Clinic with non-healing ulcer on plantar surface

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Reference no: EM133906513

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A 55-year-old male with a 10-year history of type 2 diabetes presents to the clinic with a non-healing ulcer on the plantar surface of his right foot. He reports that the ulcer has been present for about three weeks, and he has noticed increasing redness around the area. He denies fever or chills. His diabetes has been poorly controlled, with an A1c of 9.2% at his last visit. Physical Exam Findings: Vitals: BP 130/85 mmHg, HR 78 bpm, RR 16, Temp 98.6°F Foot Exam: 2 cm ulcer on the plantar surface of the right foot Surrounding erythema and mild swelling No purulent drainage, no signs of systemic infection Diminished sensation to monofilament testing Procedures Performed in the Clinic: Debridement of necrotic tissue from the ulcer using a scalpel. Wound cleaning and application of sterile dressing. Patient education on foot care and blood sugar control. Prescription for oral antibiotics due to risk of infection. Referral to a podiatrist for further wound care management.

Reference no: EM133906513

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