Date:
Patient:
MRN:
Clincian: (Rheumatologist, Orthopaedic Surgeon)
Reason for Visit:
Follow-up for hand osteoarthritis (OA)
Evaluation of joint pain, stiffness, and functional limitations
Review of X-ray results (if applicable)
Discussion of treatment plan and pain management strategies
History of Present Illness:
Briefly describe the patient’s current status:
Location and severity of joint pain (especially at the base of the thumb and fingers)
Stiffness and difficulty performing daily activities (grip strength, grasping objects)
Frequency and duration of symptoms
Response to previous treatment approaches (medication, splinting)
Past Medical History:
Underlying medical conditions (rheumatoid arthritis can mimic hand OA)
Previous hand injuries or surgeries
Social History:
Occupation and hobbies that may contribute to hand stress (manual labor, repetitive tasks)
Physical Exam:
Joint examination:
Assess for swelling, tenderness, and bony prominence at the base of the thumb (CMC joint) and finger joints (DIP and PIP joints).
Evaluate for crepitus (grinding sensation) upon joint movement.
Assess range of motion of the thumb and fingers.
Grip strength testing: May be decreased due to pain and weakness.
Imaging:
X-ray: May show joint space narrowing, osteophytes (bone spurs), and subchondral sclerosis (bone hardening beneath the cartilage).
Consider mentioning other imaging studies ordered as needed (ultrasound for soft tissue evaluation, MRI for detailed assessment in unclear cases).
Assessment:
Summarize the diagnosis and disease stage:
Confirmation of hand OA based on clinical presentation (joint pain, stiffness, and functional limitations) and X-ray findings (if available).
Stage of OA based on severity of symptoms and X-ray findings (mild, moderate, or severe).
Plan:
Outline the treatment plan based on the assessment:
Non-pharmacologic therapy:
Joint protection strategies (bracing, splinting) to reduce stress.
Physical therapy to improve flexibility, strength, and function.
Heat or cold therapy for pain management.
Weight management (if overweight or obese) to reduce stress on joints.
Pharmacologic therapy:
Acetaminophen or NSAIDs (nonsteroidal anti-inflammatory drugs) for pain relief.
Consider mentioning topical pain medications (creams, gels) for localized pain relief.
Corticosteroid injections into the affected joint(s) for short-term pain relief (limited use due to potential side effects).
Surgical intervention: May be considered in severe cases with significant pain and functional limitations (joint replacement, arthroplasty).
Prognosis:
Briefly discuss the prognosis. Hand OA is a chronic progressive condition, but treatment can effectively manage pain, improve function, and slow down the progression.
Emphasize the importance of ongoing care, adherence to treatment strategies, and activity modification to maintain hand function and quality of life.
Education:
Document any education provided to the patient regarding:
The nature of hand OA, its causes, and risk factors
The benefits of non-pharmacologic therapies (joint protection, exercise) for pain management and maintaining function
The use of medications for pain relief and potential side effects
Warning signs and symptoms of worsening OA or potential complications
The availability of support groups and resources for patients with hand OA
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about pain management, daily activities, or potential surgical intervention.
Consider the impact of hand OA on the patient’s daily life and offer occupational therapy or assistive devices if needed to help with daily tasks.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a rheumatologist or orthopaedic surgeon for diagnosis, treatment recommendations, and prognosis.