Mr. S is a 47 y/o male with DM2 (HgbA1c 12) and neuropathy who presents to clinic c/o a moderately-sized ulcer on his right great toe. This is his 3rd diabetic ulcer in two years. He has previously refused to begin insulin. Two months ago, he presented with a small sore on his right great toe. Mr. S was referred to podiatry, but he missed the appointment because the clinic forgot to fax the referral to podiatry. This small sore (see picture 1) has now progressed to the ulcer seen today.
Picture 1:[1]
His PCP examines him but forgets to document a foot exam. His PCP discusses wound care and provides him with a prescription for cephalexin. Unfortunately, the fact that his two previous diabetic ulcers grew MRSA is not documented in his chart. Mr. S is told to return if his ulcer worsens.
Mr. S calls for an appointment as his ulcer has worsened. Unfortunately, the next available appointment is in 2 weeks. When Mr. S returns, his PCP is on vacation, so he is seen by another physician. Because his PCP did not document a foot exam, the current physician does not realize how much Mr. S’s ulcer has progressed. (See picture 2)
Picture 2:[2]
Mr. S expresses uncertainty about his wound care regimen. The covering physician changes Mr. S’s antibiotic. However, before he has a chance to explain the wound care regimen, he is called away to see another patient who is quite ill. Mr. S leaves the office with a new antibiotic, but he is still confused about how to care for his wound.
Two months later, Mr. S presents to the ER with a grossly infected ulcer. The consulting surgeon sees him and recommends amputation.
Picture 3:[3]
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