question bank #3
A 47-year-old male presents with complaints of upper extremity pain of several months' duration, worsening for the prior 2 weeks. The patient was diagnosed with complex regional pain syndrome of his left upper extremity after a radial vein graft for a cardiac bypass. The patient is undergoing physical therapy and pharmacologic management with minimal pain relief. The patient is scheduled for a stellate ganglion block. Immediately after performing the procedure, the patient developed Horner's syndrome (but did not experience any pain relief). Which one of the following statements is true regarding the stellate ganglion block in this case? A - A high volume must be utilized to achieve appropriate analgesia B - Kuntz's nerves have been implicated in cases of inadequate analgesia C - The needle was not placed at the level of the C6 vertebrae tubercle (Chassaignac's) D - Multiple blocks are needed to achieve appropriate analgesia E - The pain is not sympathetically mediated
The correct answer is: B - Kuntz's nerves have been implicated in cases of inadequate analgesia EXPLANATION: This question describes technical aspects and relevant anatomy necessary to perform stellate ganglion blocks. The cervical sympathetic trunk contains 3 interconnected ganglia: superior, middle, and inferior. In 80% of people, the lowest cervical ganglion is fused with the first thoracic ganglion to form the cervicothoracic (stellate) ganglion. The preganglionic fibers for the head and neck emerge from the upper 5 thoracic spinal nerves, ascending in the sympathetic trunk to synapse in the cervical ganglia. The preganglionic fibers supplying the upper limb originate from the upper thoracic segment, probably T2-T6, ascend via the sympathetic trunk to synapse in the cervicothoracic ganglion, where postganglionic fibers pass to the brachial plexus. The white ramus (that connects to the cervicothoracic ganglion) contains most of the preganglionic fibers for the head and neck. These fibers ascend the trunk to the superior cervical ganglion from which postganglionic branches supply vasoconstriction and sudomotor nerves to the face and neck. They also supply secretory fibers to the salivary glands and muscles including dilator pupillae, and nonstriated muscles in the eyelid and orbitalis. Blockade of this ramus leads to ptosis, miosis, and enophthalmos, and loss of sweating of the face and neck (Horner's syndrome). Option B is correct since these anomalous pathways called Kuntz's nerves from the T2 and T3 sympathetic ganglia connect to the brachial plexus in 20% of people, bypassing the stellate ganglion. They have been implicated in cases of inadequate relief of sympathetically- mediated pain, despite evidence of cervical ganglia block. Option A is incorrect, as the volume was enough to cause Horner's syndrome, suggesting correct needle placement. Option C is incorrect, as the block was performed at the correct level for a patient without anatomical variant. The presence of Horner's syndrome confirms adequate placement. Option D is incorrect, as adequate analgesia can be achieved with a single block. Option E is incorrect, as although the patient did not experience analgesia, the presence of sympathetically-mediated pain cannot be ruled out due to the possible presence of Kuntz's nerves.
After a biopsy and resection of a superior chest wall mass, a patient notices weakness and instability of his shoulder. Examination shows right-sided winging of the scapula. This condition is most likely the result of injury to which one of the following locales? A - Pectoralis major B - Long thoracic nerve C - Suprascapular nerve D - Serratus anterior muscle E - Latissimus dorsi injury
The correct answer is: B - Long thoracic nerve EXPLANATION: Winging of the scapula is a characteristic sign of weakness of the serratus anterior muscle. The serratus anterior muscle is innervated by the long thoracic nerve. This is derived from C5, C6, and C7, and runs superficially from the root of the neck to the anterior chest. Injuries to the long thoracic nerve are secondary to trauma or surgical manipulation. The serratus anterior muscle is not supplied by the suprascapular nerve. The presentation does not correlate with injury to the pectoralis major. Also, it is unlikely that the serratus anterior or latissimus dorsi was injured in a surgery on the anterior chest wall.
A 35-year-old male presents with axial lower back pain. The pain is aggravated with activity and bending backwards, and relieved with sitting. Physical exam reveals pain on extension and rotation to the left. The pain is reproduced on the left side only. Physical therapy was tried—it failed after 6 weeks. The patient is a diabetic and his endocrinologist has forbid any type of cortisone treatment. The patient says the pain is not controlled by medication and his quality of life is poor. MRI reveals "facet joint hypertrophy" and "Modic type 2 changes" and no evidence of disc herniation. Two attempts at left L4, L5, and S1 median branch diagnostic blockade result in temporary pain relief. Which one of the following options would be the best choice for the next intervention? A - Intraarticular facet injection with corticosteroid B - Attempt a second course of physical therapy C - Start a trial of opioid medication treatment D - Perform a unilateral medial branch neurotomy E - Perform a L3-4, L4-5, and L5-S1 discography
Your answer is Correct: D - Perform a unilateral medial branch neurotomy EXPLANATION: The physical exam clearly points toward a facet joint problem. The MRI confirms lack of herniated discs and facet pathology. Option A is incorrect because the patient said that he cannot have cortisone treatments. The pain physician must work with each patient's other physicians to optimize outcome. Option B is incorrect, as repeating unsuccessful treatments is not logical. If one could show that the first set of therapy was done incorrectly then another course would be warranted. Option C is incorrect. Although opioid pain management is one option, long-term opioids are often not the best option when evidence-based, nonopioid options are still available to the patient. Option D is correct. Although controversial, there are published studies that suggest that 2 successful medial branch diagnostic blocks that result in 70% pain relief (or greater) result in a more likely positive outcome of subsequent medial branch neurotomy. Option E is incorrect. Although discogenic pain has not been fully ruled out, the clinical exam does not suggest discogenic pain to be the most likely cause of the pain. Typically, discogenic pain is worse with flexion and may be improved with extension.
A 15-year-old African American patient has had chronic pain since the age of 10. His acute-on-chronic pain is due to vasoocclusive crises. He is at increased risk for which one of the following painful conditions? A - Hepatitis A B - Cryptococcal meningitis C - Malaria D - Herpes zoster E - Osteomyelitis
Your answer is Correct: E - Osteomyelitis EXPLANATION: This question is regarding sickle cell disease. Patients with sickle cell disease have often had splenic infarcts and autosplenectomies by this age, placing them at an increased risk for infection by encapsulated organisms. Option E is the correct answer. Options A and D are incorrect because they are viral infections. Option C is incorrect because it is a fungal infection and there is some evidence that sickle cell trait is protective against malaria.
Fraternal twins (a girl and a boy) have bilateral knee pain that occurs intermittently. You ask each of them separately what they think the cause of the pain is. The boy may be more likely than the girl to attribute his pain to which one of the following factors? A - Weather B - Medical illness C - Emotion D - Psychological stress E - Physical exertion
Your answer is Correct: E - Physical exertion EXPLANATION: Cultural roles and expectations often shape our interpretation of events. In one study where both girls and boys experienced pain, the girls reported that their symptoms were triggered by changes in weather, medical illness, emotions, or psychological stress. Boys commonly reported that physical exertion was the primary trigger for pain. The causes of pain may vary based on gender. In addition, the investigators concluded that it may be more acceptable for boys to attribute pain to physical activity rather than other causes.
