Patient’s Data​

Patient’s name: Mohammed Khan

Age: 56-year-old male

Past medical history

• Asthma
• Bilateral Knee Osteoarthritis
• Chronic Kidney Disease (CKD) Stage 3a – EGFR stable over the past 2 years (range: 55–59). Most recent EGFR: 55 (2 weeks ago)
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Drug and Allergy History 

• Symbicort 100/6: 1 puff twice daily for maintenance, plus 1 puff as needed for symptom relief, up to a maximum of 8 inhalations per day (includes both maintenance and reliever use)
• No known drug allergy 

Recent Notes/Consultation

Seen by Dr Native (Clinical practitioner role) 4 weeks ago

Presenting complaint: Patient reports worsening Knee pain bilaterally, known to have osteoarthritis. No red flags

Examination findings: Crepitus on both knee joint movements, no lumps or bumps noted, Normal systemic examination. 

Plan:Referred for physiotherapy, repeat knee X-rays arranged, safety netting and worsening advice given. 

X-ray Report – Bilateral Knees

Findings:

Right Knee:

There is worsening narrowing of the medial joint space compared to previous Xray, consistent with severe osteoarthritis.

Subchondral sclerosis is noted in the medial compartment.

Osteophyte formation is observed along the joint margins.

There is evidence of mild patellofemoral joint involvement with small osteophytes noted at the patellar margins.

No acute fracture or dislocation is seen.

Left Knee:

Similar to the right knee, there is narrowing of the medial joint space.

Subchondral sclerosis is present in the medial compartment.

Osteophyte formation is also seen along the joint margins.

The patellofemoral joint shows severe osteoarthritic changes with osteophyte formation at the patellar margins.

No acute fracture or dislocation is seen.

Conclusion:

Bilateral severe knee osteoarthritis is noted, more prominent in the medial compartments of both knees.  The patellofemoral joints also show involvement. No evidence of acute bony injury.

Recent Investigations done 2 weeks ago

Blood tests including FBC, LFTs, CRP, ESR, and Rheumatoid screen – all within normal limits

EGFR: 62 – filed as satisfactory

Patient booked routine appointment to discuss results.