from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT
from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, PageBreak, Table, TableStyle, KeepTogether
from reportlab.lib.units import cm
from reportlab.pdfbase.ttfonts import TTFont
from reportlab.pdfbase import pdfmetrics
from reportlab.lib.colors import HexColor
from reportlab.pdfbase.pdfmetrics import stringWidth
from reportlab.pdfgen.canvas import Canvas
from reportlab.lib.pagesizes import A4
from reportlab.lib.colors import black
from reportlab.platypus import ListFlowable, ListItem
import os

OUT='/tmp/workspace/kuhs-rheumatology/output/KUHS_Rheumatology_Study_Guide.pdf'
os.makedirs(os.path.dirname(OUT), exist_ok=True)

NAVY=HexColor('#12345A'); TEAL=HexColor('#0B6E69'); GOLD=HexColor('#B78420'); PALE=HexColor('#EAF2F7'); LIGHT=HexColor('#F6F8FA'); RED=HexColor('#8A2432')
styles=getSampleStyleSheet()
styles.add(ParagraphStyle(name='CoverTitle', parent=styles['Title'], fontName='Helvetica-Bold', fontSize=27, leading=32, textColor=NAVY, alignment=TA_CENTER, spaceAfter=14))
styles.add(ParagraphStyle(name='CoverSub', parent=styles['Normal'], fontName='Helvetica', fontSize=12, leading=17, textColor=TEAL, alignment=TA_CENTER))
styles.add(ParagraphStyle(name='H1x', parent=styles['Heading1'], fontName='Helvetica-Bold', fontSize=18, leading=22, textColor=NAVY, spaceBefore=10, spaceAfter=8, keepWithNext=True))
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styles.add(ParagraphStyle(name='Q', parent=styles['BodyText'], fontName='Helvetica-Bold', fontSize=9.5, leading=13, textColor=RED, spaceBefore=7, spaceAfter=3))

def P(t, style='Bodyx'): return Paragraph(t, styles[style])
def bullets(items):
    return ListFlowable([ListItem(P(x), leftIndent=8) for x in items], bulletType='bullet', start='circle', leftIndent=15, bulletFontSize=6, spaceAfter=5)
def table(headers, rows, widths=None):
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def footer(canvas, doc):
    canvas.saveState(); w,h=A4
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    canvas.drawRightString(w-1.6*cm,.82*cm,f'Page {doc.page}')
    canvas.restoreState()

S=[]
# cover
S += [Spacer(1,3.2*cm), P('KUHS RHEUMATOLOGY','CoverTitle'), P('Complete MBBS Study Guide','CoverTitle'), Spacer(1,.25*cm), P('Long essays | Short notes | Clinical approach | Tables | Viva revision','CoverSub'), Spacer(1,1.0*cm), P('<b>For undergraduate General Medicine revision</b><br/>Organised to the KUHS MBBS rheumatology syllabus: presenting problems, examination and investigations; osteoarthritis; rheumatoid arthritis; crystal arthropathy; SLE; systemic sclerosis; spondyloarthritis; connective-tissue disease; vasculitis; osteoporosis and vitamin-D deficiency.','Box'), Spacer(1,.6*cm), P('Textbook-aligned synthesis, not a reproduction of any textbook. Prepared using standard internal-medicine principles reflected in Davidson\'s Principles and Practice of Medicine and Archith Boloor\'s Textbook of Medicine, with current safety framing. Confirm local protocols and formulary before clinical use.','Small'), PageBreak()]

