MM COLLEGE OF PHARMACY

Case presentation
On
Spondylitis

Submitted by-
Submitted to-
Deepak
Dr. Parminder Sir
Pharm-D 3rd Year
MMCP
1415808
Patient details:-
• NAME- XYZ
• Age- 45 years
• Gender- male
• IPD No.- 1803190118
• Date of Admission-19-03-18
Patient Complaints:-
General body ache since 8month
Fever since 8 month
Neck stiffness
Hip , knee joint stiffness
Early morning stiffness
Pain in the region of lumber sacral
Vitals
Vitals Day1 Day2 Day3 Day4 Day5 Day6 Day7

BP 110/74 100/60 110/80 100/60 100/60 120/60 100/60

mmHg

PR 88 84 80 80 76 82 78
/min

RR 20 20 20 20 20 20 20
/min

Temp. Afebrile Afebrile Afebrile Afebrile Afebrile Afebrile 97.8

˚F
Abnormal Laboratory Investigations:-
• HB - 11.7g/dl* (13-17g/dl)
• ESR - 80* (0-9mm at 1hr)
• Serum creatinine - 0.68mg/dl* (0.7-1.2mg/dl)
• Albumin - 2.8gm/dl* (3.5-5.3gm/dl)
• Urea - 16mg/dl* (18-40mg/dl)
 Treatment chart:-
medication Salt name Dose Route Frequency Date of start Date of stop
Tab. Hifenac mr Aceclofenac 100+325mg po BD 19-03
,paracetamol
Tab. dolo paracetamol 650mg po SOS 19-03 --

Tab. Supradin multivitamin po OD 19-03

Tab. Diclo mr diclofenac 50mg po BD 20-03

 Treatment chart:-
Medication Salt name Dose Route Frequency Date of start Date of stop

Tab. Eiodfe fort Biotin,iron,folic Po OD 20-03

acid ,vitamin
B3,B2,B1
Tab. Rantac Rantidine 150mg Po BD 22-03

Tab. Alprex alprazolam 0.25mg Po BD 22-03

Inj. Ceftriaxone Ceftriaxone 1.5gm i.v. BD 24-03

+sulbactum ,sulbactum
 remark
• A 45 year male patient was admitted in hospital with c/o fever since 8month , General body
ache since 8months and neck stiffness was found and Pain in the region of lumber sacral .
• on checking refluxes and on the basis of sign and symptoms and abnormal laboratory
parameters patient was diagnosed with spondylitis.
• Drug interaction was found
• Aceclofenac + diclofenac
1-both increase anticoagulation
2-and both increase serum potassium
• Since the albumin is quite low. Patient should be given an albumin supplement.
• No x-ray or MRI test is done for confirmation
• No test is done for HLA-B27

• Hence case is irrational