DIABETIC FOOT - MS Surgery Theory Notes

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from docx import Document
from docx.shared import Pt, Inches, RGBColor, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import copy

doc = Document()

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C_DARK_GREY  = RGBColor(0x44, 0x44, 0x44)
C_GOLD       = RGBColor(0xB8, 0x73, 0x00)

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# ════════════════════════════════════════════════════════════════════════════
#  COVER / TITLE BLOCK
# ════════════════════════════════════════════════════════════════════════════
cover = doc.add_paragraph()
cover.alignment = WD_ALIGN_PARAGRAPH.CENTER
shade_paragraph(cover, '1A3A5C')
para_spacing(cover, before=120, after=60)
add_run(cover, 'DIABETIC FOOT', bold=True, color=C_WHITE, size=22)

sub = doc.add_paragraph()
sub.alignment = WD_ALIGN_PARAGRAPH.CENTER
shade_paragraph(sub, '1A3A5C')
para_spacing(sub, before=0, after=80)
add_run(sub, 'MS Surgery | Long Question-Answer Theory Notes', bold=False, color=RGBColor(0xB0,0xD4,0xF0), size=12)

tag = doc.add_paragraph()
tag.alignment = WD_ALIGN_PARAGRAPH.CENTER
shade_paragraph(tag, '1A3A5C')
para_spacing(tag, before=0, after=120)
add_run(tag, 'IWGDF 2023  ·  IDSA 2023  ·  Wagner Classification  ·  Complete Theory Notes', italic=True, color=RGBColor(0x90,0xB8,0xD8), size=9)

doc.add_paragraph()  # spacer

# ════════════════════════════════════════════════════════════════════════════
# Helper: Question header banner
# ════════════════════════════════════════════════════════════════════════════
q_counter = [0]

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# ════════════════════════════════════════════════════════════════════════════
# Q1 ── Classic 10-marker: A 60-year-old diabetic with plantar ulcer
# ════════════════════════════════════════════════════════════════════════════
question_banner('A 60-year-old diabetic male presents with a painless non-healing ulcer on the plantar aspect of right foot for 3 months. Describe the pathophysiology, clinical evaluation, and management.')
answer_label()

section_sub('INTRODUCTION', '1A3A5C')
body('Diabetic foot refers to the spectrum of foot pathology in diabetes mellitus resulting from the triad of peripheral neuropathy, peripheral arterial disease (PAD), and susceptibility to infection. It is the most common cause of non-traumatic lower limb amputation worldwide, with 15-25% of diabetics developing a foot ulcer in their lifetime.')

section_sub('PATHOPHYSIOLOGY — THE TRIAD', '1A3A5C')

bullet('PERIPHERAL NEUROPATHY (most important factor; present in ~50% of diabetics):', bold_prefix='1. ')
bullet('Sensory neuropathy: loss of pain, temperature, pressure → "silent" repeated injury', level=2)
bullet('Motor neuropathy: intrinsic muscle wasting → claw/hammer toes, prominent MT heads → abnormal plantar pressure points', level=2)
bullet('Autonomic neuropathy: anhidrosis → dry, cracked skin (portal of entry); AV shunting → warm bounding pulses but poor nutritive flow', level=2)

bullet('PERIPHERAL ARTERIAL DISEASE (PAD):', bold_prefix='2. ')
bullet('Preferentially affects tibial and peroneal arteries (infrapopliteal / below-knee disease)', level=2)
bullet('Medial calcinosis (Monckeberg\'s) → non-compressible vessels → falsely elevated ABI (>1.3)', level=2)
bullet('Ischemia renders ulcers non-healing and predisposes to gangrene', level=2)

bullet('INFECTION:', bold_prefix='3. ')
bullet('Impaired PMN chemotaxis, phagocytosis, intracellular killing → diminished host defense', level=2)
bullet('Most common organism: Staphylococcus aureus (mild); typically polymicrobial in severe/deep infections', level=2)
bullet('Spreads along fascial planes → deep space infection, necrotizing fasciitis, osteomyelitis', level=2)

note_box('Exam Pearl: The term "neuropathic ulcer" applies when neuropathy predominates; "neuroischemic" (commonest, ~50%) when both are present.')

section_sub('CLINICAL EVALUATION', '2A6099')
body('History:', bold=True)
bullet('Duration of diabetes and glycemic control (HbA1c values)', level=1)
bullet('Symptoms: burning/tingling/numbness (neuropathy); claudication/rest pain (ischemia)', level=1)
bullet('Mechanism of ulcer: pressure, trauma, ill-fitting footwear', level=1)
bullet('Previous ulcers, hospitalizations, amputations', level=1)
bullet('Medications, smoking history, renal/cardiac status', level=1)

body('Local Examination of Ulcer (SITE, SIZE, SHAPE, DEPTH, BASE, EDGE, DISCHARGE):', bold=True)
bullet('Site: plantar surface (neuropathic) vs toe margins/heel (ischemic)', level=1)
bullet('Edges: punched-out with callus (neuropathic) vs irregular, sloping (ischemic) vs undermined (infected)', level=1)
bullet('Base: granulation tissue / slough / necrosis / visible tendon or bone', level=1)
bullet('Probe-to-bone (PTB) test: metal probe reaches bone → ~89% specific for osteomyelitis', level=1)
bullet('Surrounding skin: callus, cellulitis, lymphangitis, crepitus (gas)', level=1)
bullet('Discharge: serous / purulent / foul-smelling (anaerobic)', level=1)

body('Vascular Examination:', bold=True)
bullet('Foot pulses: dorsalis pedis + posterior tibial (absent in ischemic)', level=1)
bullet('Capillary refill time (>3 sec = abnormal)', level=1)
bullet('Temperature gradient, Buerger\'s test', level=1)
bullet('ABI measurement (unreliable if >1.3 due to medial calcinosis → use Toe-Brachial Index)', level=1)

body('Neurological Examination:', bold=True)
bullet('10g Semmes-Weinstein monofilament: 5 standard plantar sites — tests protective sensation', level=1)
bullet('128 Hz tuning fork — vibration sense', level=1)
bullet('Ankle reflexes, proprioception', level=1)
bullet('Look for deformity: claw toes, Charcot foot (rocker-bottom)', level=1)

