Ankylosing Spondylitis

Casebank History
1

Who you are:
You are an F2 in GP.

Who the patient is:
Martin Atkinson, 25 years old, came with lower back pain for 6 months.

What you should do:
Please talk to him, assess and discuss your plan of management with him and address his concerns.

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https://plabforum.co.uk/t/structure-history-based-station/4278?u=user0000000

AS related questions:
Any early morning morning stiffness?
Any hip pain and stiffness? (Sacroilitis)
Any finger swelling? (Dactilitis)
Any tiredness?
Any eye redness? (Anterior Uveitis)
Any scaly skin problem? (Psoriasis)
Any bowel problem? (Inflammatory Bowel Disease)

DDs:
Any muscular pain? (Fibromyalgia / Myositis)

MAFTOSA
What do you do for living?
Any family history of joint disease?

Psychosocial impact
ICE
Examination

Management

Diagnosis
From what you have told me and from my examinations as well (Explain briefly positive findings) I am suspecting you’ve a condition called Ankylosing Spondylitis. It’s an inflammation of your lower back

It’s not possible to reverse the damage caused by the condition. However, treatment is available to relieve the symptoms and help delay its progression.

Treatment: NSAIDS at GP

Referral to a rheumatologist

  • Ix: ESR, CRP, X-ray, MRI, HLAB 27
  • Confirm the diagnosis.
  • Review current treatment & assess any need for biological DMARDs and anti-tumour necrosis factor (TNF) medication…
  • Refer to physiotherapy for an individualised, structured exercise programme.
  • Refer to a specialist therapist (for example occupational therapy or physiotherapy) if the person has difficulty with activities of daily living.

Follow up:

  • Monitoring of disease activity, progression, and response to treatment (including adverse effects).
  • Ensuring modifiable cardiovascular risk factors are managed if present.
  • Ensuring the person receives an assessment for osteoporosis every 2 years.

Safety netting

  • Spinal fractures.
  • Hip involvement.
  • Osteoporosis.
  • Anterior uveitis (iritis).
  • Adverse effects of treatment.
  • Decreased quality of life.
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2

What examinations are we supposed to do?

3

ANKYLOSING SPONDYLITIS

You’re FY2 in GP
30 years old man who has presented with some concerns.
Talk to him and address his concerns.

APPROACH

Grips

Paraphrase

P1…back pain
Site …where exactly is this pain in ur back…lower, mid or upper
Grade it
SOCRATES
Pain worse on sitting
IPS

R/o red flags
Cauda equina
*numbness In back passage
*numbness/weakness in lower limbs

  • incontinence
    FLAWS

DD
*Ankylosing spondylitis…pain around the buttock, worse at rest /sitting but improves with exercise
*CAP…urinary sx, hematuria, dysuria, hesitancy, poor stream, nocturnal
*OA
*Trauma

R/o Red flags
*Cauda equina
*AAA
*Multiple myeloma…(r/o CRAB)

ICE…px is concerned about CA prostate cos his father has CAP
FMAM
DESA
Psychosocial…Job is long distant driver

EXAMINATION…vitals,gpe, LL nerves, tummy, back, DRE, straight leg raise test, schobers test.

DIAGNOSIS: suspect Ankylosing spondylitis meaning a long term condition causing stiffness and pain in the back

MANAGEMENT
*Address concern first…
Acknowledge concern
Ask why he is concerned
Tell him he has none of the sx of CA prostate however, u will investigate nonetheless

*Investigation
…routine bld test
…special test like RF, HLA B27
…xray of sacroiliac joint…tenderness on the sacroiliac joint

*Painkillers…NSAIDS

*Refer to rheumatologist routinely.
…specialist tests… MRI scan
…if confirmed , unfortunately there’s no cure but there are measures to delay the dxs progression of the dxs
…treatment options will involve MDT
via the Physiotherapist, Occupational therapist(e.g walking aid), Medications to reduce progression of the condition.

*Encourage to do light exercise…keep active

*As he is a driver, once confirmed,
…if he works for a company, advice to discuss role change with employer
…if self employed, offer citizen advice bureau
…he will have to inform DVLA

*Inform seniors

*Leaflets

*Safetynet for cauda equina syndrome