A 33-year-old woman has numbness in her hand that occurs at night; it is relieved by shaking her hand. She has been told by her doctor that her nerve conduction studies were consistent with carpal tunnel syndrome. She was advised by her doctor to see a neurosurgeon for release of the entrapment. She comes to your office and asks if an injection will help as much as an operation. On examination, she has a positive Tinel's sign at the wrist. She does not have focal muscle atrophy. She can distinguish sharp from dull in the distribution of the median nerve. Which one of the following recommendations should you make for this patient? A - Clinical guidelines from the American Academy of Orthopedic Surgery and The American Academy of Neurology endorse a trial of conservative treatment that may include local injection prior to surgery in mild and moderate carpal tunnel syndrome B - There are not randomized controlled studies that show comparable efficacy of corticosteroid injections and surgical decompression C - Randomized controlled studies show a much faster improvement in the Visual Analog Pain Score with surgical decompression D - There is a high rate of complication when injections are done without ultrasound guidance E - Corticosteroid injection has a better likelihood of reducing pain than surgery
he correct answer is: A - Clinical guidelines from the American Academy of Orthopedic Surgery and The American Academy of Neurology endorse a trial of conservative treatment that may include local injection prior to surgery in mild and moderate carpal tunnel syndrome EXPLANATION: A recent randomized, controlled trial of patients with mild to moderate carpal tunnel syndrome compared injection versus surgery; results showed comparable outcomes for patients who had injections versus patients who had surgery. This study followed the patients for 2 years, starting at the time of injection or surgery. Surgery is recommended for patients with severe carpal tunnel as manifested by muscle atrophy, substantial sensory loss, or severe grade on nerve conduction testing. A trial of conservative treatment is recommended for patients who are not in the category of severe carpal tunnel syndrome. Studies have shown that ultrasound guidance improves the location of the injection—but, it does not decrease the rate of adverse effects.
Your office receives a phone call asking whether you utilize hypnosis in your pain practice. This is not part of your usual treatment protocol but you are open to the idea of hypnosis and other alternative strategies. You ask what age the patient is. You are most likely to recommend hypnosis as an adjunct treatment if the patient falls into which one of the following age groups? A - 0 to 3 B - 7 to 14 C - 18 to 22 D - 35 to 64 E - 85 and older
he correct answer is: B - 7 to 14 EXPLANATION: This question is asking which age group is most susceptible to hypnosis, and therefore, which age group might find hypnosis to be a useful adjuvant treatment for pain. Ages 0 to 3 are too young to understand and participate in hypnosis. Between the ages of 7 and 14, children have the greatest imagination and are thought to be the most suggestible. The other age groups may benefit from hypnosis but not as much as the 7 to 14 age group.
An elderly gentleman with end-stage chronic obstructive pulmonary disease (COPD) is on morphine, diphenhydramine, ondansetron, and paroxetine. He reports diffuse itching without an associated rash. Which one of the following potential causes is the most likely explanation for this patient's symptoms? A - Morphine B - Diphenhydramine C - Ondansetron D - Paroxetine E - Eczema
EXPLANATION: This question is about causes of pruritus. Option A is the correct answer. Morphine is more likely to cause opioid-induced pruritus than other opioids (such as hydromorphone or oxycodone). Options B, C, and D all represent treatments for opioid-induced pruritus. Eczema can cause itching—but typically in localized patches. There is an associated rash. Opioid-induced pruritus is more diffuse than eczema.
A patient with rheumatoid arthritis, osteoporosis, inflammatory bowel disease, and left-sided L3-4, L4-5, and L5-S1 disc herniations on MRI reports chronic lower extremity pain. He undergoes a selective nerve root block with 1% lidocaine at the left S1 level. He has complete resolution of his symptoms—but only for 4 to 5 hours. One-hundred percent of the pain returns afterwards. Which one of the following statements is accurate based on the findings for this patient? A - The patient may be a candidate for a discectomy at L5-S1 B - The patient may be a candidate for a radiofrequency ablation of the S1 spinal nerve C - The patient may be a candidate for a sacroiliac joint injection for sacroiliitis D - The patient may be a candidate for vertebroplasty at L5 and S1 E - The patient is not a candidate for further interventions at this level
The correct answer is: A - The patient may be a candidate for a discectomy at L5-S1 EXPLANATION: This question is about the role of selective nerve root blocks. Option A is correct because the test showed that the L5-S1 disc is the cause of the patient's symptoms. Option B is incorrect because RFA of a spinal nerve is not an accepted course of treatment for this condition. Options C and D are unrelated to the selective nerve root block. Option E is incorrect.
An obese, sedentary 56-year-old man presents with severe acute pain in his right great toe, exacerbated by light contact with linen. He has no fever, chills, or night sweats. Physical examination demonstrates edema, erythema, diminished range of motion, and exquisite tenderness of the first metatarsophalangeal joint. There is no weakness or sensory change in either lower extremity. Serum uric acid level is elevated. Which one of the following statements is true of this patient? A - This patient has somatic pain that will likely resolve after treatment for an underlying condition B - Central pain, such as exhibited by this patient, is notoriously difficult to treat C - This patient's symptoms will probably improve after one or more fluoroscopically-guided epidural steroid injection D - Sensory stimulation by a physical therapist will be helpful in alleviating the pain E - Joint fluid analysis is likely to reveal presence of greater than 100,000 neutrophils
The correct answer is: A - This patient has somatic pain that will likely resolve after treatment for an underlying condition EXPLANATION: Physical examination points to somatic pain most likely related to acute arthropathy related to uric acid crystal deposition. Edema, erythema, diminished range of motion, and exquisite tenderness suggest joint inflammation and argue against central pain. Absence of motor or sensory changes makes acute radiculopathy (which would likely respond to axial injections) less likely. Sensory stimulation, which might help in deafferentation pain, is less useful in the setting of somatic pain. Septic arthritis would usually present with fever, chills, or night sweats.
A 23-year-old male presents with spasticity of spinal cord origin. Baclofen therapy is initiated. Which one of the following receptors does baclofen activate? A - GABA-A B - GABA-B C - a2 adrenergic receptors D - Serotonergic receptors E - Mu receptors
The correct answer is: B - GABA-B EXPLANATION: Baclofen is commonly used as skeletal muscle relaxant. Option B is correct, as baclofen activates GABA-B receptors in the brain and reduces the release of excitatory neurotransmitters in both the brain and spinal cord. Baclofen also acts by inhibiting the release of substance P in the spinal cord. Option A is incorrect, as benzodiazepines and not baclofen activate GABA-A receptors. Option C is incorrect, as tizanidine (another skeletal muscle relaxant) acts on a2 adrenergic receptors. Option D is incorrect, as cyclobenzaprine—and not baclofen—acts on serotonergic receptors. Option E is incorrect, as opioids—and not baclofen—bind to Mu receptors.
A 24-year-old woman suffers from severe chronic pain, for which she has taken several pain medications of various classes. She is very concerned about the risk for teratogenicity. Which one of the following drugs would be most appropriate for use during pregnancy? A - Aspirin B - Morphine C - Carbamazepine D - Ergotamine E - Gabapentin
The correct answer is: B - Morphine EXPLANATION: There is no evidence that exposure to maternal opioid agonists (such as morphine, option B) or agonist-antagonists during pregnancy is teratogenic. Chronic in utero exposure to opioids may lead to neonatal abstinence syndrome, but this can be effectively treated post-partum. Use of aspirin (option A) during pregnancy has been associated with an increased risk of gastroschisis. The anticonvulsant carbamazepine has been associated with fetal dysmorphic syndromes. There is some evidence that both gabapentin (option E) and pregabalin cause malformation in rodent studies, although data collected in the gabapentin pregnancy registry (n=51) did not identify an increased risk of fetal outcome. Ergotamine (option D) is contraindicated in pregnancy, as it may be teratogenic and has been shown to cause uterine contractions.
A 25-year-old man suffered a traumatic amputation of the left lower extremity after an auto accident. The patient complains of pain in the distal area of the missing extremity. Which one of the following options is the best treatment plan for this patient? A - Sympathetic blocks B - Multimodal treatment C - Narcotics D - Acupuncture E - Biofeedback
The correct answer is: B - Multimodal treatment EXPLANATION: This question describes a patient with phantom limb pain, which is pain in the area of the amputated extremity. Option A is incorrect, as sympathetic blocks alone are not effective. Option B is correct, as a variety of different techniques including pharmacologic, nonnarcotic medications, anticonvulsants and nerve blocks may all be successful in treatment of this pain. Option C is incorrect, as phantom pain may not be controlled solely with narcotics; option D is incorrect, as acupuncture is not successful long term; option E is incorrect, as biofeedback does not appear to be widely used for this type of pain.
