CASE STUDY

A 38 year old male, was

admitted in the hospital on
21st Oct 2013 with c/o
restricted neck movements
of neck, pain in back of neck
and both shoulders and low
backache since 5 years.
Occasionally he had
difficulty in bending forward
NAME - MR. NOORUDDEEN P
GENDER - MALE
AGE - 38
IP NO. -416867
DEPT. - ORTHO
DOA - 21 / 10 /2013
DOD - 25 / 10 /2013
 SUBJECTIVE
PRESENTING COMPLAINTS:
* Restricted neck movements
* Pain on back of the neck and shoulders
* Difficulty in bending forward

PAST MEDICAL HISTORY :

* No h/o HTN,T2DM,BRONCHIAL
ASTHMA,THYROID DISEASE.
*DIETIC HISTORY- Normal appetite

*SOCIO ECONOMIC HISTORY : Middle Class

*FAMILY HISTORY : NIL

 OBJECTIVE
• On examination , patient was conscious
PARAMETER VALUE REFERENCE INTERPRETATIO
N
PULSE 76 beats/min 72 beats/min ELEVATED
RR 22/min 20-24 /min NORMAL
BP 110/70 mmHg <140/90 mmHg NORMAL

Hb 14.3g% 12- 16 g% NORMAL

ESR 25mm/hr <20mm/hr INFECTION
DC.LYMPHOCYT 30% 16 – 46% NORMAL
ES
DC.EOISINOPHIL 2% 0-8% NORMAL
TEST VALUE REFERENCE INTERPRETATION

TOTAL 10,700cells/ 5,000-11000 NORMAL

COUNT mm3 cells/cu.mm
PLATELET 3.5 1.5-3.5 NORMAL
lakhs/mm3 lakhs/mm3
RBS 85 mg/dL <140 mg/dl NORMAL

UREA 30 mg% <40mg% NORMAL

CREATININ 0.8mg % 0.5-1.4 mg% NORMAL

E
»SYSTEMIC EXAMINATION:

RS: B/L Air entry equal

.
CVS: S₁S₂ heard, No murmur

CNS: No FND. HMF normal, oriented, conscious

P/A : Soft.No organomegaly

 LOCAL EXAMINATION
SPINE
* Diffuse Spine Tenderness + , C7 T1, L4L5
spinous process
• ROM- Cervical Spine fully restricted
• Lower Spine- flexion restricted
• Paraesthesis + Right middle ,index and ring
finger
• No deformity or swelling
 ASSESSMENT
• » Problem 1 :
ANKYLOSING SPONDYLITIS
Ankylosing Spondylitis
• Ankylosing spondylitis (AS) is a chronic (persistent)
rheumatic (arthritic) disease of unknown cause. It mainly
affects the spine and the sacroiliac joints. The word
ankylosing means bones that tend to join together (fuse).

CAUSE
• The cause is not known. However, there is a strong genetic
(hereditary) tendency. For example, there is a strong
association with a gene called HLA-B27.
*Back pain

*Stiffness in the lower spine.

*Other joint symptoms apart from the spine

*Inflammation of tendons and ligaments

*Inflammation of part of the eye

*General symptoms( tiredness, depression)

• Schober’s Test
Measure the ability of a patient to flex his/ her
lower back
• MRI
• X-RAY
• INCREASE IN C REACTIVE PROTEIN
• INCREASE IN ESR
 Non pharmacological therapy
• Physiotherapy and exercise
• Education

MEDICATION
-Anti inflammatory medicines
Eg :NSAIDs
Ordinary painkillers eg:paracetamol
-Immuno-suppresant medicines.
-Corticosteroids
-Biological Agents
OTHER TREATMENTS-

Other treatments sometimes used include the following:

• Trans-cutaneous electrical nerve stimulation (TENS)
machines are sometimes used to ease pain. (These give tiny
electrical currents into the affected area.)
• Heat - for example, a hot shower - may help to ease pain,
particularly each morning.
• Some people find regular massage is soothing.
• About 1 in 20 people with AS need a hip replacement at
some stage, as their hip sometimes becomes badly affected.
Rarely, surgery is needed to correct a severe spinal
deformity.
ALGORITHM
 GUIDELINES FOR ANKYLOSING
SPONDYLITIS

* National Ankylosing Spondylitis Society

(NASS)

* National Institute for Health and Care

Excellence (NICE)
 DISCUSSION ON THERAPY
BRAND NAME GENERIC NAME DOSE INDICATION ADR INTERA
CTION

TAB. HIFENAC ACECLOFENAC 100mg ANTI- Vertigo, Can

INFLAMMATORY diarrhoea, increase
, ANALGESIC dyspepsia the risk
of
kidney
problem
with
Sulfasal
azine
TAB. ULTRACET TRAMADOL 325/ PAIN Nausea,
+PARACETAMOL 37.5mg Dizziness, RAsh

TAB.SAAZ SULFASALAZINE 1g ANTI- NEUTROPENIA,

IMFLAMMATOR THROMBOCYTO
Y PENIA

DFO GEL FOR LA DICLOFENAC ANALGESIC Mild irritation

at application
site
 DATES
BRAND NAME GENERIC DOS FREQU ROUTE 21/ 22/ 23/ 24/ 25/
NAME E ENCY 10 10 10 10 10
TAB. HIFENAC ACECLOFENA 100 1-0-1 ORAL √ √ √ √ √
C mg
TAB. TRAMADOL 325/ 1-0-1 ORAL √ √ √ √ √
+PARACETAMOL 37.5
ULTRACET
mg
TAB.SAAZ SULFASALAZI 1g 0-0-1 ORAL √ √ √ √ √
NE
DFO GEL FOR DICLOFENAC LA √ √ √ √ √
LA
Tab. Pantop PANTOPRAZ 40m 1-0-0 ORAL √ √ √ √ √
OLE g
 TAB. SAAZ 1g X TO CONTINUE

TAB. ULTRACET 1 SOS X 5 days

DFO GEL X To Continue

CONTINUE SPINAL FLEXION AND

CERVICAL SPINE EXERCISE

CURRENT STATUS - SYMPTOMATICALLY IMPROVED,

DISCHARGED IN STABLE STATE
REVIEW AFTER 1 MONTH IN ORTHO OP
 PLAN
• Proper medication adherence

• Counsel the patient about Spinal flexion and

Cervical Spine exercise.
 PHARMACIST’S INTERVENTION
MODERATE INTERACTION-
Sulfasalazine may cause kidney
problems, and combining it with other
medications that can also affect the
kidney such as Diclofenac can increase
the risk. So dose adjustment can be
made
 COUNSELLING :
*Diclofenac Gel comes with an extra patient
information sheet called Medication Guide

•Do not apply Diclofenac gel to infected skin or

wound

• Gently massage the gel to skin of the affected

area. Allow the medicine to dry for atleast 10 mins
before you wear clothes over treated area

•FOR EXTERNAL USE ONLY

• Counsel the patient to take sulfasalazine
after meals
• Take sulfasalazine with a full glass of water-
240mL
• Take sulfasalazine on a regular schedule to
get maximum benefit from it
• Continue to take the medication even if you
feel well
• Donot take two doses at a time.
• Sulfasalazine may cause drowsiness and
dizziness
• It can cause you to be sun burned so easily.
Use a sun screen for protection
 REFERENCE
1. DRUG INFORMATION HANDBOOK
2. CIMS 2014 EDITION
3. painfreedr.com
4. PHARMACOTHERAPY, JOSEPH T DIPIRO
5. drugs.com/interaction checker