Chronic Osteomyelitis


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Chronic Osteomyelitis

  1. 1. Chronic Osteomyelitis Case Presentation Candice Reyes, MS-III Rashmi Desai, MD Internal Medicine
  2. 2. HPI <ul><li>G.L. is a 43y/o Hispanic male, who was referred from LAC-ER on 10-27-09 for L forearm infected ulcer x 3d. He c/o constant throbbing pain 8/10, foul odor, warmth, and oozing . He reports decreased strength and movement in L fingers and wrist. Symptoms started three days ago when he bumped his arm while moving furniture. Pain is exacerbated by movement of fingers and wrist. Pt has h/o heroin use x 20 yrs – he states that he snorts but does not inject, though he admits to occasional skin popping but not to L extremity. Last heroin use was day before admit. Pt is s/p skin graft to his L forearm here at RLA (9/2008). He stated that skin graft started peeling off after 7 mo. As per LAC, x-ray is compatible with chronic osteomyelitis with solid periosteal formation . Pt was referred to RLA for IV abx and possible skin graft. </li></ul>
  3. 3. PMHx <ul><li>HCV x 20 yrs </li></ul><ul><li>Skin graft 9/08 </li></ul><ul><li>Multiple stabs – lower chin, L scapula, L middle rib - starting at age 13, most recent was a couple months ago </li></ul><ul><li>Shot in the R lateral foot when 14y/o </li></ul>
  4. 4. PSHx <ul><li>Skin graft 9/08 </li></ul>
  5. 5. Medications <ul><li>Vicodin – Pt did not know what dose </li></ul>
  6. 6. Allergies and Vaccinations <ul><li>Allergies </li></ul><ul><ul><li>NKDA </li></ul></ul><ul><li>Vaccinations </li></ul>
  7. 7. FHx <ul><li>Mother – alive, DM, asthma, stroke x 2, questionable MI </li></ul><ul><li>Father – deceased d/t stroke (2005), DM, pacer </li></ul>
  8. 8. SocHx <ul><li>Tobacco 1ppd x 26yr (26 pack years) </li></ul><ul><li>EtOH 40oz daily x 13yr </li></ul><ul><li>Heroin snorts daily x 20yr </li></ul><ul><li>Divorced, has 3 kids (ages 24, 21, and 15) </li></ul><ul><li>Lives with sister and her son and 2 daughters </li></ul><ul><li>Used to be a truck driver x 11yr; unemployed since 2002 </li></ul>
  9. 9. ROS <ul><li>As per HPI </li></ul>
  10. 10. PE <ul><li>VS: T 96.8, P 62, R 20, O 2 Sat 100%, BP 126/68 </li></ul><ul><li>Gen: 43 y/o Hispanic male appears older than stated age, in NAD, sitting upright at in bed is A&O to person, place, time </li></ul><ul><li>Skin: multiple tattoos on arms, chest, abdomen, legs </li></ul><ul><li>HEENT: Head NCAT, scar on R frontal hairline and on lower chin from stabs ; visual acuity 20/20 in both eyes, PERRLA, EOMI, Sclera white, no icterus; canals clear, TM intact; nasal mucosa erythematous and irritated, septum slightly deviated; poor dentition , tenderness on R C2-C4 </li></ul>
  11. 11. PE <ul><li>Neck: supple, IV on R, no cervical lymph nodes palpated, no thyromegaly, no JVD </li></ul><ul><li>Respiratory: Thorax symmetric with good excursion, Expiratory wheezes present in L upper and middle lobes </li></ul><ul><li>CV: RRR without murmur, clicks, rubs; radial and dorsalis pedis pulses appreciated bilat 2+ </li></ul><ul><li>ABD: Active BS in four quadrants, soft and NT to palpitation, hepatomegaly </li></ul><ul><li>MS: Joint deformities – L wrist and fingers – ulnar deviation and flexion </li></ul>
  12. 12. PE <ul><li>Neuro: A&O x 3, CN II-XII intact, 4/5 strength in UE and LE, but unable to hyperextend L wrist; L wrist drop – mild ; grasp – 5/5; DTR 2/4 biceps, patellar and achilles bilaterally, sensory - light touch, pinprick intact </li></ul><ul><li>Wound – L forearm volar surface 11cm x 9cm x 0.5cm stage III ulcer with yellowish, malodorous discharge </li></ul>
  13. 13. Diagnostic Data <ul><li>LUE X-ray: compatible with chronic osteomyelitis with solid periosteal formation per LAC ER report </li></ul>
  14. 14. Lab Data <ul><li>10.7 133 100 16 </li></ul><ul><li>5.9 376 95 </li></ul><ul><li> 32.2 4.1 24 0.59 </li></ul><ul><li>PT 16 </li></ul><ul><li>INR 1.23 </li></ul><ul><li>CRP 34.2 </li></ul>
  15. 15. A&P <ul><li>L forearm infected ulcer – failed skin graft </li></ul><ul><ul><li>Dressing change BID with silvadene cream </li></ul></ul><ul><ul><li>Pain consult </li></ul></ul><ul><ul><li>IV abx – Zosyn and Vancomycin </li></ul></ul><ul><ul><li>Consider MRI L arm </li></ul></ul><ul><ul><li>Wound culture </li></ul></ul><ul><ul><li>Vitamins C, zinc, and multivitamin </li></ul></ul><ul><li>2) Heroin abuse </li></ul><ul><ul><li>Clonidine </li></ul></ul><ul><ul><li>IV hydration </li></ul></ul><ul><ul><li>Pain meds </li></ul></ul><ul><ul><li>Metadone </li></ul></ul>
  16. 16. A&P <ul><li>3) Nicotine Dependence </li></ul><ul><ul><li>Nicotine transdermal patch 21/24h daily </li></ul></ul><ul><li>4) H/O Hep C </li></ul><ul><li>5) L wrist drop </li></ul>