ASIPP Pain States Questions Flashcards
1
Q
- Characteristics of diffuse idiopathic skeletal hyperostosis
(DISH) include:
A. Extensive degenerative disease
B. Traumatic insult.
C. Cystic in presentation.
D. Osteophytosis without evidence of disk space narrowing
or sclerosis.
E. Posterior calcifi cation in four contiguous vertebrae
A
- Answer: D
Source: Helms CA. Fundamentals of Skeletal Radiology.
W.B. Saunders Co., 1995; p. 117.
2
Q
447. Which of the following is the most sensitive to visceral stimuli? A. Serosal membranes B. Solid visceral organs C. Walls of hollow organs D. Ligamentous structures E. Mesentery
A
- Answer: A
Source: Day MR, Board Review 2004
3
Q
448. Which of the following has been targeted as the cause of ischemic muscle pain? A. Substance P B. Potassium ion C. Leukotrienes D. Adenosine E. Histamine
A
- Answer: D
Source: Day MR, Board Review 2004
4
Q
449. The spinal pathway theorized to be involved in the pathogenesis of central pain is: A. Spinothalamic tract B. Posterior spinocerebeller tract C. Anterior corticospinal tract D. Fasciculi propii E. All of the above
A
- Answer: A
Source: Day MR, Board Review 2004
5
Q
450. Seventy percent of cervical radiculopathies caused by disc impingement involve the following nerve root: A. T1 B. C7 C. C6 D. C5 E. C4
A
- Answer: B
Explanation:
B. 70% of cervical radiculopathies involve C7.
C. 20% of cervical radiculopathies involves C6.
A, D & E. Only 10% of cervical radiculopathies involve the
nerve roots other than C6, C7.
6
Q
451.Based on burn depth classifi cation, which type/types is/are painful? A. 1st degree B. 2nd degree C. 3rd degree D. 1st and 2nd degree E. 1st, 2nd, and 3rd degree
A
- Answer: D
Explanation:
Ref: DeLoach and Stiff. Chapter 18. Burn Patient. In: Pain
Management and Regional Anesthesia in Trauma. 1st
Edition. Rosenberg, Grande, Berstein. W.B. Saunders,
1999, page 302.
Source: Day MR, Board Review 2003
7
Q
452. What is the most common etiology of brain central pain? A. Neoplasm B. Arteriovenous malformation C. Stroke D. Multiple sclerosis E. Syringobulbia
A
- Answer: C
Source: Day MR, Board Review 2004
8
Q
453. A 40-year-old man develops depressed mood, anhedonia, initial and terminal insomnia, loss of appetite, signifi cant weight loss, and sexual dysfunction. The clinical features of the patient’s psychiatric illness suggest dysfunction of the A. Frontal lobes B. Pituitary C. Hippocampus D. Hypothalamus E. Corpus Callosum
A
- Answer: D
Explanation:
D. Clinical studies of patients with major depressive
disorders indicate that an intrinsic regulatory defect
involving the hypothalamus underlies the disorder. It also
involves the monoamine pathways.
The hypothalamic modulation of neuroendocrine activity
has been implicated, as have been the neurotransmitter
systems of serotonin and norepinephrine, in major
depression. The evidence suggests a major role for the
heritability of such neurochemical disorders.
A, B, C & E. The frontal lobes, the pituitary, the
hippocampus, and the corpus callosum are related to the
emotions, memory, and neural communications.
However, they do not play a major role in the depressive
disorders as does the hypothalamus.
Source: Ebert 2004
9
Q
- The best description of the relationship between pain and
psychiatric disorders is which of the following?
A. There are low rates of psychiatric illness in patients with
chronicpain.
B. Medically ill patients are much more likely to have psychiatric
illness.
C. Psychiatric illnesses preclude the possibility of clinically
important medical illnesses(pain).
D. There is no relationship between pain, medical and
psychiatric disorders.
E. All the patients with chronic pain will also suffer with
somatization disorder
A
- Answer: B
Source: Cole EB, Board Review 2003
10
Q
- Neurological level of a C6 nerve root involvement is
identifi ed by the following:
A. Weakness in the wrist extension, loss of sensation in the
lateral arm, and biceps refl ex suppression
B. Weakness of shoulder abduction, pain in the lateral
forearm, and suppression of brachioradialis refl ex
C. Weakness of wrist extension, pain in the lateral forearm,
thumb, and index fi nger, and suppression of brachioradialis
refl ex
D. Weakness of wrist fl exion and fi nger extension, pain
in the thumb and index fi nger, loss of sensation in
the thumb and index fi nger, and triceps refl ex suppression
E. Weakness of wrist extension, pain in the lateral arm,
and brachioradialis refl ex suppression
A
- Answer: C
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels. Philadelphia,
LWW, 1997.
11
Q
- A young man with ankylosing spondylitis complains of
neck, occipital, and shoulder pain. He denies any history
of recent trauma or febrile illness. The most likely cause
of his pain is:
A. Compression fracture of C2
B. Cervical osteomyelitis
C. Atlantoaxial subluxation
D. Epidural hematoma
E. Cervical disc herniation C4/5
A
- Answer: C
Explanation:
Patients with ankylosing spondylitis may have erosion of
the odontoid or destruction of the transverse ligament,
which may allow C1 subluxation on C2.
Patients will complain of neck, occipital, and shoulder
pain. The subluxation is usually mild in these patients.
Plain radiographs and MRI should be obtained to confi rm
the diagnosis.
Treatment is symptomatic.
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
12
Q
457. Unilateral sacroiliac joint erosion or sclerosis would be characteristic of: A. Osteoporosis B. Psoriasis C. HNP L5-S1 D. Reiter’s syndrome E. Piriformis syndrome
A
- Answer: D
Source: Helms CA. Fundamentals of Skeletal Radiology.
W.B. Saunders Co., 1995; p. 125.
13
Q
458. Ramsay Hunt syndrome (herpes zoster oticus) occurs when herpes zoster involves the: A. Gasserian ganglion B. Sphenopalatine ganglion C. Ciliary ganglion D. Geniculate ganglion E. Trigeminal nerve
A
- Answer: D
Explanation:
Ramsay Hunt syndrome develops from a herpes zoster
infection involving the geniculate ganglion.
Zoster lesions of the external ear and oral mucosa on the
ipsilateral side are usually observed.
The syndrome can present as a deep, painful sensation primarily behind the ear between the pinna and mastoid
process and radiating to the face, ear, neck, and occipital
areas.
Source: Raj (Pain Review, 2nd Ed., page 236)
14
Q
- A 54-year old man complained of back pain after heaving
lifting. Two weeks later, he had diffi culty walking on his
heels, and increased pain in the lower back, buttock, and
dorsum of the foot. Straight leg raising was positive at
50°. Likely diagnosis is:
A. L3 radiculopathy
B. L4 radiculopathy
C. L5 radiculopathy
D. S1 radiculopathy
E. L3/4 disc herniation
A
- Answer: C
15
Q
460. Diagnosis of CRPS may be performed: A. typical personality B. recent surgery C. exclusion of other likely diagnosis D. psychological testing E. drug intake profi le
A
- Answer: C
Source: Racz G. Board Review 2003
16
Q
- A female patient presents with gluteal and leg pain. The pain is exacerbated when the patient lies down on the
affected side or with crossed legs. Physical examination
revealed local trochanteric tenderness with iliotibial
band tightness and tenderness. The most likely diagnosis
is:
A. Piriformis syndrome
B. Trochanteric bursitis
C. Lumbar radiculopathy
D. Sacroiliitis.
E. Osteoarthritis of hip
A
- Answer: B
Explanation:
Trochanteric bursitis or gluteal fasciitis may be seen in
approximately 25% of the patients with back pain
predominantly in women.
Etiology is typically unknown. However, one may fi nd leg
length difference, abnormal gait, muscle tightness,
osteoarthritis of the hip or spine, and occasional trauma.
Signs and symptoms:
Gluteal and leg pain, 64%
Pain lying on affected side or with crossed legs, 50%
Local trochanteric tenderness, frequently with iliotibial
band tightness and tenderness
Differential diagnosis of trochanteric bursitis includes
osteoarthritis of hip, lumbar radiculopathy, and septic
bursitis.
Source: Cole & Herring. Low Back Pain Handbook
17
Q
- A young female patient presents with buttock and leg
pain. She also reported occasional low back pain and
severe dyspareunia. Physical examination showed pain
on resisted external rotation and abduction of hip. The
likely diagnosis in this patient is:
A. Severe osteoarthritis of hip
B. Piriformis syndrome
C. Lumbar disc herniation
D. Trochanteric bursitis
E. Sacroiliac joint arthritis
A
- Answer: B
Explanation:
B. The description above indicates piriformis syndrome:
Piriformis muscle originates medially from the inner
surface of the sacrum and exits the pelvis through the
greater sciatic foramen and attaches to the greater
trochanter of the femur.
The innervation is from the fi rst and second sacral nerves
(S1 and S2).
Buttock and nerve pain or pseudosciatica resulting from
compression or infl ammation of sciatic nerve as it courses
under or through piriformis muscle in buttock is the
mechanism.
There is no particular group at risk.
Minor trauma to piriformis may result in muscle
contraction or infl ammation.
Pseudosciatica or buttock and leg pain is the most
common symptom.
Low back pain is seen in 50% of the patients.
Dyspareunia is seen in 23%.
Piriformis muscle tenderness may be found transrectally
or transgluteally.
There is pain on resisted external rotation and abduction of hip.
There is also pain on internal rotation of hip.
The piriformis should be assessed above and below 90° of
hip fl exion.
Reproduction of symptoms in combination with forceful
internal rotation of the fl exed thigh is referred to as
Freiberg’s sign.
If you add adduction, it is called Bonnet’s sign.
The pace maneuver also assesses weakness and pain with
resisted abduction and external rotation of the thigh. This
is done with the patient in the seated position.
Tenderness may present throughout the length of the
piriformis
Differential diagnosis includes lumbar radiculopathy and
sacroiliitis.
Source: Cole & Herring. Low Back Pain Handbook
18
Q
- In a patient whose headaches are positional and are
associated with diplopia, vertigo, tinnitus, nystagmus,
hearing loss, photophobia, nausea, and vomiting the
diagnosis is:
A. Cervicogenic headache
B. Intractable migraine with aura
C. Episodic cluster headache
D. Post-dural puncture headache
E. Non-intractable migraine without aura
A
- Answer: D
19
Q
464. The usual site of herniation of a cervical intervertebral disk is: A. Posterior B. Lateral C. Postero lateral D. Anterior E. Antero lateral
A
- Answer: C
Explanation:
The uncinate processes are bony protrusions located
laterally from the C3 to C7 vertebrae. They prevent the
disc form herniating laterally. The posterior longitudinal
ligament is the thickest in the cervical region. It is 4 to 5
time thicker than in the thoracic or lumbar region. The
nucleus pulposus in the cervical disc is present at birth but
by the age of 40 years it practically disappears. The adult
disc is desiccated and ligamentous. It is mainly composed
of fi brocartilage and hyaline cartilage. After the age of 40, a
herniated cervical disc is never seen because there is no
nucleus pulposus. The most common cervical herniated
nucleus pulposus (HNP) occurs between the C6 to C7
(50%) and followed by the C5 to C6 (30%)
Source: Chopra P. 2004
20
Q
- Which of the following statements is true?
