McGraw-Hill Specialty Board Review Pain Medicine

Salahadin Abdi, Pradeep Chopra, Howard Smith

Chapter 3 Pain Pathophysiology - all with Video Answers

Educators

Chapter Questions

Problem 10

A patient is referred to you by a dentist friend. This patient is having pain in and around her mouth on one side. Which of the following statements is true?
(A) Primary burning mouth syndrome is a chronic, idiopathic intraoral pain condition that is not accompanied by clinical lesions; some consider it a painful neuropathy
(B) Increasing evidence suggests that very few cases of trigeminal neuralgia that are classified as idiopathic are caused by compression of the trigeminal nerve by an aberrant loop of artery or vein
(C) About $40 \%$ of patients with multiple sclerosis develop trigeminal neuralgia
(D) Trigeminal neuralgia can occasionally be present over the occiput
(E) All of the above

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Problem 91

Common causes of acute abdominal pain in adults include
(A) intussusception in an adolescent patient
(B) abdominal aortic aneurysm in an adult population, which most likely presents with excruciating abdominal pain
(C) diabetic ketoacidosis in an elderly patient without a previous history of diabetes
(D) drug-induced pain from polypharmacy that is rarely a cause of abdominal pain in the elderly
(E) interstitial cystitis

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Problem 92

A 35-year-old woman has right arm pain. Which of the following statements regarding her pain is true?
(A) It is more likely she will have arterial thoracic outlet syndrome than neurogenic thoracic outlet syndrome
(B) If it began in the ulnar nerve distribution after an injury to the ulnar nerve, she may have complex regional pain syndrome (CRPS) type I
(C) If she also has pain radiating into her occiput, she may have involvement of the sensory portion of the $\mathrm{C} 1$ nerve
(D) If she has clawing of the small finger, the median nerve is likely involved
(E) The ulnar nerve is commonly compressed at the cubital tunnel

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Problem 93

You suspect a patient is having cluster headaches. The most convincing evidence of this type of headache would be if
(A) the patient is female
(B) although it is worse on the right side of the head, the symptoms are usually bilateral
(C) the headaches are occurring at the same time each night
(D) the patient is having a rebound headache due to excessive use of medication and the most likely underlying recurring headache is a cluster headache
(E) the patient is urinating frequently and has blurry vision

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Problem 94

Which of the following statements about migraine headache is true?
(A) Recent evidence has supported the notion that cortical spreading depression is the mechanism of migraine headache
(B) Activation of cortical spreading depression has become an interesting target for preventive migraine treatment
(C) Current evidence shows a clear causal relationship between cardiac right-toleft shunt (RLS) and migraine headaches
(D) Migraine pathophysiology involves the trigeminovascular system but not central nervous system (CNS) modulation of the pain-producing structures of the cranium
(E) More than $90 \%$ of migraineurs have auras

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Problem 95

A patient you ane seeing recently began experiencing low-back pain. You suspect zygapophysal joint arthropathy as the primary cause of the symptoms. Which of the following can be said about this disease process?
(A) Predisposing factors include spondylolisthesis and old age; however, degenerative disc pathology is not a risk factor
(B) The key to diagnosing zygapophysial joint arthropathy is the historic and physical examination
(C) An accepted method for diagnosing pain arising from the lumbar facet joints is with low-volume intra-articular or medial branch blocks because of the low false-positive rate
(D) Cadaveric studies of the facet joints in patients with suspected arthropathy have revealed histologic changes
(E) Its clinical presentation is characterized as a radicular pattern

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Problem 96

Which of the following statements regarding postmastectomy neuromas is true?
(A) In general, neuromas are palpable
(B) Neuromas form with mastectomy but usually not with lumpectomy
(C) Neuromas are most likely the cause of a painful scar
(D) Resection should not be considered for an intercostal neuroma
(E) None of the above

