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McGraw-Hill Specialty Board Review Pain Medicine

Salahadin Abdi, Pradeep Chopra, Howard Smith

Chapter 5

Diagnosis of Pain States - all with Video Answers

Educators

Chapter Questions

Problem 29

A 38-year-old police officer reports continuous neck pain lasting past 6 months. The patient recalls lifting and carrying heavy boxes while moving his house and reports some neck pain at that time. Pain has gradually worsened over the past 6 months and now patient reports heaviness and occasional weakness in his right hand. The patient often feels numbness in right index finger as well. On examination, the patient has $5 / 5$ strength in all muscle groups except mild weakness in flexors of the right elbow. Light-touch sensation is intact in all dermatomes, however, the patient reports increased sensation to light touch in the radial aspect of the right forearm. Deep tendon reflexes are intact bilaterally except for right brachioradialis reflex which is $1^*$ compared to left. This patient most likely has
(A) right $\mathrm{C} 5$ radiculopathy
(B) right C6 radiculopathy
(C) right C7 radiculopathy
(D) right C8 radiculopathy
(E) cervical facet arthritis with referred pain

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Problem 252

A 59-year-old female comes to your office complaining of moderately severe low back pain and right buttock pain which is exacerbated with prolonged sitting. On physical examination there is sciatic notch tenderness and the pain is exacerbated with flexion, adduction, and internal rotation of the right hip. Which of the following is the most likely diagnosis?
(A) L5-S1 facet syndrome
(B) Piriformis syndrome
(C) Sacroiliac (SI) joint syndrome
(D) Sciatica
(E) L3 radiculopathy

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Problem 253

A77-year-old female comes to your office complaining of 6 months of severe right buttock pain radiating into the right lower leg. The pain is also present at night and not uncommonly interferes with sleep. The pain is severe with sitting or lying on her back or right side, however, quickly dissipates with normal erect posture. Which of the following is the most likely diagnosis?
(A) Snapping bottom
(B) Sciatica
(C) Radiculopathy
(D) Piriformis syndrome
(E) Weaver's bottom

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Problem 254

A 53-year-old male comes to your office complaining of foot pain (predominantly in the heel-but also with diffuse plantar symptoms) which also occurs at night and can be exacerbated by prolonged standing or walking. It is associated with weakness of the phalanges (impairing the pushing off phase of walking) as well as sensory loss and paresthesia. After a complete history and physical examination are completed, which of the following is the next most appropriate step?
(A) Magnetic resonance imaging (MRI) of the ankle
(B) MRI of the lumbar spine
(C) Initiate anti-inflammatory medications
(D) Trial of arch support
(E) Electrodiagnostic testing

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Problem 255

A 53-year-old male comes to your office complaining of foot pain (predominantly in the heel-but also with diffuse plantar symptoms) which also occurs at night and can be exacerbated by prolonged standing or walking. It is associated with weakness of the phalanges (impairing the pushing off phase of walking) as well as sensory loss and paresthesia. Which of the following is the most likely diagnosis?
(A) Morton neuroma
(B) Peripheral neuropathies
(C) Medial plantar nerve entrapment
(D) Tarsal tunnel syndrome
(E) March fracture

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Problem 256

A 47-year-old female comes to your office complaining of an aching forearm with discomfort and numbness in the thumb and index finger, and weakness in the hand. A positive Tinel sign is present in the forearm. Which of the following is the most likely diagnosis?
(A) Anterior interosseous nerve syndrome
(B) Posterior interosseous nerve syndrome
(C) Ulnar nerve entrapment
(D) Pronator syndrome
(E) Radial nerve entrapment

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Problem 257

Complex regional pain syndrome type II (CRPS II) differs from CRPS I because in CRPS II there is
(A) allodynia
(B) movement disorder
(C) sudomotor and vasomotor changes
(D) evidence of major nerve damage
(E) severe swelling

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02:32

Problem 258

Which of the following range is the temperature most appropriate to use as a stimulus when evaluating warm temperature sensation?
(A) $25^{\circ} \mathrm{C}$ to $30^{\circ} \mathrm{C}$
(B) $30^{\circ} \mathrm{C}$ to $35^{\circ} \mathrm{C}$
(C) $35^{\circ} \mathrm{C}$ to $40^{\circ} \mathrm{C}$
(D) $40^{\circ} \mathrm{C}$ to $45^{\circ} \mathrm{C}$
(E) $45^{\circ} \mathrm{C}$ to $50^{\circ} \mathrm{C}$

Khoobchandra Agrawal
Khoobchandra Agrawal
Numerade Educator
02:32

Problem 259

Which of the following range is the temperature most appropriate to use as a stimulus when evaluating cold temperature sensation?
(A) $-5^{\circ} \mathrm{C}$ to $0^{\circ} \mathrm{C}$
(B) $0^{\circ} \mathrm{C}$ to $5^{\circ} \mathrm{C}$
(C) $5^{\circ} \mathrm{C}$ to $10^{\circ} \mathrm{C}$
(D) $10^{\circ} \mathrm{C}$ to $15^{\circ} \mathrm{C}$
(E) $15^{\circ} \mathrm{C}$ to $20^{\circ} \mathrm{C}$