A. Pneumothorax is a common complication of thoracic
epidural.
B. Thoracic facet pathology can refer pain to the scapular
region
C. The intercostal nerve innervates only the scapular
region
D. Noncardiac chest pain is purely psychogenic
E. There is no risk of pneumothorax with a simple trigger
point injection
A
- Answer: B
Explanation:
Pneumothorax is a risk from rib blocks and trigger point
injections. The thoracic facets refer to the scapular region,
but the intercostal nerve can refer into the anterior chest.
There are multiple causes of noncardiac chest pain.
Source: Trescot AM, Board Review 2004
21
Q
466. Lower esophageal pain can be relieved by blocking spinal nerve roots at which levels? A. T2 - T3 B. T2- T5 C. T5- T8 D. T8 - T9 E. T8- T10
A
- Answer: C
Explanation:
Ref: Raj. Chapter 43. Thoracoabdominal Pain. In:
Practical Management of Pain. 3rd Edition, Raj et al,
Mosby, 2000, page 620
Source: Day MR, Board Review 2003
22
Q
467. Thoracic pain can come from all of the following EXCEPT: A. intercostal nerves B. myofascial trigger points C. thoracic or cervical facets D. lung tissue E. atlanto-axial joint
A
467. Answer: E Explanation: All of the above are causes of thoracic pain except Altantoaxial Joint Source: Trescot AM, Board Review 2004
23
Q
468. What is the lifetime prevalence of radicular pain? A. 0.2% B. 2% C. 10% D. 20% E. 80%
A
- Answer: B
Source: (Bonica, 3rd Ed., page 1528)
24
Q
- The affective dimensions of the pain response include
A. Increase in pain tolerance
B. Disruption of appetitive and arousal drive states
C. Memory loss
D. Sharp, shooting pain
E. Dermatomal sensory loss
A
- Answer: B
25
Q
- A 65-year old man with a history of chronic back pain
has been a patient for 5 years, receiving 3-4 months relief
from epidural steroid injections before pain increases to
the level where repeat injection is required. Following
6 weeks after epidural, he presents to the clinic with the
complaint of a recent increase in his pain. The pain is
constant and is exacerbated by movement. NSAIDS,
bedrest, and narcotics failed to help. There was no
history of fever. The L4 and L5 vertebrae were tender to
palpation. There was also paraspinal muscle spasm. No
motor or sensory defi cits were present. The most likely
diagnosis entertained in this patient:
A. Vertebral osteomyelitis
B. Spinal stenosis
C. Herniated disc
D. Paget’s disease
E. Epidural abscess
A
- Answer: A
Explanation:
The symptoms described in the question are consistent
with the diagnosis of vertebral osteomyelitis. Clinical
features include persistent, localized pain with heat,
swelling, tenderness, and erythema over the involved bone.
Fever may be low-grade or absent. Diagnosis can be made
by history, physical examination, radiographic studies of
the spine, bone scan, blood cultures, erythrocyte
sedimentation rate, complete blood count, needle
aspiration of the intervertebral disc space, or biopsy of
infected bone. Staphylococcus aureus is the most common
causative organism, but gram-negative bacteria can also
cause osteomyelitis (most common in a urinary tract
infection) (Bonica, pp 393-394).
26
Q
471.Which of the following statements best described
Conversion Disorder?
A. Involves one or more symptoms or defi cits affecting
voluntary motor or sensory function that suggest a
neurological or other general medical condition.
B. Psychological factors are not judged to be associated
with the symptom or defi cit because the initiation or
exacerbation of the symptom or defi cit follows confl
icts with healthcare professionals.
C. Patients intentionally produce or feign symptoms and
defi cits to call attention to themselves.
D. Symptoms or defi cit can after appropriate investigation
be fully explained by a culturally sanctioned behavior
or experience.
E. It generally develops in late life.
A
- Answer: A
Source: Cole EB, Board Review 2003
27
Q
- Spondylolysis is defi ned as:
A. Dysplasia of the L5/S1 facet joints
B. Forward slippage of vertebral body
C. Traumatic degeneration of posterior elements
D. Isthmus defect without vertebral slippage
E. Pathologic dissolution of the facet joint
A
472. Answer: D Explanation: Spondylolysis is a pars defect without vertebral body slippage Source: Boswell MV, Board Review 2005
28
Q
- A 41-year-old man presents with spastic legs, bilateral
extensor plantar refl exes, hyperrefl exia and loss of
sensation (position sense and vibration) of the lower
extremities. Choose correct diagnosis:
A. Upper motor neuron disease
B. Lower motor neuron disease
C. Myelopathy
D. Radiculopathy
E. Broca’s aphasia
A
- Answer: C
Explanation:
A. Upper motor neuron (UMN) disease (above the level of
the corticospinal synapses in the gray matter) is
characterized by spastic paralysis, hyperrefl exia, and a
positive Babinski refl ex (everything is up in UMN
disease).
B. Lower motor neuron (LMN) disease (below the level of
synapse) is characterized by fl accid paralysis, signifi cant
atrophy, fasciculations, hyporefl exia, and a fl exor (normal)
Babinski refl ex (everything is down in LMN disease).
C. Myelopathy causes severe sensory loss 0 posterior
column sensation (position sense and vibration),
spasticity, hyperrefl exia, and positive Babinski refl exes.
D. A radiculopathy occurs with root compression from a
protruded disk that causes sensory loss, weakness, and
hyporefl exia in the distribution of the nerve root.
E. Broca’s aphasia (left inferior frontal gyrus) is a
nonfl uent expressive aphasia (Broca’s should remind you
of broken speech); Wernicke’s aphasia (left posteriorsuperior
temporal gyri) is a receptive aphasia because
patients lack auditory comprehension (Wernicke’s should
remind you of wordy speech that makes no sense).
(Source: Seidel, 5/e, p 798.)
29
Q
474. The superior hypogastric plexus is: A. a collection of para sympathetic nerves B. innervates the foregut C. blocked to treat pelvic pain D. may cause lumbar radiculopathy E. performed under fl uoroscopy at L2
A
- Answer: C
Explanation:
The superior hypogastric plexus is a collection of
sympathetic nerves that innervate the pelvis and is blocked
to treat pelvic pain. They are not involved in lumbar
radiculopathy.
Source: Trescot AM, Board Review 2004
30
Q
- The uncommon Sluder’s neuralgia characterized by severe
pain in the face blow the eyebrows primarily involves the
A. Gasserian ganglion
B. Sphenopalatine ganglion
C. Ciliary ganglion
D. Geniculate ganglion
E. Trigeminal nerve
A
- Answer: B
Explanation:
Sluder’s neuralgia, also known as sphenopalatine ganglion
neuralgia, is an uncommon facial neuralgia characterized
by severe pain in the face below the eyebrows.
The pain is unilateral, constant, and boring.
The cause of Sluder’s syndrome is thought to be
involement of the sphenopalatine ganglion from an
irritation such as sinusitis.
Source: Raj, P
31
Q
476. A patient with hallux valgus develops lateral displacement of the extensor and fl exor hallucis longus tendons. CHOOSE CORRECT DIAGNOSIS: A. Hammer toe B. March fracture C. Genu valgum D. Genu varum E. Bunion
A
- Answer: E
Explanation:
(Seidel, 5/e, p 732.) Improper footwear results in lateral
deviations of the great toe, extensor, and fl exor hallucis
longus tendons (bunion formation). Hammer toe often
affects the second toe. The metatarsophalangeal joint is
dorsifl exed and the proximal interphalangeal joint
displays plantar fl exion. A stress fracture of a metatarsal is
called a march fracture. Stress fractures result in bone
resorption followed by insuffi cient remodeling due to
continued activity Stress fractures occur in the tibia as well
as the metatarsal; examination typically reveals point
tenderness and swelling. In genu varum (bowleg), the
lateral femoral condyles are widely separated when the feet
are placed together in the extended position. In genu
recurvatum, the knee hyperextends, and in genu
impressum, there is fl attening and bending of the knee to
one side with displacement of the patella. Pes planus is a
fl attened longitudinal arch of the foot, often called fl at
foot.
Morton’s neuroma causes pain in the forefoot that radiates
to one or two toes with tenderness between the two
metatarsals. The pain may be further aggravated by
squeezing the metatarsals together.
32
Q
477. Which of the following is innervated by the T1 nerve root? A. Thumb B. Index finger C. Lateral biceps D. Medial arm E. Middle finger
A
- Answer: D
Explanation:
The medial arm is innervated by the intercostals brachial
nerve, and is comprised of fi bers from T1 and T2 roots.
33
Q
- A 20-year-old college student develops left shoulder
pain after jumping into a lake from a swinging rope. She
presents holding her arm beside her body (adducted) and
avoiding any shoulder movement. On examination, the
rounded contour of the shoulder is lost and the head of
the humerus is felt under the coracoid process. Which of
the following is the most likely diagnosis?
A. Inferior glenohumeral dislocation
B. Rupture of the long head of the biceps
C. Posterior glenohumeral dislocation
D. Anterior glenohumeral dislocation
E. Fracture of clavicle
A
- Answer: D
Explanation:
(Seidel, 5/e, p 720.) Glenohumeral dislocations may be
anterior, posterior, or inferior depending on the position of the head of the humerus in relation to the glenoid. The
most common dislocation is anterior (>90%)and is due to
forceful abduction, external rotation, or extension. There
is typically fl attening of the deltoid and loss of the greater
tuberosity, causing a squared-off appearance of the
shoulder. The patient is usually in severe pain and holds
the arm in slight abduction and external rotation.
Posterior dislocations are typically seen following a
seizure. Possible complications of shoulder dislocation
include damage to the axillary artery, axillary nerve
(deltoid paralysis), and brachial plexus. First-time
dislocation requires orthopedic management (surgery or
therapeutic exercise), since 80% of patients will have a
recurrence. Rupture of the long head of the biceps causes a bulge in the lower half of the arm and pain on elbow
flexion.
