Internal Medicine and Subspecialties

76 year-old white male with a history of type 2 diabetes, hyperlipidemia,dementia, complains of six months of a painful ulceration of the right foot. Two months prior to this photograph, he was seen by podiatry, cardiology and his internist who diagnosed a Venous stasis ulcer. At that time the ulcer was weeping a clear to slightly cloudy liquid.He attended A wound clinic where he was treated with silver cream and bandage changes for two weeks. Unfortunately, although the area does look better than it originally did and is not weeping at this time, the pain persists. It’s worse with weight-bearing. The circled area on the lower half of the picture with the orange arrow is the area of tenderness and warmth. The circled rash superior to the lateral malleolus and pointed out with a blue arrow appeared three days before the picture was taken. It is not tender. It is not puritic. Posterior tibial pulses are intact. The rest of his physical exam is unrevealing. He does have oncomycosis. He spends four hours a day five days a week in the garden of his home doing a lot of heavy physical labor as trimming trees and moving large rocks and dirt around his property. His shoes are very old and dirty. He’s been using them for more than one year. However because of the pain he’s not been able to wear them recently. Labs are ok except hga1c 6.4. thoughts on diagnosis and next steps?