Khoobchandra Agrawal
Khoobchandra Agrawal
Numerade Educator

Problem 260

Which of the following may potentially facilitate or perpetuate myofascial trigger points in some patients?
(A) Low creatine kinase
(B) Low aldolase
(C) Low cholesterol
(D) Low vitamin $\mathrm{D}$
(E) Low vitamin $\mathrm{B}_{12}$ or folate

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Problem 261

A 39-year-old male with persistent coughing attributed to upper respiratory infection (URI) comes to your office complaining of moderate anterior chest wall pain-it is only on the left side predominantly over the second and third costal cartilages. Bulbous swellings and point tenderness are present at these sites. Which of the following is the most appropriate diagnosis for this patient?
(A) Intercostal neuralgia
(B) Tietze syndrome
(C) Acute myocardial infarction
(D) Pneumonia
(E) Pleurisy

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Problem 262

A 66-year-old woman who did not have a history of trauma comes to your office complaining of acute, severe, constant medial right knee pain for 6 weeks. MRI imaging demonstrated extensive narrow edema of the medial femoral condyle with significant soft tissue edema around the superficial and deep compartment of the medial collateral ligament (MCL) but without MCL disruption. Which of the following is the most likely diagnosis?
(A) Stress fracture
(B) MCL tear
(C) Medial meniscal tear
(D) Spontaneous osteonecrosis of the knee (SONK)
(E) Medical femoral condyle contusion

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Problem 263

A 49-year-old male comes to your office after climbing several mountain passes in the Pyrenees on a bicycle with thigh complaints. He relates to you that he developed a painful sensation on the lateral aspect of his right thigh, which lasted for about a week. This was followed by numbness and paresthesia in the same location. Physical examination revealed sensory loss in the same location. Which of the following is the most likely diagnosis?
(A) Tensor fascia lata syndrome
(B) Meralgia paresthetica

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Problem 264

A 43-year-old male runner comes to your office complaining of dull ache in the anterior aspect of the lower legs bilaterally which occurs about 10 minutes into his running routine each time he runs and dissipates with rest. The patient states that he needs to stop running because of this ache and also notes dysesthesia in the first web space of both feet. Which of the following is the most likely diagnosis?
(A) Shin splints
(B) Stress fractures
(C) Chronic osteomyelitis
(D) Periostitis
(E) Chronic exertional anterior compartment syndrome of the lower leg

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Problem 265

A 32-year-old construction worker felt a sharp pain in his back radiating down to the heel of his right foot after lifting a large, metal girder. Two days later he noticed numbness in the sole of his right foot and fifth toe. Physical examination is notable for a decreased ability to walk on his toes, a positive straight leg raising test on the right, and a markedly diminished ankle jerk reflex. Which of the following is the most likely diagnosis?
(A) L4-5 herniated disc
(B) Discogenic low back pain
(C) L5-S1 herniated disc
(D) Spinal stenosis
(E) Piriformis syndrome

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Problem 266

An 80-year-old man presents with a 2-year history of low back pain radiating down from both legs to his ankles. He also notes numbness in his left foot and slight weakness. The pain is increased with walking and relieved within seconds of cessation of activity. Leaning forward eases his pain and lying supine relieves it. Which of the following is the most likely diagnosis?
(A) Herniated nucleus pulposus
(B) Facet arthropathy
(C) Muscle spasm
(D) Arachnoiditis
(E) Spinal stenosis

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Problem 267

A 31-year-old woman presents to your office with marked pain and swelling in her ankle 6 weeks after an open reduction internal fixation with casting. On examination, the ankle is warm and erythematous. Lightly touching the ankle with a cotton swab evokes severe, lancinating pain. You suspect CRPS I. Which of the following tests will confirm your diagnosis?
(A) Lumbar sympathetic block
(B) Phentolamine infusion test
(C) Triple phase isotope bone scan
(D) Erythrocyte sedimentation rate
(E) None of the above

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Problem 268

A 46-year-old man complains of worsening back and new onset leg pain and paresthesia 10 weeks after an L4-S1 posterior spinal fusion. One week after the surgery, the patient reported $85 \%$ pain relief. Which radiologic test would be most appropriate for detecting the cause of failed back surgery syndrome (FBSS) in this patient?
(A) Computed tomographic (CT) scan with contrast
(B) Myelography
(C) Epidural mapping via the injection of contrast under fluoroscopy through a catheter inserted through the caudal canal
(D) T2-weighted MRI with contrast
(E) Further radiologic study is not indicated at this point