A 32-year-old woman presents to pain clinic with severe musculoskeletal pain of 3 months' duration. She was previously employed as an administrative assistant but has been unable to work because of this pain. She reports that her pain is worse on days when her mood is "down" and admits sleep disturbance. She denies nausea and vomiting. If her symptoms are not intentionally produced, which one of the following diagnoses is the most likely? A - Factitious disorder B - Pain disorder C - Somatization disorder D - Malingering
The correct answer is: B - Pain disorder EXPLANATION: This question describes a patient with pain disorder. Option A is incorrect because, in factitious disorder, symptoms are deliberately feigned or produced. Option B is correct since the patient has pain causing clinically significant distress, psychological factors (i.e., depression) are playing an important role in the severity of pain and the symptom is not intentionally produced. Option C is incorrect because patient does not meet criteria for somatization disorder (4 different sites or functions, 2 gastrointestinal symptoms, 1 sexual symptom, 1 pseudoneurological symptom [balance, aphonia, etc.]). Option E is incorrect because, in conversion disorder, the symptom or deficit cannot simply be limited to pain, it must involve an additional motor or sensory function. SOURCE: Bonica's Management of Pain: 4th edition, 410-413, 2010
A 38-year-old female, diagnosed with fibromyalgia, is on multiple medications for her pain. She participates in aerobic exercise daily; yet, she continues to have debilitating pain that prevents her from returning to work as a department store manager. Which one of the following medications used to treat fibromyalgia binds to the a2d (alpha 2 delta) subunit of the voltage-dependent calcium channel in the central nervous system? A - Duloxetine B - Pregabalin C - Milnacipran D - Nortriptyline E - Venlafaxine
The correct answer is: B - Pregabalin EXPLANATION: Fibromyalgia may be treated with a variety of medications, including pregabalin, duloxetine, and milnacipran. Pregabalin, the correct response, binds to the a2d (alpha 2 delta) subunit of the voltage-dependent calcium channel in the central nervous system. However, the exact mechanism of action of pregabalin in ameliorating symptoms of fibromyalgia is unknown. Reduction of calcium influx into neurons may reduce the release of substance P, glutamate, and norepinephrine, which is thought to mediate its analgesic and anxiolytic actions. Duloxetine and milnacipran are serotonin-norepinephrine (noradrenaline) reuptake inhibitors (SNRIs), as are nortriptyline and venlafaxine.
A 25-year-old football player suffered a shoulder injury during a game. He since has not been able to raise his arm above 70° due to the pain. The shoulder MRI showed a complete tear of 2 ligaments. He was seen by an orthopedic surgeon and underwent arthroscopic surgery. Which one of the following options represents the 4 muscles that constitute the rotator cuff? A - Supraspinatus, infraspinatus, teres major, and subscapularis B - Supraspinatus, infraspinatus, teres minor, and subscapularis C - Supraspinatus, infraspinatus, levator scapulae, and deltoid D - Deltoid, infraspinatus, rhomboideus minor, and subscapularis E - Supraspinatus, infraspinatus, teres minor, and deltoid
The correct answer is: B - Supraspinatus, infraspinatus, teres minor, and subscapularis EXPLANATION: This question describes relevant shoulder anatomy in a patient with a rotator cuff injury. Option B is correct since the 4 muscles which constitute the rotator cuff are the supraspinatus, infraspinatus, teres minor, and subscapularis. Option A is incorrect, as teres major is not part of the rotator cuff muscles. Option C is incorrect, as the levator scapulae and deltoid muscles are not part of the rotator cuff muscles. Option D is incorrect, as the deltoid and rhomboideus minor are not part of the rotator cuff muscles. Option E is incorrect, as the deltoid muscle is not part of the rotator cuff muscles.
Allodynia is characterized by which one of the following options? A - Pain resulting from a non-painful stimulus B - Exaggerated pain from a painful stimulus C - It is mediated by C-fibers D - It is mediated by A-delta fibers E - It is synonymous with hyperalgesi
Your answer is Correct: A - Pain resulting from a non-painful stimulus EXPLANATION: Allodynia is defined as pain that results from a non-painful stimulus, whereas hyperalgesia is defined as an increased response to a stimulus that is normally painful. When using these terms to describe pain in a patient, one must consider the mechanisms involved. Allodynia results from the activation of A-beta fibers that then activate sensitized dorsal horn afferents that would normally not respond to A-beta fiber activation. This can occur through a "windup" phenomenon of wide dynamic range neurons in the dorsal horn, or rewiring of dorsal horn neurons after nervous system injury. Hyperalgesia results from activation of sensitized C-fibers and A-delta fibers or exaggerated response of sensitized dorsal horn cells that normally receive input from C-fibers and A-delta fibers.
he young woman in question above returns to her orthopedic surgeon for evaluation and treatment of her pain. The surgeon rules out infection or other surgery-related conditions. She prescribes gabapentin 300 mg 3 times a day and refers the patient to a pain management physiatrist. Before treatment, the physiatrist determines the baseline intensity and quality of the patient's pain so that further intervention effectiveness can be assessed. Which one of the following assessment tools is valid for determining the efficacy of a treatment or intervention for neuropathic pain over a period of time? A - Quantitative sensory testing (QST) B - The global impression of change reported by patient (PGIC) C - The painDETECT questionnaire D - Manual muscle testing (MMT) E - Health-related quality of life (HRQoL) measurement
The correct answer is: B - The global impression of change reported by patient (PGIC) EXPLANATION: It is important to continuously evaluate the efficacy of a medication or intervention, either clinically or through research. Option B is correct: The PGIC is a patient-reported outcome measure which is very sensitive to overall treatment effects that describes pain intensity measurement change at intervals. The PGIC is recommended—especially for chronic pain treatment trials. Option A (QST) is not correct, reliable, or sensitive to change for determining neurological somatosensory changes in neuropathic pain states. Option C is incorrect: painDETECT is a validated screening tool for diagnostics of neuropathic pain but not useful in assessing response to treatment. Option D is not correct: MMT can document return or loss of physical strength; however, it is limited in determining treatment efficacy, as neurological changes may not correspond to pain changes. Option E is incorrect: HRQoL is a general term and not, in itself, an outcome measurement. Specific quality-of-life indicators describe the impact of neuropathic pain on an individual's physical, psychological, and social functioning.
A 75-year-old male with rectal cancer is admitted to the palliative care unit for pain control. The patient has severe pain in the pelvic and peroneal area due to progressive disease. His pain has been refractory to pharmacologic therapy. The patient has never achieved adequate analgesia and has experienced significant side effects. The patient's performance status is poor which makes him ineligible for placement of an implantable device; however, he is being considered for neuraxial neurolysis. Which one of the following statements is correct regarding lumbosacral (intrathecal) alcohol neurolysis? A - The patient is placed in the lateral decubitus position (painful side up) with a slight backward tilt (supine), the needle enters the subarachnoid space at L4/L5, and 100% alcohol is injected in 0.1 mL increments B - The patient is placed in the lateral decubitus position (painful side up) with a slight forward tilt (prone), the needle enters the subarachnoid space at L4/L5, and 100% alcohol should be injected in 0.1 mL increments C - The patient is placed in the lateral decubitus position (painful side down) with a slight forward tilt (prone), the needle enters the subarachnoid space at L5/S1, and 6% phenol is injected in 0.5 mL increments D - The patient is placed in the lateral decubitus position (painful side up) with a slight backward tilt (supine), the needle enters the subarachnoid space at L5/S1, and 6% phenol is injected in 0.5 mL increments E - The patient is positioned in prone position, the needle enters the subarachnoid space at L4/L5, and 50% alcohol is injected in 0.2 mL increments
The correct answer is: B - The patient is placed in the lateral decubitus position (painful side up) with a slight forward tilt (prone), the needle enters the subarachnoid space at L4/L5, and 100% alcohol should be injected in 0.1 mL increments EXPLANATION: This question describes the correct patient positioning for lumbosacral intrathecal alcohol neurolysis. Alcohol is more commonly used for intrathecal neurolysis, and phenol for epidural neurolysis. For subarachnoid alcohol block, the patient is positioned in the lateral decubitus position with a slight forward tilt to maximize exposure of the fila radicularia to the neurolytic. The painful side is placed uppermost to maximize the hypobaric property of alcohol. The injection is performed in 0.1 mL aliquots using a tuberculin syringe at the spinal level where the nerve root exits the spinal cord. The patient should remain in the same position for at least 30 minutes to avoid spread onto non-targeted structures. Option B is correct since the patient receiving lumbosacral intrathecal alcohol neurolysis should be placed in the lateral decubitus position (painful side up) with a slight forward tilt (prone), the needle enters the subarachnoid space at L4/L5, and 100% alcohol is injected in 0.1 mL increments. Option A is incorrect, as patients placed in the lateral decubitus position (painful side up) with a slight backward tilt (supine) will experience neurolysis in non-targeted structures in the anterior portion of the cord due to the hypobaric properties of alcohol. Option C is incorrect, as patients placed in the lateral decubitus position (painful side down) with a slight forward tilt (prone), will experience neurolysis in non-targeted structures in the anterior portion of the cord due to the hyperbaric properties of phenol. Option D is incorrect, as patients placed in the lateral decubitus position (painful side up) with a slight backward tilt (supine), will experience neurolysis in the non-painful side due to the hyperbaric properties of the phenol. Option E is incorrect, as it is less likely to have the expected results if the patient is placed in prone position and applying 50% alcohol.
