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تبقى ملاحظة: أغلب الـ DFU سببها الرئيسي هو الـ neuropathy (ومرات مزيج من الإثنين). بنسبة قليلة فقط يكون السبب هو الـ PAD

Here's a case:

A 65-year-old man presents with an ulcer on the dorsum of his right foot. He noticed a sore area on the right foot 3 weeks ago and this has extended to an ulcerated lesion which is not painful. He has complained of pain in the legs for some months. This pain comes on when he walks and settles down when he stops.
He had an inguinal hernia repaired 2 years ago and he stopped smoking then on the advice of the anaesthetist. Previously he smoked 20 cigarettes per day. He drinks four pints of beer at weekends. His father died of a myocardial infarction aged 58 years.

On examination, his blood pressure is 136/84 mmHg. The respiratory, cardiovascular and abdominal systems are normal. There is a 3cm ulcerated area with a well-demarcated edge on the dorsum of the right foot. The posterior tibial pulses are palpable on both feet, and the dorsalis pedis on the left. The capillary return time is 4s. On neurological examination there is some loss of light touch sensation in the toes. Varicose veins are present in the long saphenous distribution on both legs.
His blood glucose is 6.4 mmol/L (115 mg/dL) and his HbA1c is 9.1%. Otherwise, his lab tests were normal.

Discussion:
The diagnosis is most likely to be diabetic foot ulcer.

Venous ulcers are usually found around the medial malleolus and are often associated with skin changes of chronic venous insufficiency. This has the features of an ulcer caused by arterial rather than venous ulceration or a mixed aetiology.
Arterial ulcers are often on the dorsum of the foot. The position and nature of ulcers provide clues to their cause.
The story of pain in the legs on walking requires a little more detail but it is suggestive of intermittent claudication related to insufficient blood supply to the exercising calf muscles.

The raised HbA1csuggests diabetes and prolonged hyperglycaemia.

Btw, diabetic neuropathy (DN) can cause a wide range of presentations. Most commonly, it causes peripheral sensory neuropathy in a glove & stocking manner (hands & feet). But it can cause cranial nerve neuropathy, autonomic, or motor neuropathy. And in a lot of cases, it's a mix of many types.

Poikilothermia:
differing temperatures between limbs with the affected side being cooler.

Cooper's ligaments (Retinacula cutis)

These are the ones responsible for giving the breast its (widely beloved and appreciated) shape

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In anemia of chronic disease, usually:
Serum iron & TIBC are low
Ferritin is high

While in iron-deficiency anemia:
Serum iron & ferritin are low
TIBC is high

Here's why aortic regurgitation (AR) can be such a pain in the ass:

It causes a murmur best heard on the lower left sternal edge, which is about the same place for hearing tricuspid sounds like tricuspid stenosis (TS).

If you wanna distinguish between the two:

• TS causes a mid-diastolic murmur, while AR causes an early diastolic murmur.
• TS is accentuated by inspiration, while AR is accentuated by expiration.
• AR is more common and often comes with aortic stenosis (mixed aortic disease). While TS often comes with tricuspid regurgitation.

قبل شوية جنت داقرة كيس mixed aortic disease وجان ذاكر بيها أنّ أكو:
diastolic murmur in the left sternal border
وخلاني أضرب أخماس بأسداس وأفترض أنها TS... تاليها طلعت mixed aortic disease

When you see a patient with murmur and they have fever or general malaise, you should always consider infective endocarditis (IE) even tho it's not the most common dx, and other infections can be the culprit (this is especially important in the elderly because their symptoms are not very specific).

Btw, the classic signs and symptoms of IE (like Janeway lesions, Osler nodes, and splinter hemorrhage) are not usually present, so don't rely on them.

Levodopa (for Parkinson's treatment) is usually used in combination with a selective dopa decarboxylase inhibitor which does not cross the blood–brain barrier and reduces peripheral adverse effects. The commonest side-effects are nausea, vomiting, dizziness, postural hypotension and neuropsychiatric problems.