Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Initial evaluation for suspected osteochondritis dissecans (OCD)
Follow-up for diagnosed OCD (monitoring symptoms, treatment response)
Evaluation of pain, swelling, or functional limitations
Chief Complaint:
pen_spark
Joint pain (often localized)
Joint swelling (may or may not be present)
Catching or locking sensation in the joint
Decreased range of motion in the affected joint
Difficulty participating in activities (sports, exercise)
History of Present Illness:
Onset, duration, and severity of symptoms.
Location of pain (specific joint affected – knee most common).
Aggravating factors (activities that worsen symptoms).
Alleviating factors (rest, medications).
History of injury or trauma to the affected joint.
Previous treatments for OCD or joint pain.
Past Medical History:
Underlying medical conditions (e.g., wcześniejszy uraz stawu
[previous joint injury] – Polish).
Previous surgeries (relevant surgeries on the affected joint).
Family History:
Family history of OCD or other joint conditions.
Social History:
Participation in sports or physical activities.
Physical Examination:
Joint examination: Assess for localized tenderness, swelling, joint
effusion (fluid collection), range of motion, and stability. Evaluate
for crepitus (grating sensation) or locking of the joint.
Neurological examination: Assess for any neurological deficits
that may contribute to gait abnormalities or joint instability.
Imaging Studies:
X-ray: May show evidence of underlying bone fragmentation or joint
space narrowing. However, X-rays may be normal in early stages of OCD.
MRI scan: The preferred imaging study for diagnosing OCD. MRI can
visualize the detached fragment of cartilage and assess for associated
bone changes.
Assessment:
Osteochondritis dissecans (OCD): Based on clinical presentation
(symptoms and physical examination findings) and confirmed with imaging
studies (MRI). Stage of OCD (early, established, or late) should be determined
based on imaging findings.
Location of OCD: Specify the affected joint (e.g., knee OCD,
ankle OCD).
Functional limitations: Assess the impact of OCD on the patient’s
daily activities and participation in sports.
Differential Diagnoses:
Consider other conditions that may mimic OCD:
Meniscus tear (knee)
Ligament sprain
Bursitis (inflammation of a bursa)
Osteoarthritis (degenerative joint disease)
Plan:
Treatment plan: Depends on the severity of OCD, stage of disease,
and patient’s symptoms and functional limitations. Treatment options
may include:
Non-surgical management: Rest, physical therapy to improve
strength and flexibility, bracing, and pain medication (e.g., NSAIDs).
Surgical management: Arthroscopic surgery to remove or fixate
the detached fragment of cartilage. May be considered for symptomatic
cases not responding to conservative management.
Rehabilitation: Physical therapy to regain strength, flexibility, and
normal joint function after surgery or conservative treatment.
Return to activity: Gradual return to sports or activities is
encouraged based on pain tolerance and functional progress.
Follow-up: Schedule regular follow-up appointments to monitor
symptoms, treatment response, and joint health.
Prognosis:
Prognosis depends on the severity of OCD and the chosen treatment
approach. Early diagnosis and treatment can improve outcomes and
minimize long-term complications (e.g., early osteoarthritis).
Patient Education:
Educate the patient about OCD, causes, symptoms, and treatment options.
Discuss the importance of following treatment recommendations, including
physical therapy exercises and activity modifications.
Advise the patient to report any worsening of symptoms or unexpected
complications.