A foot ulcer in a man with longstanding diabetes

Don is 58 years old and has had type 2 diabetes for 17 years. You do not know him well but he is well known to your practice and attends a couple of times a year, mainly for prescriptions. He takes 2 g metformin extended release at night in addition to 60 mg gliclazide extended release, 40 mg atorvastatin, 5 mg perindopril (for hypertension) and 300 mg allopurinol, all taken in the morning.

Don has for some years declined a diabetes management plan for review by a diabetes educator, dietitian or podiatrist as he says he keeps a close eye on his weight, carbohydrate intake and foot care. He also has not enabled ready review of his feet, preferring to keep appointments brief. He has never seen an endocrinologist. He tells you that the proof is in his HbA_1c results, cholesterol levels and his lack of obvious organ damage. He looks fit and not overweight. He comes to see you today as he has had an ulcer for two months under his left first metatarsal head, which has not healed and is, by his history, worsening.

Picture credit: © Michele Graham.