A 62-year-old male has suffered with contracture of his biceps femoris tendon for several years and refuses needle-based and medication-based therapies due to fear of side effects. He would like to try a non-invasive treatment modality. Which one of the following mechanisms of heat transfer is most likely to penetrate deep tissues and transfer heat there while sparing superficial tissues? A - Radiation B - Conduction C - Conversion D - Evaporation E - Convection
The correct answer is: C - Conversion EXPLANATION: Conversion (option C) is the only mechanism listed that can efficiently transfer heat to structures more than a few centimeters below the skin surface. Ultrasound generators convert electrical energy into vibratory energy through the piezoelectric properties of a crystal transducer. When these vibrations are directed into tissue, they generate heat in transitional areas of different density (e.g., between bone and muscle). Radiation (option A) is transfer of heat through thermal radiation at the surface (e.g., a heating lamp). Conduction (option B) is heat transfer through direct contact, as with a warm compress. Evaporation (option D) involves heat transfer when a fluid absorbs energy from the surrounding tissue as changes state from liquid into gas. Convection (option E) involves heat transfer through a fluid medium (e.g., warm air moving across a patient in a forced air blanket).
The Rome III Diagnostic Criteria standardized criteria for the diagnosis of functional gastrointestinal disorders. The Rome III stated that a pediatric abdominal pain syndrome must have (1) continuous or nearly continuous abdominal pain; (2) no or only occasional relationship of pain with physiological events (eating, defecation, or menses); (3) some loss of daily functioning; (4) the pain is not feigned; and (5) insufficient symptoms to meet criteria for another gastrointestinal disorder that would explain the pain. In comparison to the Rome II criteria, the Rome III criteria classified the largest percentage of children with recurrent abdominal pain as having which one of the following conditions? A - Functional abdominal pain B - Abdominal migraines C - Irritable bowel syndrome D - Acute appendicitis E - Signs of malingering
The correct answer is: C - Irritable bowel syndrome EXPLANATION: When applied in a cohort of almost 400 patients, the Rome III criteria found that 45% had irritable bowel syndrome, 23% had abdominal migraine, and 11% had functional abdominal pain. Acute appendicitis is not a cause of chronic recurrent abdominal pain. Cases of malingering are excluded by the Rome III criteria.
A 50-year-old female is thought to have piriformis syndrome. Under fluoroscopic or ultrasound guidance, you inject the muscle with botulinum toxin. Your post procedure recommendations include which one of the following statements? A - It is very important to perform core strengthening exercises B - It is very important to perform McKenzie's extension exercises C - It is very important to have a program of stretching exercises that includes adducting and internally rotating the hip while it is in the flexed position D - It is very important to flex and extend the hip
The correct answer is: C - It is very important to have a program of stretching exercises that includes adducting and internally rotating the hip while it is in the flexed position EXPLANATION: The piriformis muscle originates on the sacrum and inserts on the greater trochanter of the femur. It is stretched by the FAIR maneuver which is flexion, adduction, and internal rotation of the hip. After the patient has an injection, the patient needs to start a stretching program that includes stretching of the piriformis muscle.
A 35-year-old female with history of migraine headaches refractory to conservative treatment is being evaluated for a peripheral nerve stimulator trial after successful occipital nerve blocks. After interviewing the patient, your newly-hired physician assistant asks you which parameters would be necessary to fulfill during a peripheral nerve stimulator trial. Which one of the following statements would be the most accurate answer for your physician assistant? A - The use of the minimum amount of leads during stimulation B - Trial for a maximum of 5 to 7 days C - Stimulation coverage of most painful areas D - The use of local anesthetic along the path of the peripheral stimulator to prevent procedural pain as a possible confounding factor E - The use of intravenous sedation to facilitate lead placement
The correct answer is: C - Stimulation coverage of most painful areas EXPLANATION: This question reviews optimal parameters for a successful peripheral nerve stimulator trial. Optimal PNS trial parameters include stimulation coverage of the painful area, optimal number of leads, light sedation, coverage of painful area confirmed by patient verbal responses, and a trial period 5 to 7 days. Option C is correct since one of the most important parameters during stimulation is being able to cover the painful areas during the trial. Option A is incorrect, as there is no minimum of contacts or leads that should be utilized for trial. Option B is incorrect, as the trial period must be long enough to allow several setting changes to reach optimal stimulation as well as to let the patients familiarize themselves with the new device. The recommended trial length is 5 to 7 days. Option D is incorrect, as the use of local anesthetic along the stimulator path will preclude intraoperative testing as the painful area will be anesthetized. Option E is incorrect, as, in the majority of cases, lead placement is simple enough to warrant only local anesthetic at the needle entry site and light sedation. The patient should be able to participate with verbal responses during intraoperative testing. SOURCE: Benzon HT, Raja SN, Liu SS, Fishman SM & Cohen SP. Cervicogenic Headache. Essentials of Pain Medicine:
A 50-year-old man presents with pain over the clavicle and the scapula. He reports that he feels his arm is weak and he is having trouble lifting anything above shoulder level. Examination shows the patient to have normal tone and reflexes. There is weakness in terms of abduction and external rotation of the shoulder compared to the contra lateral side. Internal rotation of the shoulder has preserved strength as do movements at the elbow, wrist, and hand. There is atrophy of the muscles above the spine of the scapula. There are no sensory deficits. The patient may have which one of the following conditions? A - C5 radiculopathy B - Upper trunk brachial plexus injury C - Suprascapular nerve palsy D - Rotator cuff tear E - Hill-Sachs lesion
The correct answer is: C - Suprascapular nerve palsy EXPLANATION: The suprascapular nerve is a branch of the upper trunk of the brachial plexus. It travels through suprascapular notch of the scapula to reach the supraspinatus and infraspinatus muscles. It may be injured by repetitive motion, by space occupying lesions, and by wearing a knapsack that compresses the nerve (knapsack palsy). The condition causes weakness in abduction and external rotation of the shoulder but would not be associated with reflex or sensory loss. The condition can be evaluated by MRI to look for evidence of a lesion and by nerve conduction study of the nerve. A C5 radiculopathy would involve the biceps muscle and the deltoid. Neither rotator cuff tear nor instability of the humerus in the glenoid fossa would result in atrophy of the supraspinatus muscle. SOURCE: Walsworth MK, Mills ST, Michner LA.Diagnosing suprascapular neuropathy in patients with shoulder dysfunction a report of 5 cases. Physical Therapy 2004; 84:359-72
A 16-year-old female involved in a motor vehicle accident has been admitted to the hospital with severe injuries to her right leg. Pain management has been consulted to manage the pain. Management of her pain has been very difficult. Over the prior 2 days, given the deterioration in her clinical condition, vascular surgery has decided that a below-the-knee amputation is necessary. As the patient and her family cope with the news, they are very concerned about the pain after the surgery—especially with phantom pain. Which one of the following statements in regard to phantom pain should you provide to the patient and her family? A - Few amputees (<20%) experience phantom pain B - In most patients, onset of pain may be delayed for more than a year C - Phantom limb pain, if it happens, is permanent D - "Telescoping" or shortening of the phantom limb is usual E - Treatment of phantom limb pain is straightforward
The correct answer is: D - "Telescoping" or shortening of the phantom limb is usual EXPLANATION: Phantom limb pain is a frequent and unfortunate complication of amputation. It occurs in about 80% of patients who undergo amputation. Onset can be immediate but is usually within the first few days to a week after amputation. In about 50% of patients, phantom pain reduces with time and even occasionally resolves. Unfortunately, treatment of phantom pain—both pharmacologic and nonpharmacologic—is inconsistent and treatment is challenging. A sensation of shortening of the phantom limb or telescoping usually occurs in a majority of patients.