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Problem 269

Which of the following is false regarding discogenic low back pain?
(A) Sitting bent forward subjects the intervertebral disc to a greater amount of pressure than lying down, standing or sitting with one's back straight
(B) It is often diagnosed by using provocative discography
(C) Because of their caudad position in the spine, the lower lumbar discs are most prone to degenerative disc disease (DDD)
(D) Studies have shown a genetic predisposition to DDD
(E) Intradiscal steroids are an effective means for treating DDD

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00:57

Problem 270

Which of the following statements concerning central pain is true?
(A) Spinal cord injury is the leading cause of central pain in the United States
(B) Lesions involving spinothalamocortical pathways are necessary and sufficient to cause central pain
(C) Central pain is a common sequelae following neurosurgic procedures
(D) Motor cortex stimulation is an effective means to treat central pain
(E) The most typical presentation of central pain is a spontaneous, burning sensation on the entire body contralateral to the lesion site

Parvati Devi
Parvati Devi
Numerade Educator

Problem 271

Which of the following is not commonly used to diagnose the level of nerve root involvement in radicular pain?
(A) MRI
(B) CT scan
(C) Selective nerve root block
(D) Electromyography (EMG)/nerve conduction studies (NCS)
(E) Epidural injections with local anesthetic and steroids

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Problem 272

Which of the following conditions is not generally associated with a painful neuropathy?
(A) Chronic renal failure
(B) Celiac disease
(C) AIDS
(D) Fabry disease
(E) Amyloidosis

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Problem 273

A previously healthy 31-year-old woman presents to her internist with generalized muscle pain, most prominent in her right thigh. The pain travels down the back of her leg to the bottom of her foot. She also notes progressive numbness and weakness in her arms and legs. Walking is difficult and a loss of fine motor control makes routine tasks like eating a challenge. A review of her medical record reveals an URI 3 weeks earlier. Which of the following is the most likely diagnosis?
(A) Multiple sclerosis
(B) Guillain-Barré syndrome
(C) Chronic fatigue syndrome
(D) Acute lumbar and cervical radiculopathies
(E) Diabetic neuropathy

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00:32

Problem 274

Which of the following statements is true regarding SI joint pain?
(A) The SI joint is a diarthrodial synovial joint designed primarily for stability
(B) Patrick's and Gaenslen's tests are definitive diagnostic tests for SI joint pain
(C) CT scanning is the most sensitive means for diagnosing SI joint pain
(D) Lifting heavy objects is the one of the most common causes of SI joint injury
(E) When diagnostic blocks fail, surgery can usually provide long-term pain relief

Alexander Burbelo
Alexander Burbelo
Numerade Educator
01:33

Problem 275

Which of the following statements regarding headaches is false?
(A) The International Headache Society's diagnostic criteria for cervicogenic headaches includes unilaterality of symptoms and relief of pain by diagnostic anesthetic blocks
(B) Migraine with aura is more common than migraine without aura
(C) In chronic tension-type headache, the average headache frequency is equal to or greater than 15 days per month
(D) Cluster headaches are more prevalent in men than in women
(E) Tricyclic antidepressants are a mainstay of treatment for both migraine and tension-type headaches

Alexander Cheng
Alexander Cheng
Numerade Educator

Problem 276

Which of the following statements regarding postamputation pain is correct?
(A) Vascular conditions are the leading cause of both lower and upper extremity amputations
(B) There is no relationship between persistent stump pain and phantom limb pain in amputees
(C) The intensity of pain and the length of the phantom increases with time
(D) Phantom breast pain is a common cause of postmastectomy pain
(E) Phantom pain was first described in the American Civil War

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Problem 277

Which of the following statements regarding the assessment of pain in pediatric patients is true?
(A) Palmar sweating and reduced transcutaneous oxygen concentrations are indicative of pain
(B) In a hospitalized 2-year-old child, crying and increased vitals signs are likely to indicate chronic pain
(C) The FACES scale and Charleston Pain Pictures provide accurate assessments of pain in preschool children
(D) The COMFORT scale and facial action coding system (FACS) are pain instruments used in young children that are based predominantly on facial actions
(E) Visual analogue and numerical rating scales are inappropriate pain indices for most adolescents

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03:33

Problem 278

Which of the following statements is not correct regarding herpes varicella zoster?
(A) The most common presentation of acute herpes zoster ( $\mathrm{AHZ})$ is pain and a vesicular rash in the midthoracic dermatomes
(B) The polymerase chain reaction ( $\mathrm{PCR}$ ) is the most common means to diagnose $\mathrm{AHZ}$
(C) The incidence of both $\mathrm{AHZ}$ and postherpetic neuralgia increases with age
(D) There is no generally accepted time period from the onset of $\mathrm{AHZ}$ to when a diagnosis of postherpetic neuralgia is made
(E) $\mathrm{AHZ}$ involving the lumbosacral dermatomes may be misdiagnosed as a herniated disc

