ABIM Exam Review Practice Question of the Week: 30 y.o. male with low back pain and stiffness

Here’s a practice question directly from Knowmedge’s Internal Medicine Board (ABIM) Exam QVault.


30-year-old male, with a history of tobacco use, presents with lower back pain and stiffness that improves as the day progresses. It also improves with exercise. The patient denies numbness / tingling in his legs or bowel / bladder incontinence. Physical exam reveals some pain upon flexion of the back but straight leg test is negative bilaterally and there is no muscular weakness. Which of the following is the most appropriate initial step in management?


A. Encourage physiotherapy, NSAIDs for pain, and smoking cessation

B. Check HLA-B27

C. MRI of the lumbar spine

D. Xray of the lumbar spine

E. Refer patient to neurosurgery for steroid injection





This young patient presents with lower back pain and stiffness that improves with exercise and as the day progresses. There is no associated numbness, tingling, or bowel/bladder incontinence. The straight leg test is negative. The most likely diagnosis based on these features is ankylosing spondylitis. Age of onset is usually between 15 and 40 years and a positive family history of ankylosing spondylitis may be seen. The ratio of male to female patients with ankylosing spondylitis is 3-to-1.

Treatment of ankylosing spondylitis is Choice A (Physiotherapy (upright posture or swimming), NSAIDs, and smoking cessation). Note that no imaging or blood work (including HLA-B27) is needed at this time for diagnostic purposes. A referral should not be placed at this time.


You can see all the previous ABIM Exam Review Questions of the Week at the Knowmedge Blog. You can also find additional topics and questions directly from the Knowmedge Internal Medicine ABIM Board Exam Review Questions QVault.

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