QUESTION BANK #1

A 37-year-old woman reports severe widespread pain for 10 years' duration. She has multiple tender points over musculotendinous insertions with dysesthesia. Which one of the following medications is the most appropriate initial pharmacologic therapy? A - Tramadol B - Fluoxetine C - Venlafaxine D - Celecoxib E - Hydrocodone

A 37-year-old woman reports severe widespread pain for 10 years' duration. She has multiple tender points over musculotendinous insertions with dysesthesia. Which one of the following medications is the most appropriate initial pharmacologic therapy? A - Tramadol B - Fluoxetine C - Venlafaxine D - Celecoxib E - Hydrocodone

A 45-year-old patient presents to your clinic with a painful vesicular rash in a dermatomal distribution. It appeared 5 days prior. What is his likelihood of developing chronic pain in the same distribution? A - 10% to 20% B - 30% to 40% C - 50% to 60% D - 70% to 80% E - 90% to 100%

The correct answer is: A - 10% to 20% EXPLANATION: This question is about the relationship between herpes zoster and postherpetic neuralgia. The correct answer is option A (10% to 20%). Options B, C, D, and E are therefore incorrect, as each states a percentage range elevated beyond the correct level.

Which one of the following side effects of morphine is least likely to improve with chronic use? A - Miosis B - Sedation C - Nausea D - Itching E - Urinary retention

The correct answer is: A - Miosis EXPLANATION: There are many side effects associated with chronic opioid use. Chronic opioid use usually results in tolerance to the analgesic effects and all side effects, with the exception of miosis and constipation. Almost all patients universally experience constipation with chronic opioid use. The other side effects are less common and the patient usually develops a tolerance to them. The theory behind why one does not develop tolerance to miosis and constipation is that these two side effects require activation of a smaller fraction of the receptors to produce the effect—unlike actions such as analgesia, respiratory depression, and sedation, which requires activation of a larger fraction.

49-year-old man with metastatic colon cancer and back/leg pain presents to a palliative care center for pain management evaluation. The initial assessment includes determination of all presenting characteristics of his cancer and related pain. When considered together, which one of the following initially-reported answers to the pain history are the most prognostic for achieving a reliable decrease of this man's pain response after several weeks of treatment? A - Pain intensity, pain mechanism, and psychological distress B - Pain intensity, pain mechanism, and total oral morphine equivalent daily dose (MEDD) he takes for pain relief C - Pain mechanism, pain localization, and presence of metastasis D - Pain mechanism, pain localization, and patient's age E - Pain mechanism, type of cancer, and presence of metastasis

The correct answer is: A - Pain intensity, pain mechanism, and psychological distress EXPLANATION: The European Pharmacogenetic Opioid Study (EPOS) and the Italian Cancer Pain Outcome Research Study Group (CPOR) have performed observational, cross-sectional, longitudinal, and prospective studies on large populations of patients with cancer pain. Multivariate linear regression analyses of these populations indicate 4 domains of a patient's cancer pain that, when highly scored and considered together, are most prognostic for the patient (1) to develop more severe cancer pain and (2) to respond more negatively to pain treatment. These core domains include the following: pain intensity, pain mechanism, incident pain, and psychological distress. Option A is correct in that it lists 3 of these. Options B, C, D, and E are incorrect. These answers include other contributory information important for treatment choices; however, these patient descriptors do not contribute significantly as independent variables.

An 83-year-old female presents to her geriatrician's office complaining of pain in her lower extremities. The pain is mostly localized in her distal legs and feet, described as sharp and burning. The pain worsens at night, interfering with her sleep. She was diagnosed with peripheral neuropathic pain and was started on a tricyclic antidepressant. Which one of the following tricyclic antidepressants has the least anticholinergic effects? A - Doxepin B - Desipramine C - Imipramine D - Nortriptyline E - Amitriptyline

The correct answer is: B - Desipramine EXPLANATION: This question explores the side effect profile of tricyclic antidepressants in the elderly. The side effect profile of the tricyclic antidepressants, primarily anticholinergic effects, limits their widespread application, especially in patients with autonomic neuropathy, glaucoma, cardiac arrhythmias, and urinary hesitation. Option B is correct since desipramine has been proven to have the least anticholinergic side effects. It is the least sedating and has little antihistamine activity. Option E is incorrect, as amitriptyline is the tricyclic antidepressant with the most anticholinergic effects. Options A, C, and D are incorrect, as all of them have mild to moderate anticholinergic effects.

A 44-year-old nondiabetic man complains of joint and muscle pains but denies any numbness or tingling in the hands or feet. Which one of the following is associated with the presence of musculoskeletal pain without prominent neuropathic pain complaints? A - Guillain-Barré syndrome B - Hereditary motor and sensory neuropathy (Charcot-Marie-Tooth [CMT] disease type I) C - Postherpetic neuralgia D - Neuralgic amyotrophy E - Necrotizing vasculitis

The correct answer is: B - Hereditary motor and sensory neuropathy (Charcot-Marie-Tooth [CMT] disease type I) EXPLANATION: The presence, absence, and character of neuropathic pain can help the clinician identify the most likely type and etiology of a patient's neuropathy. For example, neuropathic pain is one of the defining characteristics of small fiber neuropathy. Allodynia is almost universally present in postherpetic neuralgia and is common in other sensory neuronopathy syndromes. Severe aching, boring pain is an essential feature of neuralgic amyotrophy and a common complaint in necrotizing vasculitis. By contrast, CMT may be associated with musculoskeletal pain but the presence of prominent neuropathic pain would put this diagnosis in doubt.

Which one of the following is characteristic of upper extremity postamputation pain syndrome? A - It is present in almost 100% of patients after amputation B - Stroking of the cheek or pursing the lips can result in phantom sensations C - Residual limb pain is often experienced at sites distant from the remaining part of the limb D - Phantom limb pain is often experienced in the residual limb stump E - Children have a high incidence of phantom limb pain after amputation

The correct answer is: B - Stroking of the cheek or pursing the lips can result in phantom sensations EXPLANATION: The incidence of phantom limb pain ranges from 30% to 83% as reported in the literature. It is less common in children. Residual limb pain is characterized by pain, paresthesias, and hyperalgesia in the stump whereas phantom limb pain is experienced in the phantom limb after amputation. Phantom limb pain is a central phenomenon occurring in the somatosensory cortex. The somatosensory cortex corresponding to the missing limb will undergo remapping, extending the cortical representation of the mouth into the region of the hand and arm. This results in phantom sensations when stroking the cheek or pursing the lips in some patients.

