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You are a Foundation Doctor working in GP. Mr Ade Noma is a 24 year-old-man, presenting to your surgery with back pain.

Please take a history from Ade and undertake the appropriate examination. You will then be asked to discuss the case with the examiner.

You are Ade Noma, a 24 year old man who is an avid football player, recently finding it really hard to get up in the morning because of a stiff back.

HPC: Over the last 4 or 5 months you have noticed your lower back is really stiff and painful, especially first thing in the morning – sometimes it even wakes you up it is that bad! It hasn’t been like this every day, but will come on very suddenly when it does. This is very unusual for you, as you’ve never had any trouble with your back before although you have seen the doctor about swelling, pain and stiffness of your right shoulder in the past.

Alongside the back pain, you’ve been more tired than usual, but put this down to starting a new job in a Sport’s shop where you have to get up at 6am every morning. You’ve not particularly noticed, but your partner has made a comment on how you’ve lost a bit of weight over the last couple of months, and come to think of it, the jeans you got for Christmas don’t feel as tight as they had. It’s a bit embarrassing but you are also getting quite a few bouts of diarrhoea and stomach pains recently; your mates have just told you to stop being a ‘sissy’, but they are very painful when you get them and you even noticed a bit of blood the other day. Weirdly, you feel that your back feels better when you don’t rest it, so you’re still playing football lots. Although, after a game last week, you had a really painful heel to top it all off! What’s that all about??

PMH: You used to smoke 10 a day from age of 18 to 20 but haven’t touched a cigarette since. You have struggled with psoriasis since you were 17 which used to really get you down, but seems to be a little more under control now after courses of phototherapy, and you are now just using vitamin tablets.

DH: You’ve just been taking over the counter NSAIDs like ibuprofen but they haven’t really touched the sides. You take Gaviscon when the stomach pains are really bad as Mam thought it could be reflux type symptoms. As mentioned before, you’ve been receiving phototherapy when your psoriasis really bad but now just on Calcipotriol (vitamin D analogue) for most of body and beclomethasone steroid cream for the patches on your scalp.

FH: Your Dad also has very bad psoriasis and has been complaining of stiffness and pain in his hands and feet, but he’s a lot older so you reckon this is just an old age thing – Dad likes to moan a lot about everything anyway! Your Mum mentioned that your Grandfather had very bad posture from quite a young age, and always nags you about sitting up straight.

SH: You do enjoy a binge on the weekends with your football mates. You live at home with your Mam, Dad and little sister but you’re hoping to move into a flat with girlfriend soon when you’ve saved enough from working. Won’t that be a big change!

Please observe the student take a relevant history and examination from this young man, focussing on his articular symptoms, but also including red flags for low back pain e.g. loss of power or sensation in lower limbs, sphincter dysfunction, saddle anaesthesia.

Look for the student to inquire into extra-articular symptoms of the seronegative spondyloarthritis’ such as skin, eye, bowel involvement and systemic symptoms.

A spinal examination would be the most relevant examination in this case, and the student should find limited range of movement in chest expansion, lateral and forward lumbar flexion.

If the case was in more progressive stage of illness may see loss of lumbar lordosis and excessive kyphosis in thoracic region. Schober’s test will be <5, there will be tenderness in the sacroiliac joints. The peripheral joints should be examined for synovitis and enthesitis.

Possible differentials may include:

• Ankylosing spondylitis → male of his age, presenting with pain and inflammation predominantly in the sacroiliac region which is better with exercise and worse during the night. Associated with fatigue and weight loss and stiffness.

• Psoriatic arthritis → the past medical history of psoriasis and family history of this. The skin disease with manifest with arthritic symptoms in 5% of cases

• Enteric arthritis → Bowel symptoms with blood in the stool associated with arthritis

• Reactive arthritis → but less likely due to no history of dysentery or GU infection, and unusual to effect the spine

• Mechanical back pain → very sporty and may be due to recurrent stress on the joint

• Trauma

• Neoplasm → weight loss and general malaise

Possible question for discussion may include:

• What is the mainstay of treatment for these patients? • What are the characteristic features seen on MRI? • What extra-articular manifestations can occur in Ankylosing spondylitis? • What is the clinical criteria for AS diagnosis? • What are the radiological criterion for AS? • What complications exist for patients with AS?