A 63-year-old woman, with a 10-year history of chronic spinal degenerative disk disease and back pain, is on moderately-high daily doses of long- and short-acting opioids for pain management. She then develops left lower extremity weakness and radiculopathy. Following a L4-L5 vertebral discectomy and fusion, she notes good relief of pain with return of strength in her lower extremity. She is referred to physical therapy on the second postoperative day. In order to participate in physical therapy, she requests and receives 1.5-times her baseline, scheduled long- and short-acting opioid dose. On the first day of therapy, she reports excruciating low back pain. Workup for a surgical complication is unremarkable. Which one of the following pain management modifications would be the most appropriate to order? A - Increase her current long- and short-term opioid dose B - Increase her short-term opioid dose—but decrease her current long-term opioid dose C - Decrease her current short-term opioid dose, keep the same long-term opioid dose, and add a new short-acting opioid medication D - Decrease her current long- and short-term opioid dose and add celecoxib E - Decrease her current long-and short-term opioid dose and add ibuprofen
The correct answer is: D - Decrease her current long- and short-term opioid dose and add celecoxib EXPLANATION: Postsurgical pain and hyperalgesia (described as exaggerated pain to a noxious stimulus) is a common sequela for individuals previously on long-term moderate and moderately-high opioid doses. Options A, B, and C are incorrect in that increasing opioids postoperatively can exacerbate the hyperalgesia. Maintaining the presurgical opioid doses while using adjuvant therapies such as nonsteroidal anti-inflammatory (NSAID) medications is a recognized strategy. Option E (ibuprofen) is a propionic acid NSAID—but it can interfere with bone formation and fusion, so it is contraindicated for 6 weeks after orthopedic surgery. Option D (celecoxib) is the cox-2 inhibitor NSAID proven to diminish surgical pain without interruption of bone formation.
A pedestrian is hit on the side of his right knee by an errant taxi driver, causing the unlucky pedestrian to fall to the ground. The injured pedestrian is screaming in pain. He is taken to the local ED where an MRI is read as showing an "unhappy triad." Which one of the following ligaments should be expected to be effected in this victim? A - Ulnar collateral B - Medial collateral C - Lateral collateral D - Deltoid E - Patella
Your answer is Correct: B - Medial collateral EXPLANATION: An "unhappy triad" (also known as the O'Donoghue's triad) refers to injuries to anterior cruciate ligament, medial collateral ligament, and medial meniscus, usually secondary to a valgus blow to the lateral side of the knee. The unhappy triad does not involve the other ligaments mentioned.
A patient who underwent 2 lumbar medial branch block (MBB) procedures with transient pain reduction of greater than 80% requests a radiofrequency ablation procedure (RFA) at the corresponding levels. He has recently been diagnosed with symptomatic bradycardia and is being scheduled for urgent pacemaker placement by the cardiology service at your hospital. Which one of the following steps is the most appropriate? A - Ask the cardiologist to delay the pacemaker placement until after the RFA B - Cancel the RFA permanently and continue with MBB procedures with steroids every month to treat the patient's pain C - Perform the RFA while the pacemaker is active D - Request that one of the cardiology technicians turn off the pacemaker temporarily during the RFA and restart it immediately afterwards E - Stop all interventional spine procedures given the patient's arrhythmia
The correct answer is: D - Request that one of the cardiology technicians turn off the pacemaker temporarily during the RFA and restart it immediately afterwards EXPLANATION: This question is about the relationship between RFA and pacemakers. The electrical current from the RFA generator can interfere with the pacemaker. Therefore, option D is the correct answer and option C is incorrect. Option A is incorrect because symptomatic bradycardia takes priority over low back pain. Option B is incorrect because of the toxic level of corticosteroid that would be administered over the course of a year. Option E is incorrect because it is simply unnecessary.
Given the patient's situation described above, in prescribing exercise with a physical therapist, you are interested in explaining how exercise actually works in a very deconditioned patient. Which one of the following statements regarding the Henneman principles of therapeutic exercise is accurate? A - Motor units are recruited in order of increasing size, decreasing contraction strength, and decreasing fatigue resistance B - Motor units are recruited in order of increasing size, increasing contraction strength, and increasing fatigue resistance C - Motor units are recruited in order of increasing size, decreasing contraction strength, and increasing fatigue resistance D - Motor units are recruited in order of decreasing size, decreasing contraction strength, and increasing fatigue resistance E - Motor units are recruited in order of increasing size, increasing contraction strength, and decreasing fatigue resistance
The correct answer is: E - Motor units are recruited in order of increasing size, increasing contraction strength, and decreasing fatigue resistance EXPLANATION: Option A is incorrect because less powerful muscles have the lowest firing threshold and are recruited first due to the demands for larger forces. Option B is incorrect because the most fatigue-resistant motor units, which contain slow-twitch muscle fibers, are recruited first. The largest motor units that contain the quickly fatiguing fast-twitch B fibers have the highest threshold and are recruited last. Option C is incorrect because motor units are recruited with the smaller units recruited first with the larger ones recruited after. Options D and E are incorrect on all 3 parameters.
A 72-year-old man reports severe burning pain in his ring finger and little finger and weakness of handgrip after a complicated cholecystectomy. He had no prior history of pain and no other neurological deficits. Which one of the following electromyography (EMG) findings is most associated with a good prognosis for return of muscle function? A - Increased insertional activity 3 weeks after surgery B - Increased spontaneous activity 3 weeks after surgery C - Reduced recruitment 3 weeks after surgery D - Normal insertional activity 1 week after surgery E - Paucity of spontaneous activity 3 weeks after surgery
The correct answer is: E - Paucity of spontaneous activity 3 weeks after surgery EXPLANATION: This stem describes an ulnar neuropathy, perhaps due to compression during general anesthesia. The severity of an injury can be assessed using EMG studies to compare the amplitude difference of the same nerve on affected and unaffected sides. A paucity of spontaneous activity in affected muscles 3 weeks after injury (option E) indicates an excellent outcome for the return of muscle function. The remaining choices all describe findings consistent with demyelinating nerve injury. Option D is additionally incorrect, as, often times, EMG studies are often normal in the first week after injury, even if profound injury is developing.
