What would be your next steps in this complex case of a six-month ulcer?

Because of his pain, he’s not been able to wear his shoes

A 76-year-old male with a history of type 2 diabetes, hyperlipidemia, and dementia presents with a six-month history of a painful, non-pruritic ulceration of the right foot. Two months prior, he saw a podiatrist, cardiologist, and his internist, who diagnosed a venous stasis ulcer. At that time, it was weeping a clear to slightly cloudy discharge. He was treated with a silver cream and bandage changes for two weeks but the pain persists. He has a history of onychomycosis and spends four hours a day doing heavy physical labor, such as trimming trees and moving dirty and large rocks.

What would your next steps be?

Quiz: What extra-articular clinical manifestations is most commonly associated with this patient’s condition?

A 30-year-old male presents with a one-year history of worsening lower back pain and alternating buttock pain. He mentions his symptoms are typically worse first thing in the morning, but seem to remit later in the day with NSAIDs and exercise. Physical examination reveals swelling of the proximal interphalangeal joints of several digits, restricted lumbar movement, and tenderness of the sacroiliac joint. An X-ray demonstrates the findings seen here.

See the answer here

These cases were originally published in the August 1, 2019 edition of The Differential for Chronic newsletter. The Differential is our premium newsletter which rounds up the most interesting and useful clinical cases based on your specialty. To sign up for this email in any of its 10 specialty-specific editions, download the Figure 1 app and update your email preferences.