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Abstract: The patient, a 58-year-old male, presented with recurrent low back pain for more than 10 years with kyphoscoliosis and poor mobility. The symptoms of low back pain usually decreased after activity, and after the symptoms gradually worsened, the patient visited our hospital. Combining the patient’s clinical symptoms and ancillary examinations, ankylosing spondylitis was considered. After giving the patient medication, the pain and other symptoms were significantly reduced.
Basic information】Male, 58 years old
Disease Type】Ankylosing spondylitis
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of consultation】January 2022
Treatment plan】Medication (recombinant human type II tumor necrosis factor receptor-antibody fusion protein for injection, celecoxib capsule)
Treatment Period】Hospitalization for 10 days, outpatient review after 1 month
Effectiveness】Stable condition and reduced back pain
I. Initial consultation
When we first saw the patient, he was in a clear state of mind, mentally well, and eating well. The patient reported that he had low back pain with no apparent cause more than 10 years ago, with limited movement, which was relieved by activity and aggravated by rest, and was not accompanied by other uncomfortable symptoms, and was diagnosed with ankylosing spondylitis and given medication (details unknown). More than 10 days ago, the pain in the lower back was significantly worse than before without any cause, and he could not sleep at night, and physical examination showed a kyphosis with poor mobility. The patient had been suffering from the disease for a long time, often triggered by factors such as exertion and cold, and had recurrent episodes that persisted.
II. Treatment history
The patient’s clinical symptoms and medical history led to the conclusion that the patient was suffering from ankylosing spondylitis. First, the patient was told to ensure adequate bed rest, avoid straining, and pay attention to cold and warmth to avoid aggravating the disease. Symptomatic treatment was given for the patient’s symptoms, namely celecoxib capsules for pain relief and injectable recombinant human type II tumor necrosis factor receptor-antibody fusion protein drug therapy to relieve the patient’s low back pain symptoms.
III. Treatment effect
The patient was given pain relief and recombinant human tumor necrosis factor receptor fusion protein drug treatment after admission, and the pain of low back was reduced on the third day of admission. One month after the patient was discharged from the hospital, she did not have any more severe low back pain and was able to move freely in daily life without any other uncomfortable symptoms.
IV. Notes
I was very happy to see the patient’s symptoms relieved. When the patient was discharged from the hospital, I reminded the patient that even after discharge, he should not be careless and should pay attention to the following matters.
1. the need to take medication regularly according to the doctor’s prescription so as not to affect the control of the disease.
2, patients need to avoid overexertion or cold during treatment and after discharge, especially should avoid bending, ensure adequate rest, try to choose a hard bed.
3, daily life needs to pay attention to a light and nutritious diet, can be more eggs, milk and other high-quality protein food, and at the same time, when the physical condition is better, you can choose to appropriate physical exercise, such as walking.
V. Personal Insights
Ankylosing spondylitis is a chronic disease with a long course, but generally does not affect the normal life expectancy of the population, as in the case of this patient, when taking drugs regularly under the guidance of a doctor, the condition can generally be better controlled. If people have low back pain symptoms, it is recommended to actively go to the hospital and give appropriate treatment after a clear diagnosis, which can control the progress of the disease, but if not treated in time, the disease may also progress faster. It is also not recommended that people with this disease overexert themselves in their daily lives, but rather that they take adequate rest.