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Problem 97

You suspect nerve root impingement in the cervical spine. Which of the following physical findings would support this diagnosis?
(A) You suspect C1 nerve root involvement and the patient has numbness over the occiput
(B) You suspect C6 nerve root involvement and the patient has loss of the biceps reflex
(C) You suspect C7 nerve root involvement and the patient has loss of strength in the deltoid
(D) Carpal tunnel syndrome (CTS) would be exduded by a normal examination of the abductor pollicis brevis (APB)
(E) You suspect C8 nerve root involvement and the patient has numbness in the lateral aspect of the forearm

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Problem 98

Which is the following statements regarding neck pain is true?
(A) Peer reviewed literature suggests that there may be short-term benefit derived from treatment with acupuncture
(B) Neck pain following an acceleration/deceleration injury most commonly involves the lower cervical spine
(C) If you suspect an acute cervical disc herniation, it is important to ask about bowel and bladder incontinence because of the risk of cauda equina syndrome
(D) A patient with neck pain alone may meet the criteria for fibromyalgia
(E) CTS cannot have associated neck pain

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Problem 99

Which of the following statements regarding fibromyalgia is true?
(A) Two central criteria for fibromyalgia are chronic widespread pain (CWP) defined as pain in all four quadrants of the body and the axial skeleton for at least 2 years, and the finding of pain by $25-\mathrm{kg}$ pressure on digital palpation of at least 11 of the 18 defined tender points
(B) It is generally agreed that abnormal CNS mechanisms are responsible for all of the symptoms of fibromyalgia
(C) There ane both primary and secondary fibromyalgia syndromes
(D) Fibromyalgia symptoms generally resolve if a rheumatic process is identified and treated appropriately
(E) Most of fibromyalgia patients are male

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03:49

Problem 100

Which of the following statements regarding endometriosis is true?
(A) The etiology is undear but it has recently been demonstrated that retrograde menstruation is most likely not the cause
(B) Oral contraceptives tend to exacerbatepain symptoms
(C) The "gold standard" diagnosis of the disease remains magnetic resonance imaging (MRI) of the abdomen
(D) If endometriosis is diagnosed at the time of laparoscopy, laparoscopic surgery should be the first choice of treatment
(E) Endometriosis pain does not follow menstrual cycle

April Townson

Numerade Educator

Problem 101

A 28-year-old female enters your clinic with upper extremity symptoms, You suspect thoracic outlet syndrome because
(A) she fractured her clavicle and developed symptoms afterward
(B) she has had sensory symptoms along her lateral forearm for some time
(C) radiographs confirm she does not have cervical ribs
(D) she has symptoms consistent with a chronic upper trunk brachial plexopathy
(E) all of the above

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Problem 102

A 55-year-old homeless woman presents to the emergency room (ER) by ambulance in an unconscious state. The emergency medical technician (EMT) reports discovering the patient while she was experiencing a grand mal seizure, She has no identifying information and is unaccompanied in the ER. An examination of the woman reveals that she has bilateral mastectomies, When the patient wakes up, she reports having severe pain in her ribs and along her spinal column that is getting progressively worse. Which of the following statements is true?
(A) Bisphosphonates not only can treat the bony metastases of breast cancer but can reverse osteonecrosis of the jaw often seen in this type of cancer
(B) A lange number of patients with breast cancer have osteolytic metastatic discase involving the bony skeleton
(C) Placebo-controlled trials with oral or intravenous (IV) bisphosphonates have shown that prolonged administration can reduce the frequency of skeletonrelated events by $80 \%$
(D) Hypercalcemia is the most frequent symptom of bone metastases
(E) This patient's most significant issue is most likely opiate dependence

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Problem 103

Which of the following statements is true regarding arthritis?
(A) The biologic precursor to gout is elevated serum glutamic acid levels
(B) In psoriatic arthritis the distal interphalangeal joints are regularly involved
(C) The onset of polyarthritis in rheumatoid arthritis (RA) is usually rapidly progressive and initially affects the small joints of the hands and feet
(D) Inflammatory markers such as the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) are abnormal in about $95 \%$ of patients with early RA
(E) None of the above

