He is obese and also has mild osteoarthritis, hypertension, and hypercholesterolemia. He has a 60-pack-year history of cigarette smoking but was able to quit 5 years ago after a transient ischemic attack. He reports no symptoms of leg claudication. His current medications include glipizide, lisinopril, hydrochlorothiazide, atenolol, simvastatin and aspirin.
His body mass index is 32.5 and blood pressure is 140/80 mm Hg. He is afebrile. A 3-cm plantar ulcer surrounded by a callus at the base of the second metatarsal head is noted on the right foot; the ulcer edges are necrotic. Dorsalis pedis and posterior tibialis pulses are weakly palpable. The ankle reflexes and microfilament sensation for all toes are absent bilaterally.
Which of the following should be the next step in the treatment of this patient?
A. Change the antihypertensive regimen.
B. Debride the callus and provide wet and dry dressings.
C. Perform nerve conduction studies.
D. Refer to a vascular surgeon.
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