navinjaiswal6@gmail.

com 1

CASE PRESENTATION

BY : NAVIN KUMAR JAISWAL

09/19/2021
Pharm-d 3rd year
 Problem list:
2

 Left knee ACL(anterior cruciate ligament)

insufficiency.

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 ACL:
3

The ACL attaches in front of the intercondyloid eminence of

the tibia , being blended with the anterior horn of the medial
meniscus.
These attachments allow the ACL to resist anterior translation
and medial rotation of the tibia in relation to09/19/2021
[email protected] the femur.
 Case introduction:
4

 Case comes under Orthopedics:

 Patient name : xyz
 Age : 22
 Body weight : 65 kg
 Hospital no. : 559282D
 Admitted on : 26-july-2014
 Discharge on : 31-july-2014

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 Source : CMCH ( Christian medical college and

hospital). Tamil nadu , India
 Discharge summary received by prof. Dr. T.C Arul

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 [email protected] 6

SOAP ANALYSIS
09/19/2021 LEFT KNEE ACL INSUFFICIENCY
 Subjective:
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 Patient presented with complaints of left knee pain and

instability since 7 months.
 He was apparently well till 3 years ago when he had
countinous pain in his left knee while sitting , standing
and squating.
 He was treated elsewhere MRI was taken and diagonised
as ganglion cyst of the left ACL.
 He was operated in december 2013 for same and the
ACL was removed .
 He had instability while running and also while walking
in uneven surfaces.
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 Continues….
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 There was history of buckling while climbing down

steps.
 No history of locking of knees.
 He also has intermittent pain in his left knee.

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 Objectives :
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 General examination:
 Moderately built and nourished.
 Pulse rate: 72/min
 BP : 110/80 mm of Hg
 Systemic examination:
 Normal
 Local examination of left knee:
 No obviously deformity.
 Wasting present in the left thigh compared to the right
side. [email protected] 09/19/2021
 Continues…
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 Primarily healed surgical scar present.

 No sinus , dilated veins or distal veins or distal trophic
changes.
 No effusion.
 There was no joint line tenderness.
 Patellar glide was not restricted.
 Tibia and femoral condyles normal.
 Knee ROM – 0 to 130 degree.
 The movements were not associated with pain and spasm.

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 Special tests:
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 1. Lachmanns test: positive

 Is a clinical test to diagnose injury of ACL.

 This test can be done in either an on-field evaluation in
acute injury, or in a clinical setting when a patient presents
for follow-up with knee pain.
 The knee is flexed at 20–30 degrees with the patient supine
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 Continues…
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 2. Anterior drawer test: positive

 The drawer test is used in the initial clinical assessment of

suspected rupture of the cruciate ligaments in the knee.
  The patient should be supine with the hips flexed to 45
degrees, the knees flexed to 90 degrees and the feet flat on
table. [email protected] 09/19/2021
 Continues…
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 Pivot shift test : positive

 it tests for instability, an important determinant as to how the knee will

function.
 it is instability, not simply the injury to the anterior cruciate ligament itself,
that places the menisci at future risk, and gives rise to the feeling that the
"knee is not secure" or "may give out“
 This test is performed with the patient lying in the supine position with the
hip passively flexed to 30 degrees.

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 Continues…
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 The McMurray test: Negative

 also known as the McMurray circumduction test is used to evaluate

individuals for tears in the meniscus of the knee.[1
 ] It is a rotation test for demonstrating torn cartilage of the knee. A tear

in the meniscus may cause a pedunculated tag of the meniscus which

may become jammed between the joint surfaces.
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 Continues..
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 Stress varus test : Negative.

 Stress valgus test : Negative.

 No distal neuromuscular deficits.
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 Assessment:
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 Based upon subjective and objective evidence the

patient was diagnosed as left knee anterior cruciate
ligament .

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 Operation done:
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 Left knee scopy proceed ACL reconstruction under

CMC on 28/07/2014

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 Assessment
18

Cap. Cloxacillin 500 mg four times daily for 2 weeks.

Tab. Ciprofloxacin 500mg two times daily for 2weeks
Tab. Aceclofenac 100mg two times daily for 5 days
Cap. Omez 20 mg twice daily for 2 weeks.
Tab. pregabalin 75 mg once daily at night for 2weeks
Tab. Serratopeptidase 20 mg thrice daily for 2 weeks.
Tab. Metacin 1 gm as and when required for
fever/pain relief.

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 Assessment of current therapy:
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 Cap . Cloxacillin : (cloxapen)

 Cloxacillin is a semi- synthetic, penicillinase-
resistant penicillin of the isoxazolyl penicillin group.
cloxacillin is used for the treatment of
certain bacterial infection.
this medicine is preferred to patients because infection
can enter during bone surgery that protrudes through the
skin. It can also spread from infected artificial joint,
such as knee joint, into the surrounding bone.
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20 Tab . ciprofloxacin
Ciprofloxacin is an fluoroquinolones anti – infective
agent and mainly for bacterial infection.
this medicine is prefer because the infection may
occur early after surgery if bacteria from the surface of
the skin contaminated the artificial knee . The infection
may occur years later if bacteria enter the bloodstream
and carried to the artificial knee.
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21 Tab. Aceclofenac
These drugs have anti- inflammatory and pain killer
properties. Its works by blocking the production of
hormone like substances called prostaglandins.
prostaglandin play an important role in both the
inflammatory response of the body and stimulating the
reabsorption of bone in diseases.

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22 cap. Omez(omeprazole)
Omeprazole is a gastric proton pump inhibitors. It inhibits
the activity of proton pumps transporting hydrogen ions
excess across cell membranes and they inhibit gastric acid
secretion.