A 35-year-old female is referred to you for persistent facial pain after a dental procedure. The patient reports episodes of sharp and shooting pain along the right jawline, each lasting for approximately 10 seconds. She reports 4 to 6 episodes per day, mostly associated with triggers such as cold beverages, eating, or brushing her teeth. She has been diagnosed with trigeminal neuralgia of the mandibular nerve distribution. Which one of the following areas is innervated by the mandibular nerve? A - Teeth of the upper jaw B - Skin over middle third of face C - Lower part of the nose D - Tonsillar fossa E - Temporomandibular joint
The correct answer is: E - Temporomandibular joint EXPLANATION: This question describes a patient with trigeminal neuralgia (mandibular distribution) and mentions several anatomical areas that are innervated by the mandibular nerve. The mandibular nerve (V3) is the largest of the 3 branches of the trigeminal nerve. It's made up of 2 roots: a large sensory root proceeding from the inferior angle of the trigeminal ganglion and a small motor root, which passes beneath the ganglion and unites with the sensory root just after its exit through the foramen ovale. The mandibular nerve divides into 2 trunks—anterior and posterior—giving off multiple branches along their path. The mandibular nerve innervates the mandible, anterior 2/3 of the tongue, teeth of the lower jaw, external auditory meatus, temporal region, anterior ear, and temporomandibular joint. Option E is correct since the temporomandibular joint is innervated by the mandibular division of the trigeminal nerve. Options A through D are all incorrect, as these structures are innervated by the maxillary nerve.
A 55-year-old female, former intravenous drug user on methadone maintenance treatment program had been treated effectively for lower back pain back due to degenerative disc disease by you in the past, but had not been seen in clinic for 3 years. Since last seen she has undergone a multilevel posterior lumbar fusion and developed new pain in the lower back and right lower extremity 9 months after surgery. The patient is taking several medications, including pregabalin, tizanidine, and oxycodone, with minimal benefit. These medications are being prescribed by her primary care physician who referred the patient to you because he is worried about drug abuse. Which one of the following steps in care is the most appropriate to ensue for this patient? A - Review history with primary care physician B - Do not accept the patient into your practice since she is probably abusing opioids C - Treat the patient with interventional approaches only D - Obtain a spine surgery consult E - Perform a spinal cord stimulation trial for failed back surgery syndrome
Your answer is Correct: A - Review history with primary care physician EXPLANATION: This question describes the case of a patient with recurrent lower back pain after lumbar fusion surgery on chronic opioid therapy and concern for opioid abuse. Option A is correct since a thorough evaluation must take place before deciding further treatment. The evaluation should include a review of the patient's history directly with the primary care physician or reviewing the medical records. Option B is incorrect, as not accepting the patient into your practice based on subjective data or speculations is not ethical and is not in the patient's best interest. Before making a decision to accept or refuse the patient, an appropriate investigation must take place to include but not limited to the following: review of medical records, ordering necessary imaging, toxicology screening, and communication with the methadone maintenance treatment program. Option C is incorrect, as this could be an option only after the appropriate investigation has taken place to rule out opioid abuse, misuse, or diversion; and the patient has agreed to interventional approaches. The use of nonopioid and co-adjuvant analgesics is not contraindicated in patients who are actively abusing opioids. Option D is incorrect, as a comprehensive clinical evaluation should be performed before referring a patient for spine surgery consult. Option E is incorrect, as although failed back surgery syndrome is one of the main indications for a spinal cord stimulator trial, this patient needs a full medical evaluation (including a psychological evaluation) before this procedure can take place.
Which one of the following options is a characteristic of pregabalin? A - Alpha-2-delta ligand B - Sodium-channel antagonist C - Nonlinear kinetics D - FDA approved for osteoarthritis E - Causes weight loss
Your answer is Correct: A - Alpha-2-delta ligand EXPLANATION: Pregabalin is an N-type calcium-channel modulator. It binds to the alpha-2-delta subunit of the N-type calcium channel and reduces the amount of time the channel is in the open state thus reducing intracellular calcium influx and reduced pain transmission. It has linear kinetics with plasma levels proportional to dose. It is currently FDA approved for postherpetic neuralgia, painful diabetic peripheral neuropathy, fibromyalgia, and spinal cord injury pain. Weight gain is observed in some patients, is dose- and duration-dependent, and plateaus after 3 to 4 months. Weight gain is not associated with shifts in body mass index, lipid changes, or loss of glycemic control.
Your 27-year-old patient is dying of osteosarcoma. The destructive cancer has slowly spread from his femur through his pelvis and into his spinal canal. He has concurrent sepsis and pneumonia and is having difficulty breathing. Thus far, you have increased his opioid dosage to match his pain; however, he is now starting to show signs of hypoventilation. He asks you to continue to increase his opioid dose so that he can cope with the pain. You explain the risks and benefits—the patient wants to proceed with the increase. He dies within 24 hours. The scenario illustrates a case of which one of the following options? A - Double effect B - Facilitated suicide C - Malpractice D - Unforeseen circumstances E - Withdrawal of care
Your answer is Correct: A - Double effect EXPLANATION: This question is asking about the principle of double effect, which states that the nature of an act must be good or at least morally neutral (providing analgesia for comfort) and the intention of the agent is the good effect. The bad effect may be foreseen and tolerated, but not intended (the patient dies from respiratory failure). In this case, it is appropriate to continue to treat the patient's pain despite the potential adverse effects. Therefore, this is not a case of malpractice. It is not an example of facilitated suicide since neither the patient nor the physician increased the opioid dose in order to precipitate the patient's death. The patient's death is not unforeseen since he was starting to show signs of respiratory failure. The doctor did not withdraw care. Treating pain is part of the overall care plan.
A 48-year-old man with acute cholecystitis reports severe abdominal pain despite several doses of IV fentanyl. Which one of the following agents is most appropriate to suggest that his pain is coming from biliary spasm as opposed to inadequate analgesia? A - Naloxone B - Increased dosing of IV opioids C - Opioid rotation to one to which patient is naïve D - EEG study for quantitation of pain E - fMRI study for evaluation of pain level
Your answer is Correct: A - Naloxone EXPLANATION: Sphincter of Oddi spasm is a well described side effect of opioid medications. Naloxone (option A) is a short-acting opioid antagonist that can predictably reverse the actions of opioids. If this patient's pain is primarily due to biliary spasm, then a titrated dose of naloxone should partially alleviate his pain. If his pain is due to inadequate analgesia, then a dose of naloxone will increase his pain level. Increasing the dose of IV opioid (option B) is not the best way to suggest the cause is biliary spasm, nor is rotating to a different opioid (option C). EEG and fMRI are modalities that are currently being evaluated to provide more objective measurements of patients' pain, but that have not been validated by any large studies or expert consensus opinions yet.
A 58-year-old female presents to the clinic with complaints of a gradual onset of stiffness in her bilateral wrists, knees, elbows, and metacarpophalangeal joints for the last 6 months. She reports that it takes over an hour to feel better in the morning. On physical exam, she is noted to have a nodule on the extensor surface of her proximal forearm. Which one of the following diagnoses is the most likely for this patient? A - Rheumatoid arthritis B - Osteoarthritis of multiple joints C - Psoriatic arthritis D - Gout E - Pseudogout
Your answer is Correct: A - Rheumatoid arthritis EXPLANATION: In clinical practice, the following criteria for diagnosis of rheumatoid arthritis (option A) apply: 2 or more swollen joints, and morning stiffness lasting more than one hour for at least 6 weeks. The detection of rheumatoid factors or autoantibodies can confirm the suspicion of rheumatoid arthritis. A negative autoantibody result does not exclude a diagnosis of RA. Radiographic changes (erosions, bony decalcification, joint-space narrowing seen on hand and wrist X-rays) support the diagnosis. Osteoarthritis (option B) is typically a dull, aching pain that increases with activity. Stiffness usually last less than 30 minutes and pain is worse throughout the day. Psoriatic arthritis (option C) produces joint pain as well as skin changes which cause red patches on the body. Gout (option D) typically affects the first MTP and is monoarticular. Pseudogout (option E) most commonly involves the knees, is symmetric, and is associated with fever, chills, and malaise.
