical planning (stripping, phlebectomy, or endovenous ablation).",
     "Always note which system is involved — GSV vs SSV — as treatment differs.")

item("Ulcer in the Lower Limb",
     "Venous ulcers develop due to chronic venous hypertension, leading to lipodermatosclerosis, skin breakdown, and non-healing wounds. They classically occur in the 'gaiter area' (lower third of leg, above medial malleolus). "
     "Their presence upgrades the clinical severity to CEAP C6 and indicates advanced chronic venous insufficiency (CVI). Duration of ulcer helps predict healing potential and need for surgical intervention.",
     "Venous ulcers are painless or mildly painful, have sloping edges, granulation tissue floor, and are surrounded by pigmented, eczematous skin.")

item("Pain in the Lower Limb",
     "Pain in varicose veins is typically a dull aching, heaviness, or bursting sensation, worse after prolonged standing and relieved by elevation. "
     "This is due to venous hypertension causing tissue hypoxia and accumulation of inflammatory mediators. "
     "Sudden severe pain suggests superficial thrombophlebitis. Bursting pain on walking suggests deep vein obstruction (Perthes-positive). Night cramps suggest deep venous involvement.",
     "If pain is NOT relieved by elevation, suspect arterial component or DVT — this changes management.")

# ════════════════════════════════════════════════════
# 2. HISTORY OF PRESENTING ILLNESS
# ════════════════════════════════════════════════════
section("2. HISTORY OF PRESENTING ILLNESS — SIGNIFICANCE OF EACH H/O")

item("H/O Ulcer",
     "Establishes CEAP C6 status (active ulcer) or C5 (healed ulcer). Venous ulcer implies severe, long-standing CVI. "
     "Determines need for wound care, compression therapy, and definitive surgery after ulcer healing.")

item("H/O Discharge",
     "Indicates infection or serous exudate from ulcer. Purulent discharge suggests secondary bacterial infection needing culture sensitivity and antibiotics before surgery. "
     "Serous discharge is typical of venous ulcer and signifies active venous hypertension.")

item("H/O Pain",
     "Characterize: dull aching = venous hypertension; burning = superficial thrombophlebitis; bursting on walking = deep vein obstruction (positive Perthes); nocturnal cramps = deep vein involvement. "
     "Pain character guides diagnosis of complication.")

item("H/O Trauma",
     "Trauma to superficial varicosities can cause external hemorrhage (a complication of varicose veins). "
     "Previous trauma to the limb may also cause secondary varicose veins via deep vein thrombosis (post-thrombotic syndrome) — an important distinction from primary varicose veins.")

item("H/O Itching",
     "Itching over the varicosities or gaiter area suggests varicose eczema (stasis dermatitis), caused by chronic venous hypertension and extravasation of red cells and plasma proteins. "
     "This is CEAP C4a and indicates significant CVI requiring treatment.")

item("H/O Bleeding",
     "Spontaneous or post-traumatic bleeding from varicosities is a recognised complication. Even minor trauma can rupture thin-walled sub-dermal veins causing profuse, painless bleeding. "
     "Immediate treatment: elevation and direct pressure. Surgical ligation is definitive.")

item("H/O Prolonged Standing",
     "The MOST IMPORTANT predisposing factor. Prolonged standing increases hydrostatic venous pressure in the lower limb, accelerating valve incompetence. "
     "Occupations at risk: teachers, surgeons, barbers, soldiers, cooks. This history confirms the aetiology and is elicited to correlate with primary varicose veins.")

item("H/O Discoloration of the Limb",
     "Brownish-black pigmentation in the gaiter area results from haemosiderin deposition (breakdown of extravasated RBCs). "
     "This indicates CEAP C4b (skin changes) and signifies long-standing severe CVI. Suggests the need for definitive surgical intervention.")

item("H/O Difficulty in Walking / Standing",
     "Suggests severe venous hypertension, deep vein obstruction, or advanced lipodermatosclerosis. "
     "Difficulty on walking specifically (venous claudication) is a cardinal sign of deep vein obstruction — important because Perthes test must then be done carefully before surgery.")

item("H/O Deformity of the Limb",
     "Pre-existing limb deformity (e.g., post-fracture malunion) may have caused DVT leading to secondary varicose veins. "
     "Also rules out congenital conditions like Klippel-Trenaunay syndrome (KTS) which presents with varicose veins + limb hypertrophy + port-wine stain.")

item("H/O Abdominal Pain / Distension / Constipation",
     "These symptoms suggest intra-abdominal pathology — pelvic or abdominal tumours, ascites, or portal hypertension causing secondary obstruction of the inferior vena cava (IVC) or iliac veins. "
     "Secondary varicose veins from such obstruction require treatment of the underlying cause first, not superficial vein surgery. "
     "Abdomen must be examined for organomegaly, masses, and ascites.",
     "If secondary cause is found, treating varicosities alone will lead to recurrence.")

item("H/O Fever",
     "Fever suggests superficial thrombophlebitis (localised) or cellulitis around an ulcer. "
     "High fever with rigors may indicate deep vein thrombosis with systemic sepsis. "
     "Fever contraindicates elective surgery — patient must be treated with antibiotics and NSAIDs first.")

item("H/O Bursting Type of Pain in the Lower Limb",
     "Classic symptom of deep vein obstruction / post-thrombotic syndrome. "
     "In Perthes test, if exercise causes bursting pain, the deep veins are obstructed — surgical stripping of superficial veins is then CONTRAINDICATED as they are acting as collaterals.")

item("H/O Swelling of the Limb",
     "Pitting oedema of the limb indicates CVI causing fluid transudation, or may suggest deep vein obstruction causing impaired venous return. "
     "Oedema also develops with lipodermatosclerosis and hypoproteinaemia from ulcer exudate. Brawny non-pitting oedema suggests lymphoedema as comorbidity.")

item("H/O Chest Pain / Breathlessness / Palpitation",
     "These systemic symptoms are asked to rule out pulmonary embolism (PE) as a complication. "
     "PE occurs when a thrombus from deep veins embolises to the pulmonary circulation. "
     "Also screens for cardiac disease which affects anaesthetic fitness and surgical risk.")

item("H/O Haemoptysis",
     "Blood-stained sputum in a patient with deep vein thrombosis/varicose veins strongly suggests pulmonary infarction from PE. "
     "This constitutes a surgical emergency. It affects both pre-operative workup and timing of any intervention.")

# ════════════════════════════════════════════════════
# 3. PAST HISTORY
# ════════════════════════════════════════════════════
section("3. PAST HISTORY — SIGNIFICANCE OF EACH ITEM")

item("H/O Similar Episodes in the Past",
     "Recurrent varicose veins suggest inadequate previous treatment, missed perforators, or secondary aetiology. "
     "Guides surgical planning to be more comprehensive and investigate for underlying cause.")

item("H/O DM / SHT / Asthma / Epilepsy / Heart Disease / Kidney Disease / Allergy",
     [
         "Diabetes: Impairs wound healing, increases infection risk, affects surgical outcome; glycaemic control mandatory pre-op.",
         "Systemic Hypertension: Affects anaesthetic management; antihypertensives must be continued peri-operatively.",
         "Asthma / COPD: Affects respiratory fitness for general anaesthesia; may prefer spinal anaesthesia.",
         "Epilepsy: Drug interactions with anaesthetic agents; continue anti-epileptics.",
         "Heart Disease: Cardiac evaluation needed; affects risk stratification.",
         "Kidney Disease: Affects drug metabolism, fluid management, contrast use in venography.",
         "Allergy: Prevents anaphylaxis to anaesthetic drugs, latex, contrast dyes."
     ])

item("H/O Previous Surgery in the Lower Limb",
     "Previous vascular surgery or saphenous stripping can cause scar tissue altering anatomy, making re-do surgery complex. "
     "Previous orthopaedic surgery (plating, fixation) may have caused DVT leading to secondary varicose veins.")

item("H/O Chronic Drug Intake",
     [
         "Oral Contraceptive Pills (OCPs): Major risk factor for DVT and secondary varicose veins; hypercoagulable state.",
         "Anticoagulants (Warfarin, DOACs): Must be stopped/bridged pre-operatively.",
         "Steroids: Impair wound healing; need peri-operative cover.",
         "NSAIDs: Affect platelet function; stop 7 days before surgery.",
         "Oestrogen therapy in post-menopausal women: Increases DVT risk."
     ])

item("H/O Previous Immobilisation",
     "Prolonged immobilisation (bed rest, plaster cast, long-distance travel) is a major precipitant of DVT, which can lead to post-thrombotic syndrome and secondary varicose veins. "
     "This explains the aetiology and directs further investigation with Doppler duplex.")

# ════════════════════════════════════════════════════
# 4. PERSONAL HISTORY
# ════════════════════════════════════════════════════
section("4. PERSONAL HISTORY — SIGNIFICANCE")

item("Diet (Veg / Non-Veg)",
     "Nutritional status affects wound healing and recovery. Hypoproteinaemia from a poor diet worsens oedema and impairs ulcer healing. "
     "Dietary assessment helps plan pre-operative nutritional support.")

item("Smoking",
     "Smoking is a risk factor for peripheral vascular disease (arterial insufficiency). "
     "Co-existing arterial disease changes the management of venous ulcer — compression therapy is relatively contraindicated if ABI < 0.8. "
     "Smoking also increases post-operative pulmonary complications and wound infections.")

item("Alcohol",
     "Chronic alcoholism causes liver disease and portal hypertension, which can cause secondary varicose veins via increased caval/portal pressure. "
     "Also affects drug metabolism, anaesthetic risk, and coagulation.")

item("Bowel / Bladder Habits",
     "Chronic constipation causes straining (increased intra-abdominal pressure), which impedes venous return from the lower limbs and predisposes to or worsens varicose veins. "
     "Similar to rectal tumour or any pelvic mass — must be excluded.")

item("Sleep Pattern",
     "Poor sleep may indicate chronic pain or discomfort from venous disease, helping assess severity of symptoms.")

# ════════════════════════════════════════════════════
# 5. FAMILY HISTORY
# ════════════════════════════════════════════════════
section("5. FAMILY HISTORY — SIGNIFICANCE")

item("H/O Similar Illness in Family",
     "Varicose veins have a strong hereditary component — autosomal dominant with incomplete penetrance. "
     "Deficiency or weakness of the venous wall and valve cusps is inherited. "
     "Positive family history confirms primary varicose veins as the diagnosis and is important for genetic counselling and patient education. "
     "Family history of DVT or thrombophilia (Factor V Leiden, Protein C/S deficiency) increases operative risk.",
     "If both parents had varicose veins, risk in offspring is ~90% (Das).")

# ════════════════════════════════════════════════════
# 6. MENSTRUAL HISTORY
# ════════════════════════════════════════════════════
section("6. MENSTRUAL & OBSTETRIC HISTORY — SIGNIFICANCE")

item("Age at Menarche / Regularity / Cycle Length",
     "Female sex hormones (oestrogen and progesterone) cause venous wall relaxation and valve incompetence. "
     "Irregular cycles or hormonal disorders (PCOD) may indicate hormonal imbalance contributing to varicosities. "
     "Worsening of varicosities during menstruation (due to hormonal effects) confirms hormonal aetiology.")

item("Association with Pain (Dysmenorrhoea)",
     "Dysmenorrhoea with pelvic pathology (endometriosis, fibroids) can cause pelvic vein obstruction leading to secondary varicose veins via pelvic congestion.")

item("Age at Menopause / LMP",
     "Post-menopausal women on HRT have increased DVT risk. "
     "LMP is needed to rule out pregnancy (gravid uterus compresses iliac veins causing secondary varicose veins, and surgery is contraindicated in pregnancy).")

item("Obstetric History — Multiparity",
     "MULTIPARITY is one of the most important aetiological factors in women. "
     "The gravid uterus compresses the iliac veins and IVC, raising venous pressure in the lower limbs. "
     "Progesterone causes smooth muscle relaxation of vein walls. "
     "With each successive pregnancy, varicosities worsen. Mode of delivery, complications (e.g., prolonged labour with pelvic pressure) and number of pregnancies all matter.",
     "Varicose veins appearing first during pregnancy and not resolving after delivery indicate permanent valve damage.")

# ════════════════════════════════════════════════════
# 7. GENERAL EXAMINATION
# ════════════════════════════════════════════════════
section("7. GENERAL EXAMINATION — SIGNIFICANCE OF EACH FINDING")

item("Consciousness / Orientation / Cooperation",
     "Baseline neurological status. Altered sensorium may indicate hepatic encephalopathy (portal hypertension causing secondary varicose veins) or severe sepsis from infected ulcer.")

item("Pallor",
     "Indicates anaemia — from chronic blood loss (bleeding varicose vein), ulcer exudate protein loss, or nutritional deficiency. "
     "Anaemia must be corrected to Hb > 10 g/dL before elective surgery.")

item("Jaundice",
     "Suggests hepatic disease causing portal hypertension — a cause of secondary varicose veins. "
     "Jaundice also affects drug metabolism and coagulation (decreased clotting factor synthesis), affecting surgical risk.")

item("Build and Nourishment",
     "Obesity is an independent risk factor for varicose veins — increased intra-abdominal pressure and excess weight on leg veins worsens venous hypertension. "
     "Malnutrition impairs wound healing and immune function.")

item("Clubbing",
     "Not directly related to varicose veins. Its presence suggests cardiorespiratory disease or inflammatory bowel disease — "
     "co-morbidities affecting anaesthetic and surgical risk.")

item("Cyanosis",
     "Peripheral cyanosis can occur with severe venous stasis. "
     "Central cyanosis suggests cardiopulmonary disease — affects surgical fitness and risk of PE.")

item("Pedal Oedema",
     "Bilateral pedal oedema suggests a systemic cause (cardiac failure, hypoproteinaemia, renal disease). "
     "Unilateral oedema with varicose veins suggests CVI or DVT. Must be noted to classify CEAP and plan management.")

item("Lymphadenopathy",
     "Inguinal lymphadenopathy may suggest infected varicose ulcer, cellulitis, or malignant melanoma (differentiating an ulcer). "
     "Generalised lymphadenopathy suggests systemic disease.")

item("Vital Signs (PR, BP, RR, Temperature)",
     [
         "Pulse Rate: Tachycardia may indicate infection, anaemia, PE, or DVT.",
         "Blood Pressure: Hypertension affects surgical risk; hypotension may suggest bleeding from ruptured varix.",
         "Respiratory Rate: Elevated in PE or cardiorespiratory disease.",
         "Temperature: Fever indicates active infection/thrombophlebitis — contraindicates elective surgery."
     ])

# ════════════════════════════════════════════════════
# 8. LOCAL EXAMINATION - INSPECTION
# ════════════════════════════════════════════════════
section("8. LOCAL EXAMINATION — INSPECTION (Significance)")

item("Position: Standing with Adequate Exposure (Umbilicus to Toes)",
     "Varicose veins are best seen in the standing position as venous filling is maximal due to hydrostatic pressure. "
     "In the supine position, veins may collapse and be missed. Exposure from umbilicus to toes is needed to assess both the GSV and SSV systems and look for any abdominal causes.",
     "Always examine in standing position first — this is the CORRECT position per Das.")

item("Asymmetry Compared to Opposite Side",
     "Asymmetry in limb size (swelling, hypertrophy) may indicate Klippel-Trenaunay syndrome, lymphoedema, or post-thrombotic syndrome. "
     "Limb hypertrophy with varicose veins and port-wine stain = KTS — surgery is contraindicated.")

item("Attitude of Limb / Deformity",
     "Fixed deformity from previous trauma or arthritis may have caused DVT (secondary varicose veins). "
     "Helps identify congenital limb abnormalities associated with vascular malformations.")

item("Distribution of Dilated Veins",
     [
         "Medial aspect of leg from medial malleolus, behind the knee, medial thigh: GSV (Long Saphenous) system.",
         "Lateral/posterior aspect of leg, behind lateral malleolus, popliteal fossa: SSV (Short Saphenous) system.",
         "Both systems involved: More severe disease, assess saphenofemoral junction (SFJ) AND saphenopopliteal junction (SPJ)."
     ],
     "Accurately identifying which vein system is involved is critical for choosing the correct operation.")

item("Skin Changes — Pigmentation, Eczema, Lipodermatosclerosis",
     "Brown pigmentation (haemosiderin) = CEAP C4b, long-standing CVI. "
     "Eczema (stasis dermatitis) = CEAP C4a, inflammatory response to venous hypertension. "
     "Lipodermatosclerosis (brawny induration, inverted champagne bottle) = fibrosis from chronic inflammation — indicates severe disease.")

item("Ulcer Description (Site, Size, Shape, Margin, Edge, Floor, Discharge)",
     [
         "Site: Gaiter area above medial malleolus = venous ulcer. Tip of toes/pressure points = arterial. Mixed location = mixed aetiology.",
         "Shape: Irregular, shallow = venous. Punched-out = arterial.",
         "Edge: Sloping (healing venous), undermined (Buruli), raised/everted (malignant transformation — Marjolin's ulcer).",
         "Floor: Pink granulation tissue = venous. Pale, necrotic = arterial.",
         "Discharge: Serous = venous. Purulent = infected. Malodorous = anaerobic infection.",
         "Surrounding area: Pigmentation, eczema, lipodermatosclerosis confirm venous aetiology."
     ],
     "Any chronic non-healing ulcer must be biopsied from its edge to exclude Marjolin's ulcer (squamous cell carcinoma).")

item("Expansile Cough Impulse / Blow-Outs",
     "An expansile cough impulse over a varicosity indicates a direct communication with deep veins through an incompetent perforator. "
     "Blow-outs are localised bulges from incompetent perforators — seen as localised prominences along the course of varicosities. "
     "Their exact location is marked preoperatively for targeted surgery.",
     "Fegan's method: Map blow-outs by inspection while patient stands, then confirm by palpation.")

item("Muscle Wasting",
     "Muscle wasting in the calf or thigh suggests long-standing disease with reduced mobility, deep vein obstruction, or neurological involvement. "
     "Indicates a more complex and chronic case requiring careful pre-operative planning.")

# ════════════════════════════════════════════════════
# 9. LOCAL EXAMINATION - PALPATION
# ════════════════════════════════════════════════════
section("9. LOCAL EXAMINATION — PALPATION (Significance)")

item("Warmth",
     "Warmth over varicosities indicates superficial thrombophlebitis (localised warm, tender, cord-like vein). "
     "Generalised warmth of the limb suggests deep vein thrombosis or severe cellulitis.")

item("Tenderness",
     "Tenderness along a varicosity = superficial thrombophlebitis. "
     "Tenderness in the calf muscles (Homan's sign positive) = deep vein thrombosis. "
     "Tenderness around an ulcer = secondary infection.")

item("Skin Thickening / Lipodermatosclerosis",
     "Brawny, woody induration of the skin and subcutaneous tissue in the gaiter area = lipodermatosclerosis. "
     "This is due to chronic inflammatory fibrosis from venous hypertension. "
     "It indicates severe, long-standing CVI (CEAP C4b) and predisposes to ulceration. "
     "It must be documented to plan post-operative compression therapy.")

item("Pitting Oedema",
     "Soft pitting oedema indicates active venous hypertension with plasma transudation. "
     "Grade the oedema (1+ to 4+). Oedema worsening on standing and improving with elevation confirms venous origin. "
     "Brawny non-pitting oedema suggests co-existing lymphoedema.")

item("Palpation of the Ulcer (Base, Induration, Mobility, Bleeds on Touch)",
     [
         "Base: Fixed to bone suggests osteomyelitis. Mobile suggests no deep tissue involvement.",
         "Induration: Hard indurated base/edge may suggest malignant transformation (Marjolin's ulcer).",
         "Bleeds on touch: Granulation tissue — indicates active healing or hyper-granulation.",
         "Surrounding induration/fixity: Raises suspicion of malignancy — biopsy mandatory."
     ])

# ════════════════════════════════════════════════════
# 10. SPECIAL TESTS
# ════════════════════════════════════════════════════
section("10. SPECIAL TESTS — SIGNIFICANCE OF EACH")

item("Brodie-Trendelenburg Test (Test 1 and Test 2)",
     [
         "PRINCIPLE: Determines the site of incompetence — saphenofemoral junction (SFJ), perforators, or both.",
         "METHOD: Empty the vein by elevation, apply tourniquet at the saphenofemoral junction, ask patient to stand.",
         "Test 1 (+ve): Tourniquet controls filling — SFJ incompetence confirmed. Remove tourniquet: rapid filling = SFJ.",
         "Test 2 (+ve): Filling occurs above the tourniquet even with it in place = perforator incompetence BELOW the tourniquet.",
         "Both 1 & 2 +ve: Both SFJ and perforator incompetence.",
         "SIGNIFICANCE: Directly determines whether to perform high tie at SFJ (Trendelenburg operation) and where to ligate perforators.",
     ],
     "This is the MOST IMPORTANT test for surgical planning in varicose veins (Das).")

item("Multiple Tourniquet Test",
     "Extends the Trendelenburg test by applying multiple tourniquets at different levels (upper thigh, lower thigh, upper leg, lower leg). "
     "Each tourniquet isolates a segment. By watching which segment fills first on standing, the level of perforator incompetence is precisely localized. "
     "Significance: Maps the exact location of incompetent perforators for targeted subfascial endoscopic perforator surgery (SEPS) or open ligation.")

item("Perthes Test",
     "Assesses the patency of the DEEP VENOUS SYSTEM. "
     "METHOD: Apply tourniquet above the knee while patient stands. Ask patient to walk or exercise. "
     "RESULT: If varicosities DISAPPEAR or reduce = deep veins are PATENT (venous blood pumped into patent deep system). "
     "If varicosities INCREASE and patient gets BURSTING PAIN = deep veins are OBSTRUCTED (blood cannot drain; collateral superficial veins dilate further). "
     "SIGNIFICANCE: If deep veins are obstructed, STRIPPING OF VARICOSE VEINS IS ABSOLUTELY CONTRAINDICATED — removing them would eliminate the only collateral drainage.",
     "Perthes-positive (deep veins obstructed) = only compression therapy; NEVER operate on superficial veins.")

item("Modified Perthes Test",
     "Tourniquet applied above malleolus (instead of knee). Exercise performed. Assesses patency of deep veins below the knee (posterior tibial, peroneal veins). "
     "SIGNIFICANCE: More sensitive for identifying deep vein obstruction in the distal leg, which may be missed by standard Perthes.")

item("Fegan's Test (Percussion / Fluid Thrill)",
     "MAP incompetent PERFORATORS. "
     "METHOD: Patient stands. Feel along the line of varicose veins for fascial defects (blow-outs). Mark with skin marker. "
     "SIGNIFICANCE: Identifies the exact sites of perforator incompetence for surgical ligation. "
     "Perforators are usually located at constant sites: Cockett's perforators (medial leg), Boyd's (below knee), Dodd's (thigh).")

item("Schwartz Test (Percussion / Impulse Test)",
     "Demonstrates CONTINUITY of the varicose vein column. "
     "METHOD: Tap (percuss) the varicosity at one point; feel for an impulse transmitted proximally or distally. "
     "POSITIVE: Impulse felt = the vein is a continuous, fluid-filled column (confirms varicose vein). "
     "SIGNIFICANCE: Confirms the varicosity is part of the incompetent saphenous system, not an unrelated lump. "
     "Also used to locate SFJ by percussing the varicosity and feeling the impulse at the groin.")

item("Pratt's Test",
     "Identifies incompetent PERFORATORS by watching for 'blow-outs' (localised swellings) as an elastic bandage is applied from the foot upward while the patient stands. "
     "Sites where veins bulge between the bandages = sites of incompetent perforators. "
     "SIGNIFICANCE: Pre-operative mapping of perforator sites for ligation or SEPS.")

item("Morrissey's Cough Impulse Test",
     "Tests for SFJ (Saphenofemoral Junction) incompetence. "
     "METHOD: Patient stands. Keep a finger on the saphenofemoral junction (just below and medial to the femoral pulse in the groin). Ask patient to cough. "
     "POSITIVE: An expansile impulse felt at the SFJ = SFJ is incompetent. "
     "SIGNIFICANCE: Confirms need for high tie of the SFJ (Trendelenburg operation). "
     "Negative test may indicate the reflux is at a lower level (perforator or SSV origin).")

item("Homan's Sign",
     "Assesses for DEEP VEIN THROMBOSIS. "
     "METHOD: Passive dorsiflexion of the foot with the knee extended. "
     "POSITIVE: Pain in the calf = DVT. "
     "SIGNIFICANCE: If Homan's positive, DVT is present — surgery is contraindicated; treat with anticoagulation first. "
     "Note: Homan's sign has low sensitivity and specificity but remains a useful bedside screening test.")

item("Moses Sign",
     "METHOD: Squeeze the calf from side to side (mediolateral compression). "
     "POSITIVE: Pain = DVT present. "
     "SIGNIFICANCE: Additional bedside test to screen for DVT alongside Homan's sign. "
     "Useful when Homan's is equivocal. DVT must be excluded before any surgical intervention on varicose veins.")

item("Limb Measurements",
     "Measure circumference at fixed landmarks (e.g., 10 cm below tibial tuberosity, mid-calf, ankle). "
     "SIGNIFICANCE: Documents degree of oedema, monitors response to treatment, and detects subtle differences between limbs. "
     "Limb length measurement rules out limb length discrepancy (associated with KTS or arteriovenous malformations).")

item("Peripheral Pulse Examination (Femoral, Popliteal, Dorsalis Pedis, Posterior Tibial, etc.)",
     "CRITICAL — assesses co-existing peripheral arterial disease (PAD). "
     "Absent peripheral pulses indicate significant arterial insufficiency. "
     "SIGNIFICANCE: If arterial disease co-exists (ABI < 0.8), compression therapy is relatively contraindicated. "
     "Surgical planning changes completely — arterial revascularisation takes priority. "
     "Also, ischaemia can mimic or co-exist with venous ulcers (mixed ulcer).",
     "NEVER apply compression bandaging to a limb with absent pulses without measuring ABI first.")

item("Examination of Adjacent Joints (Active and Passive Movements)",
     "Ankle joint stiffness/restriction is common in long-standing CVI due to lipodermatosclerosis and peri-articular fibrosis. "
     "Reduced ankle ROM impairs the calf muscle pump mechanism (the most important mechanism for venous return from the leg). "
     "SIGNIFICANCE: Ankle physiotherapy is part of CVI management. Also rules out arthritis or joint pathology causing reduced mobility.")

item("Neurological Examination (Sensation, Motor/Muscle Power)",
     "Peripheral neuropathy (especially in diabetics) impairs pain sensation — the patient may not feel ulcer pain, leading to delayed presentation and complicated wounds. "
     "Motor weakness from nerve damage affects the calf muscle pump, worsening venous return. "
     "SIGNIFICANCE: Identifies co-morbidities affecting healing and surgical outcome.")

item("Percussion — Schwartz Test (Fluid Wave)",
     "Confirms fluid-filled continuous varicosity. "
     "Tapping at one end transmits a fluid impulse to the other end if the vein is a single dilated column. "
     "Helps confirm the diagnosis and map the extent of involvement.")

item("Auscultation over Varicosities",
     "Auscultation over a varicosity is done to detect a BRUIT. "
     "A bruit = arteriovenous malformation or fistula (congenital AV fistula causing secondary varicose veins — e.g., Parkes-Weber syndrome). "
     "SIGNIFICANCE: If a bruit is present, surgery on the superficial veins alone will fail — the AV communication must be addressed.",
     "This is a frequently asked examiner question: 'What will you hear on auscultation?'")

# ════════════════════════════════════════════════════
# 11. SYSTEMIC EXAMINATION
# ════════════════════════════════════════════════════
section("11. SYSTEMIC EXAMINATION — SIGNIFICANCE")

item("Abdominal Examination (Organomegaly, Masses, Ascites, PR/PV)",
     [
         "Hepatomegaly/Splenomegaly + Ascites: Portal hypertension causing raised IVC pressure = secondary varicose veins. Treat underlying cause.",
         "Abdominal/Pelvic Mass: Compresses iliac veins/IVC causing secondary varicose veins. Must be treated first.",
         "PR Examination: Rectal carcinoma, fibroids compressing pelvic veins — a recognised secondary cause.",
         "PV Examination: Ovarian cysts, uterine fibroids compressing iliac veins causing unilateral varicose veins."
     ],
     "ALWAYS examine the abdomen in a varicose veins case — secondary causes from the abdomen are commonly tested in exams.")

item("Cardiovascular Examination (S1, S2, Added Sounds)",
     "Cardiac failure causes raised venous pressure, worsening oedema and venous hypertension. "
     "Arrhythmias affect anaesthetic risk. "
     "Significant cardiac disease may require cardiology clearance before surgery.")

item("Respiratory System (Normal Vesicular Breath Sounds, Added Sounds)",
     "Chronic cough from respiratory disease increases intra-thoracic and intra-abdominal pressure, impairing venous return and worsening varicosities. "
     "Added sounds (wheeze, crackles) may indicate COPD or cardiac failure.")

item("CNS Examination (No Focal Neurological Deficit)",
     "Previous stroke may cause limb immobility, promoting DVT and secondary varicose veins. "
     "Also establishes baseline neurological status for anaesthetic assessment.")

# ════════════════════════════════════════════════════
# 12. DIAGNOSIS
# ════════════════════════════════════════════════════
section("12. FINAL DIAGNOSIS — SIGNIFICANCE OF CLASSIFICATION")

data = [
    ["Component", "Stands for", "Clinical Significance"],
    ["C (Clinical)", "C0–C6: Severity of clinical signs", "C0=No signs; C1=Telangiectasia; C2=Varicose veins; C3=Oedema; C4a/b=Skin changes; C5=Healed ulcer; C6=Active ulcer — determines urgency of treatment"],
    ["E (Aetiology)", "Primary / Secondary / Congenital", "Primary=valve failure; Secondary=post-thrombotic; Congenital=KTS, AV malformation — determines surgical vs conservative"],
    ["A (Anatomy)", "GSV / SSV / Perforators / Deep", "Identifies which venous system is involved — guides surgical approach (stripping vs SEPS vs foam sclerotherapy)"],
    ["P (Pathophysiology)", "Reflux / Obstruction / Both", "Reflux=can be surgically corrected; Obstruction=surgery contraindicated; Both=complex management"]
]
t = Table(data, colWidths=[3*cm, 5.5*cm, 8.5*cm])
t.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1a237e')),
    ('TEXTCOLOR', (0,0), (-1,0), colors.white),
    ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
    ('FONTSIZE', (0,0), (-1,-1), 9),
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    ('VALIGN', (0,0), (-1,-1), 'MIDDLE'),
    ('PADDING', (0,0), (-1,-1), 5),
    ('FONTNAME', (0,1), (0,-1), 'Helvetica-Bold'),
]))
story.append(Paragraph("CEAP Classification — Why it Matters", SUBSECTION_HEADER))
story.append(t)
story.append(Spacer(1, 0.3*cm))

item("Primary vs Secondary Varicose Veins",
     [
         "PRIMARY: No underlying cause; defective vein wall/valves (hereditary). Treatment = surgery (stripping, high tie, SEPS).",
         "SECONDARY: Caused by DVT (post-thrombotic), AV fistula, pelvic mass, portal hypertension. MUST treat underlying cause first.",
         "Distinguishing them is the entire purpose of history and clinical tests — getting this wrong leads to surgical failure and recurrence."
     ])

# ════════════════════════════════════════════════════
# 13. INVESTIGATIONS
# ════════════════════════════════════════════════════
section("13. INVESTIGATIONS — SIGNIFICANCE OF EACH")

subsection("Baseline Investigations")
inv_data = [
    ["Investigation", "Significance in Varicose Veins"],
    ["Haemoglobin %", "Anaemia from chronic ulcer blood loss; must be >10 g/dL before surgery"],
    ["Total Count / DC", "Leucocytosis = active infection (thrombophlebitis, infected ulcer) — contraindicates elective surgery"],
    ["ESR", "Elevated in infection, DVT, malignancy — helps identify systemic complications"],
    ["Platelet Count", "Thrombocytopenia affects surgical haemostasis; thrombocytosis increases DVT risk"],
    ["Bleeding Time / Clotting Time", "Coagulation screening before surgery; detects coagulopathy"],
    ["Blood Grouping / Typing", "Pre-operative preparation for blood transfusion"],
    ["Random Blood Sugar", "Screening for diabetes — affects wound healing and anaesthetic risk"],
    ["Serum Urea / Creatinine", "Renal function for drug metabolism and contrast safety (venography)"],
    ["VCTC / VDRL", "Pre-operative HIV screening (VCTC); syphilitic gumma can cause ulcer (VDRL)"],
    ["HBsAg / Anti-HCV", "Infectious screening — protects surgical team, affects drug choice"],
    ["Chest X-Ray PA View", "Detects cardiomegaly (cardiac failure), COPD, pleural effusion; pre-anaesthetic assessment"],
    ["ECG (All Leads)", "Arrhythmias, cardiac disease — fitness for anaesthesia; detects features of PE (S1Q3T3)"],
    ["Urine Routine (Albumin, Sugar, Deposits)", "Albuminuria = renal disease/hypoproteinaemia; glycosuria = diabetes; pyuria = infection"],
]
t2 = Table(inv_data, colWidths=[5*cm, 12*cm])
t2.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#37474f')),
    ('TEXTCOLOR', (0,0), (-1,0), colors.white),
    ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
    ('FONTSIZE', (0,0), (-1,-1), 9),
    ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#90a4ae')),
    ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#eceff1'), colors.white]),
    ('VALIGN', (0,0), (-1,-1), 'MIDDLE'),
    ('PADDING', (0,0), (-1,-1), 5),
    ('FONTNAME', (0,1), (0,-1), 'Helvetica-Bold'),
]))
story.append(t2)
story.append(Spacer(1, 0.4*cm))

subsection("Specific Investigations")
spec_data = [
    ["Investigation", "Significance"],
    ["Doppler Duplex Ultrasound\n(GOLD STANDARD)", "Identifies site and extent of venous reflux, perforator incompetence, and deep vein patency. Non-invasive, real-time. Guides surgery. Mandatory before any operative intervention."],
    ["USG Abdomen & Pelvis", "Rules out secondary causes: pelvic/abdominal masses compressing iliac veins/IVC; portal hypertension; hepatomegaly; ovarian pathology."],
    ["Venous Doppler", "Bedside assessment of flow in femoral/popliteal veins; detects DVT; assesses deep vein patency before Perthes test."],
    ["Ascending Venogram", "Gold standard for deep vein anatomy; used when Doppler is inconclusive or deep vein reconstruction is planned. Ask only if examiner requests."],
    ["Descending Venogram", "Assesses valve function; used before valve repair surgery. Ask only if examiner requests."],
    ["Plethysmography", "Measures calf muscle pump efficiency and venous reflux quantitatively; used in research and complex cases."],
    ["Pus C/S (Ulcer with infection)", "Identifies causative organism and antibiotic sensitivity — guides targeted antibiotic therapy before surgery."],
    ["X-Ray Local Part (Ulcer)", "Detects osteomyelitis (bone destruction under chronic ulcer) or periosteal reaction — changes surgical management significantly."],
    ["Edge/Wedge Biopsy (Suspected Malignancy)", "Mandatory to rule out Marjolin's ulcer (SCC arising in chronic venous ulcer). Any indurated, raised, or non-healing ulcer edge must be biopsied."],
]
t3 = Table(spec_data, colWidths=[5*cm, 12*cm])
t3.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#b71c1c')),
    ('TEXTCOLOR', (0,0), (-1,0), colors.white),
    ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
    ('FONTSIZE', (0,0), (-1,-1), 9),
    ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#90a4ae')),
    ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#ffebee'), colors.white]),
    ('VALIGN', (0,0), (-1,-1), 'MIDDLE'),
    ('PADDING', (0,0), (-1,-1), 5),
    ('FONTNAME', (0,1), (0,-1), 'Helvetica-Bold'),
    ('WORDWRAP', (0,0), (-1,-1), True),
]))
story.append(t3)
story.append(Spacer(1, 0.5*cm))

# ── FOOTER NOTE ─────────────────────────────────────────────
story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1a237e')))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "References: Das S. — A Manual of Clinical Surgery (Latest Edition) | "
    "Rajamahendran — Surgical Principles for Clinical Examination | "
    "Bailey &amp; Love's Short Practice of Surgery | CEAP Classification (International Union of Phlebology)",
    ParagraphStyle('footer', parent=styles['Normal'], fontSize=8, textColor=colors.HexColor('#546e7a'),
                   alignment=TA_CENTER, fontName='Helvetica-Oblique')))

doc.build(story)
print("PDF created successfully.")