add_table(
    ['Feature', 'Neuropathic Foot', 'Ischemic Foot', 'Neuroischemic'],
    [
        ['Temperature', 'Warm', 'Cold', 'Cool'],
        ['Pulses', 'Present, bounding', 'Absent', 'Reduced'],
        ['Sensation', 'Absent', 'Relatively preserved', 'Reduced'],
        ['Ulcer site', 'Plantar (pressure)', 'Tip of toes, heel', 'Variable'],
        ['Pain', 'Painless', 'Painful (rest pain)', 'Variable'],
        ['Deformity', 'Common (Charcot)', 'Less common', 'Variable'],
        ['Prevalence', '35%', '15%', '50%'],
    ],
    [4.5, 4, 4, 4.5],
    hdr_color='1A3A5C'
)

section_sub('WAGNER CLASSIFICATION (Most Important for Exam)', 'C0392B')
add_table(
    ['Grade', 'Description', 'Management Summary'],
    [
        [('Grade 0', ''), 'Intact skin; callus, deformity; pre-ulcerative', 'Therapeutic footwear, podiatry, education'],
        [('Grade 1', ''), 'Superficial ulcer — skin/subcutaneous only', 'Sharp debridement, TCC offloading, dressings'],
        [('Grade 2', ''), 'Deep ulcer penetrating to tendon/capsule/bone', 'Deep debridement, wound care, MRI, antibiotics'],
        [('Grade 3', ''), 'Deep ulcer + abscess / osteomyelitis / septic arthritis', 'IV antibiotics, I&D, bone resection, ray amputation'],
        [('Grade 4', ''), 'Localized gangrene — toes or forefoot', 'Revascularize if feasible, limited amputation'],
        [('Grade 5', ''), 'Extensive gangrene of entire foot', 'Below-knee or above-knee amputation'],
    ],
    [2.5, 6.5, 7],
    hdr_color='C0392B'
)

section_sub('INVESTIGATIONS', '6A3D9A')
body('Baseline Labs:', bold=True)
bullet('Blood glucose (fasting + post-prandial), HbA1c — target <7%', level=1)
bullet('Complete blood count (leukocytosis may be absent even in severe infection in diabetics)', level=1)
bullet('Renal function tests, electrolytes (diabetic nephropathy)', level=1)
bullet('ESR, CRP, Procalcitonin — infection and monitoring markers', level=1)
bullet('Serum albumin — nutritional status (hypoalbuminemia impairs healing)', level=1)

body('Microbiological:', bold=True)
bullet('Deep tissue swab / tissue biopsy culture + sensitivity (before starting antibiotics)', level=1)
bullet('Bone biopsy: gold standard for osteomyelitis causative organism and antibiotic sensitivity', level=1)

body('Imaging:', bold=True)
add_table(
    ['Investigation', 'Indication', 'Key Interpretation'],
    [
        ['X-ray foot (AP + lateral)', 'First-line; gas, foreign body, cortical destruction', '2-3 week lag; 50% bone loss needed before visible'],
        ['MRI foot ★', 'Gold standard for osteomyelitis extent and Charcot staging', 'Shows marrow oedema early; best sensitivity+specificity'],
        ['Tc-99m bone scan', 'Sensitive for OM but non-specific', 'False positive in neuropathic/Charcot'],
        ['WBC-labeled scan', 'More specific for infection', 'Used when MRI contraindicated'],
        ['PET-CT', 'Best specificity for chronic OM', 'Increasingly used; expensive'],
    ],
    [4, 5.5, 6.5],
    hdr_color='6A3D9A'
)

body('Vascular Investigations:', bold=True)
add_table(
    ['Test', 'Normal', 'Abnormal / Critical'],
    [
        ['ABI (ABPI)', '>0.9', '<0.9 ischemia; <0.5 severe; >1.3 non-compressible (medial calcinosis)'],
        ['Toe-Brachial Index (TBI)', '>0.7', '<0.7 = ischemia; more reliable in diabetics'],
        ['TcPO₂', '>40 mmHg', '<30 mmHg = poor healing; <20 = critical ischemia'],
        ['Duplex USS', 'Normal flow', 'Maps stenosis/occlusion; non-invasive'],
        ['CT / MR Angiography', 'Patent vessels', 'Gold standard pre-revascularization map'],
    ],
    [4, 3.5, 8.5],
    hdr_color='6A3D9A'
)

section_sub('MANAGEMENT — MULTIDISCIPLINARY APPROACH', '1A7A3A')
note_box('MDT: Diabetologist, Vascular surgeon, Orthopedic/General surgeon, Podiatrist, Microbiologist, Dietitian, Orthotist, Nurse specialist')

body('A. General/Systemic Measures:', bold=True, color=C_DARK_BLUE)
bullet('Glycemic control: IV insulin infusion (inpatient); target HbA1c <7%', level=1)
bullet('Nutritional optimization: protein supplement; treat hypoalbuminemia', level=1)
bullet('Smoking cessation, statin therapy, antiplatelet agents (if PAD)', level=1)
bullet('DVT prophylaxis during prolonged immobilization', level=1)

body('B. Offloading (Critical for Neuropathic Plantar Ulcers):', bold=True, color=C_DARK_BLUE)
add_table(
    ['Method', 'Efficacy', 'Notes'],
    [
        ['Total Contact Cast (TCC) ★', 'Gold standard — reduces plantar pressure 84-92%', 'Cannot be removed by patient; ensures compliance'],
        ['Removable Cast Walker (RCW)', 'Good but patient can remove', 'Convert to iTCC by wrapping to improve compliance'],
        ['Therapeutic footwear', 'Prevention + grade 0-1', 'Custom-molded insoles, depth shoes'],
        ['Surgical offloading', 'Permanent', 'Achilles tendon lengthening, metatarsal head resection, exostectomy'],
    ],
    [4.5, 5, 6.5],
    hdr_color='1A7A3A'
)

body('C. Local Wound Care:', bold=True, color=C_DARK_BLUE)
bullet('Sharp/surgical debridement: most effective; removes callus, slough, necrotic tissue; converts chronic to acute wound', level=1)
bullet('Wound dressings: hydrogel (dry wounds); foam/alginate (exudative); silver/iodine (infected); non-adherent (granulating)', level=1)
bullet('Negative Pressure Wound Therapy (NPWT/VAC): 125 mmHg; promotes granulation, removes exudate; use post-debridement, pre-graft bed preparation', level=1)
bullet('Growth factors: PDGF (Becaplermin) — only FDA-approved growth factor for neuropathic DFU', level=1)
bullet('Hyperbaric Oxygen Therapy (HBOT): 100% O₂ at 2-3 ATA; 90-min sessions, 20-40 total; for Wagner 3-4 with non-revascularizable ischemia', level=1)
bullet('Larval therapy (maggots): secretes collagenase; excellent for infected necrotic wounds', level=1)

