Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a chronic, non-healing ulcer on the [Location: e.g., plantar aspect of the 1st metatarsal head]. Duration of lesion is [Number] weeks. Patient reports [Presence/Absence] of local pain, purulent discharge, or foul odor. History of poorly controlled Type 2 Diabetes Mellitus (HbA1c: [Value]). No history of recent trauma, but notes repetitive pressure at the site. Current symptoms include [e.g., erythema, edema, or malodor].
Clinical Examination Findings
Examination of the affected foot reveals a [Size: L x W x D in cm] ulcer. Wound bed: [e.g., granulating, sloughy, or necrotic]. Periwound skin: [e.g., macerated, erythematous, or hyperkeratotic]. Palpation: [e.g., fluctuance, warmth, or crepitus]. Neurovascular status: Pedal pulses [e.g., palpable/diminished], capillary refill [e.g., <2s], and protective sensation [e.g., intact/absent via 10g monofilament]. Probe-to-bone test: [Positive/Negative].
Treatment Protocol
Plan: 1. Sharp surgical debridement of non-viable tissue and hyperkeratotic callus. 2. Wound irrigation with normal saline. 3. Application of [e.g., collagen matrix/antimicrobial dressing]. 4. Offloading protocol initiated via [e.g., total contact cast/orthopedic shoe]. 5. Optimization of glycemic control. 6. Antibiotic therapy as per culture/sensitivity results if infection is present.