A 60-year-old male with chronic low back pain reports great pain relief after attending an intensive massage therapy. He reports receiving a massage that primarily involved kneading. Which one of the following massage techniques is the patient describing? A - Effleurage B - Tapotement C - Pétrissage D - Myofascial release E - Acupressure

The correct answer is: C - Pétrissage EXPLANATION: Classic Western techniques of massage include effleurage (stroking), pétrissage (kneading), tapotement (percussion), and Swedish (tapotement plus pétrissage plus deep-tissue massage). Deep-friction massage is used to break up adhesions in chronic muscle injuries. Myofascial release attempts to release soft tissue entrapped in tight fascia through the prolonged application of light pressure in specific directions. Eastern techniques include acupressure and Shiatsu massage.

A 67-year-old male patient with chronic neck pain has tried a long course of conservative treatments with minimal pain relief. Patient's imaging studies point to C7-T1 facet arthropathy as a possible pain generator, and medial branch block is proposed to target suspected pain mediated by facet arthropathy. Which one of the following medial branch nerves needs to be blocked in order to address pain from C7-T1 facet arthropathy? A - C5 and C6 medial branch nerves B - C6 and C7 medial branch nerves C - C7 and C8 medial branch nerves D - C8 and T1 medial branch nerves E - T1 and T2 medial branch nerves

The correct answer is: C - C7 and C8 medial branch nerves EXPLANATION: Medial branch nerve blocks are performed to address pain arising from arthropathy of the facet joints (zygapophyseal joints). The C2-3 facet joint, the highest facet joint, is innervated mainly by the third occipital nerve. Below the C2-3 level, cervical facet is innervated by medial branch nerves of the named facet. For example, the C6-7 facet joint is innervated by C6 and the C7 medial branch nerves. The C7-T1 facet is innervated by C7 and C8 medial branch nerves and is the correct answer to this question. The T1-T2 facet is innervated by C8 and T1 medial branch nerves. The T2-T3 facet joint is innervated by the T1 and T2 medial branch nerves, the T3-4 facet joint is innervated by the T2 and T3 medial branch nerves, etc., down to the L5-S1 facet joint which is innervated by the L4 and L5 medial branch nerves.

The following radiograph is from a block performed on a patient with abdominal pain secondary to terminal cancer. Which one of the following techniques is consistent with the spread of the contrast? A - Celiac plexus block: transaortic approach B - Celiac plexus block: trans-crural approach C - Celiac plexus block: retrocrural approach D - Superior hypogastric plexus block E - Inferior mesenteric plexus block

The correct answer is: C - Celiac plexus block: retrocrural approach EXPLANATION: There are 4 posterior approaches to the celiac plexus: retrocrural, anterocrural, splanchnicectomy, and transaortic. The retrocrural approach places the needle tips at the anterolateral edge of L1 but posterior to the crus of the diaphragm. The spread of contrast will remain close to the vertebral bodies and travel cephalad. The anterocrural approach enters the needles at the L1 level and closer to the midline with advancement closer to the anterior-posterior plane and advancement through the crus of the diaphragm. Contrast will spread caudad. The transaortic approach enters the needle on the left side at the L1 level and advances medial to enter the aorta. The needle is advanced until the needle is negative for blood aspiration. Contrast will spread anterior to the aorta and will pulsatile with each heartbeat. The splanchnic nerve block enters the needle at the T12 level close to the midline and advances the needle to reach the anterolateral edge of T12. Contrast will remain close to the vertebral body and will spread cephalad.

A 25-year-old patient reports pain and diffuse weakness in both arms immediately after you perform a cervical epidural steroid injection. Which one of the following steps would be the most appropriate? A - Prescribe a mild opioid analgesic and discharge the patient to home B - Reassure the patient that this is a normal reaction to a procedure in an already-painful area C - Check the motor exam every 20 minutes for 2 hours, then discharge if there is no worsening of symptoms and if the motor exam is normal D - Discharge the patient into the care of a responsible person (the patient's escort) E - Obtain a CT C-spine stat

The correct answer is: C - Check the motor exam every 20 minutes for 2 hours, then discharge if there is no worsening of symptoms and if the motor exam is normal EXPLANATION: This question is about the management of a potential procedural complication. The patient may have a spinal cord injury from needle trauma or injection of fluid into the cord. Option C is correct. Option B may also be right but the interventionalist must first ensure that the patient is not developing a spinal cord injury. Options A and D are incorrect for the same reason. Option E is incorrect because the patient's symptoms have to be assessed further and because an MRI is the test of choice.

A 76-year-old male presents with back pain and stiffness involving the thoracolumbar spine. An X-ray of his thoracolumbar spine shows anterior calcification involving 4 contiguous vertebrae and no other obvious abnormalities. Which one of the following etiologies is the most likely for this patient? A - Facet joint pain B - Ankylosing spondylosis C - Diffuse idiopathic skeletal hyperostosis D - Paget's disease E - Discogenic pain

The correct answer is: C - Diffuse idiopathic skeletal hyperostosis EXPLANATION: Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by significant spinal ligament ossification. It is mainly seen in older Caucasian males with symptoms of back stiffness and pain involving the thoracolumbar spine. It is diagnosed by the characteristic X-ray image of anterior calcification along 4 contiguous vertebrae with no loss of disc height. Facet joint pain and discogenic pain is not characterized by ligament ossification. While ankylosing spondylosis can be clinically similar to DISH, the main differentiating feature is early involvement of the SI joint in ankylosing spondylosis. Paget's disease is also a systemic disorder that usually affects much of the skeletal system. It is also associated with dysfunction of different organs and neurological symptoms. The X-ray finding seen is characteristic of DISH.

Hypersensitivity to pain resulting from abnormal central processing of normal input (such as irritable bowel syndrome or fibromyalgia) is best described as which one of the following types of pain? A - Neuropathic B - Inflammatory C - Functional D - Nociceptive E - Psychogenic

The correct answer is: C - Functional EXPLANATION: Mechanistically, pain can be classified into four categories: (1) nociceptive pain is defined as pain that travels through a normal and functioning nervous system that is reporting actual or potential tissue injury. Nociceptive pain serves as a protective function; (2) inflammatory pain is defined as pain and hypersensitivity to pain in response to tissue damage and inflammation (postoperative, trauma, arthritis) occurring during healing or repair; (3) neuropathic pain is defined as pain and hypersensitivity to pain in association with damage to or lesion of the nervous system. The injury to the nervous system results in long-term and persistent changes in neurologic function resulting in the ongoing reports of pain; (4) functional pain is defined as hypersensitivity to pain resulting from abnormal central processing of normal input. Irritable bowel syndrome and fibromyalgia are examples of functional pain. Psychogenic pain is defined as pain attributable primarily to psychological factors usually in the absence of any objective physical pathology that could account for the pain. It is rarely used and not a very effective way of describing pain patients.