body('D. Antibiotic Therapy (IWGDF/IDSA 2023):', bold=True, color=C_DARK_BLUE)
add_table(
    ['Severity', 'Route', 'Regimen', 'Duration'],
    [
        ['Mild', 'Oral', 'Amoxicillin-clavulanate OR Cefalexin + Metronidazole', '1-2 weeks'],
        ['Moderate', 'Oral/IV', 'Amoxicillin-clavulanate IV / Pip-Tazo / Ceftriaxone + Metro', '2-4 weeks'],
        ['Severe', 'IV', 'Piperacillin-tazobactam ± Vancomycin (if MRSA suspected)', '2-4 weeks'],
        ['Osteomyelitis (no surgery)', 'IV → Oral', 'Culture-guided; fluoroquinolone-based if Gram-negative', '6 weeks total'],
        ['Osteomyelitis (bone resected)', 'IV → Oral', 'Culture-guided; margins clear', '2 weeks post-resection'],
    ],
    [3, 1.5, 6, 2.5],
    hdr_color='1A3A5C'
)

body('E. Vascular Intervention:', bold=True, color=C_DARK_BLUE)
bullet('Revascularize before any major reconstruction or amputation', level=1)
bullet('Percutaneous Transluminal Angioplasty (PTA) ± stenting: first choice for short-segment iliac/femoral disease', level=1)
bullet('Bypass surgery: for long-segment occlusion; distal bypass (popliteal, tibial, peroneal); preferred conduit = autologous great saphenous vein', level=1)
bullet('Angiosome concept: direct revascularization of the angiosome containing the ulcer gives best healing outcomes', level=1)
note_box('TcPO₂ >40 mmHg = adequate for wound healing / amputation stump healing')

body('F. Surgical Management:', bold=True, color=C_DARK_BLUE)
bullet('Incision & Drainage (I&D): for abscess; open approach, no tourniquet; allow dependent drainage', level=1)
bullet('Debridement + bone resection: for osteomyelitis with infected bone', level=1)
bullet('Ray amputation: removal of toe + metatarsal shaft; for single-ray disease', level=1)
bullet('Transmetatarsal amputation (TMA): forefoot gangrene with viable heel/dorsum', level=1)
bullet('Below-knee amputation (BKA): most functional major amputation; needs patent popliteal artery; minimum 5 cm stump; TcPO₂ >40 mmHg at level', level=1)
bullet('Above-knee amputation (AKA): last resort; 3x higher energy to walk; poor rehab in elderly', level=1)
bullet('Guillotine amputation: emergency open amputation for uncontrolled sepsis / gas gangrene; closed formally after 48-72h when sepsis controlled', level=1)

body('G. Wound Closure (Reconstructive Ladder):', bold=True, color=C_DARK_BLUE)
bullet('Primary closure: clean wounds, good vascularity, no tension', level=1)
bullet('Secondary intention: infected/small wounds', level=1)
bullet('NPWT (VAC): bridge to surgery; prepare graft bed', level=1)
bullet('Split skin graft (SSG): on granulating wound bed with adequate vascularity', level=1)
bullet('Local flap (plantar rotation, V-Y advancement): weight-bearing areas', level=1)
bullet('Free flap (microsurgical): large complex defects with adequate recipient vessels', level=1)

doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# Q2 ── Wagner Classification
# ════════════════════════════════════════════════════════════════════════════
question_banner('Write short notes on the Wagner Classification of Diabetic Foot. How does it guide management?')
answer_label()
section_sub('INTRODUCTION', '1A3A5C')
body('The Wagner Classification (1979) is the most widely used and exam-asked system for grading diabetic foot ulcers. It grades severity from 0 (intact skin at risk) to 5 (whole-foot gangrene) based on depth of ulceration and presence of infection/gangrene.')

section_sub('WAGNER GRADES WITH MANAGEMENT', 'C0392B')
add_table(
    ['Grade', 'Description', 'Pathology', 'Surgical/Medical Management'],
    [
        [('Grade 0', ''), 'Pre-ulcerative / intact skin', 'Callus, deformity, bony prominence', 'Therapeutic footwear; callus shaving; patient education; regular podiatry'],
        [('Grade 1', ''), 'Superficial ulcer', 'Epidermis + dermis only; no deeper penetration', 'Sharp debridement; TCC (gold standard offloading); moist wound dressings'],
        [('Grade 2', ''), 'Deep ulcer (tendon/capsule/bone)', 'Full thickness; exposes tendon, capsule, or cortex; no OM', 'Deep surgical debridement; wound care; MRI to exclude OM; culture-guided oral antibiotics'],
        [('Grade 3', ''), 'Deep ulcer + abscess/osteomyelitis', 'OM or septic arthritis or deep space abscess', 'IV antibiotics; I&D of abscess; bone resection / ray amputation; HBOT adjunct; 4-6 week abx course'],
        [('Grade 4', ''), 'Localised gangrene', 'Toe/forefoot gangrene; proximal tissue viable', 'Revascularize first if possible; toe/ray/TMA amputation; IV antibiotics; guillotine if life-threatening sepsis'],
        [('Grade 5', ''), 'Extensive / whole-foot gangrene', 'Entire foot unsalvageable; systemic sepsis', 'Below-knee (preferred) or above-knee amputation after haemodynamic stabilization'],
    ],
    [2, 3.5, 4.5, 6],
    hdr_color='C0392B'
)
note_box('Key: Grades 0-2 = conservative/local surgery. Grade 3-4 = aggressive surgical debridement ± limited amputation. Grade 5 = major amputation.')
body('Limitations of Wagner Classification:', bold=True)
bullet('Does not separately score ischemia or infection (addressed by the University of Texas / IWGDF classification)', level=1)
bullet('University of Texas (UT) Classification adds a Stage axis (A=none, B=infection, C=ischemia, D=both) to Wagner\'s Grade (0-3) — better prognostic accuracy', level=1)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# Q3 ── Charcot Foot
# ════════════════════════════════════════════════════════════════════════════
question_banner('Describe Charcot neuroarthropathy (Charcot foot). How will you diagnose and manage it?')
answer_label()
section_sub('DEFINITION', '1A3A5C')
body('Charcot neuroarthropathy (CN) is a progressive, painless, destructive arthropathy affecting bones and joints of the foot in patients with peripheral neuropathy (most commonly diabetic), caused by repeated micro-trauma in the absence of protective pain sensation, leading to progressive bone and joint destruction.')

