This patient has clear evidence of peripheral neuropathy, given his history and physical examination. Absence of claudication does not rule out distal vessel disease, which is more common in patients who have diabetes. This patient has several risk factors for peripheral arterial disease (PAD), including Type 2 diabetes, cigarette smoking, hypertension, hyperlipidemia, and prior history of a vascular episode. Chronic neuropathic ulcers are often complicated by PAD and will not heal if the peripheral circulation remains compromised. Further work-up should therefore include an estimation of the ankle-brachial index and a referral to a vascular surgeon for consideration of an angiogram to define the vascular anatomy and determine the possible need for surgical intervention. No medical treatments (e.g., changing his antihypertensive regimen) other than prophylactic measures such as risk factor management that includes smoking cessation are very effective in the treatment of advanced PAD. Debridement and local dressings only delay the healing process in the absence of further assessment. A nerve conduction study is not likely to further contribute to an already established diagnosis.
- Screen for peripheral arterial disease and refer for vascular studies in patients with neuropathic foot ulcers.
- American Diabetes Association. Standards of medical care in diabetes—2006 [published erratum appears in Diabetes Care 2006;29:1192]. Diabetes Care 2006;29 Suppl 1:S4-42. [PMID: 16373931] [PubMed]
- Hankey GJ, Norman PE, Eikelboom JW. Medical treatment of peripheral arterial disease. JAMA. 2006;295:547-53. [PMID: 16449620] [PubMed]
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