A 26-year-old female graduate student comes to your office because of ankle pain. She suspects she sprained her ankle while she was playing intramural soccer. Which one of the following structures is most likely injured? A - Tibia B - Fibula C - Deltoid ligament D - Anterior talofibular ligament (ATFL) E - Calcaneus

The correct answer is: D - Anterior talofibular ligament (ATFL) EXPLANATION: This question is asking about the prevalence of different types of injuries in patients with ankle pain and potential ankle sprains. The most common position for an ankle sprain to occur is with the foot inverted and the ankle everted. The outer ligaments, specifically the ATFL, are the most commonly injured in this situation. The tibia is rarely injured. Occasionally, the fibula is fractured in what is known as a Maisonneuve fracture. The deltoid ligament is responsible for medial ankle sprains. The calcaneus is often associated with bone spurs and foot pain—yet, it rarely causes ankle pain.

A 50-year-old man underwent an endoscopic release of a carpal tunnel. He comes back to the office complaining of severe pain in his arm. On examination, the surgical site is clean and dry. The dorsum of the hand is swollen, the skin is shiny and without hair. The skin is moist and it is warmer than the uninvolved hand. The patient complains of pain with light stroking of the dorsum of the hand. There is no clinical evidence that the operative site is infected or that there is nerve injury related to the procedure. You consider options to offer to the patient to relieve his pain. For which one of the following options is there good or "class A" evidence of efficacy?

The correct answer is: E - Evidence-based reviews of randomized, controlled studies have not documented any treatment as being effective EXPLANATION: The patient has complex regional pain syndrome. A number of antidepressants and anticonvulsants have been shown to be effective in neuropathic pain; however, there are not studies showing efficacy in complex regional pain syndrome. There are only a few controlled studies of sympathetic blockade and spinal cord stimulators and they have given mixed results. A reasonable course of treatment for patient with complex regional pain syndrome is to initiate a course of therapy to prevent or limit edema, contracture, and deconditioning. Adjuvant pain medications (such as amitriptyline or gabapentin) are usually given a chance. Some clinicians recommend trials of sympathetic blockade or neuromodulation but the effectiveness of these procedures is unclear at this time.

Which one of the following study designs ranks the highest strength of evidence for treatment decisions (according to Guyatt and Drummond)? A - Unsystematic clinical observations B - Single observational study C - Single randomized trial D - Systematic reviews of randomized trials E - N of 1 randomized control trial (RCT)

The correct answer is: E - N of 1 randomized control trial (RCT) EXPLANATION: N of 1 RCT is at the top of Guyatt and Drummond's hierarchy of evidence for treatment decisions. Thus, option E is correct. Patients undertake pairs of treatment periods, receiving a target treatment during one period of each pair and a placebo or alternative treatment during the other period. Patients and clinicians are blind to allocation, the order of the target and control is randomized, and patients make quantitative ratings of their symptoms during each period. The trial continues until the patient and the clinician conclude that the patient is, or is not, obtaining benefit from the target intervention. N of 1 RCT is often considered to be feasible, can provide definitive evidence of treatment effectiveness in individual patients, and may lead to long-term differences in treatment administration. Option A is incorrect, as the unsystematic clinical observations have the lowest strength of evidence. Options B and C are incorrect, as they are lower in the hierarchy of evidence strength. Option D is incorrect but systematic reviews of randomized trials provide the next best evidence for treatment decisions. SOURCE: Manchikanti L. Special Features of Study and Analys

A child has just been diagnosed with systemic lupus erythematosus. Which one of the following coping strategies she uses is the most likely to be associated with increased pain intensity, increased disability, and decreased pain tolerance? A - Catastrophic thinking B - Distracting herself from the problem C - Internalizing emotions D - Yelling at others E - Information-seeking behaviors

Your answer is Correct: A - Catastrophic thinking EXPLANATION: In cases of high catastrophizing, patients expect future episodes of pain and their consequences to be extremely severe. They subsequently experience increased distress and sensitivity to pain. Distraction is a positive coping strategy. At an extreme level of avoidant thinking, it becomes a negative strategy. Information-seeking behaviors are also positive. Internalizing emotions and yelling at others are not necessarily positive but they do not have the same detrimental effects as catastrophic thinking.

You have decided to treat chronic pain in elementary, middle, and high school students as a means of building up your practice. Which one of the following chronic pain condition are you most likely to see? A - Headache B - Abdominal pain C - Limb pain D - Back pain E - Chest pain

Your answer is Correct: A - Headache EXPLANATION: This question is asking about the prevalence of various chronic pain conditions in the pediatric population. In a study of elementary and high school students, one-third had chronic pain. Headache was reported in 61%; abdominal pain in 43%; limb pain in 33%; and back pain in 30%. Chest pain was not commonly reported in the pediatric population.

A 38-year old, recently-married man with an extensive family history of peripheral neuropathy presents to discuss his desire to begin having a family soon. In counseling this man, you keep in mind that which one of the following options is the most commonly inherited peripheral neuropathy? A - Hereditary motor and sensory neuropathy (Charcot-Marie-Tooth disease; CMT) B - Amyotrophic lateral sclerosis (Lou Gehrig's disease; ALS) C - Werdnig-Hoffman syndrome D - Kennedy's disease E - Legg-Calve-Perthes disease

Your answer is Correct: A - Hereditary motor and sensory neuropathy (Charcot-Marie-Tooth disease; CMT) EXPLANATION: CMT is the most commonly inherited peripheral neuropathy with a prevalence of 17 to 40 per 100,000. CMT is a genetically heterogeneous disorder characterized by wasting of the distal limb muscles—particularly the peroneal innervated muscles, with distal sensory loss, decreased or absent muscle stretch reflexes, and skeletal deformity. CMT is often referred to as hereditary motor and sensory neuropathy (HMSN) and has been subclassified as HMSN types I through VI. HMSN I is now known as CMT1 and is characterized by low conduction velocities and segmental demyelination. None of the other diseases listed are peripheral neuropathies.

A 45-year-old man is undergoing intrathecal pump placement for severe abdominal pain secondary to pancreatic adenocarcinoma. Which one of the following drugs would be the best choice as a first-line therapy? A - Morphine B - Fentanyl C - Bupivacaine D - Baclofen E - Ketamine

Your answer is Correct: A - Morphine EXPLANATION: Deer (et al.) have published practice guidelines for management of intrathecal (IT) pump medications for cancer pain. First line therapies include morphine (option A), hydromorphone, and ziconotide. Second line therapies include fentanyl (option B), morphine/hydromorphone + ziconotide, and morphine/hydromorphone + bupivacaine (option C)/clonidine. Bupivacaine and other local anesthetics can block incoming sensory nerves and produce complete analgesia. However, this comes at the price of motor blockade resulting in weakness, and sympathetic nervous system blockade which may result in hypotension. Bupivacaine, given in doses less than 30mg/day, is an excellent adjunct to IT opioids and generally causes minimal motor block. Baclofen (option D) and ketamine (option E) are not listed on the most recent polyanalgesic algorithm for IT therapies.