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

doc = SimpleDocTemplate(
    "/tmp/workspace/varicose-veins-pdf/Inguinal_Hernia_Significance.pdf",
    pagesize=A4,
    rightMargin=2*cm, leftMargin=2*cm,
    topMargin=2.2*cm, bottomMargin=2.2*cm
)

styles = getSampleStyleSheet()

TITLE = ParagraphStyle('TITLE', parent=styles['Title'],
    fontSize=22, textColor=colors.HexColor('#1b5e20'),
    spaceAfter=4, spaceBefore=0, alignment=TA_CENTER, fontName='Helvetica-Bold')

SUBTITLE = ParagraphStyle('SUBTITLE', parent=styles['Normal'],
    fontSize=11, textColor=colors.HexColor('#37474f'),
    spaceAfter=10, spaceBefore=0, alignment=TA_CENTER, fontName='Helvetica-Oblique')

SECTION_HEADER = ParagraphStyle('SECTION_HEADER', parent=styles['Heading1'],
    fontSize=13, textColor=colors.white,
    spaceAfter=4, spaceBefore=10,
    fontName='Helvetica-Bold', backColor=colors.HexColor('#1b5e20'),
    leftIndent=-10, rightIndent=-10,
    borderPadding=(6, 10, 6, 10))

SUBSECTION_HEADER = ParagraphStyle('SUBSECTION_HEADER', parent=styles['Heading2'],
    fontSize=11.5, textColor=colors.HexColor('#1b5e20'),
    spaceAfter=3, spaceBefore=8,
    fontName='Helvetica-Bold')

ITEM_HEADER = ParagraphStyle('ITEM_HEADER', parent=styles['Normal'],
    fontSize=11, textColor=colors.HexColor('#b71c1c'),
    spaceAfter=2, spaceBefore=6, fontName='Helvetica-Bold')

BODY = ParagraphStyle('BODY', parent=styles['Normal'],
    fontSize=9.5, textColor=colors.HexColor('#212121'),
    spaceAfter=4, spaceBefore=0, leading=14,
    fontName='Helvetica', alignment=TA_JUSTIFY, leftIndent=8)

NOTE = ParagraphStyle('NOTE', parent=styles['Normal'],
    fontSize=9, textColor=colors.HexColor('#4a148c'),
    spaceAfter=4, spaceBefore=2, fontName='Helvetica-Oblique', leftIndent=8)

BULLET = ParagraphStyle('BULLET', parent=styles['Normal'],
    fontSize=9.5, textColor=colors.HexColor('#212121'),
    spaceAfter=2, spaceBefore=0, leading=13,
    fontName='Helvetica', leftIndent=20, bulletIndent=8)

story = []

# ── TITLE ───────────────────────────────────────────────────
story.append(Spacer(1, 1.2*cm))
story.append(Paragraph("INGUINAL HERNIA", TITLE))
story.append(Paragraph("Long Case History & Examination", TITLE))
story.append(Spacer(1, 0.25*cm))
story.append(HRFlowable(width="100%", thickness=3, color=colors.HexColor('#1b5e20')))
story.append(Spacer(1, 0.15*cm))
story.append(Paragraph("Significance of Every History and Examination Finding", SUBTITLE))
story.append(Paragraph("According to Das's Manual of Clinical Surgery & Rajamahendran's Surgical Principles", SUBTITLE))
story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor('#90a4ae')))
story.append(Spacer(1, 1.5*cm))

def section(title):
    story.append(Spacer(1, 0.25*cm))
    story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1b5e20')))
    story.append(Paragraph(f"  {title}", SECTION_HEADER))
    story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1b5e20')))
    story.append(Spacer(1, 0.15*cm))

def subsection(title):
    story.append(Paragraph(title, SUBSECTION_HEADER))

def item(title, body, note=None):
    story.append(Paragraph(f"▶ {title}", ITEM_HEADER))
    if isinstance(body, list):
        for b in body:
            story.append(Paragraph(f"• {b}", BULLET))
    else:
        story.append(Paragraph(body, BODY))
    if note:
        story.append(Paragraph(f"Examiner's Note: {note}", NOTE))
    story.append(Spacer(1, 0.08*cm))

# ════════════════════════════════════════════════════
# 1. CHIEF COMPLAINTS
# ════════════════════════════════════════════════════
section("1. CHIEF COMPLAINTS — WHY ASKED & SIGNIFICANCE")

item("Swelling in the Right / Left Groin",
     "The groin (inguinal region) is the most common site for a hernia. A swelling here is the cardinal presenting feature. "
     "Asking the DURATION establishes whether it is acute (strangulation risk) or chronic (elective repair). "
     "Asking whether it is unilateral or bilateral guides operative planning — bilateral hernias may need staged or simultaneous repair. "
     "Location (groin vs lower abdomen) helps differentiate inguinal from femoral hernia: inguinal hernias arise above and medial to the pubic tubercle; femoral hernias arise below and lateral to it.",
     "ALWAYS confirm the site relation to the pubic tubercle — this is the key to differentiating inguinal from femoral hernia (Das).")

item("Swelling in the Right / Left Lower Abdomen",
     "A large indirect inguinal hernia can extend into the lower abdomen, especially in thin patients. "
     "Asking this differentiates a large inguinal hernia from other lower abdominal swellings (lymph nodes, lipoma, femoral hernia, saphena varix, psoas abscess). "
     "The progressive descent from groin to scrotum — starting small and enlarging — is the classical history of indirect inguinal hernia.")

item("Pain in the Swelling",
     "An uncomplicated reducible hernia is usually painless or causes only a mild dragging sensation. "
     "Acute, severe, constant, non-relieving pain signals STRANGULATION (ischaemia of hernial contents) — a surgical emergency requiring urgent operation. "
     "Intermittent colicky pain suggests intestinal obstruction within the sac. "
     "Dull aching discomfort worsened by standing/straining = typical uncomplicated hernia pain.",
     "If pain is severe and the swelling cannot be reduced, always think strangulation first — delay is fatal.")

# ════════════════════════════════════════════════════
# 2. HISTORY OF PRESENTING ILLNESS
# ════════════════════════════════════════════════════
section("2. HISTORY OF PRESENTING ILLNESS — SIGNIFICANCE OF EACH H/O")

item("Onset (Sudden vs Insidious) of Swelling",
     "SUDDEN onset: suggests a pre-existing weakness that suddenly became apparent due to a precipitating event (cough, straining, lifting). "
     "INSIDIOUS onset: typical of a gradually enlarging hernia, often starting as a small impulse and progressively enlarging. "
     "Sudden onset with severe pain = strangulated hernia until proven otherwise.")

item("Progression from Groin to Scrotum",
     "This is the PATHOGNOMONIC progression of an indirect inguinal hernia. "
     "The sac follows the path of the processus vaginalis — from the deep inguinal ring, through the inguinal canal, out of the superficial ring, and into the scrotum. "
     "A swelling that starts in the groin and descends into the scrotum = INDIRECT inguinal hernia. "
     "A swelling that bulges directly forward in the groin without descending into the scrotum = DIRECT inguinal hernia.",
     "Direct hernias RARELY enter the scrotum because the sac passes through Hesselbach's triangle which is too medial.")

item("Aggravation by Straining, Standing, Coughing",
     "These all increase intra-abdominal pressure. When IAP rises, abdominal contents are forced through the defect in the abdominal wall. "
     "This is the fundamental mechanism of herniation. Confirming this pattern proves the swelling is a hernia (pressure-transmitted). "
     "Cough impulse is the clinical sign that directly corresponds to this — felt on palpation.")

item("Relieved by Lying Down / Manual Reduction",
     "A hernia that reduces spontaneously on lying down = REDUCIBLE hernia. This is the most favourable state. "
     "Manual reduction by the patient himself (taxis) = the patient has learned to reduce it, confirming it is reducible and not yet complicated. "
     "If the patient can no longer reduce it = IRREDUCIBLE hernia — urgent review needed to exclude strangulation.")

item("H/O Fever",
     "Fever in the context of a hernia swelling raises alarm for STRANGULATION with gangrene of the contents. "
     "Strangulated bowel undergoes ischaemia → gangrene → bacterial translocation → systemic sepsis → fever. "
     "Fever also suggests inflammation or infection around the sac. "
     "In the presence of fever with hernia, urgent surgical exploration is mandatory.",
     "A strangulated hernia with fever = surgical emergency. Never attempt forceful manual reduction.")

item("H/O Trauma",
     "Blunt trauma to the groin can precipitate herniation through a pre-existing weakness (patent processus vaginalis). "
     "Also relevant for medico-legal documentation in occupational/industrial injury cases. "
     "Trauma causing haematoma in the groin can mimic an irreducible hernia — important differential diagnosis.")

item("H/O Loss of Weight",
     "Significant unintentional weight loss raises suspicion of an underlying MALIGNANCY (colorectal carcinoma, gastric cancer, lymphoma). "
     "A rectal/colonic tumour can cause raised intra-abdominal pressure (obstruction, ascites) precipitating hernia. "
     "Malignant lymphadenopathy in the inguinal region can mimic an irreducible groin swelling. "
     "Also, weight loss causes loss of the 'fat plug' that normally obliterates the deep ring, allowing hernia formation.")

item("H/O Loss of Appetite (Anorexia)",
     "Along with weight loss, anorexia suggests a systemic malignant or chronic disease as an underlying cause. "
     "Colorectal carcinoma (causing chronic obstruction and elevated IAP) is a recognised precipitant of inguinal hernia in the elderly. "
     "Nutritional status affects wound healing and post-operative recovery.")

item("H/O Heavy Weight Lifting",
     "A MAJOR precipitating/aetiological factor for indirect and direct inguinal hernia. "
     "Heavy lifting causes sudden, extreme rise in intra-abdominal pressure, forcing abdominal contents through areas of weakness. "
     "Direct hernias are particularly precipitated by heavy lifting due to weakness of the posterior inguinal wall (transversalis fascia). "
     "Occupational history (labourers, construction workers, weightlifters) must be documented.",
     "Occupational heavy lifting is an aetiological factor in direct inguinal hernia — relevant for workmen's compensation.")

item("H/O Chronic Cough",
     "Chronic, repetitive coughing continuously raises IAP, creating a 'piston' effect on abdominal contents. "
     "This is a major aetiological factor especially for INDIRECT inguinal hernia. "
     "Conditions causing chronic cough: COPD, bronchial asthma, pulmonary TB, chronic bronchitis. "
     "The cough must be controlled peri-operatively — operating without treating the cough leads to early recurrence.",
     "Failure to treat chronic cough before hernia repair is the most common cause of early recurrence (Das).")

item("H/O Difficulty in Micturition / LUTS (Urgency, Frequency, Hesitancy, Precipitancy)",
     "These are Lower Urinary Tract Symptoms (LUTS) indicating BLADDER OUTLET OBSTRUCTION — most commonly from Benign Prostatic Hyperplasia (BPH) in elderly men. "
     "BPH causes straining to pass urine → repeated episodes of raised IAP → precipitates or worsens inguinal hernia. "
     "SIGNIFICANCE: "
     "(1) BPH MUST be treated first (or simultaneously) — operating on the hernia without addressing BPH leads to EARLY RECURRENCE. "
     "(2) Urinary bladder can be a sliding content of a direct hernia — this is the 'bladder sliding hernia' (part of the bladder forms the medial wall of the sac). USG of abdomen/pelvis is needed. "
     "(3) If urinary symptoms are present, PSA, USG, and urology referral are mandatory.",
     "Classic exam question: What will you do before repairing the hernia in a 65-year-old with LUTS? Answer: Rule out and treat BPH first.")

item("H/O Abdominal Pain",
     "Abdominal pain with hernia suggests: "
     "(1) INTESTINAL OBSTRUCTION — content of hernia sac (usually small bowel) has become obstructed, causing colicky abdominal pain. "
     "(2) Strangulation — severe constant abdominal pain with features of peritonitis. "
     "(3) Underlying bowel disease (Crohn's, diverticular disease) that may be the content of the sac. "
     "The type of pain (colicky = obstruction; constant = strangulation) must be characterised.")

item("H/O Abdominal Distension",
     "Progressive abdominal distension with an inguinal hernia strongly suggests INTESTINAL OBSTRUCTION with the bowel trapped in the sac. "
     "It is one of the four classic features of intestinal obstruction: pain, vomiting, distension, absolute constipation. "
     "Its presence mandates urgent surgical intervention.")

item("H/O Vomiting",
     "Vomiting + non-reducible inguinal hernia = OBSTRUCTED/STRANGULATED hernia until proven otherwise. "
     "Early vomiting = small bowel obstruction (content of sac). Late/faeculent vomiting = prolonged obstruction. "
     "This symptom escalates the case from elective to emergency surgery.")

item("H/O Difficulty in Defecation / Absolute Constipation",
     "Absolute constipation (no passage of flatus or faeces) is the hallmark of COMPLETE INTESTINAL OBSTRUCTION. "
     "In the context of a non-reducible inguinal hernia, this confirms the hernia content is causing bowel obstruction. "
     "Incomplete constipation (difficulty, straining) suggests partial obstruction, chronic constipation, or anorectal pathology (fissure, BPH). "
     "Chronic constipation and straining at stool are also precipitating factors for hernia development (raise IAP).")

# ════════════════════════════════════════════════════
# 3. PAST HISTORY
# ════════════════════════════════════════════════════
section("3. PAST HISTORY — SIGNIFICANCE")

item("H/O Similar Illness in the Past",
     "Previous episodes of groin swelling suggest a RECURRENT hernia or an inadequately treated hernia. "
     "Recurrence rate after repair must be assessed. A recurrent hernia has altered anatomy — increases surgical complexity and risk to vas deferens, testicular vessels.")

item("H/O DM / SHT / TB / Epilepsy / Heart Disease / Kidney Disease / Allergy",
     [
         "Diabetes Mellitus: Impairs wound healing (key in mesh repair), increases SSI (surgical site infection) risk; glycaemic control mandatory pre-op (HbA1c < 7%).",
         "Systemic Hypertension: Affects anaesthetic management; antihypertensives continued peri-operatively; risk of intra-op cardiac events.",
         "TB: Active pulmonary TB causes chronic cough (precipitates/worsens hernia). Also, inguinal lymph nodes enlarged by TB mimic an irreducible hernia.",
         "Epilepsy: Anti-epileptic drug interactions with anaesthetic agents; seizure during recovery is a risk.",
         "Heart Disease: Cardiac evaluation needed; affects anaesthetic choice (spinal vs general); fitness for surgery.",
         "Kidney Disease: Affects drug dosing, fluid management, contrast use; hypoproteinaemia from renal disease impairs wound healing.",
         "Allergy: Allergy to synthetic mesh materials (polypropylene sensitivity is rare but documented); latex allergy affects surgical gloves and equipment choices."
     ])

item("H/O Previous Surgery",
     "Previous abdominal surgery (e.g., appendicectomy, laparotomy) creates scar tissue and alters anatomy. "
     "Previous inguinal surgery (orchidopexy, vasectomy, previous hernia repair) — risk of injury to vas deferens and testicular blood supply during re-do surgery. "
     "Previous radical prostatectomy affects the anatomy of the posterior inguinal wall. "
     "This information is essential for pre-operative planning and consenting the patient about higher complication risk.")

# ════════════════════════════════════════════════════
# 4. PERSONAL HISTORY
# ════════════════════════════════════════════════════
section("4. PERSONAL HISTORY — SIGNIFICANCE")

item("Diet (Vegetarian / Non-Vegetarian)",
     "Nutritional assessment affects wound healing and post-operative recovery. "
     "A vegetarian diet low in protein impairs collagen synthesis — important for fascial repair strength. "
     "High-fibre diet prevents constipation (prevents straining → prevents recurrence post-repair).")

item("Smoking",
     "Smoking impairs wound healing (vasoconstriction, reduced tissue oxygen delivery). "
     "It is a major risk factor for CHRONIC COUGH (COPD, chronic bronchitis) — which is the most important precipitating factor for hernia and the leading cause of post-repair recurrence. "
     "Smoking must be stopped at least 4-6 weeks before elective surgery. "
     "Smokers have higher mesh infection rates and recurrence rates.")

item("Alcohol",
     "Chronic alcoholism causes hepatic cirrhosis → ascites → raised IAP → precipitates hernia. "
     "Liver disease impairs coagulation, drug metabolism, and wound healing. "
     "Alcohol withdrawal during hospital stay can cause seizures — peri-operative risk.")

item("Bowel and Bladder Habits",
     "Chronic constipation with straining = repeated IAP rise = precipitating factor for hernia and cause of recurrence. "
     "Urinary symptoms (as in LUTS above) = BPH must be treated first. "
     "Both must be addressed before and after hernia repair to prevent recurrence.")

item("Sleep Pattern",
     "Disturbed sleep may indicate chronic pain, urinary frequency (BPH), or anxiety — helps assess overall patient wellbeing and fitness for surgery.")

# ════════════════════════════════════════════════════
# 5. FAMILY HISTORY
# ════════════════════════════════════════════════════
section("5. FAMILY HISTORY — SIGNIFICANCE")

item("H/O Similar Illness in Family Members",
     "Inguinal hernia has a GENETIC component — associated with connective tissue disorders, collagen deficiency (reduced type I collagen in transversalis fascia), and patent processus vaginalis. "
     "Studies show a 4-8x increased risk if a first-degree relative has a hernia. "
     "Family history of bilateral hernias suggests an underlying connective tissue disorder (Marfan syndrome, Ehlers-Danlos syndrome). "
     "It also suggests the CONTRALATERAL side may develop a hernia — important for counselling.")

item("Health Status of Family Members",
     "General family health history screens for hereditary diseases, chronic illnesses, and infectious diseases (TB in family contacts) that may affect the patient's perioperative management.")

# ════════════════════════════════════════════════════
# 6. GENERAL EXAMINATION
# ════════════════════════════════════════════════════
section("6. GENERAL EXAMINATION — SIGNIFICANCE")

item("Consciousness / Orientation / Cooperation",
     "Baseline neurological assessment for anaesthetic planning. "
     "Altered sensorium in a hernia patient may suggest hepatic encephalopathy (advanced liver disease with ascites causing hernia) or severe sepsis from strangulation.")

item("Hydration Status",
     "Dehydration indicates vomiting and fluid loss from intestinal obstruction — must be corrected with IV fluids before emergency surgery. "
     "Poor hydration affects wound healing and renal function peri-operatively.")

item("Pallor",
     "Anaemia may be present from chronic disease (malignancy, malnutrition) or intestinal blood loss. "
     "Pre-operative Hb must be > 10 g/dL for elective surgery. "
     "Pallor + weight loss + hernia = exclude colorectal malignancy.")

item("Jaundice",
     "Hepatic cirrhosis with jaundice → ascites → raised IAP → hernia. "
     "Jaundice impairs coagulation and drug metabolism — significantly increases operative risk. "
     "Obstructive jaundice from periampullary or pancreatic tumour causing ascites can precipitate hernia.")

item("Build and Nourishment",
     "Obesity: Fat pad at deep ring may conceal the defect; higher surgical difficulty; increased wound infection; increased IAP worsens hernia and post-op recurrence. "
     "Malnutrition/wasting: Poor collagen synthesis — higher recurrence after fascial repair; mesh repair preferred.")

item("Clubbing",
     "Suggests chronic suppurative lung disease (bronchiectasis, empyema), Crohn's disease, or cyanotic heart disease. "
     "COPD/chronic lung disease = chronic cough = hernia precipitant. Crohn's disease can be content of hernia sac.")

item("Cyanosis",
     "Central cyanosis = severe cardiorespiratory disease — affects fitness for general anaesthesia. "
     "Important in COPD patients with chronic cough who are also presenting with hernia.")

item("Pedal Oedema",
     "Bilateral pedal oedema = cardiac failure, hypoproteinaemia, or renal disease — all systemic causes that affect operative risk and post-operative healing.")

item("Generalised Lymphadenopathy",
     "Generalised lymphadenopathy suggests lymphoma, TB, or HIV — all can cause inguinal lymph node enlargement that may mimic or co-exist with a hernia. "
     "Lymphoma is a differential diagnosis for groin swelling. "
     "HIV predisposes to opportunistic infections and impairs wound healing.")

item("Vital Signs (BP, PR, RR, Temperature)",
     [
         "Blood Pressure: Hypertension affects anaesthetic risk. Hypotension in a hernia patient = shock from strangulation/gangrene — emergency.",
         "Pulse Rate: Tachycardia = pain, fever, sepsis from strangulation, dehydration from obstruction. High PR with tender irreducible hernia = strangulation.",
         "Respiratory Rate: Elevated in respiratory disease (chronic cough precipitating hernia) or from pain/sepsis.",
         "Temperature: Fever = strangulation with gangrene/peritonitis — mandates emergency surgery. Afebrile = more likely elective case."
     ])

# ════════════════════════════════════════════════════
# 7. LOCAL EXAMINATION — INSPECTION
# ════════════════════════════════════════════════════
section("7. LOCAL EXAMINATION — INSPECTION (Significance)")

item("Position: Standing, Examiner Sitting, Exposure Umbilicus to Mid-Thigh",
     "STANDING: The hernia is best seen and demonstrated in the standing position as gravity + IAP cause the hernia to descend. In supine, it may reduce and become invisible. "
     "EXAMINER SITTING: Brings the examiner's eyes to the level of the groin for accurate inspection. "
     "EXPOSURE FROM UMBILICUS TO MID-THIGH: Ensures the entire inguinal canal, external genitalia, scrotum, femoral triangle, and opposite side are all visible.",
     "Always examine the OPPOSITE side — bilateral hernias are present in 20-25% of patients and may be missed if only the symptomatic side is examined.")

item("Site of Swelling",
     "ABOVE and MEDIAL to pubic tubercle = INGUINAL hernia. "
     "BELOW and LATERAL to pubic tubercle = FEMORAL hernia. "
     "This is the single most important inspection/palpation finding for differentiating the two — a common and critical examination question.",
     "The pubic tubercle is the landmark. Place two fingers on it — inguinal hernias are above/medial, femoral are below/lateral.")

item("Size and Shape",
     "A large, pear-shaped or ovoid swelling extending to the scrotum = COMPLETE indirect inguinal hernia. "
     "A small, rounded bulge restricted to the groin = either incomplete indirect or direct hernia. "
     "Size determines whether laparoscopic or open repair is more suitable.")

item("Surface and Skin Over the Swelling",
     [
         "Scar: Suggests previous surgery — re-do hernia with altered anatomy.",
         "Sinus: Could indicate mesh infection from previous repair.",
         "Dilated veins: Associated varicocele or venous congestion.",
         "Stretched/shiny/red skin: In strangulation, overlying skin becomes red, shiny, and tense — impending rupture.",
         "Redness: Strangulation, inflammation, or infection."
     ])

item("Visible Peristalsis",
     "Visible intestinal peristaltic waves over the hernia swelling confirm that BOWEL is the content of the sac (enterocele). "
     "This is a feature of large, long-standing hernias with lax abdominal wall. "
     "SIGNIFICANCE: The sac contains viable bowel — urgent repair needed before obstruction occurs.")

item("Visible Pulsation",
     "Pulsation over the groin swelling suggests either: "
     "(1) Femoral artery ANEURYSM — important differential diagnosis, must be differentiated from femoral hernia. "
     "(2) Transmitted aortic pulsation in a thin patient with a hernia over the femoral vessels. "
     "If expansile pulsation is seen = aneurysm — do NOT attempt reduction.")

item("Reducibility on Inspection",
     "A reducible hernia can be seen to reduce in size or disappear on lying down or manual compression. "
     "An IRREDUCIBLE hernia remains prominent regardless of position = risk of obstruction/strangulation.")

item("Cough Impulse on Inspection",
     "Ask the patient to cough while you inspect the groin. A visible expansile impulse = hernia is present with communication to the peritoneal cavity. "
     "ABSENCE of cough impulse in a non-reducible swelling = STRANGULATED hernia (no communication as orifice is blocked by tightly gripped contents).",
     "A strangulated hernia has NO cough impulse — this is a key examination point.")

item("Penis Position / External Urethral Meatus",
     "A buried or deviated penis may be associated with congenital anomalies. "
     "External urethral meatus inspection: hypospadias or epispadias may co-exist. "
     "These anatomical variants affect the choice of anaesthesia (caudal) and surgical approach.")

item("Scrotum and Opposite Inguinal Region",
     "Inspect the scrotum for swelling (hydrocele, varicocele, epididymo-orchitis — differentials of inguinoscrotal swelling). "
     "Inspect the opposite inguinal region for an occult or obvious hernia on the contralateral side. "
     "A bulge on the opposite side on coughing = bilateral hernia.")

# ════════════════════════════════════════════════════
# 8. LOCAL EXAMINATION — PALPATION
# ════════════════════════════════════════════════════
section("8. LOCAL EXAMINATION — PALPATION (Significance)")

item("Warmth and Tenderness",
     "Warmth and tenderness over the hernia swelling = INFLAMMATION or STRANGULATION. "
     "A tender, warm, irreducible hernia = strangulation until proven otherwise. "
     "This changes the management from elective to EMERGENCY surgery immediately.")

item("Consistency",
     "SOFT, compressible = omentum (omentocele) or reducible bowel. "
     "FIRM but not hard = bowel (resilient). "
     "HARD = thickened omentum, stone-hard = calcified lymph node (differential). "
     "Consistency helps identify the content of the sac and assess for strangulation (tense = ischaemia).")

item("Expansile Cough Impulse on Palpation",
     "Place fingers over the hernia. Ask patient to cough. "
     "An EXPANSILE (outward) impulse = the hernia communicates with the peritoneal cavity — confirms it is a hernia. "
     "A TRANSMITTED (non-expansile) impulse = the swelling is solid and nearby (e.g., lymph node, lipoma) — NOT a hernia. "
     "No cough impulse = strangulation (neck of sac is gripped, no transmission).",
     "EXPANSILE vs TRANSMITTED cough impulse is a fundamental examination skill tested in every surgery exam.")

item("Reducibility",
     "Attempt to reduce the hernia with the patient supine and relaxed. "
     "REDUCIBLE: Content returns to peritoneal cavity easily — elective surgery, good prognosis. "
     "IRREDUCIBLE (Incarcerated): Cannot be reduced — risk of obstruction/strangulation. "
     "If irreducible but no signs of strangulation: attempt GENTLE taxis. Never forceful taxis in strangulation risk. "
     "Omentocele is often harder to reduce than enterocele.")

item("'Get Above the Swelling'",
     "If you CAN get above the swelling (fingers can be placed between the swelling and the inguinal ligament): "
     "= The swelling arises BELOW the inguinal ligament = SCROTAL swelling (hydrocele, varicocele, epididymal cyst). "
     "If you CANNOT get above the swelling: "
     "= The swelling extends above the inguinal ligament = INGUINAL HERNIA. "
     "This is the single most important test to differentiate an inguinal hernia from a scrotal swelling.",
     "'Cannot get above the swelling' = hernia extending into scrotum. This is THE most-tested clinical sign in surgery exams.")

item("Cord Structures Palpable / Not Palpable",
     "In an INDIRECT inguinal hernia, the spermatic cord is palpated POSTERIOR and LATERAL to the sac — it is lateral to the hernial sac. "
     "In a DIRECT hernia, the cord is palpated MEDIAL to the sac. "
     "A thickened, nodular cord suggests cord lipoma or orchitis. "
     "Inability to palpate the cord may indicate vas deferens absence (congenital bilateral absence of vas deferens — associated with cystic fibrosis).")

item("Epididymis Palpable / Not Palpable",
     "The epididymis must be palpated to confirm it is in its normal anatomical position (posterior to the testis). "
     "This differentiates an inguinoscrotal hernia from a hydrocele (epididymis also displaced in hydrocele). "
     "If epididymis is not separately palpable, the swelling may be of epididymal origin.")

item("External Genitalia (Scrotum, Testis, Bulbar Urethra, Penis)",
     [
         "Scrotum: Scrotal oedema occurs with irreducible hernia compressing lymphatics; also seen in hydrocele.",
         "Testis: Normal positioned testes confirm the swelling is separate from testis — helps differentiate hernia from testicular tumour, orchitis, torsion.",
         "Undescended testis: An absent testis in the scrotum suggests ectopic/undescended testis which may be in the inguinal canal — an important differential for groin swelling.",
         "Bulbar Urethra: Urethral stricture can cause straining on micturition, raising IAP and precipitating hernia.",
         "Penis: Hypospadias/epispadias may co-exist with inguinal hernia (patent processus vaginalis)."
     ])

item("Deep Ring Occlusion Test",
     "METHOD: Reduce the hernia. Occlude the deep inguinal ring (1.25 cm above the midpoint of the inguinal ligament) with two fingers. Ask the patient to stand and cough. "
     "SWELLING APPEARS despite occlusion = DIRECT hernia (comes through posterior wall of inguinal canal, not through deep ring). "
     "SWELLING DOES NOT APPEAR = INDIRECT hernia (deep ring occlusion prevents the hernia from descending). "
     "SIGNIFICANCE: Accurately classifies hernia as direct or indirect — determines operative technique (mesh placement differs).",
     "The MOST IMPORTANT test to clinically differentiate direct from indirect hernia.")

item("Three-Finger Test (Zieman's Test)",
     "METHOD: Place three fingers over the three sites of hernia orifices simultaneously on the right side (or mirror image on left). "
     "Index finger = deep ring (2 cm above midpoint of inguinal ligament) = INDIRECT hernia impulse. "
     "Middle finger = Hesselbach's triangle / superficial ring = DIRECT hernia impulse. "
     "Ring finger = femoral ring = FEMORAL hernia impulse. "
     "SIGNIFICANCE: A single manoeuvre to identify the type of hernia clinically. Confirmatory of the deep ring occlusion test findings.")

item("Finger Invagination Test",
     "METHOD: Invaginate the scrotal skin upward with the little finger to enter the inguinal canal through the superficial inguinal ring. Ask the patient to cough. "
     "IMPULSE AT TIP of little finger = INDIRECT hernia (the hernia strikes the fingertip as it comes through the deep ring). "
     "IMPULSE AT PULP (belly) of little finger = DIRECT hernia (the hernia bulges forward through the posterior wall, hitting the pulp). "
     "SIGNIFICANCE: Highly accurate bedside test; particularly useful in patients with a reduced hernia where inspection alone is insufficient.")

item("Lymph Nodes Palpable / Not Palpable",
     "Inguinal lymph nodes must be palpated carefully. "
     "Enlarged, firm, matted nodes = DIFFERENTIAL DIAGNOSIS of a groin swelling (tubercular lymphadenitis, metastatic lymph nodes, lymphoma). "
     "An infected, enlarged lymph node CANNOT be reduced and has no cough impulse — distinguishes it from a hernia. "
     "Enlarged nodes also indicate infection in the lower limb, perineum, or anal region.")

# ════════════════════════════════════════════════════
# 9. PERCUSSION & AUSCULTATION
# ════════════════════════════════════════════════════
section("9. PERCUSSION & AUSCULTATION (Significance)")

item("Percussion — Resonant vs Dull",
     "RESONANT on percussion = gas-filled bowel (ENTEROCELE) is the content of the hernial sac. "
     "DULL on percussion = solid or fluid content — omentum (OMENTOCELE), ovary, bladder (sliding hernia). "
     "SIGNIFICANCE: Helps confirm the content of the sac. Omentocele is harder to reduce and more prone to irreducibility. "
     "A completely dull hernia in a female patient = possible ovary in sac (especially in infants).")

item("Auscultation — Peristaltic Sounds",
     "BOWEL SOUNDS HEARD over the hernia swelling = ENTEROCELE (bowel is the content). "
     "SILENCE = omentocele or strangulated bowel (ischaemic bowel has absent peristalsis). "
     "SIGNIFICANCE: Strangulated hernia with absent bowel sounds = surgical emergency, bowel may already be gangrenous. "
     "This finding combined with tenderness, no cough impulse = definitive strangulation.")

# ════════════════════════════════════════════════════
# 10. EXAMINATION OF OPPOSITE INGUINAL REGION
# ════════════════════════════════════════════════════
section("10. EXAMINATION OF OPPOSITE INGUINAL REGION (Significance)")

item("Opposite Side Swelling / Cough Impulse / Reducibility",
     "Bilateral inguinal hernias occur in 20-25% of patients (even higher in children). "
     "The opposite side must ALWAYS be examined as the patient may not be aware of a smaller contralateral hernia. "
     "SIGNIFICANCE: "
     "(1) If bilateral hernias found, both can be repaired simultaneously (bilateral repair) — saves patient from a second operation. "
     "(2) Bilateral hernias are more likely in patients with DIRECT hernia (bilateral posterior wall weakness). "
     "(3) Congenital (indirect) hernias in children have a high contralateral patent processus vaginalis — bilateral exploration may be offered.",
     "Never diagnose and operate on only one side without examining the other — a common surgical pitfall.")

# ════════════════════════════════════════════════════
# 11. PER RECTAL EXAMINATION
# ════════════════════════════════════════════════════
section("11. PER RECTAL EXAMINATION (Significance)")

item("PR Examination — BPH / Malignancy / Anal Fissure",
     [
         "Benign Prostatic Hyperplasia (BPH): Enlarged, smooth, firm, rubbery prostate = BPH. Straining to urinate raises IAP → precipitates/worsens hernia. BPH must be treated before hernia repair to prevent recurrence.",
         "Malignant Obstruction (Rectal Carcinoma): Hard, irregular, ulcerated rectal mass = carcinoma. Bowel obstruction from carcinoma raises IAP and can precipitate hernia. Carcinoma must be treated first.",
         "Fissure in Ano / Chronic Anal Disease: Causes straining at defecation → raised IAP → hernia aggravation.",
         "Significance of PR overall: Identifies treatable underlying causes of raised IAP that precipitate or worsen hernia — if not treated, hernia repair will fail (early recurrence)."
     ],
     "PR exam is MANDATORY in all male patients > 50 years with inguinal hernia — to detect BPH and rectal pathology.")