34
Q
479. A young, high school girl develops a painful vesicular rash around her left eye. This is followed by blurry vision that occurs only when both eyes are open. She is diagnosed with vericella zoster ophthalmicus. Which ocular motor nerve is most likely to be affected? A. Superior division of the third. B. Inferior division of the third. C. Fourth (trochlear) D. Sixth (abducens) E. Long ciliary
A
- Answer: C
Explanation:
Varicella Zoster, or herpes zoster, spreads to the face along
the trigeminal nerve. The fourth nerve is presumably
involved because it shares its nerve sheath with the
ophthalmic division of the trigeminal nerve. The third and
sixth nerves may also be involved with varicella zoster, but
this occurs much less frequently than involvement of the
fourth nerve.
Source: Anschel 2004
35
Q
- 55 year old, former sailor states that he has pain on the
right side of his face when he chews his food. It also
starts when he shaves his beard. It is a sharp, electric like
stabbing pain and not present all the time. The pain is
mostly over his right cheek and jaw. The most likely cause
of his pain is:
A. Dental caries
B. Atypical neuralgia
C. Trigeminal Neuralgia
D. Temporomandibular joint disorder
E. Atypical facial pain
A
- Answer: C
Explanation:
Trigeminal neuralgia (Tic Douloureux) is pain restricted
to the distribution of the trigeminal nerve.It can be
present in any of the three divisions - frontal (V1),
maxillary or the mandibular. The commonest to be
affected are the maxillary (V2) and the mandibular (V3).
The peak incidence is mostly between the ages of 50 years
and 70 years. The pain is intermittent with pain free
intervals. It is described as a sharp, electric, stabbing,
shooting pain. The triggers are chewing, swallowing,
talking and exposure to cold. Trigeminal neuralgia is
mostly unilateral.
Atypical neuralgias are almost always constant with very
rare pain free intervals. This is an important
distinguishing symptom with trigeminal neuralgia. The
pain burning in character and not sharp. It is not triggered
by non-noxious stimulus. It tends to affect young adults.
Source: Chopra P, 2004
36
Q
- A 43-year old male house painter reports shoulder pain
of 2 weeks duration after a half a can of paint fell onto his
right shoulder. He feels stiff and weak when attempting
to elevate his right arm overhead. When attempting to
elevate the shoulder, he does so with an overexaggerated
right shoulder shrug up to 40° and suddenly fl ops down
to his side. The most likely diagnosis is:
A. Rotator cuff tear
B. Cervical spondylosis
C. Suprascapular neuropathy
D. Brachial neuritis
E. Bicipital tendonitis
A
- Answer: A
Explanation:
Rotator cuff disorders encompasses four stages with Stage
I with edema and hemorrhage, Stage II with tendonitis,
Stage III with partial thickness tear, and Stage IV with full
thickness tear of the rotator cuff. With partial thickness
tear, there is history of tendonitis and patient can begin abduction but experiences pain or a painful arc during the
attempt. Active abduction becomes more comfortable
afterinjection of a local anesthetic and this feature helps
differentiate tendonitis or a partial tear from a complete
tear of the rotator cuff. Since the patient with a large tear
does not regain strength after the subacromial space is
anesthetized.
Full thickness tear of the rotator cuff occurs, as the fi nal
stage of the degenerative process in which the provoked
tendon succumbs to something as trivial as opening up a
stuck window or more seriously after sustaining a fall on
the shoulder or on an outstretched abducted arm. A
complete tear may also occur after greater humeral
tuberosity fracture scar or from shoulder dislocations.
Differential diagnosis includes bursitis, cervical
spondylosis, suprascapular neuropathy, and brachial
neuritis, etc.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine. St.
Louis,Inc., 2002
37
Q
- Following a radical mastectomy, the patient is found
to have winging of the scapula when the fl exed arm is
pressed against a fi xed object. This indicates injury to
which of the following nerves?
A. Axillary
B. Long thoracic
C. Lower subscapular
D. Supraclavicular
E. Thoracodorsal
A
- Answer: B
Explanation:
A. The axillary nerve, deep in the brachial portion of the
axilla, innervates the deltoid muscle.
B. The serratus anterior muscle (protractor and stabilizer
of the scapula) is innervated by the long thoracic nerve (of
Bell), which arises from roots C5 to C7 of the brachial
plexus. During modifi ed radical mastectomy, this nerve is
usually spared to maintain shoulder function. However, its
location places it in jeopardy during the lymphatic
resection.
C. The lower subscapular nerve innervates the teres major
muscle and a portion of the subscapularis muscle.
D. The supraclavicular nerves are sensory branches of the
cervical plexus.
E. The thoracodorsal nerve, which arises from the
posterior cord of the brachial plexus, innervates the
latissimus dorsi.
Source: Klein RM and McKenzie JC 2002.
38
Q
- A middle-aged man presents with complaints of right
elbow pain. He is an avid golf player. He does not play
tennis. He tried high doses of Aspirin and Tylenol
without any signifi cant relief. Physical examination
showed resisted wrist extension with elbow extended and
radial deviation, forced passive wrist fl exion and ulnar
deviation, and forearm pronation with elbow extension
reproduced the pain in the vicinity of lateral epicondyle.
The appropriate diagnosis in this patient is:
A. Radiohumeral joint infl ammation
B. Radial tunnel syndrome
C. Posterior interosseous nerve entrapment
D. Lateral epicondylitis
E. Medical epicondylitis
A
- Answer: D
Explanation:
A. Radial humeral joint infl ammation and swelling may
occur from rheumatoid arthritis, gout, or infectious
arthritis, especially in the last if there has been a history of
injections to this area, such as repeated steroid injections
for recalcitrant tennis elbow. Swelling, if present, will
occur between the lateral epicondyle and the olecranon
process below.
B. Radial tunnel syndrome may occur concomitantly with
lateral epicondylitis and is a common cause of treatment
resistant cases. It should be considered suspect when
tennis elbow fails to respond to conservative treatment including injections.
C. Involvement of the deep radial nerve is also known as
posterior interosseous nerve entrapment. This may be
confi rmed by a tension-test. The symptoms of entrapment
of posterior interosseous nerve are similar to the radial
tunnel syndrome in which pain is over the proximal dorsal
forearm, with maximal tenderness at the site of radial
tunnel, that is 4 cm distal to the lateral epicondyle over the
posterior interosseous nerve.
D. Lateral epicondylitis, or tennis elbow, is the most
common affl iction.
E. Medical epicondylitis or pain elicited on resisted wrist
fl exion and pronation, as well as extremes of the passive
wrist extension with the forearm supination and elbow
extension and ulnar deviation eliciting the pain at the
medial epicondyle.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine. St.
Louis,Inc., 2002.
39
Q
- An elderly woman presents with recent onset of swelling
of the right arm, neck and face. Her right jugular vein is visibly engorged and her right brachial pulse is
diminished. On the basis of these signs, her chest x-rays
might show
A. A left cervical rib
B. A mass in the upper lobe of the right lung
C. Aneurysm of the aortic arch
D. Right pneumothorax
E. Thoracic duct blockage in the posterior mediastinum
A
- Answer: B
Explanation:
(April, 3/e, p 265.) A Pancoast tumor in the apex of the
right lung may compress the right brachiocephalic vein
with resultant venous engorgement of the right arm and
right side of the face and neck. In addition, there may be
compression of the brachial artery, the sympathetic chain,
and recurrent laryngeal nerve with attendant defi cits. An
aneurysm of the aortic arch could reduce pulse pressures
as the great vessels are occluded, but it could not explain
the venous congestion.
Source: Klein RM and McKenzie JC 2002.
40
Q
- A woman presents with complaints of left shoulder
and arm pain approximately 2 years after undergoing
radiation therapy for breast cancer. Physical examination
reveals lymphedema of the left axilla and pressure over
the left supraclavicular area precipitating a sharp pain
that radiates down her left arm. The likely diagnoses is:
A. Thromboangiitis obliterans
B. Refl ex sympathetic dystrophy
C. Tumor metastasis
D. Radiation-induced plexopathy
E. Cervical radiculopathy
A
- Answer: D
Explanation:
Radiation-induced fi brosis of the connective tissue
surrounding the brachial plexus can cause compression
and ischemic neuropathy. Symptoms have developed 6
months to 20 years after radiation therapy. The patient
complains of deafferentation-type pain. It is characterized
as progressively increasing, diffuse, and burning. Other
symptoms and signs may include numbness, paresthesias,
dysesthesias, and C5/6 motor weakness. There are
signifi cant differences in symptoms in patients with
metastatic plexopathy versus radiation plexopathy. Most
patients with metastatic plexopathy develop sensory
changes in C8/T1 distribution versus C5/6 in radiation
plexopathy. Patients with metastatic plexopathy also have
a much higher incidence of Horner’s syndrome,
lymphedema, and swelling of the painful limb, and
development of epidural deposits.
Source: Bonica
41
Q
- A 20-year-old woman presents complaining of proximal
forearm pain exacerbated by extension of the wrist
against resistance with the elbow extended, She denies
trauma but is an avid racquetball player. Which of the
following is the most likely diagnosis?
A. Lateral epicondylar tendinitis
B. Medial epicondylar tendinitis
C. Olecranon bursitis
D. Biceps tendinitis
E. Long thoracic nerve early paralysis
A
- Answer: A
Explanation:
(Goldman, 21/e, pp 1559-1560.) Tennis elbow or lateral
epicondylar tendinitis is most commonly characterized by
tenderness of the common extensor muscles at their origin
(the lateral epicondyle of the humerus). Passive fl exion of
the fi ngers and wrist and having the patient extend the
wrist against resistance causes pain. Golfer’s elbow or
medial epicondylar tendinitis is a similar disorder of the
common fl exor muscle group at its origin, the medial
epicondyle of the humerus. Olecranon bursitis is an
infl ammation of the bursa over the olecranon process
caused by acute or chronic trauma (student’s elbow) or
secondary to gout, rheumatoid arthritis, or infection.
Clinically, there is swelling or pain on palpation of the
posterior elbow. Paralysis of the serratus anterior muscle
(innervated by the long thoracic nerve) causes the scapula
to protrude posteriorly from the posterior thoracic wall
when the patient is asked to push against a wall (winged
scapula).
42
Q
- A 50-year old woman with systemic lupus erythematosus
complains of fever, headache, and vomiting associated
with a depressed level of consciousness over the last 24 h.
She recently had begun taking ibuprofen as treatment for
diffuse joint pain. CSF examination revealed neutrophilia
and normal glucose. The most likely diagnosis is:
A. Bacterial meningitis
B. Drug-induced meningitis
C. Fungal meningitis
D. Viral meningitis
E. Encephalitis
A
- Answer: B
Explanation:
B. Drug-induced aseptic meningitis may be due to a
hypersensitivity reaction to drugs such as ibuprofen,
sulindac, tolmetin, trimethoprim-sulfamethoxazole,
azathioprine, penicillin, isoniazid, phenazopyridine, and
sulfonamides.