section_sub('PATHOPHYSIOLOGY', '1A3A5C')
bullet('Neurotraumatic theory: loss of protective sensation → repeated micro-fractures and ligament damage from normal activity', level=1)
bullet('Neurovascular theory: autonomic dysfunction → sympathetic denervation → arteriovenous shunting → hyperemia → osteoclast activation (via RANKL) → accelerated bone resorption', level=1)
bullet('Most commonly affects the midfoot (Lisfranc / Chopart joints) → "rocker-bottom" deformity', level=1)
bullet('Leads to bony prominences → plantar ulceration', level=1)

section_sub('EICHENHOLTZ CLASSIFICATION', '2A6099')
add_table(
    ['Stage', 'Name', 'Clinical Features', 'Imaging', 'Management'],
    [
        ['Stage 0', 'Prodromal / At-risk', 'Warm, red, swollen foot; unilateral; pain absent or mild', 'X-ray normal; MRI: bone marrow oedema', 'Non-weight bearing; TCC immediately; bisphosphonates'],
        ['Stage I', 'Fragmentation / Development', 'Acute inflammation persists; increasing deformity', 'Bony fragmentation, subluxation, dislocation, periarticular debris', 'Immobilization in TCC; strict non-weight-bearing'],
        ['Stage II', 'Coalescence', 'Decreased warmth and swelling', 'Absorption of debris; sclerosis begins; new bone formation', 'Transition to total contact walker; custom footwear'],
        ['Stage III', 'Reconstruction / Consolidation', 'Stable foot; cool; residual deformity', 'Remodeling, fibrosis, bony fusion, fixed deformity', 'Custom footwear; exostectomy or arthrodesis if ulceration/instability'],
    ],
    [2, 3.5, 5, 3.5, 5.5],
    hdr_color='2A6099'
)

section_sub('DIAGNOSIS', '6A3D9A')
body('Acute Charcot is commonly misdiagnosed as cellulitis. Key distinguishing features:')
bullet('No systemic signs (afebrile, normal WBC) unlike cellulitis', level=1)
bullet('Bilateral foot temperature difference >2°C (infrared thermometry) suggests active Charcot vs contralateral foot', level=1)
bullet('Bounding pulses (intact circulation due to AV shunting)', level=1)
bullet('MRI: definitive early diagnosis — shows bone marrow oedema, micro-fractures, ligamentous disruption', level=1)
bullet('X-ray: often normal in Stage 0 (early); useful from Stage I', level=1)
note_box('Remember: "Hot, red, swollen foot in a diabetic with normal X-ray and absent pain = Charcot foot until proven otherwise"')

section_sub('MANAGEMENT', '1A7A3A')
body('Non-surgical (Stages 0-II):')
bullet('Immediate offloading: non-weight bearing TCC — must start in Stage 0 to prevent progression to Stage I', level=1)
bullet('Bisphosphonates (IV pamidronate 90mg single dose): inhibit osteoclast activity; reduce inflammation; evidence strongest in acute phase', level=1)
bullet('Continue TCC until skin temperature normalizes (<2°C difference bilaterally); typically 4-12 months', level=1)
bullet('Transition to total contact walker → custom therapeutic footwear', level=1)
body('Surgical (Stage III / Complications):')
bullet('Indications: unstable deformity risking ulceration, recurrent plantar ulcers, non-reconstructable deformity', level=1)
bullet('Exostectomy: removal of bony prominence causing ulceration', level=1)
bullet('Arthrodesis (fusion): for unstable midfoot or ankle; using intramedullary nails, plate fixation, or Ilizarov external fixator ("bolt of lightning" technique)', level=1)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# Q4 ── Diabetic Foot Osteomyelitis
# ════════════════════════════════════════════════════════════════════════════
question_banner('Discuss the diagnosis and management of osteomyelitis in diabetic foot.')
answer_label()
section_sub('INCIDENCE AND IMPORTANCE', '1A3A5C')
body('Osteomyelitis (OM) complicates 20% of moderate and 50-60% of severe diabetic foot infections. It is the most common reason for major amputation and prolonged hospitalization. Wagner Grade 3 = deep ulcer + osteomyelitis/abscess.')

section_sub('CLINICAL FEATURES SUGGESTING OSTEOMYELITIS', 'C0392B')
bullet('"Sausage digit" — diffusely swollen toe', level=1)
bullet('Exposed bone at the ulcer base', level=1)
bullet('Ulcer diameter >2 cm or depth >3 mm', level=1)
bullet('Non-healing ulcer after 6 weeks of optimal care', level=1)
bullet('Overlying ulcer directly above a bony prominence', level=1)
bullet('Probe-to-bone (PTB) test positive: sensitivity 60-66%, specificity 85-89%', level=1)
note_box('PTB Test: Use a sterile metal probe through ulcer — if hard resistance (bone) felt = osteomyelitis until proven otherwise. Positive = high PPV in high-prevalence settings.')

