“Doctor, I have diabetes and this sore under my foot is getting worse. It smells bad and I’m worried I might lose my foot.”

• Presenting wound: onset, location, trauma/foreign body, footwear injury, progression, pain, swelling, erythema, warmth, purulent drainage, odour, bleeding.
• Infection severity: fever, chills, rigors, malaise, confusion, tachycardia symptoms, rapidly spreading redness, severe pain, bullae, skin necrosis, crepitus.
• Osteomyelitis risk: deep ulcer, visible bone, chronic non-healing ulcer, previous ulcers, previous osteomyelitis, previous amputation.
• Peripheral vascular disease: claudication, rest pain, cold foot, colour change, non-healing wounds, smoking history.
• Neuropathy: numbness, burning, reduced protective sensation, unrecognized injuries.
• Diabetes history: duration, recent glycemic control, home glucose readings, medications including insulin, adherence, hypoglycemia, complications.
• Comorbidities: chronic kidney disease, coronary artery disease, stroke, peripheral arterial disease, immunosuppression.
• Medication and allergy review: antibiotics, anticoagulants, steroids, SGLT2 inhibitors, drug allergies.
• Functional and social context: ability to walk, work demands, home supports, access to wound care, financial/footwear barriers.

• Vital signs and general status: temperature, heart rate, blood pressure, respiratory rate, oxygen saturation, mental status, hydration.
• Foot inspection: ulcer site, size, depth, edges, drainage, odour, surrounding cellulitis, fluctuance, necrosis, gangrene, callus, deformity, pressure areas.
• Probe-to-bone assessment: if appropriate and with sterile technique, assess whether bone can be contacted through the ulcer.
• Neurovascular exam: dorsalis pedis/posterior tibial pulses, capillary refill, skin temperature, colour, ankle-brachial index if available, monofilament sensation, vibration/proprioception.
• Musculoskeletal exam: swelling, tenderness, range of motion, Charcot-type deformity, signs of deep abscess or septic joint.
• Systemic exam: cardiac/respiratory assessment if septic or high-risk; examine other foot for ulcers and footwear fit.

• Bedside: capillary glucose, vital signs, assess for sepsis, consider ketones if very unwell or hyperglycemic.
• Laboratory: CBC, electrolytes/creatinine, CRP/ESR, glucose/A1c if not recent; blood cultures if febrile or systemically unwell.
• Microbiology: deep tissue culture after cleansing/debridement if infected. Avoid superficial swab if possible because it may reflect colonization.
• Imaging: plain X-ray of foot for gas, foreign body, bony destruction, deformity; MRI if osteomyelitis or deep abscess is suspected and diagnosis remains uncertain.
• Vascular assessment: pulses, ankle-brachial index/toe pressures if available; vascular imaging/referral if ischemia suspected.

• Disposition first: admit urgently if systemic toxicity, sepsis, rapidly progressive infection, necrosis/gangrene, suspected necrotizing infection, deep abscess, severe ischemia, inability to walk safely, poor home support, or failure of outpatient therapy.
• Urgent referral: involve wound care/podiatry, infectious disease, orthopedics/general surgery, and vascular surgery when deep infection, osteomyelitis, abscess, gangrene, or ischemia is suspected.
• Antibiotics: start empiric antibiotics based on severity, local guidance, allergy history, renal function, and MRSA/Pseudomonas risk; narrow once cultures return.
• Source control: debridement of devitalized tissue when appropriate; urgent surgical assessment if abscess, necrosis, gas, or compartment/necrotizing features.
• Off-loading: reduce pressure on the ulcer with appropriate footwear, boot, crutches, or total contact casting if appropriate under specialist supervision.
• Wound care: cleanse, dress, document size/depth, arrange regular wound review.
• Diabetes management: optimize glucose, review medications, hydration, renal function, nutrition, smoking cessation, and cardiovascular risk factors.
• Follow-up: mild outpatient cases require close reassessment, usually within 24–72 hours depending on severity and local pathway.

• Acknowledge fear: “I understand why you are worried about losing your foot. The goal is to treat this early and protect the foot.”
• Explain diagnosis clearly: diabetes can reduce sensation and blood flow, allowing wounds to worsen before they are noticed.
• Explain urgency without alarm: worsening redness, drainage, fever, or poor circulation can become serious quickly.
• Use shared decision-making: discuss need for imaging, antibiotics, wound care, and possible hospital referral depending on severity.
• Safety-net: return immediately for fever, chills, spreading redness, increasing pain, black skin, confusion, vomiting, high glucose, or feeling faint.
• Prevention: daily foot inspection, well-fitting shoes, avoid walking barefoot, prompt care for blisters/cuts, regular diabetes foot checks.

1. What features make this patient unsafe for outpatient treatment?
   Systemic toxicity, sepsis, rapidly spreading cellulitis, deep abscess, necrosis/gangrene, suspected necrotizing infection, severe ischemia, suspected osteomyelitis with unstable condition, inability to care for the wound, or poor follow-up access.
2. Why is vascular assessment important?
   Poor perfusion delays healing and increases amputation risk. Infection may not improve with antibiotics alone if ischemia is significant.
3. What is the significance of a positive probe-to-bone test?
   It increases concern for osteomyelitis, especially in a deep infected ulcer, and should prompt imaging and specialist evaluation.
4. Why should superficial swabs be avoided when possible?
   They may reflect colonizing organisms rather than the true pathogen. A deep tissue specimen after cleaning/debridement is more clinically useful.
5. What counselling would you give before discharge?
   Explain wound care, off-loading, medication adherence, glucose monitoring, close follow-up, and emergency return precautions for systemic symptoms, spreading infection, black tissue, or worsening pain.

High-scoring candidate should:

• Identify diabetic foot infection and screen for osteomyelitis, ischemia, necrotizing infection, and sepsis.
• Assess infection severity and decide whether outpatient care or hospital admission is safer.
• Ask about neuropathy, vascular symptoms, prior ulcers/amputation, renal disease, glycemic control, medications, allergies, and social supports.
• Verbalize full foot exam including pulses, capillary refill, ulcer depth, drainage, necrosis, monofilament sensation, and contralateral foot check.
• Order appropriate investigations: glucose, CBC, renal function, CRP/ESR, cultures when indicated, X-ray, MRI if osteomyelitis suspected.
• Provide management plan: antibiotics, wound care, off-loading, debridement/source control, glycemic optimization, specialist referral, and close follow-up.
• Communicate empathy, clear risk explanation, and specific safety-net instructions.

• Calling it a simple skin infection without assessing depth, perfusion, neuropathy, and systemic severity.
• Forgetting to ask about previous foot ulcers, amputations, or osteomyelitis.
• Not checking vascular status before assuming antibiotics alone will solve the problem.
• Failing to consider necrotizing infection when pain is severe or progression is rapid.
• Discharging without close reassessment and explicit return precautions.