mkdir -p /home/daytona/workspace/jaundice-presentation && ls /home/daytona/works…

~/jaundice-presentation/build.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "Medical Education";
pres.title = "Approach to Jaundice - Ward Rounds";

// ─── PALETTE ──────────────────────────────────────────────────────────────────
const C = {
  bg:       "0D1B2A",   // deep navy (dominant dark)
  panel:    "1A2E45",   // mid navy panel
  card:     "122337",   // card bg
  accent1:  "F5A623",   // amber/gold – jaundice colour
  accent2:  "2BBFA4",   // teal – action/process
  accent3:  "E05C5C",   // coral/red – danger / alerts
  accent4:  "7EB8F7",   // sky blue – info
  white:    "FFFFFF",
  lightgray:"C8D8E8",
  muted:    "8AA5BE",
};

// ─── HELPER: standard slide header bar ────────────────────────────────────────
function addHeader(slide, title, subtitle) {
  // Full-width amber top bar
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 0, w: 10, h: 0.72,
    fill: { color: C.accent1 }, line: { color: C.accent1 }
  });
  slide.addText(title.toUpperCase(), {
    x: 0.3, y: 0, w: 9.4, h: 0.72,
    fontSize: 18, bold: true, color: C.bg, valign: "middle", margin: 0,
    charSpacing: 2
  });
  if (subtitle) {
    slide.addText(subtitle, {
      x: 0.3, y: 0.72, w: 9.4, h: 0.28,
      fontSize: 9, color: C.muted, valign: "middle", italic: true, margin: 0
    });
  }
}

// ─── HELPER: coloured badge ───────────────────────────────────────────────────
function addBadge(slide, text, x, y, w, h, bg, fg) {
  slide.addShape(pres.shapes.ROUNDED_RECTANGLE, {
    x, y, w, h,
    fill: { color: bg }, line: { color: bg }, rectRadius: 0.08
  });
  slide.addText(text, {
    x, y, w, h,
    fontSize: 8.5, bold: true, color: fg || C.white,
    align: "center", valign: "middle", margin: 0
  });
}

// ─── HELPER: pearl box ────────────────────────────────────────────────────────
function addPearl(slide, text, x, y, w, h) {
  slide.addShape(pres.shapes.RECTANGLE, {
    x, y, w, h,
    fill: { color: C.panel },
    line: { color: C.accent1, pt: 1.5 }
  });
  slide.addText([
    { text: "★ PEARL  ", options: { bold: true, color: C.accent1, fontSize: 8 } },
    { text: text, options: { color: C.lightgray, fontSize: 8.5 } }
  ], { x: x + 0.1, y, w: w - 0.2, h, valign: "middle", margin: 4 });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 – TITLE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.bg };

  // Giant amber accent strip left
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 0, w: 0.18, h: 5.625,
    fill: { color: C.accent1 }, line: { color: C.accent1 }
  });

  // Decorative circle top-right
  s.addShape(pres.shapes.OVAL, {
    x: 7.5, y: -1.2, w: 4.2, h: 4.2,
    fill: { color: C.panel, transparency: 40 }, line: { color: C.accent1, pt: 1.5 }
  });

  s.addText("APPROACH TO", {
    x: 0.5, y: 1.0, w: 9, h: 0.7,
    fontSize: 22, color: C.muted, bold: false, charSpacing: 8, margin: 0
  });
  s.addText("JAUNDICE", {
    x: 0.5, y: 1.55, w: 9, h: 1.5,
    fontSize: 72, bold: true, color: C.accent1, charSpacing: 4, margin: 0
  });
  s.addText("A Systematic Ward Round Framework", {
    x: 0.5, y: 3.1, w: 8, h: 0.45,
    fontSize: 15, color: C.lightgray, italic: true, margin: 0
  });

  // Divider
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.5, y: 3.62, w: 5.5, h: 0.04,
    fill: { color: C.accent2 }, line: { color: C.accent2 }
  });

  s.addText("Harrison's 22E  ·  Schwartz's Surgery 11E  ·  Lippincott Biochemistry 8E", {
    x: 0.5, y: 3.75, w: 9, h: 0.3,
    fontSize: 9, color: C.muted, margin: 0
  });

  // 3 key concept badges
  const badges = [
    { t: "Pre-Hepatic", c: C.accent3 },
    { t: "Hepatic", c: C.accent2 },
    { t: "Post-Hepatic", c: C.accent4 }
  ];
  badges.forEach((b, i) => {
    addBadge(s, b.t, 0.5 + i * 2.1, 4.3, 1.85, 0.48, b.c, C.white);
  });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 – WHAT IS JAUNDICE? (Definition + Bilirubin pathway)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.bg };
  addHeader(s, "What Is Jaundice?", "Definition · Bilirubin pathway · Clinical threshold");

  // Left column – definition cards
  const defs = [
    { label: "Definition", text: "Yellow discolouration of skin, sclerae & mucous membranes from bilirubin deposition" },
    { label: "Threshold", text: "Normal bilirubin ≤ 1 mg/dL · Visible jaundice at 2–3 mg/dL · Scleral icterus appears first (elastin affinity)" },
    { label: "Pseudojaundice", text: "Yellow skin WITHOUT scleral icterus = Carotenemia · Bilirubin has no affinity for avascular lens → sclerae are spared" },
  ];
  defs.forEach((d, i) => {
    const yy = 1.15 + i * 1.32;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.3, y: yy, w: 4.5, h: 1.1,
      fill: { color: C.panel }, line: { color: C.accent2, pt: 1 } });
    s.addText(d.label.toUpperCase(), {
      x: 0.4, y: yy + 0.05, w: 4.3, h: 0.28,
      fontSize: 8, bold: true, color: C.accent2, margin: 0
    });
    s.addText(d.text, {
      x: 0.4, y: yy + 0.3, w: 4.3, h: 0.72,
      fontSize: 9.5, color: C.lightgray, margin: 0, wrap: true
    });
  });

  // Right column – bilirubin pathway steps
  s.addText("BILIRUBIN PATHWAY", {
    x: 5.1, y: 1.1, w: 4.6, h: 0.3,
    fontSize: 9, bold: true, color: C.accent1, charSpacing: 2, margin: 0
  });

  const steps = [
    { n:"1", label:"Production", note:"Heme → UCB in RES (spleen/liver)", col: C.accent3 },
    { n:"2", label:"Transport", note:"UCB bound to albumin in blood (not filterable)", col: C.accent3 },
    { n:"3", label:"Uptake", note:"OATP1B1/1B3 transporters in hepatocyte", col: C.accent2 },
    { n:"4", label:"Conjugation", note:"UCB + glucuronate → CB via UGT1A1", col: C.accent2 },
    { n:"5", label:"Excretion", note:"CB → bile via MRP2 → gut → stercobilin (brown stool)", col: C.accent4 },
  ];
  steps.forEach((st, i) => {
    const yy = 1.48 + i * 0.77;
    // circle number
    s.addShape(pres.shapes.OVAL, { x: 5.1, y: yy, w: 0.38, h: 0.38,
      fill: { color: st.col }, line: { color: st.col } });
    s.addText(st.n, { x: 5.1, y: yy, w: 0.38, h: 0.38,
      fontSize: 10, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });
    s.addText(st.label, { x: 5.6, y: yy, w: 1.5, h: 0.38,
      fontSize: 10, bold: true, color: C.white, valign: "middle", margin: 0 });
    s.addText(st.note, { x: 7.2, y: yy, w: 2.5, h: 0.38,
      fontSize: 8.5, color: C.muted, valign: "middle", margin: 0, wrap: true });
    // connector arrow (except last)
    if (i < steps.length - 1) {
      s.addShape(pres.shapes.RECTANGLE, { x: 5.25, y: yy + 0.38, w: 0.08, h: 0.39,
        fill: { color: C.muted }, line: { color: C.muted } });
    }
  });

  // Bottom pearl
  addPearl(s, "Liver daily capacity: >3,000 mg/day · Normal production: ~300 mg/day · This 10:1 reserve explains why pure hemolysis rarely exceeds 5 mg/dL",
    0.3, 5.05, 9.4, 0.42);
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 – THE 3-ZONE FRAMEWORK
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.bg };
  addHeader(s, "The 3-Zone Framework", "Pre-hepatic · Hepatic · Post-hepatic");

  const zones = [
    {
      title: "PRE-HEPATIC",
      color: C.accent3,
      mech: "Excess bilirubin production overwhelms conjugation capacity",
      bili: "↑ UCB (indirect)",
      urine: "Urobilinogen ↑↑  |  NO bilirubinuria",
      stool: "Dark (excess stercobilin)",
      causes: ["Hereditary: spherocytosis, SCD, G6PD, PK def.", "Acquired: MAHA (HUS/TTP), PNH, autoimmune", "Malaria, babesiosis", "Ineffective erythropoiesis: B12/folate deficiency"],
    },
    {
      title: "HEPATIC",
      color: C.accent2,
      mech: "Hepatocyte dysfunction at uptake, conjugation or excretion steps",
      bili: "UCB or CB depending on step",
      urine: "Variable – bilirubinuria in severe disease",
      stool: "Variable",
      causes: ["Viral hepatitis A/B/C/D/E, EBV, CMV", "Alcoholic hepatitis (AST:ALT >2:1)", "Drug-induced (APAP, chlorpromazine)", "Autoimmune hepatitis, Wilson's disease", "Gilbert's, Crigler-Najjar, Dubin-Johnson"],
    },
    {
      title: "POST-HEPATIC",
      color: C.accent4,
      mech: "Mechanical CBD obstruction → CB regurgitates into sinusoids",
      bili: "↑↑ CB (direct)",
      urine: "Dark (bilirubinuria) · Urobilinogen ABSENT",
      stool: "Pale / clay-coloured",
      causes: ["Choledocholithiasis (colicky RUQ pain)", "Pancreatic head ca. (painless jaundice)", "Cholangiocarcinoma (Klatskin tumour)", "Ascending cholangitis (Charcot's triad)", "Chronic pancreatitis, Mirizzi syndrome"],
    },
  ];

  zones.forEach((z, i) => {
    const x = 0.18 + i * 3.28;
    // Zone card
    s.addShape(pres.shapes.RECTANGLE, { x, y: 1.05, w: 3.1, h: 4.3,
      fill: { color: C.card }, line: { color: z.color, pt: 2 } });
    // Title bar
    s.addShape(pres.shapes.RECTANGLE, { x, y: 1.05, w: 3.1, h: 0.42,
      fill: { color: z.color }, line: { color: z.color } });
    s.addText(z.title, { x, y: 1.05, w: 3.1, h: 0.42,
      fontSize: 11.5, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

    s.addText("MECHANISM", { x: x + 0.1, y: 1.53, w: 2.9, h: 0.22,
      fontSize: 7, bold: true, color: z.color, margin: 0 });
    s.addText(z.mech, { x: x + 0.1, y: 1.72, w: 2.9, h: 0.42,
      fontSize: 8.5, color: C.lightgray, margin: 0, wrap: true });

    s.addShape(pres.shapes.RECTANGLE, { x: x + 0.1, y: 2.19, w: 2.9, h: 0.02,
      fill: { color: C.muted }, line: { color: C.muted } });

    s.addText("BILIRUBIN", { x: x + 0.1, y: 2.25, w: 2.9, h: 0.2,
      fontSize: 7, bold: true, color: z.color, margin: 0 });
    s.addText(z.bili, { x: x + 0.1, y: 2.43, w: 2.9, h: 0.22,
      fontSize: 8.5, color: C.white, margin: 0 });

    s.addText("URINE / STOOL", { x: x + 0.1, y: 2.72, w: 2.9, h: 0.2,
      fontSize: 7, bold: true, color: z.color, margin: 0 });
    s.addText(z.urine, { x: x + 0.1, y: 2.9, w: 2.9, h: 0.22,
      fontSize: 8, color: C.lightgray, margin: 0 });
    s.addText(z.stool, { x: x + 0.1, y: 3.1, w: 2.9, h: 0.22,
      fontSize: 8, color: C.lightgray, margin: 0 });

    s.addShape(pres.shapes.RECTANGLE, { x: x + 0.1, y: 3.37, w: 2.9, h: 0.02,
      fill: { color: C.muted }, line: { color: C.muted } });

    s.addText("KEY CAUSES", { x: x + 0.1, y: 3.42, w: 2.9, h: 0.2,
      fontSize: 7, bold: true, color: z.color, margin: 0 });
    z.causes.forEach((c, ci) => {
      s.addText("· " + c, { x: x + 0.1, y: 3.62 + ci * 0.31, w: 2.9, h: 0.3,
        fontSize: 8, color: C.lightgray, margin: 0, wrap: true });
    });
  });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 – DIAGNOSTIC ALGORITHM (Harrison's framework)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.bg };
  addHeader(s, "Diagnostic Algorithm", "Harrison's 22E – Fig 52-1 framework");

  // ── Branch 1: ISOLATED BILIRUBIN ELEVATION ──
  // Top box
  s.addShape(pres.shapes.RECTANGLE, { x: 3.3, y: 1.05, w: 3.4, h: 0.6,
    fill: { color: C.panel }, line: { color: C.accent1, pt: 1.5 } });
  s.addText("JAUNDICED PATIENT", { x: 3.3, y: 1.05, w: 3.4, h: 0.6,
    fontSize: 11, bold: true, color: C.accent1, align: "center", valign: "middle", margin: 0 });