section_sub('INVESTIGATIONS', '6A3D9A')
add_table(
    ['Investigation', 'Sensitivity', 'Specificity', 'Role / Notes'],
    [
        ['Plain X-ray', '54%', '68%', 'First line; late finding (2-3 weeks); periosteal reaction, cortical destruction, sequestrum'],
        ['MRI ★ Gold standard (imaging)', '90%', '83%', 'Shows bone marrow oedema early; delineates extent; guides surgical resection'],
        ['Tc-99m bone scan', '86%', '45%', 'Sensitive but non-specific; false positive with Charcot, fracture'],
        ['WBC-labeled scan', '74%', '68%', 'More specific; combined with Tc-bone scan improves specificity'],
        ['PET-CT', '81%', '83%', 'Best specificity; increasing use in chronic/recurrent OM'],
        ['ESR >70 mm/hr + CRP + CXR', 'Moderate', 'Good combination', 'Combined with clinical: high suspicion index'],
        ['Bone biopsy + culture ★ Gold standard (organism)', '—', '—', 'Definitive: identifies causative organism; guides targeted antibiotics; percutaneous or open'],
    ],
    [4.5, 2.5, 2.5, 6.5],
    hdr_color='6A3D9A'
)

section_sub('MANAGEMENT', '1A7A3A')
body('Two approaches — Medical vs Surgical:')
add_table(
    ['Approach', 'Indication', 'Regimen', 'Duration', 'Outcome'],
    [
        ['Medical (antibiotics alone)', 'Non-surgical candidates; forefoot OM with intact vascularity; patient preference', 'IV antibiotics → oral step-down based on bone biopsy culture; fluoroquinolones (good bone penetration) for Gram-negatives', '6 weeks total', 'Remission in ~65%; relapse common'],
        ['Surgical (bone resection) ★', 'Preferred where feasible', 'Resect infected bone with clean margins (ray/partial foot amputation) + 2 weeks antibiotics post-resection', '2 weeks post-op', 'Better cure rates; shorter antibiotic course'],
    ],
    [3, 4, 5.5, 2, 2.5],
    hdr_color='1A7A3A'
)
note_box('Key exam point: Surgical resection of osteomyelitic bone = only 2 weeks antibiotics post-op (vs 6 weeks if no surgery).')
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# Q5 ── Amputation levels
# ════════════════════════════════════════════════════════════════════════════
question_banner('Discuss the levels of amputation used in diabetic foot disease. What are the general principles of amputation in diabetics?')
answer_label()
section_sub('GENERAL PRINCIPLES OF AMPUTATION IN DIABETICS', '1A3A5C')
bullet('Preserve maximum viable tissue compatible with primary healing', level=1)
bullet('TcPO₂ >40 mmHg at the proposed level ensures adequate healing; <30 mmHg = poor prognosis', level=1)
bullet('Revascularize BEFORE amputation if indicated — improves stump healing and allows more distal amputation', level=1)
bullet('Avoid tourniquet (relative contraindication — impairs intraoperative perfusion assessment)', level=1)
bullet('No-tension skin closure; fashioned flaps must cover stump without tension', level=1)
bullet('Perioperative antibiotics (continue based on culture sensitivity)', level=1)
bullet('Guillotine amputation first for life-threatening sepsis → formal closure after 48-72h when infection controlled', level=1)

section_sub('LEVELS OF AMPUTATION (Distal to Proximal)', '2A6099')
add_table(
    ['Level', 'Indication', 'Key Requirements', 'Functional Outcome'],
    [
        ['Toe disarticulation', 'Isolated gangrenous/OM digit', 'Viable skin margins; no spreading infection', 'Most conservative; minimal functional loss'],
        ['Ray amputation', 'Single ray (toe + MT) disease — OM or gangrene', 'Adjacent rays viable; no proximal spread', 'Good function; minor gait alteration'],
        ['Transmetatarsal amputation (TMA)', 'Forefoot gangrene; multiple ray disease', 'Viable heel and dorsal skin; TcPO₂ >40 mmHg; patent posterior tibial artery', 'Excellent function with custom shoe and filler'],
        ["Syme's amputation", 'Distal foot disease; select neuropathic patients', 'Viable heel fat pad; adequate vascularity', 'End-bearing stump; simple prosthesis'],
        ['Below-knee (BKA) / Transtibial ★', 'Extensive foot / ankle disease; TMA not feasible', 'Patent popliteal artery; minimum 5 cm stump; TcPO₂ >40 mmHg at level', 'MOST FUNCTIONAL major amputation; 25% extra metabolic energy to walk; prosthesis easily fitted'],
        ['Knee disarticulation', 'BKA not feasible; diseased proximal tibia', 'Viable flaps over femoral condyles', 'Long lever arm; better prosthesis control than AKA'],
        ['Above-knee (AKA) / Transfemoral', 'BKA cannot heal; knee joint disease', 'Last resort; higher post-op mortality', '60-80% extra metabolic energy; poor rehab in elderly/obese; high 5-year mortality'],
        ['Guillotine (emergency)', 'Uncontrolled gas gangrene / spreading sepsis', 'Life-saving measure; open wound intentionally', 'Followed by formal amputation closure after 48-72h; patient must be haemodynamically stable'],
    ],
    [4, 4, 5, 4],
    hdr_color='2A6099'
)
note_box('Below-knee amputation is the most functional major amputation. Always attempt to preserve the knee joint.')

