Patient’s Data​

Patient’s name: Benjamin Turner

Age: 68-year-old male 

Past medical history:   

• None recorded  

Drug and Allergy History  

• Not currently on any medication    
• No Known Drug Allergy 

Recent Notes/Consultation

Seen 2 days ago by Dr Charles Lewis (Clinical Practitioner Role) 

Presenting complaint: Patient reported worsening pain in the left knee, ongoing for 4 weeks. Described the pain as waking him up at night and worse on movement. No red flag symptoms reported. He is currently managing the pain with over-the-counter ibuprofen, which he reports is helping.

Examination findings: No swelling, tenderness, or visible deformity noted in left knee. No lumps or bumps palpated. Other joints are unremarkable.
Temperature: 36.0°C. Blood pressure: 130/88 mmHg. 

Impression: Likely worsening osteoarthritis; however, in view of night pain, needs an X-ray to rule out possible underlying pathology, including tumour. 

Plan: X-ray of the left knee requested. Continue Analgesia. Safety nettin and worsening advice given. 

Imaging Report: Left Knee X-ray

Benjamin Turner | 68 years old | Male 

Clinical History: Left knee pain for 4 weeks. Worsening with movement. Night pain. Query tumour or underlying pathology.

Findings:
There is coarsening of trabecular bone, cortical thickening, and bone expansion involving the distal femur and proximal tibia, with preservation of joint space. No evidence of fracture or lytic lesion is seen. Soft tissues appear unremarkable.

These radiographic findings are in keeping with Paget’s disease of bone, involving the distal femur and proximal tibia. No aggressive features to suggest malignancy.

Conclusion:
Radiographic features are consistent with Paget’s disease of bone. 

Reported by:
Chinedu Okonkwo, BSc (Hons), PgCert (Med Imaging), HCPC Registered Reporting Radiographer

Patient booked a follow up appointment to discuss Xray Results .