# ════════════════════════════════════════════════════
# 12. OTHER SYSTEM EXAMINATION
# ════════════════════════════════════════════════════
section("12. OTHER SYSTEM EXAMINATION (Significance)")

item("Abdominal Examination — Head-Rising Test (Malgaigne's Bulging)",
     "Ask patient to lift head and shoulders from the supine position (contracts rectus abdominis). "
     "MALGAIGNE'S BULGING: Bilateral symmetrical bulging in the groin above the inguinal ligament on head-raising = weakness of the posterior inguinal wall (transversalis fascia). "
     "SIGNIFICANCE: Confirms DIRECT inguinal hernia tendency — bilateral posterior wall weakness. "
     "Also confirms the diagnosis of direct hernia when the hernia is reduced and not visible. "
     "Other abdominal findings: organomegaly (liver/spleen), ascites, masses — all raise IAP and may be secondary causes of hernia.")

item("Respiratory System (NVBS / Added Sounds)",
     "Wheeze, rhonchi = COPD, asthma — causes chronic cough = major risk factor for hernia recurrence. "
     "Crepitations = LRTI / pneumonia — contraindicates elective surgery. "
     "NVBS (Normal Vesicular Breath Sounds) = fit for surgery from respiratory standpoint. "
     "Spirometry / PFT may be needed in severe respiratory disease before general anaesthesia.")

item("Cardiovascular System (S1 S2, Murmur)",
     "Cardiac fitness for anaesthesia. "
     "Cardiac murmur may indicate valvular heart disease requiring antibiotic prophylaxis or anticoagulation. "
     "Cardiac failure raises JVP, causing systemic venous hypertension that may worsen post-operative recovery.")

item("CNS — No Focal Neurological Deficit",
     "Baseline neurological status. "
     "Post-operative nerve injuries (ilioinguinal, iliohypogastric, genitofemoral nerves) are known complications of hernia repair. "
     "A pre-operative neuro exam documents pre-existing deficits and protects the surgeon medicolegally. "
     "Also, a patient with neurological deficit causing reduced abdominal wall tone may be more prone to direct hernia.")

# ════════════════════════════════════════════════════
# 13. DIAGNOSIS CLASSIFICATION
# ════════════════════════════════════════════════════
section("13. FINAL DIAGNOSIS — SIGNIFICANCE OF EACH CLASSIFICATION COMPONENT")

diag_data = [
    ["Classification Axis", "Options", "Why It Matters Clinically"],
    ["Side", "Right / Left / Bilateral", "Bilateral hernias need simultaneous or staged repair; higher frequency of direct type"],
    ["Aetiology", "Congenital / Acquired", "Congenital = patent processus vaginalis (indirect); Acquired = muscle/fascial weakness (direct or indirect)"],
    ["Type", "Direct / Indirect", "Determines anatomical plane of surgery; mesh placement strategy differs; indirect has higher strangulation risk"],
    ["Reducibility", "Reducible / Irreducible", "Reducible = elective; Irreducible = urgent/emergency depending on strangulation features"],
    ["Region", "Inguinal / Femoral", "Femoral hernias have higher strangulation rate (narrow neck); different operative approach entirely"],
    ["Completeness", "Complete / Incomplete", "Complete = hernia in scrotum/labia; Incomplete = within inguinal canal — guides extent of surgery"],
    ["Complications", "Complicated / Uncomplicated", "Strangulation/obstruction = emergency; uncomplicated = elective; urgency and anaesthetic risk differ"],
    ["Content", "Enterocele / Omentocele", "Enterocele: bowel present — strangulation leads to bowel gangrene, resection may be needed; Omentocele: fat content — lower risk but still needs repair"],
]
t = Table(diag_data, colWidths=[3.5*cm, 4*cm, 9.5*cm])
t.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1b5e20')),
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    ('PADDING', (0,0), (-1,-1), 5),
    ('FONTNAME', (0,1), (0,-1), 'Helvetica-Bold'),
]))
story.append(t)
story.append(Spacer(1, 0.4*cm))

# ════════════════════════════════════════════════════
# 14. DIFFERENTIAL DIAGNOSES
# ════════════════════════════════════════════════════
section("14. DIFFERENTIAL DIAGNOSES — SIGNIFICANCE & HOW TO DIFFERENTIATE")

subsection("A. Differential Diagnoses for Groin Swelling")
dd_data = [
    ["Diagnosis", "Key Distinguishing Features"],
    ["Femoral Hernia", "Below and LATERAL to pubic tubercle; mostly in women; higher strangulation risk; narrow neck; no cough impulse usually"],
    ["Enlarged Inguinal Lymph Nodes", "Multiple firm/matted nodes; no cough impulse; no reducibility; may have primary infection in leg/perineum; percussion dull"],
    ["Saphena Varix", "Soft, compressible; brilliant blue colour; fills on standing; disappears on lying; cough impulse (soft thrill); associated with saphenofemoral incompetence"],
    ["Femoral Aneurysm", "Pulsatile, expansile swelling in femoral triangle; bruit on auscultation; DO NOT attempt taxis"],
    ["Lipoma of the Cord", "Soft, lobulated, non-reducible; no cough impulse; transillumination negative; confirmed on USG"],
    ["Encysted Hydrocele of Cord", "Transilluminates; smooth; separate from testis; no cough impulse; moves with cord (upward traction on testis moves it)"],
    ["Undescended / Ectopic Testis", "Absent ipsilateral testis in scrotum; swelling corresponds to testicular size; testicular sensation on pressure"],
    ["Psoas Abscess", "Fluctuant; signs of TB (fever, night sweats, weight loss); cross-fluctuance at iliac fossa and groin; lumbar spine tenderness; CXR/MRI confirms"],
    ["Malgaigne's Bulge", "Bilateral; not a true hernia; appears on straining; no sac; indicates weakness of posterior wall; seen with head-rising test"],
]
t2 = Table(dd_data, colWidths=[5*cm, 12*cm])
t2.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#2e7d32')),
    ('TEXTCOLOR', (0,0), (-1,0), colors.white),
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]))
story.append(t2)
story.append(Spacer(1, 0.4*cm))

subsection("B. Differential Diagnoses for Inguino-Scrotal Swelling")
dd2_data = [
    ["Diagnosis", "Key Features"],
    ["Congenital Hydrocele", "Cannot get above; transilluminates brilliantly; separate testis palpable at bottom; no cough impulse; neck reaches inguinal canal"],
    ["Infantile Hydrocele", "Sac extends to deep ring; no cough impulse; transilluminates; separate testis palpable"],
    ["Encysted Hydrocele of Cord", "CAN get above swelling; moves up with cord traction; transilluminates; no cough impulse"],
    ["Lipoma of the Cord", "Soft, lobulated; no transillumination; can get above in some; no impulse"],
    ["Varicocele", "Bag of worms feel; left sided (90%); disappears on lying; dilated veins on palpation; associated infertility"],
    ["Funiculitis", "Tender, thickened cord; fever; associated epididymo-orchitis; no true swelling"],
    ["Lymph Varix (Chylous)", "Translucent; associated elephantiasis/filariasis; aspirate shows milky fluid"],
]
t3 = Table(dd2_data, colWidths=[5*cm, 12*cm])
t3.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1565c0')),
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    ('PADDING', (0,0), (-1,-1), 4),
]))
story.append(t3)
story.append(Spacer(1, 0.4*cm))

# ════════════════════════════════════════════════════
# 15. INVESTIGATIONS
# ════════════════════════════════════════════════════
section("15. INVESTIGATIONS — SIGNIFICANCE OF EACH")

subsection("Baseline Investigations")
inv_data = [
    ["Investigation", "Significance in Inguinal Hernia"],
    ["Haemoglobin", "Pre-operative Hb must be >10 g/dL; anaemia from malignancy, chronic disease — must be corrected"],
    ["Total Count / DC", "Leucocytosis = active infection or strangulation with sepsis — contraindicates elective surgery; mandates emergency surgery"],
    ["ESR", "Elevated in infection (TB lymphadenitis differential), malignancy, and systemic inflammation"],
    ["Platelet Count", "Thrombocytopenia — bleeding risk during mesh repair; thrombocytosis — DVT risk post-op"],
    ["Random Blood Sugar", "Diabetes = impaired wound healing, mesh infection risk; must achieve glycaemic control pre-op"],
    ["Serum Urea / Creatinine", "Renal function: drug dosing, IV fluid management, contrast safety for CT"],
    ["Urine Routine (Albumin, Sugar, Deposits)", "Albuminuria = renal/hepatic disease; glycosuria = DM; pyuria = UTI (can worsen BPH symptoms)"],
    ["Bleeding Time / Clotting Time", "Coagulation screening; abnormal in liver disease (coagulation factor deficiency) — high-risk surgery"],
    ["Blood Grouping / Typing", "Pre-operative blood availability in case of emergency bowel resection (strangulation)"],
    ["HIV-1/HIV-2, VDRL, HBsAg, Anti-HCV", "Pre-operative infectious disease screening — protects surgical team; HIV impairs wound healing and increases mesh infection"],
    ["ECG All Leads", "Cardiac fitness; identifies arrhythmias, ischaemic changes — affects anaesthetic choice"],
    ["CXR PA View", "Detects COPD, cardiomegaly, pleural effusion; evidence of pulmonary TB (miliary, hilar lymphadenopathy)"],
]
t4 = Table(inv_data, colWidths=[5*cm, 12*cm])
t4.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#37474f')),
    ('TEXTCOLOR', (0,0), (-1,0), colors.white),
    ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
    ('FONTSIZE', (0,0), (-1,-1), 8.5),
    ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#90a4ae')),
    ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#eceff1'), colors.white]),
    ('VALIGN', (0,0), (-1,-1), 'MIDDLE'),
    ('PADDING', (0,0), (-1,-1), 4),
    ('FONTNAME', (0,1), (0,-1), 'Helvetica-Bold'),
]))
story.append(t4)
story.append(Spacer(1, 0.4*cm))

subsection("Specific Investigations (Only if Examiner Asks)")
spec_data = [
    ["Investigation", "Indication & Significance"],
    ["USG Abdomen/Pelvis\n(in elderly with LUTS)", "Prostate size, post-voidal residual urine (PVR) — guides BPH treatment before hernia repair. Also detects abdominal/pelvic masses causing secondary hernia."],
    ["CT Abdomen/Pelvis", "Obstructed or strangulated hernia — assesses bowel viability, extent of necrosis, decides open vs laparoscopic approach. Large incisional hernia — maps abdominal wall defect for prosthetic mesh planning."],
    ["MRI", "Sportsman's hernia (athletic pubalgia) — investigation of CHOICE. Shows posterior wall weakness, nerve entrapment, adductor pathology."],
    ["Herniogram", "Occult hernia (groin pain, no visible hernia) — investigation of CHOICE. Contrast injected into peritoneal cavity outlines occult sac."],
    ["Pulmonary Function Tests (PFT)", "Severe COPD/restrictive lung disease with hernia — assesses respiratory reserve, guides anaesthetic management (spinal vs general), pre-operative optimisation."],
    ["PSA (Prostate Specific Antigen)", "Elderly male with LUTS + inguinal hernia — screens for prostate carcinoma (hard irregular prostate on PR). Must not repair hernia before excluding/treating malignancy."],
]
t5 = Table(spec_data, colWidths=[4.5*cm, 12.5*cm])
t5.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#b71c1c')),
    ('TEXTCOLOR', (0,0), (-1,0), colors.white),
    ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
    ('FONTSIZE', (0,0), (-1,-1), 8.5),
    ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#90a4ae')),
    ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#ffebee'), colors.white]),
    ('VALIGN', (0,0), (-1,-1), 'MIDDLE'),
    ('PADDING', (0,0), (-1,-1), 4),
    ('FONTNAME', (0,1), (0,-1), 'Helvetica-Bold'),
]))
story.append(t5)
story.append(Spacer(1, 0.4*cm))

# ════════════════════════════════════════════════════
# 16. TREATMENT SUMMARY
# ════════════════════════════════════════════════════
section("16. TREATMENT — SIGNIFICANCE OF EACH OPERATIVE STEP")

treat_data = [
    ["Operation", "Indication", "Key Steps & Significance"],
    ["Herniotomy", "Congenital hernia (children)", "Identification of sac → Separation → Opening fundus → Reducing contents → Transfixion & ligation at deep ring → Excise excess sac. No posterior wall repair needed as wall is intact in children."],
    ["Herniorraphy", "Young adults (now rarely; replaced by hernioplasty)", "All steps of herniotomy + Anatomical tissue repair of posterior wall (Shouldice, Bassini). Uses patient's own tissue — higher tension, higher recurrence vs mesh."],
    ["Hernioplasty (GOLD STANDARD)", "Both direct and indirect hernia in adults", "All steps of herniotomy + Reinforcement of posterior wall with SYNTHETIC MESH (polypropylene). Tension-free repair — dramatically reduces recurrence rate (<1% vs 10-15% for tissue repair). Lichtenstein open or laparoscopic (TEP/TAPP)."],
]
t6 = Table(treat_data, colWidths=[3.5*cm, 4*cm, 9.5*cm])
t6.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1b5e20')),
    ('TEXTCOLOR', (0,0), (-1,0), colors.white),
    ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
    ('FONTSIZE', (0,0), (-1,-1), 8.5),
    ('GRID', (0,0), (-1,-1), 0.5, colors.HexColor('#90a4ae')),
    ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#e8f5e9'), colors.white]),
    ('VALIGN', (0,0), (-1,-1), 'MIDDLE'),
    ('PADDING', (0,0), (-1,-1), 5),
]))
story.append(t6)
story.append(Spacer(1, 0.4*cm))

# ── FOOTER ──────────────────────────────────────────────────
story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1b5e20')))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    "References: Das S. — A Manual of Clinical Surgery (Latest Edition) | "
    "Rajamahendran — Surgical Principles for Clinical Examination | "
    "Bailey &amp; Love's Short Practice of Surgery | Skandalakis' Surgical Anatomy",
    ParagraphStyle('footer', parent=styles['Normal'], fontSize=8, textColor=colors.HexColor('#546e7a'),
                   alignment=TA_CENTER, fontName='Helvetica-Oblique')))

doc.build(story)
print("PDF created successfully.")

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/varicose-veins-pdf/generate_inguinal_hernia_pdf.py'

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Successfully replaced 1 instance(s) of the string in '/tmp/workspace/varicose-veins-pdf/generate_inguinal_hernia_pdf.py'

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/varicose-veins-pdf/generate_inguinal_hernia_pdf.py'

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/varicose-veins-pdf/generate_inguinal_hernia_pdf.py'

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/varicose-veins-pdf/generate_inguinal_hernia_pdf.py'

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/varicose-veins-pdf/generate_inguinal_hernia_pdf.py'

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/varicose-veins-pdf/generate_inguinal_hernia_pdf.py'

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

# ── PAGE SETUP ──────────────────────────────────────────────
# A4 = 21cm wide. Margins 1.5cm each side → usable = 18cm
LEFT_MARGIN = RIGHT_MARGIN = 1.5 * cm
TOP_MARGIN = BOTTOM_MARGIN = 2.0 * cm
USABLE_W = 21 * cm - LEFT_MARGIN - RIGHT_MARGIN   # 18 cm = 510.24 pts

doc = SimpleDocTemplate(
    "/tmp/workspace/varicose-veins-pdf/Inguinal_Hernia_Significance.pdf",
    pagesize=A4,
    rightMargin=RIGHT_MARGIN,
    leftMargin=LEFT_MARGIN,
    topMargin=TOP_MARGIN,
    bottomMargin=BOTTOM_MARGIN,
)

styles = getSampleStyleSheet()

# ── PARAGRAPH STYLES ───────────────────────────────────────
TITLE_ST = ParagraphStyle('TITLE_ST', parent=styles['Title'],
    fontSize=20, textColor=colors.HexColor('#1b5e20'),
    spaceAfter=4, alignment=TA_CENTER, fontName='Helvetica-Bold')

SUBTITLE_ST = ParagraphStyle('SUBTITLE_ST', parent=styles['Normal'],
    fontSize=10, textColor=colors.HexColor('#37474f'),
    spaceAfter=8, alignment=TA_CENTER, fontName='Helvetica-Oblique')

SEC_HDR = ParagraphStyle('SEC_HDR', parent=styles['Normal'],
    fontSize=12, textColor=colors.white,
    spaceAfter=3, spaceBefore=8,
    fontName='Helvetica-Bold',
    backColor=colors.HexColor('#1b5e20'),
    borderPadding=(5, 8, 5, 8))

SUBSEC_HDR = ParagraphStyle('SUBSEC_HDR', parent=styles['Normal'],
    fontSize=10.5, textColor=colors.HexColor('#1b5e20'),
    spaceAfter=3, spaceBefore=6, fontName='Helvetica-Bold')

ITEM_HDR = ParagraphStyle('ITEM_HDR', parent=styles['Normal'],
    fontSize=10.5, textColor=colors.HexColor('#b71c1c'),
    spaceAfter=2, spaceBefore=5, fontName='Helvetica-Bold')

BODY_ST = ParagraphStyle('BODY_ST', parent=styles['Normal'],
    fontSize=9, textColor=colors.HexColor('#212121'),
    spaceAfter=3, leading=13,
    fontName='Helvetica', alignment=TA_JUSTIFY, leftIndent=8)

NOTE_ST = ParagraphStyle('NOTE_ST', parent=styles['Normal'],
    fontSize=8.5, textColor=colors.HexColor('#4a148c'),
    spaceAfter=3, fontName='Helvetica-Oblique', leftIndent=8)

BULLET_ST = ParagraphStyle('BULLET_ST', parent=styles['Normal'],
    fontSize=9, textColor=colors.HexColor('#212121'),
    spaceAfter=2, leading=12,
    fontName='Helvetica', leftIndent=18, bulletIndent=6)

# ── TABLE CELL STYLES ──────────────────────────────────────
# These are used INSIDE table cells as Paragraph objects
THDR = ParagraphStyle('THDR',
    fontSize=8, textColor=colors.white,
    fontName='Helvetica-Bold', leading=10,
    spaceAfter=0, spaceBefore=0)

TCELL = ParagraphStyle('TCELL',
    fontSize=8, textColor=colors.HexColor('#111111'),
    fontName='Helvetica', leading=10,
    spaceAfter=0, spaceBefore=0, alignment=TA_LEFT)

TCELL_B = ParagraphStyle('TCELL_B',
    fontSize=8, textColor=colors.HexColor('#111111'),
    fontName='Helvetica-Bold', leading=10,
    spaceAfter=0, spaceBefore=0)

def make_table(data, col_widths, hdr_bg=colors.HexColor('#1b5e20'),
               row_colors=None, pad=4):
    """
    data: list of lists of strings.
    col_widths: list of floats in pts. MUST sum to <= USABLE_W.
    Wraps every cell in a Paragraph so text wraps correctly.
    """
    assert abs(sum(col_widths) - USABLE_W) < 2, \
        f"col_widths sum {sum(col_widths):.1f} != USABLE_W {USABLE_W:.1f}"

    if row_colors is None:
        row_colors = [colors.HexColor('#e8f5e9'), colors.white]

    wrapped = []
    for r, row in enumerate(data):
        new_row = []
        for c, cell in enumerate(row):
            if r == 0:
                new_row.append(Paragraph(str(cell), THDR))
            elif c == 0:
                new_row.append(Paragraph(str(cell), TCELL_B))
            else:
                new_row.append(Paragraph(str(cell), TCELL))
        wrapped.append(new_row)

    tbl = Table(wrapped, colWidths=col_widths, repeatRows=1, splitByRow=1)

    cmd = [
        ('BACKGROUND',  (0, 0), (-1,  0), hdr_bg),
        ('TEXTCOLOR',   (0, 0), (-1,  0), colors.white),
        ('GRID',        (0, 0), (-1, -1), 0.4, colors.HexColor('#bdbdbd')),
        ('VALIGN',      (0, 0), (-1, -1), 'TOP'),
        ('TOPPADDING',  (0, 0), (-1, -1), pad),
        ('BOTTOMPADDING',(0,0), (-1, -1), pad),
        ('LEFTPADDING', (0, 0), (-1, -1), pad),
        ('RIGHTPADDING',(0, 0), (-1, -1), pad),
    ]
    # Alternating row backgrounds
    for i in range(1, len(data)):
        bg = row_colors[i % len(row_colors)]
        cmd.append(('BACKGROUND', (0, i), (-1, i), bg))

    tbl.setStyle(TableStyle(cmd))
    return tbl

# ── HELPERS ───────────────────────────────────────────────
story = []

def section(title):
    story.append(Spacer(1, 0.2 * cm))
    story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1b5e20')))
    story.append(Paragraph(f"  {title}", SEC_HDR))
    story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1b5e20')))
    story.append(Spacer(1, 0.12 * cm))

def subsection(title):
    story.append(Paragraph(title, SUBSEC_HDR))

def item(title, body, note=None):
    elems = [Paragraph(f"&#9654; {title}", ITEM_HDR)]
    if isinstance(body, list):
        for b in body:
            elems.append(Paragraph(f"• {b}", BULLET_ST))
    else:
        elems.append(Paragraph(body, BODY_ST))
    if note:
        elems.append(Paragraph(f"Examiner's Note: {note}", NOTE_ST))
    elems.append(Spacer(1, 0.06 * cm))
    story.extend(elems)

# ════════════════════════════════════════════════════════════
# TITLE PAGE
# ════════════════════════════════════════════════════════════
story.append(Spacer(1, 1.0 * cm))
story.append(Paragraph("INGUINAL HERNIA", TITLE_ST))
story.append(Paragraph("Long Case History &amp; Examination", TITLE_ST))
story.append(Spacer(1, 0.2 * cm))
story.append(HRFlowable(width="100%", thickness=3, color=colors.HexColor('#1b5e20')))
story.append(Spacer(1, 0.12 * cm))
story.append(Paragraph("Significance of Every History and Examination Finding", SUBTITLE_ST))
story.append(Paragraph("According to Das's Manual of Clinical Surgery &amp; Rajamahendran's Surgical Principles", SUBTITLE_ST))
story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor('#90a4ae')))
story.append(Spacer(1, 1.2 * cm))

# ════════════════════════════════════════════════════════════
# 1. CHIEF COMPLAINTS
# ════════════════════════════════════════════════════════════
section("1. CHIEF COMPLAINTS — WHY ASKED & SIGNIFICANCE")

item("Swelling in the Right / Left Groin",
     "The groin is the most common site for a hernia. A swelling here is the cardinal presenting feature. "
     "Asking the DURATION establishes whether it is acute (strangulation risk) or chronic (elective repair). "
     "Unilateral vs bilateral guides operative planning — bilateral hernias may need staged or simultaneous repair. "
     "Location relative to the pubic tubercle: ABOVE and MEDIAL = inguinal hernia; BELOW and LATERAL = femoral hernia.",
     "ALWAYS confirm the site relative to the pubic tubercle — the key to differentiating inguinal from femoral hernia (Das).")

item("Swelling in the Right / Left Lower Abdomen",
     "A large indirect inguinal hernia can extend into the lower abdomen, especially in thin patients. "
     "The progressive descent from groin to scrotum — starting small and enlarging — is the classical history of indirect inguinal hernia.")

item("Pain in the Swelling",
     "An uncomplicated reducible hernia is usually painless or causes only mild dragging discomfort. "
     "Acute, severe, constant, non-relieving pain = STRANGULATION (ischaemia of contents) — surgical emergency. "
     "Intermittent colicky pain = intestinal obstruction within the sac. "
     "Dull aching worsened by standing/straining = typical uncomplicated hernia.",
     "Severe pain + irreducible swelling = strangulation until proven otherwise. Never attempt forceful taxis.")

# ════════════════════════════════════════════════════════════
# 2. HISTORY OF PRESENTING ILLNESS
# ════════════════════════════════════════════════════════════
section("2. HISTORY OF PRESENTING ILLNESS — SIGNIFICANCE OF EACH H/O")

item("Onset (Sudden vs Insidious)",
     "SUDDEN onset: suggests pre-existing weakness that became apparent due to precipitating event (cough, straining, lifting). "
     "INSIDIOUS onset: typical of gradually enlarging hernia. "
     "Sudden onset with severe pain = strangulated hernia until proven otherwise.")

item("Progression from Groin to Scrotum",
     "PATHOGNOMONIC of indirect inguinal hernia. The sac follows the path of the processus vaginalis — from deep ring, through inguinal canal, out of superficial ring, into scrotum. "
     "Swelling starting in groin and descending into scrotum = INDIRECT. "
     "Swelling bulging directly forward in groin without descending into scrotum = DIRECT.",
     "Direct hernias RARELY enter the scrotum as the sac passes through Hesselbach's triangle which is too medial.")

item("Aggravation by Straining, Standing, Coughing",
     "All increase intra-abdominal pressure (IAP). When IAP rises, contents are forced through the fascial defect. "
     "Confirming this pattern proves the swelling is a hernia. Cough impulse is the corresponding clinical sign.")

item("Relieved by Lying Down / Manual Reduction",
     "Reduces spontaneously on lying = REDUCIBLE hernia — most favourable state. "
     "Manual reduction by patient himself = confirms reducibility. "
     "Cannot be reduced any longer = IRREDUCIBLE — urgent review to exclude strangulation.")

item("H/O Fever",
     "Fever with irreducible hernia = STRANGULATION with gangrene of contents → systemic sepsis. "
     "Strangulated bowel: ischaemia → gangrene → bacterial translocation → fever. "
     "In presence of fever + non-reducible hernia = urgent surgical exploration mandatory.",
     "Never attempt forceful manual reduction in a strangulated hernia with fever.")

item("H/O Trauma",
     "Trauma to groin can precipitate herniation through a pre-existing weakness. "
     "Relevant for medico-legal documentation in occupational injury. "
     "Haematoma in groin can mimic irreducible hernia — important differential.")

item("H/O Loss of Weight",
     "Significant unintentional weight loss suggests underlying MALIGNANCY (colorectal carcinoma, lymphoma). "
     "Rectal/colonic tumour causes raised IAP (obstruction, ascites) precipitating hernia. "
     "Also: weight loss causes loss of fat plug at deep ring, allowing hernia formation. "
     "Pallor + weight loss + hernia = exclude colorectal malignancy.")

item("H/O Loss of Appetite (Anorexia)",
     "Along with weight loss, suggests systemic malignant or chronic disease as underlying cause. "
     "Colorectal carcinoma causing chronic obstruction and elevated IAP is a recognised precipitant in the elderly.")

item("H/O Heavy Weight Lifting",
     "MAJOR precipitating/aetiological factor for both indirect and direct hernias. "
     "Sudden extreme IAP rise forces contents through fascial weakness. "
     "Direct hernias particularly precipitated — weakness of posterior inguinal wall (transversalis fascia). "
     "Occupational history (labourers, construction workers, weightlifters) must be documented.",
     "Occupational heavy lifting is a recognised aetiological factor — relevant for workmen's compensation.")

item("H/O Chronic Cough",
     "Chronic repetitive coughing continuously raises IAP — a major aetiological factor, especially for indirect hernia. "
     "Causes: COPD, bronchial asthma, pulmonary TB, chronic bronchitis. "
     "The cough MUST be controlled peri-operatively — operating without treating cough leads to early recurrence.",
     "Failure to treat chronic cough before hernia repair is the most common cause of early recurrence (Das).")

item("H/O Difficulty in Micturition / LUTS (Urgency, Frequency, Hesitancy, Precipitancy)",
     "Lower Urinary Tract Symptoms indicate BLADDER OUTLET OBSTRUCTION — most commonly BPH in elderly men. "
     "BPH causes straining to pass urine → repeated raised IAP → precipitates/worsens hernia. "
     "SIGNIFICANCE: (1) BPH MUST be treated first — operating without addressing BPH leads to EARLY RECURRENCE. "
     "(2) Urinary bladder can be sliding content of direct hernia — 'bladder sliding hernia'. "
     "(3) If urinary symptoms present, PSA, USG and urology referral are mandatory.",
     "Classic exam: What to do before repairing hernia in 65-yr-old with LUTS? Answer: Rule out and treat BPH first.")

item("H/O Abdominal Pain",
     "Colicky abdominal pain + hernia = INTESTINAL OBSTRUCTION (bowel trapped in sac). "
     "Constant severe pain = STRANGULATION with peritonitis. "
     "The type of pain (colicky vs constant) determines urgency of surgical intervention.")

item("H/O Abdominal Distension",
     "Progressive abdominal distension + non-reducible hernia = INTESTINAL OBSTRUCTION. "
     "One of the four classic features: pain, vomiting, distension, absolute constipation. "
     "Its presence mandates urgent surgical intervention.")

item("H/O Vomiting",
     "Vomiting + non-reducible hernia = OBSTRUCTED/STRANGULATED hernia until proven otherwise. "
     "Early vomiting = small bowel obstruction. Late faeculent vomiting = prolonged obstruction. "
     "Escalates management from elective to emergency surgery.")

item("H/O Difficulty in Defecation / Absolute Constipation",
     "Absolute constipation (no flatus/faeces) = COMPLETE INTESTINAL OBSTRUCTION. "
     "With non-reducible hernia = bowel obstruction confirmed — emergency surgery. "
     "Chronic constipation + straining at stool = raises IAP → precipitates hernia (aetiological factor).")

# ════════════════════════════════════════════════════════════
# 3. PAST HISTORY
# ════════════════════════════════════════════════════════════
section("3. PAST HISTORY — SIGNIFICANCE")

item("H/O Similar Illness in the Past",
     "Previous episodes suggest RECURRENT hernia or inadequately treated hernia. "
     "Re-do hernia has altered anatomy → increases risk to vas deferens and testicular vessels.")

item("H/O DM / SHT / TB / Epilepsy / Heart Disease / Kidney Disease / Allergy",
     [
         "DM: Impairs wound healing; increases mesh infection risk; HbA1c < 7% mandatory pre-op.",
         "Hypertension: Affects anaesthetic management; antihypertensives continued peri-operatively.",
         "TB: Active pulmonary TB causes chronic cough = hernia precipitant. TB lymphadenitis mimics irreducible hernia.",
         "Epilepsy: Drug interactions with anaesthetic agents; seizure during recovery is a risk.",
         "Heart Disease: Cardiac evaluation needed; affects anaesthetic choice (spinal vs general).",
         "Kidney Disease: Drug dosing, fluid management, contrast use; hypoproteinaemia impairs wound healing.",
         "Allergy: Allergy to polypropylene mesh (rare but documented); latex allergy affects equipment choice."
     ])

item("H/O Previous Surgery",
     "Previous abdominal surgery creates scar tissue, alters anatomy. "
     "Previous inguinal surgery (orchidopexy, vasectomy, prior hernia repair): risk of vas deferens and testicular vessel injury during re-do surgery. "
     "Essential for pre-operative planning and consenting about higher complication risk.")

# ════════════════════════════════════════════════════════════
# 4. PERSONAL HISTORY
# ════════════════════════════════════════════════════════════
section("4. PERSONAL HISTORY — SIGNIFICANCE")

item("Diet (Vegetarian / Non-Vegetarian)",
     "Nutritional status affects wound healing. Protein deficiency impairs collagen synthesis — vital for fascial repair strength. "
     "High-fibre diet prevents constipation (prevents straining → prevents recurrence).")

item("Smoking",
     "Major risk factor for CHRONIC COUGH (COPD, chronic bronchitis) — most important precipitating factor for hernia and leading cause of post-repair recurrence. "
     "Impairs wound healing. Increases mesh infection and recurrence rates. Must be stopped 4-6 weeks before elective surgery.")

item("Alcohol",
     "Hepatic cirrhosis → ascites → raised IAP → hernia. "
     "Impairs coagulation, drug metabolism, wound healing. "
     "Alcohol withdrawal during hospitalisation can cause seizures — peri-operative risk.")

item("Bowel and Bladder Habits",
     "Chronic constipation + straining = repeated IAP rise = precipitating factor and cause of recurrence. "
     "Urinary symptoms = BPH must be treated first. Both must be addressed before and after repair.")

item("Sleep Pattern",
     "Disturbed sleep may indicate chronic pain, urinary frequency (BPH), or anxiety — helps assess overall wellbeing and fitness.")

# ════════════════════════════════════════════════════════════
# 5. FAMILY HISTORY
# ════════════════════════════════════════════════════════════
section("5. FAMILY HISTORY — SIGNIFICANCE")

item("H/O Similar Illness in Family",
     "Inguinal hernia has a GENETIC component — collagen deficiency (reduced type I collagen in transversalis fascia) is inherited. "
     "4-8x increased risk if first-degree relative has a hernia. "
     "Family history of bilateral hernias suggests connective tissue disorder (Marfan, Ehlers-Danlos). "
     "Contralateral side may also develop a hernia — important for counselling.")

item("Health Status of Family Members",
     "Screens for hereditary diseases, chronic illnesses, and infectious diseases (TB in family contacts) affecting perioperative management.")

# ════════════════════════════════════════════════════════════
# 6. GENERAL EXAMINATION
# ════════════════════════════════════════════════════════════
section("6. GENERAL EXAMINATION — SIGNIFICANCE")

item("Consciousness / Orientation / Cooperation",
     "Baseline neurological assessment for anaesthetic planning. "
     "Altered sensorium = hepatic encephalopathy (advanced liver disease with ascites causing hernia) or severe sepsis from strangulation.")

item("Hydration Status",
     "Dehydration indicates vomiting + fluid loss from intestinal obstruction — must be corrected with IV fluids before emergency surgery. "
     "Poor hydration affects wound healing and renal function peri-operatively.")

item("Pallor",
     "Anaemia from chronic disease, malignancy, or nutritional deficiency. "
     "Pre-operative Hb must be > 10 g/dL for elective surgery. "
     "Pallor + weight loss + hernia = exclude colorectal malignancy.")

item("Jaundice",
     "Hepatic cirrhosis → ascites → raised IAP → hernia. "
     "Impairs coagulation and drug metabolism — significantly increases operative risk. "
     "Obstructive jaundice from periampullary or pancreatic tumour causing ascites can precipitate hernia.")

item("Build and Nourishment",
     "Obesity: Fat at deep ring may conceal defect; higher surgical difficulty; increased wound infection; increased IAP worsens hernia and recurrence. "
     "Malnutrition: Poor collagen synthesis — higher recurrence after fascial repair; mesh repair preferred.")

item("Clubbing",
     "Suggests chronic suppurative lung disease (COPD, bronchiectasis) = chronic cough = hernia precipitant. "
     "Crohn's disease can be content of hernia sac.")

item("Cyanosis",
     "Central cyanosis = severe cardiorespiratory disease — affects fitness for general anaesthesia. "
     "Important in COPD patients with chronic cough presenting with hernia.")

item("Pedal Oedema",
     "Bilateral oedema = cardiac failure, hypoproteinaemia, or renal disease — affect operative risk and post-operative healing.")

item("Generalised Lymphadenopathy",
     "Suggests lymphoma, TB, or HIV — all can cause inguinal lymph node enlargement mimicking or co-existing with hernia. "
     "HIV impairs wound healing and increases mesh infection risk.")

item("Vital Signs (BP, PR, RR, Temperature)",
     [
         "Blood Pressure: Hypertension affects anaesthetic risk. Hypotension = shock from strangulation/gangrene — emergency.",
         "Pulse Rate: Tachycardia = pain, fever, sepsis from strangulation, dehydration from obstruction.",
         "Respiratory Rate: Elevated in respiratory disease or from pain/sepsis.",
         "Temperature: Fever = strangulation with gangrene/peritonitis — mandates emergency surgery."
     ])

# ════════════════════════════════════════════════════════════
# 7. LOCAL EXAMINATION — INSPECTION
# ════════════════════════════════════════════════════════════
section("7. LOCAL EXAMINATION — INSPECTION (Significance)")

item("Position: Standing, Examiner Sitting, Exposure Umbilicus to Mid-Thigh",
     "STANDING: Hernia best seen as gravity + IAP cause it to descend. In supine, it may reduce and be invisible. "
     "EXAMINER SITTING: Brings eyes to the level of the groin for accurate inspection. "
     "EXPOSURE: Ensures inguinal canal, genitalia, scrotum, femoral triangle, and opposite side are all visible.",
     "Always examine the OPPOSITE side — bilateral hernias in 20-25%; may be missed if only symptomatic side examined.")

item("Site of Swelling — Relation to Pubic Tubercle",
     "ABOVE and MEDIAL to pubic tubercle = INGUINAL hernia. "
     "BELOW and LATERAL to pubic tubercle = FEMORAL hernia. "
     "This is the single most important finding for differentiating the two types.",
     "The pubic tubercle is THE landmark. Place two fingers on it — inguinal above/medial, femoral below/lateral.")

item("Size and Shape",
     "Large pear-shaped swelling extending to scrotum = COMPLETE indirect inguinal hernia. "
     "Small rounded bulge in groin = incomplete indirect or direct hernia. "
     "Size determines laparoscopic vs open approach suitability.")

item("Skin Over the Swelling",
     [
         "Scar: Previous surgery — re-do hernia with altered anatomy.",
         "Sinus: Mesh infection from previous repair.",
         "Dilated veins: Associated varicocele or venous congestion.",
         "Red/shiny/tense skin: Strangulation — impending rupture; emergency surgery."
     ])

item("Visible Peristalsis",
     "Peristaltic waves over hernia = BOWEL is the content (enterocele). "
     "Feature of large long-standing hernias. Urgent repair needed before obstruction occurs.")

item("Visible Pulsation",
     "Pulsation over groin swelling = femoral artery ANEURYSM (differential) or transmitted aortic pulsation. "
     "If expansile pulsation seen = aneurysm — DO NOT attempt reduction.")

item("Cough Impulse on Inspection",
     "Visible expansile impulse on coughing = hernia communicates with peritoneal cavity — confirms hernia. "
     "ABSENCE of cough impulse on non-reducible swelling = STRANGULATED hernia (orifice blocked by gripped contents).",
     "Strangulated hernia has NO cough impulse — a critical examination point.")

item("Penis, External Urethral Meatus, Scrotum, Opposite Side",
     "Buried/deviated penis = congenital anomalies may co-exist. "
     "Scrotum inspection: hydrocele, varicocele — differentials of inguinoscrotal swelling. "
     "Opposite inguinal region: bulge on coughing = bilateral hernia.")