section_sub('REHABILITATION POST-AMPUTATION', '1A7A3A')
bullet('BKA: prosthesis fitting at 6-8 weeks; most patients achieve community ambulation', level=1)
bullet('AKA: 60-80% extra energy expenditure; prosthesis training; many elderly patients become wheelchair-dependent', level=1)
bullet('Stump care: compression bandaging; physiotherapy; contralateral foot protection (high risk for second amputation)', level=1)
bullet('Psychological support and diabetic team follow-up essential', level=1)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# Q6 ── IDSA Infection Classification
# ════════════════════════════════════════════════════════════════════════════
question_banner('Classify diabetic foot infection according to IDSA/IWGDF 2023 criteria and outline antibiotic management for each class.')
answer_label()
section_sub('IDSA / IWGDF 2023 INFECTION CLASSIFICATION', 'C0392B')
add_table(
    ['Class', 'Severity', 'Clinical Definition', 'Key Features'],
    [
        ['Class 1', 'Uninfected', 'No systemic or local signs of infection', 'Wound colonized; do NOT start antibiotics; wound care only'],
        ['Class 2', 'Mild', '≥2 signs of inflammation (warmth, erythema, pain, tenderness, induration, purulent discharge); cellulitis <2 cm around ulcer; superficial; no systemic involvement', 'Oral antibiotics for 1-2 weeks; outpatient management usually adequate'],
        ['Class 3', 'Moderate', 'Cellulitis >2 cm from ulcer edge; OR lymphangitis; OR deep tissue involvement (fascia, tendon, muscle, joint, bone); OR abscess; NO systemic signs', 'IV antibiotics; hospitalization; surgical drainage; bone biopsy if OM suspected; 2-4 weeks'],
        ['Class 4', 'Severe', 'Any infection WITH systemic inflammatory response syndrome (SIRS): ≥2 of — temp >38°C or <36°C; HR >90; RR >20 or PaCO₂ <32; WBC >12,000 or <4,000', 'IV broad-spectrum antibiotics; ICU if unstable; urgent surgical debridement/amputation; 2-4 weeks'],
    ],
    [2, 2.5, 6.5, 5],
    hdr_color='C0392B'
)
note_box('Infection ≠ colonization. Clinical signs of infection (≥2 criteria) are required — do NOT diagnose infection by swab culture alone (IWGDF 2023).')
body('Antibiotic Regimens (IWGDF/IDSA 2023):')
add_table(
    ['Severity', 'Route', 'First-line Regimen', 'MRSA suspected → Add'],
    [
        ['Mild (Class 2)', 'Oral', 'Amoxicillin-clavulanate 625mg TDS\nOR Cefalexin 500mg QDS + Metronidazole', 'Doxycycline or Co-trimoxazole'],
        ['Moderate (Class 3)', 'IV or oral', 'Amoxicillin-clavulanate IV 1.2g TDS\nOR Piperacillin-tazobactam 4.5g TDS\nOR Ceftriaxone 1-2g OD + Metronidazole 500mg TDS', 'Vancomycin 15-20 mg/kg BD\nOR Daptomycin'],
        ['Severe (Class 4)', 'IV', 'Piperacillin-tazobactam 4.5g TDS\nOR Imipenem-cilastatin (if ESBL suspected)', 'Vancomycin + cover for GNB\nLinezolid (oral bioavailability = IV)'],
        ['Osteomyelitis (no surgery)', 'IV → PO', 'Culture-guided; fluoroquinolones (ciprofloxacin/levofloxacin) for Gram-negatives; rifampicin combination for staph (bone penetration)', '6 weeks total'],
        ['Osteomyelitis (post-resection)', 'IV → PO', 'Culture-guided; shorter course acceptable', '2 weeks post-op only'],
    ],
    [2.5, 1.5, 7, 5],
    hdr_color='1A3A5C'
)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# Q7 ── Vascular assessment & revascularization
# ════════════════════════════════════════════════════════════════════════════
question_banner('How do you assess the vascular status of a diabetic foot? Discuss the indications and options for revascularization.')
answer_label()
section_sub('WHY VASCULAR ASSESSMENT IS CRITICAL', '1A3A5C')
body('PAD affects 15-25% of diabetics with foot ulcers. Unlike typical atherosclerosis, diabetic PAD preferentially involves infrapopliteal (tibial/peroneal) arteries with medial calcinosis (Monckeberg\'s) — making ABI unreliable. Without revascularization, ischemic ulcers will not heal regardless of other treatment.')

section_sub('CLINICAL ASSESSMENT', '2A6099')
bullet('Palpation of foot pulses (dorsalis pedis, posterior tibial)', level=1)
bullet('Capillary refill time (>3 sec = abnormal)', level=1)
bullet('Buerger\'s angle: elevation pallor <25° = critical ischemia', level=1)
bullet('Temperature gradient: cool extremity with dependent rubor', level=1)

section_sub('NON-INVASIVE VASCULAR TESTS', '2A6099')
add_table(
    ['Test', 'Method', 'Interpretation', 'Limitation in Diabetics'],
    [
        ['ABI (ABPI)', 'Ankle systolic pressure / brachial systolic pressure', '>0.9 normal; 0.5-0.9 mild-mod ischemia; <0.5 severe; <0.3 critical; >1.3 non-compressible', 'Medial calcinosis → falsely elevated (>1.3) in 20-30% diabetics'],
        ['Toe-Brachial Index (TBI)', 'Toe systolic pressure / brachial pressure (digital photoplethysmography)', '>0.7 normal; <0.7 ischemia; <0.3 critical; absolute toe pressure <30 mmHg = critical', 'More reliable than ABI in diabetics; toes rarely calcified'],
        ['TcPO₂', 'Transcutaneous O₂ tension at dorsum of foot', '>40 mmHg: adequate healing; 30-40: borderline; <30: poor healing; <20: critical ischemia', 'Affected by oedema, inflammation; need calibration'],
        ['Duplex Ultrasound', 'B-mode + Doppler flow mapping', 'Identifies stenosis/occlusion level; velocity ratios', 'Operator-dependent; calcified vessels reduce quality'],
        ['CT Angiography ★', 'Contrast-enhanced CT with 3D reconstruction', 'Gold standard map; shows tibial/peroneal disease precisely', 'Contrast nephrotoxicity; radiation; calcification artifact'],
        ['MR Angiography', 'Gadolinium-enhanced MRI', 'No radiation; good soft tissue detail', 'Gadolinium risk in renal impairment (NSF); longer time'],
    ],
    [3.5, 4, 5.5, 4],
    hdr_color='2A6099'
)

section_sub('REVASCULARIZATION OPTIONS', '1A7A3A')
add_table(
    ['Procedure', 'Indication', 'Key Points'],
    [
        ['PTA (Percutaneous Transluminal Angioplasty) ± stenting', 'Short-segment stenosis (iliac, femoral, popliteal, tibial)', 'First-line endovascular; can do tibial balloon angioplasty; less invasive; can be repeated'],
        ['Bypass surgery (distal bypass)', 'Long-segment occlusion; tibial/peroneal target vessels; endovascular failure', 'Great saphenous vein (in-situ or reversed) is gold standard conduit; synthetic (PTFE) if vein unavailable; patency better with vein'],
        ['Endarterectomy', 'Common/superficial femoral artery stenosis', 'Open surgical; good for localized disease'],
        ['Angiosome-directed revascularization', 'All revascularization planning', 'Each artery supplies a 3D angiosome; direct revascularization of the angiosome containing the wound improves healing vs indirect'],
    ],
    [4.5, 5, 6.5],
    hdr_color='1A7A3A'
)
note_box('If no revascularization possible (non-reconstructable disease) → amputation at the lowest viable level. HBOT can be adjunct for borderline ischemic wounds.')
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# Q8 ── Prevention
# ════════════════════════════════════════════════════════════════════════════
question_banner('Discuss the prevention of diabetic foot ulcers and screening protocol.')
answer_label()
section_sub('PRIMARY PREVENTION', '1A7A3A')
bullet('Glycemic control: HbA1c <7% — slows neuropathy progression (UKPDS, DCCT evidence)', level=1)
bullet('Patient education: daily foot self-inspection; avoid barefoot walking; inspect shoes before wearing; proper nail care', level=1)
bullet('Appropriate footwear: well-fitting, soft leather, roomy toe box; avoid narrow/pointed/high-heeled shoes', level=1)
bullet('Annual comprehensive foot examination by healthcare professional', level=1)