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Problem 104

A patient enters your office complaining of leg pain after having a sural nerve biopsy. Which of the following statements is true about this type of complex regional pain synd rome (CRPS)?
(A) Increased tremor has been documented in the context of this type of CRPS
(B) This is most likely CRPS type I
(C) This type of CRPS has been described to occur after stroke
(D) The CNS does not appear to be involved in the pathophysiology of CRPS
(E) All of the above

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01:51

Problem 105

Which of the following statements is true reganding pain in the context of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS)?
(A) Distal symmetrical polyneuropathy is the most common peripheral nerve disonder associated with HIV
(B) Headache is the second most common of the AIDS-related pain syndromes
(C) Progressive polyradiculopathy is most commonly associated with herpes virus
(D) Kaposi sarcoma has been shown to cause muscular pain but not bone pain
(E) None of the above

Joanna Quigley

Numerade Educator

04:29

Problem 106

. Which of the following statements about central pain is correct?
(A) Central pain occurs with stroke and spinal cord injury (SCI) but not with multiple sclerosis
(B) In syringomyelia, central pain is often the first symptom of the disease
(C) The pathophysiology of pain associated with SCI has yet to be completely elucidated, but supraspinal pathways, not spinal pathways, are most likely involved
(D) After injury to the CNS, it is the denervated synaptic sites that serve an inhibitory role preventing the development of central pain
(E) All of the above

Noor Ul Ain

Numerade Educator

Problem 107

A 35-year-old female with chronic low-back pain comes to see you in your office for the first time. You immediately notice her unusual affect and behavior. Which of the following statements is true?
(A) Patients with somatization disorder, hypochondriasis, factitious physical disonders, and malingering may have pain complaints as part of their illness
(B) Malingeners, by definition, are not consciously aware of their motivation
(C) Other psychiatric disorders, such as depression, anxiety, and panic attacks, may strongly influence chronic pain without directly causing it; posttraumatic stress disorders do not usually impact a pain complaint
(D) One of the main differences between pain associated with malingering and pain associated with anxiety is that in malingering, complaints or symptoms go beyond what should be expected from a specific disease process
(E) None of the above

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Problem 109

A patient is referred to you with facial pain. Which of the following statements is true?
(A) The pain of glossopharyngeal neuralgia is very similar to that of trigeminal neuralgia but affects anterior two-thinds of the tongue, tonsils, and pharynx
(B) Giant cell arteritis is a vasculitic condition that can lead to visual loss but has never been reported in a case of stroke
(C) Cervical carotid artery dissection most commonly presents with neck, head, or facial pain
(D) Pune facial pain is rarely associated with sinusitis alone
(E) None of the above

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Problem 110

A 47-year-old woman comes into the ER complaining of a vague sense of nausea and heart palpitations. She has a history of chronic refractory angina. Which of the following statements regarding chest pain is false?
(A) In acute coronary syndrome men are more likely to present with chest pain, left arm pain, or diaphoresis and women may present with nausea
(B) To consider the diagnosis of cardiac syndrome $\mathrm{X}$, this patient would have to have an abnormal coronary arteriography
(C) Controlled studies suggest that in patients with chronic refractory angina, spinal cord stimulation (SCS) provides symptomatic relief that is equivalent to that provided by surgical or endovascular reperfusion procedures, but with a lower rate of complications and rehospitalization
(D) The mechanism of action of spinal cord stimulation in treating angina is not yet completely defined
(E) None of the above

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Problem 111

Which of the following statements regarding knee pain is true?
(A) Children and adolescents who present with knee pain are likely to have one of three common conditions: patellar subluxation, tibial apophysitis, or pseudogout
(B) A patient with a history of diabetes who presents with acute onset of pain and swelling of the joint with no antecedent trauma is likely to have a patellofemoral pain syndrome
(C) In pseudogout calcium pyrophosphate crystals are the causative agents
(D) You would not expect to see cystic changes on radiography of a knee with suspected osteoarthritis
(E) All of the above