# ════════════════════════════════════════════════════════════
# 8. LOCAL EXAMINATION — PALPATION
# ════════════════════════════════════════════════════════════
section("8. LOCAL EXAMINATION — PALPATION (Significance)")

item("Warmth and Tenderness",
     "Warmth + tenderness = INFLAMMATION or STRANGULATION. "
     "Tender, warm, irreducible hernia = strangulation until proven otherwise — changes management to EMERGENCY surgery.")

item("Consistency",
     "Soft, compressible = omentum or reducible bowel. Firm but resilient = bowel. Hard = calcified lymph node (differential). "
     "Tense, board-hard = strangulation with ischaemia.")

item("Expansile Cough Impulse on Palpation",
     "EXPANSILE (outward) impulse on coughing = communicates with peritoneal cavity = HERNIA confirmed. "
     "TRANSMITTED (non-expansile) impulse = solid swelling nearby (lymph node, lipoma) = NOT hernia. "
     "NO cough impulse = strangulation.",
     "Expansile vs transmitted cough impulse is a fundamental skill tested in every surgery exam.")

item("Reducibility",
     "REDUCIBLE: Content returns to peritoneal cavity easily — elective surgery. "
     "IRREDUCIBLE (Incarcerated): Cannot be reduced — risk of obstruction/strangulation. "
     "Gentle taxis acceptable if no strangulation signs. NEVER forceful taxis in strangulation.")

item("'Get Above the Swelling' — THE MOST IMPORTANT TEST",
     "CAN get above the swelling (fingers between swelling and inguinal ligament) = swelling arises BELOW inguinal ligament = SCROTAL swelling (hydrocele, varicocele). "
     "CANNOT get above the swelling = extends above inguinal ligament = INGUINAL HERNIA. "
     "Single most important test to differentiate inguinal hernia from scrotal swelling.",
     "'Cannot get above the swelling' = inguinal hernia into scrotum. THE most-tested clinical sign in surgery exams.")

item("Cord Structures Palpable",
     "Indirect hernia: cord is POSTERIOR and LATERAL to sac. "
     "Direct hernia: cord is MEDIAL to sac. "
     "Absent vas deferens: congenital bilateral absence (associated with cystic fibrosis).")

item("Epididymis Palpable",
     "Confirms epididymis in normal position (posterior to testis) — differentiates hernia from hydrocele. "
     "If not separately palpable, swelling may be of epididymal origin.")

item("External Genitalia (Scrotum, Testis, Bulbar Urethra, Penis)",
     [
         "Scrotum: Oedema with irreducible hernia compressing lymphatics.",
         "Testis: Normal position confirms swelling separate from testis — differentiates from testicular tumour/torsion.",
         "Undescended testis: Absent ipsilateral testis in scrotum — swelling may BE the testis.",
         "Bulbar Urethra: Urethral stricture causes straining on micturition, raising IAP, precipitating hernia.",
         "Penis: Hypospadias/epispadias may co-exist with inguinal hernia (patent processus vaginalis)."
     ])

item("Deep Ring Occlusion Test",
     "Reduce hernia. Occlude deep inguinal ring (1.25 cm above midpoint of inguinal ligament). Ask patient to stand and cough. "
     "SWELLING APPEARS = DIRECT hernia (comes through posterior wall, not deep ring). "
     "SWELLING DOES NOT APPEAR = INDIRECT hernia (deep ring occlusion prevents descent). "
     "SIGNIFICANCE: Accurately classifies direct vs indirect hernia — determines operative technique.",
     "The MOST IMPORTANT test to clinically differentiate direct from indirect hernia.")

item("Three-Finger Test (Zieman's Test)",
     "Index finger = deep ring = INDIRECT hernia impulse. "
     "Middle finger = Hesselbach's triangle / superficial ring = DIRECT hernia impulse. "
     "Ring finger = femoral ring = FEMORAL hernia impulse. "
     "SIGNIFICANCE: Single manoeuvre to identify all three hernia types simultaneously.")

item("Finger Invagination Test",
     "Invaginate scrotal skin upward with little finger into inguinal canal through superficial ring. Ask patient to cough. "
     "IMPULSE AT TIP = INDIRECT hernia (strikes fingertip as it comes through deep ring). "
     "IMPULSE AT PULP = DIRECT hernia (bulges forward through posterior wall, hits pulp).")

item("Lymph Nodes Palpable",
     "Enlarged, firm, matted nodes = DIFFERENTIAL DIAGNOSIS (TB lymphadenitis, metastatic nodes, lymphoma). "
     "Node cannot be reduced and has no cough impulse — distinguishes it from hernia. "
     "Also indicates infection in lower limb, perineum, or anal region.")

# ════════════════════════════════════════════════════════════
# 9. PERCUSSION & AUSCULTATION
# ════════════════════════════════════════════════════════════
section("9. PERCUSSION & AUSCULTATION (Significance)")

item("Percussion — Resonant vs Dull",
     "RESONANT = gas-filled bowel (ENTEROCELE) is the content. "
     "DULL = solid/fluid content — omentum (OMENTOCELE), ovary, bladder (sliding hernia). "
     "Completely dull hernia in a female/infant = possible ovary in sac.")

item("Auscultation — Peristaltic Sounds",
     "BOWEL SOUNDS HEARD = ENTEROCELE (bowel is content). "
     "SILENCE = omentocele OR strangulated bowel (ischaemic bowel has absent peristalsis). "
     "Strangulated hernia with absent bowel sounds = surgical emergency — bowel may already be gangrenous.")

# ════════════════════════════════════════════════════════════
# 10. EXAMINATION OF OPPOSITE INGUINAL REGION
# ════════════════════════════════════════════════════════════
section("10. OPPOSITE INGUINAL REGION & PER RECTAL EXAMINATION")

item("Opposite Side — Swelling / Cough Impulse / Reducibility",
     "Bilateral inguinal hernias occur in 20-25% of patients. Patient may not be aware of contralateral hernia. "
     "SIGNIFICANCE: Both can be repaired simultaneously — saves second operation. "
     "Bilateral hernias more likely in direct type (bilateral posterior wall weakness). "
     "In children, high rate of contralateral patent processus vaginalis.",
     "Never diagnose and operate on only one side without examining the other — a common surgical pitfall.")

item("PR Examination — BPH / Malignancy / Anal Fissure",
     [
         "BPH: Enlarged smooth rubbery prostate. Straining to urinate raises IAP — must treat BPH before hernia repair to prevent recurrence.",
         "Rectal Carcinoma: Hard irregular ulcerated rectal mass. Bowel obstruction from carcinoma raises IAP. Must treat malignancy first.",
         "Fissure in Ano / Chronic Anal Disease: Causes straining at defecation — raises IAP, aggravates hernia.",
         "Overall: Identifies treatable underlying causes of raised IAP — if not treated, hernia repair will fail."
     ],
     "PR exam is MANDATORY in all male patients > 50 years with inguinal hernia — detects BPH and rectal pathology.")

# ════════════════════════════════════════════════════════════
# 11. OTHER SYSTEM EXAMINATION
# ════════════════════════════════════════════════════════════
section("11. OTHER SYSTEM EXAMINATION (Significance)")

item("Abdomen — Malgaigne's Bulging (Head-Rising Test)",
     "Ask patient to lift head and shoulders from supine (contracts rectus abdominis). "
     "MALGAIGNE'S BULGING: Bilateral symmetrical bulging above inguinal ligament = weakness of posterior inguinal wall (transversalis fascia) = confirms DIRECT hernia tendency. "
     "Other findings: organomegaly, ascites, masses — all raise IAP causing secondary hernia.")

item("Respiratory System (NVBS / Added Sounds)",
     "Wheeze, rhonchi = COPD/asthma = chronic cough = major cause of hernia recurrence. "
     "Crepitations = LRTI/pneumonia — contraindicates elective surgery. "
     "Spirometry/PFT may be needed in severe respiratory disease before GA.")

item("CVS (S1 S2, Murmur) / CNS (No Focal Deficit)",
     "Cardiac fitness for anaesthesia; valvular disease may need antibiotic prophylaxis. "
     "CNS: Post-operative nerve injuries (ilioinguinal, iliohypogastric, genitofemoral) are known complications — pre-op neuro exam documents pre-existing deficits.")

# ════════════════════════════════════════════════════════════
# 12. DIAGNOSIS CLASSIFICATION
# ════════════════════════════════════════════════════════════
section("12. FINAL DIAGNOSIS — SIGNIFICANCE OF EACH CLASSIFICATION")

item("Why Classification Matters",
     "Every axis of the final diagnosis directly determines the URGENCY and TYPE of operation. "
     "Getting the classification wrong leads to wrong surgery, complications, or missed emergencies.")

# ════════════════════════════════════════════════════════════
# 13. CLASSIFICATION TABLE
# ════════════════════════════════════════════════════════════
section("13. DIAGNOSIS CLASSIFICATION TABLE")

# 3-col table: 4cm + 4cm + 10cm = 18cm
diag_data = [
    ["Classification Axis", "Options", "Clinical Significance"],
    ["Side",
     "Right / Left / Bilateral",
     "Bilateral hernias need simultaneous or staged repair; bilateral more common with direct type"],
    ["Aetiology",
     "Congenital / Acquired",
     "Congenital = patent processus vaginalis (indirect); Acquired = muscle/fascial weakness (direct or indirect)"],
    ["Type",
     "Direct / Indirect",
     "Determines anatomical plane of surgery; mesh placement differs; indirect has higher strangulation risk"],
    ["Reducibility",
     "Reducible / Irreducible",
     "Reducible = elective surgery; Irreducible = urgent/emergency depending on strangulation features"],
    ["Region",
     "Inguinal / Femoral",
     "Femoral hernias have higher strangulation rate (narrow neck); completely different operative approach"],
    ["Completeness",
     "Complete / Incomplete",
     "Complete = hernia in scrotum/labia; Incomplete = within inguinal canal; guides extent of dissection"],
    ["Complications",
     "Complicated / Uncomplicated",
     "Strangulation/obstruction = emergency; uncomplicated = elective; urgency and anaesthetic risk differ markedly"],
    ["Content",
     "Enterocele / Omentocele",
     "Enterocele: bowel present — strangulation leads to gangrene, bowel resection may be needed; Omentocele: lower risk"],
]
story.append(make_table(
    diag_data,
    col_widths=[4*cm, 4*cm, 10*cm],
    hdr_bg=colors.HexColor('#1b5e20'),
    row_colors=[colors.HexColor('#e8f5e9'), colors.white]
))
story.append(Spacer(1, 0.4*cm))

# ════════════════════════════════════════════════════════════
# 14. DIFFERENTIAL DIAGNOSES
# ════════════════════════════════════════════════════════════
section("14. DIFFERENTIAL DIAGNOSES — HOW TO DIFFERENTIATE")

subsection("A. Differential Diagnoses for Groin Swelling")

# 2-col table: 4.5cm + 13.5cm = 18cm
dd_data = [
    ["Diagnosis", "Key Distinguishing Features"],
    ["Femoral Hernia",
     "Below and LATERAL to pubic tubercle; mostly in women; higher strangulation risk (narrow neck); usually no cough impulse"],
    ["Enlarged Inguinal Lymph Nodes",
     "Multiple firm/matted nodes; no cough impulse; no reducibility; may have primary infection in leg/perineum; percussion dull"],
    ["Saphena Varix",
     "Soft, compressible, brilliant blue; fills on standing; disappears on lying; cough impulse (soft thrill); associated with saphenofemoral incompetence"],
    ["Femoral Aneurysm",
     "Pulsatile, EXPANSILE swelling in femoral triangle; bruit on auscultation; DO NOT attempt taxis or reduction"],
    ["Lipoma of the Cord",
     "Soft, lobulated, non-reducible; no cough impulse; no transillumination; confirmed on USG"],
    ["Encysted Hydrocele of Cord",
     "Transilluminates brilliantly; smooth; CAN get above swelling; no cough impulse; moves upward with traction on testis"],
    ["Undescended / Ectopic Testis",
     "Absent ipsilateral testis in scrotum; swelling corresponds to testicular size; testicular sensation on pressure"],
    ["Psoas Abscess",
     "Fluctuant, cross-fluctuance at iliac fossa and groin; signs of TB (fever, night sweats, weight loss); lumbar spine tenderness; MRI confirms"],
    ["Malgaigne's Bulge",
     "Bilateral; not a true hernia; appears on straining; no sac; indicates weakness of posterior inguinal wall; seen on head-rising test"],
]
story.append(make_table(
    dd_data,
    col_widths=[4.5*cm, 13.5*cm],
    hdr_bg=colors.HexColor('#2e7d32'),
    row_colors=[colors.HexColor('#f1f8e9'), colors.white]
))
story.append(Spacer(1, 0.4*cm))

subsection("B. Differential Diagnoses for Inguino-Scrotal Swelling")

dd2_data = [
    ["Diagnosis", "Key Features"],
    ["Congenital Hydrocele",
     "Cannot get above swelling; transilluminates brilliantly; separate testis palpable at bottom; no cough impulse; neck reaches inguinal canal"],
    ["Infantile Hydrocele",
     "Sac extends to deep ring; no cough impulse; transilluminates; separate testis palpable below"],
    ["Encysted Hydrocele of Cord",
     "CAN get above swelling; moves up with cord traction on testis; transilluminates; no cough impulse"],
    ["Lipoma of the Cord",
     "Soft, lobulated; no transillumination; can get above in some cases; no cough impulse"],
    ["Varicocele",
     "Bag of worms feel; left-sided in 90%; disappears on lying; dilated veins; associated with male infertility"],
    ["Funiculitis",
     "Tender, thickened cord; fever; associated epididymo-orchitis; no discrete swelling"],
    ["Lymph Varix (Chylous)",
     "Translucent; associated elephantiasis/filariasis; aspirate shows milky chylous fluid"],
]
story.append(make_table(
    dd2_data,
    col_widths=[4.5*cm, 13.5*cm],
    hdr_bg=colors.HexColor('#1565c0'),
    row_colors=[colors.HexColor('#e3f2fd'), colors.white]
))
story.append(Spacer(1, 0.4*cm))

# ════════════════════════════════════════════════════════════
# 15. INVESTIGATIONS
# ════════════════════════════════════════════════════════════
section("15. INVESTIGATIONS — SIGNIFICANCE OF EACH")

subsection("Baseline Investigations")

# 2-col: 5cm + 13cm = 18cm
inv_data = [
    ["Investigation", "Significance in Inguinal Hernia"],
    ["Haemoglobin",
     "Pre-operative Hb must be > 10 g/dL. Anaemia from malignancy, chronic disease — must be corrected before elective surgery"],
    ["Total Count / DC",
     "Leucocytosis = active infection or strangulation with sepsis — contraindicates elective surgery; mandates emergency surgery"],
    ["ESR",
     "Elevated in infection (TB lymphadenitis differential), malignancy, and systemic inflammation"],
    ["Platelet Count",
     "Thrombocytopenia = bleeding risk during mesh repair; thrombocytosis = DVT risk post-operatively"],
    ["Random Blood Sugar",
     "DM = impaired wound healing, mesh infection risk; must achieve glycaemic control pre-op (HbA1c < 7%)"],
    ["Serum Urea / Creatinine",
     "Renal function assessment: drug dosing, IV fluid management, contrast safety for CT scan"],
    ["Urine Routine (Albumin, Sugar, Deposits)",
     "Albuminuria = renal/hepatic disease; glycosuria = DM; pyuria = UTI (can worsen BPH symptoms)"],
    ["Bleeding Time / Clotting Time",
     "Coagulation screening; abnormal in liver disease (coagulation factor deficiency) — high-risk surgery"],
    ["Blood Grouping / Typing",
     "Pre-operative blood availability in case of emergency bowel resection during strangulation surgery"],
    ["HIV-1/HIV-2, VDRL, HBsAg, Anti-HCV",
     "Pre-operative infectious screening — protects surgical team; HIV impairs wound healing and increases mesh infection risk"],
    ["ECG All Leads",
     "Cardiac fitness for anaesthesia; identifies arrhythmias, ischaemic changes — affects anaesthetic choice and monitoring"],
    ["CXR PA View",
     "Detects COPD, cardiomegaly, pleural effusion; evidence of pulmonary TB (miliary pattern, hilar lymphadenopathy)"],
]
story.append(make_table(
    inv_data,
    col_widths=[5*cm, 13*cm],
    hdr_bg=colors.HexColor('#37474f'),
    row_colors=[colors.HexColor('#eceff1'), colors.white]
))
story.append(Spacer(1, 0.4*cm))

subsection("Specific Investigations (Only if Examiner Asks)")

spec_data = [
    ["Investigation", "Indication & Significance"],
    ["USG Abdomen/Pelvis\n(elderly with LUTS)",
     "Prostate size, post-voidal residual urine (PVR) — guides BPH treatment before hernia repair. Also detects abdominal/pelvic masses causing secondary hernia"],
    ["CT Abdomen/Pelvis",
     "Obstructed or strangulated hernia — assesses bowel viability, extent of necrosis, guides open vs laparoscopic approach. Large incisional hernia — maps defect for mesh planning"],
    ["MRI",
     "Sportsman's hernia (athletic pubalgia) — INVESTIGATION OF CHOICE. Shows posterior wall weakness, nerve entrapment, adductor pathology"],
    ["Herniogram",
     "Occult hernia (groin pain, no visible hernia) — INVESTIGATION OF CHOICE. Contrast injected into peritoneal cavity outlines occult sac"],
    ["Pulmonary Function Tests (PFT)",
     "Severe COPD/restrictive lung disease with hernia — assesses respiratory reserve, guides anaesthetic management (spinal vs general), pre-operative optimisation"],
    ["PSA (Prostate Specific Antigen)",
     "Elderly male with LUTS + inguinal hernia — screens for prostate carcinoma (hard irregular prostate on PR). Must not repair hernia before excluding/treating malignancy"],
]
story.append(make_table(
    spec_data,
    col_widths=[5*cm, 13*cm],
    hdr_bg=colors.HexColor('#b71c1c'),
    row_colors=[colors.HexColor('#ffebee'), colors.white]
))
story.append(Spacer(1, 0.4*cm))

# ════════════════════════════════════════════════════════════
# 16. TREATMENT
# ════════════════════════════════════════════════════════════
section("16. TREATMENT — SIGNIFICANCE OF EACH OPERATIVE STEP")

# 3-col: 3.5cm + 4cm + 10.5cm = 18cm
treat_data = [
    ["Operation", "Indication", "Key Steps & Significance"],
    ["Herniotomy",
     "Congenital hernia (children)",
     "Identification of sac → Separation of sac from cord → Opening fundus → Reducing contents → Transfixion and ligation at deep ring → Excise excess sac. No posterior wall repair needed — wall is intact in children"],
    ["Herniorraphy",
     "Young adults (now rarely performed; replaced by hernioplasty)",
     "All steps of herniotomy + Anatomical tissue repair of posterior wall (Shouldice, Bassini). Uses patient's own tissue — higher tension, higher recurrence (10-15%) compared to mesh repair"],
    ["Hernioplasty\n(GOLD STANDARD)",
     "Both direct and indirect hernia in adults",
     "All steps of herniotomy + Reinforcement of posterior wall with SYNTHETIC MESH (polypropylene). Tension-free repair — dramatically reduces recurrence rate to < 1%. Lichtenstein open or laparoscopic (TEP/TAPP)"],
]
story.append(make_table(
    treat_data,
    col_widths=[3.5*cm, 4*cm, 10.5*cm],
    hdr_bg=colors.HexColor('#1b5e20'),
    row_colors=[colors.HexColor('#e8f5e9'), colors.white]
))
story.append(Spacer(1, 0.5*cm))

# ── FOOTER ──────────────────────────────────────────────────
story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1b5e20')))
story.append(Spacer(1, 0.15*cm))
story.append(Paragraph(
    "References: Das S. — A Manual of Clinical Surgery (Latest Edition) | "
    "Rajamahendran — Surgical Principles for Clinical Examination | "
    "Bailey &amp; Love's Short Practice of Surgery | Skandalakis' Surgical Anatomy",
    ParagraphStyle('footer', parent=styles['Normal'], fontSize=7.5,
                   textColor=colors.HexColor('#546e7a'),
                   alignment=TA_CENTER, fontName='Helvetica-Oblique')))

doc.build(story)
print("PDF created successfully.")

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

# ── PAGE SETUP ──────────────────────────────────────────────
# A4 = 21cm. Margins 1.5cm each side → usable = 18cm
LEFT_MARGIN = RIGHT_MARGIN = 1.5 * cm
TOP_MARGIN = BOTTOM_MARGIN = 2.0 * cm
USABLE_W = 21 * cm - LEFT_MARGIN - RIGHT_MARGIN  # exactly 18 cm

doc = SimpleDocTemplate(
    "/tmp/workspace/varicose-veins-pdf/Varicose_Veins_Significance.pdf",
    pagesize=A4,
    rightMargin=RIGHT_MARGIN, leftMargin=LEFT_MARGIN,
    topMargin=TOP_MARGIN, bottomMargin=BOTTOM_MARGIN,
)

styles = getSampleStyleSheet()

# ── PARAGRAPH STYLES ───────────────────────────────────────
TITLE_ST = ParagraphStyle('TITLE_ST', parent=styles['Title'],
    fontSize=20, textColor=colors.HexColor('#1a237e'),
    spaceAfter=4, alignment=TA_CENTER, fontName='Helvetica-Bold')

SUBTITLE_ST = ParagraphStyle('SUBTITLE_ST', parent=styles['Normal'],
    fontSize=10, textColor=colors.HexColor('#37474f'),
    spaceAfter=8, alignment=TA_CENTER, fontName='Helvetica-Oblique')

SEC_HDR = ParagraphStyle('SEC_HDR', parent=styles['Normal'],
    fontSize=12, textColor=colors.white,
    spaceAfter=3, spaceBefore=8,
    fontName='Helvetica-Bold',
    backColor=colors.HexColor('#1a237e'),
    borderPadding=(5, 8, 5, 8))

SUBSEC_HDR = ParagraphStyle('SUBSEC_HDR', parent=styles['Normal'],
    fontSize=10.5, textColor=colors.HexColor('#1a237e'),
    spaceAfter=3, spaceBefore=6, fontName='Helvetica-Bold')

ITEM_HDR = ParagraphStyle('ITEM_HDR', parent=styles['Normal'],
    fontSize=10.5, textColor=colors.HexColor('#b71c1c'),
    spaceAfter=2, spaceBefore=5, fontName='Helvetica-Bold')

BODY_ST = ParagraphStyle('BODY_ST', parent=styles['Normal'],
    fontSize=9, textColor=colors.HexColor('#212121'),
    spaceAfter=3, leading=13,
    fontName='Helvetica', alignment=TA_JUSTIFY, leftIndent=8)

NOTE_ST = ParagraphStyle('NOTE_ST', parent=styles['Normal'],
    fontSize=8.5, textColor=colors.HexColor('#4a148c'),
    spaceAfter=3, fontName='Helvetica-Oblique', leftIndent=8)

BULLET_ST = ParagraphStyle('BULLET_ST', parent=styles['Normal'],
    fontSize=9, textColor=colors.HexColor('#212121'),
    spaceAfter=2, leading=12,
    fontName='Helvetica', leftIndent=18, bulletIndent=6)

# ── TABLE CELL STYLES ──────────────────────────────────────
THDR = ParagraphStyle('THDR',
    fontSize=8, textColor=colors.white,
    fontName='Helvetica-Bold', leading=10,
    spaceAfter=0, spaceBefore=0)

TCELL = ParagraphStyle('TCELL',
    fontSize=8, textColor=colors.HexColor('#111111'),
    fontName='Helvetica', leading=10,
    spaceAfter=0, spaceBefore=0, alignment=TA_LEFT)

TCELL_B = ParagraphStyle('TCELL_B',
    fontSize=8, textColor=colors.HexColor('#111111'),
    fontName='Helvetica-Bold', leading=10,
    spaceAfter=0, spaceBefore=0)


def make_table(data, col_widths, hdr_bg=colors.HexColor('#1a237e'),
               row_colors=None, pad=4):
    """Wrap every cell in a Paragraph so text wraps correctly inside cells."""
    assert abs(sum(col_widths) - USABLE_W) < 2, \
        f"col_widths {sum(col_widths):.1f} != USABLE_W {USABLE_W:.1f}"
    if row_colors is None:
        row_colors = [colors.HexColor('#e8eaf6'), colors.white]

    wrapped = []
    for r, row in enumerate(data):
        new_row = []
        for c, cell in enumerate(row):
            if r == 0:
                new_row.append(Paragraph(str(cell), THDR))
            elif c == 0:
                new_row.append(Paragraph(str(cell), TCELL_B))
            else:
                new_row.append(Paragraph(str(cell), TCELL))
        wrapped.append(new_row)

    tbl = Table(wrapped, colWidths=col_widths, repeatRows=1, splitByRow=1)
    cmd = [
        ('BACKGROUND',   (0, 0), (-1,  0), hdr_bg),
        ('TEXTCOLOR',    (0, 0), (-1,  0), colors.white),
        ('GRID',         (0, 0), (-1, -1), 0.4, colors.HexColor('#bdbdbd')),
        ('VALIGN',       (0, 0), (-1, -1), 'TOP'),
        ('TOPPADDING',   (0, 0), (-1, -1), pad),
        ('BOTTOMPADDING',(0, 0), (-1, -1), pad),
        ('LEFTPADDING',  (0, 0), (-1, -1), pad),
        ('RIGHTPADDING', (0, 0), (-1, -1), pad),
    ]
    for i in range(1, len(data)):
        cmd.append(('BACKGROUND', (0, i), (-1, i), row_colors[i % len(row_colors)]))
    tbl.setStyle(TableStyle(cmd))
    return tbl


# ── HELPERS ───────────────────────────────────────────────
story = []

def section(title):
    story.append(Spacer(1, 0.2 * cm))
    story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1a237e')))
    story.append(Paragraph(f"  {title}", SEC_HDR))
    story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1a237e')))
    story.append(Spacer(1, 0.12 * cm))

def subsection(title):
    story.append(Paragraph(title, SUBSEC_HDR))

def item(title, body, note=None):
    story.append(Paragraph(f"&#9654; {title}", ITEM_HDR))
    if isinstance(body, list):
        for b in body:
            story.append(Paragraph(f"• {b}", BULLET_ST))
    else:
        story.append(Paragraph(body, BODY_ST))
    if note:
        story.append(Paragraph(f"Examiner's Note: {note}", NOTE_ST))
    story.append(Spacer(1, 0.06 * cm))


# ════════════════════════════════════════════════════════════
# TITLE
# ════════════════════════════════════════════════════════════
story.append(Spacer(1, 1.0 * cm))
story.append(Paragraph("VARICOSE VEINS", TITLE_ST))
story.append(Paragraph("Long Case History &amp; Examination", TITLE_ST))
story.append(Spacer(1, 0.2 * cm))
story.append(HRFlowable(width="100%", thickness=3, color=colors.HexColor('#1a237e')))
story.append(Spacer(1, 0.12 * cm))
story.append(Paragraph("Significance of Every History and Examination Finding", SUBTITLE_ST))
story.append(Paragraph("According to Das's Manual of Clinical Surgery &amp; Rajamahendran's Surgical Principles", SUBTITLE_ST))
story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor('#90a4ae')))
story.append(Spacer(1, 1.2 * cm))

# ════════════════════════════════════════════════════════════
# 1. CHIEF COMPLAINTS
# ════════════════════════════════════════════════════════════
section("1. CHIEF COMPLAINTS — WHY ASKED & SIGNIFICANCE")

item("Multiple Swellings / Dilated Tortuous Veins in the Lower Limb",
     "The primary presenting feature of varicose veins. Tortuous, dilated, elongated superficial veins result from incompetent valves in the great saphenous vein (GSV), small saphenous vein (SSV), or their tributaries. "
     "Asking the duration establishes chronicity. Varicosities starting below the knee and progressing upward suggest perforator incompetence. "
     "Medial aspect = GSV system; lateral/posterior = SSV system. Guides surgical planning (stripping, phlebectomy, or endovenous ablation).",
     "Always note which system is involved — GSV vs SSV — as treatment differs.")

item("Ulcer in the Lower Limb",
     "Venous ulcers develop due to chronic venous hypertension → lipodermatosclerosis → skin breakdown → non-healing wounds. "
     "Classically in the 'gaiter area' (lower third of leg, above medial malleolus). "
     "Upgrades severity to CEAP C6 (active ulcer) or C5 (healed ulcer). Duration predicts healing potential and need for surgical intervention.",
     "Venous ulcers: painless/mildly painful, sloping edges, granulation floor, surrounded by pigmented eczematous skin.")

item("Pain in the Lower Limb",
     "Dull aching/heaviness/bursting sensation — worse after prolonged standing, relieved by elevation. "
     "Due to venous hypertension causing tissue hypoxia and inflammatory mediator accumulation. "
     "Sudden severe pain = superficial thrombophlebitis. Bursting pain on walking = deep vein obstruction (Perthes positive). Night cramps = deep venous involvement.",
     "Pain NOT relieved by elevation → suspect arterial component or DVT — this changes management.")

# ════════════════════════════════════════════════════════════
# 2. HISTORY OF PRESENTING ILLNESS
# ════════════════════════════════════════════════════════════
section("2. HISTORY OF PRESENTING ILLNESS — SIGNIFICANCE OF EACH H/O")

item("H/O Ulcer",
     "Establishes CEAP C6 (active ulcer) or C5 (healed ulcer). Indicates severe long-standing CVI. "
     "Determines need for wound care, compression therapy, and definitive surgery after ulcer healing.")

item("H/O Discharge",
     "Purulent discharge = secondary bacterial infection — needs culture/sensitivity and antibiotics before surgery. "
     "Serous discharge = active venous hypertension — typical of venous ulcer.")

item("H/O Pain — Character",
     "Dull aching = venous hypertension. Burning = superficial thrombophlebitis. "
     "Bursting on walking = deep vein obstruction (Perthes positive). Nocturnal cramps = deep vein involvement.")

item("H/O Trauma",
     "Trauma to superficial varicosities can cause profuse external haemorrhage (a complication). "
     "Previous limb trauma may have caused DVT → post-thrombotic syndrome → secondary varicose veins. "
     "Important distinction from primary varicose veins.")

item("H/O Itching",
     "Suggests varicose eczema (stasis dermatitis) — CEAP C4a. Caused by chronic venous hypertension and extravasation of RBCs and plasma proteins. "
     "Indicates significant CVI requiring treatment.")

item("H/O Bleeding",
     "Spontaneous or post-traumatic bleeding from varicosities is a recognised complication. "
     "Even minor trauma can rupture thin-walled sub-dermal veins causing profuse painless bleeding. "
     "Immediate treatment: elevation + direct pressure. Surgical ligation is definitive.")

item("H/O Prolonged Standing",
     "THE MOST IMPORTANT predisposing factor. Prolonged standing increases hydrostatic venous pressure, accelerating valve incompetence. "
     "At-risk occupations: teachers, surgeons, barbers, soldiers, cooks. "
     "Confirms aetiology and correlates with primary varicose veins.")

item("H/O Discoloration of the Limb",
     "Brownish-black pigmentation in gaiter area = haemosiderin deposition (RBC breakdown extravasation). "
     "CEAP C4b — long-standing severe CVI. Suggests need for definitive surgical intervention.")

item("H/O Difficulty in Walking / Standing",
     "Suggests severe venous hypertension, deep vein obstruction, or advanced lipodermatosclerosis. "
     "Venous claudication (difficulty on walking specifically) = cardinal sign of deep vein obstruction → Perthes test must be done carefully before surgery.")

item("H/O Deformity of the Limb",
     "Pre-existing deformity (post-fracture) may have caused DVT → secondary varicose veins. "
     "Limb hypertrophy + varicose veins + port-wine stain = Klippel-Trenaunay syndrome (KTS) — surgery contraindicated.")

item("H/O Abdominal Pain / Distension / Constipation",
     "Suggest intra-abdominal pathology — pelvic/abdominal tumours, ascites, or portal hypertension causing secondary IVC/iliac vein obstruction → secondary varicose veins. "
     "Treating varicosities alone without addressing the underlying cause = recurrence. "
     "Abdomen must be examined for organomegaly, masses, and ascites.",
     "If secondary cause found, treating varicosities alone leads to immediate recurrence.")

item("H/O Fever",
     "Suggests superficial thrombophlebitis (localised) or cellulitis around ulcer. "
     "High fever with rigors = DVT with systemic sepsis. "
     "Fever contraindicates elective surgery — treat with antibiotics and NSAIDs first.")

item("H/O Bursting Type of Pain in the Lower Limb",
     "Classic symptom of deep vein obstruction / post-thrombotic syndrome. "
     "In Perthes test, bursting pain on exercise = deep veins obstructed → surgical stripping CONTRAINDICATED (superficial veins acting as collaterals).")

item("H/O Swelling of the Limb",
     "Pitting oedema = CVI causing fluid transudation, or deep vein obstruction. "
     "Brawny non-pitting oedema = lymphoedema as comorbidity. "
     "Oedema worsening on standing and improving with elevation confirms venous origin.")

item("H/O Chest Pain / Breathlessness / Palpitation",
     "Rule out pulmonary embolism (PE) as a complication — thrombus from deep veins embolises to pulmonary circulation. "
     "Also screens for cardiac disease affecting anaesthetic fitness and surgical risk.")

item("H/O Haemoptysis",
     "Blood-stained sputum in a patient with DVT/varicose veins = pulmonary infarction from PE. "
     "Constitutes a surgical emergency — affects pre-operative workup and timing of intervention.")

