Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of chronic osteomyelitis of the right tibia. Reports persistent/intermittent localized pain, localized erythema, and occasional serous drainage from a chronic sinus tract. Denies systemic symptoms of fever or chills. Current antibiotic regimen is [Insert Medication], with adherence noted.
Clinical Examination Findings
Right lower extremity examination reveals a chronic, non-healing ulcer/sinus tract over the anterior aspect of the tibia. Surrounding tissue shows induration, hyperpigmentation, and mild warmth. No evidence of acute cellulitis or fluctuance. Neurovascular status is intact with palpable dorsalis pedis and posterior tibial pulses. Capillary refill < 2 seconds.
Treatment Protocol
Continue long-term suppressive antibiotic therapy as per culture and sensitivity results. Wound care protocol: daily saline irrigation and sterile dressing changes. Surgical consultation for potential debridement or sequestrectomy if clinical status worsens. Maintain off-loading of the affected limb.