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 23 Tab. Pregabalin(lyrica)
Pregabalin is an anti-convulsant and neuropathic pain
agent. Exactly how pregabalin works is not known. It is
thought to bind to certain areas in the brain that helps to
reduce seizures, nerve pain and anxiety.
it also used to treat fibromyalgia.

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 24 Tab. Serratiopeptidase:
Serratiopeptidase is an enzyme having anti-inflammatory,
anti-oedemic and fibrinolytic activity and it also acts
rapidly on localized inflammation(headache , muscles and
joint pain).
This super protein digesting enzyme breaks
down “non-living” matter in the human body including
cysts, aterial plaque, blood clots and scar tissue.
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25 Tab. Metacin
Metacin tablets (paracetamol) is a recommended OTC
medicine for light headache , body pain and cold.
Metacin tablets are made of paracetamol I.P 0.5
gm. So it doesn’t have any side effects and as such it
works well for minor body disorder.

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 Therapeutic plan:
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Discharge medication:
Cap. Cloxacillin 500 mg four times daily for 2 weeks.
Tab. Ciprofloxacin 500mg two times daily for 2weeks
Tab. Aceclofenac 100mg two times daily for 5 days
Cap. Omez 20 mg twice daily for 2 weeks.
Tab. pregabalin 75 mg once daily at night for 2weeks
Tab. Serratopeptidase 20 mg thrice daily for 2 weeks.
Tab. Metacin 1 gm as and when required for fever/pain
relief.
and also ACL REHABILITATION:
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 ACL REHABILITATION:
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 Day 1 to 2 weeks:
 Goals:
 50% weight bearing with 2 crutches.
 Patella mobilization.
 Hamstring , gastroc – soleus stretches.
 Active static quadriceps isometrics( in full extension)
 Knee flexion ( active, 0-90degree ) in supine position and
sitting.
 Knee extension – sitting (active –assited .90-45 degree)
 Weight shift side / side and forward / backward with crutches.
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 3- 4 weeks:
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 Goals
 0-120 degree ROM should be aimed for by 4 weeks.
 Continue patella mobilization.
 Isometric training : multi-angle – static co-contraction of hamstring
and quadriceps at o and 60 degree continue. Do these with the tibia
externally rotated( both legs together)
 Hamstring curls – standing ( active ,0-90 degree)
 Knee extension – sitting( active , 90-30degree)
 Closed –chain – 45 degree wall sits.
 Balance training:
 Weight shift side / side and forward / backward with crutches.
 Cup walking. [email protected] 09/19/2021
 4-6 weeks:
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 0-135 degree ROM

 Isometric training : multi- angle ( 90, 60,30 degree)
 Heel raise / toe raise ( both legs together)
 Hamstring curls – standing (active , 0-90degree)
 Straight leg raises.

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 6-12 weeks:
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 Goals:
 Straight leg raises.
 NB, still no open chain resisted leg extensions.
 Heel raise / toe raise (both legs together)
 Hamstring curls with weights (active,0-90degree)
 Closed chain –half squats.
 balance training:
 Single limb stance.
 Walking steps:
 Climb steps sideways : 2-4” height without support(after 10
weeks)
 Walking backward. [email protected] 09/19/2021
 3-6 months:
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 PHONE YOUR DOCTOR AND INFORM HIM OF YOUR

PROGRESS AT THIS STAGE.
 Goals:
 Heel raise / toe raise (single limb)
 Hamstring curls with weights (active, 0-90degree)
 NB, still no open chain resisted leg extensions.
 Closed chain half squats.
 Balance training and running:
 Single limb stance on uneven ground.
 Agility work, eg: catching a ball, sideways running, two leg
jumping, step work on progressively higher steps, cycling(5-
months), and backward run. [email protected] 09/19/2021
 More than 6 months:
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 PHONE YOUR DOCTOR AND INFORM HIM OF

YOUR PROGRESS AT THIS STAGE.
 Goal:
 Can begin open chain leg extensions with weights.
 Sport specific skills and cardiovascular fitness must be
excellent before to competition.

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 Drugs to be avoided:
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 Theophylline
 Antacids
 Doxycycline
 gentamycin

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 Therapeutic monitoring:
34

 To maintain signs and symptoms .

 To clean the operation area with anti-infective agents.
 Regular follow the therapy.
 Toxicity monitoring:
 Ciprofloxacin: skin rash, dizziness, nausea, headache
 Serratiopeptidase: anorexia, gastric discomfort, nausea.
 Pregabalin: drowsiness, dizziness, blurred vision or light
headedness.
 Cloxacillin: hepatotoxicity, nephrotoxicity,
Gastrointestinal effects (nausea, vomiting,
[email protected] diarrhea).
09/19/2021
 Patient counselling :
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 About drugs:
 Take ciprofloxacin with meal to minimize the GI
discomfort. Do not take with antacids, Fe(iron) or
any diary products.
 Pregabalin comes with an extra patient information
sheet called a medication guide. Read it again each
time you get pregabalin refilled.
 serratiopeptidase drug should be used with caution
by pregnant and lactating women.
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36

 Swallow aceclofenac tablets with whole glass of

drinking water. Do not chew or break the tablets.
 If you miss a dose, take it as soon as possible. If it
almost time for next dose, skip the missed dose and
go back to your regular dosing schedule. Do not
take 2 doses at once.
 About diseases:
 Wound potential for infection, for example clean,
contaminated , dirty and infected site.
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37

 Physical status of patient like normal healthy

patient, patient with mild systemic disease.
 Duration of therapy.

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 Follow up / review:
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 Review in ortho 2nd OPD after one year.

 Physiotherapy advice : discuss with local
physiotherapist.


patient education:
 About drugs.
 About disease.
 About therapy.
 About follow up/review.
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 Thank you…….

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