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  <head>
    <title>033-02 Pattern-based rheumatology, limb emergencies, and immune-treatment strategy</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Pattern-based rheumatology and limb emergencies">
      <outline text="Defining the pattern">
        <outline text="Synovitis: swelling, warmth, active and passive loss">
          <outline text="Deep joints conceal swelling"/>
        </outline>
        <outline text="Tendon pain on resisted contraction or stretch"/>
        <outline text="Active-only pain suggests contractile tissue"/>
        <outline text="Inflammatory: long stiffness, eases with movement"/>
        <outline text="Mechanical: worse with use, settles with rest"/>
        <outline text="Distribution discriminates">
          <outline text="Symmetric MCP and PIP: rheumatoid arthritis"/>
          <outline text="DIP with nail change: psoriatic arthritis"/>
          <outline text="Abrupt first MTP: gout"/>
        </outline>
      </outline>
      <outline text="Trauma assessment">
        <outline text="Mechanism predicts hidden injury">
          <outline text="Twisting under load: ligaments, menisci"/>
          <outline text="Outstretched hand: wrist, elbow, shoulder"/>
        </outline>
        <outline text="Neurovascular status before and after reduction"/>
        <outline text="Warm pink limb can hide arterial injury">
          <outline text="Collateral flow masks it"/>
        </outline>
      </outline>
      <outline text="Compartment syndrome">
        <outline text="Perfusion emergency, not absent pulses"/>
        <outline text="Fracture, crush, reperfusion, burns, dressings"/>
        <outline text="Venous outflow fails first">
          <outline text="Interstitial pressure rises"/>
          <outline text="Capillary flow and nerve conduction fall"/>
        </outline>
        <outline text="Rising analgesic need, passive stretch pain"/>
        <outline text="Sedation, regional block, youth conceal pain"/>
        <outline text="Pressure measurement must not delay fasciotomy"/>
      </outline>
      <outline text="Hot joint and aspiration">
        <outline text="Treat as infection until disproved"/>
        <outline text="Fluid count overlaps bacterial, crystal, immune"/>
        <outline text="Gram stain cannot exclude infection"/>
        <outline text="Blood cultures may be positive alone"/>
        <outline text="Prosthetic infection: sample before antibiotics"/>
        <outline text="Small volume: prioritise the decisive test"/>
      </outline>
      <outline text="Osteomyelitis">
        <outline text="Haematogenous: metaphysis in children, vertebrae in adults"/>
        <outline text="Contiguous: trauma, surgery, ulcers"/>
        <outline text="Ischaemic, neuropathic foot: poor delivery, healing"/>
        <outline text="Deep culture beats superficial swabs"/>
        <outline text="Remove dead bone, restore perfusion, off-load"/>
      </outline>
      <outline text="Osteoarthritis and gout">
        <outline text="Osteoarthritis: whole-joint maladaptation">
          <outline text="Cartilage lacks nerves"/>
          <outline text="Radiograph and symptom discordance"/>
        </outline>
        <outline text="Analgesia enables but cannot replace rehabilitation"/>
        <outline text="Hyperuricaemia necessary but not sufficient"/>
        <outline text="Disturbed deposits trigger neutrophilic inflammation"/>
        <outline text="Urate lowering dissolves the crystal burden">
          <outline text="Early flares from mobilised deposits"/>
          <outline text="Prophylaxis prevents abandonment"/>
        </outline>
      </outline>
      <outline text="Rheumatoid arthritis and spondyloarthritis">
        <outline text="Pannus damages cartilage, bone, tendon"/>
        <outline text="Early treatment within the damage window"/>
        <outline text="Activity from joints and function, not titre"/>
        <outline text="Pain without swelling: consider other causes">
          <outline text="Fibromyalgia, damage, mood, sleep"/>
        </outline>
        <outline text="Persistent swelling advances damage"/>
        <outline text="Inflammatory back pain is a pattern"/>
        <outline text="HLA-B27 cannot screen indiscriminately"/>
        <outline text="Red painful photophobic eye: urgent review"/>
      </outline>
      <outline text="Lupus and systemic sclerosis">
        <outline text="Lupus needs coherent evidence, not ANA alone"/>
        <outline text="Urine examination: nephritis may be quiet"/>
        <outline text="Hydroxychloroquine needs retinal surveillance"/>
        <outline text="Glucocorticoid toxicity: steroid sparing"/>
        <outline text="New severe Raynaud or ulcers: systemic disease"/>
        <outline text="Renal crisis: ACE inhibition despite creatinine">
          <outline text="High-dose steroids may raise risk"/>
        </outline>
      </outline>
      <outline text="Vasculitis and myopathy">
        <outline text="Unrelated organs sharing ischaemia"/>
        <outline text="Purpura, red-cell casts, lung haemorrhage"/>
        <outline text="Infection, emboli, drugs mimic vasculitis"/>
        <outline text="Biopsy before prolonged immunosuppression"/>
        <outline text="Giant-cell arteritis with visual threat: treat now"/>
        <outline text="Myopathy: weakness more than pain">
          <outline text="Creatine kinase can be normal"/>
        </outline>
        <outline text="Exclude inclusion-body myositis and mimics"/>
      </outline>
      <outline text="Immune-treatment strategy">
        <outline text="Weigh untreated disease and treatment risk"/>
        <outline text="Screen tuberculosis, hepatitis, pregnancy"/>
        <outline text="Fever: infection, flare, or toxicity">
          <outline text="Reflexive stopping or escalating is dangerous"/>
        </outline>
        <outline text="Least cumulative toxicity that achieves control"/>
        <outline text="Final record separates each dimension">
          <outline text="Success means function, not laboratory values"/>
        </outline>
        <outline text="New breathlessness: parallel differential">
          <outline text="Low markers do not exclude infection"/>
        </outline>
        <outline text="Vaccinate before strong immunosuppression">
          <outline text="Check live vaccines per drug and time"/>
        </outline>
      </outline>
    </outline>
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