  // Arrow down
  s.addShape(pres.shapes.RECTANGLE, { x: 4.96, y: 1.65, w: 0.08, h: 0.3,
    fill: { color: C.muted }, line: { color: C.muted } });

  // Question box
  s.addShape(pres.shapes.RECTANGLE, { x: 2.7, y: 1.95, w: 4.6, h: 0.55,
    fill: { color: C.card }, line: { color: C.accent2, pt: 1 } });
  s.addText("Are other LFTs abnormal?  (ALT · AST · ALP · GGT)", {
    x: 2.7, y: 1.95, w: 4.6, h: 0.55,
    fontSize: 10, color: C.lightgray, align: "center", valign: "middle", margin: 0
  });

  // Left branch: NO – isolated
  s.addShape(pres.shapes.RECTANGLE, { x: 2.7, y: 1.95, w: 0, h: 0 });
  s.addText("NO", { x: 0.5, y: 2.05, w: 0.5, h: 0.28,
    fontSize: 8.5, bold: true, color: C.accent3 });
  // horizontal arrow left
  s.addShape(pres.shapes.RECTANGLE, { x: 0.9, y: 2.2, w: 1.8, h: 0.05,
    fill: { color: C.muted }, line: { color: C.muted } });

  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 2.5, w: 2.5, h: 1.4,
    fill: { color: C.panel }, line: { color: C.accent3, pt: 1.5 } });
  s.addText("ISOLATED BILIRUBIN ↑", { x: 0.2, y: 2.5, w: 2.5, h: 0.35,
    fontSize: 9, bold: true, color: C.accent3, align: "center", valign: "middle", margin: 0 });
  s.addText([
    { text: "Indirect dominant → ", options: { bold: true, color: C.lightgray } },
    { text: "Hemolysis, Gilbert's, Crigler-Najjar, Drugs\n", options: { color: C.muted } },
    { text: "Direct dominant → ", options: { bold: true, color: C.lightgray } },
    { text: "Dubin-Johnson, Rotor syndrome", options: { color: C.muted } },
  ], { x: 0.3, y: 2.9, w: 2.3, h: 1.0, fontSize: 8, margin: 0, wrap: true });

  // Right branch: YES
  s.addText("YES", { x: 9.0, y: 2.05, w: 0.6, h: 0.28,
    fontSize: 8.5, bold: true, color: C.accent2 });
  s.addShape(pres.shapes.RECTANGLE, { x: 7.3, y: 2.2, w: 1.7, h: 0.05,
    fill: { color: C.muted }, line: { color: C.muted } });

  // Hepatocellular box
  s.addShape(pres.shapes.RECTANGLE, { x: 5.2, y: 2.6, w: 2.1, h: 1.6,
    fill: { color: C.panel }, line: { color: C.accent2, pt: 1.5 } });
  s.addText("HEPATOCELLULAR", { x: 5.2, y: 2.6, w: 2.1, h: 0.35,
    fontSize: 8, bold: true, color: C.accent2, align: "center", valign: "middle", margin: 0 });
  s.addText("↑↑ ALT/AST\nout of proportion\nto ALP", {
    x: 5.3, y: 3.0, w: 1.9, h: 0.55,
    fontSize: 8, color: C.lightgray, margin: 0 });
  s.addText("→ Viral serology\n→ Toxicology\n→ Autoimmune\n→ Ceruloplasmin (<55y)", {
    x: 5.3, y: 3.6, w: 1.9, h: 0.6,
    fontSize: 7.5, color: C.muted, margin: 0 });

  // Cholestatic box
  s.addShape(pres.shapes.RECTANGLE, { x: 7.5, y: 2.6, w: 2.2, h: 1.6,
    fill: { color: C.panel }, line: { color: C.accent4, pt: 1.5 } });
  s.addText("CHOLESTATIC", { x: 7.5, y: 2.6, w: 2.2, h: 0.35,
    fontSize: 8, bold: true, color: C.accent4, align: "center", valign: "middle", margin: 0 });
  s.addText("↑↑ ALP + GGT\nout of proportion\nto ALT/AST", {
    x: 7.6, y: 3.0, w: 2.0, h: 0.55,
    fontSize: 8, color: C.lightgray, margin: 0 });
  s.addText("→ Ultrasound first\n  Dilated ducts → ERCP\n  Non-dilated → AMA\n  serologies/biopsy", {
    x: 7.6, y: 3.6, w: 2.0, h: 0.6,
    fontSize: 7.5, color: C.muted, margin: 0 });

  // Bottom section – LFT pattern summary
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 4.35, w: 9.6, h: 0.08,
    fill: { color: C.accent1 }, line: { color: C.accent1 } });
  s.addText("BILIRUBIN FRACTIONATION  ·  ALT/AST  ·  ALP  ·  GGT  ·  ALBUMIN  ·  PT/INR — Order on every jaundiced patient", {
    x: 0.2, y: 4.5, w: 9.6, h: 0.3,
    fontSize: 8.5, color: C.muted, align: "center", margin: 0
  });

  // PT/INR pearls
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 4.85, w: 4.65, h: 0.55,
    fill: { color: C.card }, line: { color: C.accent1, pt: 1 } });
  s.addText("PT corrects with IV Vit K → biliary obstruction (malabsorption)\nPT does NOT correct → hepatocellular synthetic failure", {
    x: 0.3, y: 4.88, w: 4.5, h: 0.5,
    fontSize: 8, color: C.lightgray, margin: 0
  });

  s.addShape(pres.shapes.RECTANGLE, { x: 5.1, y: 4.85, w: 4.7, h: 0.55,
    fill: { color: C.card }, line: { color: C.accent2, pt: 1 } });
  s.addText("Low albumin → chronic process (cirrhosis, malignancy)\nNormal albumin → acute process (viral hepatitis, choledocholithiasis)", {
    x: 5.2, y: 4.88, w: 4.5, h: 0.5,
    fontSize: 8, color: C.lightgray, margin: 0
  });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 – HISTORY-TAKING PEARLS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.bg };
  addHeader(s, "History-Taking", "\"The single most important part of evaluation\" — Harrison's 22E");

  const rows = [
    { domain: "Drugs & Toxins", ask: "All Rx, OTC, herbal, anabolic steroids", clue: "Drug-induced liver injury (DILI)", col: C.accent3 },
    { domain: "Alcohol", ask: ">3 drinks/day men, >2/day women; last drink", clue: "Alcoholic hepatitis / cirrhosis", col: C.accent3 },
    { domain: "Parenteral", ask: "IV drugs, tattoos, transfusions, piercings", clue: "Hepatitis B, C", col: C.accent2 },
    { domain: "Travel", ask: "Endemic areas, recent travel", clue: "Hepatitis A/E, malaria, leptospirosis", col: C.accent2 },
    { domain: "Food", ask: "Raw shellfish, contaminated water", clue: "Hepatitis A, E (fecal-oral)", col: C.accent2 },
    { domain: "Pain character", ask: "Colicky vs constant; location", clue: "Colicky → stone; constant → inflammation; none → malignancy", col: C.accent1 },
    { domain: "Urine / Stool", ask: "Dark urine? Pale stools?", clue: "Dark urine + pale stool = post-hepatic (obstructive)", col: C.accent1 },
    { domain: "Associated Sx", ask: "Fever, chills, pruritus, weight loss, arthralgias", clue: "Cholangitis, cholestasis, malignancy, viral prodrome", col: C.accent4 },
    { domain: "Duration", ask: "Days vs weeks vs months", clue: "Acute → viral/toxic; subacute/chronic → cirrhosis/malignancy", col: C.accent4 },
    { domain: "Pregnancy", ask: "Trimester?", clue: "3rd trimester: AFLP, ICP, HELLP — all are emergencies", col: C.accent3 },
  ];

  // Table header
  const hdrCols = ["DOMAIN", "ASK SPECIFICALLY", "CLINICAL CLUE"];
  const hdrW = [1.8, 3.6, 3.9];
  const hdrX = [0.25, 2.05, 5.65];
  hdrCols.forEach((h, i) => {
    s.addShape(pres.shapes.RECTANGLE, { x: hdrX[i], y: 1.08, w: hdrW[i], h: 0.32,
      fill: { color: C.accent1 }, line: { color: C.accent1 } });
    s.addText(h, { x: hdrX[i], y: 1.08, w: hdrW[i], h: 0.32,
      fontSize: 8, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });
  });

  rows.forEach((r, i) => {
    const yy = 1.42 + i * 0.38;
    const bg = i % 2 === 0 ? C.panel : C.card;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.25, y: yy, w: 9.55, h: 0.37,
      fill: { color: bg }, line: { color: bg } });
    // Color dot
    s.addShape(pres.shapes.OVAL, { x: 0.3, y: yy + 0.1, w: 0.18, h: 0.18,
      fill: { color: r.col }, line: { color: r.col } });
    s.addText(r.domain, { x: 0.52, y: yy, w: 1.48, h: 0.37,
      fontSize: 8.5, bold: true, color: C.white, valign: "middle", margin: 0 });
    s.addText(r.ask, { x: 2.05, y: yy, w: 3.55, h: 0.37,
      fontSize: 8, color: C.lightgray, valign: "middle", margin: 4 });
    s.addText(r.clue, { x: 5.65, y: yy, w: 3.85, h: 0.37,
      fontSize: 8, color: C.muted, valign: "middle", margin: 4 });
  });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 – PHYSICAL EXAMINATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.bg };
  addHeader(s, "Physical Examination", "Stigmata of CLD · Abdominal signs · Lymph nodes");

  // Left column – Stigmata CLD
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 1.05, w: 3.1, h: 0.35,
    fill: { color: C.accent3 }, line: { color: C.accent3 } });
  s.addText("STIGMATA OF CHRONIC LIVER DISEASE", { x: 0.2, y: 1.05, w: 3.1, h: 0.35,
    fontSize: 8, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });

  const cld = [
    ["Spider nevi (>5, SVC territory)", "Estrogen excess (impaired hepatic metabolism)"],
    ["Palmar erythema", "Same oestrogen mechanism"],
    ["Gynaecomastia / testicular atrophy", "Oestrogen-androgen imbalance"],
    ["Caput medusae", "Portal HTN → umbilical vein recanalization"],
    ["Dupuytren's contracture", "Alcoholic liver disease"],
    ["Parotid enlargement", "Alcohol use"],
    ["Terry's nails / leukonychia", "Hypoalbuminaemia"],
    ["Clubbing", "Hepatopulmonary syndrome"],
    ["Asterixis (flapping tremor)", "Hepatic encephalopathy"],
  ];
  cld.forEach((row, i) => {
    const yy = 1.45 + i * 0.41;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: yy, w: 3.1, h: 0.39,
      fill: { color: i % 2 === 0 ? C.panel : C.card }, line: { color: i % 2 === 0 ? C.panel : C.card } });
    s.addText("· " + row[0], { x: 0.28, y: yy + 0.01, w: 3.0, h: 0.2,
      fontSize: 7.5, bold: true, color: C.lightgray, margin: 0 });
    s.addText(row[1], { x: 0.28, y: yy + 0.2, w: 3.0, h: 0.18,
      fontSize: 7, color: C.muted, italic: true, margin: 0 });
  });

  // Middle column – Abdominal signs
  s.addShape(pres.shapes.RECTANGLE, { x: 3.5, y: 1.05, w: 3.2, h: 0.35,
    fill: { color: C.accent2 }, line: { color: C.accent2 } });
  s.addText("ABDOMINAL FINDINGS", { x: 3.5, y: 1.05, w: 3.2, h: 0.35,
    fontSize: 8, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });

  const abd = [
    ["Smooth tender hepatomegaly", "Viral/alcoholic hepatitis, congestive"],
    ["Hard nodular hepatomegaly", "Malignancy, late cirrhosis"],
    ["Enlarged left lobe at xiphoid", "Cirrhosis (right lobe shrinks, left hypertrophies)"],
    ["Splenomegaly", "Portal HTN, hemolysis, haem. malignancy"],
    ["Murphy's sign +ve", "Acute cholecystitis"],
    ["Palpable non-tender GB", "Courvoisier's sign → malignant obstruction"],
    ["Ascites + jaundice", "Cirrhosis or peritoneal malignancy"],
  ];
  abd.forEach((row, i) => {
    const yy = 1.45 + i * 0.51;
    s.addShape(pres.shapes.RECTANGLE, { x: 3.5, y: yy, w: 3.2, h: 0.49,
      fill: { color: i % 2 === 0 ? C.panel : C.card }, line: { color: i % 2 === 0 ? C.panel : C.card } });
    s.addText("· " + row[0], { x: 3.58, y: yy + 0.01, w: 3.1, h: 0.24,
      fontSize: 8, bold: true, color: C.lightgray, margin: 0 });
    s.addText(row[1], { x: 3.58, y: yy + 0.24, w: 3.1, h: 0.22,
      fontSize: 7.5, color: C.muted, italic: true, margin: 0 });
  });

