Kristina Karylle S.

Araojo
2011

December 21,
Medical History

General Objective:
To present a case of Osteomyelitis
Specific Objectives:

Present the clinical manifestations of Osteomyelitis.

Explain its pathophysiologic mechanisms.
Describe its Diagnostic approach.
Elaborate the management and prevention of this disease.

General Data:
Name: Editha Baco
December 1, 2011
Age: 63 years old

Date of consultation:
Reliability: 80 %

Sex: Female
Address: Purok 8, Lakewood, Zamboanga del Sur
Marital Status: Married
Occupation: Housewife
Religion: Roman Catholic
Nationality: Filipino
Chief Complaint: Bone Pain
History of Present Illness:
1 week prior to consult, patient experienced pain on the left femur, with a
pain scale of 5, characterized as gnawing and radiates to the knee. Pain is
aggravated by movement of the affected limb. This was associated with
intermittent, low to moderate grade fever. The patient did not take any medications.
No consult was done.
Hours prior to consult, patient is still in pain and fever persisted. There are no
other associated signs and symptoms such as chills and seizures. The patient did
not take any medications but this time sought consult at the Rural Health Unit.

Past Medical History:

One (1) year ago, the patient fell from a bridge hitting her left femur.
Accordingly, the patient had an open fracture and a hilot was sought. The patient
was not hospitalized nor brought to the center. No surgery was done.

Family History:
The patient has no heredo familial diseases such as diabetes mellitus,
hypertension, asthma and cancer on both paternal and maternal sides. Both her
parents died of old age.
Personal and Social History:
The patient is a housewife with 2 children and was widowed at the age of 50.
She is a non smoker and a non- alcohol beverage drinker. Her usual meal is
composed of vegetables, fish and rice.
Review of Systems:
General:

(+) loss of appetite, (+) body malaise, (+) weight loss

Skin:

(-) rashes, (-) lesions,

HEENT:

(-) dizziness, (-) headache, (-) blurring of vision, (-) ear discharges, (-)
ear pain, (-) hearing changes, (-) epistaxis, (-) nasal discomfort, (-) sore
throat, (-) vocal changes

Neck:

(-) neck pain, (-)dysphagia

Respiratory: (-) dyspnea, (-) cough, (-) hemoptysis

Cardiovascular: (-) chest pain, (-) palpitations
Gastrointestinal: (-) abdominal pain, (-) abdominal distention, (-) changes in bowel
habits, (-) bloody stools
Urinary: (-) urinary frequency, (-) dysuria, (-) nocturia
Extremities: (+) bone pain (-) wound discharges
Neurologic: (-) memory loss, (-) loss of consciousness
Hematologic: (-) easy bruising, (-) lymph node swelling
Endocrine: (-) excessive hunger, (-) excessive thirst

Physical Examination:
General: patient is awake, febrile, coherent and not in respiratory distress
Vital signs:
Temperature: 37.8 C
Blood pressure: 120 / 90 mmHg
Respiratory Rate: 14 cycles per minute
Pulse rate: 98
Limb measurement: Left Limb: 38.3 inches

Right Limb: 39 inches

Skin: dry with good skin turgor , healed wound on the left femur
HEENT:
no lesions on the head. Head is normocephalic and no mass palpated.
With pink palpebral conjunctivae, dirty sclera with pupils equally reactive to light
and accommodation;
Neck: no mass, no lesion, no cervical lymphadenopathies
Chest and Lungs: no gross deformities, no lesions, symmetrical chest expansion, no
chest lagging, no chest indrawing, no intercostals retractions, no use of accessory
muscles, clear breath sounds on both lung fields, equal vocal and tactile fremiti
Cardiovascular: Adynamic precordium. PMI at the 5 th ICS Left Midclavicular line. No
heaves. No thrills. Regular rate and rhythm. S1 > S2 at the apex. S2 > S1 at the
base. No murmurs.
Abdomen: flat abdomen, normo- active bowel sounds, tympanitic, no tenderness or
masses.
Extremities: good capillary refill time, good bipedal pulses, shortening of the left
limb
Diagnosis: Chronic Osteomyelitis
Basis for diagnosis:
History of fracture
No medical or surgical intervention done to treat the wound / fracture
(+) body malaise

(+) weight loss

(+) shortening of the limb

Differential Diagnosis:
Rule in
(+) fever
(+) healed wound

Rule out
(+) shortening of the limb
Chronicity

Rheumatoid Arthritis

Female
(+) Knee pain
Chronic onset

(+)fever
(+) history fracture
(+) shortening of the limb

Metastatic malignancy to
the bone

(+)
(+)
(+)
(+)

(-) association with a

primary lesion

Soft tissue Infection

bone pain
weight loss
body malaise
anorexia

Case Discussion
Microorganisms enter the
bone

Phagocytes attempt to contain

the infection

Pus spreads into vascular

channels

Enzymes are released that

lyse the bone

Increased intaosseous
pressure

Impaired blood flow

Ischemic necrosis of bone

Separation of large
devascularized fragments
(sequestra)

Formation of subperiosteal or
soft tissue abcesses

Pus breaks through the cortex

Elevated periosteum deposits

new bone (involucrum) around
the sequestrum

Management:

1. Refer patient to hospital.

2. Surgical debridement is usually warranted in cases of chronic
osteomyelitis.
3. Complete drainage and debridement ofall necrotic soft tissue and
resection of dead and infected bone.
4. Antibiotic treatment is typically begun immediately after appropriate
cultures are obtained.
IANTIBIOTIC THERAPY
Microorganism

Agent of Choice

Alternative

Staphylococcus aureus
(methicillin sensitive)

Oxacillin or nafcillin, 2 Oxacillin or nafcillin, 2 g

g IV q6h
IV q6h

Staphylococcus aureus
(methicillin resistant)

Vancomycin, 1 g IV
q12h

Vancomycin, 1 g IV
q12h

Group A or B -hemolytic
streptococci and Streptococcus
pneumoniae
Enterococci

Penicillin G, 1020
million units IV daily

Penicillin G, 1020
million units IV daily

Ampicillin, 2 g IV q4h

Ampicillin, 2 g IV q4h

Neisseria gonorrhoeae

Enteric gram-negative bacilli

Pseudomonas aeruginosa
Bacteroides sp
Mixed infection (aerobic and
anaerobic microorganisms)

Ceftriaxone, 1 g IM or IV
qd, followed by oral
cefixime, 400 mg bid,
or ciprofloxacin, 500 mg
bid 710 days. If
penicillin sensitive, use
penicillin G, ampicillin,
or amoxicillin with
probenecid
Ciprofloxacin, 400750
mg IV q12h
Ciprofloxacin, 400 mg
IV q12h
Clindamycin, 600 mg IV
q6h
Ampicillin-sulbactam,
23 g q68h

If allergic to -lactams,
ciprofloxacin, 500 mg IV
q12h, or spectinomycin
(also if pregnant), 2 g IM
q12h, followed by oral
therapy 7 days

Ceftriaxone, levofloxacin
Piperacillin plus
aminoglycoside
Imipenem, metronidazole,
ampicillin
Imipenem, levofloxacin
plus metronidazole

Suggested Paraclinicals / Tests:

CBC - leukocytosis

ESR and CRP levels are elevated in most cases of active osteomyelitis

Technetium radionuclide scan

Ga citrate, Indium and Immunoglobulin scan

Ultrasound

MRI

CT Scan