S += [P('How to use this guide','H1x'), P('For a 10-mark long essay, use the order: <b>definition -> epidemiology/causes -> pathogenesis -> clinical features -> investigations -> diagnosis/classification -> management -> complications/prognosis.</b> Underline headings and draw one comparison table or simple flowchart. For a short note, include definition, 4 to 6 key points, investigations and treatment principle.'), P('KUHS study priorities','H2x'), table(['Tier','Topics'],[['Long essay core','Rheumatoid arthritis, SLE, gout, osteoarthritis knee, axial spondyloarthritis, osteoporosis, vasculitis, systemic sclerosis'],['Short-note core','Acute monoarthritis, synovial fluid, DMARDs, methotrexate, ANA/ANCA, Sjogren syndrome, antiphospholipid syndrome, polymyalgia rheumatica, pseudogout'],['Viva core','Joint examination, hand deformities, crystal microscopy, HLA-B27, anti-CCP, steroid toxicity, red flags']], [3*cm,13*cm]), P('Contents','H2x'), bullets(['1. Clinical approach to joint disease and investigations','2. Rheumatoid arthritis','3. Osteoarthritis and regional pain syndromes','4. Spondyloarthritis','5. Crystal arthritis and septic arthritis','6. Connective-tissue diseases: SLE, systemic sclerosis, Sjogren syndrome and myositis','7. Vasculitis','8. Metabolic bone disease','9. Drugs in rheumatology','10. KUHS long essays, short notes and viva checklist']), PageBreak()]

# modules helper
S += [P('1. Clinical approach to rheumatology','H1x'), P('First decide whether the presentation is articular, periarticular, bone, muscle or referred pain. Then define duration, number and distribution of joints, inflammatory features and systemic involvement. <b>Never miss septic arthritis, crystal arthritis, vasculitis with threatened organ function, giant-cell arteritis with visual symptoms, or spinal fracture in ankylosed spine.</b>','Box'), P('Inflammatory versus mechanical pain','H2x'), table(['Feature','Inflammatory arthritis','Mechanical / osteoarthritis'],[['Stiffness','Usually prolonged after rest; classically >30-60 min','Brief, after inactivity'],['Pain','At rest/night; improves with gentle activity','Worse on use; improves with rest'],['Examination','Warmth, soft-tissue swelling, synovitis','Bony enlargement, crepitus, reduced range'],['Markers','May have raised ESR/CRP','Often normal'],['Examples','RA, SLE, SpA, crystal arthritis','OA, tendinopathy']], [3.2*cm,6.7*cm,6.1*cm]), P('Pattern recognition','H2x'), bullets(['<b>Acute monoarthritis:</b> septic arthritis, gout/CPPD, trauma/haemarthrosis. Aspirate urgently if an effusion is present and infection is possible.','<b>Chronic monoarthritis:</b> OA, inflammatory arthritis, TB/fungal infection, internal derangement.','<b>Symmetric small-joint polyarthritis:</b> RA, SLE, viral arthritis.','<b>Asymmetric lower-limb oligoarthritis with enthesitis:</b> spondyloarthritis.','<b>Proximal muscle pain and weakness:</b> distinguish PMR (pain/stiffness without true weakness) from inflammatory myopathy (objective weakness).']), P('History and examination','H2x'), bullets(['Ask onset, preceding diarrhoea/urethritis, psoriasis, uveitis, IBD, rashes/photosensitivity, Raynaud phenomenon, sicca, fever, weight loss, drugs, family history and thrombotic/obstetric history.','Examine for synovitis, tenderness, range, deformity, enthesitis, dactylitis, skin/nails, eyes, nodes, lungs, heart, abdomen, nerves and vascular signs.','Joint examination sequence: <b>look, feel, move, measure function, examine above and below, then screen other systems.</b>']), P('Investigations','H2x'), table(['Test','Use and caveat'],[['CBC, ESR, CRP','Inflammation and cytopenias. Normal results do not exclude disease.'],['RF and anti-CCP','Anti-CCP is more specific for RA; interpret with clinical synovitis.'],['ANA with specific antibodies','Screen only when connective-tissue disease is clinically plausible. Positive ANA alone is not SLE.'],['Urinalysis, creatinine, urine protein','Essential in suspected SLE or systemic vasculitis.'],['X-ray / ultrasound / MRI','X-ray for damage; ultrasound for synovitis/aspiration; MRI for early sacroiliitis or occult pathology.'],['Synovial fluid','Appearance, cell count/differential, Gram stain/culture and crystal microscopy. Crystals do not exclude infection.']], [4.2*cm,11.8*cm]), PageBreak()]