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Problem 112

A patient comes into your clinic complaining of right foot pain. Which of the following would be a correct diagnosis?
(A) The most commonly seen neuropathy in diabetes, because the symptoms are unilateral
(B) Plantar fasciitis, because the patient develops the symptoms after prolonged activity
(C) Morton neuroma, because it is located on the heel
(D) Tarsal tunnel syndrome, compression of the posterior tibial nerve as it passes by the medial malleolus
(E) None of the above

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Problem 113

A 35-year-old woman comes to your clinic complaining of pelvic pain. Which of the following is important to consider during her evaluation?
(A) Endometriosis is the most common cause of pelvic pain in women
(B) Endometriosis most likely does not have an inflammatory component
(C) Endometriosis has been shown to be primarily dependent on blood levels of the hormone progesterone
(D) An inflammatory process would be supported by findings of a decrease of interleukin 8 in testing of peritoneal fluid
(E) All of the above

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Problem 114

An 85-year-old man comes to your clinic having recovered from "a bad pneumonia" recently. He now complains of chest pain. Which of the following statements is false?
(A) While the parietal pleura does not contain any nociceptive innervation, the visceral pleura does
(B) Viral infection is the most common cause of pleurisy
(C) A description of pain with coughing would be consistent with pleurisy
(D) Pulmonary embolism is a possible cause of these symptoms
(E) None of the above

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Problem 115

Which of the following statements regarding repetitive strain injuries is true?
(A) Repetitive strain injury does not include the specific disorder cubital tunnel syndrome
(B) Repetitive strain injury is a controversial diagnosis partially because there are few studies showing an association between physical risk factors and injury
(C) Psychosocial factors are more clearly correlated than physical risk factors in repetitive strain injury
(D) The "unifying hypothesis" of repetitive strain injury states that most often these diseases can be demonstrated to be due to focal injury
(E) All of the above

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Problem 116

. A 56-year-old woman comes into your dinic complaining of chest pain on the left. She has a history of breast cancer with mastectomy and radiation treatment. She may still have chemotherapy. Which of the following statements is true?
(A) As treatments for breast cancer have advanced in the past decade, the incidence of this type of pain has plummeted
(B) The incidence of peripheral neuropathy would be higher with cisplatin than with paclitaxel
(C) With chemotherapy, there is a higher incidence of motor than sensory neuropathy
(D) Axillary dissection poses risks to the intercostobrachial nerve and the medial cutaneous nerve of the arm
(E) All of the above

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Problem 117

A 52-year-old obese male with a 5-year history of diabetes is complaining of foot pain. Which of the following statements is false?
(A) If this patient has "large-fiber" nerve dysfunction, it may include weakness
(B) Blood sugar abnormalities have been shown to correlate with degree of nerve dysfunction
(C) Neuropathy has been described in the context of diabetes and blood sugar levels less than the criteria for diabetes mellitus as defined by the American Diabetes Association have not been shown to correlate with neuropathy
(D) Small fiber neuropathy can have autonomic features
(E) None of the above

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Problem 118

An 85-year-old woman comes into your clinic with chronic pain over her left breast for more than 1 year. The symptoms began after she broke out in a rash in the same distribution. Which of the following statements is true?
(A) Zoster reactivation is always accompanied by a rash
(B) Zoster reactivation may occur two to three times for a healthy individual
(C) Post herpetic neuralgia (PHN) is pain that persists for more than 120 days
(D) The incidence of $\mathrm{PHN}$ is expected to remain stable in the future
(E) All of the above

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Problem 119

A patient comes into your clinic without a referral. He has a long history of chronic pain. He reports having some implantable device but he is unsure what it is. On examination, you find a surgical scar over the left lower quadrant of his abdomen. Over the past several weeks he has been developing worsening lower extremity pain. Your examination reveals spasticity. Which of the following is important to consider?
(A) If the patient is getting intrathecal morphine, the rate of infusion would not have any impact on his complaint
(B) If this patient has an intrathecal pump, only intrathecal morphine has been shown to result in granuloma formation
(C) A microscopic investigation of an intrathecal morphine related granuloma would reveal necrotic tissue without immune cells
(D) Morphine is a hydrophilic molecule
(E) All of the above