  // Right column – Pearls
  s.addShape(pres.shapes.RECTANGLE, { x: 6.9, y: 1.05, w: 2.9, h: 0.35,
    fill: { color: C.accent4 }, line: { color: C.accent4 } });
  s.addText("KEY CLINICAL PEARLS", { x: 6.9, y: 1.05, w: 2.9, h: 0.35,
    fontSize: 8, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

  const pearls = [
    { t: "Courvoisier's Law", b: "Palpable non-tender GB + jaundice → malignant obstruction (NOT stones; stones cause fibrosis → shrunken GB)" },
    { t: "Virchow's node", b: "Left supraclavicular LN = Troisier's sign → GI/abdominal malignancy" },
    { t: "Sister Mary Joseph's", b: "Periumbilical nodule → peritoneal metastasis" },
    { t: "Temporal wasting", b: "Long-standing disease: pancreatic cancer or cirrhosis" },
    { t: "JVD + pulsatile liver", b: "Right heart failure as cause of congestive hepatopathy" },
  ];
  pearls.forEach((p, i) => {
    const yy = 1.45 + i * 0.8;
    s.addShape(pres.shapes.RECTANGLE, { x: 6.9, y: yy, w: 2.9, h: 0.76,
      fill: { color: C.panel }, line: { color: C.accent4, pt: 1 } });
    s.addText("★ " + p.t, { x: 7.0, y: yy + 0.04, w: 2.7, h: 0.25,
      fontSize: 8.5, bold: true, color: C.accent4, margin: 0 });
    s.addText(p.b, { x: 7.0, y: yy + 0.28, w: 2.7, h: 0.44,
      fontSize: 7.5, color: C.lightgray, margin: 0, wrap: true });
  });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 – LFT PATTERN INTERPRETATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.bg };
  addHeader(s, "LFT Pattern Interpretation", "Hepatocellular vs Cholestatic — critical distinction");

  // HEPATOCELLULAR PATTERN
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 1.05, w: 4.6, h: 0.38,
    fill: { color: C.accent2 }, line: { color: C.accent2 } });
  s.addText("HEPATOCELLULAR PATTERN", { x: 0.2, y: 1.05, w: 4.6, h: 0.38,
    fontSize: 10, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

  const hcRows = [
    ["ALT / AST", "↑↑↑ (disproportionate to ALP)"],
    ["ALP", "Normal or mildly ↑"],
    ["Bilirubin", "↑ Mixed (CB + UCB)"],
    ["Albumin", "↓ in chronic disease"],
    ["PT/INR", "↑ – synthetic failure"],
    ["AST:ALT ratio", ">2:1 = Alcoholic hepatitis (De Ritis ratio)"],
    ["AST:ALT >10:1", "Ischaemic hepatitis or APAP toxicity"],
    ["ALP paradoxically LOW", "Wilson's disease acute liver failure (Cu inhibits ALP)"],
  ];
  hcRows.forEach((row, i) => {
    const yy = 1.5 + i * 0.42;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: yy, w: 4.6, h: 0.4,
      fill: { color: i % 2 === 0 ? C.panel : C.card }, line: { color: i % 2 === 0 ? C.panel : C.card } });
    s.addText(row[0], { x: 0.3, y: yy, w: 1.7, h: 0.4,
      fontSize: 8.5, bold: true, color: C.lightgray, valign: "middle", margin: 0 });
    s.addText(row[1], { x: 2.1, y: yy, w: 2.6, h: 0.4,
      fontSize: 8.5, color: C.muted, valign: "middle", margin: 0 });
  });

  // CHOLESTATIC PATTERN
  s.addShape(pres.shapes.RECTANGLE, { x: 5.2, y: 1.05, w: 4.6, h: 0.38,
    fill: { color: C.accent4 }, line: { color: C.accent4 } });
  s.addText("CHOLESTATIC PATTERN", { x: 5.2, y: 1.05, w: 4.6, h: 0.38,
    fontSize: 10, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

  const cholRows = [
    ["ALP + GGT", "↑↑↑ (disproportionate to ALT/AST)"],
    ["ALT / AST", "Normal or mildly ↑"],
    ["Bilirubin", "↑↑ CB (direct) dominant"],
    ["Urine", "Dark (bilirubinuria)"],
    ["Stool", "Pale / clay-coloured (post-hepatic)"],
    ["ALP alone ↑, GGT normal", "Bone source — NOT hepatic (confirm with GGT)"],
    ["GGT alone ↑", "Alcohol or enzyme-inducing drugs (no structural damage)"],
    ["Next step", "Ultrasound → dilated ducts? → MRCP/ERCP"],
  ];
  cholRows.forEach((row, i) => {
    const yy = 1.5 + i * 0.42;
    s.addShape(pres.shapes.RECTANGLE, { x: 5.2, y: yy, w: 4.6, h: 0.4,
      fill: { color: i % 2 === 0 ? C.panel : C.card }, line: { color: i % 2 === 0 ? C.panel : C.card } });
    s.addText(row[0], { x: 5.3, y: yy, w: 2.0, h: 0.4,
      fontSize: 8.5, bold: true, color: C.lightgray, valign: "middle", margin: 0 });
    s.addText(row[1], { x: 7.4, y: yy, w: 2.3, h: 0.4,
      fontSize: 8.5, color: C.muted, valign: "middle", margin: 0 });
  });

  // divider
  s.addShape(pres.shapes.RECTANGLE, { x: 5.0, y: 1.0, w: 0.04, h: 4.4,
    fill: { color: C.accent1 }, line: { color: C.accent1 } });

  // Bottom severity tests
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 5.05, w: 9.6, h: 0.38,
    fill: { color: C.card }, line: { color: C.accent1, pt: 1 } });
  s.addText("SEVERITY:  Child-Pugh score  ·  MELD score (bilirubin + creatinine + INR)  ·  Maddrey DF = 4.6×(PT−control) + bilirubin  [>32 → consider steroids in AH]", {
    x: 0.3, y: 5.05, w: 9.4, h: 0.38,
    fontSize: 8, color: C.accent1, valign: "middle", margin: 0, bold: false
  });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 – URINE / STOOL DIPSTICK TABLE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.bg };
  addHeader(s, "Urine & Stool Analysis", "Most underused bedside test — urine dipstick");

  // Big table
  const headers = ["", "PRE-HEPATIC\n(Hemolysis)", "HEPATIC\n(Hepatocellular)", "POST-HEPATIC\n(Obstruction)"];
  const hColors = [C.panel, C.accent3, C.accent2, C.accent4];

  const tRows = [
    ["Serum Bilirubin type", "↑ UCB (indirect)", "↑ Mixed CB+UCB", "↑↑ CB (direct)"],
    ["Urine bilirubin (dipstick)", "ABSENT ✗", "Present ↑", "Present ↑↑"],
    ["Urine urobilinogen", "↑↑ (excess)", "Variable (↑ or ↓)", "ABSENT ✗"],
    ["Stool colour", "Dark brown (↑ stercobilin)", "Normal → pale", "Pale / clay ✗"],
    ["Why no bilirubinuria\nin hemolysis?", "UCB bound to albumin → too large to filter", "CB is water-soluble\n→ filtered by kidney", "CB water-soluble\n→ filtered by kidney"],
    ["Why absent urobilinogen\nin obstruction?", "–", "–", "No bile reaches gut\n→ no enterohepatic\ncycling"],
  ];

  // Header row
  const colX = [0.2, 2.7, 5.3, 7.7];
  const colW = [2.4, 2.5, 2.35, 2.1];
  headers.forEach((h, i) => {
    s.addShape(pres.shapes.RECTANGLE, { x: colX[i], y: 1.05, w: colW[i], h: 0.48,
      fill: { color: hColors[i] }, line: { color: hColors[i] } });
    s.addText(h, { x: colX[i], y: 1.05, w: colW[i], h: 0.48,
      fontSize: 9, bold: true, color: i === 0 ? C.muted : C.bg, align: "center", valign: "middle", margin: 0 });
  });

  tRows.forEach((row, ri) => {
    const yy = 1.57 + ri * 0.62;
    const rowBg = ri % 2 === 0 ? C.panel : C.card;
    colX.forEach((cx, ci) => {
      s.addShape(pres.shapes.RECTANGLE, { x: cx, y: yy, w: colW[ci], h: 0.6,
        fill: { color: rowBg }, line: { color: rowBg } });
      const textColor = ci === 0 ? C.lightgray : (row[ci].includes("ABSENT") ? C.accent3 : C.muted);
      s.addText(row[ci], { x: cx + 0.08, y: yy, w: colW[ci] - 0.16, h: 0.6,
        fontSize: 8.5, color: textColor, valign: "middle", margin: 0,
        bold: ci === 0 });
    });
  });

  // Pearl
  addPearl(s, "Complete CBD obstruction → urobilinogen ABSENT in both urine and stool. Dark urine from CB (water-soluble) + zero urobilinogen = powerful clue for complete mechanical obstruction",
    0.2, 5.27, 9.6, 0.2);
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 – CRITICAL CLINICAL SYNDROMES
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.bg };
  addHeader(s, "Critical Clinical Syndromes", "Pattern recognition on the ward");

  const syndromes = [
    {
      cat: "EMERGENCY",
      color: C.accent3,
      items: [
        { title: "Charcot's Triad", body: "Fever + RUQ pain + Jaundice → Ascending cholangitis\n→ IV antibiotics + urgent ERCP" },
        { title: "Reynolds' Pentad", body: "Charcot's + Shock + Confusion → Septic cholangitis\n→ ICU + emergency ERCP/PTC" },
        { title: "AFLP / HELLP", body: "3rd trimester jaundice → Acute fatty liver of pregnancy or HELLP\n→ Immediate delivery (both are obstetric emergencies)" },
      ]
    },
    {
      cat: "ACUTE JAUNDICE",
      color: C.accent1,
      items: [
        { title: "Fever + travel + splenomegaly", body: "Malaria → urgent thick + thin blood film\nRepeat if first negative" },
        { title: "Leptospirosis (Weil's disease)", body: "Conjunctival suffusion + muscle tenderness + jaundice + AKI\n+ epidemiological exposure (sewage, flooding, water sports)" },
        { title: "Viral hepatitis prodrome", body: "Arthralgias/myalgias → jaundice → HAV, HBV (seronegative window)\nAlways check IgM anti-HAV and HBsAg + anti-HBc IgM" },
      ]
    },
    {
      cat: "CHRONIC / PROGRESSIVE",
      color: C.accent4,
      items: [
        { title: "Painless progressive + weight loss", body: "Pancreatic head Ca or ampullary Ca\nCourvoisier's sign ± CA 19-9 ↑ → CT + ERCP/EUS" },
        { title: "Middle-aged woman + pruritus + AMA+", body: "Primary biliary cholangitis (PBC)\nALP ↑↑, AMA >1:40, antimitochondrial Ab M2 subtype" },
        { title: "Young + IBD + strictures on MRCP", body: "Primary sclerosing cholangitis (PSC)\npANCA ±, beads-on-string on cholangiography; risk of CCA" },
        { title: "<55 yr + neuro/psych + KF rings + low ALP", body: "Wilson's disease → ceruloplasmin ↓, 24h urine Cu ↑\nLow ALP in acute WD liver failure = red flag" },
      ]
    },
  ];

  let col = 0;
  let colXarr = [0.2, 3.45, 6.6];
  let colWw = 3.05;
  syndromes.forEach((cat, ci) => {
    const cx = colXarr[ci];
    // Category header
    s.addShape(pres.shapes.RECTANGLE, { x: cx, y: 1.05, w: colWw, h: 0.35,
      fill: { color: cat.color }, line: { color: cat.color } });
    s.addText(cat.cat, { x: cx, y: 1.05, w: colWw, h: 0.35,
      fontSize: 9, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

    cat.items.forEach((item, ii) => {
      const yy = 1.45 + ii * 1.34;
      s.addShape(pres.shapes.RECTANGLE, { x: cx, y: yy, w: colWw, h: 1.28,
        fill: { color: C.panel }, line: { color: cat.color, pt: 1 } });
      s.addText(item.title, { x: cx + 0.1, y: yy + 0.06, w: colWw - 0.2, h: 0.28,
        fontSize: 9, bold: true, color: cat.color, margin: 0 });
      s.addText(item.body, { x: cx + 0.1, y: yy + 0.35, w: colWw - 0.2, h: 0.88,
        fontSize: 8, color: C.lightgray, margin: 0, wrap: true });
    });
  });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 – GENETIC / ISOLATED HYPERBILIRUBINAEMIA
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.bg };
  addHeader(s, "Isolated Hyperbilirubinaemia — Genetic Syndromes", "No other LFT abnormality");

