Basic Information

Patient name: T. F.
Age: 68 years old
Sex: Male
Occupation: -

Medical History

Anamnesis: Three months ago, the patient suffered a fracture of the distal right fibular epiphysis, treated with cast immobilization. One month later, he experienced an ankle sprain followed by persistent ankle pain. MRI revealed aseptic necrosis of the talus. Past medical history includes hypertension treated with Preductal and prostate adenoma.
Family history: None known.

CLINICAL PRESENTATION:

Symptoms: Ankle pain.
Duration: 1 month.
Aggravating factors: Walking.
Relieving factors: None.

Treatment History:

Current medication: None.
Previous treatments: None prescribed.

Investigations:

Results: Foot MRI.
Diagnosis: Avascular necrosis of the right talus.

Treatment Plan:

Recommended medication: None prescribed.
Therapeutic interventions: 20 hyperbaric therapy sessions.

EVOLUTION AND PROGNOSIS:

Evolution: Edema has decreased by approximately 90%.

FINAL OBSERVATIONS:

Reevaluation is recommended as needed, along with orthopedic follow-up.