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Problem 120

The patient from question 119 , relates that over the past decade he has had three back surgeries. This is why he thinks that the intrathecal pump was implanted. He reports that the first back surgery helped him for 6 months but the symptoms returned. The subsequent back surgeries only made his symptoms worse. Which of the following statements regarding this patient's condition is true?
(A) In failed back surgery syndrome (FBSS), the most common structural cause of symptoms has been shown to be foraminal stenosis
(B) In FBSS, pure psychogenic pain is somewhat common
(C) In the context of chronic pain, an improvement of $30 \%$ is usually considered satisfactory
(D) Failed back surgery syndrome, for the most part, implies a specific anatomical derangement
(E) None of the above

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01:35

Problem 121

Which of the following statements is false regarding pain and pregnancy?
(A) One of the common causes of pain in early pregnancy includes stretch and hematoma formation in the round ligaments
(B) Radicular symptoms usually suggest a herniated disc
(C) Pregnancy is not an absolute contraindication to radiography
(D) Migraine headaches rarely begin during pregnancy
(E) All of the above

Amy Adkisson

Numerade Educator

04:00

Problem 122

A 10-year-old boy with a diagnosis of sickle cell disease comes into your clinic. Which of the following statements is true regarding his condition?
(A) A vasoocclusive crisis commonly involves the back, legs, and eyes
(B) Acute pain in patients with sickle cell disease is caused by ischemic tissue injury resulting from the occlusion of macrovascular beds by sickled erythrocytes during an acute crisis
(C) When a vasoocclusive crisis lasts longer than 7 days, it is important to search for other causes of bone pain
(D) Patients with homozygous sickle cell and sickle cell- $\beta$-thalassemia have a lower frequency of vasoocclusive pain crises than patients with hemoglobin sickle cell and sickle cell- $\beta$-thalassemia genotype
(E) None of the above

Sheryl Ezze

Numerade Educator

Problem 123

You enter a clinic's examination room to do a new evaluation on a patient, You find the patient leaning back on the chair in a deep sleep. Upon waking the patient up, you immediately notice an inappropriate affect and decreased movement of the right arm and leg. Which of the following statements is false?
(A) Sleep disturbance, which can occur in the context of depression, can cause chronic pain
(B) The diagnostic criteria of substance abuse includes recurrent substance use in situations where it is physically hazardous
(C) The diagnostic criteria of substance dependence includes recurrent substance use in situations where it is physically hazardous
(D) Conversion disorder is voluntary
(E) None of the above

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Problem 124

A patient comes into your clinic several years after sustaining a SCl. He complains of pain in multiple areas of his body. Which of the following statements is true regarding this patient's pain?
(A) Chronic pain is a major complication of SCI with approximately two-thirds of all SCI patients experiencing some type of chronic pain and up to one-third complaining that their pain is severe
(B) Central pain is the only cause of pain in patients with $\mathrm{SCI}$
(C) Cervical spine injuries have the highest incidence of central pain of all the spinal cord injuries
(D) Central pain that occurs at the level of the $\mathrm{SCl}$ is because of nerve root damage
(E) All of the above

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02:07

Problem 125

The patient from the previous question used to be an anatomy and physiology teacher at a local college and is asking about some details about the mechanism of central pain in spinal cord injury (SCI). Which of the following explanations would you not give him?
(A) Prolonged high intensity noxious stimulation activates the $\mathrm{N}$-methyl-Daspartate (NMDA) receptors which induces a cascade that may result in central sensitization
(B) Abnormal sodium channel expression may be involved
(C) Thalamic neurons thought to be involved in the generation of pain undergo changes after $\mathrm{SCl}$
(D) Thalamic neurons in SCI are relay stations for pain signals but not pain generators
(E) All of the above