Dennis Howard
Dennis Howard
Numerade Educator
01:43

Problem 279

Which of the following statements regarding electrophysiologic testing is true?
(A) Nerve conduction velocities are more likely to decrease in conditions such as alcoholic and diabetic neuropathy that are characterized by Wallerian degeneration than in demyelinating neuropathies such as Guillain-Barré
(B) EMG can provide information about the type, extent and timing of injuries to motor units and individual muscle fibers
(C) The $\mathrm{H}$ reflex can aid in the evaluation of brachial plexus injuries
(D) The $\mathrm{F}$ response is used to diagnose pure sensory neuropathies
(E) EMG can readily identify processes causing muscle denervation (neuropathies), but is incapable of identifying myopathies

Joanna Quigley
Joanna Quigley
Numerade Educator
03:15

Problem 280

Which of the following statements is true about quantitative sensory testing (QST)?
(A) QST can be used to pinpoint which nerve is injured and where along its path the lesion lies
(B) Thermal sensation is used to measure the integrity of large, myelinated nerve fibers
(C) A beta function can be evaluated using either a tuning fork or von Frey hair
(D) QST can be used to evaluate the function of all different types of nerve fibers
(E) An advantage of QST is that it can accurately assess function in uncooperative or incapacitated patients

Rikhil Makwana
Rikhil Makwana
Numerade Educator

Problem 281

A 38-year-old construction worker presents to you with complaints of right lower extremity pain for the last 8 months. Pain radiates from the lower back to the outer aspect of the right leg and goes down to the dorsum of the right foot. The patient reports a problem with walking and on examination reveals an antalgic gait and inability to do heel-walking on right, though toe-walking is not affected. Strength is $5 / 5$ in all muscle groups except dorsi-flexion of the right ankle which is $4 / 5$ and strength testing for extensor hallucis longus reveals $4 / 5$ strength. Deep tendon reflexes are 2* at both knees and both ankles. Sensory testing reveals mildly reduced sensation to light touch and pinprick on the dorsum of the right foot when compared to the left foot. This patient most likely has
(A) right piriformis syndrome
(B) right L4 radiculopathy
(C) right L5 radiculopathy
(D) right S1 radiculopathy
(E) facet arthritis

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Problem 282

A 46-year-old female with past medical history of depression, anxiety, irritable bowl syndrome, and asthma is referred to you for evaluation of her lower back pain. History reveals onset of generalized pain that started after she was involved in a car accident 4 years ago. Physical examination reveals nonfocal neurologic examination. Musculoskeletal examination reveals multiple areas of hypersensitivity. The patient reports marked pain with moderate digital pressure at base of skull, her neck, front of her chest, her elbows as well as her lower back, and bilateral lower extremities. The patients MRI scan of the lumbar spine reveals preserved disc height, no facet arthritis and minimal disc bulge at L4-5 without any spinal or foraminal stenosis. This patient most likely has
(A) fibromyalgia syndrome
(B) discogenic pain
(C) myofascial pain disorder
(D) somatoform disorder
(E) opioid hyperalgesia

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Problem 283

A 25-year-old, healthy female volleyball player has developed severe pain in right hand. This pain started while playing volleyball and after a reported wrist sprain. One month after the initial injury and despite conservative care with nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and hand splint to avoid any movement related pain, the patient complains of even worse burning pain. Pain is worse with light touch, even blowing air or rubbing of clothes trigger unbearable pain. The patient also reports her right hand to be cold and often wet because of localized sweating. On examination the patient has a markedly swollen, redappearing hand. Patient is unable to make a fist with her fingers and measurement of temperature reveals a $7^{\circ} \mathrm{C}$ lower temperature compared to opposite extremity. Which of the following is the most likely diagnosis?
(A) CRPS I (RSD)
(B) CRPS II (causalgia)
(C) Peripheral vascular disease
(D) Deep venous thrombosis of upper extremity
(E) Median neuralgia

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Problem 284

A 38-year-old man developed complete T4 spinal cord injury after a motorcycle accident. Two months after the injury the patient continues to complain of severe radiating pain to the front of chest just above nipple line. The pain is worse with light touching and improves with movement restriction and use of morphine on as needed basis. This patient most likely has
(A) central dysesthesia syndrome
(B) syringomyelia
(C) transitional zone pain
(D) myofascial pain
(E) autonomic dysreflexia

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01:56

Problem 285

After a car accident 5 days ago, a 42 -year-old engineer reports severe neck and midback pain. The patient was rear ended while stopped at a traffic light by a pickup truck. The patient reports severe pain in neck that radiates down to both shoulders and upper arm as well as to the midback region. The pain is a severe stabbing and aching sensation that is markedly exaggerated by movement of neck. Examination reveals otherwise intact neurologic system, 5/5 strength, and intact deep tendon reflexes without any sensory deficit. Imaging studies are essentially normal except for straightening of cervical lordosis. The patient most likely has
(A) bilateral C5 radiculopathy
(B) myofascial pain
(C) fibromyalgia
(D) thoracic outlet syndrome
(E) malingering