Facial swelling, urticaria, pruritus, and conjunctivitis may
also occur along with the fever, headache, vomiting, and
depressed level of consciousness.
Symptoms usually resolve rapidly after the causative drug
is eliminated.
CSF studies show predominance of neutrophils and low or
normal glucose.
Patients with lupus, Sjögren’s syndrome, or mixed
connective tissue disease have the greatest risk of
developing drug-induced meningitis.
The incidence is higher in women.
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
43
Q
488. The relationship between social and biologic processes in the causation of psychopathology has historically been classifi ed by the following terms. A. Classically conditioned B. Organic and functional C. Genetic and familial D. Neuropathologic and sociopathologic E. Psychoanalytic and dynamic
A
- Answer: B
Explanation:
The relationship between social and biologic processes has
historically been regarded by psychiatry and medicine as
organic and functional.
Organic mental illnesses have included the dementias and
the toxic psychoses.
The functional mental illnesses have included the various depressive syndromes, the schizophrenias, and the
neuroses.
The Psychoanalytic (dynamic) approaches and an
understanding of conditioning (learning) played
important roles in the evolution and development of an
integrated biobehavioral understanding of human
behavior and human biology.
44
Q
489. The most common painful symptom associated with central pain is A. Burning pain B. Dysesthesias C. Lancinating pain D. Visceral pain E. Muscle pain
A
- Answer: A
45
Q
- A unilateral throbbing headache, associated with
nausea, phonophobia, photophonia, without preceding
symptoms, would meet the IHS criteria for what type of
headache?
A. Migraine with aura
B. Migraine without aura
C. Cluster headache
D. Trigeminal neuralgia
E. Tic doloureux
A
- Answer: B
Explanation:
A. Migraines with aura are associated with preceding
symptoms.
B. Migraine without aura has symptomatology as
described.
C. Cluster headaches are usually centered over the eye.
D. Trigeminal neuralgia is usually a sharp, lancinating
pain.
E. Tic Douloureux is trigeminal neuralgia
Source: Trescot AM, Board Review 2004
46
Q
- A patient complains of morning stiffness and pain
in multiple joints, including the joints of the hand.
Subcutaneous nodules are present over the extensor
surfaces, and diagnostic tests indicate abnormal amounts
of HLA-DR4. The most likely diagnosis is:
A. Osteoarthritis
B. Rheumatoid arthritis
C. Gout
D. Degenerative arthritis
E. Fibromyalgia Syndrome
A
- Answer: B
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition
47
Q
492. The presence of what factor distinguishes CRPS II from CRPS I? A. Sudomotor changes B. An identifi able nerve injury C. Allodynia D. Sympathetically maintained pain E. Hyperalgesia
A
- Answer: B
Source: Day MR, Board Review 2004
48
Q
- A 40-year-old male presents with anterior shoulder
pain. Physical examination shows full range of motion
with painful arc present on elevation and depression
at approximately 50° on both the upswing and the
downswing. There is no muscle wasting. There is no
cuff wasting and the patient admits to a history of cuff
impingement and suspected tear of his right shoulder of
several years’ duration that was operated a year before.
There is tenderness noted in the shoulder, shoulder
abduction, and glenohumeral rotation are painful. The
likely diagnosis is:
A. Bicipital tendonitis
B. Anterior shoulder instability
C. The coracoid impingement syndrome
D. Subdeltoid bursitis
E. Glenohumeral joint arthritis
A
- Answer: A
Explanation:
The biceps, a long fusiform muscle that arises by two
heads, has no direct connection with the humerus as it
originates above the shoulder and inserts below the elbow
joint.
The long head of the biceps arises from the supraglenoid
tubercle and arches obliquely over the top of the humeral
head within the capsule of the shoulder joint.
The biceps tendon is intraarticular but extrasynovial.
The short head of the biceps arises within the
coracobrachialis from the scapulas coracoid process and
runs down the medial side of the long head of the biceps.
The two belles join as a common distal tendon shortly the
elbow joint as fl attened tendon, only to separate into two
distal insertions.
The most common cause (95% to 98%) of bicipital
tendonitis actually results as a secondary involvement of
the biceps after primary impingement or tearing of the
rotator cuff.
Proximal biceps tendonitis is evidenced by proximal
anterior shoulder pain and possibly a painful arc during
shoulder fl exion and extension while the biceps is tensed
and by tenderness in the bicipital groove on palpation.
Pain may radiate to the muscle belly or proximally, like pain from cuff impingement, radiate to the deltoid
insertion.
However, there is no radiation into the neck or distally
beyond the biceps muscle belly.
Pain is less intense during rest and worse with use.
Nighttime exacerbation is common.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention.
49
Q
494. Brachial plexopathy following breast cancer treatment is most often the result of A. Radiation therapy B. Axillary dissection C. Lymphedema D. Chemotherapy E. Metastases
A
- Answer: A
Explanation:
Radiation therapy is more likely to cause brachial
plexopathy in patients with breast cancer. In lung cancer,
plexopathy is more often due to metastatic disease.
50
Q
495. Which of the following is considered to be the least helpful treatment for spinal cord injury pain? A. Amitryptiline B. Opioids C. Marjiuana D. Massage E. Acupuncture
A
495. Answer: A Explanation: (Shah, Central Pain States Lecture; Cardenas, Pain; Warms, Clin J Pain) Source: Shah RV, Board Review 2004
51
Q
- A 42-year-old male presents with pain in the region of the
deltoid that began when he started to build a fence in his
back yard 6 weeks ago. Now his pain is sharp, followed by
a dull aching and increases when he elevates and lowers
his arm during activity. He demonstrates a midrange
painful arc when he elevates his arm. His symptoms are
provoked with resisted shoulder abduction. However, the
same test is negative when pulling on his humerus along
its long axis. What is your diagnosis?
A. External impingement with subacromiodeltoid bursitis
B. External impingement with supraspinatus tendonitis
C. Internal impingement with infraspinatus tendonitis
D. Internal impingement with supraspinatus tendonitis
E. Internal impingement with subacromiodeltoid bursitis
A
- Answer: A
Source: Sizer Et Al - Pain Practice March & June 2003
52
Q
- A 27-year-old female patient presents with glenohumeral
instability. Her imaging, demonstrates a dent in the
posterior humeral head. How would this dent be
classifi ed?
A. Bankhart Lesion
B. Bennett’s lesion
C. Gray’s Lesion
D. Hill Sach’s lesion
E. Callifi c Tendinitis
A
- Answer: D
Source: Sizer Et Al - Pain Practice March & June 2003
53
Q
- A radiological defi nition of severe spinal stenosis is:
A. Spinal canal <25% of the AP dimension of a normal
level
A
- Answer: A
Source: Day MR, Board Review 2004
54
Q
499. The most commonly used descriptor for central pain is: A. Lancinating B. Achy C. Steady D. Crampy E. Burning
A
- Answer: E
Source: Day MR, Board Review 2004
55
Q
500. Weakness, atrophy, and fasciculation in the triceps and wrist extensors would indicate stenosis at what spinal level? A. C5 B. C6 C. C7 D. C8 E. T1
A
- Answer: C
Source: Day MR, Board Review 2004
56
Q
- A 47-year-old man fell on his outstretched right hand
while rollerblading. Several days later, he develops right
wrist pain that is constant and progressive. Pain is in the
area of the anatomical snuffbox and is worse with wrist flexion, extension, and ulnar deviation. The anatomical
snuffbox is tender to palpation but there is no swelling.
Finkelstein test is negative. Which of the following is the
most likely diagnosis?
A. Cervical radiculopathy
B. Scaphoid fracture
C. Compartment syndrome
D. de Quervain’s disease
E. Boxer’s fracture
A
- Answer: B
Explanation:
A. Cervical (C6-C8) radiculopathy causes pain,
numbness, and tingling from the neck to the hand.
B. Scaphoid fractures occur as a result of a fall on an
outstretched hand.
These fractures heal poorly due to a poor blood supply in
this area.
Radiographs done early may be negative, but later
radiographs may show evidence of healing (callus
fracture).
C. Compartment syndrome is a surgical emergency and is
due to a tight cast or swelling causing compression of the
blood vessels and nerves in the forearm.
D. de Quervain’s disease or tenosynovitis of the tendon
sheath of the extensor pollicis brevis and abductor pollicis
longus causes swelling and tenderness of the anatomic
snuffbox.
This disorder is usually found in middle-aged women
who perform repetitive activity.
The Finkelstein test is positive (patient makes a fi st
around his or her own thumb; pain is produced with
adduction toward the ulnar side) in de Quervain’s disease.
E. A boxer’s fracture causes fl attening or loss of the fi fth
knuckle prominence due to displacement of the
metacarpal toward the palm. It is usually the result of
striking an object with a clenched fi st.
Source: Seidel
57
Q
- Which of the following statements concerning
spontaneous spinal epidural abscess is correct?
A. Interventional techniques present greater risk than
surgery
B. Most cases present with nonspecifi c symptoms
C. Myelography is the most appropriate diagnostic test
D. Skin structures are the usual source of infection
E. Leukocytosis is usually present
A
- Answer: E
Explanation:
Leukocytosis is usually present. MRI with gadolinium is
the most sensitive diagnostic test, although myelogram is
usually abnormal. However, spinal puncture may increase
the risk of spinal fl uid seeding of bacteria. Gram positive
organisms are most commonly cultured.
Source: Merritt’s Neurology. 10th ed
58
Q
- A 36-year-old executive of a Wall Street fi nancial company
presents with headaches for many years. The headaches
are episodic. Usually on the left side, they may occur in
the maxillary, frontal or temporal region. Each attack
lasts for approximately 2 hours. He describes the pain like
a knife being driven through the head. It often wakes him
up in the morning. The headache attacks some several
times a day. This may continue for a week at a time.
When he has an attack he is restless and unable to fi nd a
comfortable position. What is the diagnosis?
A. Tension type headache
B. Hypertensive headache
C. Subdural hematoma
D. Cluster headaches
E. Intractable Migraine with Aura
A
- Answer: D
Explanation:
A. Tension type headaches are constricting
B. Hypertensive headaches are associated with nausea,
vomiting, seizures and confusion.
- There is a sudden rate of increase of blood pressure.
- The headache is sudden, severe and unrelenting.
- Fundoscopic examination often reveals severe
hypertensive vascular changes.
C. Subdural hematomas are commonly secondary to a
trauma or anticoagulation therapy.
- There is tearing of the bridging veins.
- The headaches are chronic, mild to moderate in severity.
- Neurological changes are usually subtle.
D. Cluster headaches are unilateral, temporal, frontal or
temporal.
Cluster headaches are 6 times more common in men.
- The usually start between the 3rd and 4th decade of life.
- These are short lasting attacks that come together over a
period of time.