Christina Sorrentino

Numerade Educator

03:24

Problem 127

The definition of pain that is endorsed by the International Association for the Study of Pain is "Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." There are a host of physiologic mechanisms by which injuries lead to nociceptive responses and ultimately to pain. That being said, not all nociceptive signals are perceived as pain and not every pain sensation originates from nociception. Which of the following statements regarding pain is false?
(A) Mainly two types of pain receptors are activated by nociceptive input. These include low-threshold nociceptors that are connected to fast pain-conducting Afibers, and high-threshold nociceptors that conduct impulses in slow (unmyelinated) C fibers
(B) Many neurotransmitters (ie, glutamate and substance P) are able to modulate postsynaptic responses with further transmission to supraspinal sites (thalamus, anterior cingulated cortex, insular cortex, and somatosensory cortex) via ascending pathways
(C) Prolonged or strong activity of dorsal horn neurons caused by repeated or sustained noxious stimulation may subsequently lead to increased neuronal responsiveness or central sensitization
(D) Windup refers to a mechanism present in the peripheral nervous system in which repetitive noxious stimulation results in a slow temporal summation that is experienced in humans as increased pain
(E) Substance $\mathrm{P}$ is an important nociceptive neurotransmitter. It lowers the threshold of synaptic excitability, resulting in the unmasking of normally silent interspinal synapses and the sensitization of second-order spinal neurons

Jameson Kuper

Numerade Educator

01:52

Problem 128

The presence of several pain inhibitory and facilitatory centers in the brainstem is well recognized. Which of the following regarding these systems is incorrect?
(A) The dorsolateral funiculus is involved in a pathway for descending pain inhibitory systems
(B) One function of the descending inhibitory pathway is to expand the excitation of the dorsal hom neurons
(C) The activity in descending pathways is not constant but can be modulated, for example, by the level of vigilance or attention and by stress
(D) Certain cognitive styles and personality traits have been associated with amplification of pain and its extension in the absence of tissue damage. These include somatization, catastrophizing, and hypervigilance
(E) All of the above

Christina Sorrentino

Numerade Educator

03:41

Problem 129

Which of the following statements is incorrect regarding the mechanisms of neuropathic pain?
(A) Injured and neighboring noninjured sensory neurons can develop a change in their excitability sufficient to generate pacemaker-like potentials, which evoke ectopic action potential discharges, a sensory inflow independent of any peripheral stimulus
(B) Central sensitization represents a state of heightened sensitivity of dorsal horn neurons such that their threshold of activation is reduced, and their responsiveness to synaptic inputs is augmented
(C) After peripheral nerve injury $C$ fiber input may arise spontaneously and drive central sensitization
(D) The negative symptoms of neuropathic pain, such as allodynia, essentially reflect loss of sensation owing to axon/neuron loss
(E) All of the above

Rikhil Makwana

Numerade Educator

Problem 130

Which of the following statements about prolonged opiate use is false?
(A) A patient who maintains the same dose of opiate over a prolonged period of time is not at risk for developing tolerance
(B) Patients who receive long-term opiate therapy may be at risk of developing a paradoxical opioid induced pain
(C) Pharmacologic induction of pain may occur through activation of the rostral ventromedial medulla
(D) There is evidence that over the long term, opiates suppress pain by upregulation of spinal dynorphin, and enhanced, evoked release of excitatory transmitters from primary afferents
(E) None of the above

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02:13

Problem 131

An anatomy/physiology professor sees you in clinic. You believe he meets criteria for CRPS. He has several questions about the autonomic nervous system. Which of the following would you highlight to him as a significant difference between the peripheral pathways of the autonomic and somatic motor nervous system?
(A) Unlike the somatic motor system which has its motor neurons in the CNS, the motor neurons of the autonomic nervous system (ANS) are located in the periphery
(B) The peripheral efferent pathways of the somatic motor nervous system has two components: a primary presynaptic or preganglionic neuron, and a secondary postsynaptic or postganglionic neuron
(C) The cell bodies of somatic motor nerves forms aggregates in the periphery called ganglia
(D) There are no significant differences
(E) All of the above

