Case history
Case history #1
A 62-year-old man with diabetes mellitus presents with a 3-day history of progressive left foot swelling, redness, and malaise. He reports noticing a blister on his forefoot several months ago after he started wearing work boots for a new job. He has dressed the area daily with bandages; however, it has not healed. He also has a history of sensory neuropathy, chronic kidney disease (stage 2), and hypertension. He is a smoker (1 pack per day). Physical examination is notable for fever (38.1°C [100.6°F]) and mild tachycardia (pulse rate of 105 bpm). There is a malodorous left foot ulcer overlying the first metatarsophalangeal joint. Fluctuance and blanching erythema extends 4 cm beyond the ulcer border. The remaining areas of the foot and ankle are notable for moderate pitting oedema. The dorsalis pedis pulse is palpable.
Case history #2
A 70-year-old man presents with a 3-month history of a non-healing foot ulcer. He is unsure how it began. He reports seeing a podiatrist once in the past, but failed to return for follow-up care. His medical history is notable for diabetes mellitus, remote stroke without residual neurological deficit, laser photocoagulation for retinopathy, and two previous percutaneous coronary interventions following myocardial infarcts. He stopped smoking cigarettes 3 years ago. Physical examination is notable for a plantar forefoot ulcer beneath the second metatarsal head. There is no associated erythema, swelling, or foul odour. No pedal pulses are palpable.
Other presentations
Posterior heel ulcers occur less frequently in ambulatory patients; they are often due to decubitus pressure in non-ambulatory patients who are debilitated by reduced mobility (e.g., by previous stroke or due to increased bed rest). Leg/calf ulcers (occurring between the knee and the malleoli at the ankle) are generally due to chronic venous insufficiency. Occasionally, infections are initiated by a puncture wound rather than ulceration from repetitive trauma.
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