  const conditions = [
    {
      name: "GILBERT'S SYNDROME",
      color: C.accent2,
      bili: "UCB ↑ (<6 mg/dL)",
      defect: "UGT1A1 activity ~30% of normal",
      trigger: "Fasting, stress, illness, alcohol",
      incidence: "4–7% of population (M:F = 7:1)",
      clue: "Benign, cardioprotective (UCB is antioxidant). Fasting test confirms: 48h fast → bilirubin doubles",
      treatment: "Reassurance only",
    },
    {
      name: "CRIGLER-NAJJAR TYPE I",
      color: C.accent3,
      bili: "UCB >>20 mg/dL",
      defect: "Complete UGT1A1 absence",
      trigger: "—",
      incidence: "Very rare; neonates",
      clue: "Kernicterus inevitable. No response to phenobarbitone. Fatal without liver transplant",
      treatment: "Liver transplant (only cure)",
    },
    {
      name: "CRIGLER-NAJJAR TYPE II",
      color: C.accent1,
      bili: "UCB 6–20 mg/dL",
      defect: "Partial UGT1A1 deficiency",
      trigger: "—",
      incidence: "Rare; neonates/infants",
      clue: "Responds to phenobarbitone (induces residual UGT activity). Less severe than type I",
      treatment: "Phenobarbitone; phototherapy",
    },
    {
      name: "DUBIN-JOHNSON",
      color: C.accent4,
      bili: "CB ↑ (asymptomatic)",
      defect: "MRP2 (ABCC2) mutation → can't excrete CB into bile",
      trigger: "OCP, illness",
      incidence: "Rare; any age",
      clue: "Black liver pigment on biopsy (melanin-like). Coproporphyrin I in urine ↑↑. Benign",
      treatment: "Reassurance",
    },
    {
      name: "ROTOR SYNDROME",
      color: C.muted,
      bili: "CB ↑ (asymptomatic)",
      defect: "OATP1B1/1B3 deficiency → impaired hepatic CB reuptake",
      trigger: "—",
      incidence: "Very rare",
      clue: "Normal liver biopsy (vs Dubin-Johnson). Coproporphyrin III in urine ↑↑. Benign",
      treatment: "Reassurance",
    },
  ];

  conditions.forEach((c, i) => {
    const x = 0.15 + (i % 3) * 3.3;
    const y = i < 3 ? 1.05 : 3.35;
    const w = 3.05;
    const h = i < 3 ? 2.15 : 2.15;

    s.addShape(pres.shapes.RECTANGLE, { x, y, w, h,
      fill: { color: C.card }, line: { color: c.color, pt: 1.5 } });
    s.addShape(pres.shapes.RECTANGLE, { x, y, w, h: 0.32,
      fill: { color: c.color }, line: { color: c.color } });
    s.addText(c.name, { x, y, w, h: 0.32,
      fontSize: 8, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

    const rows = [
      ["Bilirubin", c.bili],
      ["Defect", c.defect],
      ["Trigger", c.trigger],
      ["Clue", c.clue],
      ["Rx", c.treatment],
    ];
    rows.forEach((r, ri) => {
      s.addText(r[0] + ":", { x: x + 0.1, y: y + 0.36 + ri * 0.34, w: 0.65, h: 0.32,
        fontSize: 7.5, bold: true, color: c.color, margin: 0 });
      s.addText(r[1], { x: x + 0.78, y: y + 0.36 + ri * 0.34, w: w - 0.88, h: 0.32,
        fontSize: 7.5, color: C.lightgray, margin: 0, wrap: true });
    });
  });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 11 – THE 3 BEDSIDE QUESTIONS + SUMMARY
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.bg };
  addHeader(s, "The 3 Bedside Questions", "Ask these on every jaundiced patient — in order");

  // Three large question cards
  const questions = [
    {
      n: "1",
      q: "Which fraction is elevated?",
      a: "UCB dominant (indirect) → Pre-hepatic or hepatic conjugation defect\nCB dominant (direct) → Hepatic excretion defect or post-hepatic obstruction",
      color: C.accent3,
    },
    {
      n: "2",
      q: "Are other LFTs abnormal?",
      a: "YES + ALT/AST ↑↑ → Hepatocellular (hepatitis, cirrhosis)\nYES + ALP ↑↑ → Cholestatic → USS first\nNO → Benign isolated (Gilbert's, hemolysis)",
      color: C.accent2,
    },
    {
      n: "3",
      q: "What does the full clinical picture say?",
      a: "Urine/stool colour · Pain character · Fever · CLD signs · Courvoisier's · Lymph nodes · Weight loss",
      color: C.accent4,
    },
  ];

  questions.forEach((q, i) => {
    const yy = 1.05 + i * 1.42;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: yy, w: 9.6, h: 1.35,
      fill: { color: C.panel }, line: { color: q.color, pt: 2 } });
    // Number circle
    s.addShape(pres.shapes.OVAL, { x: 0.35, y: yy + 0.3, w: 0.72, h: 0.72,
      fill: { color: q.color }, line: { color: q.color } });
    s.addText(q.n, { x: 0.35, y: yy + 0.3, w: 0.72, h: 0.72,
      fontSize: 22, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });
    s.addText(q.q, { x: 1.22, y: yy + 0.1, w: 8.4, h: 0.42,
      fontSize: 13, bold: true, color: q.color, margin: 0 });
    s.addText(q.a, { x: 1.22, y: yy + 0.54, w: 8.3, h: 0.72,
      fontSize: 9, color: C.lightgray, margin: 0, wrap: true });
  });

  // Source footer
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.25, w: 10, h: 0.375,
    fill: { color: C.card }, line: { color: C.card } });
  s.addText("Sources: Harrison's Principles of Internal Medicine 22E (2025) · Schwartz's Principles of Surgery 11E · Lippincott Illustrated Reviews Biochemistry 8E · Goldman-Cecil Medicine", {
    x: 0.2, y: 5.27, w: 9.6, h: 0.33,
    fontSize: 7, color: C.muted, valign: "middle", margin: 0, italic: true
  });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 12 – CLINICAL PEARLS RAPID-FIRE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.bg };
  addHeader(s, "Clinical Pearls — Rapid Fire", "High-yield facts for ward rounds and exams");

  const pearls = [
    { p: "Sclerae → skin", d: "Scleral icterus appears before skin jaundice (elastin affinity)" },
    { p: "No bilirubinuria in hemolysis", d: "UCB is albumin-bound, molecular weight too large to pass glomerular filtration" },
    { p: ">5 mg/dL in hemolysis", d: "Look for concomitant liver disease or pigment gallstones (30% in SCD)" },
    { p: "Gilbert's fasting test", d: "48h fast → bilirubin doubles; benign; 4-7% population" },
    { p: "AST:ALT >2:1", d: "Alcoholic hepatitis (De Ritis ratio): mitochondrial AST + pyridoxine deficiency ↓ ALT" },
    { p: "ALP low in Wilson's ALF", d: "Copper directly inhibits ALP — unique red flag for Wilson's in acute liver failure" },
    { p: "GGT confirms ALP source", d: "ALP↑ + GGT↑ = hepatic; ALP↑ + GGT normal = bone/pregnancy" },
    { p: "Courvoisier's", d: "Painless palpable GB + jaundice → malignant biliary obstruction (stones = fibrosed GB)" },
    { p: "Charcot's → ERCP", d: "Fever + RUQ pain + jaundice = ascending cholangitis; Reynolds' pentad adds shock + confusion" },
    { p: "PT + Vit K test", d: "PT corrects = biliary; PT unchanged = hepatocellular synthetic failure" },
    { p: "Absent urobilinogen", d: "Complete CBD obstruction → no bile in gut → no enterohepatic cycling" },
    { p: "Pseudojaundice rule", d: "Yellow skin without scleral icterus = carotenemia, not jaundice" },
  ];

  // 2-column layout
  const half = Math.ceil(pearls.length / 2);
  pearls.forEach((p, i) => {
    const col = i < half ? 0 : 1;
    const row = i < half ? i : i - half;
    const x = col === 0 ? 0.2 : 5.1;
    const y = 1.12 + row * 0.57;
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 4.7, h: 0.5,
      fill: { color: C.panel }, line: { color: row % 2 === 0 ? C.accent1 : C.accent2, pt: 1 } });
    s.addText("★ " + p.p, { x: x + 0.1, y, w: 4.5, h: 0.22,
      fontSize: 8.5, bold: true, color: row % 2 === 0 ? C.accent1 : C.accent2, margin: 0 });
    s.addText(p.d, { x: x + 0.1, y: y + 0.22, w: 4.5, h: 0.26,
      fontSize: 8, color: C.lightgray, margin: 0 });
  });
}


// ── WRITE OUTPUT ──────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/jaundice-presentation/Approach_to_Jaundice_Ward_Rounds.pptx" })
  .then(() => console.log("Done: Approach_to_Jaundice_Ward_Rounds.pptx"))
  .catch(err => { console.error(err); process.exit(1); });

cd /home/daytona/workspace/jaundice-presentation && node build.js 2>&1

ls -lh /home/daytona/workspace/jaundice-presentation/

python3 -c " import pdfplumber path = '/home/daytona/workspace/attachments/fdc0f…

python3 -c " import pdfplumber path = '/home/daytona/workspace/attachments/fdc0f…

mkdir -p /home/daytona/workspace/stroke-presentation && ls /home/daytona/workspa…

~/stroke-presentation/build.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "Medical Education";
pres.title = "Approach to Stroke – Ward Rounds";

// ─── PALETTE ─────────────────────────────────────────────────────────────────
const C = {
  bg:       "0A1628",   // deep navy
  panel:    "132040",   // mid-navy panel
  card:     "0E1A33",   // card bg
  accent1:  "E63946",   // red – emergency / stroke urgency
  accent2:  "2EC4B6",   // teal – process / ischaemia
  accent3:  "F4A261",   // amber – warning / pearl
  accent4:  "A8DADC",   // sky – info / features
  accent5:  "6A994E",   // green – safe / management
  white:    "FFFFFF",
  light:    "C8D8EC",
  muted:    "7B9AB8",
};

// ─── HELPERS ─────────────────────────────────────────────────────────────────
function bg(slide) { slide.background = { color: C.bg }; }

function headerBar(slide, title, sub) {
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    x: 0, y: 0, w: 10, h: 0.68,
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    fontSize: 17, bold: true, color: C.bg, valign: "middle", charSpacing: 2, margin: 0
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    slide.addText(sub, {
      x: 0.28, y: 0.68, w: 9.4, h: 0.26,
      fontSize: 8.5, italic: true, color: C.muted, valign: "middle", margin: 0
    });
  }
}

function pearl(slide, text, x, y, w, h) {
  slide.addShape(pres.shapes.RECTANGLE, {
    x, y, w, h,
    fill: { color: C.panel }, line: { color: C.accent3, pt: 1.5 }
  });
  slide.addText([
    { text: "★ PEARL  ", options: { bold: true, color: C.accent3, fontSize: 8 } },
    { text: text, options: { color: C.light, fontSize: 8 } }
  ], { x: x + 0.1, y, w: w - 0.2, h, valign: "middle", margin: 3 });
}

function badge(slide, text, x, y, w, h, col, fg) {
  slide.addShape(pres.shapes.ROUNDED_RECTANGLE, {
    x, y, w, h,
    fill: { color: col }, line: { color: col }, rectRadius: 0.07
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  slide.addText(text, {
    x, y, w, h,
    fontSize: 8, bold: true, color: fg || C.white,
    align: "center", valign: "middle", margin: 0
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}

function divLine(slide, x, y, w, col) {
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  slide.addText(String(n), {
    x, y, w: r, h: r,
    fontSize: 11, bold: true, color: C.bg,
    align: "center", valign: "middle", margin: 0
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 – TITLE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s);

  // Left vertical accent
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 0, w: 0.16, h: 5.625,
    fill: { color: C.accent1 }, line: { color: C.accent1 }
  });

  // Decorative arcs
  s.addShape(pres.shapes.OVAL, {
    x: 7.2, y: -1.5, w: 5, h: 5,
    fill: { color: C.panel, transparency: 50 }, line: { color: C.accent1, pt: 1.5 }
  });
  s.addShape(pres.shapes.OVAL, {
    x: 7.8, y: -0.8, w: 3.5, h: 3.5,
    fill: { color: C.accent1, transparency: 82 }, line: { color: C.accent1, pt: 0.5 }
  });

  s.addText("APPROACH TO", {
    x: 0.45, y: 0.85, w: 9, h: 0.55,
    fontSize: 18, color: C.muted, charSpacing: 8, margin: 0
  });
  s.addText("STROKE", {
    x: 0.45, y: 1.32, w: 9, h: 1.6,
    fontSize: 88, bold: true, color: C.accent1, charSpacing: 3, margin: 0
  });
  s.addText("A Systematic Ward Round Framework", {
    x: 0.45, y: 3.0, w: 8, h: 0.42,
    fontSize: 14, color: C.light, italic: true, margin: 0
  });

  divLine(s, 0.45, 3.5, 6, C.accent2);

  s.addText("Faculty PDF  ·  Fuster & Hurst's The Heart 15E  ·  Bradley & Daroff's Neurology  ·  Neuroanatomy through Clinical Cases 3E", {
    x: 0.45, y: 3.62, w: 9.3, h: 0.26,
    fontSize: 8, color: C.muted, margin: 0
  });

  // Bottom row of zone badges
  const zones = [
    { t: "History", c: C.accent2 },
    { t: "Vascular Territory", c: C.accent3 },
    { t: "Aetiology", c: C.accent1 },
    { t: "Mimics", c: C.accent4 },
    { t: "Management", c: C.accent5 },
  ];
  zones.forEach((z, i) => badge(s, z.t, 0.45 + i * 1.88, 4.42, 1.72, 0.46, z.c, C.bg));
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 – DEFINITION + KEY CONCEPTS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s);
  headerBar(s, "Definition & Pathophysiology", "The 'Sudden' rule · Penumbra · Core");