James Thierer

Numerade Educator

00:28

Problem 132

The professor from question 131 has several more questions about the autonomic nervous system. You would make all of the following statements about the sympathetic and parasympathetic divisions of the autonomic nervous system, EXCEPT
(A) the parasympathetic preganglionic fibers travel from the CNS to synapse in ganglia located close to their target organs
(B) while sympathetic nerve fibers are distributed throughout the body, parasympathetic fibers generally only innervate visceral organs
(C) the preganglionic sympathetic neurons have their cell bodies in the gray matter of the brainstem and their fibers travel with the oculomotor, facial, glossopharyngeal, and vagus nerves
(D) the efferent portion of the sympathetic division of the ANS includes preganglionic neurons, the two paravertebral (lateral) sympathetic chains, prevertebral and terminal ganglia, and postganglionic neurons
(E) none of the above

Aadit Sharma

Numerade Educator

Problem 133

A patient with a history of cancer comes to your clinic complaining of neck, shoulder, and arm pain. Which of the following is an important consideration?
(A) Most tumors that affect the brachial plexus are from skin cancer
(B) The most common presenting complaint of a tumor affecting the brachial plexus is pain
(C) Radiation induced plexopathy has not been shown to be dependent on dose of radiation
(D) Clinically, it is nearly impossible to distinguish between neoplastic and radiation plexopathy
(E) All of the above

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Problem 134

A patient with a history of multiple sclerosis comes into your office for an initial consult. She is wheelchair bound and has an intrathecal pump. She skipped the last appointment with
her previous pain physician because she "did not like his bed-side manner." She cannot recall exactly, but it probably has been 3 months since she saw a pain physician. Which of the follow: ing is an important consideration?
(A) A withdrawal syndrome from intrathecal baclofen (TTB) may include respiratory depression and hypotonia
(B) ПВ is a calcium channel blocker that acts primarily at the dorsal root ganglion (DRG)
(C) Withdrawal syndromes from IIB can be fatal
(D) Symptoms of ITB overdose include pruritus and hyperthermia
(E) All of the above

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Problem 135

A hearing impaired patient with severe learning disabilities comes to your office accompanied by his mother. The day prior to seeing you, the patient had a translaminar lumbar epidural steroid injection for low-back pain at a "major medical center" and the physician performing the procedure said it was a perfect injection. The patient is not able to communicate proficiently at his baseline. The mother reports that since the injection was done, the patient appears more comfortable lying down than standing. He is groggy and keeps his eyes closed for most of your interaction, but he has been up most of the night. The patient has a low-grade fever and mild tachycardia. His neck is somewhat stiff but he is otherwise uncooperative. Which of the following is the most appropriate next step of management?
(A) Place an IV line to prepare the patient for a blood patch
(B) Explain to the mother that the patient should exhaust conservative therapy for 48 to 72 hours prior to considering a blood patch
(C) Send the patient to the ER for immediate performance of a lumbar puncture
(D) Schedule the patient for an MRI of the lumbar spine
(E) Initiate high-dose narcotic therapy

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Problem 136

Chronic pancreatitis is the progressive and permanent destruction of the pancreas resulting in exocrine and endocrine insufficiency and, often, chronic disabling pain. Which of the following statements about chronic pancreatitis is incorrect?
(A) Excessive alcohol use plays a significant role in up to $70 \%$ of adults with chronic pancreatitis, whereas genetic and structural defects predominate in children
(B) The pain with chronic pancreatitis is commonly described as midepigastric postprandial pain that radiates to the back and that can sometimes be relieved by sitting upright or leaning forward
(C) Autoimmune pancreatitis accounts for up to $5 \%$ of cases
(D) Because of its uniform presentation most cases of chronic pancreatitis are diagnosed
(E) None of the above

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Problem 136

A physician is performing a cervical transforaminal epidural steroid injection at the $\mathrm{C} 4-5$ level. After the needle is placed in what the practitioner believes is an appropriate position, he removes the stylet and gets retum of pulsating red blood. This would be most conceming if
(A) the needle is in the anterior neuroforamen
(B) the needle is in the posterior neuroforamen
(C) no need for concern, as the practitioner is only planning on injecting triamcinolone
(D) the patient is feeling new radicular pain symptoms that are severe in the $C 5$ dermatome
(E) the patient has a significant history of vasovagal responses