A 35-year-old athlete complains of new onset right shoulder pain with elevation of the shoulder. She also complains that the pain is worse at night and with lying on her right side. Her exam shows an area of tenderness in the anterior shoulder between the coracoid and acromion processes that increases with shoulder extension. She has pain with flexion and internal rotation of the right arm. Which one of the following potential causes is the most likely for this patient? A - Supraspinatus tendon impingement B - Rotator cuff injury C - Bicipital tendinitis D - AC joint arthritis E - Cervical spondylosis
Your answer is Correct: A - Supraspinatus tendon impingement EXPLANATION: Shoulder impingement syndrome presents as shoulder pain that worsens with shoulder elevation. The pain localizes to the anterior or lateral shoulder usually. This patient shows characteristic symptoms and signs of shoulder impingement syndrome. Supraspinatus impingement is most likely as the patient exhibits a positive Hawkins test indicative of supraspinatus impingement against the coracoacromial ligament. Rotator cuff injury, while somewhat similar in presentation, has a more widespread area of pain with a greater limitation of mobility, a characteristic painful arc on abduction, and wasting of cuff muscles and shoulder instability. Bicipital tendinitis shows much less limitation of mobility with positive Speed's and Yergason's tests. AC joint arthritis shows characteristic pain and tenderness over the joint with no signs of impingement. Cervical spondylosis usually is accompanied by neck pain with referral to suprascapular area, exacerbated by cervical spine maneuvers.
A 50-year-old man presents with a complaint of pain on the anterior surface of the forearm. The patient does not have numbness and tingling in his hand; however, he reports that his grip is weak. On examination, his reflexes at the biceps, triceps, and brachioradialis are normal. Strength at the shoulder, elbow, and wrist are normal. The patient has difficulty maintaining his first and second fingers in the position of a circle against resistance. Sensory examination of the extremity is normal. MRI is without evidence of radiculopathy. The patient likely has which one of the following conditions? A - Brachial plexus injury B - Anterior interosseous syndrome C - Thoracic outlet syndrome D - Carpal tunnel syndrome E - Compression of the ulnar nerve in Guyon's canal
Your answer is Correct: B - Anterior interosseous syndrome EXPLANATION: The anterior interosseous nerve innervates the pronator quadratus, flexor pollicis longus, and the first 2 heads of the flexor digitorum profundus muscle. The patient has difficulty maintaining the "OK sign" because of weakness of the flexor pollicis longus and the first head of the flexor digitorum profundus. This syndrome may be autoimmune in origin—or, it may be caused by proximal entrapment of the median nerve. This may occur under the ligament of Struthers (a band between the distal humerus and the medial epicondyle, present in 2% of the population). It may occur under the fascia associated with the biceps tendon (lacertus fibrosus) or between the 2 heads of the pronator teres. It may occur under the fibrous arch of the flexor digitorum superficialis muscle. The recommendation is for conservative treatment for 6 to 12 months before an exploration of the median nerve to look for entrapment. The distribution of weak muscles would not be typical of a brachial plexus injury, carpal tunnel syndrome, or an ulnar nerve injury.
A 57-year-old male presents with a history of alcohol abuse. The patient complains of severe abdominal pain, which is unrelieved by opioids. The pain is sharp, aching, radiating to the back. Which one of the following treatment plans is most effective? A - Lumbar Sympathetic blocks B - Celiac plexus blocks C - Stellate ganglion blocks D - Thoracic epidural E - Spinal anesthesia
Your answer is Correct: B - Celiac plexus blocks EXPLANATION: This question describes a pain due to alcoholic pancreatitis. The best treatment is option B (celiac plexus block) as this is useful for relieving pain caused by acute visceral disease. Option A is incorrect, as lumbar sympathetic blocks are used to relieve pain in the lower extremities. Option C is incorrect, as stellate ganglion blocks are useful for head and upper extremity pain. Option D is incorrect, as thoracic epidurals cannot be used for long term pain relief. Option E is incorrect, as spinal anesthesia only provides relief for a few hours and causes motor block of the lower extremities. SOURCE: Bonica Practical management of pain
A 44-year-old hospice patient with AIDS, metastatic lung cancer, and tuberculosis has a combination of pain, nausea, and loss of appetite. He is wasting rapidly. His family asks you if he can be prescribed a synthetic form of marijuana to control his symptoms. Dronabinol, a synthetic prescription form of marijuana has FDA approval for which one of the following conditions? A - Terminal cancer-related pain B - Chemotherapy-induced nausea C - AIDS-related pain D - Panic disorder E - Glaucoma
Your answer is Correct: B - Chemotherapy-induced nausea EXPLANATION: Studies suggest that synthetic marijuana can be effective for terminal cancer-related pain and glaucoma. It may also be effective for terminal AIDS-related pain. It is only FDA-approved for chemotherapy-induced nausea and for AIDS-related anorexia and weight loss. The FDA does not endorse medical marijuana (the inhaled form). Marijuana in either form is not helpful for panic disorder and some evidence suggests that marijuana may precipitate panic attacks.
A 68-year-old man is the victim of a stabbing and has an 8 cm laceration of the left forearm. He is given hydromorphone 1 mg IV in the emergency room, and reports good analgesia with no other side effects. Which one of the following sites represents the most important site of action of hydromorphone? A - Rexed lamina I B - Rexed lamina II C - Rexed lamina III D - Rexed lamina IV E - Rexed lamina V
Your answer is Correct: B - Rexed lamina II EXPLANATION: The most important site of action of opiate medications is the substantia gelatinosa of the spinal cord, which is located in Rexed lamina II (option B). These lamina were identified on the basis of pathological specimens based on tissue architecture, and later correlated with physiological functionality. Rexed lamina I houses nociceptive specific neurons, but is not the most important site of opioid action. Most of these cells have a specific field only connected to 1 or 2 dermatomal areas. Rexed lamina V is home to wide dynamic range neurons, which can be activated similarly but correlate to a broader distribution of bodily tissues. Rexed laminae III and IV are known together as the nucleus proprius, and receive mostly non-noxious input from the periphery, conveying this input to deeper levels of the spinal cord. They are not an important site of action for opioids.
A 40-year-old female presents with diffuse pain on both sides of the body, and above and below the waist, for the prior 3 months. You identify 18 specific tender points. She reports an associated sleep disturbance. The rest of the diagnostic workup is unremarkable. If the patient's tender points were biopsied, the pathology would most likely reveal which one of the following findings? A - Ragged red fibers B - Lymphocytic proliferation C - No abnormalities D - Increased substance P E - Increased nitrogen
Your answer is Correct: C - No abnormalities EXPLANATION: This question is asking about the pathophysiology of fibromyalgia. Fibromyalgia is thought to be a central disorder—not a localized muscle disease. Therefore, option C is correct. Options A, B, and E are incorrect for the same reason. Patients with fibromyalgia may have increase substance P levels in the cerebrospinal fluid—not in the muscle. Therefore, option D is incorrect.
A 46-year-old female suffers from severe, left, lower extremity pain and has defied diagnosis despite conventional testing. You decide to do a differential spinal blockade to try to determine the etiology of her pain. Subarachnoid infusion of saline produces no pain relief; however, she experiences profound pain relief with 0.25% procaine. Which one of the following diagnoses is the most likely for this patient? A - Placebo responder B - Psychogenic mechanism C - Sympathetic mechanism D - Somatic mechanism E - Central mechanism
Your answer is Correct: C - Sympathetic mechanism EXPLANATION: In conventional differential spinal block, 4 solutions are prepared; these include the following: saline, 0.25% procaine, 0.5% procaine, and 5% procaine. Each solution is then introduced through a spinal needle, and the patient is asked how and if symptoms change. If saline improves symptoms, then either a psychogenic (if permanent relief) or placebo (if temporary relief) is suspected. If 0.25% procaine produces relief, then a sympathetic mechanism is likely. If 0.5% procaine produces relief, then a somatic mechanism of pain is likely. If there is no relief even with 5% procaine, then a central mechanism of pain is likely. In this case, relief with 0.25% procaine suggests a sympathetic mechanism—option C.