  // Left – definition cards
  const cards = [
    { lbl: "STROKE DEFINED", text: "Focal (or global) neurological deficit due to a vascular cause lasting >24 hours — OR producing permanent deficit/death within 24 hours", col: C.accent1 },
    { lbl: "TRANSIENT ISCHAEMIC ATTACK (TIA)", text: "Same mechanism but deficit resolves completely within 24 h (modern: <1 h with no DWI lesion). NOT benign — 10–15% stroke risk within 2 days", col: C.accent3 },
    { lbl: "WHY 'SUDDEN' MATTERS", text: "Stroke produces instantaneous maximal deficit at onset. The brain has no pain receptors in parenchyma — you feel the loss of function, not the cell death. Gradual onset = tumour, abscess, SDH", col: C.accent2 },
  ];
  cards.forEach((c, i) => {
    const y = 1.02 + i * 1.45;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 4.55, h: 1.38,
      fill: { color: C.card }, line: { color: c.col, pt: 1.5 } });
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 4.55, h: 0.3,
      fill: { color: c.col }, line: { color: c.col } });
    s.addText(c.lbl, { x: 0.2, y, w: 4.55, h: 0.3,
      fontSize: 8, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });
    s.addText(c.text, { x: 0.3, y: y + 0.34, w: 4.35, h: 1.0,
      fontSize: 9, color: C.light, margin: 0, wrap: true });
  });

  // Right – Penumbra vs Core diagram (text-based)
  s.addShape(pres.shapes.RECTANGLE, { x: 5.1, y: 1.02, w: 4.65, h: 0.32,
    fill: { color: C.accent1 }, line: { color: C.accent1 } });
  s.addText("ISCHAEMIC PENUMBRA CONCEPT", { x: 5.1, y: 1.02, w: 4.65, h: 0.32,
    fontSize: 9, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

  // Core circle
  s.addShape(pres.shapes.OVAL, { x: 6.2, y: 1.48, w: 2.4, h: 2.4,
    fill: { color: C.accent1, transparency: 15 }, line: { color: C.accent1, pt: 2 } });
  s.addShape(pres.shapes.OVAL, { x: 5.8, y: 1.28, w: 3.2, h: 3.2,
    fill: { color: C.accent3, transparency: 60 }, line: { color: C.accent3, pt: 1.5 } });

  s.addText("CORE", { x: 6.85, y: 2.28, w: 1.1, h: 0.35,
    fontSize: 9, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });
  s.addText("CBF <10 mL/100g/min\nIrreversible death\nwithin minutes", { x: 6.25, y: 2.65, w: 2.3, h: 0.58,
    fontSize: 7.5, color: C.light, align: "center", margin: 0 });

  s.addText("PENUMBRA", { x: 5.88, y: 1.42, w: 1.5, h: 0.28,
    fontSize: 9, bold: true, color: C.accent3, margin: 0 });
  s.addText("CBF 10–20 mL/100g/min\nDysfunctional but ALIVE\nSALVAGEABLE with\nreperfusion therapy", { x: 5.2, y: 1.72, w: 1.7, h: 0.7,
    fontSize: 7.5, color: C.light, margin: 0 });

  // CBF threshold legend
  s.addShape(pres.shapes.RECTANGLE, { x: 5.1, y: 4.65, w: 4.65, h: 0.65,
    fill: { color: C.panel }, line: { color: C.accent2, pt: 1 } });
  s.addText([
    { text: "Normal CBF: ", options: { bold: true, color: C.accent2 } },
    { text: "50 mL/100g/min  ", options: { color: C.light } },
    { text: "Penumbra: ", options: { bold: true, color: C.accent3 } },
    { text: "10–20  ", options: { color: C.light } },
    { text: "Core death: ", options: { bold: true, color: C.accent1 } },
    { text: "<10\n", options: { color: C.light } },
    { text: "Every minute of untreated major stroke = ~1.9 million neurons die → 3.6 years of brain ageing", options: { bold: false, color: C.muted, fontSize: 7.5 } }
  ], { x: 5.2, y: 4.67, w: 4.45, h: 0.61, fontSize: 8.5, margin: 0, wrap: true });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 – HISTORY-TAKING
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s);
  headerBar(s, "History-Taking", "Presenting complaint · Symptom analysis · Aetiology · Complications");

  // Opening case
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 0.98, w: 9.6, h: 0.52,
    fill: { color: C.panel }, line: { color: C.accent2, pt: 1 } });
  s.addText([
    { text: "OPENING CASE:  ", options: { bold: true, color: C.accent2 } },
    { text: "Mr. X, 65 y/o, known HTN + DM, presented with ", options: { color: C.light } },
    { text: "sudden onset left-sided face + arm + leg weakness", options: { bold: true, color: C.accent3 } },
    { text: " for 2 hours", options: { color: C.light } }
  ], { x: 0.3, y: 0.98, w: 9.4, h: 0.52, fontSize: 9.5, valign: "middle", margin: 0 });

  // Col 1 - PC + Symptom Analysis
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 1.58, w: 3.05, h: 0.3,
    fill: { color: C.accent2 }, line: { color: C.accent2 } });
  s.addText("PRESENTING COMPLAINT", { x: 0.2, y: 1.58, w: 3.05, h: 0.3,
    fontSize: 8, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

  const pc = [
    "Sudden onset face, arm, leg weakness",
    "Altered consciousness",
    "Facial weakness / double vision / numbness",
    "Difficulty talking / dysphagia / nasal regurg",
    "Loss of balance / ataxia (cerebellar)",
  ];
  pc.forEach((t, i) => {
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 1.9 + i * 0.33, w: 3.05, h: 0.31,
      fill: { color: i%2===0?C.card:C.panel }, line: { color: i%2===0?C.card:C.panel } });
    s.addText("· " + t, { x: 0.3, y: 1.9 + i * 0.33, w: 2.9, h: 0.31,
      fontSize: 8, color: C.light, valign: "middle", margin: 0 });
  });

  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 3.58, w: 3.05, h: 0.28,
    fill: { color: C.accent3 }, line: { color: C.accent3 } });
  s.addText("SYMPTOM ANALYSIS (5 Questions)", { x: 0.2, y: 3.58, w: 3.05, h: 0.28,
    fontSize: 8, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });
  const sq = ["What was patient doing at onset?", "Type: Face / Arm / Leg / Speech", "Loss of consciousness?", "UL vs LL predominant?", "Progression: resolved / static / worsening?"];
  sq.forEach((t, i) => {
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 3.88 + i * 0.31, w: 3.05, h: 0.29,
      fill: { color: i%2===0?C.card:C.panel }, line: { color: i%2===0?C.card:C.panel } });
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      fontSize: 8, color: C.light, valign: "middle", margin: 0 });
  });

  // Col 2 - Aetiology history
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    fill: { color: C.accent1 }, line: { color: C.accent1 } });
  s.addText("AETIOLOGY HISTORY", { x: 3.45, y: 1.58, w: 3.25, h: 0.3,
    fontSize: 8, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });

  const aetiRows = [
    { cause: "Atherosclerosis", ask: "DM, HTN, smoking, dyslipidaemia\nAngina, claudication, past TIA", col: C.accent3 },
    { cause: "Cardioembolism", ask: "Palpitations/AF, rheumatic fever\nMI, valvular disease, endocarditis", col: C.accent1 },
    { cause: "Vasculitis", ask: "SLE (joint pain, rash, oral ulcers)\nHIV, syphilis (IV drugs, sexual hx)", col: C.accent4 },
    { cause: "Thrombophilia", ask: "FHx young stroke\nRecurrent pregnancy losses, DVT/PE", col: C.accent2 },
    { cause: "Haemorrhagic", ask: "Anticoagulant use\nSevere HTN, cocaine/amphetamines", col: C.accent1 },
  ];
  aetiRows.forEach((r, i) => {
    const y = 1.93 + i * 0.62;
    s.addShape(pres.shapes.RECTANGLE, { x: 3.45, y, w: 3.25, h: 0.6,
      fill: { color: i%2===0?C.card:C.panel }, line: { color: i%2===0?C.card:C.panel } });
    s.addShape(pres.shapes.RECTANGLE, { x: 3.45, y, w: 0.07, h: 0.6,
      fill: { color: r.col }, line: { color: r.col } });
    s.addText(r.cause, { x: 3.56, y: y+0.03, w: 1.1, h: 0.25,
      fontSize: 8, bold: true, color: r.col, margin: 0 });
    s.addText(r.ask, { x: 3.56, y: y+0.28, w: 3.06, h: 0.3,
      fontSize: 7.5, color: C.muted, margin: 0 });
  });

  // Col 3 - Mimics + complications
  s.addShape(pres.shapes.RECTANGLE, { x: 6.88, y: 1.58, w: 2.9, h: 0.3,
    fill: { color: C.accent4 }, line: { color: C.accent4 } });
  s.addText("EXCLUDE STROKE MIMICS", { x: 6.88, y: 1.58, w: 2.9, h: 0.3,
    fontSize: 8, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

  const mimics = [
    ["Todd's paresis", "Preceding seizure → post-ictal weakness"],
    ["Hypoglycaemia", "BGL <2.8 mmol/L → check FIRST"],
    ["Brain tumour", "Morning headache + vomiting (weeks)"],
    ["Hemiplegic migraine", "Aura + throbbing HA, FHx"],
    ["CNS infection", "Fever + altered behaviour before deficit"],
    ["Metabolic", "Bilateral; liver/renal disease; Na+ abnormal"],
    ["Subdural haematoma", "Trauma hx (trivial in elderly); gradual"],
  ];
  mimics.forEach((m, i) => {
    const y = 1.93 + i * 0.42;
    s.addShape(pres.shapes.RECTANGLE, { x: 6.88, y, w: 2.9, h: 0.4,
      fill: { color: i%2===0?C.card:C.panel }, line: { color: i%2===0?C.card:C.panel } });
    s.addText(m[0], { x: 6.96, y: y+0.02, w: 2.76, h: 0.18,
      fontSize: 8, bold: true, color: C.accent4, margin: 0 });
    s.addText(m[1], { x: 6.96, y: y+0.2, w: 2.76, h: 0.18,
      fontSize: 7.5, color: C.muted, margin: 0 });
  });

  pearl(s, "CHECK GLUCOSE FIRST in every focal deficit — hypoglycaemia is the most reversible stroke mimic. Glucose before diagnosis, always.",
    0.2, 5.2, 9.6, 0.28);
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 – VASCULAR TERRITORY IDENTIFICATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s);
  headerBar(s, "Vascular Territory Identification", "Anterior · Posterior · Lacunar Circulation");

  const territories = [
    {
      name: "ANTERIOR CIRCULATION",
      sub: "ICA → MCA / ACA",
      col: C.accent2,
      features: [
        "Contralateral face + arm + leg weakness",
        "Higher cortical dysfunction:",
        "  · Aphasia (dominant hemisphere)",
        "  · Neglect, anosognosia (non-dominant)",
        "  · Hemianopia (homonymous)",
        "  · Memory loss, calculation errors",
        "Arm > leg weakness = MCA territory",
        "Leg > arm weakness = ACA territory",
      ],
      pearl: "Aphasia = dominant hemisphere (L in >95% right-handers). Screen with: fluency, comprehension, repetition.",
    },
    {
      name: "POSTERIOR CIRCULATION",
      sub: "Vertebrobasilar → PICA/AICA/SCA/PCA",
      col: C.accent3,
      features: [
        "D-V-F Triad:",
        "  · Diplopia (CN III/IV/VI nuclei)",
        "  · Vertigo (vestibular nuclei)",
        "  · Facial numbness + weakness",
        "Dysphagia + nasal regurgitation (CN IX/X)",
        "Dysarthria (slurring of speech)",
        "Imbalance / truncal ataxia",
        "Crossed signs = PATHOGNOMONIC",
      ],
      pearl: "CROSSED SIGNS = brainstem: ipsilateral CN deficit + contralateral limb findings. Unique to brainstem anatomy.",
    },
    {
      name: "LACUNAR CIRCULATION",
      sub: "Deep penetrating arteries (lenticulostriate, thalamoperforators)",
      col: C.accent1,
      features: [
        "No cortical signs (no aphasia, neglect, hemianopia)",
        "Classic syndromes:",
        "  · Pure Motor Hemiparesis (internal capsule/pons)",
        "  · Pure Sensory Stroke (thalamus VPL+VPM)",
        "  · Ataxic Hemiparesis",
        "  · Dysarthria-Clumsy Hand",
        "  · Sensorimotor Stroke",
        "Infarct ≤2 cm on DWI / ≤1.5 cm on CT",
      ],
      pearl: "Any cortical sign (aphasia, neglect, hemianopia) EXCLUDES lacunar – re-examine your localisation.",
    },
  ];

  territories.forEach((t, i) => {
    const x = 0.2 + i * 3.27;
    s.addShape(pres.shapes.RECTANGLE, { x, y: 1.02, w: 3.1, h: 4.35,
      fill: { color: C.card }, line: { color: t.col, pt: 2 } });
    s.addShape(pres.shapes.RECTANGLE, { x, y: 1.02, w: 3.1, h: 0.4,
      fill: { color: t.col }, line: { color: t.col } });
    s.addText(t.name, { x, y: 1.02, w: 3.1, h: 0.4,
      fontSize: 9.5, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });
    s.addText(t.sub, { x: x+0.1, y: 1.44, w: 2.9, h: 0.3,
      fontSize: 8, italic: true, color: t.col, margin: 0 });

    divLine(s, x+0.1, 1.76, 2.9, t.col);

    t.features.forEach((f, fi) => {
      s.addText(f, { x: x+0.1, y: 1.82 + fi * 0.3, w: 2.9, h: 0.28,
        fontSize: 8, color: f.startsWith("  ·") ? C.muted : (f.includes(":") ? C.light : C.light),
        bold: f.includes(":") && !f.startsWith("  "),
        margin: 0 });
    });