# RA
S += [P('2. Rheumatoid arthritis','H1x'), P('<b>Definition:</b> a chronic systemic autoimmune inflammatory disease characterised by persistent synovitis, usually involving peripheral joints symmetrically, with potential cartilage destruction, bone erosion and extra-articular disease.'), P('Pathogenesis','H2x'), P('Genetic susceptibility and environmental triggers, particularly cigarette smoking, promote loss of tolerance to citrullinated proteins. Autoantibodies including RF and anti-CCP may precede clinical disease. Cytokine-driven synovitis, notably TNF, IL-6 and others, produces pannus, cartilage damage and erosions.'), P('Clinical features','H2x'), bullets(['Insidious onset with fatigue, malaise and symmetrical pain/swelling of MCP, PIP, wrists and MTP joints. DIP joints are usually spared.','Morning stiffness, reduced grip and functional limitation. Large joints may later be involved.','Deformities: ulnar deviation, MCP subluxation, swan-neck, boutonniere, Z-thumb and hammer toes.','Extra-articular: nodules, anaemia, episcleritis/scleritis, interstitial lung disease, pleural disease, neuropathy, vasculitis, osteoporosis and accelerated cardiovascular risk.']), P('Investigations and classification','H2x'), bullets(['Clinical synovitis is central. ESR/CRP may support activity; RF and anti-CCP support diagnosis and prognosis.','Baseline tests before DMARDs include CBC, liver and renal function; screen for infection as appropriate.','Radiographs show periarticular osteopenia, marginal erosions and uniform joint-space narrowing. Ultrasound/MRI identify early synovitis/erosion.','2010 ACR/EULAR scoring uses joint involvement, serology, acute-phase reactants and symptom duration. Use criteria as an aid, not a replacement for clinical judgement.']), P('Management: treat to target','H2x'), table(['Component','Key points'],[['General','Education, smoking cessation, vaccinations, exercise, physiotherapy, occupational therapy, foot care and cardiovascular-risk control.'],['Symptom bridge','NSAID if appropriate; short glucocorticoid course/intra-articular steroid only as a bridge while DMARD takes effect.'],['Disease modification','Start a conventional DMARD early, usually methotrexate if no contraindication. Alternatives/combinations include sulfasalazine, hydroxychloroquine and leflunomide. Folic acid is used with methotrexate.'],['Escalation','Persistent active disease requires rheumatology review for biologic or targeted synthetic therapy after infection screening and shared decision-making.'],['Monitoring','Assess disease activity, function, toxicity, adherence, pregnancy plans and drug interactions regularly.']], [3.4*cm,12.6*cm]), P('KUHS long essay skeleton: RA','Q'), P('<b>Introduction:</b> define RA. <b>Body:</b> causes/pathogenesis, articular features, extra-articular features, investigations, diagnosis, management, complications. <b>Conclusion:</b> early DMARD-based treat-to-target care prevents structural damage and disability.'), P('Short-note prompts: rheumatoid nodules, Felty syndrome, cervical spine disease in RA, anti-CCP antibody, methotrexate, biologic DMARDs, hand deformities.'), PageBreak()]