Prabhu Ramji
Prabhu Ramji
Numerade Educator

Problem 286

A 64-year-old female with a history of coronary artery disease, peripheral vascular disease, and type 1 diabetes mellitus, controlled with insulin, presents to your pain clinic with gradually worsening bilateral leg and feet pain. The patient reports a history of a fall approximately 5 years ago which resulted in severe back and leg pain. That pain resolved, however, the patient started developing numbness and tingling in both legs and feet. On examination the patient reveals otherwise normal appearing legs and feet, patient does have a nonhealing ulcer on her right great toe. Neurologic testing reveals bilateral $5 / 5$ muscle strength and $2^{+}$patellar and ankle reflexes. Sensory testing reveals intact proprioception but reduced sensation to light touch and pinprick. The patient also reported marked sensitivity to light touch. This patient most likely has
(A) CRPS I
(B) peripheral vascular disease
(C) diabetic polyneuropathy
(D) lumbar spondylosis
(E) central pain

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Problem 287

A 32-year-old female develops severe stabbing, "like an ice pick," pain at the base of tongue after an infratemporal neurosurgic procedure. Pain comes in paroxysms and last a few seconds and is triggered by swallowing, yawning, and coughing. This patient most likely has
(A) trigeminal neuralgia
(B) geniculate neuralgia
(C) glossopharyngeal neuralgia
(D) migraine with atypical aura
(E) cluster headache

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Problem 288

A 38-year-old patient care technician while lifting a $400 \mathrm{lb}$ patient heard a pop in his back. The patient developed severe back pain with radiation to the right leg. Patient described the pain as stabbing back pain with electrical sensations down the back of the right leg all the way to the sole of the right foot. On examination the patient appeared very uncomfortable, sitting in a wheel chair. Straight leg raise and cross straight leg raise test was positive. Muscle strength was $5 / 5$ in all muscle groups except plantar flexion at right ankle which was $4 / 5$. Deep tendon reflexes were intact at the patella bilaterally; however, the reflex at the right ankle is diminished compared to the left ankle. The patient most likely has a herniated disc at
(A) L4-L5 resulting in L4 nerve root compression
(B) L4-L.5 resulting in L.5 nerve root compression
(C) L5-S1 resulting in L5 nerve root compression
(D) L5-S1 resulting in S1 nerve root compression
(E) L1-L2 resulting in compression of cauda equina

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Problem 289

A48-year-old patient after a gunshot wound to the upper chest develops a partial cord transection involving the right spinothalamic tract at T2 level. This patient is most likely to develop loss of pain and temperature sensation:
(A) At the level of the transection
(B) Below and on right side from the level of transection
(C) Below and on left side from the level of transection
(D) Patient is not likely to develop central dysesthetic pain
(E) Below and bilateral lower extremity

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Problem 291

A 42-year-old man underwent a celiac plexus block procedure with $20 \mathrm{~mL}$ of $50 \%$ alcohol. All of the following listed conditions are complications of this intervention EXCEPT
(A) genitofemoral neuralgia
(B) hypertension
(C) diarrhea
(D) paralysis
(E) infection

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Problem 292

A two-needle lumbar sympathetic plexus block at L2 and L.3 when performed appropriately may help in the diagnosis of
(A) sympathetically mediated pain
(B) lumbar discogenic pain
(C) lumbar radiculopathy
(D) diabetic neuropathy
(E) facet arthritis

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01:36

Problem 293

A patient who received $1 \mathrm{cc}$ of $0.25 \%$ bupivacaine after negative aspiration following a cervical selective nerve root injection became agitated and then developed generalized tonicclonic movements. Which of the following is the most likely explanation?
(A) High spinal anesthetic from accidental intrathecal injection
(B) Anxiety attack from pain during injection
(C) Vertebral artery injection of local anesthetic
(D) Injection into spinal cord
(E) Hypoxia

Asma Venkitta
Asma Venkitta
Numerade Educator

Problem 294

Medial branch nerve blocks may aid in the diagnosis of
(A) facet arthritis
(B) sympathetically mediated pain
(C) spinal nerve irritation
(D) sciatica
(E) myofascial pain

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00:29

Problem 295

Which of the following is the most likely side effect of a SI joint injection?
(A) Perforation of bladder
(B) Left lower extremity weakness
(C) Stroke
(D) High spinal resulting in cardiorespiratory depression
(E) Injury to pudendal nerve

Chinwe Abaraoha
Chinwe Abaraoha
Numerade Educator

Problem 296

The potential complications of the vertebroplasty procedure include all EXCEPT
(A) spinal cord compression
(B) venous embolism
(C) pedicle fracture
(D) cement leak in soft tissue
(E) bowl perforation