- They may have several attacks in a day and this may
continue for several weeks or months.
The headaches are very severe and sharp, often associated
with lacrimation and conjunctival injection.
- In contrast to migraines, these patients tend to restless
and pace up and down.
Abortive management of an acute cluster headache
includes: oxygen by face mask, ergotamine (nasal) or
sumatriptan.
- Preventive treatment is recommended because of the
severity of the attacks. A short course of steroids, lithium
verapamil and/or valproic acid can be used.
E. Intractable migraine with aura is associated with one or
more fully reversible symptoms.
Source: Chopra P, 2004
59
Q
- Buttock pain that is reproduced by internal rotation of
the femur suggests pain arising from the:
A. Hip joint
B. Spinal nerve
C. Piriformis muscle
D. Obturator neuralgia
E. Tensor fascia lata
A
- Answer: C
Explanation:
Pain reproduced by internal rotation of the femur suggests
piriformis syndrome, because the piriformis muscle
externally rotates the hip; stretch on the muscle may
aggravate pain. External rotation induced pain suggests
hip joint or sacroiliac joint dysfunction.
60
Q
- A patient has been scheduled for a block to differentiate
somatic versus visceral pain. Appropriate blocks include:
A. Thoracic paravertebral block
B. Thoracic epidural block with 2% lidocaine
C. Splanchnic nerve block
D. Intercostal nerve block – T4-T9
E. Intercostal nerve block – T8-T10
A
- Answer: C
61
Q
506. Which of the following describes the location of pain relief following a percutaneous cordotomy performed at T3? A. Contralateral side at T6 and below B. Contralateral side T3 and below C. Ipsilateral side at T3 and below D. Ipsilateral side atT6 and below E. Bilaterally at T6 and below
A
- Answer: A
Explanation:
STT fi bers cross within several segmental levels. Clinical
and experimental evidence indicate that the uppermost
level of analgesia is several segments (perhaps as many as
5) caudad to the level of the cordotomy.
Source: Bonica’s Management of Pain, 2nd edition, page
54.
62
Q
- A middle aged woman in late 50’s presents with a one year history of weakness and diffi culty with walking, with
no signifi cant pain. Exam fi ndings include weak, wasted
muscles with spasticity, fasciculations, extensor plantar
responses, and hyperrefl exia. Most likely diagnosis is:
A. Dorsal spinal root disease
B. Ventral spinal root disease
C. Arcuate fasciculus damage
D. Motor neuron disease
E. Purkinje cell damage
A
- Answer: D
Explanation:
Motor neuron disease in the anterior horns of the spinal
cord and damage to the corticospinal tracts or motor
neurons contributing axons to the corticospinal tracts
would account for these neurologic signs. Damage to the
dorsal spinal root would be expected to produce sensory,
rather than motor, defi cits and would produce arefl exia,
rather than hyperrefl exia, at the level of the injury.
Damage to the ventral spinal roots would produce
weakness and wasting, but no spasticity or hyperrefl exia
would develop.
Purkinje cell damage would be expected to produce ataxia
without substantial weakness. The accurate fasciculus
connects elements of the cerebral cortex not involved in
the regulation of strength or motor tone.
Source: Anschel 2004
63
Q
- A 45 year old lady with a long standing history for
migraines with aura which has been well controlled with
rizatriptan, states that she has been having a constant
headache which has not responded to any of her usual
medications. The headache started a month ago and has
progressively increased during this time. Last week she
slipped and fell twice. What is the next best step?
A. Lumbar puncture for CSF
B. Increase the dose of Rizatriptan
C. MRI of the head
D. Aspirin
E. Intramuscular Demerol
A
- Answer: C
Explanation:
Any change in the character of headache must raise the
suspicion of a new organic pathology. Conditions that are
red fl ags in headaches are:
New neurologic symptoms, papilledema or change in the
level of consciousness.
New onset of headache.
A slow but crescendo increase in headache over weeks or
months.
Significant change in the character or pattern of a
preexisting headache.
Unexplained fever, neck rigidity.
Increase in headache with exertion as in coughing, bowel
movement or after sexual intercourse.
The differential diagnosis of change in the character of a
headache or a new onset headache maybe subarachnoid or
subdural headache, brain tumor, meningitis, glaucoma,
stroke, internal carotid artery dissection, sinusitis,
idiopathic intracranial hypertension, hypertensive
encephalopathy.
A. Lumbar puncture is contraindicated in the presence of a
raised intracranial pressure.
C. An MRI of the head is one of the most sensitive tests
that can be done to rule out intracranial pathology as in a
space occupying lesion.
Ref: Robbins
Source: Chopra P, 2004
64
Q
509. A 48-year-old man presents with spastic paralysis, hyperrefl exia, and an extensor plantar refl ex. Choose correct diagnosis: A. Upper motor neuron disease B. Lower motor neuron disease C. Myelopathy D. Radiculopathy E. Broca’s aphasia
A
- Answer: A
Explanation:
A. Upper motor neuron (UMN) disease (above the level of
the corticospinal synapses in the gray matter) is
characterized by spastic paralysis, hyperrefl exia, and a
positive Babinski refl ex (everything is up in UMN
disease).
B. Lower motor neuron (LMN) disease (below the level of
synapse) is characterized by fl accid paralysis, signifi cant
atrophy, fasciculations, hyporefl exia, and a fl exor (normal)
Babinski refl ex (everything is down in LMN disease).
C. Myelopathy causes severe sensory loss 0 posterior
column sensation (position sense and vibration),
spasticity, hyperrefl exia, and positive Babinski refl exes.
D. A radiculopathy occurs with root compression from a
protruded disk that causes sensory loss, weakness, and
hyporefl exia in the distribution of the nerve root.
E. Broca’s aphasia (left inferior frontal gyrus) is a
nonfl uent expressive aphasia (Broca’s should remind you
of broken speech); Wernicke’s aphasia (left posteriorsuperior
temporal gyri) is a receptive aphasia because
patients lack auditory comprehension (Wernicke’s should
remind you of wordy speech that makes no sense).
(Source: Seidel, 5/e, p 798.)
65
Q
- The celiac plexus:
A. can safely and reliably performed by an anterior approach.
B. innervates the entire gastrointestinal tract
C. commonly used to treat the pain of pancreatic cancer
D. commonly used to treat pelvic pain
E. may b
A
- Answer: C
Explanation:
The celiac plexus innervates the forgut, and can be approached from an anterior or posterior approach to
treat pancreatic pain. Pelvic pain of a sympathetic origin
may be treated with a superior hypogastric plexus
injection
Source: Trescot AM, Board Review 2004
66
Q
- The treatment of epicondylitis includes the following:
A. Absolute rest with no activity
B. Ice massage for 20 minutes, three times a day in the
acute stage and the use of heat during acute or subacute
stages
C. Weekly steroid injections
D. Stretching regimen to gain length in the extensor supinator
muscle mass
E. Strengthening with gradual concentric, as well as eccentric
exercises
A
- Answer: E
Explanation:
A. Selecting rest preferably will avoid stressful activity
until the pain has subsided. However, pain free
movements are encouraged. Excessive activity or early
return to activity may direct excessive stress to healing
scar tissue. Activities that involve strong, repetitive
grasping, such as hammering or tennis playing, should be
restricted until there is minimal pain on resisted isometric
wrist extension and little or no pain when the tendon is
passively stretched. In the acute stage, the total rest may be
achieved by immobilization of the wrist, hand, and fi ngers
in a resting splint. However, the splint may be removed
several times a day, so that the patient can gently and
slowly actively move the wrist into fl exion, the forearm
into pronation, and the elbow into extension to maintain
the muscle and tendon extensibility.
B. Ice massage for 20 minutes is recommended. Elevation
and compression are not necessary because appreciable
swelling does not occur.
C. Steroid injections are recommended if all other
modalities of treatments fail. However, these are
administered with the intent of providing pain relief only
to allow progressional rehabilitation effort. Thus, some
believe that healing may occur through rehabilitation but
not from steroid injection. However, there is no evidence
to prove or disprove this assumption.
D & E. Strengthening and stretching regimen is
recommended.
Other treatment modalities include:
- High-voltage galvanic stimulation
- Gradual return to activity
- Anti-infl ammatory medications
- Local anti-infl ammatory treatment
- Iontophoresis or phonophoresis with hydrocortisone
cream and dy lidocaine or dexamethasone injection may
also be helpful.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine. St. Louis,
Inc., 2002
67
Q
512. Myofascial pain is an example of A. A central pain state B. Neuropathic pain C. Psychogenic pain D. Somatic pain E. Visceral pain
A
- Answer: D
68
Q
- A 52-year-old nurse has a history of low back pain for 2 months. She states the pain started after she lifted a heavy
patient at work. It is a nagging pain that worsens with
bed rest. She has tried nonsteroidal antiInfl ammatory
agents without any relief and has continued to work. She
has a past medical history signifi cant for breast cancer 8
years ago and, except for a recent 10-lb weight loss, has
been well since her lumpectomy. Her neurologic exam
and straight-leg raising test are normal. The rest of her
physical examination is unremarkable. Which of the
following is the most likely diagnosis?
A. Lumbosacral strain
B. Metastatic breast cancer
C. Disk herniation of L5-S1
D. Spondylolysis
E. Spondylolisthesis
A
- Answer: B
Explanation:
Lower back pain is a very common complaint. The
differential diagnosis includes soft tissue problems
(muscles and ligaments), disk problems (prolapse), facet
problems (degenerative joint disease), spinal canal disease (spinal stenosis), and vertebral body diseases
(osteoporosis causing a compression fracture, infection,
metastatic disease, spondylolisthesis).
A. A lumbosacral strain is an injury to a ligament or
muscle; it may mimic disk disease, but the neurologic
exam and straight-leg raising test generally remain
normal.
B. Even though radiologic studies are needed to make a
defi nitive diagnosis, the leading diagnosis with her history
of breast cancer and weight loss is metastatic disease to
the lumbosacral area.
Pain made worse by lying down or at night may be a sign
of malignancy or infection.
C. Patients with disk herniation at L5-S1 may present with
S1 nerve root compression The patient is unable to stand
on her toes and has an absent Achilles refl ex (S1).
The straight-leg raising test is positive.
D. Spondylolysis is a defect of a lumbar vertebra (lack of
ossifi cation of the articular processes) and rarely causes
symptoms.
E. Spondylolisthesis occurs when the vertebra slips
forward from its position and is generally a consequence
of spondylolysis
It is usually asymptomatic.
69
Q
- Renal changes in the kidney in a patient with diabetes
mellitus of 30 years duration may result in which of the
following:
A. Decreased permeability to plasma proteins
B. Enhanced selectivity of the fi ltration barrier
C. Hyperalbuminemia
D. A generalized increase in osmotic pressure
E. Compensatory secretion of aldosterone
A
- Answer: E
Explanation:
(Kumar, 6/e, pp 446, 570. McKenzie and Klein, p 341.