section_sub('IWGDF RISK STRATIFICATION & SCREENING FREQUENCY', '2A6099')
add_table(
    ['IWGDF Category', 'Risk Factors Present', 'Review Frequency'],
    [
        ['Category 0', 'No neuropathy, no PAD, no foot deformity', 'Once a year'],
        ['Category 1', 'Peripheral neuropathy (±mild deformity)', 'Every 6 months'],
        ['Category 2', 'Peripheral neuropathy + PAD or foot deformity', 'Every 3 months'],
        ['Category 3', 'Previous foot ulcer OR previous amputation', 'Every 1-3 months'],
    ],
    [3.5, 8.5, 4],
    hdr_color='2A6099'
)

section_sub('SECONDARY PREVENTION (Post-ulcer Recurrence)', '1A7A3A')
bullet('Custom therapeutic footwear: reduces recurrence from 58% to 28% at 2 years', level=1)
bullet('Regular podiatry review: callus removal, nail care', level=1)
bullet('Patient adherence monitoring: pressure-sensing insoles detect dangerous hot-spots', level=1)
bullet('TCC for any new plantar ulcer immediately — do not delay offloading', level=1)
bullet('Screen and treat PAD aggressively in patients with history of ulceration', level=1)

section_sub('COMPREHENSIVE FOOT EXAMINATION COMPONENTS', '6A3D9A')
bullet('Dermatological: skin integrity, callus, maceration, nail changes, tinea pedis', level=1)
bullet('Musculoskeletal: deformity (claw toes, Charcot, hallux valgus), range of motion, limited joint mobility', level=1)
bullet('Neurological: 10g monofilament (5 sites), vibration (128 Hz), pin-prick, ankle reflexes', level=1)
bullet('Vascular: pedal pulses, capillary refill, ABI, TBI (if pulses absent)', level=1)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# Q9 ── Short notes cluster
# ════════════════════════════════════════════════════════════════════════════
question_banner('Write short notes on: (a) Total Contact Cast  (b) Hyperbaric Oxygen Therapy  (c) Guillotine amputation  (d) Probe-to-bone test')
answer_label()

section_sub('(a) TOTAL CONTACT CAST (TCC)', '1A3A5C')
body('Gold standard offloading device for neuropathic plantar diabetic foot ulcers (IWGDF 2023).')
bullet('Mechanism: redistributes plantar pressure evenly across entire foot surface; reduces forefoot plantar pressure by 84-92%', level=1)
bullet('Construction: fiberglass or plaster cast applied over thin cotton/foam padding; molds to entire plantar surface; non-removable (ensures compliance)', level=1)
bullet('Changed every 1-2 weeks; wound inspected at each change', level=1)
bullet('Contraindications: active infection/abscess (must treat first), severe ischemia (ABI <0.5), poor skin integrity, unreliable patient', level=1)
bullet('Healing rates with TCC: 73-100% for neuropathic plantar ulcers vs 50% with standard care', level=1)
bullet('Drawback: non-removable; skin breakdown if not properly applied; requires trained staff', level=1)
note_box('Removable cast walkers are equally effective if made irremovable (iTCC) by wrapping with a cohesive bandage.')

section_sub('(b) HYPERBARIC OXYGEN THERAPY (HBOT)', '2A6099')
body('Administration of 100% oxygen at 2-3 atmospheres absolute (ATA) pressure in a hyperbaric chamber.')
bullet('Mechanism: raises tissue PaO₂ dramatically; stimulates angiogenesis (HIF-1α); enhances neutrophil bactericidal activity; reduces oedema; promotes collagen synthesis', level=1)
bullet('Protocol: 90-minute sessions; 20-40 sessions total (daily, 5 days/week)', level=1)
bullet('Indications in diabetic foot: Wagner Grade 3-4 with critical/non-revascularizable ischemia; non-healing ulcers with TcPO₂ <30 mmHg that rises to >200 mmHg under HBOT (predictive of response)', level=1)
bullet('Evidence: COCHRANE review — HBOT reduces major amputation risk (NNT ~4-5 for salvage) in severe ischemic DFU', level=1)
bullet('Contraindications: untreated pneumothorax, recent ear/sinus surgery, claustrophobia, active chemotherapy with bleomycin/adriamycin', level=1)
bullet('Side effects: barotrauma, oxygen toxicity (seizures rare), reversible visual changes', level=1)

section_sub('(c) GUILLOTINE AMPUTATION', '1A7A3A')
body('Emergency open amputation performed as a life-saving measure for uncontrolled spreading infection.')
bullet('Indications: advancing gas gangrene (Clostridium, mixed anaerobes); necrotizing fasciitis not controlled by debridement; septic shock from foot source; rapid proximal spread', level=1)
bullet('Technique: rapid transection of all tissues at required level (no flap fashioning); wound left OPEN intentionally; packed with antiseptic gauze', level=1)
bullet('Goal: rapidly remove infected source; save life; haemodynamic stabilization', level=1)
bullet('Followed by: ICU management; IV antibiotics; resuscitation; formal amputation with proper flap closure after 48-72 hours when patient stable and infection controlled', level=1)
bullet('Must ensure: level chosen above all visible gangrene/infection; correct level established later at formal closure', level=1)

