Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a doctor working in family medicine. Your next patient is Derek Love, a 25-year-old male presenting with back pain. Please take a history and perform a relevant examination.
Patient History:
Derek Love (Derek), 25y/o M, a master's student studying sports science.
You have been experiencing back pain for 5 months, but it isn't causing any trouble for you. You decide to see a doctor as it has gradually worsened to the point where you have difficulty getting out of bed. You can't remember if it has happened suddenly or gradually. Aching lower back pain starts on and off and worsens in the morning when you wake up, but it gets better throughout the day. Pain doesn't radiate and is rated at 4/10. It also gets slightly better following taking ibuprofen.
You have been having poor sleep as sometimes pain wakes you up early in the morning. You, therefore, feel tired all the time.
No neurologic symptoms/fever/ weight loss/ dyspnoea.
Only mention if asked: You had 2 episodes of a random painful red eye over the last 5 months, which you remember you were given steroid drops at the eye casualty and a pupil dilator which you need to store in the fridge.
Ideas, Concerns, Expectations:
You think you might have possibly injured your back as you are a gym fanatic – you are not sure if you have injured yourself after squatting too hard at the gym. You have stopped going to the gym since then because of this. You are worried that you need surgery to fix your back. You want to know what might be causing the problem and better painkillers.
Past Medical History:
Psoriasis
Drug History:
Topical Steroids to control psoriasis (currently well controlled), currently taking ibuprofen for back pain. NKDA
Family History:
Your father occasionally also suffers back pain since he was young, but you are no longer in contact with your father, so you do not know what happened to him.
Social History:
Smoker – 20 cigarettes/day for 1 year
Drink socially e.g. a pint of beer every week when going out with friends
Not an IVDU
Occupation: student
Live alone – managing well.
Examination Findings:
Abnormal Schober’s test with reduced lumbar flexion
Reduced spinal lumbar rotation, extension, lateral flexions
Differentials:
Ankylosing Spondylitis
Back Injury
Psoriatic arthritis
Investigations:
Bedside:
Basic observations
Full neurological assessment – to rule out spinal cord injury
Bloods:
FBC (may show anaemia in AS)
LFT (Baseline)
U&E (Baseline)
Bone Profile
CRP/ESR (raised in AS)
HLA-B27 (may be positive in AS)
Imaging:
Spine/Sacrum X-Ray – may show fusion of sacroiliac, facet or costovertebral joints. Other features include squaring of the vertebral body, syndesmophytes, ossification of ligaments, joints and discs, and subchondral sclerosis/ erosion. The classical appearance of “bamboo spine”.
MRI Spine – may show sacroiliitis, and bone marrow oedema in AS. Also, to rule out other spinal pathologies.
Management:
Conservative:
Physiotherapy
Stop smoking
Encourage exercise and stretching
Medical:
Rheumatology referral/review
NSAID e.g. ibuprofen
Steroids during flares (oral, IM or joint injection)
Anti-TNF e.g. etanercept/ infliximab
Anti-Interleukin e.g. Secukinumab
Bisphosphonates (those with osteoporosis)
Surgery:
May be required to fix spine/joint deformity
Treatment of complications
Viva Questions:
What are the associated complications of Ankylosing Spondylitis?
What are the associations of HLA-B27?
What is the most common age/gender of onset?
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