Patient is here regarding worsening of the left lateral ankle ulcer no fever or chills. The patient is present with his wife. The ulcer has been present since 12/2019 per patient. The patient started seeing me 10/5/22. MRI /tissue culture and arterial dopplers were preformed. Initially unremarkable. The ulcer appears initially be venous in nature. However did not respond to conventional treatment. The ulcer initially improved going from necrotic tissue -> healthier granulation tissue noted on 11/18/22. Skin substitute were started and the ulcer worsened again with increase slough necrosis of the tissue and increase in size. MRI on 1/2023 noted osteomyelitis confirmed with bone culture. Positive cultures with multidrug resistant pseudomonas Patient was placed on 6 weeks of Vancomycin / Cefepime and Flagyl per ID. The patient has been evaluated by Mayo clinic wound care vascular and orthopedic. Recommended possible amputation. He was placed in a boot that placed more pressure on the ulcer. Local wound care was changed and the appearance of the ulcer was worse with increase slough and necrotic tissue. Patient has been doing telehealth with me but with the recent development requested that he come in. The periwound appears inflamed. Pain has increased. Patient MRI done at Mayo on 5/10/23 worsening osteomyelitis. Chronic refractory osteomyelitis. Discussed possibility of HBO2. Pictures range from 3/2023 to 5/2023.