Known Ankylosing Spondylitis Whose Back Pain Has Flared — Free SCA Practice Case
Young man with known ankylosing spondylitis whose back pain has flared
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Materials for Candidate
Please review before starting the consultation
Full Name
Callum Grant
Age
25 years
Consultation Type
VideoAge
25
Situation
Video Consultation.
Reason for Encounter
"My back pain's flared up and the usual painkillers aren't touching it. I've got ankylosing spondylitis and I think it's playing up again."
Medical Records
- ●PMH: Ankylosing spondylitis (HLA-B27 positive; diagnosed 5 years ago).
- ●Medications: Ibuprofen 400 mg TDS PRN (currently ineffective). No DMARDs.
- ●Allergies: NKDA.
- ●Rheumatology letter (5 years ago): AS confirmed (inflammatory back pain, HLA-B27 positive); well controlled on PRN ibuprofen; advised structured physiotherapy; educated on red flags (spinal fracture, cauda equina); discharged with re-referral if deterioration.
Patient Script
For the friend playing the patient role
Character Overview: You are Callum, a 25-year-old self-employed barber with ankylosing spondylitis, diagnosed five years ago. For the last two weeks your lower back pain has gradually worsened — worse in the mornings with stiffness, easing with movement — and your usual ibuprofen and paracetamol are not controlling it. It is affecting your work (lots of standing), and as you are self-employed, fewer clients means less income. You think it is a flare. You did not attend physiotherapy before because you felt better at the time. You are practical and want effective treatment so you can keep working — you do not want time off or benefits.
Opening Sentence: "Hi Doctor. My back's really flared up over the last couple of weeks — worst in the mornings, stiff, eases when I get moving. My usual ibuprofen and paracetamol aren't doing the job. I've got ankylosing spondylitis, so I reckon it's a flare. I need to get on top of it because it's affecting my work."
History if Asked (Data Gathering Phase)
- ●The pain: "Lower back, a dull ache, worse in the early morning with a couple of hours of stiffness, and it eases once I'm moving. Came on gradually over about two weeks."
- ●Treatment tried: "Ibuprofen and paracetamol, as I always have, but they're not controlling it this time."
- ●Physiotherapy (if asked): "I was referred years ago but didn't go — I felt better at the time so didn't think I needed it."
- ●Work impact: "I'm a self-employed barber, on my feet all day. The pain means I'm taking fewer clients, and that hits my income."
- ●What he wants: "Something that actually works so I can keep cutting hair. I don't want time off."
ICE — Ideas, Concerns, Expectations
The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.
- ●Ideas: Callum is confident this is a flare of his AS, the same pattern as before. "I'm pretty sure it's my AS flaring — it's the same kind of pain, just worse."
- ●Concerns: His dominant concern is the impact on his work and income as a self-employed person. "My worry is my livelihood — fewer clients means less money, and I can't afford that."
- ●Expectations: He wants effective treatment to control the flare and keep working, not time off. "I want treatment that works so I can keep going, not to be signed off."
If Asked — Red-Flag and Extra-Articular Screen
The patient answers these only when directly asked.
- ●If asked about recent trauma/fall or sudden severe pain: "No trauma, no fall. It came on gradually, not suddenly." (Reassuring against fracture.)
- ●If asked about leg weakness, numbness, or tingling: "No, no weakness or numbness in my legs."
- ●If asked about saddle numbness or bladder/bowel dysfunction: "No numbness down below, no problems with my waterworks or bowels." (No cauda equina.)
- ●If asked about weight loss, fever, or night pain: "No weight loss, no fever, and it doesn't wake me from a dead sleep with new severe pain."
- ●If asked about eye symptoms (red/painful eye, blurred vision, light sensitivity — uveitis): "No eye problems."
- ●If asked about heel/tendon pain (enthesitis), psoriasis, or gut symptoms (IBD): "No heel pain, no skin rashes, no tummy or bowel trouble."
Responses to Management (The Negotiation Phase)
- ●If the Doctor confirms a flare and offers an alternative NSAID: "So a stronger anti-inflammatory like naproxen? Will that work better than the ibuprofen?" (The tested point is NSAID optimisation with gastroprotection.)
- ●If the Doctor recommends physiotherapy again: "I skipped it last time — do I really need it? What would it do for me?" (The tested point is explaining the central role of physiotherapy in AS.)
- ●If the Doctor offers to liaise with rheumatology: "Would you speak to the specialists who saw me before? Do I need to go back to them?" (The tested point is rheumatology liaison and awareness of escalation.)
- ●If the Doctor mentions the biologic pathway: "There are other treatments if this keeps happening? Injections or something?" (The tested point is awareness of the biologic pathway for inadequately controlled AS.)
- ●If the Doctor offers a fit note/social prescriber: "No thanks — I don't want time off or benefits, I just want to be able to work."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Ankylosing Spondylitis and Inflammatory Back Pain
- ●Ankylosing spondylitis (AS) is a chronic inflammatory spondyloarthritis affecting the spine and sacroiliac joints, associated with HLA-B27. Inflammatory back pain develops gradually, is worse in the morning with prolonged stiffness (>30 minutes), and improves with movement rather than rest. AS runs a relapsing–remitting course with flares.
Red Flags in a Flare
- ●Even in known AS, screen for spinal fracture (sudden severe pain after minor trauma — AS spines are fracture-prone) and cauda equina syndrome (saddle anaesthesia, bladder/bowel dysfunction, bilateral leg weakness), plus malignancy/infection (weight loss, fever, night pain). Any red flag needs urgent assessment.
Extra-Articular Associations
- ●Screen for anterior uveitis (red, painful eye — an ophthalmic emergency), enthesitis, psoriasis, and inflammatory bowel disease — the recognised extra-articular features of spondyloarthritis.
Symptomatic Management
- ●NSAIDs are the mainstay of symptomatic treatment; optimise the NSAID (e.g. switch to regular naproxen) with gastroprotection. Physiotherapy and regular exercise (spinal mobility, posture, aerobic activity) are central to maintaining function.
The Biologic Escalation Pathway
- ●AS inadequately controlled by NSAIDs and physiotherapy warrants specialist consideration of biologic therapy — anti-TNF agents or IL-17 inhibitors (per NICE). Recognise when to liaise with or re-refer to rheumatology.
Occupational and Holistic Support
- ●Provide workplace-adjustment advice and support tailored to the patient's job, respecting their goals (here, continuing self-employed work).
Safety-Netting and Follow-Up
- ●Safety-net for fracture/cauda equina red flags and arrange follow-up (2–4 weeks), sooner with specialist advice or deterioration.
Common Candidate Mistakes in This Case
- ●Not screening for red flags: missing fracture or cauda equina risk in a known-AS flare.
- ●Failing to optimise NSAIDs/omitting gastroprotection: or not recognising NSAIDs as the mainstay.
- ●Neglecting physiotherapy: not re-referring or not conveying its central role.
- ●No rheumatology liaison or awareness of biologics: managing a poorly-controlled flare without considering escalation.
- ●Overriding his wishes: pushing time off/benefits he has declined, rather than focusing on keeping him working.