# ════════════════════════════════════════════════════════════
# 3. PAST HISTORY
# ════════════════════════════════════════════════════════════
section("3. PAST HISTORY — SIGNIFICANCE")

item("H/O Similar Episodes in the Past",
     "Recurrent varicose veins suggest inadequate previous treatment, missed perforators, or secondary aetiology. "
     "Guides surgical planning to be more comprehensive; investigate for underlying cause.")

item("H/O DM / SHT / Asthma / Epilepsy / Heart Disease / Kidney Disease / Allergy",
     [
         "DM: Impairs wound healing, increases infection risk; glycaemic control mandatory pre-op.",
         "Hypertension: Affects anaesthetic management; antihypertensives continued peri-operatively.",
         "Asthma / COPD: Affects respiratory fitness for GA; may prefer spinal anaesthesia.",
         "Epilepsy: Drug interactions with anaesthetic agents; continue anti-epileptics.",
         "Heart Disease: Cardiac evaluation needed; affects risk stratification.",
         "Kidney Disease: Affects drug metabolism, fluid management, contrast use in venography.",
         "Allergy: Prevents anaphylaxis to anaesthetic drugs, latex, contrast dyes."
     ])

item("H/O Previous Surgery in the Lower Limb",
     "Previous vascular surgery/saphenous stripping causes scar tissue altering anatomy, making re-do surgery complex. "
     "Previous orthopaedic surgery may have caused DVT → secondary varicose veins.")

item("H/O Chronic Drug Intake",
     [
         "Oral Contraceptive Pills (OCPs): Major DVT risk factor; hypercoagulable state — secondary varicose veins.",
         "Anticoagulants (Warfarin, DOACs): Must be stopped/bridged pre-operatively.",
         "Steroids: Impair wound healing; need peri-operative cover.",
         "NSAIDs: Affect platelet function; stop 7 days before surgery.",
         "Oestrogen therapy: Increases DVT risk in post-menopausal women."
     ])

item("H/O Previous Immobilisation",
     "Prolonged immobilisation (bed rest, plaster cast, long-distance travel) is a major DVT precipitant → post-thrombotic syndrome → secondary varicose veins. "
     "Directs further investigation with Doppler duplex.")

# ════════════════════════════════════════════════════════════
# 4. PERSONAL HISTORY
# ════════════════════════════════════════════════════════════
section("4. PERSONAL HISTORY — SIGNIFICANCE")

item("Diet (Veg / Non-Veg)",
     "Nutritional status affects wound healing and recovery. "
     "Hypoproteinaemia from poor diet worsens oedema and impairs ulcer healing. "
     "Helps plan pre-operative nutritional support.")

item("Smoking",
     "Risk factor for peripheral arterial disease — co-existing PAD changes management of venous ulcer. "
     "Compression therapy relatively contraindicated if ABI < 0.8. "
     "Increases post-operative pulmonary complications and wound infections.")

item("Alcohol",
     "Chronic alcoholism causes liver disease + portal hypertension — secondary varicose veins via increased caval/portal pressure. "
     "Affects drug metabolism, anaesthetic risk, and coagulation.")

item("Bowel / Bladder Habits",
     "Chronic constipation causes straining (increased IAP) → impedes venous return → worsens varicose veins. "
     "Must exclude rectal tumour or pelvic mass as secondary cause.")

# ════════════════════════════════════════════════════════════
# 5. FAMILY HISTORY
# ════════════════════════════════════════════════════════════
section("5. FAMILY HISTORY — SIGNIFICANCE")

item("H/O Similar Illness in Family",
     "Varicose veins have a strong hereditary component — autosomal dominant with incomplete penetrance. "
     "Deficiency or weakness of venous wall and valve cusps is inherited. "
     "Positive family history confirms primary varicose veins. "
     "Family history of DVT or thrombophilia (Factor V Leiden, Protein C/S deficiency) increases operative risk.",
     "If both parents had varicose veins, risk in offspring is ~90% (Das).")

# ════════════════════════════════════════════════════════════
# 6. MENSTRUAL & OBSTETRIC HISTORY
# ════════════════════════════════════════════════════════════
section("6. MENSTRUAL & OBSTETRIC HISTORY — SIGNIFICANCE")

item("Age at Menarche / Regularity / Cycle Length",
     "Female sex hormones (oestrogen and progesterone) cause venous wall relaxation and valve incompetence. "
     "Worsening of varicosities during menstruation confirms hormonal aetiology. "
     "Irregular cycles/PCOD indicates hormonal imbalance contributing to varicosities.")

item("Association with Pain / Age at Menopause / LMP",
     "Dysmenorrhoea with pelvic pathology (endometriosis, fibroids) can cause pelvic vein obstruction → secondary varicose veins. "
     "Post-menopausal women on HRT: increased DVT risk. "
     "LMP needed to rule out pregnancy — gravid uterus compresses iliac veins; surgery contraindicated in pregnancy.")

item("Obstetric History — Multiparity",
     "MULTIPARITY is one of the most important aetiological factors in women. "
     "Gravid uterus compresses iliac veins and IVC → raises venous pressure in lower limbs. "
     "Progesterone causes smooth muscle relaxation of vein walls. "
     "Varicosities worsen with each successive pregnancy.",
     "Varicose veins first appearing in pregnancy and not resolving after delivery indicate permanent valve damage.")

# ════════════════════════════════════════════════════════════
# 7. GENERAL EXAMINATION
# ════════════════════════════════════════════════════════════
section("7. GENERAL EXAMINATION — SIGNIFICANCE")

item("Consciousness / Orientation",
     "Baseline neurological status. Altered sensorium = hepatic encephalopathy (portal hypertension causing secondary varicose veins) or severe sepsis from infected ulcer.")

item("Pallor",
     "Anaemia from chronic blood loss (bleeding varicosity), ulcer exudate protein loss, or nutritional deficiency. "
     "Must correct to Hb > 10 g/dL before elective surgery.")

item("Jaundice",
     "Suggests hepatic disease → portal hypertension → secondary varicose veins. "
     "Jaundice also affects drug metabolism and coagulation (decreased clotting factor synthesis), affecting surgical risk.")

item("Build and Nourishment",
     "Obesity: independent risk factor — increased IAP and excess weight worsens venous hypertension. "
     "Malnutrition: impairs wound healing and immune function.")

item("Clubbing / Cyanosis",
     "Clubbing suggests cardiorespiratory disease or IBD — co-morbidities affecting anaesthetic risk. "
     "Peripheral cyanosis with severe venous stasis. Central cyanosis = cardiopulmonary disease — affects surgical fitness and PE risk.")

item("Pedal Oedema",
     "Bilateral = systemic cause (cardiac failure, hypoproteinaemia, renal disease). "
     "Unilateral = CVI or DVT. Determines CEAP classification and management plan.")

item("Lymphadenopathy",
     "Inguinal lymphadenopathy = infected varicose ulcer, cellulitis, or malignant melanoma. "
     "Generalised lymphadenopathy = systemic disease.")

item("Vital Signs (PR, BP, RR, Temperature)",
     [
         "Pulse Rate: Tachycardia = infection, anaemia, PE, or DVT.",
         "Blood Pressure: Hypertension affects surgical risk; hypotension may suggest bleeding from ruptured varix.",
         "Respiratory Rate: Elevated in PE or cardiorespiratory disease.",
         "Temperature: Fever = active infection/thrombophlebitis — contraindicates elective surgery."
     ])

# ════════════════════════════════════════════════════════════
# 8. LOCAL EXAMINATION — INSPECTION
# ════════════════════════════════════════════════════════════
section("8. LOCAL EXAMINATION — INSPECTION (Significance)")

item("Position: Standing with Adequate Exposure (Umbilicus to Toes)",
     "Varicose veins BEST SEEN in standing position — venous filling maximal due to hydrostatic pressure. "
     "In supine, veins may collapse and be missed. "
     "Exposure from umbilicus to toes assesses both GSV and SSV systems and looks for abdominal causes.",
     "Always examine in STANDING position first — correct position per Das.")

item("Asymmetry / Attitude / Deformity",
     "Asymmetry in limb size = Klippel-Trenaunay syndrome, lymphoedema, or post-thrombotic syndrome — surgery may be contraindicated. "
     "Fixed deformity from trauma may have caused DVT → secondary varicose veins.")

item("Distribution of Dilated Veins",
     [
         "Medial aspect — from medial malleolus, behind knee, medial thigh: GSV (Long Saphenous) system.",
         "Lateral/posterior aspect — behind lateral malleolus, popliteal fossa: SSV (Short Saphenous) system.",
         "Both systems: More severe disease — assess SFJ AND SPJ."
     ],
     "Accurately identifying GSV vs SSV involvement is critical for choosing the correct operation.")

item("Skin Changes — Pigmentation, Eczema, Lipodermatosclerosis",
     "Brown pigmentation (haemosiderin) = CEAP C4b. "
     "Eczema (stasis dermatitis) = CEAP C4a. "
     "Lipodermatosclerosis (brawny induration, inverted champagne bottle) = fibrosis from chronic inflammation — severe disease.")

item("Ulcer Description (Site, Size, Shape, Margin, Edge, Floor, Discharge, Surroundings)",
     [
         "Site: Gaiter area above medial malleolus = venous. Tip of toes/pressure points = arterial.",
         "Shape: Irregular, shallow = venous. Punched-out = arterial.",
         "Edge: Sloping = healing venous. Undermined = Buruli. Raised/everted = malignant (Marjolin's ulcer).",
         "Floor: Pink granulation = venous. Pale/necrotic = arterial.",
         "Discharge: Serous = venous. Purulent = infected. Malodorous = anaerobic.",
         "Surroundings: Pigmentation, eczema, lipodermatosclerosis confirm venous aetiology."
     ],
     "Any chronic non-healing ulcer must be biopsied from its edge to exclude Marjolin's ulcer (SCC).")

item("Expansile Cough Impulse / Blow-Outs",
     "Expansile cough impulse over a varicosity = direct communication with deep veins through incompetent perforator. "
     "Blow-outs are localised bulges from incompetent perforators — marked pre-operatively for targeted surgery.",
     "Fegan's method: Map blow-outs by inspection while patient stands, then confirm by palpation.")

# ════════════════════════════════════════════════════════════
# 9. LOCAL EXAMINATION — PALPATION
# ════════════════════════════════════════════════════════════
section("9. LOCAL EXAMINATION — PALPATION (Significance)")

item("Warmth",
     "Warmth over varicosities = superficial thrombophlebitis (localised warm, tender, cord-like vein). "
     "Generalised warmth = DVT or severe cellulitis.")

item("Tenderness",
     "Tenderness along varicosity = superficial thrombophlebitis. "
     "Tenderness in calf muscles (Homan's sign) = DVT. "
     "Tenderness around ulcer = secondary infection.")

item("Skin Thickening / Lipodermatosclerosis",
     "Brawny, woody induration in gaiter area = lipodermatosclerosis — CEAP C4b. "
     "Due to chronic inflammatory fibrosis. Predisposes to ulceration. "
     "Must be documented to plan post-operative compression therapy.")

item("Pitting Oedema",
     "Soft pitting oedema = active venous hypertension with plasma transudation. "
     "Worsening on standing, improving with elevation = venous origin. "
     "Brawny non-pitting = co-existing lymphoedema.")

item("Palpation of the Ulcer",
     [
         "Base fixed to bone: suggests osteomyelitis.",
         "Hard indurated base/edge: malignant transformation (Marjolin's ulcer) — biopsy mandatory.",
         "Bleeds on touch: active granulation tissue or hyper-granulation.",
         "Surrounding induration/fixity: raises suspicion of malignancy."
     ])

# ════════════════════════════════════════════════════════════
# 10. SPECIAL TESTS
# ════════════════════════════════════════════════════════════
section("10. SPECIAL TESTS — SIGNIFICANCE OF EACH")

item("Brodie-Trendelenburg Test (Test 1 & 2)",
     [
         "PRINCIPLE: Determines site of incompetence — SFJ, perforators, or both.",
         "METHOD: Empty vein by elevation, apply tourniquet at SFJ, ask patient to stand.",
         "Test 1 (+ve): Tourniquet controls filling → SFJ incompetence. Remove tourniquet: rapid filling = SFJ.",
         "Test 2 (+ve): Filling above the tourniquet despite occlusion = perforator incompetence BELOW it.",
         "Both +ve: SFJ AND perforator incompetence.",
         "SIGNIFICANCE: Determines whether to perform high tie at SFJ (Trendelenburg operation) and where to ligate perforators."
     ],
     "THE MOST IMPORTANT test for surgical planning in varicose veins (Das).")

item("Multiple Tourniquet Test",
     "Extends the Trendelenburg test — multiple tourniquets applied at different levels. "
     "Each segment isolated to identify which segment fills first on standing = level of perforator incompetence. "
     "Maps exact location of incompetent perforators for targeted SEPS or open ligation.")

item("Perthes Test",
     "Assesses DEEP VENOUS SYSTEM PATENCY. Apply tourniquet above knee while standing, ask patient to walk/exercise. "
     "Varicosities DISAPPEAR = deep veins PATENT (blood pumped into patent deep system). "
     "Varicosities INCREASE + BURSTING PAIN = deep veins OBSTRUCTED. "
     "SIGNIFICANCE: If deep veins obstructed → STRIPPING ABSOLUTELY CONTRAINDICATED — superficial veins are the only collateral drainage.",
     "Perthes positive = only compression therapy. NEVER operate on superficial veins in deep vein obstruction.")

item("Modified Perthes Test",
     "Tourniquet applied above malleolus instead of knee. "
     "Assesses patency of deep veins below the knee — more sensitive for distal deep vein obstruction.")

item("Fegan's Test",
     "Maps incompetent PERFORATORS. "
     "Feel along varicose veins for fascial defects (blow-outs) while patient stands. "
     "Mark exact sites for surgical ligation. "
     "Perforators at constant sites: Cockett's (medial leg), Boyd's (below knee), Dodd's (thigh).")

item("Schwartz Test (Percussion / Fluid Thrill)",
     "Demonstrates CONTINUITY of the varicose vein column. "
     "Tap varicosity at one point — feel for impulse transmitted proximally or distally. "
     "Positive = continuous fluid-filled column = confirms varicose vein. "
     "Also locates SFJ by percussing varicosity and feeling impulse at the groin.")

item("Pratt's Test",
     "Identifies incompetent perforators by watching for blow-outs as elastic bandage is applied from foot upward. "
     "Sites where veins bulge between bandages = incompetent perforators. "
     "Pre-operative mapping for SEPS or open ligation.")

item("Morrissey's Cough Impulse Test",
     "Tests for SFJ INCOMPETENCE. Keep finger on SFJ (just below medial to femoral pulse in groin). Ask patient to cough. "
     "POSITIVE: Expansile impulse = SFJ incompetent → confirms need for high tie (Trendelenburg operation). "
     "Negative test = reflux at lower level (perforator or SSV origin).")

item("Homan's Sign",
     "Passive dorsiflexion of foot with knee extended. "
     "POSITIVE: Calf pain = DVT present → surgery contraindicated; treat with anticoagulation first. "
     "Low sensitivity and specificity but remains a useful bedside screening test.")

item("Moses Sign",
     "Squeeze the calf from side to side (mediolateral compression). "
     "POSITIVE: Pain = DVT. Additional test alongside Homan's sign. DVT must be excluded before any surgical intervention.")

item("Limb Measurements",
     "Circumference at fixed landmarks documents degree of oedema, monitors treatment response, and detects subtle inter-limb differences. "
     "Limb length measurement rules out limb length discrepancy (KTS or AV malformations).")

item("Peripheral Pulse Examination",
     "CRITICAL — assesses co-existing peripheral arterial disease (PAD). "
     "Absent pulses = significant arterial insufficiency. "
     "If ABI < 0.8 → compression therapy relatively contraindicated. "
     "Arterial disease may co-exist with venous ulcer (mixed ulcer — changes management).",
     "NEVER apply compression to a limb with absent pulses without measuring ABI first.")

item("Examination of Adjacent Joints (Active & Passive Movements)",
     "Ankle stiffness = common in long-standing CVI due to lipodermatosclerosis. "
     "Reduced ankle ROM impairs calf muscle pump — most important mechanism for venous return from the leg. "
     "Ankle physiotherapy is part of CVI management.")

item("Neurological Examination (Sensation, Motor)",
     "Peripheral neuropathy (especially in diabetics) impairs pain sensation — delayed presentation and complicated wounds. "
     "Motor weakness affects calf muscle pump, worsening venous return.")

item("Auscultation over Varicosities",
     "Auscultation to detect a BRUIT. "
     "Bruit = arteriovenous malformation or fistula (congenital AV fistula causing secondary varicose veins — Parkes-Weber syndrome). "
     "If bruit present, surgery on superficial veins alone will fail.",
     "Frequently asked examiner question: What will you hear on auscultation? Answer: Normally silence; bruit = AV fistula.")

# ════════════════════════════════════════════════════════════
# 11. SYSTEMIC EXAMINATION
# ════════════════════════════════════════════════════════════
section("11. SYSTEMIC EXAMINATION — SIGNIFICANCE")

item("Abdominal Examination (Organomegaly, Masses, Ascites, PR/PV)",
     [
         "Hepatomegaly/Splenomegaly + Ascites: Portal hypertension → raised IVC pressure → secondary varicose veins. Treat underlying cause.",
         "Abdominal/Pelvic Mass: Compresses iliac veins/IVC → secondary varicose veins. Must be treated first.",
         "PR Examination: Rectal carcinoma, fibroids compressing pelvic veins — recognised secondary cause.",
         "PV Examination: Ovarian cysts, uterine fibroids compressing iliac veins → unilateral varicose veins."
     ],
     "ALWAYS examine the abdomen — secondary causes are commonly tested in exams.")

item("CVS (S1, S2, Added Sounds) / RS (NVBS, Added Sounds) / CNS",
     "Cardiac failure = raised venous pressure, worsening oedema and venous hypertension. "
     "Chronic cough from respiratory disease increases IAP, worsening varicosities. "
     "Previous stroke = limb immobility → DVT → secondary varicose veins.")

# ════════════════════════════════════════════════════════════
# 12. DIAGNOSIS — CEAP CLASSIFICATION
# ════════════════════════════════════════════════════════════
section("12. FINAL DIAGNOSIS — CEAP CLASSIFICATION & SIGNIFICANCE")

item("Primary vs Secondary Varicose Veins",
     [
         "PRIMARY: No underlying cause; defective vein wall/valves (hereditary). Treatment = surgery (stripping, high tie, SEPS).",
         "SECONDARY: Caused by DVT (post-thrombotic), AV fistula, pelvic mass, portal hypertension. MUST treat underlying cause first.",
         "Distinguishing them is the entire purpose of history and clinical tests — getting this wrong leads to surgical failure and recurrence."
     ])

# ════════════════════════════════════════════════════════════
# 13. CEAP TABLE
# ════════════════════════════════════════════════════════════
section("13. CEAP CLASSIFICATION TABLE")

# 3-col: 3cm + 5cm + 10cm = 18cm
ceap_data = [
    ["Component", "Stands for", "Clinical Significance"],
    ["C (Clinical)",
     "C0-C6: Severity of clinical signs",
     "C0=No signs; C1=Telangiectasia; C2=Varicose veins; C3=Oedema; C4a=Eczema; C4b=Pigmentation; C5=Healed ulcer; C6=Active ulcer — determines urgency of treatment"],
    ["E (Aetiology)",
     "Primary / Secondary / Congenital",
     "Primary=valve failure; Secondary=post-thrombotic; Congenital=KTS, AV malformation — determines surgical vs conservative approach"],
    ["A (Anatomy)",
     "GSV / SSV / Perforators / Deep",
     "Identifies which venous system is involved — guides surgical approach (stripping vs SEPS vs foam sclerotherapy)"],
    ["P (Pathophysiology)",
     "Reflux / Obstruction / Both",
     "Reflux=can be surgically corrected; Obstruction=surgery contraindicated (superficial veins are collaterals); Both=complex management"],
]
story.append(make_table(
    ceap_data,
    col_widths=[3*cm, 5*cm, 10*cm],
    hdr_bg=colors.HexColor('#1a237e'),
    row_colors=[colors.HexColor('#e8eaf6'), colors.white]
))
story.append(Spacer(1, 0.4 * cm))

# ════════════════════════════════════════════════════════════
# 14. INVESTIGATIONS
# ════════════════════════════════════════════════════════════
section("14. INVESTIGATIONS — SIGNIFICANCE OF EACH")

subsection("Baseline Investigations")

# 2-col: 5cm + 13cm = 18cm
inv_data = [
    ["Investigation", "Significance in Varicose Veins"],
    ["Haemoglobin %",
     "Anaemia from chronic ulcer blood loss or nutritional deficiency. Must be > 10 g/dL before elective surgery"],
    ["Total Count / DC",
     "Leucocytosis = active infection (thrombophlebitis, infected ulcer) — contraindicates elective surgery"],
    ["ESR",
     "Elevated in infection, DVT, malignancy — helps identify systemic complications"],
    ["Platelet Count",
     "Thrombocytopenia affects surgical haemostasis; thrombocytosis increases DVT risk"],
    ["Bleeding Time / Clotting Time",
     "Coagulation screening before surgery; detects coagulopathy in liver disease"],
    ["Blood Grouping / Typing",
     "Pre-operative preparation for blood transfusion in case of emergency"],
    ["Random Blood Sugar",
     "Screening for diabetes — affects wound healing, anaesthetic risk; glycaemic control mandatory pre-op"],
    ["Serum Urea / Creatinine",
     "Renal function for drug metabolism and contrast safety (venography)"],
    ["VCTC / VDRL",
     "Pre-operative HIV screening (VCTC); syphilitic gumma can cause ulcer (VDRL)"],
    ["HBsAg / Anti-HCV",
     "Infectious screening — protects surgical team, affects drug choice"],
    ["Chest X-Ray PA View",
     "Detects cardiomegaly (cardiac failure), COPD, pleural effusion; pre-anaesthetic assessment"],
    ["ECG (All Leads)",
     "Arrhythmias, cardiac disease — fitness for anaesthesia; detects features of PE (S1Q3T3 pattern)"],
    ["Urine Routine (Albumin, Sugar, Deposits)",
     "Albuminuria = renal disease/hypoproteinaemia; glycosuria = diabetes; pyuria = infection"],
]
story.append(make_table(
    inv_data,
    col_widths=[5*cm, 13*cm],
    hdr_bg=colors.HexColor('#37474f'),
    row_colors=[colors.HexColor('#eceff1'), colors.white]
))
story.append(Spacer(1, 0.4 * cm))

subsection("Specific Investigations")

spec_data = [
    ["Investigation", "Significance"],
    ["Doppler Duplex Ultrasound\n(GOLD STANDARD)",
     "Identifies site and extent of venous reflux, perforator incompetence, and deep vein patency. Non-invasive, real-time. Mandatory before any operative intervention"],
    ["USG Abdomen & Pelvis",
     "Rules out secondary causes: pelvic/abdominal masses compressing iliac veins/IVC; portal hypertension; hepatomegaly; ovarian pathology"],
    ["Venous Doppler",
     "Bedside assessment of flow in femoral/popliteal veins; detects DVT; assesses deep vein patency before Perthes test"],
    ["Ascending Venogram",
     "Gold standard for deep vein anatomy; used when Doppler inconclusive or deep vein reconstruction planned. Ask only if examiner requests"],
    ["Descending Venogram",
     "Assesses valve function; used before valve repair surgery. Ask only if examiner requests"],
    ["Plethysmography",
     "Measures calf muscle pump efficiency and venous reflux quantitatively; used in research and complex cases"],
    ["Pus C/S (Ulcer with infection)",
     "Identifies causative organism and antibiotic sensitivity — guides targeted antibiotic therapy before surgery"],
    ["X-Ray Local Part (Ulcer)",
     "Detects osteomyelitis (bone destruction under chronic ulcer) or periosteal reaction — changes surgical management significantly"],
    ["Edge/Wedge Biopsy\n(Suspected Malignancy)",
     "Mandatory to rule out Marjolin's ulcer (SCC arising in chronic venous ulcer). Any indurated, raised, or non-healing ulcer edge must be biopsied"],
]
story.append(make_table(
    spec_data,
    col_widths=[5*cm, 13*cm],
    hdr_bg=colors.HexColor('#b71c1c'),
    row_colors=[colors.HexColor('#ffebee'), colors.white]
))
story.append(Spacer(1, 0.5 * cm))

# ── FOOTER ──────────────────────────────────────────────────
story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#1a237e')))
story.append(Spacer(1, 0.15 * cm))
story.append(Paragraph(
    "References: Das S. — A Manual of Clinical Surgery (Latest Edition) | "
    "Rajamahendran — Surgical Principles for Clinical Examination | "
    "Bailey &amp; Love's Short Practice of Surgery | CEAP Classification (International Union of Phlebology)",
    ParagraphStyle('footer', parent=styles['Normal'], fontSize=7.5,
                   textColor=colors.HexColor('#546e7a'),
                   alignment=TA_CENTER, fontName='Helvetica-Oblique')))

doc.build(story)
print("PDF created successfully.")

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

# ── PAGE SETUP ──────────────────────────────────────────────
LEFT_MARGIN = RIGHT_MARGIN = 1.5 * cm
TOP_MARGIN = BOTTOM_MARGIN = 2.0 * cm
USABLE_W = 21 * cm - LEFT_MARGIN - RIGHT_MARGIN  # exactly 18 cm

doc = SimpleDocTemplate(
    "/tmp/workspace/varicose-veins-pdf/Thyroid_Significance.pdf",
    pagesize=A4,
    rightMargin=RIGHT_MARGIN, leftMargin=LEFT_MARGIN,
    topMargin=TOP_MARGIN, bottomMargin=BOTTOM_MARGIN,
)

styles = getSampleStyleSheet()

TITLE_ST = ParagraphStyle('TITLE_ST', parent=styles['Title'],
    fontSize=20, textColor=colors.HexColor('#4a148c'),
    spaceAfter=4, alignment=TA_CENTER, fontName='Helvetica-Bold')

SUBTITLE_ST = ParagraphStyle('SUBTITLE_ST', parent=styles['Normal'],
    fontSize=10, textColor=colors.HexColor('#37474f'),
    spaceAfter=8, alignment=TA_CENTER, fontName='Helvetica-Oblique')

SEC_HDR = ParagraphStyle('SEC_HDR', parent=styles['Normal'],
    fontSize=12, textColor=colors.white,
    spaceAfter=3, spaceBefore=8,
    fontName='Helvetica-Bold',
    backColor=colors.HexColor('#4a148c'),
    borderPadding=(5, 8, 5, 8))

SUBSEC_HDR = ParagraphStyle('SUBSEC_HDR', parent=styles['Normal'],
    fontSize=10.5, textColor=colors.HexColor('#4a148c'),
    spaceAfter=3, spaceBefore=6, fontName='Helvetica-Bold')

ITEM_HDR = ParagraphStyle('ITEM_HDR', parent=styles['Normal'],
    fontSize=10.5, textColor=colors.HexColor('#b71c1c'),
    spaceAfter=2, spaceBefore=5, fontName='Helvetica-Bold')

BODY_ST = ParagraphStyle('BODY_ST', parent=styles['Normal'],
    fontSize=9, textColor=colors.HexColor('#212121'),
    spaceAfter=3, leading=13,
    fontName='Helvetica', alignment=TA_JUSTIFY, leftIndent=8)

NOTE_ST = ParagraphStyle('NOTE_ST', parent=styles['Normal'],
    fontSize=8.5, textColor=colors.HexColor('#1a237e'),
    spaceAfter=3, fontName='Helvetica-Oblique', leftIndent=8)

BULLET_ST = ParagraphStyle('BULLET_ST', parent=styles['Normal'],
    fontSize=9, textColor=colors.HexColor('#212121'),
    spaceAfter=2, leading=12,
    fontName='Helvetica', leftIndent=18, bulletIndent=6)

THDR = ParagraphStyle('THDR',
    fontSize=8, textColor=colors.white,
    fontName='Helvetica-Bold', leading=10,
    spaceAfter=0, spaceBefore=0)

TCELL = ParagraphStyle('TCELL',
    fontSize=8, textColor=colors.HexColor('#111111'),
    fontName='Helvetica', leading=10,
    spaceAfter=0, spaceBefore=0, alignment=TA_LEFT)

TCELL_B = ParagraphStyle('TCELL_B',
    fontSize=8, textColor=colors.HexColor('#111111'),
    fontName='Helvetica-Bold', leading=10,
    spaceAfter=0, spaceBefore=0)


def make_table(data, col_widths, hdr_bg=colors.HexColor('#4a148c'),
               row_colors=None, pad=4):
    total = sum(col_widths)
    assert abs(total - USABLE_W) < 2, \
        f"col_widths sum {total:.1f} != USABLE_W {USABLE_W:.1f}"
    if row_colors is None:
        row_colors = [colors.HexColor('#f3e5f5'), colors.white]
    wrapped = []
    for r, row in enumerate(data):
        new_row = []
        for c, cell in enumerate(row):
            if r == 0:
                new_row.append(Paragraph(str(cell), THDR))
            elif c == 0:
                new_row.append(Paragraph(str(cell), TCELL_B))
            else:
                new_row.append(Paragraph(str(cell), TCELL))
        wrapped.append(new_row)
    tbl = Table(wrapped, colWidths=col_widths, repeatRows=1, splitByRow=1)
    cmd = [
        ('BACKGROUND',    (0, 0), (-1,  0), hdr_bg),
        ('TEXTCOLOR',     (0, 0), (-1,  0), colors.white),
        ('GRID',          (0, 0), (-1, -1), 0.4, colors.HexColor('#bdbdbd')),
        ('VALIGN',        (0, 0), (-1, -1), 'TOP'),
        ('TOPPADDING',    (0, 0), (-1, -1), pad),
        ('BOTTOMPADDING', (0, 0), (-1, -1), pad),
        ('LEFTPADDING',   (0, 0), (-1, -1), pad),
        ('RIGHTPADDING',  (0, 0), (-1, -1), pad),
    ]
    for i in range(1, len(data)):
        cmd.append(('BACKGROUND', (0, i), (-1, i),
                    row_colors[i % len(row_colors)]))
    tbl.setStyle(TableStyle(cmd))
    return tbl


story = []

def section(title):
    story.append(Spacer(1, 0.2 * cm))
    story.append(HRFlowable(width="100%", thickness=2,
                             color=colors.HexColor('#4a148c')))
    story.append(Paragraph(f"  {title}", SEC_HDR))
    story.append(HRFlowable(width="100%", thickness=2,
                             color=colors.HexColor('#4a148c')))
    story.append(Spacer(1, 0.12 * cm))

def subsection(title):
    story.append(Paragraph(title, SUBSEC_HDR))

def item(title, body, note=None):
    story.append(Paragraph(f"&#9654; {title}", ITEM_HDR))
    if isinstance(body, list):
        for b in body:
            story.append(Paragraph(f"• {b}", BULLET_ST))
    else:
        story.append(Paragraph(body, BODY_ST))
    if note:
        story.append(Paragraph(f"Examiner's Note: {note}", NOTE_ST))
    story.append(Spacer(1, 0.06 * cm))


# ══════════════════════════════════════════════════════
# TITLE
# ══════════════════════════════════════════════════════
story.append(Spacer(1, 1.0 * cm))
story.append(Paragraph("THYROID SWELLING", TITLE_ST))
story.append(Paragraph("MNG | SNG | Toxic Goitre | Diffuse Goitre | Carcinoma Thyroid", TITLE_ST))
story.append(Spacer(1, 0.2 * cm))
story.append(HRFlowable(width="100%", thickness=3,
                         color=colors.HexColor('#4a148c')))
story.append(Spacer(1, 0.12 * cm))
story.append(Paragraph(
    "Significance of Every History and Examination Finding", SUBTITLE_ST))
story.append(Paragraph(
    "According to Das's Manual of Clinical Surgery &amp; Rajamahendran's Surgical Principles",
    SUBTITLE_ST))
story.append(HRFlowable(width="100%", thickness=1,
                         color=colors.HexColor('#90a4ae')))
story.append(Spacer(1, 1.2 * cm))

# ══════════════════════════════════════════════════════
# 1. CHIEF COMPLAINTS
# ══════════════════════════════════════════════════════
section("1. CHIEF COMPLAINTS — WHY ASKED & SIGNIFICANCE")

item("Swelling in the Front / Anterior Aspect of the Neck",
     "The neck swelling is the cardinal presenting feature of thyroid pathology. "
     "Asking the DURATION establishes acuity — a long-standing, slowly growing swelling favours benign disease (colloid goitre, MNG), "
     "while rapid growth in a previously stable goitre strongly suggests malignant change (anaplastic carcinoma). "
     "Asking HOW IT WAS NOTICED (bath, mirror, neighbour) establishes the size at onset — if noticed by a neighbour it was visible from a distance, indicating a large swelling. "
     "The SITE (front/anterior neck, moves with deglutition) immediately establishes a thyroid origin vs other neck swellings (lymph nodes, cystic hygroma, branchial cyst).",
     "A midline neck swelling that moves with swallowing AND with tongue protrusion = thyroglossal cyst, NOT thyroid.")

item("Pain in the Swelling",
     "Pain is NOT a feature of a benign thyroid swelling in its early stages. "
     "SUDDEN severe pain = haemorrhage into a nodule (rapid painful enlargement) or acute thyroiditis. "
     "Dull aching pain = subacute (De Quervain's) thyroiditis. "
     "Progressive pain + hard consistency = malignant infiltration of surrounding structures. "
     "Pain radiating to the ear = involvement of superior laryngeal nerve (malignancy). "
     "Significance: The character, onset and radiation of pain narrow the differential diagnosis significantly.",
     "Painful thyroid swelling: think thyroiditis, haemorrhage into nodule, or malignant infiltration.")