# OA / regional
S += [P('3. Osteoarthritis and regional pain syndromes','H1x'), P('<b>Osteoarthritis (OA)</b> is a disorder of synovial joints with structural change of cartilage, subchondral bone, synovium, ligaments and periarticular muscle, causing pain and functional limitation.'), P('Risk factors and features','H2x'), bullets(['Age, obesity, previous joint injury, malalignment, repetitive loading, muscle weakness and genetic predisposition. Secondary OA may follow trauma, inflammatory arthritis, metabolic disease or congenital abnormality.','Pain worsens with activity, brief gelling stiffness, crepitus, bony enlargement and limitation. Knee: joint-line tenderness, varus/valgus deformity, effusion. Hand: Heberden nodes at DIP, Bouchard nodes at PIP, thumb-base OA.']), P('Diagnosis and treatment of knee OA','H2x'), table(['Step','Approach'],[['Diagnosis','Usually clinical. Weight-bearing X-ray when diagnosis is uncertain, symptoms are severe or surgical planning is needed: non-uniform joint-space loss, osteophytes, sclerosis and cysts.'],['Core treatment','Education, realistic activity advice, structured strengthening/aerobic exercise, weight loss when overweight, walking aid if needed.'],['Analgesia','Topical NSAID first where suitable. Oral NSAID only after GI, renal and cardiovascular risk assessment. Avoid routine long-term opioid use.'],['Procedures','Intra-articular corticosteroid may offer short-term relief in selected painful flares. Arthroplasty is for severe pain/function loss despite optimal non-operative care.']], [3.3*cm,12.7*cm]), P('Regional pain conditions','H2x'), table(['Condition','Hallmark','Initial management'],[['Fibromyalgia','Widespread pain, fatigue, poor sleep, cognitive symptoms; no synovitis','Explanation, graded exercise, sleep and mood management; avoid unnecessary tests/opioids.'],['Carpal tunnel syndrome','Median-nerve paraesthesia, nocturnal symptoms, thenar weakness late','Wrist splint, address cause, injection or decompression when indicated.'],['De Quervain tenosynovitis','Radial wrist pain, positive Finkelstein manoeuvre','Activity modification, splint, NSAID; injection if persistent.'],['Lateral epicondylitis','Pain with resisted wrist extension','Load modification, physiotherapy; avoid repeated steroid injections.'],['Adhesive capsulitis','Painful global passive and active shoulder restriction','Analgesia, supervised exercise; consider injection/orthopaedic referral.']], [3.4*cm,5.2*cm,7.4*cm]), P('KUHS long essay skeleton: OA knee','Q'), P('Define OA -> risk factors/pathology -> symptoms/signs -> X-ray features -> differential -> non-drug treatment -> drug safety -> indications for arthroplasty.'), PageBreak()]

# SpA
S += [P('4. Spondyloarthritis','H1x'), P('Spondyloarthritis (SpA) includes axial SpA/ankylosing spondylitis, psoriatic arthritis, reactive arthritis and enteropathic arthritis. Shared features are axial inflammation, asymmetric peripheral arthritis, enthesitis, dactylitis, uveitis and association with HLA-B27.'), P('Axial SpA / ankylosing spondylitis','H2x'), bullets(['Inflammatory back pain begins before 45 years: gradual onset, improvement with exercise, no improvement with rest, night pain and prolonged morning stiffness.','Sacroiliitis progresses to spinal syndesmophytes and ankylosis. Examine posture, chest expansion, spinal flexion and hip movement.','Extra-articular disease: acute anterior uveitis, psoriasis, IBD, aortic regurgitation and restrictive chest-wall disease.','X-ray may show sacroiliitis and syndesmophytes. MRI detects active sacroiliitis earlier. HLA-B27 supports but neither confirms nor excludes disease.']), P('Management','H2x'), bullets(['Education, smoking cessation, regular exercise, posture and physiotherapy are fundamental.','NSAID is usually first-line if safe. Persistent objectively active disease needs rheumatology assessment for biologic or targeted therapy.','Treat uveitis urgently with ophthalmology and coordinate care for psoriasis/IBD. In a rigid spine, minor trauma can cause unstable fracture: maintain spinal precautions and obtain appropriate imaging.']), P('Psoriatic and reactive arthritis','H2x'), table(['Disorder','Key clues','Principles'],[['Psoriatic arthritis','Psoriasis, nail pitting/onycholysis, dactylitis, enthesitis; may be asymmetric, DIP-predominant or axial','Assess skin/nails, joints and comorbidity. NSAID for symptoms; DMARDs for peripheral inflammatory disease; specialist biologics according to domains.'],['Reactive arthritis','Acute asymmetric lower-limb oligoarthritis and enthesitis after GI/GU infection; conjunctivitis/uveitis, urethritis, mucocutaneous lesions may occur','Exclude septic arthritis; test/treat active infection where indicated; NSAID, local steroid, rehabilitation; persistent disease needs referral.']], [3.2*cm,6.7*cm,6.2*cm]), P('Short-note prompts: inflammatory back pain, enthesitis, dactylitis, HLA-B27, sacroiliitis, psoriatic arthritis, reactive arthritis, acute anterior uveitis.'), PageBreak()]