    // Pearl at bottom of each card
    s.addShape(pres.shapes.RECTANGLE, { x: x+0.08, y: 4.68, w: 2.95, h: 0.62,
      fill: { color: C.panel }, line: { color: C.accent3, pt: 1 } });
    s.addText("★ " + t.pearl, { x: x+0.15, y: 4.7, w: 2.8, h: 0.58,
      fontSize: 7.5, color: C.light, margin: 0, wrap: true });
  });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 – LACUNAR SYNDROMES TABLE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s);
  headerBar(s, "Lacunar Stroke Syndromes", "Neuroanatomy through Clinical Cases 3E · Fuster & Hurst 15E");

  // Table
  const hdr = ["SYNDROME", "CLINICAL FEATURES", "LOCATION", "ARTERY"];
  const hdrW = [2.2, 2.85, 2.5, 2.1];
  const hdrX = [0.2, 2.42, 5.28, 7.8];

  hdr.forEach((h, i) => {
    s.addShape(pres.shapes.RECTANGLE, { x: hdrX[i], y: 1.02, w: hdrW[i], h: 0.38,
      fill: { color: C.accent1 }, line: { color: C.accent1 } });
    s.addText(h, { x: hdrX[i], y: 1.02, w: hdrW[i], h: 0.38,
      fontSize: 8.5, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });
  });

  const rows = [
    ["Pure Motor Hemiparesis", "Face + arm + leg UMN weakness\nNo sensory loss, no cortical signs", "Post. limb internal capsule\nVentral pons\nCorona radiata", "Lenticulostriate\nPontine perforators"],
    ["Pure Sensory Stroke\n(Thalamic lacune)", "All modality sensory loss:\nContralateral face + body", "Thalamus VPL + VPM nuclei", "Thalamoperforators (PCA branch)"],
    ["Ataxic Hemiparesis", "Ipsilateral weakness\n+ ipsilateral limb ataxia", "Pons / internal capsule /\ncorona radiata", "Pontine perforators\nLenticulostriate"],
    ["Dysarthria-Clumsy Hand", "Dysarthria +\ncontralateral hand clumsiness", "Pons / internal capsule", "Pontine perforators"],
    ["Sensorimotor Stroke\n(Thalamocapsular)", "Combined thalamic + motor\nhemiparesis features", "Post. limb IC +\nthalamic VPL/VPM", "Thalamoperforators\n+ lenticulostriate"],
    ["Basal Ganglia Lacune", "Often asymptomatic\nMay → hemiballismus", "Caudate, putamen,\nglobus pallidus, STN", "Lenticulostriate\nAnterior choroidal"],
  ];

  rows.forEach((row, ri) => {
    const y = 1.44 + ri * 0.62;
    const bg2 = ri % 2 === 0 ? C.panel : C.card;
    hdrX.forEach((cx, ci) => {
      s.addShape(pres.shapes.RECTANGLE, { x: cx, y, w: hdrW[ci], h: 0.6,
        fill: { color: bg2 }, line: { color: bg2 } });
      s.addText(row[ci], { x: cx + 0.06, y, w: hdrW[ci] - 0.12, h: 0.6,
        fontSize: ci === 0 ? 8.5 : 8, bold: ci === 0,
        color: ci === 0 ? C.light : C.muted, valign: "middle", margin: 0, wrap: true });
    });
  });

  pearl(s, "All lacunar strokes share one key feature: ABSENT cortical signs. Presence of aphasia, neglect, or hemianopia means the lesion is NOT lacunar — it is cortical or involves white matter projection fibres.",
    0.2, 5.24, 9.6, 0.27);
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 – AETIOLOGY (TOAST CLASSIFICATION)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s);
  headerBar(s, "Aetiology — TOAST Classification", "Fuster & Hurst 15E · Faculty PDF framework");

  const types = [
    {
      title: "LARGE ARTERY\nATHEROSCLEROSIS",
      col: C.accent3,
      patho: "Plaque rupture → in-situ thrombosis OR artery-to-artery embolism from carotid/vertebral",
      clues: ["DM, HTN, smoking, dyslipidaemia", "Angina / intermittent claudication", "Past TIA in same territory", "Carotid bruit on exam"],
      prev: "Antiplatelet + statin + BP control\nCarotid endarterectomy if ICA ≥70%",
    },
    {
      title: "CARDIOEMBOLISM",
      col: C.accent1,
      patho: "Thrombus from heart → sudden complete occlusion → large cortical infarct (no time for collaterals to develop)",
      clues: ["AF (most common — >40% in >60yr)", "Rheumatic MS → LA thrombus", "Recent MI → mural thrombus", "Infective endocarditis → septic emboli"],
      prev: "Anticoagulation (NOAC for AF)\nWARFARIN for mechanical valves",
    },
    {
      title: "LACUNAR / SMALL\nARTERY OCCLUSION",
      col: C.accent2,
      patho: "Lipohyalinosis + microaneurysm (Charcot-Bouchard) in penetrating arteries from chronic HTN/DM",
      clues: ["Classic lacunar syndrome", "No cortical signs", "Lesion ≤2cm on DWI", "Same vessels rupture → deep ICH"],
      prev: "Aggressive BP control (PRIMARY)\nAntiplatelet + statin",
    },
    {
      title: "VASCULITIS /\nOTHER CAUSES",
      col: C.accent4,
      patho: "Vessel wall inflammation → stenosis/thrombosis. Young patients. Always screen in stroke <45 years",
      clues: ["SLE: joint pain, rash, oral ulcers", "HIV/syphilis: sexual/IV drug hx", "Dissection: neck pain/trauma", "APS: recurrent thrombosis/fetal loss"],
      prev: "Treat underlying cause\nAntiphospholipid → anticoagulation",
    },
  ];

  types.forEach((t, i) => {
    const x = 0.2 + (i % 2) * 4.88;
    const y = i < 2 ? 1.02 : 3.3;
    const w = 4.62; const h = 2.1;

    s.addShape(pres.shapes.RECTANGLE, { x, y, w, h,
      fill: { color: C.card }, line: { color: t.col, pt: 1.5 } });
    s.addShape(pres.shapes.RECTANGLE, { x, y, w, h: 0.38,
      fill: { color: t.col }, line: { color: t.col } });
    s.addText(t.title, { x, y, w, h: 0.38,
      fontSize: 9.5, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

    s.addText("Pathophysiology:", { x: x+0.1, y: y+0.42, w: w-0.2, h: 0.2,
      fontSize: 7.5, bold: true, color: t.col, margin: 0 });
    s.addText(t.patho, { x: x+0.1, y: y+0.62, w: w-0.2, h: 0.42,
      fontSize: 8, color: C.light, margin: 0, wrap: true });

    divLine(s, x+0.1, y+1.06, w-0.2, t.col);

    s.addText("Key history clues:", { x: x+0.1, y: y+1.12, w: w-0.2, h: 0.2,
      fontSize: 7.5, bold: true, color: t.col, margin: 0 });
    t.clues.forEach((c, ci) => {
      s.addText("· " + c, { x: x+0.1, y: y+1.32 + ci*0.17, w: w*0.55, h: 0.17,
        fontSize: 7.5, color: C.muted, margin: 0 });
    });

    s.addText("Prevention:", { x: x + w*0.57, y: y+1.12, w: w*0.4, h: 0.2,
      fontSize: 7.5, bold: true, color: C.accent5, margin: 0 });
    s.addText(t.prev, { x: x + w*0.57, y: y+1.32, w: w*0.4, h: 0.62,
      fontSize: 7.5, color: C.muted, margin: 0, wrap: true });
  });

  pearl(s, "Haemorrhagic transformation is hallmark of CARDIOEMBOLISM: embolus fragments → reperfusion into ischaemic BBB-damaged tissue → bleeding. Reason anticoagulation timing must be carefully considered (1-3-6-12 day rule).",
    0.2, 5.46, 9.6, 0.0);
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 5.2, w: 9.6, h: 0.34,
    fill: { color: C.panel }, line: { color: C.accent3, pt: 1.5 } });
  s.addText([
    { text: "★ PEARL  ", options: { bold: true, color: C.accent3, fontSize: 8 } },
    { text: "Haemorrhagic transformation is hallmark of CARDIOEMBOLISM: large embolus occludes then fragments → reperfusion into ischaemic BBB-damaged tissue → petechial/confluent haemorrhage. Anticoagulation timing: small non-disabling stroke → day 1–3; large disabling → wait 6–12 days.", options: { color: C.light, fontSize: 8 } }
  ], { x: 0.3, y: 5.2, w: 9.4, h: 0.34, valign: "middle", margin: 3 });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 – PHYSICAL EXAMINATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s);
  headerBar(s, "Physical Examination", "General · Neurological · Cardiovascular · Functional");

  // Col 1 – General exam
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 1.02, w: 2.35, h: 0.3,
    fill: { color: C.accent2 }, line: { color: C.accent2 } });
  s.addText("GENERAL EXAM", { x: 0.2, y: 1.02, w: 2.35, h: 0.3,
    fontSize: 8, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

  const gen = [
    ["GCS", "Baseline + trend; falling GCS in ischaemia = herniation/HT"],
    ["Neck stiffness", "SAH (meningism); test gently"],
    ["Plethora", "Polycythaemia → ↑ viscosity → thrombosis"],
    ["Pallor", "Anaemia; consider cardiac cause"],
    ["Xanthelasma/arcus", "Hyperlipidaemia → atherosclerosis"],
    ["Osler's nodes/splinters", "Infective endocarditis → septic emboli"],
    ["Livedo reticularis", "Antiphospholipid syndrome"],
    ["Rash + oral ulcers", "SLE / vasculitis aetiology"],
    ["Bed sores", "Examine on admission as baseline"],
  ];
  gen.forEach((r, i) => {
    const y = 1.35 + i * 0.44;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 2.35, h: 0.42,
      fill: { color: i%2===0?C.card:C.panel }, line: { color: i%2===0?C.card:C.panel } });
    s.addText(r[0], { x: 0.28, y: y+0.01, w: 2.2, h: 0.19,
      fontSize: 8, bold: true, color: C.accent2, margin: 0 });
    s.addText(r[1], { x: 0.28, y: y+0.21, w: 2.2, h: 0.19,
      fontSize: 7.5, color: C.muted, margin: 0 });
  });

  // Col 2 – Neurological exam
  s.addShape(pres.shapes.RECTANGLE, { x: 2.75, y: 1.02, w: 2.95, h: 0.3,
    fill: { color: C.accent1 }, line: { color: C.accent1 } });
  s.addText("NEUROLOGICAL EXAM", { x: 2.75, y: 1.02, w: 2.95, h: 0.3,
    fontSize: 8, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });

  const neuro = [
    { item: "Motor", detail: "Spastic weakness, hyperreflexia, Babinski +ve\nAcute stroke: initially hypotonic (diaschisis)" },
    { item: "Pronator Drift", detail: "Arms extended palms up, eyes closed →\naffected arm drifts DOWN + PRONATES (early UMN sign)" },
    { item: "Cranial Nerves", detail: "CN VII: UMN = forehead spared\nCN XII: tongue deviates towards lesion" },
    { item: "Hemianopia", detail: "Test each visual field quadrant\nMCA/PCA involvement; patient unaware (neglect)" },
    { item: "Sensory", detail: "Pure sensory: all modalities (thalamic lacune)\nCortical: graphaesthesia + stereognosis impaired" },
    { item: "Higher Functions", detail: "MMSE/MoCA, aphasia screen:\nFluency / Comprehension / Repetition / Naming" },
    { item: "Cerebellar", detail: "Finger-nose, heel-shin, dysdiadochokinesia\nGait and tandem walking" },
  ];
  neuro.forEach((r, i) => {
    const y = 1.35 + i * 0.59;
    s.addShape(pres.shapes.RECTANGLE, { x: 2.75, y, w: 2.95, h: 0.57,
      fill: { color: i%2===0?C.card:C.panel }, line: { color: i%2===0?C.card:C.panel } });
    s.addText(r.item, { x: 2.83, y: y+0.03, w: 2.79, h: 0.22,
      fontSize: 8.5, bold: true, color: C.light, margin: 0 });
    s.addText(r.detail, { x: 2.83, y: y+0.26, w: 2.79, h: 0.3,
      fontSize: 7.5, color: C.muted, margin: 0, wrap: true });
  });

