A 35-year-old man is evaluated for pain and swelling behind his right foot that is exacerbated by walking. He reports chronic back pain that occurs mostly in the morning and at night. The pain improves during the day and with exercise, but not with rest. He takes over-the-counter ibuprofen with significant back pain relief. The patient has no fatigue, headaches, vision problems, or abdominal complaints. He has no other medical problems. His mother suffers from rheumatoid arthritis.
Laboratory results are as follows:

Physical examination should focus specifically on which of the following?

Question

A 35-year-old man is evaluated for pain and swelling behind his right foot that is exacerbated by walking.  He reports chronic back pain that occurs mostly in the morning and at night.  The pain improves during the day and with exercise, but not with rest.  He takes over-the-counter ibuprofen with significant back pain relief.  The patient has no fatigue, headaches, vision problems, or abdominal complaints.  He has no other medical problems.  His mother suffers from rheumatoid arthritis.
Laboratory results are as follows:

Physical examination should focus specifically on which of the following?

Quizplus · Accepted Answer

11ec193a_9933_a96e_853d_f522832e3026_MD0002_00 This patient's presentation suggests ankylosing spondylitis (AS). Ankylosing spondylitis usually presents in adults age < 40 with chronic low back pain due to sacroiliitis. The pain occurs during the day and night and tends to improve with exercise, but not with rest. Patients usually develop enthesitis at insertion sites of tendons to bone (eg, Achilles tendon, plantar fascia, shoulder), limited spinal mobility or chest wall expansion, and possible extra-articular manifestations (eg, anterior uveitis, osteopenia with increased fracture risk). Limited chest wall expansion is due to costovertebral rigidity. Normal chest wall expansion is > 5 cm after maximum forced expiration followed by maximum inspiration. Expansion < 2.5 cm is considered abnormal and suggests AS. Patients with kyphoscoliosis and deformity above T10 are at increased risk for nocturnal hypoventilation and apneic events as well as respiratory failure. Advanced AS may have x-ray findings of continuous fusion of the lumbar spine ("bamboo spine"). Treatment of respiratory impairment includes pulmonary rehabilitation and noninvasive positive-pressure ventilation. bamboo spine (Choice A) Marfan syndrome usually presents with increased arm span to height ratio and is associated with aortic root dilatation/dissection, ectopia lentis, mitral valve prolapse, and pneumothorax. (Choice C) The Dix-Hallpike maneuver is a diagnostic test to identify benign paroxysmal positional vertigo. In the presence of posterior canal dysfunction, the maneuver generally provokes vertigo and nystagmus. (Choice D) The drop arm test is used to assess the integrity of the supraspinatus tendon for rotator cuff injuries. A positive test occurs when the patient is unable to lower the affected arm from a fully abducted position in a smooth, controlled manner compared to the unaffected arm. (Choice E) The Romberg test is used to test proprioception (dorsal columns of the spinal cord). Causes of a positive test include cervical spondylotic myelopathy, B12 deficiency, and neurosyphilis. Educational objective: Patients with ankylosing spondylitis have limited chest wall expansion that, if severe enough, can lead to hypoventilation and respiratory failure. Treatment of respiratory impairment includes pulmonary rehabilitation and noninvasive positive pressure ventilation. __________ References: The effect(s) of a six-week home-based exercise program on the respiratory muscle and functional status in ankylosing spondylitis. (http://www.ncbi.nlm.nih.gov/pubmed/19265348) Cricoarytenoid arthritis in ankylosing spondylitis. a cause of acute respiratory failure and cor pulmonale. (http://www.ncbi.nlm.nih.gov/pubmed/7297162) Ankylosing spondylitis. (http://www.ncbi.nlm.nih.gov/pubmed/8519080)

A 35-Year-Old Man Is Evaluated for Pain and Swelling Behind