# crystal, infection
S += [P('5. Acute monoarthritis, crystal arthritis and septic arthritis','H1x'), P('<b>Acute hot swollen joint is septic arthritis until proven otherwise.</b> Aspirate before antibiotics when this does not delay resuscitation or treatment. Send fluid for Gram stain, culture, cell count/differential and crystals. Obtain blood cultures if febrile/systemically unwell.' ,'Box'), P('Gout','H2x'), bullets(['Gout results from deposition of monosodium urate crystals. Risk factors include CKD, diuretics, alcohol, high purine intake, obesity, metabolic syndrome, rapid cell turnover and genetic predisposition.','Typical acute attack: abrupt, severe pain with redness and swelling, often first MTP joint. Recurrent attacks may lead to tophi, erosive disease and urate stones.','Definitive diagnosis: needle-shaped, strongly negatively birefringent monosodium urate crystals in synovial fluid. Serum urate can be normal during a flare.']), P('Acute and long-term gout treatment','H2x'), table(['Situation','Management principle'],[['Acute flare','Start anti-inflammatory treatment promptly: NSAID, low-dose colchicine, or systemic/intra-articular glucocorticoid according to comorbidity and contraindications. Rest/ice and analgesia adjuncts.'],['Urate-lowering therapy','Indicated for recurrent flares, tophi, chronic gouty arthritis, urate stones and selected high-risk patients. Use treat-to-target serum urate strategy under follow-up.'],['Drug options','Allopurinol is common first-line and should be started low then titrated. Febuxostat is an alternative in selected patients. Anti-inflammatory prophylaxis during initiation reduces flares.'],['Lifestyle','Weight management, limit alcohol especially beer/spirits, avoid sugary drinks, review diuretics where possible; do not rely on diet alone for established gout.']], [3.8*cm,12.2*cm]), P('Gout versus CPPD','H2x'), table(['Feature','Gout','CPPD (pseudogout)'],[['Crystal','Needle-shaped, negatively birefringent MSU','Rhomboid/rod-like, weakly positively birefringent CPP crystals'],['Typical setting','First MTP, ankle, knee; tophi possible','Knee/wrist; older patients; may be associated with metabolic disease'],['X-ray','Erosions with overhanging edges in chronic disease','Chondrocalcinosis may be present']], [3.4*cm,6.3*cm,6.3*cm]), P('Septic arthritis','H2x'), P('Risk factors include pre-existing joint disease, prosthesis, diabetes, immunosuppression, skin infection, injection drug use and older age. Features are acute pain, restricted active and passive movement, effusion and fever which may be absent. Management requires urgent cultures, antimicrobial therapy directed by local protocol and drainage/washout when indicated. Do not dismiss infection because crystals are seen.'), P('KUHS long essay skeleton: gout','Q'), P('Define -> causes of hyperuricaemia -> acute/chronic features -> crystal diagnosis -> treat acute flare -> indications and principles of long-term urate lowering -> lifestyle and complications.'), PageBreak()]