  // Col 3 – CVS exam + functional
  s.addShape(pres.shapes.RECTANGLE, { x: 5.9, y: 1.02, w: 3.9, h: 0.3,
    fill: { color: C.accent3 }, line: { color: C.accent3 } });
  s.addText("CARDIOVASCULAR + FUNCTIONAL", { x: 5.9, y: 1.02, w: 3.9, h: 0.3,
    fontSize: 8, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

  const cvs = [
    ["Pulse", "Irregularly irregular → AF (cardioembolic)\nBP both arms (>20 mmHg diff = subclavian steal)"],
    ["Apex beat", "Displaced = LV dilation → CCF → AF → embolism"],
    ["Heart murmurs", "Mitral stenosis = most common valvular cause\nin young patients (rheumatic fever)"],
    ["Carotid bruits", "ICA stenosis 40-80% (bruit disappears >95%)\nAlways do duplex regardless of auscultation"],
    ["Lung exam", "Aspiration pneumonia (most common\ncause of early death after stroke)"],
  ];
  cvs.forEach((r, i) => {
    const y = 1.35 + i * 0.6;
    s.addShape(pres.shapes.RECTANGLE, { x: 5.9, y, w: 3.9, h: 0.58,
      fill: { color: i%2===0?C.card:C.panel }, line: { color: i%2===0?C.card:C.panel } });
    s.addText(r[0], { x: 5.98, y: y+0.03, w: 3.74, h: 0.22,
      fontSize: 8.5, bold: true, color: C.accent3, margin: 0 });
    s.addText(r[1], { x: 5.98, y: y+0.27, w: 3.74, h: 0.3,
      fontSize: 7.5, color: C.muted, margin: 0, wrap: true });
  });

  pearl(s, "PRONATOR DRIFT: arms extended horizontally palms up, eyes closed 10s → affected arm drifts DOWN + PRONATES. More sensitive than Babinski for subtle corticospinal lesions.",
    0.2, 5.18, 9.6, 0.3);
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 – INVESTIGATIONS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s);
  headerBar(s, "Investigations", "Immediate · Second-line · Imaging · Young stroke screen");

  // IMMEDIATE panel
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 1.02, w: 4.65, h: 0.3,
    fill: { color: C.accent1 }, line: { color: C.accent1 } });
  s.addText("IMMEDIATE (First Hour) — EVERY PATIENT", { x: 0.2, y: 1.02, w: 4.65, h: 0.3,
    fontSize: 9, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });

  const imm = [
    ["Blood glucose (BEDSIDE)", "Exclude hypoglycaemia BEFORE anything else", C.accent3],
    ["FBC", "Polycythaemia, anaemia, thrombocytopenia, infection", C.accent2],
    ["Coagulation: INR, APTT, platelets", "Bleeding risk; anticoagulant status for tPA eligibility", C.accent2],
    ["U&E, creatinine", "Renal function; Na+ (SIADH in SAH)", C.accent2],
    ["Blood glucose + HbA1c", "Hyperglycaemia = directly toxic to ischaemic neurones", C.accent3],
    ["ECG", "AF, recent MI (mural thrombus), prolonged QTc", C.accent1],
    ["NCCT Brain (MANDATORY)", "100% sensitive for haemorrhage. Often NORMAL in early ischaemia — does NOT exclude stroke", C.accent1],
  ];
  imm.forEach((r, i) => {
    const y = 1.35 + i * 0.42;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 4.65, h: 0.4,
      fill: { color: i%2===0?C.card:C.panel }, line: { color: i%2===0?C.card:C.panel } });
    s.addShape(pres.shapes.OVAL, { x: 0.26, y: y+0.11, w: 0.18, h: 0.18,
      fill: { color: r[2] }, line: { color: r[2] } });
    s.addText(r[0], { x: 0.52, y: y+0.01, w: 4.28, h: 0.19,
      fontSize: 8, bold: true, color: C.light, margin: 0 });
    s.addText(r[1], { x: 0.52, y: y+0.2, w: 4.28, h: 0.18,
      fontSize: 7.5, color: C.muted, margin: 0 });
  });

  // SECOND LINE + IMAGING
  s.addShape(pres.shapes.RECTANGLE, { x: 5.1, y: 1.02, w: 4.7, h: 0.3,
    fill: { color: C.accent2 }, line: { color: C.accent2 } });
  s.addText("SUBSEQUENT + YOUNG STROKE SCREEN", { x: 5.1, y: 1.02, w: 4.7, h: 0.3,
    fontSize: 9, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

  const sub = [
    ["MRI Brain (DWI)", "Gold standard: positive within minutes; penumbra mapping", C.accent2],
    ["Lipid profile + LFTs", "Dyslipidaemia; statin monitoring", C.accent2],
    ["ESR + CRP", "Vasculitis, infective endocarditis", C.accent4],
    ["Echo (TTE/TOE)", "LV thrombus, MS, valvular disease, PFO", C.accent1],
    ["Carotid duplex", "ICA stenosis in anterior circulation stroke", C.accent3],
    ["CT/MR Angiography", "Large vessel occlusion for thrombectomy", C.accent3],
    ["ANA, ANCA, APS screen", "Young stroke — vasculitis/thrombophilia", C.accent4],
    ["HIV, VDRL/TPHA", "Young stroke — infective vasculitis", C.accent4],
    ["Protein C/S, AT-III, Factor V Leiden", "Thrombophilia screen in young patients", C.accent4],
    ["Haemoglobin electrophoresis", "Sickle cell disease in young/ethnic patients", C.accent4],
  ];
  sub.forEach((r, i) => {
    const y = 1.35 + i * 0.38;
    s.addShape(pres.shapes.RECTANGLE, { x: 5.1, y, w: 4.7, h: 0.36,
      fill: { color: i%2===0?C.card:C.panel }, line: { color: i%2===0?C.card:C.panel } });
    s.addShape(pres.shapes.OVAL, { x: 5.16, y: y+0.09, w: 0.18, h: 0.18,
      fill: { color: r[2] }, line: { color: r[2] } });
    s.addText(r[0], { x: 5.42, y: y+0.01, w: 4.3, h: 0.18,
      fontSize: 8, bold: true, color: C.light, margin: 0 });
    s.addText(r[1], { x: 5.42, y: y+0.19, w: 4.3, h: 0.16,
      fontSize: 7, color: C.muted, margin: 0 });
  });

  pearl(s, "NCCT normal ≠ no stroke. CT excludes haemorrhage and mimics (tumour/abscess). Ischaemia is invisible on CT for 6-24h. MRI DWI detects ischaemia within MINUTES of onset.",
    0.2, 5.2, 9.6, 0.3);
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 – ACUTE MANAGEMENT
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s);
  headerBar(s, "Acute Management", "Salvage the penumbra · Faculty PDF protocol");

  // 4 ENEMIES OF THE PENUMBRA
  s.addText("THE 4 ENEMIES OF THE PENUMBRA — ACT ON ALL FROM MINUTE 1", {
    x: 0.2, y: 1.0, w: 9.6, h: 0.28,
    fontSize: 9, bold: true, color: C.accent3, margin: 0
  });

  const enemies = [
    { e: "HYPOTENSION", t: "Maintain BP: permissive HTN in acute phase\n>220/120 mmHg → careful lowering\nAfter 72h → gradual antihypertensives", c: C.accent1 },
    { e: "HYPERGLYCAEMIA", t: "Target glucose 7–10 mmol/L\nGlucose → lactate in ischaemic tissue → local acidosis → accelerates cell death", c: C.accent3 },
    { e: "PYREXIA", t: "1°C rise = 10% ↑ metabolic demand\nTreat fever aggressively: paracetamol, cooling\nCommon source: aspiration pneumonia", c: C.accent1 },
    { e: "HYPOXIA", t: "Target SpO2 >94%\nO2 delivery to marginal tissue is critical\nIntubate if needed for airway protection", c: C.accent2 },
  ];
  enemies.forEach((e, i) => {
    const x = 0.2 + i * 2.42;
    s.addShape(pres.shapes.RECTANGLE, { x, y: 1.32, w: 2.28, h: 1.62,
      fill: { color: C.card }, line: { color: e.c, pt: 2 } });
    s.addShape(pres.shapes.RECTANGLE, { x, y: 1.32, w: 2.28, h: 0.32,
      fill: { color: e.c }, line: { color: e.c } });
    s.addText(e.e, { x, y: 1.32, w: 2.28, h: 0.32,
      fontSize: 9, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });
    s.addText(e.t, { x: x+0.1, y: 1.67, w: 2.1, h: 1.25,
      fontSize: 8, color: C.light, margin: 0, wrap: true });
  });

  divLine(s, 0.2, 3.02, 9.6, C.accent1);

  // Ischaemic specific treatment
  s.addText("SPECIFIC TREATMENT — ISCHAEMIC STROKE", {
    x: 0.2, y: 3.1, w: 4.7, h: 0.28,
    fontSize: 9, bold: true, color: C.accent2, margin: 0
  });

  const isc = [
    { n: "1", t: "ASPIRIN 300 mg IMMEDIATELY after haemorrhage excluded on NCCT", col: C.accent2 },
    { n: "2", t: "IV ALTEPLASE (rt-PA): within 4.5 hours of onset, if no contraindications (see next slide)", col: C.accent3 },
    { n: "3", t: "PERMISSIVE HTN: do NOT lower BP unless >220/120 (or >185/110 for tPA). Brain autoreg shifted right — penumbra needs the pressure", col: C.accent3 },
    { n: "4", t: "THROMBECTOMY: large vessel occlusion (ICA, M1 MCA) within 6h (up to 24h in selected patients — DAWN/DEFUSE-3)", col: C.accent5 },
    { n: "5", t: "MALIGNANT MCA SYNDROME: >2/3 MCA territory + midline shift >5mm → decompressive HEMICRANIECTOMY (peaks day 3–5)", col: C.accent1 },
  ];
  isc.forEach((r, i) => {
    numbCircle(s, r.n, 0.2, 3.42 + i * 0.4, 0.32, r.col);
    s.addText(r.t, { x: 0.58, y: 3.42 + i * 0.4, w: 4.4, h: 0.38,
      fontSize: 8, color: C.light, valign: "middle", margin: 0, wrap: true });
  });

  // ICH treatment
  s.addText("SPECIFIC TREATMENT — HAEMORRHAGIC STROKE (ICH)", {
    x: 5.1, y: 3.1, w: 4.7, h: 0.28,
    fontSize: 9, bold: true, color: C.accent1, margin: 0
  });

  const ich = [
    { n: "1", t: "BP TARGET: SBP <140 mmHg (INTERACT2 trial) — OPPOSITE to ischaemic. Reduces haematoma expansion", col: C.accent1 },
    { n: "2", t: "CEREBELLAR HAEMORRHAGE >3 cm + deteriorating + brainstem compression → URGENT surgical evacuation or EVD", col: C.accent3 },
    { n: "3", t: "SUPRATENTORIAL lobar clot >30 mL within 1 cm of surface + clinical deterioration → surgical evacuation", col: C.accent3 },
    { n: "4", t: "REVERSE anticoagulation immediately: Vit K + PCC for warfarin; idarucizumab for dabigatran; andexanet for Xa inhibitors", col: C.accent2 },
    { n: "5", t: "SAH: Nimodipine (prevents vasospasm), EVD if hydrocephalus, coil/clip aneurysm urgently", col: C.accent4 },
  ];
  ich.forEach((r, i) => {
    numbCircle(s, r.n, 5.1, 3.42 + i * 0.4, 0.32, r.col);
    s.addText(r.t, { x: 5.48, y: 3.42 + i * 0.4, w: 4.3, h: 0.38,
      fontSize: 8, color: C.light, valign: "middle", margin: 0, wrap: true });
  });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 – tPA CRITERIA
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s);
  headerBar(s, "Thrombolysis — IV Alteplase (rt-PA)", "Faculty PDF criteria · 4.5-hour window (ECASS III)");

  // Indications
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 1.02, w: 4.5, h: 0.35,
    fill: { color: C.accent5 }, line: { color: C.accent5 } });
  s.addText("INDICATIONS", { x: 0.2, y: 1.02, w: 4.5, h: 0.35,
    fontSize: 11, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

  const indic = [
    "Age > 18 years",
    "Clinical diagnosis of ischaemic stroke",
    "Measurable neurological deficit present",
    "Onset of symptoms within 4.5 hours",
    "No haemorrhage on CT brain",
  ];
  indic.forEach((t, i) => {
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 1.4 + i * 0.48, w: 4.5, h: 0.46,
      fill: { color: i%2===0?C.card:C.panel }, line: { color: i%2===0?C.card:C.panel } });
    s.addShape(pres.shapes.OVAL, { x: 0.28, y: 1.54 + i*0.48, w: 0.2, h: 0.2,
      fill: { color: C.accent5 }, line: { color: C.accent5 } });
    s.addText("✓", { x: 0.28, y: 1.54 + i*0.48, w: 0.2, h: 0.2,
      fontSize: 9, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });
    s.addText(t, { x: 0.56, y: 1.4 + i*0.48, w: 4.1, h: 0.46,
      fontSize: 9.5, color: C.light, valign: "middle", margin: 0 });
  });