A 23-year-old female—who was recently discharged from the hospital after an open reduction internal fixation of femur—develops severe chest pain 48 hours later. The pain is severe and unrelenting and associated with shortness of breath. Which one of the following medications may have caused this reaction? A - Oral contraceptives B - Opioids C - Benzodiazepines D - Antidepressants

Your answer is Correct: A - Oral contraceptives EXPLANATION: This patient is suffering from a pulmonary embolism. Option A is correct, as oral contraceptives in this setting may be contributing to a hypercoagulable state, causing a dvt/pe. Option B is incorrect, as nsaids do not cause dvts. Option C is incorrect, as opioids are not involved in thrombus formation. Option D is incorrect, as benzodiazepines do not cause dvt. Option E is incorrect, as antidepressants are not associated with PE or dvt.

After acute herpes zoster infection, postherpetic neuralgia (PHN) is diagnosed based on which one of the following criteria? A - Pain arising or persisting in areas affected by herpes zoster at least 3 months after healing of the skin lesion B - Positive and negative sensory signs and symptoms in the affected area C - Lack of pain relief with intradermal injection of lidocaine in the affected area D - Pain, numbness, and tingling in the affected area must be present to make the diagnosis E - High herpes zoster viral titer

Your answer is Correct: A - Pain arising or persisting in areas affected by herpes zoster at least 3 months after healing of the skin lesion EXPLANATION: The medical literature contains a variety of definitions for PHN—but, the most accepted definition is "pain arising or persisting in areas affected by herpes zoster at least 3 months after healing of the skin lesions." PHN presents with a variety of signs and symptoms, both positive and negative; however, this is present in many neuropathic pain syndromes and is not specific to PHN. The neuropathic pain questionnaire-short form uses three items (numbness, tingling, and increased pain to touch). The presence of all three of the items correlates highly with neuropathic pain but is not specific to PHN. High viral titers occur in acute herpes zoster and are not present in PHN.

A 49-year-old patient with fibromyalgia has participated in a regular physical therapy program as well as cognitive behavioral therapy. Her sleep has improved over time but she continues to have significant pain. She asks to try an FDA-approved medication for her condition. Which one of the following medications would you suggest? A - Pregabalin B - Gabapentin C - Nortriptyline D - Meprobamate E - Tizanidine

Your answer is Correct: A - Pregabalin EXPLANATION: This question pertains to FDA-approved treatments for fibromyalgia. Option A is the correct answer. Options B and C are often used to treat fibromyalgia—however, they are not FDA-approved at this time. Option D has been investigated to treat sleep disturbances associated with fibromyalgia; further, it has not been clinically-accepted or FDA-approved. Tizanidine is occasionally prescribed for fibromyalgia—but, it is not considered a first-line therapy. It is also not FDA-approved.

Per the previous description of the patient's presentation, which one of the following terms best describes the symptoms of upper limb pain radiating down from the cervical spine from a disc injury? A - Radiculopathy B - Myelopathy C - Disc herniation D - Compression E - Sciatica

Your answer is Correct: A - Radiculopathy EXPLANATION: Option A is correct, as this term most correctly describes the clinical condition of spine pain radiating down a limb when the origin is from the spinal nerves. Option B is incorrect, as this term describes symptoms arising from damage to the spinal cord, not the spinal nerves. Option C describes the actual injury—not the set of symptoms that arise from such injury. Option D describes the pathophysiology of the clinical symptoms—not the symptom presentation. Option E is a description of symptoms of lower back pain radiating down a lower limb.

A 58-year-old male presents with pain in the back of right shoulder. Which one of the following nerve blocks is best for this patient's presentation? A - Suprascapular nerve block B - Interscalene block C - Supraclavicular block D - Axillary block E - Median nerve block

Your answer is Correct: A - Suprascapular nerve block EXPLANATION: Pain in the posterior aspect of the shoulder could be from the supraspinatus or infraspinatus muscle group. Option A is correct, as blockade of the suprascapular nerve is usually indicated in the treatment of chronic shoulder pain. Option B is incorrect, as interscalene blocks will anesthetize the entire shoulder. Option C is incorrect, as supraclavicular blocks will anesthetize the arm. Option D is incorrect, as axillary blocks will anesthetize the distal arm. Option E is incorrect, as median nerve blocks block the hand and wrist pain. This patient is suffering from suprascapular neuralgia with irritation of the suprascapular nerve in the right shoulder distribution and blockade of this nerve is therapeutic for his care.

A 35-year-old male presents with complaints of lateral elbow pain of 4-months' duration. He is a mechanic and has to rotate his arm and elbow constantly. The pain occurs at work and is dependent upon the number of hours operating the machines. Physical exam reveals pain on finger extension directed to the lateral elbow. The likely diagnosis is lateral epicondylitis. Which one of the following treatments has been shown to have a likelihood of a detrimental long-term outcome? A - Evaluate and correct work station B - Corticosteroids injection alone C - Placebo injection alone D - Physiotherapy alone E - Platelet-rich plasma (PRP)

Your answer is Correct: B - Corticosteroids injection alone EXPLANATION: This question describes a clinical scenario where lateral epicondylitis has become chronic. Option A is a treatment that is not necessarily proven by evidence. However, clearly there has been no evidence to suggest a detrimental effect. Option B suggests a treatment that historically was the standard intervention for lateral epicondylitis. However, recent data has shown that corticosteroid injections for lateral epicondylitis are associated with worse outcomes at one year than other treatments, including placebo injections. Option C was found to not result in worse outcomes in the studies. Option D is incorrect because physiotherapy does not make things worse at one year. Improvement is uneven. Option E is incorrect, as PRP has not been show to worsen outcome. With some preparations, PRP has been shown to be helpful.

A 38-year-old female homemaker presents to the office with complaints of pain at the right elbow that radiates to the wrist. She reports that it has been gradual in onset and has gotten worse over the prior month. She denies numbness. On examination, she is noted to have pain with resisted dorsiflexion. She is tender to palpation along her lateral condyle. Which one of the following diagnoses is the most likely for this patient? A - Medial epicondylitis B - Lateral epicondylitis C - Olecranon bursitis D - Osteoarthritis of the wrist E - Triceps tendinitis

Your answer is Correct: B - Lateral epicondylitis EXPLANATION: Option B is correct, as the patient in the above scenario is demonstrating a case of lateral epicondylitis—also known as tennis elbow. Patients often complain of tenderness to palpation at the lateral condyle, and have pain with resisted wrist extension. Lateral epicondylitis usually occurs in person over 35 years of age. Option A is consistent with medial epicondylitis—or golfer's elbow. Options C, D, and E are not consistent with the location of the pain and the physical findings. SOURCE: Braddom RL. Physical Medicine & Rehabilitation. 2011 Philadelphia: Elsevier. P. 771-776.