# CTD
S += [P('6. Connective-tissue diseases','H1x'), P('Systemic lupus erythematosus','H2x'), P('<b>Definition:</b> a chronic multisystem autoimmune disease in which autoantibodies and immune complexes cause inflammatory tissue injury. It commonly affects young women but occurs at all ages and in all sexes.'), bullets(['Clinical features: fatigue/fever, photosensitive rash, malar rash, oral/nasal ulcers, alopecia, non-erosive inflammatory arthritis, serositis, nephritis, neuropsychiatric disease, cytopenias and thrombosis/pregnancy morbidity due to antiphospholipid antibodies.','Investigations: CBC, ESR/CRP, urinalysis, sediment, creatinine/eGFR, protein quantification, ANA, anti-dsDNA, anti-Sm, complement C3/C4, antiphospholipid antibody panel. Renal biopsy guides therapy in significant nephritis.','ANA is sensitive but non-specific. Rising anti-dsDNA and falling complement may correlate with activity in some patients.']), P('SLE management','H2x'), table(['Severity','Principles'],[['All patients','Education, sun protection, smoking cessation, immunisation planning, cardiovascular and bone-health care; hydroxychloroquine unless contraindicated with eye monitoring.'],['Mild mucocutaneous/musculoskeletal','Topicals/NSAID cautiously, hydroxychloroquine, low-dose steroid only if needed; steroid-sparing agents for recurrent disease.'],['Organ-threatening disease','Urgent specialist-led glucocorticoid plus immunosuppressive induction tailored to organ involvement, then maintenance. Nephritis and CNS disease require close multidisciplinary care.'],['Pregnancy','Plan during low disease activity; review teratogenic drugs, renal status and antiphospholipid risk before conception.']], [3.8*cm,12.2*cm]), P('Antiphospholipid syndrome','H2x'), P('APS is defined by arterial/venous/small-vessel thrombosis or specified obstetric morbidity with persistent antiphospholipid antibodies on repeat testing. Test lupus anticoagulant, anticardiolipin and anti-beta-2 glycoprotein I. Management depends on thrombotic/obstetric history and must be specialist-led.'), P('Systemic sclerosis','H2x'), bullets(['Fibrosis and vasculopathy cause Raynaud phenomenon, puffy fingers progressing to skin thickening/sclerodactyly, digital ulcers, telangiectasia and calcinosis. Limited cutaneous disease may have pulmonary arterial hypertension; diffuse disease has higher early risk of ILD and renal crisis.','Assess lungs (PFT/HRCT as indicated), heart/pulmonary pressure, renal function/BP and GI disease. Treatment is organ-specific. <b>New hypertension/AKI suggests scleroderma renal crisis: urgent ACE inhibitor-based management.</b>']), P('Sjogren syndrome and inflammatory myopathy','H2x'), table(['Condition','Key points'],[['Sjogren syndrome','Dry eyes/mouth, dental caries, parotid swelling, fatigue, arthralgia; anti-Ro/SSA and anti-La/SSB may support. Assess systemic disease and lymphoma warning signs. Symptomatic eye/oral care plus specialist therapy for systemic involvement.'],['Polymyositis / dermatomyositis','Symmetrical proximal weakness, raised muscle enzymes and myopathic tests. Dermatomyositis has heliotrope rash and Gottron papules. Screen appropriately for interstitial lung disease and associated malignancy; treat with specialist-guided immunosuppression and rehabilitation.']], [3.8*cm,12.2*cm]), PageBreak()]

# vasculitis
S += [P('7. Vasculitis','H1x'), P('Vasculitis is inflammation of vessel walls causing tissue ischaemia, aneurysm or haemorrhage. Consider it with constitutional symptoms plus purpura, neuropathy, glomerulonephritis, pulmonary haemorrhage, ENT disease, unexplained hypertension/limb claudication or multisystem inflammation.'), table(['Vessel size','Important disorders','Typical clues'],[['Large','Giant-cell arteritis, Takayasu arteritis','Headache/jaw claudication/visual symptoms; pulseless disease'],['Medium','Polyarteritis nodosa, Kawasaki disease','Neuropathy, skin/livedo, renal/mesenteric ischaemia; no glomerulonephritis in classic PAN'],['Small','GPA, MPA, EGPA, IgA vasculitis, cryoglobulinaemic vasculitis','Purpura, glomerulonephritis, pulmonary/ENT disease, asthma/eosinophilia depending on type']], [3*cm,6.5*cm,6.5*cm]), P('Giant-cell arteritis and polymyalgia rheumatica','H2x'), bullets(['GCA occurs in older adults: new headache, scalp tenderness, jaw claudication, visual disturbance/loss, constitutional symptoms and raised inflammatory markers.','<b>Start high-dose glucocorticoid immediately if GCA is suspected, especially with visual symptoms. Do not wait for temporal artery ultrasound/biopsy.</b> Arrange urgent specialist assessment.','PMR causes bilateral shoulder/hip girdle pain and morning stiffness in older adults, without true muscle weakness. Screen for GCA symptoms at every review.']), P('ANCA-associated vasculitis','H2x'), table(['Disease','Pattern','Work-up and treatment concept'],[['GPA','ENT disease, nodules/cavities, glomerulonephritis; often PR3-ANCA','Urine, renal function, chest imaging, ANCA and tissue diagnosis where possible. Organ-threatening disease needs urgent induction immunosuppression under specialists.'],['MPA','Pulmonary-renal syndrome, glomerulonephritis; often MPO-ANCA','Same urgency for haematuria/proteinuria, rising creatinine or pulmonary haemorrhage.'],['EGPA','Asthma, eosinophilia, sinus disease, neuropathy, pulmonary infiltrates','Assess cardiac, neurological and renal involvement; specialist immunosuppression.']], [3*cm,6.0*cm,7*cm]), P('Takayasu arteritis / PAN / IgA vasculitis','H2x'), bullets(['Takayasu: young women, limb claudication, unequal BP/pulses, bruits, hypertension from renal artery stenosis. Image the aorta and branches.','PAN: fever, weight loss, hypertension, livedo, nodules, mononeuritis multiplex, abdominal pain/renal ischaemia. Test for hepatitis B; classically spares pulmonary capillaries.','IgA vasculitis: palpable purpura, arthralgia, abdominal pain and renal involvement. Monitor BP, urinalysis and renal function.']), P('KUHS long essay skeleton: GCA','Q'), P('Definition -> clinical features and visual emergency -> investigations/confirmation -> immediate steroid treatment -> monitoring and PMR association.'), PageBreak()]