Junqueira, 9/e, p 362.) In patients who have suffered from
diabetes mellitus for many years there is compensatory
release of aldosterone. The initial change is the thickening
of the glomerular basement membrane. The separation of
laminae rarae and densa is obliterated, which results in a
loss of selectivity of the fi ltration barrier. This causes the
loss of protein from the blood to the urine (proteinuria).
The liver adjusts to the proteinuria by producing more
proteins (e.g., albumin). After continued proteinuria, the
liver is unable to produce suffi cient protein, which results
in hypoalbuminemia. This leads to an overall decrease in
osmotic pressure. The result is edema as fl uid leaves the
vasculature to enter the tissues. The movement of fl uid
from the vasculature to the tissues results in reduced
plasma volume and decreased glomerular fi ltration rate
(GFR). The overall effect is further edema because of
compensatory release of aldosterone coupled with reduced
GFR and the already existing edema. These renal changes
are known as nephrotic syndrome. The foot processes are
affected in many diseases, such as diabetes mellitus, that
lead to nephrotic syndrome. Loss of anionic charge and
fusion of the foot processes result in the obliteration of the
fi ltration slits.
Source: Klein RM and McKenzie JC 2002.
70
Q
515. What percentage of spinal cord injury patients have central pain? A. 90% C. 8-40% D. 50-60% E. 60-70%
A
- Answer: C
Explanation:
(Shah, Central Pain States Lecture)
Source: Shah RV, Board Review 2004
71
Q
516. A treatment of rib fracture pain may include: A. intercostal nerve block B. thoracic sympathetic block C. trigger point injections D. splanchnic nerve block E. costochondral injection
A
- Answer: A
Explanation:
A. Intercostal and thoracic epidural blocks are used to treat
rib fracture pain.
B. Thoracic sympathetic blocks are usually effective for
upper extremity pain.
C. Trigger point injections are ineffective in managing
pain due to fractured rib.
D. Splanchnic nerve blocks are for abdominal pain.
E. Costo-chondral injections are ineffective in managing
pain due to fracture rib.
Source: Trescot AM, Board Review 2004
72
Q
- Spondylolisthesis, is a anterior offset of S1 on L5. Grade
II spondylolisthesis would be best described as:
A. 25% but less than 50% in length of the S1 end plate
B. Less than 20% of the length of the S1 end plate.
C. Parallel axial line in place.
D. 50% to 75% in length of the S1 end plate.
E. Greater than 75% in length of the S1 end plate
A
- Answer: A
Source: Helms CA. Fundamentals of Skeletal Radiology.
W.B. Saunders Co., 1995; p. 87.
73
Q
- A 70-year old man complains of severe back pain in the region of L3/4, with gradual worsening of the back pain
with radiation into the lower extremity up to the knee
joint. This patient received interlaminar epidural steroid
injection for spinal stenosis at L3/4. The most likely
diagnosis in this patient is:
A. Epidural abscess
B. Anterior spinal artery syndrome
C. Discitis
D. Cauda equina syndrome
E. Epidural hematoma
A
- Answer: A
Explanation:
A. Epidural abscess is an extremely rare complication
following epidural steroid injections. However,
symptoms from an epidural abscess may not become
apparent for several days after injection has been
administered. The symptoms of epidural abscess include
severe back pain, sensory disturbances, and motor
weakness.Infections occur in 1% to 2% of spinal injections
and range from minor to severe conditions such as
meningitis, epidural abscess, and osteomyelitis. One case
of discitis following caudal epidural steroid injection also
has been reported. Severe infections are rare and occur
between 1 and 1,000 and 1 in 10,000 spinal injections.
Poor sterile technique is the most common cause of
infection. Staphylococcus aureus is the most common
infectious organism and is contracted from skin
structures. Epidural abscess presents with severe back
pain, fever, and chills with a leukocytosis developing on
the third or fourth day following the injection. Patients
with diabetes or other immunocompromising conditions
are more susceptible to infection. Epidural abscess
requires emergent surgical drainage to avoid neural
damage or other complications.
B. Anterior spinal artery syndrome due to damage to the
anterior spinal artery or the feeding artery, the artery of
Adamkiewicz, leads to ischemia in the thoracolumbar
region of the spinal cord. This syndrome is characterized
predominantly by motor weakness or paralysis of the
lower extremities.
C. Discitis from epidural steroid injections is extremely
uncommon. However, there has been a case report of this
following a caudal epidural steroid injection. Usually,
discitis from lumbar discography involves a gramnegative
arrow, is self-limited, and resolves with early
recognition and administration of appropriate antibiotics.
Symptoms are related to back pain and leukocytosis. The
most common organisms infecting the lumbar disc or
staphylococcus aureus and staphylococcus epidermatitis. Discitis usually presents as an increase in spine pain 5 to
14 days following discography. Acutely, no change in the
patient’s neurological status should be evident. An
elevated sedimentation rate will be seen within the fi rst
week to 10 days. Magnetic resonance imaging is now
considered the gold standard in the detection of discitis,
which was found to be superior to bone scan with 92%
sensitivity, 97% specifi city, and a 95% overall accuracy.
D. Cauda equina syndrome may be seen with trauma,
lumbar disc herniation, compression of tumors, or in
ankylosing spondylitis. The only absolute surgical
indication for lumbar disc herniation is the cauda equina
syndrome. This syndrome is characterized by bilateral
lower extremity weakness and pain, saddle anesthesia,
urinary retention, and diminished rectal tone.
E. Signifi cant epidural bleeding may cause the
development of an epidural hematoma. Clinically
signifi cant epidural hematomas are rare and have a
reported incidence of less than 1 in 4,000 to 1 in 10,000
lumbar epidural steroid injections. however, they may lead
to irreversible neurologic compromise if not surgically
decompressed within 24 hours. Retroperitoneal
hematomas which may occur following spinal injections if
the large vessels are inadvertently penetrated, usually are
self-limited but may cause acute hypolemma or anemia.
Epidural hematoma as an acute onset of symptomatology
with rapidly progressing neurological dysfunction. An
immediate physical examination followed by a CT or MRI
scan is essential for patients thought to have an epidural
hematoma, because early surgical intervention can limit or
even prevent permanent neurological damage.
74
Q
- An 18 year old girl presents with frequent headaches, each lasting for several days. She has to take time off from
school. She describes them as throbbing, localized to the
temporal region. They are associated with nausea and
vomiting, sensitivity to sound and light. A recent MRI was
normal. A diagnostic lumbar puncture done was normal.
The most probable cause of her headaches is:
A. Migraine without aura
B. Post dural puncture headache
C. Tension type headache
D. Temporal arteritis
E. Trigeminal Neuralgia
A
- Answer: A
Explanation:
According to the International Headache Society,
headaches are classifi ed into primary and secondary
headache disorders. The primary headache disorders
consist of:
1.Migraine with aura
2.Migraine without aura
3.Tension type headache - chronic and episodic
4.Cluster headache - chronic and episodic
Primary headaches such as migraine with or without aura,
tension-type, and cluster headache constitute about 90%
of all headaches
Migraine as defi ned by the International Headache Society
is – Idiopathic, recurring headache disorder manifesting in
attacks lasting 4 to 72 hours.
A. Diagnostic Criteria for Migraine With and Without
Aura
Migraine Without Aura
i. At least fi ve attacks fulfi lling II-IV.
ii. Headache attacks lasting 4-72 h (untreated or
unsuccessfully treated).
iii. Headache has at least two of the following
characteristics:
1.Unilateral location.
2.Pulsating quality.
3.Moderate or severe intensity (inhibits or prohibits daily
activities).
4.Aggravation by walking stairs or similar routine
physical activity.
iv. During headache at least one of the following:
1.Nausea and/or vomiting.
2.Photophobia and phonophobia.
v. At least one of the following:
1.History & physical and neurologic examinations do not
suggest headaches secondary to organic or systemic
metabolic disease).
2.History and/or physical and/or neurologic examinations
do suggest such disorder, but it is ruled out by appropriate
investigations.
3.Such disorder is present, but migraine attacks do not
occur for the fi rst time in close temporal relation to the
disorder.
Migraine With Aura
i. At least two attacks fulfi lling ii.
ii. At least three of the following four characteristics:
1.One or more fully reversible aura symptoms indicating
focal cerebral cortical and/or brain stem dysfunction.
2.At least one aura symptom develops gradually over more
than four minutes or two or more symptoms occur in
succession.
3.No aura symptom lasts more than 60 minutes. If more
than one aura symptom is present, accepted duration is
proportionally increased.
4.Headache follows aura with a free interval of less than 60 minutes. (It may also begin before or simultaneously with
the aura).
C. At least one of the following:
1.History & physical and neurologic examinations do not
suggest headaches secondary to organic or systemic
metabolic disease.
2.History and/or physical and/or neurologic examinations
do suggest such disorder, but it is ruled out by appropriate
investigations.
Such disorder is present, but migraine attacks do not occur
for the fi rst time in close temporal relation to the
disorder.
B. Post dural puncture headaches develop after a dural
puncture such as a spinal tap. The pain is usually frontal
and occipital. It becomes worse in the upright position and
is relieved signifi cantly with lying supine. Some patients
develop sixth cranial nerve palsy because of the long
intracranial course of the sixth cranial nerve.
C. The differentiation between tension-type headache
(TTH) and migraine without aura more diffi cult. Very
often both headaches coexist. Tension-type headaches are
tightening or pressing in character. They are mild to
moderate in intensity and are bilateral. Tension-type
headache are seldom associated with nausea and in most
patients Tension-type headaches are not greatly
exacerbated by physical activity.
D. Giant cell (temporal) arteritis affects the extracranial
vessels of the head and arms. There is tenderness over the
scalp. The temporal or occipital arteries are enlarged and
tender. They may have visual symptoms including
amaurosis fugax, diplopia and blindness. Most patients
also have symptoms of intermittent claudication with
chewing. A temporal artery biopsy is diagnostic.
E. Trigeminal neuralgia presents with typical lancinating,
sharp, electric like, stabbing pain.
Ref: Drugs for Pain
Source: Chopra P, 2004
75
Q
- A 67-year old white male presents with back pain,
stiffness located in thoracolumbar region with history
of dysphagia. Radiographic evidence showed fl owing
anterior calcifi cation, along four contiguous vertebrae.
The remaining evaluation was normal. The most likely
diagnosis is:
A. Lumbar facet joint pain
B. Lumbar disc herniation
C. Diffuse idiopathic skeletal hyperostosis
D. Osteoporotic fracture
E. Spondylolisthesis
A
- Answer: C
Explanation:
Diffuse idiopathic skeletal hyperostosis, also called DISH,
or Forester’s disease is probably a variant of osteoarthritis
characterized by exuberant ossifi cation of spinal ligaments.