A 25-year-old female patient presents with chronic severe low back pain. You ask about her social history, including childhood physical abuse. Approximately what percentage of females with severe chronic pain is likely to have experienced childhood physical abuse? A - 10 B - 30 C - 50 D - 70 E - 90

Your answer is Correct: C - 50 EXPLANATION: This question is asking about the prevalence of childhood physical abuse in patients with chronic pain. In one study of over 1,000 patients with non-cancer-related chronic pain, the investigators assessed self-reports of childhood abuse. The study suggested that the lifetime history of physical abuse was 47% of women and 22% of men. A similar gender distribution of a history of sexual abuse was reported, with 35% of women and 10% of men reporting abuse.

A 48-year-old male presents to the ED with severe abdominal pain radiating to his back. The pain has been constant since it began 48 hours before presentation. He finds some relief with sitting forward and hugging his knees. On exam, he is tender to deep palpation. Serum amylase and lipase are significantly elevated. Which one of the following risk factors in his likely diagnosis is the most probable for this patient? A - Cigarette smoking B - Habitual use of marijuana C - Alcohol use D - Vegan diet E - High-protein, high-fat diet

Your answer is Correct: C - Alcohol use EXPLANATION: This patient's presentation is consistent with acute pancreatitis. Common causes of pancreatitis include alcohol use (option C), gallstones, and medications (including furosemide and thiazides). It may occur postoperatively. It has not been shown to be caused by cigarette smoking (option A), use of cannabinoids (option B), or specific diets (options D and E).

Virtual reality (VR) is a psychological intervention for pain management that immerses an individual with pain into a distracting environment so as to reduce the pain. VR distraction that incorporates the individual into the most comprehensive, 3-dimensional, computer-simulated, customized environment provides the most efficacious pain reduction. Which one of the following painful conditions has the most beneficial short-term effect from VR distraction? A - Dental procedural pain B - Acute pain produced by needle C - Burn injuries D - Peripheral vascular pain E - Neuropathic spinal cord injury pain

Your answer is Correct: C - Burn injuries EXPLANATION: Option C is correct: VR distraction significantly decreases pain associated with dressing changes following burn injuries. Options A, B, D, and E are incorrect. These diagnoses include both acute and chronic conditions that are being investigated for VR therapy to provide short-term analgesia. VR significantly decreases experimentally-induced acute pain; however, larger, controlled studies are required to prove its effectiveness for dental procedural pain, venipuncture, peripheral vascular, and neuropathic spinal cord injury pain.

54-year-old female presents to your office with neck pain radiating into the left arm and forearm. The symptoms started after waking up with a stiff neck 6 weeks prior. She complains of numbness of the ring finger of that hand. Physical exam of the left upper limb reveals weakness of elbow extension, absent triceps reflex unilaterally, and reduced pain sensation into the long finger. Which one of the following spinal nerves is most likely affected by this injury? A - C5 B - C6 C - C7 D - C8 E - T1

Your answer is Correct: C - C7 EXPLANATION: Option A is incorrect, as the muscles affected would be the biceps (which causes elbow flexion). Option B is incorrect, as injury to this spinal nerve cause numbness typically in the area of the thumb and index finger. Option C is correct. Injury to this spinal nerve results in the symptom profile of absent right triceps reflex, numbness in the C7 dermatome, and weakness of elbow and finger flexors. Option D is incorrect, as C8 dermatome is the ulnar aspect of the hand and weakness occurs in the hand intrinsic muscles. Option E is incorrect, as the muscles that would weaken after injury to this spinal nerve include hand muscles only.

A 55-year-old man with postlaminectomy syndrome has failed multiple interventions and a spinal cord stimulator trial. He is currently managed on long-term opioid therapy and TENS therapy. He reports significant daytime somnolence. Which one of the following elements on history would suggest that a sleep study is indicated? A - Methadone dose of 20 mg/day total B - Morphine sulfate dose of 50 mg/day total C - Concomitant lorazepam use of 2 mg/day total D - BMI of 29 E - History of asthma

Your answer is Correct: C - Concomitant lorazepam use of 2 mg/day total EXPLANATION: This question addresses the issue of sleep-disordered breathing, which research has associated with opioid consumption. Several opioids (including morphine, hydrocodone, oxycodone, and fentanyl) have all been implicated. Data suggest that sleep studies are advisable for patients taking methadone more than 40 mg/day, other opioids at more than 100 mg/day of morphine equivalent, those on concomitant benzodiazepines (option C), or with high BMI.

A 43-year-old male has severe complex regional pain syndrome (CRPS) type 2. On physical exam, the patient is noted to have a blue, swollen hand. The hand does not move due to severe pain. Palpatory exam is described as resulting in hyperalgesia, hyperpathia, and allodynia. Which one of the following definitions would best apply to allodynia in this case? A - A frequency-dependent increase in the excitability of spinal cord neurons B - Exaggerated levels of pain evoked by nociceptive stimuli C - Pain due to a stimulus which does not normally provoke pain D - An unpleasant, abnormal sense of touch E - The point at which pain begins to be felt

Your answer is Correct: C - Pain due to a stimulus which does not normally provoke pain EXPLANATION: Option A is incorrect because a frequency-dependent increase in the excitability of spinal cord neurons describes "wind up" phenomenon. Option B is incorrect, as hyperpathia is defined as nociceptive stimuli that evoke exaggerated levels of pain. Option C is correct, as pain due to a nonpainful stimulus defines allodynia. Option D is incorrect, as an unpleasant, abnormal sense of touch defines dysesthesia. Option E is incorrect, as the point at which pain begins to be felt is the pain threshold.

A 23-year-old man with a disc herniation at L4/5 impinging upon the S1 nerve root is referred for epidural steroid injection. He has read about the possibility of embolic phenomena to the radicular arteries associated with particulate steroid and asks to use a steroid with the least risk of this embolic phenomenon. Which one of the following agents would both minimize this specific risk and maintain anti-inflammatory potency? A - Hydrocortisone B - Triamcinolone C - Methylprednisolone D - Dexamethasone E - Betamethasone

Your answer is Correct: D - Dexamethasone EXPLANATION: Embolic events associated with epidural steroid injections are thought to be due to the particulate nature of the steroids injected. If inadvertently injected into a radicular artery, they may embolize in the spinal cord and result in ischemia and permanent disability. Of the agents listed, both dexamethasone (option D) and hydrocortisone (option A) are nonparticulate. However, dexamethasone's anti-inflammatory effects are approximately 25 times more potent when compared to hydrocortisone. Thus, dexamethasone is the correct answer. Triamcinolone (option B), methylprednisolone (option C), and betamethasone (option E) are all particulate steroids and would have a comparatively greater theoretical risk of spinal cord infarction.

