Let's go on to another case. A 57-year-old man presents to his primary care provider with
progressive right foot swelling, redness, and malaise. He reports seeing a blister on his forefoot
several months ago and he started using new work boots. He has dressed the affected area daily with
bandages. However, healing has not occurred. He has type 2 diabetes for 16 years and a stage
2 chronic kidney disease for 3 years. He smoked 20-30 cigarettes a day for 25 years. His vital
signs include a temperature of 38.1°C, a blood pressure of 110/70, and a pulse rate of
102 beats/minute. On physical examination, there is a malodorous right foot ulcer overlying the
1st metatarsophalangeal joint. Fluctuance and erythema extend 3 cm beyond the ulcer border.
Moderate pitting edema is notable over the remaining areas of the foot and ankle. What is the
best initial step for this patient? This is a chronic diabetic who started wearing new shoes who
developed swelling and ulceration of the foot. He is a smoker with type 2 diabetes which will
increase his likelihood for peripheral vascular disease. Infection is implied by the low-grade fever
and tachycardia. Examination of the foot ulcer reveals fluctuance of the skin, edema, and redness
otherwise known as cellulitis. This patient has a classic diabetic foot ulcer. In this case,
antibiotics such as clindamycin added to a quinolone should be started. They are indicated in
cases with signs of infection. They can be given orally in mild cases or parenterally in severe
cases. Podiatrist referral is always recommended because the wound will probably need to be
debrided. If slow resolution or poor response to antibiotics, consider bone involvement or
osteomyelitis. This can be done by ordering a bone scan. In this image, we see a classic diabetic
foot ulcer on the pressure point under the foot. You can see the surrounding slough and erythema,
which is classic for this condition. Diabetic foot ulcers increase the risk for amputation and
disability. The etiology is multifactorial. Loss of peripheral sensation usually from diabetic
neuropathy leads to significant injuries undetected by the patient. Peripheral arterial disease
which may be co-existent further in the low extremities causes ischemic ulcers and impairs healing.
Altered leukocyte function because of hypoglycemia impedes wound healing as well. An annual
foot exam to check pedal pulses, sensation, to rule out the presence of ulcers, skin or nail
infections as well as assessment of ankle reflexes and joint instability should be performed.
Daily inspection of the feet for early detection of any abnormality by the patient and wearing
of appropriate footwear should be recommended. Careful selection of footwear is paramount in these
cases as new footwear or inappropriate footwear are major risk factors for the development
of diabetic foot ulcers.