section_sub('(d) PROBE-TO-BONE (PTB) TEST', 'C0392B')
body('Bedside clinical test for diagnosis of osteomyelitis in diabetic foot ulcer.')
bullet('Technique: sterile blunt metal probe (or sterile cotton swab holder) inserted gently through the ulcer base — if hard, gritty resistance consistent with bone is felt = positive', level=1)
bullet('Sensitivity: 60-66%; Specificity: 85-89%', level=1)
bullet('Positive Predictive Value (PPV): ~89% in high-prevalence setting (severe/deep ulcer)', level=1)
bullet('Negative Predictive Value (NPV): 56% in high-prevalence, ~98% in low-prevalence settings', level=1)
bullet('Interpretation: positive PTB + clinical suspicion → treat as osteomyelitis and proceed to MRI and bone biopsy', level=1)
bullet('Low-tech, rapid, free, no radiation — ideal bedside screening test', level=1)
note_box('Positive PTB + ESR >70 mm/hr = high predictive value for osteomyelitis even without imaging.')
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# Q10 ── Differential diagnosis
# ════════════════════════════════════════════════════════════════════════════
question_banner('What are the differential diagnoses of a diabetic foot ulcer? How will you differentiate them?')
answer_label()
section_sub('DIFFERENTIAL DIAGNOSIS', '1A3A5C')
add_table(
    ['Condition', 'Site', 'Distinguishing Feature', 'Diagnosis'],
    [
        ['Neuropathic DFU', 'Plantar surface, pressure points', 'Painless; callus; bounding pulses; absent sensation; warm foot', '10g monofilament; NCS/EMG'],
        ['Ischemic ulcer (arterial)', 'Tip of toes, heel, lateral margin', 'Painful; pale, necrotic base; absent pulses; cold foot; rest pain at night', 'ABI <0.5; CT angiography'],
        ['Venous ulcer', 'Medial gaiter area (above medial malleolus)', 'Irregular edges; lipodermatosclerosis; haemosiderin staining; normal pulses; associated varicosities', 'Duplex USS for venous insufficiency'],
        ["Marjolin's ulcer", 'Long-standing wound/scar', 'Everted, indurated, rolled edges; bleeds easily; in scar tissue; malodorous', 'Biopsy — SCC'],
        ['Tropical ulcer', 'Lower leg / foot (young, malnourished)', 'Rapid onset; foul-smelling; Fusospirochetal organisms; painful', 'Gram stain, culture; dark-field microscopy'],
        ['Pressure sore', 'Heel, lateral malleolus, bony prominence', 'Immobile patient; associated with prolonged pressure; graded I-IV', 'Clinical; assess depth with staging'],
        ['Rheumatoid vasculitic ulcer', 'Digital tips, lower leg', 'RA on background; punched-out; digital vasculitis; positive RF/anti-CCP', 'Serology; skin biopsy'],
        ['Pyoderma gangrenosum', 'Lower leg', 'Violaceous, undermined, overhanging edges; painful; associated with IBD/RA', 'Biopsy; pathergy test; exclude infection'],
    ],
    [4, 3.5, 6.5, 3],
    hdr_color='1A3A5C'
)
doc.add_paragraph()

# ════════════════════════════════════════════════════════════════════════════
# HIGH-YIELD EXAM REVISION TABLE
# ════════════════════════════════════════════════════════════════════════════
p = doc.add_paragraph()
shade_paragraph(p, '8B1A1A')
para_spacing(p, before=200, after=60)
add_run(p, '  ★  HIGH-YIELD EXAM REVISION — MUST-KNOW FACTS', bold=True, color=C_WHITE, size=12)

add_table(
    ['Key Point', 'Answer / Fact'],
    [
        ['Most common cause of non-traumatic lower limb amputation', 'Diabetes mellitus'],
        ['Most important single pathological factor in diabetic foot', 'Peripheral neuropathy (NOT ischemia alone)'],
        ['Most common type of diabetic foot (mixed)', 'Neuroischemic foot (~50%)'],
        ['Gold standard offloading for neuropathic plantar ulcer', 'Total Contact Cast (TCC)'],
        ['Wagner Grade with osteomyelitis / abscess', 'Grade 3'],
        ['Gold standard imaging for osteomyelitis', 'MRI (imaging) + Bone biopsy (organism identification)'],
        ['ABI >1.3 interpretation', 'Non-compressible vessels due to medial calcinosis → use Toe-Brachial Index (TBI)'],
        ['TcPO₂ thresholds', '<30 mmHg = poor healing; >40 mmHg = adequate for healing / amputation level'],
        ['PTB test: sensitivity / specificity', 'Sensitivity 60-66%; Specificity 85-89%'],
        ['Most functional major amputation', 'Below-knee (transtibial) amputation'],
        ['Preferred bypass conduit for distal bypass', 'Autologous great saphenous vein'],
        ['Emergency amputation for uncontrolled sepsis', 'Guillotine amputation → formal closure at 48-72h'],
        ['Most common organism (mild DFI)', 'Staphylococcus aureus'],
        ['Organisms in severe DFI', 'Polymicrobial (Gram-pos + Gram-neg + anaerobes)'],
        ['Only FDA-approved growth factor for DFU', 'PDGF — Becaplermin'],
        ['HBOT indication in diabetic foot', 'Wagner 3-4; non-revascularizable ischemia; TcPO₂ responds to HBOT challenge'],
        ['Charcot foot: classic presentation', 'Hot, red, swollen foot; normal X-ray; absent pain → Stage 0'],
        ['Bisphosphonate used in Charcot foot', 'IV Pamidronate 90 mg (single dose) — acute phase'],
        ['Osteomyelitis — antibiotic duration (no surgery)', '6 weeks total'],
        ['Osteomyelitis — antibiotic duration (bone resected)', '2 weeks post-resection only'],
        ['SINBAD scoring', 'Site, Ischemia, Neuropathy, Bacterial infection, Area, Depth (0-6)'],
        ['Current gold-standard guidelines', 'IWGDF 2023 / IDSA 2023 (Senneville et al.)'],
        ['IWGDF Category 3 review frequency', 'Every 1-3 months (previous ulcer or amputation)'],
        ['Angiosome concept', 'Direct revascularization of the wound-specific angiosome improves healing vs indirect'],
        ['5-year mortality after major amputation in diabetics', '~50% (worse prognosis than most cancers)'],
    ],
    [8, 9],
    hdr_color='8B1A1A'
)

# Footer
from docx.oxml.ns import qn as ns_qn
footer_para = doc.add_paragraph()
para_spacing(footer_para, before=200, after=0)
footer_para.alignment = WD_ALIGN_PARAGRAPH.CENTER
add_run(footer_para,
        'References: Wagner FW (1979) · IWGDF Guidelines 2023 · IWGDF/IDSA 2023 (Senneville et al.) · '
        'Wagner Classification · UT Classification (Lavery 1996) · WIfI Classification (Mills 2014)\n'
        'Compiled for MS Surgery Theory Examination  |  © 2026',
        italic=True, color=C_DARK_GREY, size=8)

out = '/tmp/workspace/diabetic-foot/Diabetic_Foot_LongQA_Notes.docx'
doc.save(out)
print(f"Saved: {out}")