  // Contraindications
  s.addShape(pres.shapes.RECTANGLE, { x: 5.1, y: 1.02, w: 4.7, h: 0.35,
    fill: { color: C.accent1 }, line: { color: C.accent1 } });
  s.addText("CONTRAINDICATIONS", { x: 5.1, y: 1.02, w: 4.7, h: 0.35,
    fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });

  const contra = [
    ["Minor/rapidly resolving symptoms", "Risk-benefit unfavourable; may resolve spontaneously"],
    ["Stroke / serious head trauma within 3 months", "Recently infarcted brain = high haemorrhagic transformation risk"],
    ["Known history of ICH", "Prior ICH = underlying vascular abnormality; catastrophic re-bleed"],
    ["SBP >185 or DBP >110 at treatment time", "Can treat BP first, then give tPA if achieved"],
    ["Symptoms suggestive of SAH", "tPA in SAH = catastrophic outcome"],
    ["GI or GU haemorrhage within 21 days", "Systemic haemorrhage risk"],
    ["Arterial puncture at non-compressible site within 7 days", "Bleeding risk at puncture site"],
    ["Heparin within 48h + elevated APTT", "Active anticoagulation"],
    ["Platelets < 100,000 / μL", "Coagulopathy; inadequate haemostasis"],
  ];
  contra.forEach((r, i) => {
    const y = 1.4 + i * 0.42;
    s.addShape(pres.shapes.RECTANGLE, { x: 5.1, y, w: 4.7, h: 0.4,
      fill: { color: i%2===0?C.card:C.panel }, line: { color: i%2===0?C.card:C.panel } });
    s.addShape(pres.shapes.RECTANGLE, { x: 5.1, y, w: 0.08, h: 0.4,
      fill: { color: C.accent1 }, line: { color: C.accent1 } });
    s.addText(r[0], { x: 5.22, y: y+0.01, w: 4.5, h: 0.2,
      fontSize: 8, bold: true, color: C.light, margin: 0 });
    s.addText(r[1], { x: 5.22, y: y+0.22, w: 4.5, h: 0.17,
      fontSize: 7.5, color: C.muted, margin: 0 });
  });

  pearl(s, "TIME IS BRAIN: every minute = ~1.9 million neurons die. Door-to-needle target < 60 min. The 4.5h window extended from 3h by ECASS III trial. Beyond 4.5h — thrombectomy in eligible large vessel occlusion patients.",
    0.2, 5.2, 9.6, 0.3);
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 11 – COMPLICATIONS + BARTHEL INDEX
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s);
  headerBar(s, "Complications & Functional Assessment", "Daily ward vigilance · Barthel Index");

  // Medical complications
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 1.02, w: 4.75, h: 0.3,
    fill: { color: C.accent1 }, line: { color: C.accent1 } });
  s.addText("MEDICAL COMPLICATIONS — Proactively Screen Daily", { x: 0.2, y: 1.02, w: 4.75, h: 0.3,
    fontSize: 8.5, bold: true, color: C.white, align: "center", valign: "middle", margin: 0 });

  const medComp = [
    { c: "Aspiration Pneumonia", d: "Most common cause of early death after stroke\nDysphagia in 28–65% — water swallow test BEFORE oral intake\nNil by mouth → NG tube until SLT clears patient", col: C.accent1 },
    { c: "UTI", d: "Urinary retention (bladder areflexia), catheter use\nAvoid urinary catheter if possible", col: C.accent3 },
    { c: "DVT / PE", d: "Immobility + limb paresis + post-stroke hypercoagulable state\nCompression stockings + LMWH + early mobilisation", col: C.accent4 },
    { c: "Pressure Sores", d: "Immobility + nutritional deficiency\n2-hourly repositioning; pressure-relieving mattress", col: C.accent3 },
    { c: "Epileptic Seizures", d: "Cortical irritation — 3–10% of stroke patients\nAED if seizures occur; seizure precautions", col: C.accent2 },
  ];
  medComp.forEach((r, i) => {
    const y = 1.35 + i * 0.67;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 4.75, h: 0.65,
      fill: { color: i%2===0?C.card:C.panel }, line: { color: i%2===0?C.card:C.panel } });
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 0.08, h: 0.65,
      fill: { color: r.col }, line: { color: r.col } });
    s.addText(r.c, { x: 0.34, y: y+0.03, w: 4.53, h: 0.24,
      fontSize: 9, bold: true, color: r.col, margin: 0 });
    s.addText(r.d, { x: 0.34, y: y+0.3, w: 4.53, h: 0.32,
      fontSize: 8, color: C.muted, margin: 0, wrap: true });
  });

  // Neurological complications
  s.addShape(pres.shapes.RECTANGLE, { x: 5.15, y: 1.02, w: 4.65, h: 0.3,
    fill: { color: C.accent3 }, line: { color: C.accent3 } });
  s.addText("NEUROLOGICAL COMPLICATIONS", { x: 5.15, y: 1.02, w: 4.65, h: 0.3,
    fontSize: 8.5, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });

  const neurComp = [
    { c: "Malignant MCA Syndrome", d: "CT >50% MCA territory + septum pellucidum shift >5mm\nPeak day 3–5 → herniation\nDecompressive hemicraniectomy (age <60, within 48h)", col: C.accent1 },
    { c: "Haemorrhagic Transformation", d: "Reperfusion of BBB-damaged ischaemic tissue\nEspecially post-tPA and cardioembolic stroke\nRepeat CT if neurological deterioration", col: C.accent1 },
    { c: "Cerebral Vasospasm (SAH)", d: "Blood breakdown products → smooth muscle contraction\nPeak day 5–14 → delayed cerebral ischaemia\nNimodipine prophylaxis", col: C.accent3 },
    { c: "Hydrocephalus", d: "IVH or SAH blocking CSF drainage\nEarly post-haemorrhage; EVD may be needed", col: C.accent2 },
  ];
  neurComp.forEach((r, i) => {
    const y = 1.35 + i * 0.82;
    s.addShape(pres.shapes.RECTANGLE, { x: 5.15, y, w: 4.65, h: 0.78,
      fill: { color: i%2===0?C.card:C.panel }, line: { color: i%2===0?C.card:C.panel } });
    s.addShape(pres.shapes.RECTANGLE, { x: 5.15, y, w: 0.08, h: 0.78,
      fill: { color: r.col }, line: { color: r.col } });
    s.addText(r.c, { x: 5.3, y: y+0.04, w: 4.42, h: 0.24,
      fontSize: 9, bold: true, color: r.col, margin: 0 });
    s.addText(r.d, { x: 5.3, y: y+0.32, w: 4.42, h: 0.42,
      fontSize: 8, color: C.muted, margin: 0, wrap: true });
  });

  // Barthel strip
  s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y: 5.08, w: 9.6, h: 0.42,
    fill: { color: C.panel }, line: { color: C.accent2, pt: 1 } });
  s.addText([
    { text: "BARTHEL INDEX (0–100):  ", options: { bold: true, color: C.accent2, fontSize: 9 } },
    { text: "Bathing · Toileting · Dressing · Hygiene · Grooming · Eating · Mobility · Transfers · Recreation · Speech & Higher functions  ", options: { color: C.light, fontSize: 8 } },
    { text: "| Also: PT & OT started? Social support? Home environment barriers?", options: { color: C.muted, fontSize: 7.5, italic: true } }
  ], { x: 0.3, y: 5.08, w: 9.4, h: 0.42, valign: "middle", margin: 3 });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 12 – CLINICAL PEARLS RAPID-FIRE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s);
  headerBar(s, "Clinical Pearls — Rapid Fire", "High-yield bedside rules for ward rounds and exams");

  const pearls = [
    { p: "'Sudden' onset = vascular", d: "Instantaneous maximal deficit. Gradual onset → tumour, abscess, SDH, metabolic" },
    { p: "Bilateral weakness ≠ stroke", d: "Think metabolic, bilateral lesions, spinal cord. Unilateral = stroke until proven otherwise" },
    { p: "Crossed signs = brainstem", d: "Ipsilateral CN deficit + contralateral limb = brainstem lesion. Pathognomonic" },
    { p: "No cortical signs = lacunar", d: "Aphasia / neglect / hemianopia EXCLUDE lacunar syndrome" },
    { p: "Check glucose FIRST", d: "Hypoglycaemia <2.8 mmol/L perfectly mimics stroke. Reversible. Give glucose before tPA" },
    { p: "NCCT normal ≠ no stroke", d: "CT excludes haemorrhage; ischaemia invisible for 6–24h. MRI DWI detects within minutes" },
    { p: "Permissive HTN in ischaemia", d: "Do NOT lower BP <220/120 (without tPA). Autoreg shifts right — penumbra needs the pressure" },
    { p: "Fever kills the penumbra", d: "1°C rise = 10% ↑ metabolic demand. Treat fever aggressively from minute 1" },
    { p: "Dysphagia screen before mouth", d: "28–65% of acute strokes. Aspiration pneumonia = most common cause of early death" },
    { p: "Carotid bruit can disappear", d: ">95% ICA stenosis → flow too low → bruit disappears. Always do duplex regardless" },
    { p: "Charcot-Bouchard = HTN vessel", d: "Same microaneurysms that occlude → lacunar infarct will rupture → deep ICH (HTN)" },
    { p: "Cerebellar ICH >3 cm = surgery", d: "Small posterior fossa → rapid brainstem compression + hydrocephalus. Neurosurgical emergency" },
    { p: "AF + stroke → anticoagulate", d: "Antiplatelets are insufficient for AF. NOAC first choice; timing depends on stroke severity" },
    { p: "'Worst headache of life' = SAH", d: "Thunderclap onset. CT first (98% within 12h), then LP at 12h if CT negative (xanthochromia)" },
  ];

  // 2 columns × 7 rows
  const half = 7;
  pearls.forEach((p, i) => {
    const col = i < half ? 0 : 1;
    const row = i < half ? i : i - half;
    const x = col === 0 ? 0.2 : 5.1;
    const y = 1.02 + row * 0.63;
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 4.72, h: 0.58,
      fill: { color: C.panel },
      line: { color: row % 2 === 0 ? C.accent1 : C.accent2, pt: 1 }
    });
    s.addText("★ " + p.p, { x: x+0.1, y: y+0.04, w: 4.52, h: 0.24,
      fontSize: 9, bold: true, color: row%2===0 ? C.accent1 : C.accent2, margin: 0 });
    s.addText(p.d, { x: x+0.1, y: y+0.3, w: 4.52, h: 0.24,
      fontSize: 8, color: C.light, margin: 0 });
  });
}


// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 13 – THE 3 BEDSIDE QUESTIONS + SOURCES
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); bg(s);
  headerBar(s, "The 3 Bedside Questions", "Ask these on every stroke patient — in order");

  const questions = [
    {
      n: "1",
      q: "What is the temporal profile?",
      a: "SUDDEN onset → vascular (stroke/TIA)\nGradual (weeks) → tumour\nDays + fever → abscess/encephalitis\nMinutes + seizure history → Todd's paresis",
      col: C.accent2,
    },
    {
      n: "2",
      q: "Which vascular territory?",
      a: "Anterior: face+arm+leg + cortical signs\nPosterior: D-V-F triad + crossed signs\nLacunar: pure motor/sensory, NO cortical signs\n→ Localise before imaging",
      col: C.accent3,
    },
    {
      n: "3",
      q: "What is the aetiology?",
      a: "Atherosclerosis: RF + TIA + bruit\nCardioembolism: AF + murmur + maximal deficit\nLacunar: HTN + DM + no cortical signs\nYoung: vasculitis + thrombophilia + dissection",
      col: C.accent1,
    },
  ];

  questions.forEach((q, i) => {
    const y = 1.05 + i * 1.4;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 9.6, h: 1.33,
      fill: { color: C.panel }, line: { color: q.col, pt: 2 } });
    s.addShape(pres.shapes.OVAL, { x: 0.35, y: y+0.3, w: 0.72, h: 0.72,
      fill: { color: q.col }, line: { color: q.col } });
    s.addText(q.n, { x: 0.35, y: y+0.3, w: 0.72, h: 0.72,
      fontSize: 24, bold: true, color: C.bg, align: "center", valign: "middle", margin: 0 });
    s.addText(q.q, { x: 1.22, y: y+0.08, w: 8.4, h: 0.38,
      fontSize: 13, bold: true, color: q.col, margin: 0 });
    s.addText(q.a, { x: 1.22, y: y+0.5, w: 8.3, h: 0.75,
      fontSize: 9, color: C.light, margin: 0, wrap: true });
  });

  // Source footer
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.25, w: 10, h: 0.375,
    fill: { color: C.card }, line: { color: C.card } });
  s.addText("Sources: Faculty PDF (Stroke vith del.pdf) · Fuster & Hurst's The Heart 15E · Neuroanatomy through Clinical Cases 3E · Bradley & Daroff's Neurology in Clinical Practice", {
    x: 0.2, y: 5.27, w: 9.6, h: 0.33,
    fontSize: 7, color: C.muted, valign: "middle", margin: 0, italic: true
  });
}


// ── WRITE ─────────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/stroke-presentation/Approach_to_Stroke_Ward_Rounds.pptx" })
  .then(() => console.log("Done: Approach_to_Stroke_Ward_Rounds.pptx"))
  .catch(err => { console.error(err); process.exit(1); });

cd /home/daytona/workspace/stroke-presentation && node build.js 2>&1

ls -lh /home/daytona/workspace/stroke-presentation/