You are paged about a 7-year-old boy with osteosarcoma who was hospitalized 2 days prior for a downturn in his medical condition. The patient reports that the pain is unbearable. Which one of the following potential causes of this patient's pain is the most likely true reason for his suffering? A - Disease-related treatment B - Anxiety C - Cancer spread D - A desire to obtain attention from his parents E - Musculoskeletal but unrelated to his cancer

Your answer is Incorrect. The correct answer is: A - Disease-related treatment EXPLANATION: This question is asking about the most common causes of pain in the hospitalized pediatric cancer population. The most frequent cause of pain is disease-related treatment. This is more common than pain caused directly by the cancer. One study suggests that the pain associated with procedural treatment, including intravenous line (IV) placement, causes children the most pain and distress in the entire experience. Anxiety can worsen all forms of pain—but is unlikely to be the primary cause of pain. Children can have musculoskeletal pain—but it is less likely to be the primary cause of pain in this situation. It is unlikely that a hospitalized child with cancer would exaggerate pain symptoms for attention.

A 43-year-old male presents to the pain clinic with complaints of left elbow pain. He states that his pain started recently, after returning from a vacation at a golf course. He has used over-the-counter acetaminophen and ibuprofen with no significant relief. His exam shows tenderness over the left lateral epicondyle. He also shows resisted wrist extension with elbow extended and forearm pronation with elbow extension reproducing the pain. Which one of the following diagnoses is the most appropriate for this patient's presentation? A - Olecranon bursitis B - Radial tunnel syndrome C - Distal biceps rupture D - Lateral epicondylitis E - Medial epicondylitis

Your answer is Correct: D - Lateral epicondylitis EXPLANATION: Olecranon bursitis can occur from systemic arthritis (like gout or rheumatoid arthritis). It is usually associated with a tender swelling that occurs over the olecranon process and does not correlate with the physical findings in this case. Radial tunnel syndrome is very similar to lateral epicondylitis and should be suspected with treatment resistance. The area of tenderness is 4 to 5 cm distal to the lateral epicondyle. It is usually seen in occupations that hold the elbow in constant extension. It is unlikely in this patient. It is due to entrapment of the posterior interosseous nerve. Distal bicep rupture occurs acutely and is characterized by elbow pain that is surprisingly minimal, elbow bruising, bunching up of the elbow with flexion (Popeye sign), and pain and difficulty with supination of forearm. The features described in this case are most likely from lateral epicondylitis or "tennis elbow." The onset with tenderness over the lateral epicondyle and physical exam are appropriate with this diagnosis. In medial epicondylitis, the pain is over the medial condyle and is elicited on resisted wrist flexion and pronation. SOURCE: Raj's Practical Management of Pain, pgs. 339-340

A 32-year-old female patient presents with pain in the right buttock. The pain started after giving birth 1 year earlier; it is largely nonradiating and well-localized. Occasionally, the pain radiates to the groin. Neurologic exam is normal. There is localized tenderness on palpation exam. A Gaenslen's test is positive. A Stinchfield test is negative. A FABER test is positive with buttock pain, but no groin pain. The most likely way to confirm the diagnosis would be which one of the following options? A - MRI lumbosacral spine B - MRI of the right hip joint C - Additional physical exam maneuvers D - Local infiltration of anesthetic into the sacroiliac joint E - Local infiltration on anesthetic and steroid into the L5-S1 foramen

Your answer is Correct: D - Local infiltration of anesthetic into the sacroiliac joint EXPLANATION: The signs and symptoms of this case suggest most strongly a diagnosis of sacroiliac joint (SIJ) pain. It is generally accepted that up to 25% of patients with persistent mechanical low back pain below L5 have the diagnosis of sacroiliac joint pathology. Option A is incorrect because the MRI in a sacroiliac joint problem is most likely negative—or, if positive for disc abnormalities, it would be a nonsymptomatic finding. Option B is incorrect, as the Stinchfield test was negative and the FABER test was negative for hip joint pathology directly. SIJ pathology can refer pain from the buttock to the groin, as the joint goes anterior as well as posterior. Option C is incorrect, as multiple studies suggest that physical exam maneuvers are not a reliable means of confirmation of the diagnosis of sacroiliac pain. Option D is correct, as similar studies suggest the best way to confirm the diagnosis is with a local infiltration of anesthetic under fluoroscopic guidance. Option E is incorrect, as the history and exam did not suggest a radiculopathy is present.

A 62-year-old developmentally delayed man presents to the OR for repeat knee arthroscopy. The surgeon reports that at last visit the man suffered from severe postoperative knee pain, which necessitated admission to the hospital for 3 days. He asks that you administer an intraarticular opioid for the patient in the recovery room, as the patient has minimal communication skills and has been unable to operate a PCA pump in the past. The case involved anterior cruciate ligament reconstruction. Which one of the following agents is most appropriate for intra-articular injection? A - Fentanyl B - Sufentanil C - Meperidine D - Morphine E - Placebo

Your answer is Correct: D - Morphine EXPLANATION: Intra-articular (IA) morphine (option A) has been shown to provide improved analgesia after knee arthroscopy when compared to local anesthetic alone or to saline placebo (option E). IA morphine seems to be more beneficial for use in "high inflammatory" knee surgery (which includes anterior cruciate ligament reconstruction, lateral release, patellar shaving, or plicae removal) than "low inflammatory" surgery (knee arthroscopy for meniscectomy). IA fentanyl (option A) and sufentanil (option B) have also been studied. IA fentanyl analgesia in doses up to 100ug or sufentanil 10ug both have been shown to be modestly successful in decreasing pain after knee arthroscopy. However, there is a paucity of data when compared to IA morphine.