# bone + drugs
S += [P('8. Osteoporosis, osteomalacia and vitamin-D deficiency','H1x'), P('<b>Osteoporosis:</b> a skeletal disorder characterised by reduced bone strength predisposing to fragility fracture. A fragility fracture occurs from low-energy trauma, such as a fall from standing height.'), P('Assessment and management','H2x'), table(['Area','Key points'],[['Risk factors','Age, female sex, previous fragility fracture, low BMI, parental hip fracture, smoking, alcohol, glucocorticoids, hypogonadism and secondary disease.'],['Diagnosis','DXA measures BMD. In postmenopausal women and men aged 50 or above, T-score <= -2.5 defines osteoporosis. A fragility fracture may establish high risk regardless of BMD.'],['Investigations','CBC, renal/liver function, calcium, phosphate, ALP, vitamin D and tests for secondary cause when indicated.'],['Non-drug','Weight-bearing/resistance exercise, adequate protein/calcium intake, correct vitamin-D deficiency, stop smoking, reduce alcohol, vision/footwear/home fall prevention.'],['Drug therapy','Choice is based on fracture risk, renal function, contraindications and prior treatment. Common antiresorptives include bisphosphonates; selected very-high-risk patients may need anabolic therapy. Review adherence and duration.']], [3.5*cm,12.5*cm]), P('Osteomalacia','H2x'), P('Osteomalacia is defective mineralisation of osteoid in adults, often due to vitamin-D deficiency. It causes diffuse bone pain, proximal muscle weakness, fractures/pseudofractures and biochemical abnormalities, commonly raised ALP. Identify the cause: low intake/sun exposure, malabsorption, CKD, liver disease, drugs or phosphate disorders. Replace vitamin D and calcium as appropriate while treating the cause.'), P('9. Drugs in rheumatology','H1x'), table(['Class','Use','Major safety points'],[['NSAIDs','Pain/inflammation in OA, SpA, acute gout','GI ulcer/bleeding, renal injury, fluid retention, BP/CV risk; use lowest dose/shortest duration and consider gastroprotection if indicated.'],['Glucocorticoids','Short bridge, flares, organ-threatening autoimmune disease','Infection, hyperglycaemia, osteoporosis, cataract, hypertension, adrenal suppression. Use lowest effective dose; bone protection and taper planning.'],['Methotrexate','Anchor DMARD for RA and some peripheral inflammatory arthritis','Teratogenic; liver, marrow and lung toxicity. Folic acid and blood/liver/renal monitoring; avoid with significant liver disease and counsel on infection.'],['Hydroxychloroquine','SLE and mild RA components','Retinal toxicity risk: dose and ophthalmic monitoring.'],['Sulfasalazine / leflunomide','Alternative DMARDs','CBC/liver monitoring; leflunomide teratogenic and long-lasting.'],['Biologic/targeted agents','Moderate-severe immune-mediated disease','Serious infection risk; screen for TB/hepatitis per local policy, update vaccines, specialist prescribing.']], [3.6*cm,4.4*cm,8*cm]), PageBreak()]