Epidemiology
- More common with increase in age
- Observed in 10% of spine fi lms in elderly
- It is twice as common in men as women
- It is more common in Caucasians than African-
Americans
Etiology:
- Unknown, not associated with B27; may be increased in
diabetics
Signs and Symptoms
- Back stiffness in 80%
- Back pain in 50% to 60%
- Pain is typically thoracolumbar
- Dysphagia as a result of large cervical osteophytes in
approximately 20%
Diagnosis
- Flowing anterior calcifi cation along four contiguous
vertebrae
- Preservation of disc height
- No sacroiliac involvement
Treatment
- Active exercise program to optimize range of motion
- Non-steroidal anti-infl ammatory agents
- Rarely surgical removal of osteophytes
- Role of interventional techniques is not known
76
Q
- Wallenberg’s syndrome is characterized by:
A. hoarseness of voice
B. contralateral facial sensory loss
C. ipsilateral pain and temperature loss in the body
D. ipsilateral lateral gaze palsy
E. mydriasis
A
- Answer: A
Explanation:
(Shah, Pain States Lecture and Raj, Pain Mgmt Review)
Wallenberg’s syndrome is lateral medullary syndrome,
which is characterized by: Ipsilateral facial sensory loss
Contralateral pain and temperature loss in body
Ipsilateral cranial nerve defi cits
–IX, X- loss of taste
–IX, X- palatal weakness (dysphagia), vocal cord weakness
(hoarseness), diminished gag
Ipsilateral cerebellar signs
–Inferior cerebellar peduncle: clumsiness and ataxia (may
be confused with true weakness)
Source: Shah RV, Board Review 2004
77
Q
- All of the following are true regarding phantom limb pain
EXCEPT:
A. Described as burning, aching, or cramping.
B. Incidence decreases with more proximal amputations.
C. The etiology is not clearly defi ned.
D. The usual course of phantom limb pain is to remain
unchanged or to improve.
E. Neuromas are found in 20% of patients
A
- Answer: B
Explanation:
Ref: Hord and Shannon. Chapter 16. Phantom Pain. In:
Practical Management of Pain, 3rd Edition. Raj et al.
Mosby, 2000, pages 213-218.
Source: Day MR, Board Review 2003
78
Q
- A previously healthy 36-year old woman presents with a complaint of generalized muscular pain with aching in the
left buttock for 1 week, 4 weeks after left transforaminal
epidural injection at L5. The pain travels down the back
of her leg to the heel and lateral side of her foot to the
small toe. She has also noted a progressive numbness
in her legs and arms, which has worsened over the week.
On examination, walking was very diffi cult and her legs
buckled when she stood up. The most likely diagnosis is:
A. Postherpetic neuralgia
B. Brain tumor
C. Hysterical reaction
D. Guillain-Barré syndrome
E. Epidural abscess
A
- Answer: D
Explanation:
The patient has symptoms consistent with Guillain-Barré
acute infl ammatory demyelinating polyneuropathy. Pain is
a common early symptom of the disease. The patient may
complain of muscular or radicular pain or both, followed
by sensorimotor dysfunction. The pain may be severe but usually resolves as the symptoms improve. Presentation
of epidural abscess with back pain is 1-2 weeks after
injections.
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
79
Q
- A patient with cholecystic pain will often present with
pain from which somatic dermatome?
A. T1-T3 due to the ascending nature of the afferent visceral
tracts involved
B. T3 only as it overlies the affected area
C. T8 only as it overlies the affected area
D. T6-T8 as it refl ects the referred component of the upper
viscera
E. T9-T11 as it refl ects the referred component of the upper
viscera
A
- Answer: D
Source: Giordano J, Board Review 2003
80
Q
- A 65 year old man presents with symptoms of pain in
the cervical region. He also complains of radiation of his
pain along the lateral part of his right forearm He has an
MRI of the cervical region with evidence of a herniated
disc between the fi fth and the sixth cervical vertebra. The
nerve root that is most likely compressed is:
A. Fourth cervical nerve root
B. Fifth cervical nerve root
C. Sixth cervical nerve root
D. Seventh cervical nerve root
E. Eight cervical nerve root
A
- Answer: C
Explanation:
Disc herniations in the cervical region are relatively less
common than the lumbar region. In the cervical region the
C5 and C6 and C7 intervertebral disc are most susceptible
to herniation. The C6 and C7 intervertebral disk
herniation is the most common cervical disk herniations.
In the cervical region each spinal nerve emerges above the
corresponding vertebra. An intervertebral disc protrusion
between C5 and C6 will compress the sixth cervical spinal
nerve. There are seven cervical vertebra and eight cervical
spinal nerves. These patients characteristically present
with pain in the lower part of the posterior cervical region,
shoulder and in the dermatomal distribution of the
affected nerve root.
Source: Chopra P. 2004
81
Q
526. A pituitary adenoma is likely to result in A. Cushing’s syndrome B. Defi ciency in T3 and T4 C. Diabetes insipidus D. Osteoporosis E. Stunted growth or dwarfi sm
A
- Answer: A
Explanation:
(Junqueira, 9/e, pp 380-383, 394, 402-405.) Pituitary
adenomas are anterior pituitary specifi c. A corticotrophadenoma
would cause increased levels of ACTH and
stimulate excessive production of corticosteroids from the
adrenal cortex (Cushing’s syndrome). LH and FSHproducing
gonadotrophs occur but tend to result in
hypogonadism. Somatotropic tumors produce GH and
cause giantism. Prolactinomas are the most common form
of pituitary adenoma resulting in infertility, galactorrhea
(excessive production of milk), and amenorrhea. Diabetes
insipidus is caused by absence of vasopressin [arginine
vasopressin (AVP)], leading to excretion of a large
quantity of dilute fl uid (hypotonic polyuria).
Overproduction of parathyroid hormone (PTH) leads to
osteoporotic changes, but PTH is not regulated by the
anterior pituitary.
Source: Klein RM and McKenzie JC 2002.
82
Q
- A 28-year old female secretary complained for 6 months
of paresthesias and aching in the right hand. The aching
and numbness were most pronounced in the middle
fi nger. The aching, tingling, and numbness made it
diffi cult for her to sleep at night. She also noted that she
was dropping things. The most likely diagnosis is:
A. Refl ex sympathetic dystrophy
B. Pancoast syndrome
C. Ulnar neuropathy
D. Carpal tunnel syndrome
E. Radial nerve entrapment
A
- Answer: D
Explanation:
The patient’s symptoms are most consistent with carpal
tunnel syndrome,which is due to entrapment of the
median nerve at the wrist.
Prolongation of distal motor latency may be seen on EMG.
83
Q
528. The number one etiology of cord central pain is: A. Neoplasm B. Infl ammatory C. Cord infarction D. Arteriovenous malformation E. Trauma
A
- Answer: E
Source: Day MR, Board Review 2004
84
Q
529. The most common presenting symptom of rheumatoid arthritis is: A. Pain in the small joints of the hand B. Neck pain C. Knee pain D. Low back pain E. Shoulder pain
A
- Answer: B
Explanation:
Neck pain is the most common presenting symptom of
rheumatoid arthritis (RA). Approximately 50% of the
head’s rotation is at the atlanto-axial joint, the rest is at the
sub axial cervical spine. The atlanto-axial joint complex is
made up of three articulations.The axis articulates with
the atlas at the two facet joints laterally and another joint
posterior to the odontoid process. A bursa separates the
transverse band of the cruciate ligament from the dens.
Rheumatoid arthritis affects all three joints. The
articulations formed by the uncinate processes also known
as the joint of Luschka, are not true joints and do not have
synovial membrane. Hence, they are not subject to the
same changes as seen in RA.
Rheumatoid arthritis is an infl ammatory polyarthritis that
typically affects young to middle-aged women. They
present with a joint pain and stiffness in the hands. They
have a history for morning stiffness. Almost 80% of these
patients have a positive rheumatoid factor.
Source: Chopra P. 2004
85
Q
- A young patient presents with a 6-month history of
an aching right arm, which is exacerbated by carrying
heavy objects or by raising his arms over his head. No
neurologic defi cits were found. There was obliteration of
the radial pulse with arm extension and abduction. The
most likely diagnosis is:
A. Herniated nucleus pulposus
B. Brachial plexitis
C. Pancoast’s tumor
D. Thoracic outlet syndrome
E. Neurofi broma of the brachial plexus
A
- Answer: D
Explanation:
Thoracic outlet syndrome may be due to a cervical rib,
abnormal fi rst thoracic rib, hypertrophy of the scalenus
anterior, abnormal insertion of the scalenus medius, bands
in Sibson’s fascia, or costoclavicular abnormalities. There
is usually involvement of the subclavian vessels and
brachial plexus (most commonly C8-T1). The degree of
vascular and neurologic dysfunction is variable. Patients
may complain of radicular pain or a poorly localized, deep,
aching pain under the arm. Cold weather, lifting heavy
objects, working with arms over the head, and repetitive
movement may worsen symptoms. Pain may occur for
years before any neurologic symptoms or signs develop.
Diagnosis is made by physical examination and radiologic
studies of the neck and chest. Treatment is conservative if
there is no signifi cant vascular or neurologic compromise.
(Bonica).
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
86
Q
- Of those patients chronic neck pain due to whiplash,
approximately what percentage would respond to a
diagnostic intra-articular facet injections or medial
branch blocks?
A. 10%
B. 20%
C. 30%
D. 90%
E. 50%
A
- Answer: E
87
Q
- A patient with a history of breast cancer 10 years ago was
treated with a radical mastectomy and radiation therapy.
Recently she developed dull, ipsilateral arm pain and
associated swelling in the thoracic region. Your diagnosis
is:
A. Radiation plexopathy
B. Re-occurrence of cancer
C. Lymphoedema
D. Tumor invasion in brachial plexus
E. Lymphangiosarcoma
A
- Answer: E
Explanation:
Stewart-Treves Syndrome (lymphangiosarcoma) is a rare,
aggressive and cutaneous angiosarcoma often associated
with long standing lymphedema. The malignancy arises
from the endothelial cells of the lymphatic system. Most
cases arise from lymphedema induced by a radical
mastectomy in breast cancer patients with an average onset
of 5 - 15 years and an occurance rate of
88
Q
533. The sitting position that places the lowest load on the L3 disc is with the back of the chair at A. 90° without a lumbar support cushion B. 90° with a lumbar support cushion C. 110° without lumbar support D. 100° with lumbar support E. 100° without lumbar support
A
- Answer: D
Explanation:
Maximum load on the disc occurs when a person is sitting
against a 90° back rest without lumbar support. There is
slightly less load on the lumbar spine when one sits at 90°
with lumbar support. There is even less load on the
lumbar spine when the back of the chair is inclined to 110°
without lumbar support. There is least pressure on the
spine with the back of the chair at 100° with a lumbar
support (Bonica).
