This document presents a case study of an 18-year-old male patient admitted with pain and swelling in his left thigh for 3 months along with pus discharge for 1 month. He was diagnosed with osteomyelitis based on laboratory tests, blood cultures, and imaging showing bone marrow abnormalities. He underwent two surgeries to drain pus and was treated with antibiotics including ampicillin, cloxacillin, cefuroxime, ofloxacin and amikacin. He was also started on anti-tubercular treatment as his blood cultures grew M.tuberculosis. He showed improvement and was discharged on a course of ofloxacin, omeprazole and diclofenac+

1. Presented by-
Shahnawaz Ahmad Teli
M.Pharm 2nd Semester
(clinical pharmacy)

2. Osteomyelitis
 Inflammation of bone and marrow
 Types
 Pyogenic osteomyelitis
 Tuberculous osteomyelitis

3. Case presentation

4.  Patient ID- 731560/17
 Name - XYZ
 Age – 18 yrs
 Sex – Man
 DOA- 26/02/17
 DOD- 15/03/17
Patient details- Subjective

5. Reason for admission- subjective (Cont..)
 Chief complaints at the time of admission:-
o Pain in left thigh x 3 months
o Swelling in thigh x 3 months
o Pus discharge from left thigh – since 1 month
 Provisional Diagnosis:- Chondrosarcoma

6. Reason for admission- subjective (cont..)
o Past Medical History:- Tuberculosis since 4 months.
o Past medication history- On Anti-tubercular treatment.
o Social history- Non-vegeterian
o Family history- Nil
Physical Examination-
General condition -- sick
CNS -- Conscious, well oriented
CVS – S1 and S2 sounds heard.
Abdomen -- Non-tender, Non-distended (Normal).
Vital signs-
B.P- 110/80 mmHg
P.R- 70/Min
Resp.- 78/min
Temp.- 98.4 F

7. Laboratory Test
Laboratory test 26/02/17 02/03/17 14/03/17 Discharge
time
Normal
range
Hemoglobin 7.3 (L) 8.9 (L) 9.3 (L) 11.1 (L) 12-15 g/dl
TLC 12500 (H) - 19000 (H) 10500 (H) 4000-11000
c/mm3
Neutrophils 86 (H) - 83 (H) 40 (L) 36-73 %
Lymphocytes 60 (H) - 10 (N) 25 (H) 20-24 %
ESR 112 (H) 92 (H) 70 (H) 36 (H) 0-15 mm/hr

8. Other Investigations
 Blood culture was positive for S.aureus and M.tuberculosis.
 MRI:- showed localized bone marrrow abnormality.
 USG:- Showed presence of fluid adjacent to bone and
Elevation and thickening of periosteum.

9. Final Diagnosis
 On the basis of Laboratory investigations, Blood
culture and Radio imaging, the patient was diagnosed
as Osteomyelitis.

10. Day to day assesment
 DAY 1ST : (26/02/17)
 Inj. Ampicillin + Cloxacillin 125gm iv –BD
 Tab. Diclofenac + paracetamol 50mg, 500mg – BD
 Tab. Omeprazole 20mg- BD
 Day 2nd: (27/02/17)
 Shifted to Ortho ward.
 Advice to perform surgery of left thigh.

11. Continue......
o Day 5th: (01/03/17)
 Iv fluid DNS 1 Unit
 Transfused 1 unit of blood
 Iv fluid NS 100ml/hr
o Day 6th: (02/03/17)
 Surgery removal of pus
 Inj. Cefuroxime 250mg
 Tab. Alprazolam 0.2mg HS

12. Continue.......
 Day 14th: (10/03/17)
 Again surgery was performed for removal of pus.
 Inj. Diclofenac- SOS
 Isoniazid+rifampicin+pyrazinamide 75mg, 150mg, 500mg
 Ethambutol 750mg- OD
 Pyridoxine 100mg –SOS
 Day 16th: (16/03/17)
 Syp. Metaclopromide 5mg/ml SOS
 Tab. Ofloxacin 200mg – BD
 Inj. Amikacin 100mg/2ml BD
 Stop Inj. Ampicillin + Cloxacillin

13. Treatment
Name of drug
Frequency,
Route
Strength Date Date Class
Started Stopped
Inj. Ampicillin + Cloxacillin
(BD/IV)
1.2gm 26/02/17 15/03/17 Penicillins
Tab. Diclofenac
+Paracetamol
(BD/ORAL)
50mg +
500mg
26/02/17 02/03/17 Analgesic and
Antipyretic
Tab. Omeprazole
(BD/PO)
20mg 26/02/17 till disch. PPI
Inj. Cefuroxime (BD/IV) 250mg 03/03/17 till disch. Cephalosporin
Tab. Alprazolam
(HS/PO)
0.25mg 03/03/17 09/03/17 Benzodiazepine
Tab. Pyridoxine
(OD/PO)
10mg 11/03/17 till disch. Vitamin -B6

14. Continue.......
Name of drug,
Route, frequency
strength Date Date Class
Started Stopped
Tab. INH +
Rifampicin +
Pyrazinamide +
Ethambutol
(OD/PO)
75mg,
150mg,
500mg,
750mg
11/03/17 till disch. Anti-TB drugs
Inj.
Metaclopromide
(SOS/IV)
5mg/2ml 15/03/17 Antiemetic
Tab. Ofloxacin
(Oral/BD)
200mg 15/03/17 conti.. Flouroquinolone
Inj. Amikacin
(IV/BD)
100mg/2ml 15/03/17 15/03/17 Aminoglycoside

15. Clinical justification
The treatment given was not satisfactory almost as the
condition of the patient was not improving, apart from this
there were some suggestions-
o The DOTS therapy should be continued otherwise relapse
may occur.
o The Alprazolam was given to the patient but there was no
complaint of insomnia.
o Aminoglycoside, cephalsporine, penicillin were not effective
still only these 3 classes of drugs are used for continuous
treatment.

16. Discharge summary
Tab. Ofloxacin 200mg BD Oral (7 days)
Inj. Metoclopromide 5mg/2ml SOS IV
Tab. Omeprazole 20mg BD Oral (7 days)
Tab. Diclofenac +Paracetamol 50mg+500mg BD PO (5 days)

17.  Ofloxacin + Diclofenac:- Minor Interaction
Displacement of GABA from receptors in brain
( risk of stimulation/Seizures)

18. Patient
Counseling
 Adhere to the Medications.
 To come for Review after 7 days.

19. Reference
 www.rxlist.com>home>drug interactions checker
 www.micromedexsolutions.com
 www.drugs.com/drug_interactions.html