# Q bank
S += [P('10. KUHS question bank and rapid revision','H1x'), P('Model long essays','H2x'), bullets(['Define rheumatoid arthritis. Describe the clinical features, investigations and management of RA.','Discuss clinical manifestations, investigations and management of SLE.','Describe acute and chronic gout. Discuss diagnosis and management.','Describe osteoarthritis of the knee and its management.','Describe ankylosing spondylitis with emphasis on diagnosis and treatment.','Classify vasculitis. Describe giant-cell arteritis / granulomatosis with polyangiitis.','Define osteoporosis. Discuss risk factors, diagnosis, prevention and management.','Describe systemic sclerosis and its organ involvement.']), P('High-yield short notes','H2x'), table(['Topic cluster','Short-note titles'],[['Clinical','Acute monoarthritis; synovial-fluid analysis; inflammatory back pain; Raynaud phenomenon; ANA; anti-CCP; ANCA; HLA-B27.'],['RA','Extra-articular RA; rheumatoid hand; Felty syndrome; methotrexate; biologic DMARDs; steroid toxicity.'],['SpA / crystals','Psoriatic arthritis; reactive arthritis; enthesitis; dactylitis; CPPD; colchicine; allopurinol.'],['CTD','Lupus nephritis; APS; Sjogren syndrome; scleroderma renal crisis; dermatomyositis.'],['Vasculitis / bone','PMR; GCA; Takayasu; PAN; IgA vasculitis; osteomalacia; vitamin-D deficiency; Paget disease.']], [4*cm,12*cm]), P('Last-day tables to reproduce','H2x'), table(['Comparison','Write these differentiators'],[['RA vs OA','Inflammatory versus mechanical pattern; small joint synovitis/erosions versus bony change/osteophytes; DMARDs versus exercise/analgesia/arthroplasty.'],['Gout vs septic arthritis','Both acute hot joint; aspiration is required; crystals support gout but do not rule out infection.'],['Gout vs CPPD','Crystal shape/birefringence, typical joint, radiographic chondrocalcinosis.'],['SLE vs systemic sclerosis','Immune-complex multisystem disease versus vasculopathy/fibrosis and organ-specific complications.'],['GCA vs PMR','Cranial ischaemic emergency versus girdle stiffness; frequently coexist.']], [4*cm,12*cm]), P('Viva: 20 one-line answers','H2x'), bullets(['<b>Arthralgia:</b> joint pain without objective synovitis. <b>Arthritis:</b> joint inflammation with swelling, warmth, pain or restricted movement.','<b>Enthesitis:</b> inflammation at tendon/ligament insertion. <b>Dactylitis:</b> diffuse swelling of an entire digit.','RA typically affects MCP, PIP, wrists and MTP joints; DIP joints are usually spared.','Anti-CCP supports RA and is relatively specific. RF is not specific.','MSU crystals are needle-shaped and negatively birefringent. CPP crystals are weakly positively birefringent.','GCA with visual symptoms is treated immediately with glucocorticoids while confirmation is arranged.','Scleroderma renal crisis presents with acute hypertension and renal impairment; ACE inhibition is central.','Long-term glucocorticoids require infection, glucose, BP, eye and bone-risk planning.']), P('References and scope','H2x'), P('Primary study sources for the framework: <i>Davidson\'s Principles and Practice of Medicine</i>, rheumatology chapters; Archith Boloor, <i>Textbook of Medicine</i>, rheumatology sections. This guide is an original educational synthesis rather than copied text. The KUHS MBBS syllabus includes presenting problems, examination, assessment and investigations of rheumatological disease; osteoarthritis, rheumatoid arthritis, crystal arthropathy, SLE, systemic sclerosis, seronegative spondyloarthropathies, reactive arthritis, connective-tissue diseases, vasculitis, osteoporosis and vitamin-D deficiency. Use your edition and university notices for exact coverage.'), P('<b>Clinical safety:</b> This is for exam revision, not individual medical advice. Drug selection, dosing and monitoring must follow the treating clinician, local policy and patient-specific contraindications.','Box')]

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