This page is dedicated to organizing various examples of standardized exam questions whose answer is ankylosing spondylitis. While this may seem a odd practice, it is useful to see multiple examples of how ankylosing spondylitis will be characterized on standardized exams (namely the boards and the shelf exams). This page is not meant to be used as a traditional question bank (as all of the answers will be the same), however seeing the classic “test” characterization for a disease is quite valuable.
KEY CHARACTERISTICS OF THIS CONDITION (ON EXAMS)
When it comes to standardized exams, each condition has its own “code” marked by key buzzwords, lab findings, clues, etc. If you are well versed in this code you will be able to more quickly identify the condition that is being discussed, and get the right answer on the exam you are taking. Below is the “code” for ankylosing spondylitis.
- Back Pain: this is the most common chief complaint. It has the features listed below
- Improvement of pain with exercise/movement
- Pain not relieved with rest: can sometimes present with nocturnal pain
- Tenderness along lower back caused by sacroiliitis.
- Limited spinal mobility
- Heel Pain: tenderness at tendon insertion site (can be the heel or other places such as the shoulders)
- Pain at other tendon insertion sites (enthesitis) such as the elbows, shoulders, hips, iliac crests, and tibial tuberosities may also be present.
- Young patient: typically those affected are <40 when the issues begin
- Elevated ESR
- Bamboo spine on X-ray (fusion of vertebrae)
- Sacroiliac joint fusion on X-ray (can begin as narrowing of these joint spaces and/or sclerosis at these joints)
- Chest wall restriction can be seen on pulmonary function testing (patients may have difficulty breathing)
Question # 1
A 25 year old male comes to the clinic for pulmonary function testing. He has been experiencing difficulty breathing on exertion. He denies any other symptoms except for some chronic lower back pain. He explains that the pain is worse at night but improves during the day with exercise. He has been taking naproxen as needed for his back pain. His medical history is notable for smoking 1 pack of cigarettes a day, and drinking a 6-pack of beer every weekend. His ESR is 80 mm/hr. The results of his pulmonary function testing are listed below:
- Vital capacity: 70% of predicted
- FEV1/FVC: 96%
- FRC: 108% of predicted
What underlying condition might this patient have?
Explanation # 1
Back pain + back pain improves with exercise + elevated ESR + signs of chest wall restriction on pulmonary function testing = ankylosing spondylitis
Question # 2
A 27 year old male comes to the clinic because he has had a 4 month history of right shoulder pain. He also has noticed swelling and pain in his heels, as well as his lower back. He has tried to use a topical cream for arthritis, but that has not received his symptoms. His past medical history is notable for pneumonia as a child, but is otherwise unremarkable. He does not take any medications, does not drink, has never smoked, and refrains from using any illicit drugs. His temperature is 98.7°F, blood pressure is 120/75 mm Hg, pulse is 60/min, and his respirations are 11/min. A physical exam reveals resisted abduction of the shoulder, and tenderness at the acromiclavicular junction. He also has limited spinal mobility, and palpation over the heels and iliac crests elicits tenderness. What might the underlying diagnosis be in this patient?
Explanation # 2
Back pain + heel pain/shoulder pain (where tendons insert) + limited spinal mobility = ankylosing spondylitis
Question # 3
A 33 year old male comes to the clinic because he has been suffering from lower back pain for several years. The patient explains that he has stiffness and pain that’s worse in the morning but seems to get better throughout the day as he gets up and walks around. Recently he is noticed that taking over-the-counter ibuprofen has been giving him some relief. An X-ray study is performed that reveals that his sacroiliac joints are fused. What is the likely diagnosis in this patient?
Explanation # 3
Back pain + worse in morning/improves with movement + sacroiliac joint fusion seen on X-ray = ankylosing spondylitis
Question # 4
A 30-year-old male comes the clinic because he has a six-month history of low back pain. He also has noticed that his back is most stiff in the morning. The patient explains that the pain has slowly progressed over time and he denies any recent recent trauma. He has tried to treat himself with over-the-counter acetaminophen however this is not provided much relief. The patient explains that while he usually sleeps on his back he must now lie on his side or else he cannot fall asleep. The patient’s past medical history is noncontributory and his final signs are all within normal limits. A physical examination shows limited forward flexion of the spine. An X-ray is ordered and reveals narrowing of the sacroiliac joints. What is the likely diagnosis in this patient?