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Problem 297

A 70-year-old man reports severe cramps and "charley horse" sensation in both legs when walking more than one block. Resting usually helps in relieving pain. On examination patient reveals an intact neurologic examination without any sensory or motor deficit. Lower extremity examination reveals normal appearance, and no vascular insufficiency. Ankle brachial index performed 1 month ago is unremarkable. Which of the following is the most likely diagnosis?
(A) Neurogenic claudication
(B) Vascular claudication
(C) Diabetic peripheral neuropathy
(D) Amyloid neuropathy
(E) Fibromyalgia

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Problem 298

A 32-year-old healthy female presents with a 2month history of gradually worsening right lower extremity pain. The pain is sharp shooting in character and radiates down the right leg all the way to the right foot. On examination, patient has $5 / 5$ muscle strength in all muscle groups except plantar flexors of the right ankle. The patient is unable to stand on her toes. There is no sensory deficit. Flexion, adduction, and internal rotation of the right hip results in reproduction of the symptoms. MRI of lumbar spine is normal with no evidence of herniated discs. This patient most likely has
(A) right $\mathrm{S} 1$ radiculopathy
(B) piriformis syndrome
(C) SI arthritis
(D) somatization disorder
(E) discogenic pain

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Problem 299

A 25-year-old construction worker, 8 months after a fall from a ladder, is unable to walk without assistance. However, worker compensations lawyers have provided video evidence of the patient being able to walk and also able to run with his dog. Which of the following is the most likely diagnosis?
(A) Hypochondriasis
(B) Factitious disorder
(C) Malingering
(D) Conversion disorder
(E) Somatization disorder

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Problem 300

A 43-year-old gentleman has developed left groin pain 6 months after an inguinal hemia repair. The patient reports pain to be severe stabbing pain in the left groin radiating down to the left testicle. On examination, the patient has a well-healed incision and marked cutaneous allodynia and hyperalgesia. This patient most likely has
(A) ilioinguinal neuralgia
(B) mesh infection
(C) recurrent hernia
(D) wound dehiscence
(E) incarceration

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Problem 301

Which of the following is the most common complication from the celiac plexus block?
(A) Hypotension
(B) Seizure
(C) Diarrhea
(D) Hematoma
(E) Subarachnoid injection

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Problem 302

A patient with history of three lumbar spinal fusions from an injury while working in a halfway home who is responsive to MS Contin (sustained-release morphine) $30 \mathrm{mg}$, three times a day and Norco (hydrocodone $5 \mathrm{mg}$ with acetaminophen $325 \mathrm{mg}$ ) eight tablets per day with adequate analgesia and improved functionality, but limited activity secondary to side effects, receives an intrathecal opioid pump trial after been cleared by his psychologist. After confirmation of appropriate placement of the catheter under fluoroscopy, he is put on $0.5 \mathrm{mg} / \mathrm{d}$ of intrathecal morphine and gradually escalated up to $10 \mathrm{mg} / \mathrm{d}$ because of inadequate analgesia. Twelve hours after the procedure, he complains of nausea, headache, and sensation of "skin peeling off his body." Which of the following is the best course of action in this case?
(A) Increase the intrathecal morphine until pain relief and resolution of symptoms
(B) CT scan of his spine to confirm correct placement of the catheter
(C) Removal of the catheter and institution of oral opioids
(D) Urine toxicology
(E) Consultation with a spine surgeon

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00:32

Problem 303

Migraine headaches are directly related to
(A) estrogen increase
(B) estrogen decrease
(C) progesterone increase
(D) progesterone decrease
(E) none of the above

Jonathan Temple
Jonathan Temple
Numerade Educator

Problem 304

A 50-year-old female comes in complaining of sudden onset pain in bilateral lower extremities and loss of bladder function. Her physical examination reveals motor weakness in her left lower extremity $3 / 5$ compared to the right along with diminished sensation to light touch, pinprick, and temperature along $\mathrm{L} 5$ and $\mathrm{S} 1$ dermatomes on the right compared to the left. Rest of her physical, musculoskeletal, and neurologic examination is normal. Lumbosacral $x$-rays done by her primary care physician demonstrate anterolisthesis of L5 on S1. Which of the following is the most appropriate immediate action?
(A) Consult the spine surgeon
(B) Intravenous Opioids
(C) Physical therapy
(D) Reassurance and return to home with a follow-up visit in 2 weeks if symptoms persist
(E) A course of oral steroids

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00:27

Problem 305

The approaches to celiac plexus block are all EXCEPT
(A) retrocrural
(B) transcrural
(C) transaortic
(D) intercrural
(E) lateral