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Problem 137

Which of the following statements is true regarding phantom limb pain and stump pain?
(A) Mastectomy has been documented to lead to phantom sensation in the breast in well more than $90 \%$ of cases
(B) Phantom sensations are almost always more vivid in the distal extremity
(C) All amputees that have neuromata have stump pain
(D) Phantom limb sensations usually change with time; the distal part of the limb usually disappears first
(E) None of the above

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Problem 138

A 35-year-old ex-football player enters your office complaining of shoulder pain. Which of the following statements is true of his condition?
(A) A complaint along the deltoid has been shown to correlate with rotator cuff pathology
(B) A history of a thyroid disorder could suggest dysfunction of the acromioclavicular joint
(C) Acromioclavicular joint pathology usually presents with diffuse shoulder pain
(D) If the pain began before the age of 30 , this would most fit the clinical picture of a rotator cuff tear
(E) All of the above

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Problem 139

You suspect nerve root impingement in the lumbar spine. Which of the following physical findings would support this diagnosis?
(1) You suspect L.2 nerve root involvement and the patient has weakness of hip flexion and sensory loss on the lateral aspect of the calf
(2) You suspect L4 nerve root involvement and the patient has weakness of leg extension and loss of patellar reflex
(3) You suspect L.5 nerve root involvement and the patient cannot dorsiflex his big toe and has a loss of the Achilles reflex
(4) You suspect 51 nerve root involvement and the patient has loss of sensation over the bottom of the foot. Achilles reflex is normal

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01:41

Problem 140

Which of the following structures that play a role in the neurobiology of addiction are properly linked?
(1) Nucleus locus ceruleus-arousal, attention, and anxiety
(2) Anterior cingulate cortex-functional part of limbic system
(3) Amygdala-mediates drug craving
(4) Nucleus accumbens - one of the brain's reward centers

Emily Himsel

Numerade Educator

Problem 141

Which of the following is true regarding seizures as one of the multiple side effects from the use of opioids?
(A) Morphine and related opioids can cause seizure activity when moderate doses are given
(B) Seizure activity is more likely with meperidine, especially in the elderly and with renal dysfunction
(C) Seizure activity is mediated through stimulation of $\mathrm{N}$-methyl-D-aspartate (NMDA) receptors
(D) Naloxone is very effective in treating seizures produced by morphine and related drugs including meperidine
(E) Seizure activity is most likely related with the fact that opioids stimulate the production of $\gamma$-aminobutyric acid (GABA)

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Problem 142

Which of the following is true regarding respiratory depression related to the use of opioids?
(A) Opioid agonists, partial agonists, and agonist/antagonists produce the same degree of respiratory depression
(B) Opioids produce a leftward shift of the $\mathrm{CO}_2$ response curve
(C) Depression of respiration is produced by a decrease in respiratory rate, with a constant minute volume
(D) Naloxone partially reverses the opioidinduced respiratory depression
(E) The apneic threshold is decreased

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03:44

Problem 143

The use of which of the following opioids would produce the greatest incidence of delayed respiratory depression?
(A) $25 \mu \mathrm{g}$ intravenous (IV) fentanyl (bolus)
(B) $4 \mathrm{mg}$ IV morphine (bolus)
(C) $5 \mu \mathrm{g}$ IV sufentanil (bolus)
(D) $8 \mathrm{mg}$ epidural, preservative free morphine
(E) $0.05 \mathrm{mg}$ intrathecal, preservative free morphine

Dr. Satish Ingale

Numerade Educator

Problem 144

Opioids in general reduce the sympathetic output and produce a dose-dependant bradycardia, EXCEPT
(A) morphine
(B) fentanyl
(C) meperidine
(D) sufentanil
(E) alfentanil

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