Basic Information

Patient name: T.D.
Age: 36 years old
Gender: Female
Occupation: Entrepreneur

Medical History

Anamnesis: The patient presents with a diabetic ulceration, with no healing tendency. History of TB 8 years ago, with lower limb edema and lymphangitis.
Family history: Diabetes in mother.

CLINICAL PRESENTATION:

Symptoms: Ulceration on the big toe of the left foot, on the plantar surface, approximately 2 x 2 cm and approximately 1 cm deep, without bone involvement, with adjacent redness and edema, decreased sensitivity, intact mobility.
Duration: 2 months.
Aggravating factors: Diabetes with its complications, including polyneuropathy and microangiopathy.
Alleviating factors: None.

Treatment History:

Current medications: Forxiga, Bydureon (Insulin), Xarelto, Aspenter, Atorvastatin.
Previous treatments: Local and topical treatments, without effect.

Investigations:

Arteriography: None.
Diagnosis: Diabetic ulcer left foot, Lymphangitis, Dermatitis, Type 2 diabetes, PNP.

Treatment Plan:

Recommended medication: Chronic medication, without additional medications.
Therapeutic interventions: 20 sessions of hyperbaric therapy.

EVOLUTION AND PROGNOSIS:

Evolution: The patient's condition is favorable, with the wound showing an evident healing tendency. Granulation tissue has been observed, and the wound size has been reduced to 1 x 1 cm. The wound has been completely cleaned, with the initial necrosis being eliminated.
Prognosis: Favorable. Continuation of therapy is recommended until complete wound closure.

FINAL OBSERVATIONS:

The patient will return to continue the treatment.