An 65 year old gentleman presented with blackish discolration of great toe and nail since 15days A/w Foul smelly pus discharge, non healing ulcer which is painless and surroundings edema. Non healing ulcer surround by callus on bilateral medial aspect of heel region. With Bilateral cellulitis. By occupation he is a bus conductor H/O Type 2 DM since 15 Year’s HTN since 10 year and DPN since 12 Year’s After detailed examination his Sugars are uncontrolled Dyslipidemia Acute kidney injury ABI is normal 1.0 TBI I couldn’t examine in this patient VPT reviled he has severe neuropathy in both legs But no deformity as such (no Neuroarthropathy) Ecg is normal So I diagnosed this case as Infective Gangrene of right Hallux Neuropathy ulcer over bilateral medial ascpect of heel region Callus over left plantar aspect of fore foot Treatment Debridement done Cefperazone+ Saulbactum inj intravenous started Statin, Aspirin and clopidogrel tablets started ACE inhibitors also started For sugar control premix insulin twice and OHA triple combination started..... Doctors please kindly suggest of anything else I need to change

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Rt great toe gangrene, need to be amputated immediately with the consent of the patient witnessed by the family member. Other ulcers are to be debrided as well as calluses are to be trimmed. Basal bolus insulin dose has to be started. Pus from the innermost part of the ulcer has to be sent for c/s. If there is vascular stiffening or calcification, then ABI will show normal values that does not mean that the vascularity is intact. Angiography will suggest the vascular health. Loss of sensation suggests that the ulcers are neurotrophic in nature. Deformity can be established from the foot scan & I think definitely there is some sort of deformity. Offloading is a must for the patient.

Sir, It is an infective ulcer with cellulitis sir. Hence I had tried with debridement I’d pressure reduces then the blood flow will improve sir. They are very poor people sir if this approach not improve his condition then my plan is colour Doppler sir. I will review with pics sir Thanks for advice sir
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Very good management.some suggestions The ulcers are multiple and appear both infected secondary Hence it is required to establish good vascularity of small vessels and so MRA/CTA of lower limbs Offloading of both feet as the ulcers involve the heels and Ball of feet with windows for dressing X-ray of both feet to rule out osteomyelitis and Charcot's Left foot appears to be Charcot's foot from pics seen Esteemed colleagues have already suggested other steps

Ok sir I will follow it sir thanks for your advice.
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I think you are doing enough,control sugar,do a culture and sensitivity of the pus to achieve better infection control.blind use of antibiotics without culture is not a good working practices.if no infection what is the use of antibiotics.also do a gram stain you never know in india, T B could be lurking any where.

Ok sir I will follow your advice sir
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There is a procedure i had described and published nearly 3decades ago called Posterior Tibial artery decompression at the medial malleolus and excising the vein that compresses it . This increases perfusion pressure by nearly 40mm of Hg thus bringing in more blood to heal tissue

Ok sir I will check of it
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Diabetic tropical ulcer As pt is dm ht ckd TT systemic diseases Controll dm b urea X-ray affected part to see bony inv Dopller study from efestival vasculariry If no vascular embankment TT if conservativ line If gangrene n bony inv n impaired circulation Surgery is option

Ok sir
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Thanks
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Diabetic foot.-Trophic Ulcer.-Badly infected. Adv.Pus C/S &Select antibiotics along with dressing with Mupirocin ointment.

Ok sir
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DX Tinea Pedis infection Rx Tab.Monocane 100 bd Tab.Allegra 180 od Infs.Lizomed 600 bd ont.Lt Mac locally bd

Diabetic foot..best management sir

@Dr. Mir Javaid Hussain sir thanks
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