Alexander Burbelo
Alexander Burbelo
Numerade Educator

Problem 306

A 25-year-old male presents to you with leftsided neck pain with radiation along lateral aspect of the left arm, forearm, and thumb, index, and middle finger. He has associated tingling and numbness. On neurologic examination, the sensation to pinprick is diminished in the above mentioned distribution and brachioradialis jerk is lost on the left compared to intact $2^*$ on the right. The MRI of C-spine is compatible with an acute cervical disc herniation. Which of the following is the most appropriate initial treatment?
(A) A course of oral opioids, oral steroids, and spine surgical consultation
(B) A series of cervical epidural steroid injections under fluoroscopy
(C) Physical therapy
(D) Spinal cord stimulation (SCS)
(E) Referral to pain psychologist for coping strategies

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01:09

Problem 307

Hoffmann sign is indicative of
(A) upper motor neuron lesion (UMNL)
(B) lower motor neuron lesion (L.MNL)
(C) radiculopathy
(D) instability of cervical spine
(E) malingering

Cody Delk
Cody Delk
Numerade Educator

Problem 308

A 65-year-old male comes in complaining of pain in between the third and the fourth toes. The pain can be reproduced by palpation of the pulp between metatarsal heads. There is some relief of pain following localized administration of local anesthetic. Which of the following is the most likely diagnosis?
(A) Plantar fascitis
(B) Metatarsalgia
(C) Tarsal tunnel syndrome
(D) Morton neuroma
(E) Painful calcaneal spur

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Problem 309

Which of the following is the most common nerve missed with the interscalene brachial plexus nerve block?
(A) Ulnar
(B) Radial
(C) Musculocutaneous
(D) Median
(E) Axillary

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Problem 310

A 23-year-old gymnast while performing a double loop hears a popping sound in her left knee. Her knee immediately swells up and is very painful. On physical examination, tendemess on palpation and effusion is demonstrated. McMurray test is positive. Which of the following is the most likely diagnosis?
(A) Baker cyst
(B) Anterior cruciate ligament tear
(C) Posterior cruciate ligament tear
(D) Torn medial meniscus
(E) Pes anserine bursitis

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Problem 311

A 35-year-old female is rear ended at $45 \mathrm{mph}$ resulting in acute neck pain that was diagnosed to be of musculoskeletal nature in the emergency room. On the next day, her symptoms progress to right upper extremity pain and weakness, both of which are exacerbated with ipsilateral flexion of her neck and reaching overhead. She has no neurologic deficits and MRI of her neck shows no obvious pathology. There is obliteration of the radial pulse with arm extension and abduction. Which of the following is the most likely diagnosis?
(A) Brachial plexitis
(B) Cervical degenerative disc disease
(C) Whiplash injury
(D) Pancoast tumor
(E) Thoracic outlet syndrome

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05:01

Problem 312

The following is true about the $\mathrm{H}$ reflex EXCEPT
(A) in clinical practice $\mathrm{H}$ reflex is limited to calf muscles
(B) it is recorded in gastrocnemius and soleus muscles by stimulating the posterior tibial nerve in the popliteal fossa
(C) because of the distance the impulse travels, the latency of the $\mathrm{H}$ wave is shorter than the $\mathrm{F}$ wave
(D) the $\mathrm{H}$ reflex recorded from the soleus muscle is primarily mediated by the S1 nerve root
(E) $\mathrm{H}$ reflex is normal in $\mathrm{L} 5$ radiculopathy whereas is prolonged in S1 radiculopathy

Rikhil Makwana
Rikhil Makwana
Numerade Educator
00:16

Problem 313

The arteria radicularis magna, also known as artery of Adamkiewicz arises from aorta, at the following spinal levels:
(A) L4.5
(B) $\mathrm{T} 9-12$
(C) $15-8$
(D) $\mathrm{T} 11-12$
(E) $15-9$

Alexander Burbelo
Alexander Burbelo
Numerade Educator

Problem 314

A 56-year-old male who is an avid golfer comes in with left elbow pain not relieved after antiinflammatory medication trial, warm compress, and physical therapy. He has not been able to play 18 holes recently and this is making him quite depressed. On examination, passive flexion or extension against resistance of his left wrist causes pain. Which of the following is the most probable diagnosis in this patient?
(A) Posterior interosseous nerve entrapment
(B) Medial epicondylitis
(C) Lateral epicondylitis
(D) de Quervain disease
(E) Brachioradialis tendonitis

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04:13

Problem 315

All of these cervical pathologies are seen in patients with rheumatoid arthritis EXCEPT
(A) subaxial subluxation
(B) cranial settling
(C) posterior-longitudinal ligament thickening
(D) atlantoaxial subluxation
(E) instability of cervical-zygapophyseal joints

Mariana Roldan
Mariana Roldan
Numerade Educator

Problem 316

While undergoing lumbar sympathetic block for CRPS, patient complains of sudden onset of sharp ipsilateral groin and genital pain on injection of the contrast agent. Which of the following is the most likely cause of this symptom?
(A) Trauma to L2 nerve root
(B) Trauma to genitofemoral nerve
(C) Psoas spasm
(D) Epidural injection
(E) Successful lumbar sympathetic block