A patient with degenerative disc disease at L1-2, L2-3, L3-4, and L5-S1 undergoes lumbar discography. The patient reports no pain with pressure manometry at L1-2 and L2-3. He reports concordant pain at L3-4 at 40 psi and discordant pain at L5-S1 at 100 psi. These findings suggest that which one of the following statements is accurate? A - The patient may be a good candidate for surgery at L1-2, L2-3, L3-4, and L5-S1 B - The patient may be a good candidate for surgery at L3-4 and L5-S1 C - The patient may be a good candidate for surgery at L3-4 D - The patient may be a good candidate for surgery at L5-S1 E - The patient is not a good surgical candidate
Your answer is Correct: C - The patient may be a good candidate for surgery at L3-4 EXPLANATION: This question is about the theory behind discography. The correct answer is option C. The patient is experiencing his typical axial low back symptoms at that level and is a candidate for surgery at that level. Option D is false because the patient experienced discordant pain—pain that is different from the pain that brought him in to seek treatment. It is most likely procedure-related pain. Option A is incorrect because the patient had no symptoms at the first 2 levels. Option B is incorrect because the patient may not require surgery at L5-S1 given his discordant pain. Option E is incorrect—because he has concordant pain at 40 psi, the patient is a surgical candidate.
A 50-year-old female with neck pain for 8 months following a work-related injury presents to your clinic for her scheduled visit. She was prescribed acetaminophen with oxycodone for pain management. She reports that over the past 3 weeks she took more medication than prescribed, as she felt it was becoming less effective in controlling her pain. She ran out of medication a couple of days ago. She reports diarrhea and is noted to have dilated pupils and is sweating on examination. Which one of the following phenomena does this patient's symptoms exemplify? A - Addiction B - Analgesia C - Nociception D - Dependence
Your answer is Correct: D - Dependence EXPLANATION: When an individual persists with the use of alcohol or other drugs despite problems related to use of the substance, substance dependence (option D) may be diagnosed. Compulsive and repetitive use may result in tolerance (option E) to the effect of the drug and withdrawal symptoms when use is reduced or stopped. Addiction (option A) is characterized by craving, impaired control over drug use, compulsive use, and continued use despite harm. Analgesia (option B) is an appropriate decrease in pain resulting from normally painful stimuli. Nociception (option C) describes receptors which are preferentially receptive to noxious stimuli. SOURCE: Braddom RL. Physical Medicine & Rehabilitation. 2011 Philadelphia: Elsevier. P. 953.
A 67-year-old male with chronic back pain (which has not responded well to conservative management) undergoes an MRI. On reviewing the imaging study, you note signal changes in the bone marrow adjacent to a vertebral endplate. Which one of the following terms best describes such a feature on an MRI scan? A - High-intensity zone B - Waddell sign C - Sulcus sign D - Modic changes E - Posterior sag sign
Your answer is Correct: D - Modic changes EXPLANATION: "Modic changes" refers to signal changes in the bone marrow adjacent to a vertebral endplate on MRI scans. Modic changes imply inflammatory response to an injury to the disc. Option A refers to very bright signals that occur in the posterior annulus of lumbar intervertebral discs. Option B refers to findings in physical exam that may point to nonorganic source of low back pain. Options C and E pertain to physical exam findings in a musculoskeletal exam (shoulder and knee, respectively).
Patients with facet syndrome will most likely have pain with which one of the following maneuvers? A - While patient is extending the low back, the examiner applies a downward force from the shoulders through the low back while turning the patient's shoulders B - Patients neck and trunk are in full flexion while seated, the examiner flexes the hip, extends the knee, and dorsiflexes the patient's ankle C - Patient lies prone on the table while examiner extends the hip and maintains knee flexion D - Patient lies on his back while holding one leg in knee and hip flexion, the examiner then extends the other hip E - Patient hopes on each foot in turn
our answer is Correct: A - While patient is extending the low back, the examiner applies a downward force from the shoulders through the low back while turning the patient's shoulders EXPLANATION: Facet pain is generated from lumbar zygapophyseal joints. Axial loading with a rotation component tends to place the most stress along the facet joint exacerbates pain. Option A describes lumbar facet grind test and is the correct choice. Option B is incorrect, as a slump test is used to diagnose sciatic nerve irritation. Option C is incorrect, as a femoral nerve stretch test places a stress along the femoral nerve. Option D is incorrect, as a modified Gaenslen's test is used to diagnose sacroiliac disorders. Option E is incorrect, as the action described is not a physical examination maneuver described to date.
A 53-year-old male is driving 65 mph on the freeway when the vehicle in front of him suddenly brakes to a halt. The man is propelled into forward flexion in his seat. Which one of the following structures prevents extreme forward flexion? A - Anterior longitudinal ligament B - Posterior longitudinal ligament C - Ligamentum flavum D - Spinous processes E - Psoas muscles
our answer is Correct: B - Posterior longitudinal ligament EXPLANATION: The posterior longitudinal ligament prevents excessive forward flexion. The anterior longitudinal ligament prevents excessive extension. The ligamentum flavum and spinous processes are both posterior structures but do not prevent forward flexion. The psoas muscles are involved in hip flexion.
A 43-year-old African American female complains of joint stiffness lasting more than one hour in the morning and swelling in the wrist, hands, and fingers. She is also noted to have rheumatoid nodules in the elbows. Rheumatoid arthritis is suspected as a diagnosis. Which one of the following statements is accurate regarding this patient's condition? A - Cyclic citrullinated peptide (CCP) level is inversely correlated with joint erosion B - Pencil-in-cup deformity may be seen on X-ray C - Approximately 80% of rheumatoid arthritis patients test positive for rheumatoid factor D - Synovial fluid typically has a white blood cell count exceeding 250,000 cells per cubic millimeter E - Patients with features that suggest more mild disease are typically started on methotrexate
our answer is Correct: C - Approximately 80% of rheumatoid arthritis patients test positive for rheumatoid factor EXPLANATION: Option A is incorrect because a CCP level is directly correlated with more erosive disease. Option B is incorrect, as rheumatoid arthritis in its early disease reveals only juxtaarticular osteopenia and soft tissue swelling. In more advanced disease, there is narrowing of joint spaces, erosions at the margins of the joint, and eventually subluxation. Pencil-in-cup deformity is associated with psoriatic arthritis. Option C is correct. Approximately 80% of rheumatoid arthritis patients have a positive rheumatoid factor result. Option D is incorrect because synovial fluid usually has a white blood count that varies from 5,000 to 25,000 cells per cubic millimeter. Option E is incorrect, as patients with features that suggest more severe disease are typically started on methotrexate.
The parents of a 5-year-old female present to the ED; their daughter fell from a tree 2 hours previously and continues to complain of arm pain. According to the College of Emergency Medicine, a child with moderate to severe pain should receive appropriate analgesia within 20 minutes of arriving at the ED. Age-appropriate assessment of acute pain in children who present to the ED optimizes analgesic treatment. Appropriate analgesia will decrease the child's anxiety and facilitate physical examination and diagnostic testing. Which one of the following procedures is the standard of care for assessing pain and managing a 5 year old with acute pain after presenting to the ED with a broken humerus? A - The parent is instructed, while in the waiting room, how to evaluate the severity of the child's pain by observing and reporting whether or not the child begins to cry or scream B - The nurse observes the child's behavior—but not her reports of pain, as a child cannot accurately describe traumatic acute pain C - The physician uses a numerical rating scale to assess the magnitude of pain intensity and then discusses pain treatment medications with the parent and child D - The nurse evaluates the child's behavior and physiological changes and utilizes the Wong-Baker FACES rating scale to assess the presence of acute pain E - The nurse and physician assess the child's pain with the parent out of the room following the College of Emergency Medicine (CEM) observation tool for assessing acute pain
our answer is Correct: D - The nurse evaluates the child's behavior and physiological changes and utilizes the Wong-Baker FACES rating scale to assess the presence of acute pain EXPLANATION: Acute pain management of children in an emergency situation requires appropriate evaluation by utilization of valid, accurate protocol. Therefore, option D is correct. The nurse is one of the first clinical professionals that will evaluate the child. The Wong-Baker FACES rating scale is appropriate for a 5 year old; it incorporates the nurse's observations, the child's behavior, and the child's reports of pain. Option A is incorrect: Crying or screaming is not always related to pain. Options B, C, and E are incorrect and not accurate statements.