# ══════════════════════════════════════════════════════
# 2. HISTORY OF PRESENTING ILLNESS
# ══════════════════════════════════════════════════════
section("2. HISTORY OF PRESENTING ILLNESS — SIGNIFICANCE OF EACH H/O")

item("Onset — Sudden vs Insidious",
     "SUDDEN onset of thyroid swelling: haemorrhage into a pre-existing nodule, acute suppurative thyroiditis, or rapidly growing anaplastic carcinoma. "
     "INSIDIOUS onset: benign slow-growing goitre (colloid, MNG, follicular adenoma), well-differentiated carcinoma (papillary, follicular). "
     "Onset history is the first clue to whether the disease is benign or malignant.")

item("Progression of the Swelling",
     [
         "STATIC: Long-standing stable size — likely benign (longstanding colloid goitre).",
         "SLOWLY PROGRESSIVE: Benign — simple/colloid goitre, follicular adenoma, well-differentiated carcinoma.",
         "RAPIDLY PROGRESSIVE: MALIGNANT — anaplastic carcinoma is notorious for rapid growth. Always suspect malignancy.",
         "INITIALLY SLOW THEN RAPID: Long-standing benign goitre undergoing malignant transformation (e.g., MNG → carcinoma).",
         "INITIALLY INCREASING THEN REGRESSIVE: Inflammatory/infectious — subacute thyroiditis; swelling may reduce with treatment.",
         "SIGNIFICANCE: Rate of growth is one of the most important indicators of malignancy (Das)."
     ])

item("H/O Fever",
     "Fever with thyroid swelling suggests: "
     "(1) Acute suppurative thyroiditis — bacterial infection; rare but presents with high fever, painful tender thyroid. "
     "(2) Subacute (De Quervain's) thyroiditis — mild fever, very painful thyroid, follows viral upper respiratory infection. "
     "(3) Hashimoto's thyroiditis flare — low-grade fever. "
     "Fever contraindicates elective surgery — treat the infection first.")

item("H/O Trauma",
     "Direct trauma to the neck can cause haemorrhage into a thyroid nodule — sudden painful enlargement. "
     "Also relevant for medico-legal documentation. "
     "Trauma causing tracheal compression is an airway emergency.")

subsection("Pressure Symptoms — Why Each is Asked")

item("Difficulty in Swallowing (Dysphagia)",
     "Indicates INFILTRATION OF THE OESOPHAGUS by malignant thyroid tumour, or mechanical compression of the oesophagus by a large goitre. "
     "Malignant invasion = dysphagia is progressive, constant, initially to solids then liquids. "
     "Mechanical compression = dysphagia is intermittent, related to posture. "
     "SIGNIFICANCE: Dysphagia changes the CEAP/TNM staging to T4 disease if infiltration is confirmed — affects resectability and prognosis.",
     "Always ask: dysphagia to solids only, or solids and liquids? Progression indicates malignant infiltration.")

item("Difficulty in Breathing (Dyspnoea)",
     "Indicates COMPRESSION or INFILTRATION OF THE TRACHEA. "
     "Large goitres (especially retrosternal) compress the trachea — progressive exertional dyspnoea. "
     "Malignant infiltration = constant severe dyspnoea, stridor, and respiratory distress. "
     "SIGNIFICANCE: Tracheal compression is an indication for surgery even if the goitre is benign. "
     "Pre-operative airway assessment and anaesthetic planning are mandatory.")

item("Change in Voice (Hoarseness / Dysphonia)",
     "Indicates INFILTRATION or COMPRESSION OF THE RECURRENT LARYNGEAL NERVE (RLN). "
     "In benign goitre: hoarseness can occur due to mechanical stretching of the RLN by a large nodule. "
     "In malignant thyroid tumour: RLN invasion is a feature of T4 disease — very important staging finding. "
     "SIGNIFICANCE: Pre-operative indirect laryngoscopy (ILN) MUST be done in all thyroid cases with hoarseness to document pre-existing vocal cord palsy. "
     "Post-operative RLN injury is the most feared complication of thyroidectomy.",
     "Hoarseness + thyroid swelling = malignancy until proven otherwise. Document vocal cord status before surgery.")

item("Giddiness / Syncope — Carotid Artery Involvement",
     "Indicates INFILTRATION OR COMPRESSION OF THE CAROTID ARTERY by malignant thyroid tumour. "
     "Carotid artery compression reduces cerebral blood flow → giddiness, syncope, stroke. "
     "Berry sign (obliteration of carotid pulsation) on palpation correlates with this. "
     "SIGNIFICANCE: Carotid involvement makes the tumour unresectable or requires vascular reconstruction — affects surgical planning significantly.")

item("Stridor",
     "Stridor = TRACHEAL COMPRESSION or INFILTRATION. "
     "Inspiratory stridor = upper airway obstruction (trachea compressed above thoracic inlet). "
     "A MEDICAL AND SURGICAL EMERGENCY — airway may be critically compromised. "
     "Requires urgent evaluation, possible tracheostomy, and expedited surgery. "
     "Pemberton's sign (stridor/facial congestion on raising arms) demonstrates positional tracheal obstruction from retrosternal goitre.")

subsection("Features of Hyperthyroidism — Why Each is Asked")

item("Loss of Weight Despite Good Appetite",
     "The PATHOGNOMONIC symptom of HYPERTHYROIDISM. Elevated T3/T4 increases basal metabolic rate (BMR) → increased catabolism → weight loss despite increased food intake. "
     "Presence confirms a TOXIC goitre (Graves' disease, toxic MNG, toxic adenoma). "
     "Differentiates from hypothyroid weight gain and from malignancy-related cachexia (where appetite is also reduced).",
     "Weight loss WITH good appetite = hyperthyroidism. Weight loss WITH poor appetite = malignancy/cachexia.")

item("Excitability / Irritability / Sleeplessness",
     "Neuropsychiatric features of hyperthyroidism due to excess thyroid hormone stimulating the sympathetic nervous system and CNS. "
     "Irritability, emotional lability, restlessness, insomnia — collectively called 'thyroid neurosis'. "
     "These symptoms confirm a toxic state and the need for anti-thyroid drugs (ATD) before elective surgery.")

item("Intolerance to Heat / Excessive Sweating",
     "Excess T3/T4 raises BMR → increased heat production → patient feels hot and sweats excessively even in cool environments. "
     "Warm, moist, velvety skin on examination. "
     "SIGNIFICANCE: Confirms hyperthyroid state; helps grade severity. Intolerance to cold = hypothyroidism (opposite).")

item("Tremors",
     "Fine tremors of outstretched hands — due to excess adrenergic stimulation by thyroid hormones. "
     "Ask patient to hold hands outstretched — visible fine tremor. "
     "Grade of tremors correlates with severity of thyrotoxicosis. "
     "Responds to beta-blockers (propranolol) which is part of pre-operative preparation.")

item("Chest Pain / Palpitation / Breathlessness / Syncope",
     "Cardiovascular manifestations of hyperthyroidism: "
     "Excess T3/T4 → increased heart rate, increased cardiac output, decreased peripheral resistance → palpitation, tachycardia. "
     "Atrial fibrillation (AF) is the most important cardiac complication — occurs in ~10-20% of thyrotoxic patients. "
     "AF → embolic stroke. "
     "Heart failure (high-output cardiac failure) → breathlessness, swelling of legs. "
     "SIGNIFICANCE: Cardiac complications MUST be controlled before surgery — propranolol, digoxin for AF, antithyroid drugs.",
     "Palpitation + thyroid swelling = suspect AF. Always do ECG in thyroid cases.")

item("Swelling in Both Legs",
     "Bilateral pedal oedema in hyperthyroidism = HIGH-OUTPUT CARDIAC FAILURE. "
     "Excess thyroid hormone increases cardiac output — eventually the heart fails, causing oedema. "
     "Must be distinguished from myxoedema (hypothyroid oedema) — which is non-pitting and occurs in hypothyroidism.")

item("Loose Stools",
     "Hyperthyroidism increases GI motility → frequent loose stools (not true diarrhoea). "
     "Due to increased sympathetic stimulation of the gut. "
     "Confirms hyperthyroid state.")

item("Protruding Eyes (Proptosis) / Double Vision (Diplopia)",
     "EXOPHTHALMOS (proptosis) is pathognomonic of GRAVES' DISEASE (diffuse toxic goitre). "
     "Due to glycosaminoglycan deposition in the retro-orbital fat and extraocular muscles by TSH receptor antibodies. "
     "Important: proptosis is NOT caused by thyroid hormone levels — it can persist or worsen even after treatment of hyperthyroidism. "
     "Double vision = restrictive myopathy of inferior/medial rectus muscles. "
     "SIGNIFICANCE: Graves' disease requires specific management including ophthalmology review. "
     "Proptosis does NOT occur in toxic MNG or toxic adenoma.",
     "Exophthalmos in a toxic goitre = Graves' disease. No exophthalmos = toxic MNG or toxic adenoma.")

subsection("Features of Hypothyroidism — Why Each is Asked")

item("Increased Weight Despite Poor Appetite",
     "The cardinal feature of HYPOTHYROIDISM — decreased BMR → reduced energy expenditure → weight gain despite eating less. "
     "Also due to myxoedematous deposits (glycosaminoglycans) in subcutaneous tissue. "
     "Clinically correlates with puffy face, macroglossia, and periorbital puffiness.")

item("Lethargy / Easy Fatigability / Memory Loss",
     "ALL DUE TO REDUCED METABOLIC RATE from deficient thyroid hormones. "
     "The brain is dependent on thyroid hormones for normal function — deficiency causes: "
     "slowness of thought, impaired memory (especially recent memory), depression, psychosis (myxoedema madness). "
     "SIGNIFICANCE: Hypothyroid patient has delayed metabolism of anaesthetic drugs — prolonged anaesthetic recovery, increased sensitivity to sedatives.")

item("Intolerance to Cold",
     "Decreased BMR → decreased heat production → patient feels cold in normal or warm environments. "
     "The OPPOSITE of hyperthyroidism (heat intolerance). "
     "Dry, coarse, cold skin on examination.")

item("Constipation",
     "Decreased GI motility in hypothyroidism (opposite of loose stools in hyperthyroidism). "
     "Severe hypothyroidism can cause paralytic ileus.")

item("Loss of Hair / Dryness of Skin",
     "Thyroid hormones promote normal hair growth and skin cell metabolism. "
     "Deficiency → diffuse hair loss (including lateral one-third of eyebrows — characteristic sign), dry coarse skin. "
     "Skin changes confirm hypothyroid state and help in diagnosis.")

subsection("Features of Metastasis — Why Each is Asked")

item("Loss of Weight / Loss of Appetite",
     "Constitutional features of malignancy (cancer cachexia). "
     "In thyroid carcinoma, anorexia + weight loss = advanced disease with distant metastases. "
     "Differentiates from hyperthyroid weight loss (where appetite is INCREASED).")

item("Chronic Cough / Haemoptysis",
     "Suggests PULMONARY METASTASIS from thyroid carcinoma. "
     "Lung is the most common site of distant metastasis in follicular and papillary carcinoma. "
     "Haemoptysis = erosion of pulmonary vessels by metastatic deposits. "
     "Requires CXR and CT chest for staging.")

item("Headache / Vomiting / Seizures",
     "Suggest BRAIN METASTASIS from thyroid carcinoma. "
     "Thyroid carcinoma (especially follicular) can metastasise to the brain. "
     "Raised intracranial pressure → headache, vomiting, seizures. "
     "Requires CT/MRI brain for staging.")

item("Abdominal Pain / Distension / Jaundice",
     "Suggest LIVER METASTASIS (jaundice, hepatomegaly) or peritoneal metastasis (distension). "
     "Rare in thyroid carcinoma but occurs in advanced follicular and anaplastic carcinoma. "
     "Abdominal USG and CT are needed.")

item("Bony Pain / Low Back Pain",
     "Suggest BONE METASTASIS — the SECOND MOST COMMON site of distant metastasis in follicular carcinoma (after lung). "
     "Characteristic radiological appearance: 'blow-out' lytic lesions (expansile). "
     "Bone scan or PET scan is needed for staging. "
     "Pathological fractures can occur at metastatic sites.",
     "Follicular carcinoma metastasises to bone and lung (blood-borne). Papillary carcinoma metastasises to lymph nodes first.")

item("Swelling Elsewhere in the Body",
     "Lymph node metastasis (cervical, supraclavicular) = most common in papillary thyroid carcinoma. "
     "A child/young adult with a cervical lymph node is thyroid carcinoma until proven otherwise (Das). "
     "Distant soft tissue metastasis = advanced disease.")

subsection("H/O Horner Syndrome — Why Asked")

item("Drooping of Eyelids (Ptosis) / Absence of Sweating in Face (Anhidrosis)",
     "HORNER SYNDROME = triad of ptosis, miosis (small pupil), and anhidrosis on the same side. "
     "Caused by INVOLVEMENT OF THE CERVICAL SYMPATHETIC CHAIN by a malignant thyroid tumour. "
     "The cervical sympathetic chain runs in close relation to the posterolateral thyroid. "
     "SIGNIFICANCE: Horner syndrome in a thyroid case = malignant invasion of the sympathetic chain = T4 disease = very advanced malignancy. "
     "This makes the tumour essentially unresectable for cure.",
     "Horner syndrome with thyroid swelling = advanced malignancy. A very important surgical examination finding.")

# ══════════════════════════════════════════════════════
# 3. PAST HISTORY
# ══════════════════════════════════════════════════════
section("3. PAST HISTORY — SIGNIFICANCE")

item("H/O Similar Illness in the Past",
     "Previous episodes of thyroid swelling suggest recurrent goitre or inadequately treated disease. "
     "Helps document disease progression and previous response to treatment.")

item("H/O DM / SHT / TB / Asthma / Allergy / Heart Disease / Kidney Disease / Epilepsy",
     [
         "DM: Impairs wound healing; increases infection risk; thyroid hormones affect glycaemic control (hyperthyroidism worsens DM).",
         "Hypertension: Important in thyrotoxicosis (sympathetic stimulation raises BP); antihypertensives peri-operatively.",
         "TB: TB of lymph nodes in the neck can mimic thyroid carcinoma with nodal metastases — important differential.",
         "Asthma: Beta-blockers (propranolol) used for thyrotoxicosis are contraindicated in asthma — use cardioselective beta-1 blockers or calcium channel blockers.",
         "Heart Disease: Thyrotoxicosis precipitates AF and heart failure; hypothyroidism causes pericardial effusion — cardiac workup mandatory.",
         "Kidney Disease: Affects drug metabolism; hypothyroidism also impairs renal function.",
         "Allergy: Important for iodine allergy (relevant for radioiodine therapy and contrast scans)."
     ])

item("H/O Previous Surgery in the Neck",
     "Previous thyroid surgery = risk of bilateral RLN injury in re-do surgery (airway emergency). "
     "Previous neck dissection = altered anatomy, scar tissue, risk to carotid vessels and jugular vein. "
     "Previous parathyroid removal = risk of hypocalcaemia post-op. "
     "Recurrent thyroid disease after surgery = higher malignancy risk.")

item("H/O Childhood Irradiation to Neck",
     "THIS IS A SPECIFIC AND CRITICAL HISTORY. "
     "External beam radiation to the neck in childhood (for thymic enlargement, tonsillitis, acne in the past) is the MOST WELL-ESTABLISHED RISK FACTOR for PAPILLARY THYROID CARCINOMA. "
     "Latent period: 10-40 years after irradiation. "
     "SIGNIFICANCE: Any thyroid nodule in a patient with history of childhood neck irradiation must be presumed malignant until proven otherwise.",
     "Childhood neck irradiation → papillary carcinoma. Mandatory to ask in every thyroid case (Das).")

item("H/O Chronic Drug Intake",
     [
         "Amiodarone: Contains 37% iodine by weight — causes both hypothyroidism and hyperthyroidism (amiodarone-induced thyroid disease).",
         "Lithium: Inhibits thyroid hormone release → causes hypothyroidism and goitre.",
         "Iodine-containing drugs (expectorants, contrast agents): Can cause iodine-induced hyperthyroidism (Jod-Basedow effect) or hypothyroidism.",
         "Anti-thyroid drugs (Carbimazole, PTU): Documents treatment for hyperthyroidism; guides choice of surgery timing."
     ])

# ══════════════════════════════════════════════════════
# 4. PERSONAL HISTORY
# ══════════════════════════════════════════════════════
section("4. PERSONAL HISTORY — SIGNIFICANCE")

item("Diet (Vegetarian / Non-Vegetarian)",
     "Nutritional status affects wound healing and recovery. "
     "Vegetarian diet alone does not cause goitre — but combined with iodine-deficient diet it does.")

item("H/O Intake of Brassica Family Vegetables",
     "Brassica family (cabbage, cauliflower, broccoli, turnip, Brussels sprouts, kale) contain GOITROGENS — specifically thiocyanates and isothiocyanates. "
     "Goitrogens inhibit thyroid peroxidase enzyme → impair iodine organification → reduced T3/T4 synthesis → compensatory TSH rise → GOITRE. "
     "SIGNIFICANCE: Excessive consumption of raw brassica vegetables is a DIETARY CAUSE of simple goitre. "
     "This is particularly relevant in endemic goitre regions where iodine deficiency and goitrogens act synergistically.",
     "Important exam question: Name dietary goitrogens — Brassica family vegetables (cabbage, cauliflower, broccoli, cassava, soybean).")

item("H/O Rock/Brick Salt vs Iodized Salt",
     "IODINE DEFICIENCY is the most common worldwide cause of goitre (endemic goitre). "
     "Rock salt or brick salt does NOT contain iodine. "
     "Taking non-iodized salt = chronic iodine deficiency → compensatory TSH rise → diffuse hyperplasia → simple/endemic goitre. "
     "This is the SINGLE MOST COMMON PREVENTABLE CAUSE OF GOITRE globally. "
     "SIGNIFICANCE: Establishes the aetiological diagnosis of simple endemic goitre; guides treatment with iodine supplementation.",
     "Always ask: Do you use iodized salt or rock salt? The answer directly points to endemic goitre aetiology.")

item("H/O Smoking",
     "Cigarette smoke contains thiocyanates — goitrogens that inhibit iodine uptake by the thyroid. "
     "Smoking is a risk factor for goitre development and worsening in iodine-deficient areas. "
     "Also affects respiratory fitness for surgery and increases post-operative complications.")

item("H/O Alcohol",
     "Chronic alcoholism causes liver disease affecting drug metabolism. "
     "Also, alcohol itself has some anti-thyroid effect (decreases thyroid hormone levels). "
     "Alcohol withdrawal during hospital stay is a peri-operative risk.")

item("Bowel and Bladder Habits / Sleep Pattern",
     "Bowel habits: Loose stools = hyperthyroidism; Constipation = hypothyroidism — directly helps diagnose thyroid status. "
     "Sleep pattern: Insomnia = hyperthyroidism (excess adrenergic stimulation); Excessive sleep/somnolence = hypothyroidism.")

# ══════════════════════════════════════════════════════
# 5. FAMILY HISTORY
# ══════════════════════════════════════════════════════
section("5. FAMILY HISTORY — SIGNIFICANCE")

item("H/O Similar Illness in Family Members",
     "ENDEMIC GOITRE: Multiple family members affected in an iodine-deficient geographical area. Entire family drinking from the same water source or using the same non-iodized salt. "
     "MEN SYNDROME (Multiple Endocrine Neoplasia): "
     "MEN 2A = Medullary thyroid carcinoma + Phaeochromocytoma + Primary hyperparathyroidism. "
     "MEN 2B = Medullary thyroid carcinoma + Phaeochromocytoma + Marfanoid habitus + Mucosal neuromas. "
     "Family history of MEN 2A/2B = RET proto-oncogene mutation testing mandatory for all family members. "
     "Graves' disease: Autoimmune — familial tendency (HLA-DR3, HLA-B8 association). "
     "Hashimoto's thyroiditis: Autoimmune — familial tendency.",
     "Family history of medullary thyroid carcinoma = MEN syndrome until proven otherwise. Check RET gene mutation.")

# ══════════════════════════════════════════════════════
# 6. MENSTRUAL & OBSTETRIC HISTORY
# ══════════════════════════════════════════════════════
section("6. MENSTRUAL & OBSTETRIC HISTORY — SIGNIFICANCE")

item("Menstrual History — Regularity, Cycle, Menarche, Menopause",
     "MENORRHAGIA (heavy, prolonged periods): Feature of HYPOTHYROIDISM — excess TSH/oestrogen imbalance causes anovulation and heavy bleeding. "
     "OLIGOMENORRHOEA / AMENORRHOEA: Feature of HYPERTHYROIDISM — excess thyroid hormones suppress GnRH, reducing FSH/LH. "
     "Irregular cycles with thyroid swelling suggest the thyroid disorder is affecting the hypothalamic-pituitary-gonadal axis. "
     "SIGNIFICANCE: Menstrual disturbance directly reflects the functional state of the thyroid and helps classify toxic vs hypothyroid disease.",
     "Menorrhagia = hypothyroidism. Oligomenorrhoea/amenorrhoea = hyperthyroidism. Vital clue for functional diagnosis.")

item("Obstetric History — Multiparity / Pregnancy",
     "PREGNANCY AND GOITRE: Physiological demands of pregnancy increase iodine requirements by ~50%. "
     "In iodine-deficient areas, pregnancy can precipitate or worsen goitre. "
     "Untreated hypothyroidism in pregnancy: Miscarriage, pre-eclampsia, cretinism in the child. "
     "Untreated hyperthyroidism in pregnancy: Miscarriage, preterm labour, neonatal hyperthyroidism. "
     "SIGNIFICANCE: Thyroid disease in a multiparous woman must be evaluated with obstetric history to assess impact on previous pregnancies and foetal outcome.")

item("Treatment History — Thyroid Drugs",
     "H/O thyroxine (levothyroxine) intake = previously diagnosed hypothyroidism — check TSH levels pre-op to ensure euthyroid state. "
     "H/O anti-thyroid drugs (Carbimazole, PTU) = previously diagnosed hyperthyroidism — assess current thyroid status and whether euthyroid before surgery. "
     "SIGNIFICANCE: Operating on a hypothyroid or hyperthyroid patient is dangerous — hypothyroid patient has increased anaesthetic sensitivity; hyperthyroid patient risks thyroid storm.")

# ══════════════════════════════════════════════════════
# 7. GENERAL EXAMINATION
# ══════════════════════════════════════════════════════
section("7. GENERAL EXAMINATION — SIGNIFICANCE")

item("Dyspnoea / Tachypnoea",
     "Dyspnoea at rest in a thyroid patient suggests: "
     "(1) Tracheal compression/deviation by large goitre or malignancy. "
     "(2) High-output cardiac failure from hyperthyroidism. "
     "(3) Tracheal infiltration by anaplastic carcinoma. "
     "Tachypnoea = increased respiratory rate — suggests significant respiratory compromise; airway must be assessed urgently.")

item("Pallor",
     "Anaemia in thyroid cases: "
     "Hypothyroidism can cause normochromic normocytic anaemia (reduced erythropoietin), macrocytic anaemia (folate/B12 deficiency), or iron deficiency anaemia (menorrhagia). "
     "Malignancy causes anaemia of chronic disease. "
     "Pre-operative Hb > 10 g/dL required.")

item("Jaundice",
     "Jaundice with thyroid disease suggests hepatic involvement: "
     "(1) Liver metastasis from thyroid carcinoma. "
     "(2) Hyperthyroidism-related liver dysfunction (rare). "
     "(3) Drug-induced jaundice from PTU (very rare hepatotoxicity). "
     "Also affects drug metabolism and surgical risk.")

item("Build and Nourishment",
     "THIN, wasted, restless, sweating = HYPERTHYROID habitus. "
     "OBESE, puffy, lethargic, pale, slow = HYPOTHYROID (myxoedematous) habitus. "
     "Build and nourishment together give the FIRST IMPRESSION of thyroid functional status on inspection.")

item("Clubbing",
     "Thyroid acropachy (a specific form of clubbing) occurs in Graves' disease — periosteal new bone formation with soft tissue swelling of fingers, associated with pretibial myxoedema. "
     "Clubbing also suggests co-existing cardiorespiratory disease.")

item("Pedal Oedema",
     "BILATERAL PITTING OEDEMA: High-output cardiac failure from hyperthyroidism (associated with AF). "
     "NON-PITTING (brawny) OEDEMA: Myxoedema — hypothyroidism causes GAG deposition in dermis — 'dough-like', non-pitting. "
     "Pretibial myxoedema: Bilateral, non-pitting, brownish-orange plaque-like lesion on the shin — PATHOGNOMONIC of Graves' disease.",
     "Pretibial myxoedema + exophthalmos + goitre = Graves' disease triad.")

item("Generalised Lymphadenopathy",
     "Cervical lymphadenopathy in a thyroid case = metastatic papillary carcinoma until proven otherwise. "
     "In young patients with a thyroid nodule, palpable cervical nodes are the most common presentation of papillary carcinoma. "
     "Generalised lymphadenopathy = lymphoma (thyroid lymphoma is a distinct entity).")

item("Pulse Rate — Rate, Rhythm, Volume, Tension, Character",
     [
         "RATE: Tachycardia (HR > 100) = hyperthyroidism. Bradycardia (HR < 60) = hypothyroidism.",
         "RHYTHM: Irregularly irregular = ATRIAL FIBRILLATION — complication of thyrotoxicosis. Mandates ECG and anticoagulation assessment.",
         "VOLUME: Increased pulse volume (bounding pulse) = hyperthyroid high-output state. Decreased (small volume) = hypothyroid.",
         "CHARACTER: Collapsing (water-hammer) pulse = high-output hyperthyroidism.",
         "Radio-radial delay: Absent — relevant to rule out thoracic aortic pathology in large retrosternal goitre.",
         "SIGNIFICANCE: Pulse examination alone can diagnose hyperthyroidism (tachycardia, AF, bounding pulse) or hypothyroidism (bradycardia)."
     ],
     "An irregularly irregular pulse in a thyroid patient = atrial fibrillation from thyrotoxicosis. Always do ECG.")

item("Blood Pressure",
     "Hypertension in thyroid: "
     "Hyperthyroidism: systolic BP elevated, diastolic may be low (wide pulse pressure from high-output state). "
     "Hypothyroidism: diastolic hypertension (increased peripheral resistance). "
     "Significant if associated with palpitation and thyroid swelling → screen for phaeochromocytoma (MEN 2A).")

# ══════════════════════════════════════════════════════
# 8. LOCAL EXAMINATION — INSPECTION
# ══════════════════════════════════════════════════════
section("8. LOCAL EXAMINATION — INSPECTION (Significance)")

item("Position: Patient Sitting, Examiner Standing in Front, Exposure Chin to Nipple",
     "Patient sitting: Allows full inspection of the neck, clavicle, and upper chest. "
     "Chin-to-nipple exposure: Ensures the full extent of the thyroid swelling (especially retrosternal extension), tracheal position, dilated veins, and any secondary lymph node swellings are all visible. "
     "Standing in front of patient: Correct anatomical vantage point for inspection of anterior neck structures.",
     "Always note lower border clearly — if lower border is NOT seen on inspection = retrosternal goitre.")

item("Movement with Deglutition (Swallowing)",
     "THE MOST IMPORTANT DIAGNOSTIC SIGN of a thyroid swelling. "
     "The thyroid gland is enclosed in the pre-tracheal fascia, which is attached to the tracheal rings. "
     "When the patient swallows, the trachea and larynx move upward, dragging the attached thyroid with them. "
     "POSITIVE: Swelling moves upward with swallowing = CONFIRMS THE SWELLING IS OF THYROID ORIGIN. "
     "Exceptions: Heavily fibrotic malignant thyroid (anaplastic carcinoma) invading surrounding structures may NOT move — ominous sign.",
     "Loss of movement with deglutition in a previously mobile goitre = malignant infiltration until proven otherwise.")

item("Movement with Tongue Protrusion",
     "If the swelling moves BOTH with swallowing AND with tongue protrusion = THYROGLOSSAL CYST (not thyroid). "
     "A thyroglossal cyst is attached to the hyoid bone via the thyroglossal tract — tongue protrusion elevates the hyoid, moving the cyst. "
     "SIGNIFICANCE: Distinguishes thyroglossal cyst from thyroid swelling — completely different surgical treatment (Sistrunk's operation for thyroglossal cyst).")

item("Site, Size, Shape, Extent of Swelling",
     [
         "Site: Right lobe/left lobe/isthmus/diffuse — localises the lesion to a lobe or isthmus.",
         "Size: Small (<1cm) = clinically occult; 1-4cm = moderate; >4cm = large goitre.",
         "Shape: Globular/rounded = benign. Irregular/nodular = MNG. Hard, irregular = carcinoma.",
         "Extent: Above (relation to thyroid cartilage), below (relation to sternal notch), laterally (relation to anterior border of SCM). Cannot see lower border = retrosternal extension."
     ])

item("Surface, Margin, Skin Over the Swelling",
     [
         "Surface: Smooth = simple goitre/adenoma. Nodular = MNG. Irregular = carcinoma.",
         "Margin: Well-defined = benign. Ill-defined = malignant/inflammatory.",
         "Skin: Scar = previous surgery (re-do case). Sinus = malignant/TB. Dilated veins = obstruction of anterior jugular veins from large goitre or retrosternal extension.",
         "Stretched/shiny skin over thyroid = rapid expansion (haemorrhage or malignancy)."
     ])

item("Visible Pulsations",
     "Pulsations over the thyroid swelling: "
     "TRANSMITTED pulsation from carotid = non-pulsatile mass adjacent to carotid. "
     "TRUE PULSATION = vascular aneurysm (differential diagnosis) or highly vascular tumour. "
     "Bruit on auscultation distinguishes vascular tumour from simple transmitted pulsation.")

item("Lower Border Not Seen / Tracheal Position / Dilated Veins",
     "Lower border NOT SEEN = RETROSTERNAL GOITRE — extends below the sternal notch into the mediastinum. Requires CT for full evaluation and special anaesthetic considerations (difficult airway). "
     "Tracheal position: Deviation suggests large unilateral goitre or carcinoma with tracheal invasion. "
     "Dilated anterior neck veins = SUPERIOR VENA CAVA OBSTRUCTION from retrosternal goitre or mediastinal metastasis.")

# ══════════════════════════════════════════════════════
# 9. LOCAL EXAMINATION — PALPATION
# ══════════════════════════════════════════════════════
section("9. LOCAL EXAMINATION — PALPATION (Significance)")

item("Warmth and Tenderness",
     "Warmth + tenderness = acute/subacute thyroiditis or haemorrhage into nodule. "
     "Very tender thyroid = De Quervain's (subacute) thyroiditis. "
     "Tender + fever = acute suppurative thyroiditis (rare). "
     "Woody hard, non-tender = Riedel's thyroiditis (fibrous thyroiditis — rare; mimics malignancy).")

item("Consistency",
     [
         "SOFT: Colloid cyst, simple goitre.",
         "FIRM: Hashimoto's thyroiditis, Graves' disease.",
         "HARD: Malignancy (papillary, follicular, medullary, anaplastic carcinoma), calcification in MNG.",
         "STONE HARD: Anaplastic carcinoma or calcified benign nodule.",
         "FLUCTUANT: Thyroid abscess or cystic nodule.",
         "SIGNIFICANCE: Hardness of a thyroid nodule is the single most important palpatory feature suggesting malignancy (Das)."
     ],
     "Hard thyroid nodule = malignancy until proven otherwise.")

item("Palpable Thrill over the Upper Pole",
     "A THRILL (vibration) felt over the upper pole of the thyroid = HIGHLY VASCULAR GLAND = GRAVES' DISEASE. "
     "Due to markedly increased blood flow in the thyroid (the gland is virtually an arteriovenous fistula in severe Graves' disease). "
     "Correlates with BRUIT on auscultation. "
     "SIGNIFICANCE: Confirms Graves' disease — requires pre-operative potassium iodide (Lugol's solution) to reduce vascularity before surgery.")

item("All Borders Made Out — Lower Border",
     "If the lower border of the thyroid CANNOT BE FELT = RETROSTERNAL EXTENSION of the goitre. "
     "This is confirmed by percussion over the manubrium sternum (dull = retrosternal mass). "
     "Retrosternal goitre requires special anaesthetic management (armoured endotracheal tube, awake intubation) and sternal split if needed.")

item("Mobility",
     "A MOBILE thyroid swelling = benign (not adherent to surrounding structures). "
     "REDUCED MOBILITY = malignancy invading surrounding structures (trachea, oesophagus, carotid). "
     "FIXED, HARD thyroid = anaplastic carcinoma invading all surrounding structures. "
     "This is confirmed by asking the patient to swallow — loss of movement = fixation.")

item("Plane of Swelling — Deep to Strap Muscles, Deep to SCM",
     "Thyroid is DEEP TO THE STRAP MUSCLES and DEEP TO THE SCM. "
     "When the patient contracts the SCM (turn head to opposite side), the swelling becomes LESS PROMINENT = it is deep to SCM = thyroid or deep cervical swelling. "
     "If it becomes MORE PROMINENT = it is superficial to SCM.")

item("Tracheal Position — Three Finger Test",
     "Place three fingers over the trachea above the sternal notch. "
     "The trachea should be in the midline with equal space on both sides. "
     "DEVIATED trachea: Large unilateral goitre pushes trachea to opposite side. "
     "Anaplastic carcinoma PULLS the trachea towards the tumour (fixation). "
     "SIGNIFICANCE: Tracheal deviation indicates need for pre-op CT to assess airway and plan intubation.")

item("Carotid Pulse — Felt / Displaced / Absent",
     "BERRY SIGN: Absence of carotid pulsation on one side = MALIGNANT THYROID TUMOUR has encased the carotid artery. "
     "This is a PATHOGNOMONIC sign of malignancy — specifically anaplastic or locally advanced papillary/follicular carcinoma. "
     "Carotid displacement (pushed laterally) = large benign goitre. "
     "Carotid encasement/absent pulse = malignancy.",
     "Berry sign positive = malignant thyroid. Do not operate without vascular surgery standby.")

item("Palpable Lymph Nodes",
     "CERVICAL LYMPH NODES palpable with thyroid swelling: "
     "PAPILLARY carcinoma — characteristically spreads to CERVICAL LYMPH NODES (most common). "
     "MEDULLARY carcinoma — early nodal spread. "
     "FOLLICULAR carcinoma — rarely spreads to nodes (blood-borne spread preferred). "
     "Hard, matted nodes = metastatic. Soft, tender nodes = reactive/inflammatory. "
     "Node biopsy/FNAC must be done if malignancy is suspected.")

subsection("Special Signs — Significance")

item("Berry Sign",
     "Obliteration of carotid pulsation by the thyroid swelling. "
     "POSITIVE Berry sign = malignant thyroid tumour has encased or invaded the carotid artery. "
     "Indicates T4 disease and unresectability for curative intent.")

item("Kocher's Test",
     "GENTLY compress the thyroid swelling laterally between two fingers. "
     "POSITIVE: Stridor appears during lateral compression = the trachea is narrow and soft — further compression can precipitate airway obstruction. "
     "SIGNIFICANCE: Confirms tracheal compression and predicts difficult post-operative tracheomalacia (trachea may collapse after goitre removal — fish-mouth breathing). "
     "Requires tracheostomy standby during surgery.",
     "Positive Kocher test = tracheostomy standby during thyroidectomy is mandatory.")

item("Pemberton's Sign",
     "Ask the patient to raise both arms above the head (abduct fully). "
     "POSITIVE: Within 1-2 minutes: facial congestion (plethora), cyanosis, distension of neck veins, and stridor appear. "
     "MECHANISM: Raising arms causes the retrosternal goitre to move upward, further compressing the thoracic inlet, obstructing venous return from the head/neck. "
     "SIGNIFICANCE: PATHOGNOMONIC of RETROSTERNAL GOITRE with thoracic inlet obstruction. "
     "Confirms retrosternal extension even when not visible on inspection.",
     "Pemberton's sign positive = retrosternal goitre compressing thoracic inlet. Very frequently tested in exams.")