An obese 68-year-old man reports severe abdominal pain after open revision of a partial gastric resection for obesity. He has an epidural catheter in place. He reports that he suffers from sleep apnea. Which one of the following epidural opioid medications is most likely to cause delayed respiratory depression? A - Fentanyl B - Sufentanil C - Hydromorphone D - Morphine E - Meperidine

Your answer is Correct: D - Morphine EXPLANATION: The theorized mechanism of delayed respiratory depression via epidural opioids is that the drug diffuses cephalad within the epidural and/or intrathecal space and acts at the brain stem to decrease the spontaneous respiratory rate. All opioids have the potential to cause delayed respiratory depression when administered via the epidural route. Those agents with the highest hydrophilicity (or, equivalently, the lowest lipid solubility) are less likely to enter the intravascular space and are more likely to stay within the neuraxial space (either epidural or intrathecal space). This means that more of the drug can migrate cephalad and cause respiratory depression at the brainstem. The listed opioid with the highest hydrophilicity is morphine (option D). Fentanyl (option A) and sufentanil (option B) have the lowest hydrophilicity and are least likely to cause delayed respiratory depression. Hydromorphone (option C) and meperidine (option E) are intermediate compared to the other choices.

An overweight woman presents with pain along the lateral border of her left thigh. After examining the patient, you suspect that she has meralgia paresthetica or entrapment of the lateral femoral cutaneous nerve. The diagnosis is best confirmed by which one of the following evaluations? A - Nerve conduction studies B - MRI C - Diagnostic ultrasound D - Nerve block with lidocaine E - A therapeutic trial of gabapentin

Your answer is Correct: D - Nerve block with lidocaine EXPLANATION: Nerve conduction studies of the lateral femoral cutaneous nerve are technically difficult because of the small size of the nerve and the large amount of overlying tissue. Ultrasound has been used to help localize the nerve for injection but has not been shown to be reliable for diagnosing a compression. The nerve is not imaged well with MRI. Relief of symptoms with injection can help confirm the clinical diagnosis. Response to medication is nonspecific as far as diagnosis is concerned.

A 76-year-old man presents with chronic buttock and left leg pain. He shows you a lumbar MRI with moderate lumbar stenosis in at the L4-5 level. Your exam finds him to be very wobbly on his feet. You find that he has increased (over normal) reflexes throughout the upper and lower limbs, a positive Hoffman's sign on the left, and an "upgoing toe" on the left. Which one of the following treatment options would be the best to ensue with this patient? A - Perform a left epidural injection transforaminal approach B - Order 6 weeks of physical therapy C - Order pregabalin 75 mg twice per day D - Order a cervical MRI scan E - Perform a lumbar epidural injection interlaminar approach

Your answer is Correct: D - Order a cervical MRI scan EXPLANATION: The concern in this patient is that although he presents with a pain complaint, the physical exam reveals upper motor neuron signs. That, coupled with the imbalance in gait, strongly suggests this patient has cervical myelopathy in addition to lumbar stenosis. Another less common alternative would be a brain disorder—such as multiple sclerosis (MS) or normal pressure hydrocephalus (NPH). Option A is incorrect, as the concern now is to investigate for the possibility of cervical myelopathy. Ultimately, epidural treatment of lumbar sciatica might be appropriate. Option B is incorrect, as cervical myelopathy in a patient of this age who is otherwise healthy is a concerning situation that needs a diagnosis before starting a conservative treatment program. Surgical treatment might be more appropriate. Option C is incorrect, as treatment of the pain is secondary now to making the diagnosis of myelopathy versus other pathology, such as NPH. Option D is the correct next diagnostic test to order. Option E is incorrect, as treatment of the pain is secondary now to making the diagnosis of the myelopathy.

A 78-year-old woman presents with chronic neuropathic pain. Even light touch bothers her. Wide dynamic range (WDR) neurons are implicated in the process of allodynia. Which one of the following features is characteristic of WDR neurons? A - They are first order neurons B - WDR cells are concentrated in superficial laminae of the dorsal horn (I, II) C - They receive input from low threshold A-ß fibers only D - They are activated by both innocuous and noxious stimuli E - They are sensitized less readily when compared to nociceptive-specific (NS) cells

Your answer is Correct: D - They are activated by both innocuous and noxious stimuli EXPLANATION: Wide dynamic range (WDR) neurons are activated by both noxious and non-noxious stimuli. Option A is incorrect, as WDR neurons are second order neurons and not first order neurons. Option B is incorrect as WDR cells are concentrated in the deeper laminae of the dorsal horn (III to V) and not the superficial laminae. Option C in incorrect, as WDR neurons receive input from both low threshold A-ß and nociceptive A-d and C fibers. Option E is incorrect, as WDR cells are sensitized more readily than do nociceptive-specific (NS) cells.

A 42-year-old male chronic pain patient is requesting an adjuvant regimen for improved pain control—but would like to avoid additional opioids. You recommend clonidine as that adjuvant medication. Which one of the following statements is accurate with regards to clonidine? A - Clonidine accentuates the nociceptive input from A-delta and C-fibers B - Intrathecal clonidine is associated with side effects such as respiratory depression and pruritus C - Neuraxial placement of clonidine stimulates spinal substance P release D - Side effects of intrathecal clonidine includes hypertension and tachycardia E - Clonidine's analgesic activity is mediated through alpha-2 receptors localized in the spinal cord

Your answer is Correct: E - Clonidine's analgesic activity is mediated through alpha-2 receptors localized in the spinal cord EXPLANATION: Clonidine's analgesic activity is mediated through presynaptic and postsynapatic alpha-2 receptors localized in the superficial layers of the spinal dorsal horn. Option A is incorrect because clonidine, in fact, attenuates—not accentuates—the nociceptive input from A-delta and C-fibers. Option B is incorrect because intrathecal clonidine is not associated with the side effects of spinal opioids (such as respiratory depression and pruritus) and has less potential for causing urinary retention. Option C is incorrect, as neuraxial placement of clonidine inhibits spinal substance P release. Option D is incorrect because the side effects of intrathecal clonidine include hypotension and bradycardia—not hypertension and tachycardia.

A 50-year-old female presents with a complaint of burning pain along the lateral border of her left thigh. The pain extends from the hip to the knee—but not below the knee. Examination shows no abnormality in reflex or strength. Sensation is decreased on the lateral border of the thigh but not the anterior surface of the thigh. Pain is reproduced by extension of the hip. MRI of the lumbar spine is remarkable for disc degeneration and flattening at L4L5 and L5S1. This patient most likely has which one of the following conditions? A - Iliotibial band syndrome B - Irritation of the L3 nerve root C - Lumbar radiculopathy D - Osteoarthritis of the hip E - Compression of the lateral femoral cutaneous nerve

Your answer is Correct: E - Compression of the lateral femoral cutaneous nerve EXPLANATION: Meralgia paresthetica is caused by compression of the lateral femoral cutaneous nerve as it approaches the anterior iliac spine, curves around the anterior iliac spine, passes through the inguinal ligament or in a fibrous tunnel in the tensor fascia lata. Iliotibial band syndrome would not result in sensory deficits. An L3 radiculopathy would affect motor strength and sensation on the anterior surface of the thigh. Osteoarthritis of the hip would be reproduced by internal rotation of the hip and would not affect sensory examination. MRI showed changes at lower lumbar levels which would not produce symptoms or sensory deficit in the distribution of the lateral femoral cutaneous nerve.

