A patient with back pain and

breathlessness

DR. Tanjila Afroj Aireen

Intern
Department of Medicine,
TMC & RCH

Salient feature
Mr. Majed, 50 years,
normotensive,
nondiabetic hailing from
Katnarpara, Bogra
attended in outpatient
department of medicine
on 04th June, 2016 with
the complaints of back
pain 15 for years and
shortness of breath for
3 months.

 According to statement of the patient

he was reasonably alright 15 years
back then he gradually developed
low back pain. The back pain is
present all the time, more marked in
the morning and after periods of
inactivities. Movements somewhat
relieves the pain but there is always
a gelling effect on movement. Pain
does not aggravates or relieved by
sitting, stooping forward, climbing
stairs or while cycling.

 While asking about severity of pain

he mentioned it is of moderate
intensity and often interferes some
tasks.

 Coughing, sneezing or straining does

not provoke pain. Pain from back
does not radiate anywhere. He did
not have night pain. The low back
pain became worse in successive
days. He also developed restriction of
movement of his back in all planes.
There is no history of trauma,
bending, lifting, fever preceding this
back pain.

 There is no history of diarrhoea

preceding the history of joint pain.
There is no history of
intravenousdrug abuse.

 There is no history of passage of

blood in urine, flank pain, urinary
incontinence, retention, hesitancy,
urgency, dribbling. He denied about
increased frequency, nocturia,
narrowing of stream, sensation of
incomplete voiding, rectal pain or
perineal aching .
There is no history of oral ulceration.
There is no history of pain in other
large or small joints.

 Before developing this back pain he

suffered from pain and swelling of right
knee joint 15 years back. Pain of knee
joint was present all the time and
severe enough to restrict movement of
the joint at that time. There is no history
of trauma, fever at that time. His
bladder and bowel habit were normal
during and preceding that episode of
knee pain. Knee pain and swelling
subsided gradually in one month
without any medications.

 Following the knee pain he

developed pain over right buttock/
gluteal region which was present all
the time, more marked at morning
and after a period of inactivity. On
subsequent days this pain subsided
and he developed similar type of
pain in left buttock/ gluteal region.
There is no history of urethral
discharge in any time relating to joint
pain and back symptoms.

 He also complained about cough for 3

years which is dry in nature, non nonproductive with occasional scanty
serous sputum expectoration. Sputum is
not purulent, not foul smelling & have
no blood. Cough is present throughout
the day & night, more on exposure to
dust or cold. He gave history of allergy
with certain foods such as bringel,
Hilsha fish. Eating these foods provokes
cough and itching.

 He also complained about breathlessness

which he developed in last 3 months.
Initially the patient felt breathlessness
during moderate to severe exertion , but
for last 1 month it is progressively
increasing day by day & become worse
even with mild exertion such as bathing,
dressing, walking, climbing stairs. There is
no history of orthopnoea or PND. No
history of ankle swelling. It dont
aggravates in cold weather or dusty
environment. There is no history of
exposure to birds, hen or other farm
animals.

 He has occasional attack of running nose

& sneezing, more marked on exposure to
dust.
He also complained about redness of eye
associated with pain & blurring of vision
for last 3 years. Redness and pain
alternate in left and right eye. His vision
became blurred, occasionally completely
lost during this periods of ocular redness.
Each year he suffer from redness and
pain in eye which subsides by using eye
drops. Opthalmologist told him that
attacks of red eye are due to uveitis.

 On query he mentionded about

erectile dysfunction.

Kyphosis
Extreme disability

 Mr. Majed used to work as an

accountant in a plastic factory. Desk
job for a prolonged period is his daily
routine. He is the only earning
member of his family. He lives in a
house having brick walls and roof.
He quitted smoking 10 years back.
He is non alcoholic.
Systematic enquiry yield no other
complaints.

 Clinical examination
revealed patient have a
below average body
built and a stooped
posture. Co operative.
He is not anaemic, non
icteric. Have no
cyanosis, clubbing,
koilonychia,
leuchonychia, splinter
haemorrhage. There is
no nail pitting.

 His pulse is 80/ min, blood pressure

110/80 mm Hg, temperature 98 0 F,
respiratory rate 14/min.
There is no oedema, lymph nodes are
not palpable, thyroid gland not
enlarged.
There is paucity of body hair. Skin
complexion normal.
His body weight 40 kg.

 On examination of
musculoskeletal
system and doing
GALS screening it was
found that patient
walks with a stooped
posture but step
distance, pace,
swinging movement of
arm during walking
are normal.

 Arm and leg examination were

normal beside below average muscle
mass.

 Spine is almost
straight in lumber
region loosing its
curvature.
Kyphosis present in
thoracic spine. No
gibbus or deformity
found.

Scoliosis on left
side noted in
thoracic spine.

 Modified
Schobers test
showed flexion
of lumber spine
to 17 cm.
Lateral bending
is restricted.

 Occiput to wall
distance is 13
cm.

 Lateral bending is restricted. SLR test

is 70 0 bilaterally. FABER test did not
yield positive result.
Movement of thoracic spine also
restricted in all directions.
Movement of cervical spine is
restricted in all planes.

 On examination of
respiratory system
chest appeared
depressed near
lower end of
sternum, breathing
is abdominal,
movement of chest
is equal on both
side but extremely
restricted.

 There is no scar
mark.
Trachea is
central, apex
beat in left 5th
intercostal
space 9 cm
from midline.
Chest
expansion is
symmetrical
but is only 0.5
cm. Vocal

 Percussion note resonant on both

side.
Breath sound vesicular all over the
lung field, intensity diminished over
left lower chest from back. Few
crepitations heard over same area.
Examination of other system yield no
abnormalities.

Provisional diagnosis
Ankylosing spondylitis

Differential diagnosis
Reactive arthritis
Psoriatic arthritis

Investigations

Confirm diagnosis
Patient has Ankylosing Spondylitis
(aetiology) as evidenced by a
stooped, question-mark posture with
fixed kyphoscoliosis of the thoracic
spine with loss of lumber lordosis
(lesion) and restricted chest
movement causing shortness of
breath (functional status)

Treatment
Exercise
NSAIDS

Thank you