# ══════════════════════════════════════════════════════
# 10. PERCUSSION & AUSCULTATION
# ══════════════════════════════════════════════════════
section("10. PERCUSSION & AUSCULTATION (Significance)")

item("Percussion over Manubrium Sternum",
     "Normally the manubrium sternum is RESONANT on percussion (air in trachea beneath). "
     "DULL PERCUSSION over the manubrium = RETROSTERNAL GOITRE or mediastinal mass extending below the sternum. "
     "SIGNIFICANCE: Simple, reliable bedside test for retrosternal extension of goitre — correlates with inability to see/feel the lower border of the thyroid.",
     "Dull percussion over manubrium = retrosternal goitre. Confirmed by CT thorax.")

item("Auscultation — Bruit over the Upper Pole",
     "A BRUIT (vascular murmur) heard over the thyroid, especially the upper pole: "
     "= Markedly INCREASED BLOOD FLOW in the thyroid = GRAVES' DISEASE. "
     "The superior thyroid artery (branch of external carotid) is massively dilated in Graves' disease. "
     "SIGNIFICANCE: Confirms the diagnosis of Graves' disease. Correlates with palpable thrill. "
     "Pre-operative Lugol's iodine given for 10-14 days reduces vascularity before surgery — bruit disappears if Lugol's is effective. "
     "A bruit over the thyroid must be distinguished from a carotid bruit (present in the carotid triangle, not over the thyroid itself).",
     "Bruit over thyroid upper pole = Graves' disease. One of the most important auscultatory findings in surgery.")

# ══════════════════════════════════════════════════════
# 11. EYE SIGNS
# ══════════════════════════════════════════════════════
section("11. EXAMINATION OF EYES — SIGNIFICANCE OF EACH SIGN")

item("Why Eye Signs are Examined",
     "Eye signs in thyroid disease are divided into two groups: "
     "(1) SYMPATHOMIMETIC signs — caused by excess thyroid hormone stimulating the sympathetic nervous system. Present in ALL causes of hyperthyroidism. "
     "(2) INFILTRATIVE OPHTHALMOPATHY — caused by TSH receptor antibody-mediated orbital inflammation. Present ONLY in Graves' disease.")

eye_data = [
    ["Eye Sign", "Test", "Significance"],
    ["Stellwag's Sign\n(FIRST TO APPEAR)",
     "Infrequent or incomplete blinking",
     "Sympathomimetic. Occurs in ALL thyrotoxicosis. Due to excess adrenergic stimulation of levator palpebrae superioris. First sign to appear in hyperthyroidism."],
    ["Dalrymple's Sign",
     "Lid retraction — white sclera visible above the cornea (upper limbus)",
     "Sympathomimetic. Staring appearance. Due to retraction of upper eyelid by overstimulated Muller's muscle (sympathetic supply)."],
    ["Von Graefe's Sign",
     "Upper eyelid lags behind the eyeball on downward gaze",
     "Sympathomimetic. 'Lid lag'. Ask patient to follow finger downward — upper lid lags, exposing sclera. Due to sympathetic overaction of levator."],
    ["Joffroy's Sign",
     "Absence of wrinkling of forehead when looking upward",
     "Sympathomimetic. In hyperthyroidism, the eyebrows do not furrow when looking up — due to excessive levator stimulation already holding the lid high."],
    ["Jellinek's Sign",
     "Brownish pigmentation of the eyelids",
     "Sympathomimetic. Due to increased melanin stimulation from adrenergic excess."],
    ["Moebius Sign",
     "Loss of convergence — eyes diverge when a near object is brought close",
     "INFILTRATIVE. Weakness of medial rectus due to extraocular muscle myopathy from Graves' ophthalmopathy. Indicates Graves' disease specifically."],
    ["Naffziger's Sign",
     "Standing behind patient — proptosis visible above the supraorbital ridge",
     "INFILTRATIVE. Confirms exophthalmos. Due to retro-orbital inflammation and fat deposition in Graves' ophthalmopathy."],
    ["Gifford's Sign",
     "Difficulty in everting the upper eyelid",
     "INFILTRATIVE. Fibrosis of the orbital contents in Graves' disease makes it difficult to evert the upper lid."],
]
story.append(make_table(
    eye_data,
    col_widths=[4*cm, 5*cm, 9*cm],
    hdr_bg=colors.HexColor('#1a237e'),
    row_colors=[colors.HexColor('#e8eaf6'), colors.white]
))
story.append(Spacer(1, 0.3 * cm))

item("Indirect Laryngoscopy — Why Mandatory",
     "INDIRECT LARYNGOSCOPY must be performed in EVERY thyroid case. "
     "PURPOSE: To assess the movement of BOTH vocal cords PRE-OPERATIVELY. "
     "A pre-existing unilateral vocal cord palsy (from previous surgery, malignant RLN invasion) MUST be documented before surgery. "
     "SIGNIFICANCE: If a patient already has one paralysed vocal cord (unknown pre-operatively) and the surgeon injures the other RLN intra-operatively = BILATERAL RLN PALSY = BILATERAL ABDUCTOR PARALYSIS = RESPIRATORY EMERGENCY requiring tracheostomy. "
     "Pre-operative ILN protects the surgeon medicolegally and guides surgical decision-making.",
     "Indirect laryngoscopy is MANDATORY before any thyroid surgery — no exceptions (Das & Rajamahendran).")

# ══════════════════════════════════════════════════════
# 12. SYSTEMIC EXAMINATION
# ══════════════════════════════════════════════════════
section("12. SYSTEMIC EXAMINATION — SIGNIFICANCE")

item("Cardiovascular System (S1, S2, Added Sounds)",
     "Thyrotoxicosis: S1 is LOUD; tachycardia; flow murmurs; signs of cardiac failure (S3 gallop, basal crackles). "
     "AF detected on CVS examination — mandates ECG and anticoagulation. "
     "Hypothyroidism: Bradycardia; soft heart sounds; pericardial effusion (dullness on percussion, distant heart sounds). "
     "CVS examination directly reflects the functional state of the thyroid.")

item("Respiratory System (NVBS, Added Sounds)",
     "Inspiratory stridor detected = tracheal compression — requires urgent evaluation. "
     "Wheeze/COPD = chronic cough (may be from tracheal compression or co-existing disease). "
     "Added sounds may indicate pleural effusion (hypothyroidism, metastasis).")

item("Abdomen (Organomegaly, Free Fluid, PR/PV)",
     "Hepatomegaly = liver metastasis from thyroid carcinoma (advanced disease). "
     "Ascites = peritoneal metastasis. "
     "PR/PV = to detect any gynaecological or anorectal pathology that may be coincident. "
     "Splenomegaly = rarely in thyroid lymphoma.")

item("CNS — No Focal Neurological Deficit",
     "Neurological deficits in thyroid case = brain metastasis. "
     "Hypothyroid carpal tunnel syndrome (bilateral) — compression neuropathy from myxoedematous deposits. "
     "Cerebellar signs = hypothyroid cerebellar ataxia (rare). "
     "Baseline neurological status documented pre-operatively.")

# ══════════════════════════════════════════════════════
# 13. DIAGNOSIS CLASSIFICATION
# ══════════════════════════════════════════════════════
section("13. DIAGNOSIS CLASSIFICATION — SIGNIFICANCE")

item("Why Each Axis of Diagnosis Matters",
     "The final diagnosis must classify the thyroid disease along all axes — each axis directly determines the treatment plan. "
     "Getting any axis wrong leads to wrong treatment — e.g., operating on a toxic patient without achieving euthyroid state risks thyroid storm.")

# 3-col: 4cm + 4cm + 10cm = 18cm
diag_data = [
    ["Classification Axis", "Options", "Clinical Significance"],
    ["Toxic / Non-toxic",
     "Toxic / Non-toxic / Sub-clinical",
     "Toxic = hyperthyroid. Must achieve euthyroid state with ATDs before surgery. Non-toxic = normal function; elective surgery after workup."],
    ["Malignant / Non-malignant",
     "Benign / Malignant",
     "Malignant = total thyroidectomy + neck dissection if nodal involvement + radioiodine + TSH suppression. Benign = hemithyroidectomy or conservative."],
    ["Type of Goitre",
     "MNG / SNG / Diffuse",
     "MNG = most common thyroid disease; usually benign but malignant change possible. SNG = higher malignancy risk per nodule. Diffuse = Graves'/Hashimoto's/simple colloid."],
    ["Lobe / Isthmus",
     "Right / Left / Isthmus / Diffuse",
     "Determines extent of surgery — right lobectomy vs left vs isthmusectomy vs total thyroidectomy."],
    ["Pressure Symptoms",
     "With / Without",
     "With pressure symptoms = urgency of surgery even in benign disease. Affects anaesthetic planning (difficult airway)."],
    ["Metastasis",
     "With / Without",
     "With metastasis = advanced disease; radioiodine and TSH suppression are key; prognosis depends on histology."],
]
story.append(make_table(
    diag_data,
    col_widths=[4*cm, 4*cm, 10*cm],
    hdr_bg=colors.HexColor('#4a148c'),
    row_colors=[colors.HexColor('#f3e5f5'), colors.white]
))
story.append(Spacer(1, 0.4 * cm))

# ══════════════════════════════════════════════════════
# 14. INVESTIGATIONS
# ══════════════════════════════════════════════════════
section("14. INVESTIGATIONS — SIGNIFICANCE OF EACH")

subsection("Baseline Investigations")

# 2-col: 5cm + 13cm = 18cm
inv_data = [
    ["Investigation", "Significance in Thyroid Disease"],
    ["Haemoglobin %",
     "Anaemia of chronic disease (malignancy), iron deficiency from menorrhagia (hypothyroidism), or macrocytic anaemia (hypothyroidism with B12/folate deficiency). Pre-op Hb > 10 g/dL required."],
    ["Total Count / DC",
     "Leucocytosis = acute thyroiditis, infected thyroid. Leucopenia = rare complication of anti-thyroid drug (carbimazole) — agranulocytosis risk."],
    ["ESR",
     "Very high ESR (>100) = De Quervain's subacute thyroiditis (characteristic). Also elevated in malignancy, infection, and autoimmune thyroiditis."],
    ["Platelet Count",
     "Thrombocytopenia affects surgical haemostasis; thyrotoxicosis can rarely cause thrombocytopenia."],
    ["Bleeding Time / Clotting Time",
     "Coagulation screening before surgery; liver disease from metastasis or alcohol affects coagulation."],
    ["Blood Grouping / Typing",
     "Thyroid surgery (especially re-do or for carcinoma) can involve major vessels — blood availability mandatory."],
    ["Random Blood Sugar",
     "Hyperthyroidism worsens glucose control in diabetics (increases glycogenolysis). Hypothyroidism can cause hypoglycaemia. DM affects wound healing."],
    ["Serum Urea / Creatinine",
     "Hypothyroidism impairs renal function. Drug dosing and contrast safety for CT/MRI."],
    ["VCTC / VDRL",
     "Pre-operative HIV and syphilis screening. Syphilitic gumma can rarely involve the thyroid."],
    ["HBsAg / Anti-HCV",
     "Pre-operative infectious screening — protects surgical team; PTU causes hepatotoxicity; baseline LFT also needed."],
    ["Chest X-Ray PA View",
     "MOST IMPORTANT baseline investigation in thyroid: (1) Tracheal deviation / tracheal compression (2) Retrosternal goitre shadow (3) Pulmonary metastasis from thyroid carcinoma (4) Cardiomegaly from thyrotoxic cardiomyopathy or hypothyroid pericardial effusion."],
    ["ECG All Leads",
     "Atrial fibrillation (irregular, no P waves) = thyrotoxicosis. Tachycardia = hyperthyroid. Bradycardia/flat T waves = hypothyroid. Low voltage = pericardial effusion (hypothyroid)."],
    ["Urine Routine",
     "Albuminuria = renal disease (hypothyroid nephropathy); glycosuria = DM exacerbated by thyrotoxicosis."],
]
story.append(make_table(
    inv_data,
    col_widths=[5*cm, 13*cm],
    hdr_bg=colors.HexColor('#37474f'),
    row_colors=[colors.HexColor('#eceff1'), colors.white]
))
story.append(Spacer(1, 0.4 * cm))

subsection("Specific Investigations")

spec_data = [
    ["Investigation", "Indication & Significance"],
    ["Thyroid Profile\n(T3, T4, TSH)",
     "THE MOST IMPORTANT THYROID INVESTIGATION. TSH is the best single test: Low TSH = hyperthyroid; High TSH = hypothyroid; Normal TSH = euthyroid. T3/T4 quantify severity. Free T3/T4 more accurate (not affected by binding proteins). Guides drug choice and pre-op optimisation."],
    ["USG Neck (Ultrasound)",
     "FIRST-LINE IMAGING. Confirms the swelling is in the thyroid. Assesses: (1) Number of nodules (SNG vs MNG), (2) Size and exact location, (3) Echogenicity (hypoechoic = malignancy risk), (4) Calcification (microcalcifications = papillary carcinoma), (5) Vascularity (Doppler), (6) Cervical lymph nodes, (7) TIRADS scoring for malignancy risk."],
    ["FNAC (Fine Needle Aspiration Cytology)",
     "INVESTIGATION OF CHOICE to distinguish benign from malignant thyroid nodules. Bethesda system (I-VI): I=Non-diagnostic, II=Benign, III=Atypia of undetermined significance, IV=Follicular neoplasm, V=Suspicious malignancy, VI=Malignant. Bethesda III/IV = repeat FNAC or diagnostic lobectomy. Safe, outpatient, inexpensive."],
    ["Core Needle Biopsy",
     "Done when FNAC is non-diagnostic or inconclusive (Bethesda I/III). Provides histological diagnosis (not just cytology). Especially useful for lymphoma and Riedel's thyroiditis. Larger needle — gives tissue core for architecture assessment."],
    ["Radioactive Iodine Scan\n(RAI Scan)",
     "Classifies nodules as: HOT (increased uptake) = autonomous/toxic adenoma — rarely malignant; COLD (decreased uptake) = 15-25% malignancy risk — requires FNAC; WARM (equal uptake) = same risk as background thyroid. Also used for: (1) Ectopic thyroid tissue, (2) Thyroid remnant post-thyroidectomy, (3) Metastasis detection after total thyroidectomy."],
    ["X-Ray Neck",
     "Detects: (1) Tracheal deviation, (2) Tracheal compression and narrowing, (3) Calcification within the thyroid (eggshell/flecked = benign MNG; psammoma body/microcalcification = papillary carcinoma), (4) Retrosternal extension (soft tissue shadow behind sternum)."],
    ["CT Neck",
     "For: (1) Retrosternal goitre — defines extent and tracheal/vascular relationships before surgery, (2) Locally advanced thyroid carcinoma — assesses invasion of trachea, oesophagus, carotid. Note: CT with iodine contrast delays radioiodine therapy by 6-8 weeks due to iodine load."],
    ["MRI Neck",
     "Preferred over CT for: (1) Soft tissue detail (carcinoma vs benign), (2) No iodine load — does not delay radioiodine therapy, (3) Retropharyngeal extension, (4) RLN involvement. Expensive but superior soft tissue resolution."],
    ["PET Scan\n(FDG-PET)",
     "For: (1) Differentiated thyroid carcinoma with elevated Tg (thyroglobulin) but negative RAI scan — 'Tg-positive RAI-negative' = dedifferentiated disease, (2) Medullary carcinoma staging, (3) Anaplastic carcinoma. Most sensitive for aggressive non-iodine-avid tumours."],
    ["ENT Examination\n(Indirect Laryngoscopy)",
     "Mandatory before ALL thyroid surgeries. Assesses bilateral vocal cord mobility. Detects pre-existing RLN palsy from malignant invasion. Protects surgeon medicolegally. Post-operatively detects RLN injury."],
    ["Thyroid Auto-Antibodies",
     "Anti-TPO antibodies (Anti-thyroid peroxidase): Elevated in HASHIMOTO'S THYROIDITIS and Graves' disease. TSH receptor antibodies (TRAb): PATHOGNOMONIC of GRAVES' DISEASE — confirms autoimmune aetiology. Anti-thyroglobulin antibodies: Non-specific, elevated in autoimmune thyroiditis."],
]
story.append(make_table(
    spec_data,
    col_widths=[4.5*cm, 13.5*cm],
    hdr_bg=colors.HexColor('#b71c1c'),
    row_colors=[colors.HexColor('#ffebee'), colors.white]
))
story.append(Spacer(1, 0.5 * cm))

# ── FOOTER ──────────────────────────────────────────────────
story.append(HRFlowable(width="100%", thickness=2,
                         color=colors.HexColor('#4a148c')))
story.append(Spacer(1, 0.15 * cm))
story.append(Paragraph(
    "References: Das S. — A Manual of Clinical Surgery (Latest Edition) | "
    "Rajamahendran — Surgical Principles for Clinical Examination | "
    "Bailey &amp; Love's Short Practice of Surgery | Schwartz's Principles of Surgery",
    ParagraphStyle('footer', parent=styles['Normal'], fontSize=7.5,
                   textColor=colors.HexColor('#546e7a'),
                   alignment=TA_CENTER, fontName='Helvetica-Oblique')))

doc.build(story)
print("PDF created successfully.")

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

LEFT_MARGIN = RIGHT_MARGIN = 1.5 * cm
TOP_MARGIN = BOTTOM_MARGIN = 2.0 * cm
USABLE_W = 21 * cm - LEFT_MARGIN - RIGHT_MARGIN  # exactly 18 cm

doc = SimpleDocTemplate(
    "/tmp/workspace/varicose-veins-pdf/CA_Breast_Significance.pdf",
    pagesize=A4,
    rightMargin=RIGHT_MARGIN, leftMargin=LEFT_MARGIN,
    topMargin=TOP_MARGIN, bottomMargin=BOTTOM_MARGIN,
)

styles = getSampleStyleSheet()

TITLE_ST = ParagraphStyle('TITLE_ST', parent=styles['Title'],
    fontSize=20, textColor=colors.HexColor('#880e4f'),
    spaceAfter=4, alignment=TA_CENTER, fontName='Helvetica-Bold')
SUBTITLE_ST = ParagraphStyle('SUBTITLE_ST', parent=styles['Normal'],
    fontSize=10, textColor=colors.HexColor('#37474f'),
    spaceAfter=8, alignment=TA_CENTER, fontName='Helvetica-Oblique')
SEC_HDR = ParagraphStyle('SEC_HDR', parent=styles['Normal'],
    fontSize=12, textColor=colors.white, spaceAfter=3, spaceBefore=8,
    fontName='Helvetica-Bold', backColor=colors.HexColor('#880e4f'),
    borderPadding=(5, 8, 5, 8))
SUBSEC_HDR = ParagraphStyle('SUBSEC_HDR', parent=styles['Normal'],
    fontSize=10.5, textColor=colors.HexColor('#880e4f'),
    spaceAfter=3, spaceBefore=6, fontName='Helvetica-Bold')
ITEM_HDR = ParagraphStyle('ITEM_HDR', parent=styles['Normal'],
    fontSize=10.5, textColor=colors.HexColor('#b71c1c'),
    spaceAfter=2, spaceBefore=5, fontName='Helvetica-Bold')
BODY_ST = ParagraphStyle('BODY_ST', parent=styles['Normal'],
    fontSize=9, textColor=colors.HexColor('#212121'),
    spaceAfter=3, leading=13, fontName='Helvetica',
    alignment=TA_JUSTIFY, leftIndent=8)
NOTE_ST = ParagraphStyle('NOTE_ST', parent=styles['Normal'],
    fontSize=8.5, textColor=colors.HexColor('#1a237e'),
    spaceAfter=3, fontName='Helvetica-Oblique', leftIndent=8)
BULLET_ST = ParagraphStyle('BULLET_ST', parent=styles['Normal'],
    fontSize=9, textColor=colors.HexColor('#212121'),
    spaceAfter=2, leading=12, fontName='Helvetica',
    leftIndent=18, bulletIndent=6)
THDR = ParagraphStyle('THDR', fontSize=8, textColor=colors.white,
    fontName='Helvetica-Bold', leading=10, spaceAfter=0, spaceBefore=0)
TCELL = ParagraphStyle('TCELL', fontSize=8, textColor=colors.HexColor('#111111'),
    fontName='Helvetica', leading=10, spaceAfter=0, spaceBefore=0, alignment=TA_LEFT)
TCELL_B = ParagraphStyle('TCELL_B', fontSize=8, textColor=colors.HexColor('#111111'),
    fontName='Helvetica-Bold', leading=10, spaceAfter=0, spaceBefore=0)

def make_table(data, col_widths, hdr_bg=colors.HexColor('#880e4f'),
               row_colors=None, pad=4):
    assert abs(sum(col_widths) - USABLE_W) < 2, \
        f"col sum {sum(col_widths):.1f} != {USABLE_W:.1f}"
    if row_colors is None:
        row_colors = [colors.HexColor('#fce4ec'), colors.white]
    wrapped = []
    for r, row in enumerate(data):
        new_row = []
        for c, cell in enumerate(row):
            if r == 0:
                new_row.append(Paragraph(str(cell), THDR))
            elif c == 0:
                new_row.append(Paragraph(str(cell), TCELL_B))
            else:
                new_row.append(Paragraph(str(cell), TCELL))
        wrapped.append(new_row)
    tbl = Table(wrapped, colWidths=col_widths, repeatRows=1, splitByRow=1)
    cmd = [
        ('BACKGROUND',    (0,0), (-1,0), hdr_bg),
        ('TEXTCOLOR',     (0,0), (-1,0), colors.white),
        ('GRID',          (0,0), (-1,-1), 0.4, colors.HexColor('#bdbdbd')),
        ('VALIGN',        (0,0), (-1,-1), 'TOP'),
        ('TOPPADDING',    (0,0), (-1,-1), pad),
        ('BOTTOMPADDING', (0,0), (-1,-1), pad),
        ('LEFTPADDING',   (0,0), (-1,-1), pad),
        ('RIGHTPADDING',  (0,0), (-1,-1), pad),
    ]
    for i in range(1, len(data)):
        cmd.append(('BACKGROUND', (0,i), (-1,i), row_colors[i % len(row_colors)]))
    tbl.setStyle(TableStyle(cmd))
    return tbl

story = []

def section(title):
    story.append(Spacer(1, 0.2*cm))
    story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#880e4f')))
    story.append(Paragraph(f"  {title}", SEC_HDR))
    story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#880e4f')))
    story.append(Spacer(1, 0.12*cm))

def subsection(title):
    story.append(Paragraph(title, SUBSEC_HDR))

def item(title, body, note=None):
    story.append(Paragraph(f"&#9654; {title}", ITEM_HDR))
    if isinstance(body, list):
        for b in body:
            story.append(Paragraph(f"• {b}", BULLET_ST))
    else:
        story.append(Paragraph(body, BODY_ST))
    if note:
        story.append(Paragraph(f"Examiner's Note: {note}", NOTE_ST))
    story.append(Spacer(1, 0.06*cm))

# ── TITLE ─────────────────────────────────────────────────
story.append(Spacer(1, 1.0*cm))
story.append(Paragraph("CARCINOMA BREAST", TITLE_ST))
story.append(Paragraph("EBC | LABC | Metastatic Breast Carcinoma", TITLE_ST))
story.append(Spacer(1, 0.2*cm))
story.append(HRFlowable(width="100%", thickness=3, color=colors.HexColor('#880e4f')))
story.append(Spacer(1, 0.12*cm))
story.append(Paragraph("Significance of Every History and Examination Finding", SUBTITLE_ST))
story.append(Paragraph("According to Das's Manual of Clinical Surgery &amp; Rajamahendran's Surgical Principles", SUBTITLE_ST))
story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor('#90a4ae')))
story.append(Spacer(1, 1.2*cm))

# ══════════════════════════════════════════════════════
# 1. CHIEF COMPLAINTS
# ══════════════════════════════════════════════════════
section("1. CHIEF COMPLAINTS — WHY ASKED & SIGNIFICANCE")

item("Lump in the Right / Left Breast",
     "The most common presenting complaint of carcinoma breast. Asking the DURATION establishes acuity and rate of growth. "
     "A lump noticed incidentally (while bathing, self-examination, mammography screening) in an early stage has far better prognosis than one noticed due to symptoms. "
     "Unilateral vs bilateral is important — bilateral synchronous breast carcinoma occurs in 1-2% of cases. "
     "Confirming premenopausal vs postmenopausal status at the outset is critical — it determines hormonal receptor status, chemotherapy protocol, and prognosis.",
     "A breast lump in a postmenopausal woman is malignant until proven otherwise (Das).")

item("Pain in the Breast",
     "Classical teaching: carcinoma breast is PAINLESS. Pain is more a feature of benign conditions (fibroadenosis, mastitis). "
     "However, 10-15% of carcinoma breast cases do present with pain. "
     "SUDDEN severe pain = haemorrhage into a cyst. "
     "Dull aching pain = fibroadenosis or advanced carcinoma with chest wall involvement. "
     "Pain radiating to the axilla = involvement of the axillary lymphatics or intercostobrachial nerve. "
     "Significance: Character of pain helps distinguish benign from malignant causes and identifies nerve involvement.",
     "Painless lump in breast = carcinoma until proven otherwise. Painful lump = more likely benign, but malignancy must be excluded.")

# ══════════════════════════════════════════════════════
# 2. HISTORY OF PRESENTING ILLNESS
# ══════════════════════════════════════════════════════
section("2. HISTORY OF PRESENTING ILLNESS — SIGNIFICANCE OF EACH H/O")

item("Onset and Progression of Lump",
     "INSIDIOUS onset + SLOWLY PROGRESSIVE = consistent with well-differentiated carcinoma (IDC, ILC). "
     "RAPIDLY PROGRESSIVE over weeks-months = inflammatory carcinoma or high-grade carcinoma (triple-negative). "
     "SUDDEN INCREASE in a previously stable lump = haemorrhage into cyst, or malignant change in a benign lesion. "
     "Rate of progression directly correlates with histological grade and prognosis — faster growth = more aggressive tumour.")

item("H/O Nipple Discharge",
     "Nipple discharge with a breast lump is highly significant for malignancy. "
     "BLOOD-STAINED (serosanguineous) nipple discharge = INTRADUCTAL PAPILLOMA or INTRADUCTAL CARCINOMA (DCIS). "
     "WATERY discharge = early ductal carcinoma. "
     "MILKY discharge (galactorrhoea) = not malignant; suspect prolactinoma or drug effect. "
     "PUS discharge = breast abscess/mastitis. "
     "Significance: Blood-stained nipple discharge with a lump = DCIS or invasive ductal carcinoma — mandates ductography and biopsy.",
     "Blood-stained nipple discharge = malignancy until proven otherwise. Always check which duct it comes from.")

item("H/O Recent Retraction of Nipple",
     "RECENT nipple retraction (new onset) in a woman with a breast lump = MALIGNANCY invading and shortening the lactiferous ducts, pulling the nipple inward. "
     "This is one of the classical signs of carcinoma breast. "
     "Distinguish from: CONGENITAL nipple retraction (present since adolescence, bilateral, no lump — benign). "
     "Significance: Recent unilateral nipple retraction = strong sign of underlying malignancy — biopsy mandatory.",
     "Recent unilateral nipple retraction = malignancy. Lifelong bilateral retraction = congenital (benign).")

item("H/O Fever",
     "Fever with breast swelling suggests: "
     "(1) ACUTE MASTITIS / BREAST ABSCESS — usually in lactating women; unilateral, tender, warm, fluctuant. "
     "(2) INFLAMMATORY CARCINOMA — presents with red, warm, swollen breast, fever, may mimic mastitis. "
     "INFLAMMATORY CARCINOMA is the most aggressive form — must not be mistaken for simple mastitis. "
     "Key distinction: mastitis improves with antibiotics; inflammatory carcinoma does NOT. "
     "Significance: If fever + breast swelling does not resolve with antibiotics in 7-10 days = biopsy mandatory.",
     "Red, warm, swollen breast NOT responding to antibiotics = inflammatory carcinoma. Do punch biopsy — never drain.")

item("H/O Trauma",
     "Direct trauma does NOT cause breast carcinoma. "
     "However, trauma may draw attention to a pre-existing lump that was previously unnoticed. "
     "Fat necrosis after trauma can mimic carcinoma — hard, irregular, skin-tethered mass. "
     "Significance: Documents the history; rules out fat necrosis as the cause of the lump.")

item("H/O Ulcer",
     "Ulceration over a breast lump = advanced local disease (T4d — ulceration is a T4 feature in TNM staging). "
     "Cancer en cuirasse: hard, plate-like infiltration with ulceration of the chest wall. "
     "Significance: Presence of ulceration = T4 disease = LABC (Locally Advanced Breast Cancer) — changes management from surgery-first to NACT (neoadjuvant chemotherapy) first.",
     "Ulceration over breast lump = T4 disease = LABC. Primary surgery is contraindicated; start NACT.")

item("H/O Loss of Weight / Loss of Appetite",
     "Constitutional symptoms of MALIGNANCY and cancer cachexia. "
     "Anorexia and weight loss in a patient with breast lump = advanced or metastatic disease. "
     "Combined with other metastatic symptoms, it indicates stage IV disease. "
     "Guides staging workup and precludes curative intent surgery.")

subsection("Features of Distant Metastasis — Why Each is Asked")

item("H/O Low Back Pain / Bony Pain",
     "BONE IS THE MOST COMMON SITE OF DISTANT METASTASIS in carcinoma breast (occurs in ~70% of metastatic cases). "
     "Bone metastasis in breast carcinoma is predominantly OSTEOLYTIC (unlike prostate which is osteoblastic). "
     "LOW BACK PAIN: lumbar vertebrae, sacrum, pelvis are commonly involved. "
     "BONY PAIN at other sites: long bones (femur, humerus), ribs, skull. "
     "Pathological fractures occur at metastatic sites. "
     "Hypercalcaemia occurs with extensive bone metastases. "
     "SIGNIFICANCE: Bone pain in a breast carcinoma patient = bone scan + skeletal survey + serum calcium mandatory.",
     "Bone = most common metastatic site in breast carcinoma. Bone scan is part of staging in all LABC and suspected metastatic cases.")

item("H/O Chest Pain / Breathlessness / Haemoptysis / Chronic Cough",
     "LUNG IS THE SECOND MOST COMMON SITE OF DISTANT METASTASIS in carcinoma breast. "
     "Lung metastasis presents as: chronic cough (endobronchial metastasis), breathlessness (pleural effusion from metastatic pleural seeding), haemoptysis (erosion of pulmonary vessels). "
     "Pleural effusion with breathlessness = malignant effusion — cytology of fluid confirms metastatic breast carcinoma. "
     "SIGNIFICANCE: These symptoms mandate CXR, CT chest, and pleural fluid analysis for complete staging.")

item("H/O Abdominal Pain / Abdominal Distension / Jaundice",
     "LIVER IS THE THIRD MOST COMMON SITE OF DISTANT METASTASIS. "
     "Liver metastasis presents as: RUQ abdominal pain, hepatomegaly, jaundice (obstructive or hepatocellular from extensive replacement). "
     "Abdominal distension = malignant ascites from peritoneal metastases. "
     "SIGNIFICANCE: These symptoms mandate LFT, USG abdomen, and CT abdomen for staging. "
     "Liver metastasis changes management to palliative chemotherapy.")

item("H/O Loss of Consciousness / Headache / Vomiting / Seizures",
     "BRAIN METASTASIS from carcinoma breast. "
     "Brain is a common site of metastasis, especially in HER2-positive and triple-negative breast carcinoma. "
     "Raised intracranial pressure (RICP) presents as: headache (worse in morning), vomiting (projectile), seizures, altered consciousness. "
     "SIGNIFICANCE: Brain metastasis = very poor prognosis; whole brain radiotherapy (WBRT) or stereotactic radiosurgery (SRS). "
     "Requires CT/MRI brain for staging.")

# ══════════════════════════════════════════════════════
# 3. PAST HISTORY
# ══════════════════════════════════════════════════════
section("3. PAST HISTORY — SIGNIFICANCE")

item("H/O Similar Illness in the Past",
     "Previous breast carcinoma = CONTRALATERAL breast carcinoma risk is 2-6x higher than general population. "
     "Previous breast biopsy showing atypical ductal hyperplasia (ADH) = 4-5x increased carcinoma risk. "
     "Previous DCIS = risk of progression to invasive carcinoma.")

item("H/O DM / SHT / Asthma / Allergy / TB / Epilepsy / Heart Disease / Kidney Disease",
     [
         "DM: Impairs wound healing after mastectomy/reconstruction; worsens chemotherapy-induced neuropathy.",
         "Hypertension: Affects anaesthetic management; some chemotherapy agents (anthracyclines) are cardiotoxic — baseline cardiac function essential.",
         "Asthma/Respiratory disease: Affects fitness for surgery and tolerance of chemotherapy.",
         "Allergy: To drugs — critical for chemotherapy planning (taxane hypersensitivity reactions).",
         "TB: TB of lymph nodes mimics axillary lymph node metastasis — important differential.",
         "Epilepsy: Seizure risk during induction; drug interactions with chemotherapy.",
         "Heart Disease: MANDATORY to assess — anthracyclines (doxorubicin) and trastuzumab (Herceptin) are cardiotoxic. Baseline ECHO/EF needed.",
         "Kidney Disease: Affects drug dosing, hydration during chemotherapy."
     ])

item("H/O Previous Irradiation to Chest / Breast",
     "PREVIOUS RADIATION TO THE CHEST is a well-established RISK FACTOR for breast carcinoma. "
     "Women who received mantle radiotherapy for Hodgkin lymphoma in childhood/young adulthood have markedly increased breast carcinoma risk (8-10x). "
     "Latent period: 10-30 years. "
     "SIGNIFICANCE: Any woman with prior chest irradiation presenting with a breast lump = carcinoma until proven otherwise. "
     "Also, prior breast radiation affects options for re-irradiation in recurrence.",
     "Mantle radiotherapy for Hodgkin lymphoma = highest radiation-associated breast cancer risk. Annual MRI screening recommended from age 25 or 8 years after radiation.")

item("H/O Chronic Drug Intake",
     [
         "Hormone Replacement Therapy (HRT): Combined oestrogen-progestogen HRT increases breast carcinoma risk by 26% (WHI trial). Oestrogen-only HRT: slightly lower risk.",
         "Oral Contraceptive Pills (OCPs): Slightly increased relative risk (RR 1.24) — returns to baseline after stopping.",
         "Tamoxifen (SERM): Being taken = known previous carcinoma or high-risk prophylaxis (BRCA carrier) — extremely important to document.",
         "Aromatase inhibitors: Documents active treatment for previous carcinoma."
     ])

item("H/O Previous Surgeries in the Breast",
     "Previous lumpectomy/wide local excision = altered anatomy; possible recurrence at scar site. "
     "Previous breast augmentation (implants) = affects mammography interpretation; implant rupture mimics mass. "
     "Previous breast biopsy with histology = documented benign or high-risk lesion.")