Of the 10 sodium channels in humans, NaV1.7 and NaV1.8 have attracted interest as potential targets for pain reduction. Which one of the following statements is true regarding the voltage-gated sodium channels (VGSC) NaV1.8? A - NaV1.8 is normally only expressed in secondary afferents B - NaV1.8 has a relatively low threshold for activation C - NaV1.8 is relatively susceptible to steady-state inactivation D - NaV1.8 recovers from inactivation very slowly E - NaV1.8 is VGSC alpha subunit primarily responsible for action potential initiation in the majority of nociceptors

Your answer is Correct: E - NaV1.8 is VGSC alpha subunit primarily responsible for action potential initiation in the majority of nociceptors EXPLANATION: Option A is incorrect because NaV1.8 is normally only expressed in primary afferents. Option B is incorrect because NaV1.8 has a relatively-high threshold for activation. Option C is incorrect because NaV1.8 is relatively-resistant to steady-state inactivation, a voltage-dependent process whereby channels residing in a closed or resting state transition to an inactive state before they ever get a chance to open. Option D is incorrect because NaV1.8 recovers from inactivation rapidly. Option E is correct because the VGSC alpha subunit primarily responsible for action potential initiation in the majority of nociceptors is NaV1.8.

A 17-year-old mother and her 2-year-old son are in an automobile accident and flown to the nearest children's hospital for triage. Upon admission to the ED, the mother of the child requires intubation secondary to a cervical spinal cord injury. The 2-year-old child is lethargic but begins to respond. Both are transferred to the ICU. Which one of the following pain assessments is the most appropriate to use on both the mother and child to determine their pain levels? A - Visual Analogue Scale (VAS) using smiley faces B - Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale C - Comfort Behavioral Scale D - Checklist for Nonverbal Pain Indicators (CNPI) E - Critical-Care Pain Observation Tool (CPOT)

he correct answer is: B - Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale EXPLANATION: This question encompasses 4 considerations of appropriate pain assessment for patients in the ICU: (1) behavioral assessment for adults compared to children; (2) initial pain assessment upon admission into critical care management; (3) the adult who is unable to respond to verbal pain rating scales; and (4) the child who is very young (2 years of age) and not able to explain pain. For this question, the 17-year-old is considered a young adult who would normally be transferred to an adult unit of the hospital due to her spinal cord injury. Initially, however, she can also be managed safely in the PICU—which would be able to accommodate and stabilize an adolescent. Option B is the correct response due to the confirmation that the FLACC is a valid, reliable behavioral pain tool for both children and adults. For adults who cannot communicate, it is especially comparable to numerical rating scores. Option A is incorrect and inappropriate for either a child or adult because it is not a behavioral scale nor is it valid for a critically-ill child of 2 years. Option C is incorrect. It is a valid tool for children only. Options D and E are incorrect, as these assessments are valid for adults only.

A 43-year-old woman presents with a painful skin rash. The pain is a burning pain, associated with pruritus and erythema in the distribution of the rash. Nociceptive fibers from the skin terminate in which one of the following laminas of the spinal cord? A - Lamina I B - Lamina I, II, V C - Lamina V D - Lamina II and V E - Lamina VI

our answer is Correct: B - Lamina I, II, V EXPLANATION: Primary afferent axons carry nociceptive information from synaptic contacts with neurons in the spinal cord gray matter. Option B is correct, because nociceptive afferent fibers from the skin terminate in lamina I, II and V of the dorsal horn. Option A is incorrect, as lamina I is not the only lamina involved. Option C is incorrect, as lamina V is not the only lamina involved. Option D is incorrect because lamina I is involved, as well. Option E is incorrect because lamina VI does not receive inputs from the skin. The patient is suffering from a painful skin rash, the nerve fibers that carry nociception from the skin terminate in laminas I, II, and V.

A 35-year-old patient presents with severe axial low back pain with hip movement. She also reports intermittent shooting pains down the back of her leg. Review of systems is positive for abdominal pain with defecation. She has dysuria, urinary frequency, and hematuria. From which one of the following types of cancer is this patient most likely suffering? A - Gastric B - Osteosarcoma of the hip joint C - Liver D - Cervical E - Renal

our answer is Correct: D - Cervical EXPLANATION: This question is about pain syndromes in people with cervical cancer. The patient is most at risk for cervical cancer given her age and gender (female). People at risk for the other cancers are typically older. These symptoms are likely from localized spread to the bladder and bowel as well as pelvic wall extension of the cancer. Options A, B, and C are incorrect for that reason. Option E is unlikely because renal cancer typically does not affect this age group nor does it usually cause much pain.

A 37-year-old patient reveals to you that, as a child, she was a victim of childhood physical and sexual abuse. She understands that this may be one factor that could be contributing to her chronic abdominal pain. Which one of the following factors related to sexual abuse is most likely to influence the severity of her chronic pain symptoms? A - If the primary perpetrator was a family member B - If the perpetrator was an unrelated authority figure C - If the perpetrator was a stranger D - If the perpetrator was a peer E - If there was more than one perpetrator

our answer is Correct: E - If there was more than one perpetrator EXPLANATION: A history of sexual abuse is found in almost 40% of adults with chronic gastrointestinal symptoms and chronic pain. A meta-analysis on child sexual abuse found that child sexual abuse is a significant (although general and nonspecific) risk factor for anxiety disorders. This may also mediate the risk of developing chronic pain in later life. Children appear to be most at risk for posttraumatic stress disorder. The gender of the child and severity of the abuse appear to be less relevant. Alterations in brain structure or function, information processing biases, parental anxiety disorders, family dysfunction, and other forms of child abuse may also affect the development of anxiety disorders. The number of perpetrators of physical and sexual abuse is more likely to influence the severity of chronic pain symptoms more than the identity of the perpetrator.

A 32-year-old man with severe facial pain is to undergo trigeminal nerve block with local anesthetic via an oral approach. Which one of the following agents is most appropriate for antisepsis with this approach? A - Alcohol B - Chlorhexidine gluconate C - Chlorhexidine gluconate with alcohol D - Ultraviolet light E - Povidone iodine

our answer is Correct: E - Povidone iodine EXPLANATION: Of the choices above, only option E (povidone iodine) is recommended for use on mucous membranes. It offers good to excellent antisepsis; however, its speed of action is the slowest of the choices above. Alcohol denatures proteins and is effective against bacteria and viruses; however, poses a safety risk because of flammability. Chlorhexidine gluconate is not flammable, and also offers good to excellent antisepsis against bacteria and viruses.