Ulcers in both his feet for ten years at metatarsophalangeal area.

 The possible therapy or medical management for this is Toe amputation. The level of
infection and viable skin should dictate the level of amputation. The aim should be to
salvage the maximum amount of proximal toe, up to the base of the proximal phalanx. If
the capsule of the metatarsophalangeal joint must be entered, then the amputation should
be taken to the neck of the metatarsal to avoid exposure of the articular cartilage. 

Recurrent infections. Needs debridement and IV antibiotics.

 Debridement is a procedure for treating a wound in the skin. Which involves thorough
cleaning of the wound and removing all hyperkeratotic (thickened skin or callus),
 infected, and nonviable (necrotic or dead) tissue, foreign debris, and residual material
from dressings. Removal may be surgical, mechanical, chemical, and autolytic.
 Mild soft tissue infection can be treated effectively with oral antibiotics,
including dicloxacillin, cephalexin, and clindamycin. Severe soft tissue infection can be
initially treated intravenously
with ciprofloxacin plus clindamycin; piperacillin/tazobactam; or imipenem/cilastatin.

Amputation suggested by Physician, but refused.

 Amputation is the only remaining option to avoid the development of life-threatening

sepsis. Partial foot amputation, if possible, is preferable to below-knee amputation. The
most commonly performed partial foot amputations are ray amputation, transmetatarsal
amputation, Chopart amputation, or Symes amputation.

Sole ulcers on both feet: 2x3 cm wide on the right foot and 4x3 cm wide on his left foot, this
being severe.
 First to be done is the prevention of infection. Next is taking the pressure off the area,
which is called “off-loading”. Followed by “debridement” and applying of medication or
dressings to the ulcer.

Toes are moist, soft and also smell bad which may indicate infection.
 Mild soft tissue infection can be treated effectively with oral antibiotics,
including dicloxacillin, cephalexin, and clindamycin. Severe soft tissue infection can be
initially treated intravenously
with ciprofloxacin plus clindamycin; piperacillin/tazobactam; or imipenem/cilastatin.

Dorsal pedal and posterior tibial pulses in the right foot are very weak.

 Absent or weak dorsalis pedis and/or posterior tibial pulses are independent predictors of

major vascular outcomes in patients with type 2 diabetes. If the patient is smoker,
permanent abstinence from cigarette smoking is the most important factor related to
outcomes in patients with intermittent claudication. Exercise has shown to increase the
walking time of patients with claudication by 150 percent in those who comply with the
regimen. Antiplatelet therapy was evaluated for risk reduction in serious vascular events
 including stroke, nonfatal myocardial infarction, or death from a vascular cause. Together
with aspirin, clopidogrel (Plavix) and cilostazol (Pletal).

The DOMINATE acronym wound care management system:

Debridement: removal of nonviable tissue that impedes healing by means of mechanical and
cleaning techniques.
Offloading: it eliminates wound stress and trauma which interfere with healing with a 1.5cm
thick pad and walking devices. Appropriate shoes with anterior offload should be used.
Moisture, malignant, medications, mental health: control of chronic exudates by proper
absorbent dressing (calcium alginate). Education of patients on the need of their cooperation for
the care plan. Continuous supervision of instructions. Verification of medications that may
interfere with wound healing. Control of stress and its effects on tissue inhibitors of
metalloproteases (TIMPs).
Infection, inflammation: control of infection, identification of infection signs, antimicrobial
therapy such as polyhexanide-betaine solution (Prontosan®), cadexomer iodine (Iodosorb®).
Wound culture and systemic antibiotics under medical prescription5 .
Nutrition: identification of malnutrition, correction of deficits and early referral no dieticians
(endocrinology). Glycated hemoglobin levels should be kept under
Arterial insufficiency: weak pedal and posterior tibial pulses in the right foot and absent in the
left foot. Non-significant ankle-brachial index in view of calcification shown on the US. Referral
to specialist (vascular surgeon) to assess potential revascularization.
Technical advances: moist control with daily cures and moist-free products.
Edema: control of edema. The patient will exercise his lower limbs while avoiding weight
bearing (cycling, strengthening lower limb muscles), low-elasticity multi-layer bandage in his
left leg.
Education: on his disease.
Empowerment: He is notified that without his cooperation good results are difficult to achieve.
References:
Sontheimer, D. 2006.Peripheral Vascular Disease: Diagnosis and Treatment.
Retrieved from https://www.aafp.org/afp/2006/0601/p1971.html

Leykum, B. & Armstrong, D. 2012. Surgical management of diabetic foot ulcers.

Retrieved from
file:///C:/Users/ADMIN/Downloads/SurgicalManagementofDiabeticFootUlcers-
LeykumFioritoandArmstrongchapterTeotBanwell2012.pdf

Armstrong DG, Rosales MA, Gashi A. Effi cacy of fi fth metatarsal head resection
for treatment of chronic diabetic foot ulceration. J Am Podiatr Med Assoc 2005;
95: 353–6.

Delgado, M. 2018. Clinical case: Complicated Diabetic Foot Ulcer. Retrived from
http://scielo.isciii.es/pdf/sanipe/v20n3/1575-0620-sanipe-20-03-121.pdf