# ══════════════════════════════════════════════════════
# 4. PERSONAL HISTORY
# ══════════════════════════════════════════════════════
section("4. PERSONAL HISTORY — SIGNIFICANCE")

item("Diet",
     "High-fat, high-calorie diet associated with increased breast carcinoma risk — particularly postmenopausal breast carcinoma (hormone-receptor positive). "
     "Obesity (BMI > 30) is an independent risk factor — adipose tissue converts androgens to oestrogen (aromatisation), increasing oestrogen exposure. "
     "Nutritional status affects tolerance of chemotherapy and wound healing.")

item("Chronic Smoking",
     "Tobacco smoke contains carcinogens (polycyclic aromatic hydrocarbons) that directly damage DNA. "
     "Active smoking modestly increases breast carcinoma risk (especially pre-menopausal women). "
     "Smoking impairs wound healing and increases post-mastectomy wound complications. "
     "Smoking increases anaesthetic and cardiorespiratory risk.")

item("Chronic Alcohol",
     "ALCOHOL is a well-established RISK FACTOR for breast carcinoma. "
     "Even moderate alcohol consumption (1-2 drinks/day) increases risk by 7-10% per drink/day. "
     "Mechanism: Alcohol increases circulating oestrogen levels and produces acetaldehyde (carcinogen). "
     "Significant dose-response relationship — heavier drinking = higher risk. "
     "Also affects liver function (relevant for drug metabolism during chemotherapy).",
     "Alcohol is one of the few modifiable risk factors for breast carcinoma — document carefully.")

item("Bowel / Bladder Habits / Sleep Pattern",
     "Bowel habits: Chronic constipation suggests opioid use (pain from metastasis). Altered bowel habits = GI metastasis. "
     "Sleep: Insomnia from pain/anxiety = indicator of disease burden. "
     "Night sweats = either chemo-induced menopause or constitutional features of malignancy.")

# ══════════════════════════════════════════════════════
# 5. FAMILY HISTORY
# ══════════════════════════════════════════════════════
section("5. FAMILY HISTORY — SIGNIFICANCE")

item("H/O Cancer in Family Members",
     "Family history is one of THE MOST IMPORTANT risk factors for breast carcinoma. "
     "BRCA1 mutation: Lifetime risk 65-80% for breast CA, 40-60% for ovarian CA. Associated with triple-negative carcinoma, bilateral disease. "
     "BRCA2 mutation: Lifetime risk 45-55% for breast CA, 10-20% for ovarian CA. Also associated with male breast CA. "
     "HEREDITARY BREAST-OVARIAN CANCER SYNDROME (HBOC): Multiple first-degree relatives with breast/ovarian cancer. "
     "Requires GENETIC COUNSELLING and BRCA1/2 genetic testing. "
     "First-degree relative with breast CA at < 40 years = STRONGEST risk indicator. "
     "Risk stratification determines screening protocol (annual MRI vs mammography) and prophylactic options (tamoxifen, bilateral risk-reducing mastectomy).",
     "First-degree relative with bilateral or pre-menopausal breast CA = BRCA mutation possible. Offer genetic testing.")

# ══════════════════════════════════════════════════════
# 6. MENSTRUAL HISTORY
# ══════════════════════════════════════════════════════
section("6. MENSTRUAL HISTORY — SIGNIFICANCE")

item("Age at Menarche",
     "EARLY MENARCHE (< 12 years) = INCREASED breast carcinoma risk. "
     "Earlier menarche = longer lifetime oestrogen exposure = greater cumulative oestrogenic stimulation of breast tissue. "
     "This is one of the non-modifiable hormonal risk factors for breast carcinoma. "
     "Women with menarche at < 12 years have ~20% higher breast carcinoma risk than those with menarche at > 15 years.",
     "Early menarche + late menopause = maximum lifetime oestrogen exposure = highest hormonal breast cancer risk.")

item("Age at Menopause / LMP",
     "LATE MENOPAUSE (> 55 years) = INCREASED breast carcinoma risk (longer lifetime oestrogen exposure). "
     "PREMENOPAUSAL vs POSTMENOPAUSAL STATUS is critical for management: "
     "Premenopausal: Ovarian ablation/LHRH analogues used; tamoxifen first-line hormonal therapy. "
     "Postmenopausal: Aromatase inhibitors (anastrozole, letrozole) are preferred over tamoxifen. "
     "LMP establishes exact menopausal status — affects choice of hormonal therapy.",
     "Menopausal status directly determines choice of hormonal therapy — tamoxifen vs aromatase inhibitor.")

item("Cycle Regularity / Dysmenorrhoea",
     "Irregular cycles may suggest anovulatory cycles — associated with lower progesterone levels and relative oestrogen dominance. "
     "Relevant for understanding hormonal background.")

# ══════════════════════════════════════════════════════
# 7. MARITAL & OBSTETRIC HISTORY
# ══════════════════════════════════════════════════════
section("7. MARITAL & OBSTETRIC HISTORY — SIGNIFICANCE")

item("Age at Marriage / Age at First Child Birth",
     "NULLIPARITY or LATE FIRST PREGNANCY (first child after age 30) = INCREASED breast carcinoma risk. "
     "Full-term pregnancy causes terminal differentiation of breast lobular epithelium — making cells less susceptible to malignant transformation. "
     "The earlier the first pregnancy, the greater the protective differentiation. "
     "Nulliparous women have same risk as women with first child after age 30. "
     "SIGNIFICANCE: A woman who has never been pregnant or had her first child late has had prolonged undifferentiated, oestrogen-stimulated breast epithelium — highest risk.",
     "Nulliparity and late first childbirth = established independent risk factors for breast carcinoma (Das).")

item("Number of Children / Breast Feeding",
     "MULTIPARITY provides some protection against breast carcinoma. "
     "BREASTFEEDING is PROTECTIVE against breast carcinoma: "
     "Each 12 months of breastfeeding reduces breast carcinoma risk by ~4.3%. "
     "Mechanism: Breastfeeding delays resumption of ovulation, reducing total lifetime oestrogen exposure. "
     "Also causes further terminal differentiation of breast lobular epithelium. "
     "SIGNIFICANCE: A woman who did not breastfeed has HIGHER risk than one who breastfed for extended periods.",
     "Prolonged breastfeeding is protective. Non-breastfeeding (especially in multipara) is a risk factor for breast carcinoma.")

# ══════════════════════════════════════════════════════
# 8. GENERAL EXAMINATION
# ══════════════════════════════════════════════════════
section("8. GENERAL EXAMINATION — SIGNIFICANCE")

item("Premenopausal / Postmenopausal",
     "Documented at the start of examination — determines hormonal receptor profile, chemotherapy/hormonal therapy options, and prognosis. "
     "Postmenopausal ER-positive carcinoma = aromatase inhibitor preferred. "
     "Premenopausal ER-positive = tamoxifen + ovarian suppression.")

item("Consciousness / Orientation",
     "Altered consciousness in a breast carcinoma patient = brain metastasis with RICP, or hypercalcaemia from bone metastasis. "
     "Both are oncological emergencies requiring immediate management.")

item("Hydration",
     "Dehydration may indicate vomiting (chemotherapy side effect, brain metastasis), poor oral intake (cachexia), or hypercalcaemia (thirst + polyuria + dehydration = 'bones, stones, groans, psychic moans' of hypercalcaemia).")

item("Pallor",
     "Anaemia in breast carcinoma: "
     "(1) Anaemia of chronic disease (most common), "
     "(2) Chemotherapy-induced bone marrow suppression, "
     "(3) Bone marrow metastasis (pancytopenia — normocytic anaemia + low WBC + low platelets). "
     "Pre-operative Hb > 10 g/dL required for surgery.")

item("Jaundice",
     "Liver metastasis from breast carcinoma causing obstructive or hepatocellular jaundice. "
     "Also: chemotherapy-induced hepatotoxicity, biliary obstruction by metastatic nodes.")

item("Build and Nourishment",
     "Wasting and cachexia = advanced/metastatic disease — ECOG performance status assessed. "
     "Obesity = risk factor AND affects prognosis (higher BMI = worse outcomes in hormone-receptor positive breast CA). "
     "Obese patients have more wound complications after mastectomy.")

item("Clubbing",
     "Digital clubbing suggests chronic suppurative lung disease or intrathoracic malignancy. "
     "In context of breast lump, clubbing may indicate extensive pulmonary metastases or hypertrophic pulmonary osteoarthropathy from lung involvement.")

item("Pedal Oedema",
     "Bilateral pedal oedema = hypoproteinaemia (cachexia), cardiac failure (anthracycline cardiotoxicity), or inferior vena cava compression by peritoneal metastasis. "
     "Unilateral limb oedema = lymphoedema from axillary lymph node involvement or post-axillary node dissection.")

item("Generalised Lymphadenopathy",
     "Cervical, axillary, inguinal lymphadenopathy in a breast carcinoma patient = widespread nodal metastases — N3 disease or distant metastases. "
     "SUPRACLAVICULAR LYMPHADENOPATHY in breast carcinoma = N3c disease = advanced locoregional disease (not technically distant metastasis but poor prognosis). "
     "CONTRALATERAL axillary nodes = distant metastasis = stage IV.",
     "Ipsilateral supraclavicular lymph node metastasis in breast carcinoma = N3c = LABC, treated with NACT.")

item("Vital Signs (PR, BP, RR, Temperature)",
     [
         "Pulse Rate: Tachycardia = anaemia, pain, fever (infection/inflammatory CA), PE (pulmonary embolism — 3-4x higher risk in breast CA).",
         "Blood Pressure: Hypertension affects anthracycline-based chemotherapy safety; bevacizumab (anti-VEGF) causes hypertension.",
         "Respiratory Rate: Elevated = pleural effusion/lung metastasis/pulmonary embolism.",
         "Temperature: Fever = post-chemotherapy neutropenic sepsis (oncological emergency), inflammatory carcinoma, or breast abscess."
     ])

# ══════════════════════════════════════════════════════
# 9. LOCAL EXAMINATION — INSPECTION
# ══════════════════════════════════════════════════════
section("9. LOCAL EXAMINATION — INSPECTION (Significance)")

item("Position: Sitting, Arms by Side — Adequate Exposure",
     "BOTH breasts must be fully exposed — asymmetry, skin changes, and nipple changes are best seen in a well-lit room with the patient sitting. "
     "Arms by the side initially — relaxes the pectoralis major, allowing the breast to hang naturally. "
     "The four positions of inspection (arms by side, arms raised, leaning forward, contracting pectoralis) each reveal different aspects of tumour fixity.",
     "Inspect BOTH breasts simultaneously — asymmetry in size, shape, or position is the first sign of an underlying lesion.")

item("Position of Breast / Asymmetry / Size / Shape",
     "A breast displaced upward or inward = underlying tumour pulling skin and gland by fibrotic bands (Cooper's ligament retraction). "
     "Asymmetry in size: sudden increase in one breast = inflammatory carcinoma. "
     "Shape: fullness or flattening in one quadrant = underlying mass.")

item("Skin Changes — Dimpling / Puckering / Retraction",
     "Caused by malignant tumour invading and shortening the COOPER'S LIGAMENTS (fibrous bands connecting breast parenchyma to the overlying skin). "
     "DIMPLING: Focal inward pulling of the skin = tumour is tethering the overlying skin. "
     "PUCKERING: Irregular wrinkling of skin. "
     "RETRACTION: Flat, indrawn area of skin. "
     "SIGNIFICANCE: ALL indicate malignancy invading Cooper's ligaments — T4b in TNM staging (skin involvement). "
     "Enhanced on inspection with arms raised (stretches the ligaments, making the dimple more prominent).",
     "Dimpling and puckering on arm-raising = Cooper's ligament involvement by carcinoma. T4b disease.")

item("Peau d'Orange (Orange Peel Skin)",
     "Oedema of the skin of the breast with prominent hair follicle openings resembling the skin of an orange. "
     "MECHANISM: Malignant tumour blocks the SUBDERMAL LYMPHATICS → lymphoedema of the skin → skin becomes thickened and dimpled at follicular openings (the tethered, inextensible fibrous septa remain depressed). "
     "SIGNIFICANCE: Peau d'orange = T4b disease = LABC = surgery is NOT the primary treatment. "
     "Patient receives NEOADJUVANT CHEMOTHERAPY (NACT) first, then reassessed for surgery.",
     "Peau d'orange = blocked dermal lymphatics = T4b = LABC. Chemotherapy first; surgery later.")

item("Ulceration / Nodules / Fungation",
     "ULCERATION of the skin over the tumour = T4b disease = direct extension of carcinoma through the skin. "
     "SATELLITE NODULES (discrete skin nodules around the main tumour) = dermal metastases from intralymphatic spread. "
     "FUNGATION (cauliflower-like exophytic growth through the skin) = very advanced T4 disease. "
     "All indicate LABC or metastatic disease. Wounds are infected, malodorous, require wound care before any treatment.")

item("Nipple Changes — Position, Shape, Discharge",
     [
         "RECENT RETRACTION: Malignant duct infiltration pulling nipple inward = strong sign of malignancy.",
         "DEVIATION: Nipple pulled to one side by an underlying mass or fibrosis.",
         "PAGET'S DISEASE OF NIPPLE: Eczematous change of the nipple (erythema, scaling, ulceration, itching) = intraepithelial spread of ductal carcinoma from the underlying DCIS to the nipple epidermis (Paget cells).",
         "BLOODY NIPPLE DISCHARGE from a single duct: Intraductal papilloma or DCIS.",
         "SIGNIFICANCE: Paget's disease of the nipple = always associated with underlying DCIS or invasive carcinoma — biopsy mandatory."
     ],
     "Eczema of the nipple that does not respond to topical steroids = Paget's disease = biopsy mandatory.")

item("Areola — Size, Surface, Colour",
     "Areola involvement by eczema = Paget's disease spreading from nipple. "
     "Asymmetric areola = underlying mass deforming architecture. "
     "Increased vascularity/dilated veins over breast = increased blood flow due to high-grade vascular tumour.")

item("Arms / Thorax — Oedema / Nodules",
     "LYMPHOEDEMA OF THE ARM (unilateral) = involvement of axillary lymphatics by tumour (N2-N3 disease) or post-treatment. "
     "Skin nodules on the arm or chest wall = satellite metastatic skin deposits = advanced disease. "
     "Chest wall nodules = carcinoma en cuirasse.")

item("Axilla / Supraclavicular Fossa — Swelling / Fullness",
     "AXILLARY SWELLING on inspection = palpably enlarged axillary lymph nodes (N1-N3 disease). "
     "SUPRACLAVICULAR FULLNESS = supraclavicular lymph node involvement = N3c disease. "
     "Both are visible in advanced disease and indicate nodal metastasis.")

item("Inspection with Arms Raised Above Head",
     "FIXITY: If skin dimpling, retraction, or peau d'orange becomes MORE PROMINENT with arms raised = tumour is tethered to the skin (T4b). "
     "Raising arms STRETCHES the Cooper's ligaments — makes subtle skin tethering visible that was not apparent with arms by the side. "
     "SIGNIFICANCE: Most sensitive position for detecting skin fixity.")

item("Inspection on Leaning Forward",
     "Patient leans forward from the waist — breasts hang freely by gravity. "
     "FIXITY TO CHEST WALL: The affected breast does not swing freely and remains elevated/fixed = tumour invades pectoralis major or chest wall (T4a). "
     "SIGNIFICANCE: Detects deep fixity not appreciable in upright position.")

item("Inspection on Contracting / Relaxing Pectoralis Major",
     "Ask patient to press hands on hips and push inward (contracts pectoralis major). "
     "SWELLING BECOMES MORE PROMINENT on contraction = tumour is fixed to or within pectoralis major (T4a). "
     "SWELLING BECOMES LESS PROMINENT = tumour deep to pectoralis, moves with the muscle. "
     "SIGNIFICANCE: Assesses pectoralis major muscle fixity — changes surgical plan (simple mastectomy vs radical mastectomy).",
     "Pectoralis fixity test: if lump becomes more prominent on contraction = fixed to muscle = T4a = LABC.")

# ══════════════════════════════════════════════════════
# 10. LOCAL EXAMINATION — PALPATION
# ══════════════════════════════════════════════════════
section("10. LOCAL EXAMINATION — PALPATION (Significance)")

item("Warmth and Tenderness",
     "Warmth + tenderness + erythema = INFLAMMATORY CARCINOMA or acute mastitis. "
     "Inflammatory carcinoma: skin warm, red, tender, oedematous — rapidly progressive. "
     "Key: does NOT resolve with antibiotics — biopsy needed. "
     "Also: tenderness in a breast lump = benign cyst or fibroadenosis more commonly.")

item("Single or Multiple Lumps — Size, Site, Shape, Surface, Margin, Consistency",
     [
         "SINGLE lump: More suspicious of carcinoma. MULTIPLE lumps: More likely benign (fibroadenosis, cysts).",
         "SIZE: > 2cm = T1c; > 5cm = T2 boundary; > 5cm = T3. Size directly determines TNM staging.",
         "SITE/QUADRANT: Upper outer quadrant (50%) is the most common site for carcinoma breast — contains the most breast tissue (tail of Spence extends into axilla).",
         "SHAPE: IRREGULAR = malignant. Rounded/ovoid = benign (fibroadenoma).",
         "SURFACE: IRREGULAR/NODULAR = malignant. Smooth = benign.",
         "MARGIN: ILL-DEFINED = malignant (infiltrates surrounding tissue). Well-defined = benign.",
         "CONSISTENCY: STONY HARD = carcinoma (scirrhous/desmoplastic reaction). Firm rubbery = fibroadenoma. Soft fluctuant = cyst.",
         "SIGNIFICANCE: Hard, irregular, ill-defined lump = malignant until proven otherwise."
     ],
     "Upper outer quadrant = most common site for breast carcinoma. Always examine the tail of Spence extending into the axilla.")

item("Skin Fixity",
     "Is the skin freely mobile over the lump, or is it tethered/fixed? "
     "FREE MOBILITY: Skin not involved — early disease. "
     "TETHERING (dimpling on skin movement): Cooper's ligament infiltration = T4b. "
     "FIXED: Skin directly invaded = ulceration/nodules = T4b. "
     "SIGNIFICANCE: Skin fixity = T4 disease = LABC.")

item("Mobility of the Lump",
     "MOVES WITH BREAST TISSUE: Lump moves when the whole breast is moved — it is WITHIN the breast parenchyma. "
     "MOVES INDEPENDENT OF BREAST TISSUE: Lump is SEPARATE from the breast — may be in the subcutaneous tissue or chest wall. "
     "A malignant lump initially moves freely within the breast; as it grows it becomes fixed to overlying skin or underlying muscle.")

item("Fixity to Muscles — Pectoralis Major, Serratus Anterior, Latissimus Dorsi",
     [
         "PECTORALIS MAJOR TEST: Ask patient to press hands on hips (contract PM). If lump becomes LESS MOBILE = fixed to PM. If IMMOBILE on PM contraction = invades PM = T4a.",
         "SERRATUS ANTERIOR: Test by asking patient to push against a wall. Fixity to SA detected.",
         "LATISSIMUS DORSI: Assessed by asking patient to pull arms backward against resistance.",
         "SIGNIFICANCE: Fixity to any chest wall muscle = T4a = LABC = primary surgery contraindicated; NACT required."
     ],
     "T4a = fixity to chest wall (pectoralis major/minor, serratus anterior, ribs, intercostals). T4b = skin involvement.")

item("Fixity to Chest Wall",
     "Lump that is immobile even with all muscle groups relaxed = fixed to CHEST WALL (ribs, intercostal muscles). "
     "This is T4a disease — most advanced local stage. "
     "RADICAL SURGERY (radical mastectomy with chest wall resection) may be considered but usually NACT first.")

item("Nipple — Discharge, Retraction, Lump",
     "Palpate the subareolar region for a lump behind the nipple. "
     "Central lump behind nipple = DCIS, intraductal carcinoma, or Paget's disease. "
     "Express nipple discharge and note character (blood-stained vs serous). "
     "Recent palpable retraction = malignant shortening of lactiferous ducts.")

item("Axillary Lymph Node Examination",
     [
         "GROUPS: Anterior (pectoral), Central, Posterior (subscapular), Lateral (brachial), Apical (infraclavicular) — assess all 5 groups.",
         "NUMBER: Single node vs multiple vs matted mass.",
         "SIZE: Nodes > 1cm clinically significant.",
         "CONSISTENCY: Hard = metastatic. Soft = reactive. Firm, rubbery = lymphoma.",
         "MOBILITY: Mobile nodes = N1 (operable). FIXED or MATTED = N2 disease (fixed to each other or to axillary vein) = LABC.",
         "FIXED TO AXILLARY VEIN: Immovable mass in axilla = N2b = LABC.",
         "SIGNIFICANCE: Axillary nodal status is the SINGLE MOST IMPORTANT PROGNOSTIC FACTOR in breast carcinoma (Das). Each positive node worsens 5-year survival by approximately 10-15%."
     ],
     "Axillary node status = single most important prognostic factor in breast carcinoma. N0 vs N1 vs N2 vs N3 directly determines treatment and prognosis.")

item("Percussion over Sternum — Resonant or Dull",
     "Percussion over the manubrium sternum and sternal body. "
     "DULL PERCUSSION = retrosternal lymph node metastasis (internal mammary chain) or mediastinal involvement. "
     "Internal mammary chain nodes receive lymphatic drainage from the medial and central breast quadrants. "
     "Their involvement = N3b disease = LABC. "
     "RESONANT = normal.")

item("Examination of Opposite Breast",
     "MUST be examined in every breast carcinoma case. "
     "Contralateral breast carcinoma: synchronous = 1-2%, metachronous = higher lifetime risk. "
     "Bilateral disease changes surgical and oncological planning. "
     "Any abnormality in the opposite breast must be investigated with USG and FNAC.")

# ══════════════════════════════════════════════════════
# 11. SYSTEMIC EXAMINATION
# ══════════════════════════════════════════════════════
section("11. SYSTEMIC EXAMINATION — SIGNIFICANCE")

item("CVS (S1, S2, Murmurs, Added Sounds)",
     "Anthracyclines (doxorubicin) and trastuzumab (Herceptin) are CARDIOTOXIC — baseline cardiac assessment mandatory. "
     "S3 gallop or basal crackles = early cardiac failure from cardiotoxic chemotherapy. "
     "Pericardial rub/effusion = pericardial metastasis or radiation-induced pericarditis.")

item("RS (NVBS, Added Sounds)",
     "DECREASED BREATH SOUNDS at base = pleural effusion from pleural metastasis. "
     "Stony dull percussion + absent breath sounds = large malignant pleural effusion. "
     "Wheeze/added sounds = endobronchial metastasis or radiation pneumonitis.")

item("Abdomen (Organomegaly, Free Fluid, PR/PV)",
     [
         "Hepatomegaly: Liver metastasis — firm, irregular, nodular liver. Affects LFT and precludes hepatotoxic chemotherapy.",
         "Ascites: Malignant ascites from peritoneal metastases — cytology of fluid confirms metastatic breast carcinoma.",
         "PR: Rectal metastasis (rare); rectal wall involvement from pelvic peritoneal disease.",
         "PV: Ovarian metastasis from breast carcinoma (Krukenberg tumour-like). BRCA1/2 patients: ovarian carcinoma may co-exist."
     ])

item("Spine Examination",
     "Tenderness over vertebral spinous processes = vertebral metastasis. "
     "Spinal cord compression from vertebral metastases = motor weakness, sensory loss, bladder dysfunction — SPINAL EMERGENCY. "
     "Requires urgent MRI spine and corticosteroids.")

item("Cranium Examination",
     "Skull metastases are palpable as hard nodular deposits. "
     "Associated intracranial pressure elevation = papilloedema on fundoscopy. "
     "Skull tenderness = lytic metastasis. "
     "Requires skull X-ray and CT/MRI brain.")

item("PV / PR Examination",
     "PV: Assess for ovarian metastasis (enlarged, firm, irregular ovaries). BRCA carrier patients at high risk. "
     "PR: Assess for pelvic nodal disease or rectal wall involvement. "
     "Also relevant for staging workup in advanced disease.")

# ══════════════════════════════════════════════════════
# 12. DIAGNOSIS — TNM STAGING
# ══════════════════════════════════════════════════════
section("12. DIAGNOSIS — TNM STAGING & SIGNIFICANCE")

# 3-col: 3cm + 5cm + 10cm = 18cm
tnm_data = [
    ["Stage", "TNM Definition", "Clinical Significance"],
    ["EBC (Early Breast Cancer)",
     "T1-T2, N0-N1, M0",
     "Lump < 5cm, mobile, no fixed nodes, no distant metastasis. Primary surgery (BCS or mastectomy + SLNB/ALND) is the treatment of choice. Excellent prognosis (5-yr survival 80-95%)."],
    ["LABC (Locally Advanced)",
     "T3-T4 any N M0, or any T N2-N3 M0",
     "T4 = skin/chest wall involvement (peau d'orange, ulceration, fixity). N2-N3 = fixed/matted nodes or supraclavicular nodes. Primary NACT (neoadjuvant chemotherapy) first; surgery later. 5-yr survival 50-70%."],
    ["MBC (Metastatic)",
     "Any T, any N, M1",
     "Distant metastases (bone, liver, lung, brain). Palliative intent. Systemic therapy (chemotherapy, hormonal, targeted). Median survival 2-3 years. Goal = quality of life + disease control."],
    ["T1", "Tumour ≤ 2cm", "T1a ≤ 0.5cm, T1b 0.5-1cm, T1c 1-2cm. BCS usually appropriate."],
    ["T2", "Tumour 2-5cm", "BCS or mastectomy depending on breast size. Sentinel node biopsy."],
    ["T3", "Tumour > 5cm", "NACT may be considered to downstage for BCS."],
    ["T4a", "Chest wall fixity", "Pectoralis major/minor, serratus anterior, ribs fixed. LABC. NACT first."],
    ["T4b", "Skin involvement", "Peau d'orange, ulceration, satellite nodules. LABC. NACT first."],
    ["T4c", "Both T4a + T4b", "Combined chest wall and skin involvement. Very advanced LABC."],
    ["T4d", "Inflammatory CA", "Diffuse brawny induration, erythema > 1/3 breast skin. Most aggressive. NACT mandatory."],
    ["N0", "No regional nodes", "No axillary involvement. Best prognosis. Sentinel node biopsy to confirm."],
    ["N1", "Mobile ipsilateral nodes", "1-3 nodes involved. Operable. ALND done."],
    ["N2", "Fixed/matted ipsilateral nodes", "N2a = nodes fixed to each other. N2b = internal mammary nodes. LABC. NACT first."],
    ["N3", "Infraclavicular/supraclavicular", "N3c = supraclavicular = LABC. Worst nodal stage. NACT first."],
]
story.append(make_table(
    tnm_data,
    col_widths=[3*cm, 5*cm, 10*cm],
    hdr_bg=colors.HexColor('#880e4f'),
    row_colors=[colors.HexColor('#fce4ec'), colors.white]
))
story.append(Spacer(1, 0.4*cm))

# ══════════════════════════════════════════════════════
# 13. INVESTIGATIONS
# ══════════════════════════════════════════════════════
section("13. INVESTIGATIONS — SIGNIFICANCE OF EACH")

subsection("Baseline Investigations")

# 2-col: 5cm + 13cm = 18cm
inv_data = [
    ["Investigation", "Significance in Carcinoma Breast"],
    ["Haemoglobin",
     "Anaemia of chronic disease, chemotherapy-induced myelosuppression, or bone marrow metastasis. Pre-op Hb > 10 g/dL. Also relevant for chemotherapy dose-limiting toxicity assessment."],
    ["Total Count / DC",
     "Baseline WBC essential — chemotherapy causes neutropenia. Post-chemo neutropenic fever (WBC < 1000/mm³) = oncological emergency. DC also detects eosinophilia (metastatic disease)."],
    ["ESR",
     "Elevated in malignancy, infection, and metastatic disease. Useful baseline but non-specific."],
    ["Platelet Count",
     "Thrombocytopenia from bone marrow metastasis or chemotherapy. Affects surgical and chemotherapy planning."],
    ["Random Blood Sugar",
     "DM affects wound healing and chemotherapy tolerance. Steroids (dexamethasone used with chemo) worsen glycaemia."],
    ["Serum Urea / Creatinine",
     "Renal function for drug dosing (cyclophosphamide, methotrexate). Hypercalcaemia from bone metastasis causes renal impairment."],
    ["Urine Routine",
     "Proteinuria = renal involvement. Glycosuria = DM. Haematuria = bladder involvement by pelvic disease."],
    ["Bleeding Time / Clotting Time",
     "Pre-operative coagulation screening. Chemotherapy and liver metastasis affect coagulation."],
    ["Blood Grouping / Typing",
     "Mastectomy ± axillary clearance requires blood availability. Especially important in modified radical mastectomy."],
    ["HIV/VDRL/HBsAg/Anti-HCV",
     "Pre-operative screening. HIV affects immunosuppression and chemotherapy tolerance. Hepatitis affects hepatotoxic drug choices."],
    ["ECG All Leads",
     "Baseline cardiac assessment before anthracycline-based chemotherapy. Detects AF, ischaemia, LVH. Trastuzumab requires baseline ECHO (not ECG alone)."],
    ["CXR PA View",
     "Pulmonary metastases (nodular shadows, hilar lymphadenopathy), pleural effusion (malignant), pericardial effusion. Pre-anaesthetic assessment."],
]
story.append(make_table(
    inv_data,
    col_widths=[5*cm, 13*cm],
    hdr_bg=colors.HexColor('#37474f'),
    row_colors=[colors.HexColor('#eceff1'), colors.white]
))
story.append(Spacer(1, 0.4*cm))

subsection("Specific Investigations")

spec_data = [
    ["Investigation", "Indication & Significance"],
    ["USG Breast & Axilla",
     "FIRST-LINE IMAGING in women < 40 years (dense breast tissue). Characterises solid vs cystic lesions. USG-guided FNAC/CNB. Axillary node assessment (size, cortical thickness, loss of fatty hilum = suspicious). LIMITATIONS: < 1cm lesions may be missed; no role in screening."],
    ["Mammography",
     "GOLD STANDARD IMAGING for breast. Both breasts always imaged. Findings of malignancy: microcalcifications (linear/branching/stipulated), architectural distortion, spiculated soft tissue mass, increased density, skin thickening, loss of symmetry. BIRADS scoring (0-6) determines management. Annual mammography from age 40 (average risk); earlier in BRCA carriers."],
    ["FNAC of Breast Lump\n(C0-C5 grading)",
     "TRIPLE ASSESSMENT: Clinical + USG + FNAC. FNAC grading: C0=no cells; C1=scanty cells (inadequate); C2=benign; C3=atypical; C4=suspicious; C5=malignant. C3/C4 = repeat or proceed to CNB. ADVANTAGES: Quick, outpatient, cheap, no general anaesthesia. LIMITATION: Cannot distinguish invasive from in situ carcinoma; no receptor testing possible."],
    ["Core Needle Biopsy (CNB)",
     "PREFERRED over FNAC for: (1) histological diagnosis (architecture assessment), (2) receptor testing (ER, PR, HER2, Ki-67), (3) distinguishing invasive from in situ. Bethesda B1-B5. MANDATORY for NACT planning — receptors must be known before starting chemotherapy."],
    ["BIRADS Classification\n(Mammography)",
     "BIRADS 0 = additional imaging needed. BIRADS 1 = negative (routine screening). BIRADS 2 = benign (routine follow-up). BIRADS 3 = probably benign (6-month follow-up). BIRADS 4 = suspicious (biopsy recommended). BIRADS 5 = highly suspicious (biopsy mandatory). BIRADS 6 = known malignancy (treatment planning)."],
    ["Liver Function Tests (LFT)",
     "Mandatory in all LABC and metastatic cases. Elevated LFT = liver metastasis or chemotherapy hepatotoxicity. ALP elevated in both liver and bone metastasis. Baseline before hepatotoxic drugs (methotrexate, taxanes)."],
    ["USG Abdomen & Pelvis",
     "Liver metastases (hypoechoic nodules), ascites, pelvic metastases, ovarian metastases (BRCA patients). Mandatory staging investigation in LABC and MBC."],
    ["Excision / Incision Biopsy",
     "Excision biopsy: for small lesions (< 3cm) — removes entire lesion for histology. Incision biopsy: for large/LABC lesions where only a portion is taken for diagnosis. Core biopsy has largely replaced incision biopsy."],
    ["Ductography (Galactography)",
     "When blood-stained nipple discharge is present. Contrast injected into the discharging duct. Shows intraductal filling defect (papilloma or DCIS). Investigation of CHOICE for single-duct blood-stained nipple discharge."],
    ["CT Chest / CECT Chest",
     "EBC: Not routine. LABC/MBC: Mandatory — detects pulmonary metastases, mediastinal nodes, pleural effusion, pericardial effusion. CECT superior to plain CT for vascular assessment."],
    ["CT Abdomen & Pelvis / CECT",
     "Mandatory in LABC and MBC. Liver metastases, adrenal metastases, retroperitoneal nodes, pelvic disease. Ascites quantification."],
    ["Bone Scan / Skeletal Survey",
     "Bone scan (technetium-99m): MOST SENSITIVE test for bone metastases. Hot spots = active bone turnover at metastatic sites. Skeletal survey (plain X-rays): Used when bone scan unavailable. INDICATION: Any LABC, or bone pain in EBC. Breast CA bone metastases are predominantly LYTIC (appear as dark holes on X-ray)."],
    ["BRCA1/2 Genetic Testing",
     "Indicated in: (1) First-degree relative with breast/ovarian CA, (2) Bilateral breast CA, (3) Male breast CA, (4) Triple-negative CA < 60 years, (5) Multiple primary cancers. Positive result: prophylactic contralateral mastectomy, prophylactic salpingo-oophorectomy, PARP inhibitor therapy (olaparib). Genetic counselling mandatory before testing."],
]
story.append(make_table(
    spec_data,
    col_widths=[4.5*cm, 13.5*cm],
    hdr_bg=colors.HexColor('#b71c1c'),
    row_colors=[colors.HexColor('#ffebee'), colors.white]
))
story.append(Spacer(1, 0.4*cm))

subsection("EBC-Specific vs LABC-Specific Investigations")

stage_data = [
    ["Investigation", "EBC (Early Breast Cancer)", "LABC (Locally Advanced)"],
    ["Core Needle Biopsy",
     "Mandatory — histology + receptor status",
     "Mandatory — needed before NACT starts"],
    ["USG Breast & Axilla",
     "Mandatory — characterise lump, assess nodes",
     "Mandatory — assess response to NACT"],
    ["Mammography",
     "Mandatory (both breasts)",
     "Opposite breast only (affected breast assessed clinically + USG)"],
    ["USG Abdomen & Pelvis",
     "Routine — liver/pelvic metastases",
     "Mandatory — full staging"],
    ["CXR",
     "Routine pre-op",
     "Routine staging"],
    ["LFT",
     "Routine",
     "Mandatory — liver mets assessment"],
    ["CECT Chest",
     "Not routine unless symptomatic",
     "Mandatory staging"],
    ["CECT Abdomen & Pelvis",
     "Not routine unless symptomatic",
     "Mandatory staging"],
    ["Bone Scan",
     "Only if bone pain/symptoms",
     "Mandatory staging (or skeletal survey if unavailable)"],
]
story.append(make_table(
    stage_data,
    col_widths=[4.5*cm, 6.75*cm, 6.75*cm],
    hdr_bg=colors.HexColor('#1a237e'),
    row_colors=[colors.HexColor('#e8eaf6'), colors.white]
))
story.append(Spacer(1, 0.5*cm))

# ── FOOTER ──────────────────────────────────────────────────
story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor('#880e4f')))
story.append(Spacer(1, 0.15*cm))
story.append(Paragraph(
    "References: Das S. — A Manual of Clinical Surgery (Latest Edition) | "
    "Rajamahendran — Surgical Principles for Clinical Examination | "
    "Bailey &amp; Love's Short Practice of Surgery | AJCC Cancer Staging Manual (8th Edition)",
    ParagraphStyle('footer', parent=styles['Normal'], fontSize=7.5,
                   textColor=colors.HexColor('#546e7a'),
                   alignment=TA_CENTER, fontName='Helvetica-Oblique')))

doc.build(story)
print("PDF created successfully.")