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01:55

Problem 317

Which of the following is the most common inherited neuropathy?
(A) Familial amyloid polyneuropathy
(B) Fabry disease
(C) Porphyric neuropathy
(D) Charcot-Marie-Tooth disease
(E) Diabetic polyneuropathy

Vidushi Ahuja
Vidushi Ahuja
Numerade Educator

Problem 318

A 52-year-old man comes to your office complaining of $1^1 / 2$ years of "burning" pain in the metatarsal areas of his left foot. Which of the following is the most likely diagnosis?
(A) Posterior tibial neuritis
(B) Plantar fasciitis
(C) Morton neuroma
(D) Tarsal tunnel syndrome
(E) Hallux rigidus

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03:08

Problem 319

In MRI of the lumbar spine T2-weighted images
(1) are generally more time-consuming to obtain
(2) are ideal to image the anatomic detail of end-plate reactive changes
(3) exhibit increased sensitivity to higher water content and thus, may be useful in imaging infectious processes or inflammation
(4) can be used in place of gadoliniumDTPA (diethylenetriamine pentaacetic acid) contrast in imaging of postoperative patients to differentiate scarring from intervertebral disc issues

Donald Albin
Donald Albin
Numerade Educator

Problem 320

In EMG and NCS, the H reflex
(1) is the electrical equivalent of a muscle stretch reflex elicited by tendon tap
(2) is mostly present in the soleus muscle but at times also can be elicited in the forearm flexor muscles
(3) may be delayed or absent in S1 radiculopathy
(4) latencies are length-dependent and should be adjusted for patient's height

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Problem 321

A previously healthy 83-year-old male presents to your office complaining of acute abdominal pain but without obvious etiology. Medical conditions which should be investigated include
(1) pneumonia
(2) inflammatory bowel disease
(3) pyelonephritis
(4) inferior wall myocardial infarction

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00:29

Problem 322

Patients diagnosed with cubital tunnel syndrome may have
(1) pain and numbness in the ulnar border of the forearm and hand
(2) clawing of the small finger
(3) Wartenberg sign
(4) a deep aching sensation in the mid forearm

Sam Limsuwannarot
Sam Limsuwannarot
Numerade Educator

Problem 323

A 53-year-old male comes to your office complaining of foot pain (predominantly in the heel-but also with diffuse plantar symptoms) which also occurs at night and can be exacerbated by prolonged standing or walking. It is associated with weakness of the phalanges (impairing the pushing off phase of walking) as well as sensory loss and paresthesia. After a complete history and physical examination are completed, the differential diagnosis may include
(1) plantar fasciitis
(2) peripheral neuropathies
(3) posterior tibial nerve entrapment
(4) tarsal tunnel syndrome

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Problem 324

The diagnostic criteria for CRPS I - as accepted in 1994 by the International Association for the Study of Pain (IASP) -includes which of the following?
(1) The presence of an initiating noxious event, or a cause of immobilization
(2) Continuing pain, allodynia, or hyperalgesia with which the pain is disproportionate to any inciting event
(3) Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain
(4) This diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction

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Problem 325

The paroxysmal hemicranias are rare benign headache disorders that may typically be associated with
(1) conjunctival injection
(2) rhinorrhea
(3) ptosis
(4) eyelid edema

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Problem 326

Which of the following statement(s) is (are) true?
(1) The most common cause of thoracic radiculopathy is diabetes mellitus
(2) The most common levels affected by herniated disc at cervical level are $\mathrm{C} 4-5$, C5-6, and $\mathrm{C} 6-7$
(3) L4-5 disc is more commonly herniates than L5-S1
(4) The nerve roots involved most commonly in thoracic outlet syndromes are $\mathrm{C} 8$ and $\mathrm{T} 1$

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Problem 327

The characteristics of conus medullaris syndrome include
(1) asymmetric paraplegia
(2) symmetric paraplegia
(3) bladder function preservation
(4) upper motor neuron lesion signs

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Problem 328

Which of the following statement(s) is (are) true for central pain of spinal cord origin?
(1) Most common etiology is of traumatic origin
(2) Most common type of pain in these patients is spontaneous steady, buming, or dysesthetic pain affecting approximately $96 \%$ of patients
(3) Bowel and bladder dysfunction can be seen in these patients
(4) Most patients will develop cord central pain within 1 to 6 months of causative lesion although some may present more than 5 years out

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Problem 329

A positive Froment sign indicates which of the following?
(1) Weakness of first dorsal interosseous
(2) Weakness of flexor pollicis brevis
(3) Weakness of adductor pollicis
(4) Weakness of hypothenar muscles

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Problem 330

The potential for drug-induced painful neuropathies exist with which of the following agents?
(1) Amiodarone
(2) Metronidazole
(3) Pyridoxine
(4) Vincristine

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Problem 331

Spinal cord stimulation (SCS) has been used for the treatment of
(1) failed back surgery syndrome
(2) CRPS
(3) angina
(4) peripheral vascular disease

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