Basic Information

Patient name: M. M. T.
Age: 14 years old
Sex: Male
Occupation: Student

Medical History

Anamnesis: The patient presents with aseptic osteonecrosis of the navicular bone in the left foot. He suffered a sprain 7 months ago, which temporarily improved. For the past month, the foot pain has returned. MRI confirmed the diagnosis. Pain intensity was 6–7/10, especially in the morning. No chronic medication, no prior medical history.
Family history: Not known.

CLINICAL PRESENTATION:

Symptoms: Pain of 6–7/10 intensity in the left foot.
Duration: 1 month.

Treatment History:

Current medication: None.
Previous treatments: None prescribed.

Investigations:

Results: Foot MRI.
Diagnosis: Aseptic osteonecrosis of the navicular bone, left foot; Lyme disease.

Treatment Plan:

Recommended medication: None prescribed.
Therapeutic interventions: 20 hyperbaric therapy sessions. Continued treatment and physical rest are recommended until full tissue recovery.

EVOLUTION AND PROGNOSIS:

Evolution: At follow-up, the patient reports that the pain has almost completely disappeared, now 1/10 compared to 6–7/10 initially. Mobility has improved. Control MRI shows an approximate 70% reduction in edema.

FINAL OBSERVATIONS:

Significantly improved status, normal anatomical mobility, left foot without signs of local inflammation; normal mobility; peripheral vascularization, mobility, and sensitivity intact.