Explanation # 4
Back pain + limited forward flexion + sacroiliac joint fusion (narrowing of joints) seen on X-ray = ankylosing spondylitis
Question # 5
35-year-old male comes to the clinic because he has been suffering from a one year history of low back pain and stiffness. He explains that his symptoms are worse in the morning but improve during the day. Is back pain radiates down his buttocks but not down his legs. He has also noticed that sitting for long periods of time gives him marked back stiffness. During the physical exam the patient is unable to bend forward completely. What is the likely diagnosis in this patient?
Explanation # 5
Back pain + symptoms worse in morning + limited forward flexion = ankylosing spondylitis
Question # 6
A 27-year-old male comes to his physician because he has been experiencing a four month history of right shoulder pain. He has also noticed pain and swelling at his heels. The patient has previously tried using over the counter analgesics that have given him some relief. Is medical history is unremarkable, He does not take any regular medications, and he does not smoke or drink alcohol. The patient’s vitals are within normal limits. On a physical examination there is marked pain with abduction of the shoulder and there is tenderness of the acromioclavicular junction. Palpation over the heels, iliac crest, and to be old tuberosities also elicit pain in the patient. What is the likely diagnosis in this patient?
Explanation # 6
Young patient + heel pain + tenderness of multiple tendon insertion sites = ankylosing spondylitis
Question # 7
A 22-year-old male comes the clinic because he has been suffering from half a year of increasing lower back pain. He explains that his pain is most severe upon awaking in the morning, but he feel some relief by stretching. He denies any past history of trauma. His past medical history is unremarkable, and he takes no medications regularly. A physical exam shows decreased forward flexion of the spine and there is also marked tenderness over the lumbrosacral area. The insertion side of the Achilles tendon is also tender bilaterally. What is the likely diagnosis is patient?
Explanation # 7
Back pain + worse in morning/improves with movement + decreased forward flexion of spine + heel pain/tenderness at tendon insertion site = ankylosing spondylitis
Question # 8
An otherwise healthy 10-year-old boy is brought to his pediatrician because he has been suffering from low back pain for the past year. The pain is present throughout the day, but it is most severe when he first wakes up in the morning. He describes the pain as a dull ache, and he also complains of stiffness in the morning or after a long period of inactivity. The patient walks with a stooped gate but otherwise appears well. A physical exam shows tenderness of the sacroiliac joints. There is also decreased forward flexion at the waist. The rest of the physical exam is non-contributory. Laboratory analysis reveals an elevated ESR. An x-ray of the spine is shown below:
What is the diagnosis in this patient?
Explanation # 8
Back pain + symptoms worse in morning/with inactivity + decreased forward flexion + bamboo spine (seen on X-ray) = ankylosing spondylitis
Question # 9
A 35-year-old woman comes to the clinic because she has been experiencing severe pain in her lower back for the past year. She describes the pain as being dull in nature, and complains of morning stiffness that lasts for a few hours and only stars to improve after she starts to walk around her apartment. She has no remarkable past medical history and denies any history of trauma. Her vital signs are all within normal limits. A physical exam reveals tenderness to palpation over both sacroiliac joints. The exam also reveals decreased flexion and extension of the lumbar spine. An x-ray of the lumbosacral spine is ordered and reveals the presence of sclerosis over both sacroiliac joints. What is the likely diagnosis in this patient?
Explanation # 9
Back pain + symptoms worse in morning/improve with activity + decreased forward flexion + sclerosis of sacroiliac joints (seen on X-ray) = ankylosing spondylitis
TESTABLE FACTS ABOUT THIS CONDITION (BEYOND ITS IDENTIFICATION)
Many questions on standardized exams go beyond simply recognizing the underlying condition. Often there are specific testable facts regarding some aspect of the disease’s pathophysiology/management/clincial implications that are commonly asked. Some of these are listed below:
- Associated HLA: HLA-B27 (class I MHC/HLA)
- Complicates: hypoventilation (due to decreased chest wall expansion)
Page Updated: 04.01.2017