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
89
Q
- A 26-year-old woman presents with the chief complaint of
weakness that worsens throughout the day. She especially
notices weakness and feeling tired when chewing food.
The patient states that she feels strong on arising in the
morning but the weakness develops over the course of
the day. She also complains of her eyelids drooping and
occasional diplopia. Neurologic examination reveals
ptosis after 1 min of sustained upward gaze. Which of the
following is the most likely diagnosis?
A. Lambert-Eaton syndrome
B. Botulism
C. Myasthenia gravis
D. Multiple sclerosis
E. Friedreich’s ataxia
A
- Answer: C
Explanation:
A. Lambert-Eaton myasthenic syndrome (LEMS) is a
progressive generalized weakness that improves with
exercise and is associated with small cell carcinoma of the
lung.
Ocular bulbar muscles are spared, but patients often have
autonomic dysfunction.
B. Botulism causes rapid progressive paralysis of the
bulbar (dilated pupils) and extraocular muscles and
eventually causes skeletal and respiratory muscle
weakness.
The disorder is caused by ingestion of the exotoxin
produced by Clostridium botulinum, which blocks
acetylcholine release from nerve terminals.
C. Myasthenia gravis is fatigable weakness that primarily
affects the respiratory, bulbar, and ocular muscles.
The etiology of the disorder is autoimmune, causing
destruction of the acetylcholine receptors in the affected
muscles.
Thymic abnormalities often accompany the disorder, and
the Tensilon test (injection of edrophonium, which is an
acetylcholinesterase inhibitor) often results in
improvement of symptoms.
90
Q
- A 72-year old woman complains of a 3-year history of
progressive lower back pain with aching and numbness
radiating from the right buttock to the lateral aspect and
dorsum of his right foot. Pain is increased with walking.
She reported that leaning on a shopping cart and using
it as support for ambulation was very helpful. The most
likely diagnosis is:
A. Herniated nucleus pulposus
B. Lumbar plexopathy
C. Spinal stenosis
D. Arachnoiditis
E. Severe spondylolisthesis
A
- Answer: C
Explanation:
The patient has lumbar spinal stenosis involving the L5
and S1 nerve roots most prominently.
Spinal stenosis is a slowly progressive disease and
therefore allows for neural adaptation over time.
Shopping cart syndrome is a hallmark of spinal stenosis.
91
Q
- An obese woman presents with complaints of anterior
knee pain after running. She reported a grinding
sensation in her knee, with stiffness and pain in the
morning hours that occur following the activity for
sitting several hours each day. However, she reported
feeling better after she started running or walking.
She occasionally experiences a giving away sensation
during descent, as if she cannot rely on the affl icted leg.
Kneeling is extremely uncomfortable. There is no history
of trauma to her knee or back. Family history shows
osteoarthritis of both knees and hips in her mother and
father. Physical and neurological examination is normal.
She had no problems with the other knee except for some
grinding sensation. The most likely diagnosis:
A. Plica syndrome
B. Fat pad infl ammation
C. Patellofemoral osteoarthritis
D. Retropatellar pain syndrome
E. Chondromalacia of the patella
A
- Answer: E
Explanation:
A. Plica syndrome is synovial or embryologic remnants
presenting as folds of tissue adjacent to the patella. They
are a rare source of pain and dysfunction at the knee and
may present a challenge to differentiating from
chondromalacia. Synovial plica may prove symptomatic
and manifest as knee stiffness following sitting with the
knee bent for any length of time. Stiffness may be
experienced when attempting to get up out of this
position.The key, however, to differentiating from plica
and chondromalacia derived pain is by historically
determining when the patient experiences pain. Pain
during activity is generally seen with patellar tracking of
abnormalities such as chondromalacia or patellar
instability, whereas pain after activity is typical of
infl ammatory disorders such as synovial plica irritation.
B. Fat pad infl ammation or fi brosis, is a relatively
common problem contributing to inferior knee pain in
patients’ who have had previous knee surgery or in those
who play sports or engaging vocations that directly
traumatize this area. Pain is located immediately adjacent
to the patellar ligament and stems from the richly
innervated fad pad. If fi brosis is extensive, as it may be
following several knee surgeries or severe trauma to this
site, the retropatellar tendon bursae, as well as the
infrapatellar tendon will eventually scar down to the
proximal tibia.
C. Patellofemoral osteoarthritis represents the end
sequelae of chondromalacia and presents with symptoms
similar to chondromalacia. However, the articular surface
involvement is more advanced with subchondral bone
exposure and often has a poorer prognosis. Unlike
chondromalacia, radiographs of patellofemoral
osteoarthritis show narrowing of the joint space, sclerosis
and spurring. These patellofemoral osteophytes typically
form on the marginal areas of the femur and may be
palpated during the physical examination and viewed on
infrapatellar radiographs. These osteophytes may result in
catching and popping sensations from synovial catching,
entrapment, and irritation from these bone spurs.
Patellofemoral arthritis may show a relatively short onset
following traumatic injury or may have a more insidious
onset in patients with long-standing patellofemoral
complaints. The latter typically occurs in patients who
endure abnormal forces to the knee, such as maybe
incurred from rough sports or heavy work, over many
years.
D. Retropatellar pain, pre-parapatellar pain, and
patellofemoral stress syndrome all describe an overuse
injury characterized by peripatellar pain following acutely
or slowly from repetitive knee fl exion-extension activities
such as jumping, running or kicking. This type of patellar
disorder differs from chondromalacia in that arthroscopy evaluation of the retropatellar surface does not reveal the
typical fi brillated cartilage surfaces associated with
chondromalacia or degenerative changes following an
acute blow to the patella.
E. Chondromalacia of the patella is commonly
encountered in joggers and long-distance runners and has
subsequently been called “runners knee.” Nevertheless, the
increasing interest in sports among the general population,
patellofemoral pain has been identifi ed as the primary
complaint of knee pain. Adolescent females are often
susceptible to developing chondromalacia as well as
patellofemoral instability. Chondromalacia is literally a
pathologic description that means softening of the
articular cartilage located along the underside of the
patella and is commonly the diagnosis given to patients
with anterior knee pain. Chondromalacia is a degenerative
process believed to result from excessive loading of
articular cartilage lining the patellar facets. Articular
cartilage is loaded by compressive forces that may be
exceeded resulting in decreased diffusion of nutrients and
eventual malacia of the involved facet. Classic physical
symptoms of chondromalacia include retropatellar pain,
recurrent effusion, retropatellar crepitation,
patellofemoral grinding during the knee fl exion or
extension, and tenderness upon palpation of the patellar
facets.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine,St.
Louis,Inc., 2002
92
Q
537. The incidence of fractured ribs found in closed thoracic trauma is: A. 10-20% B. 20-30% C. 30-40% D. 40-50% E. > 50%
A
- Answer: E
Explanation:
Ref: Sinatra and Ennevor. Chapter 19. Trauma Patient
with Thoracic and Abdominal Injuries. In: Pain
Management and Regional Anesthesia in Trauma.1st
Edition. Rosenberg, Grande, Berstein. W.B. Saunders, - page 312.
Source: Day MR, Board Review 2003
93
Q
- A 33-year-old graduate student complains of low back
pain after carrying heavy suitcases on a recent vacation
in Europe. Because of his pain, he went to a neurologist
in London who recommended bed rest and nonsteroidal
anti-infl ammatory agents. After 10 days, the back pain
resolved, but the patient comes to see you because of new
weakness of his right anterior tibialis. The rest of the
physical examination is normal. Which of the following
is the most likely diagnosis?
A. Nerve root impingement
B. Tibial stress fracture
C. Anterior compartment syndrome
D. Gastrocnemius muscle tear
E. Popliteal cyst
A
- Answer: A
Explanation:
A. Lumbar disk herniation may occur after lifting heavy
objects.
A short period of rest (“unloading the spine”) and
nonsteroidal anti-infl ammatory agents may help.
If a patient develops signifi cant neurologic defi cit after the
initial pain has resolved, the diagnosis is most likely nerve
root impingement.
B. Tibial stress fractures (shin splints) may occur due to
weight-bearing exercises or training errors. These injuries
cause anterior tibial pain after exercise but not weakness.
C. Anterior compartment syndrome occurring after
weight-bearing exercise may cause a neuropraxia of the peroneal nerve, leading to footdrop.
D. A gastrocnemius muscle tear usually occurs suddenly
after rapid dorsifl exion of the ankle and causes severe
midcalf pain.
In a few days, the calf characteristically develops a bluish
discoloration.
E. A popliteal cyst (Baker’s cyst) causes calf pain, swelling,
and knee effusion. It is often a complication of rheumatoid
arthritis and represents a diverticulum of the synovial sac
that protrudes through the posterior joint capsule of the
knee.
(Source: Goldman, 21/e, p 2187.)
94
Q
- All of the following are true regarding carpal tunnel
syndrome except:
A. Caused by compression of the median nerve by the
transverse carpal ligament.
B. History of wrist pain and paresthesias in the thumb,
index fi nger, and long fi ngers.
C. Physical examination may demonstrate atrophy of the
hypothenar eminence.
D. EMGs/NCTs may confi rm denervation of thenar musculature
E. Treatment includes splints, steroid injections, and/or
surgical release.
A
- Answer: C
Explanation:
Ref: Merkow. Chapter 16. Hand Disorders. In: Manual of
Rheumatology and Outpatient Orthopedic Disorders, 2nd
Edition. Beary; Little, Brown and Company, 1990, page 95-
96.
Source: Day MR, Board Review 2003
95
Q
- Costochondritis is characterized by all of the following
except:
A. Can mimic intrathoracic and intrabdominal disease
B. Local tenderness with palpation
C. May produce radiating symptoms
D. Presents as infl ammation of multiple costovertebral
articulations
E. Most often occurs in adults over 40 years of age
A
- Answer: D
Explanation:
Ref: Raj. Chapter 13. Miscellaneous Pain Syndromes. In:
Pain Medicine: A Comprehensive Review, 2nd Edition,
Raj, Mosby, 2003, page 121.
Source: Day MR, Board Review 2003
96
Q
541. Classic hemophilia A is associated with a defi ciency of which factor? A. V B. VIII C. IX D. X E. All of the above
A
- Answer: B
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition
97
Q
- Which of the following analgesics are least effective with
the treatment of chronic post-stroke pain?
A. Morphine
B. Mexilitene
C. Carbamazepine
D. Doxepin
E. Propanolol
A
- Answer: A
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Edition, page 262)
Central post-stroke pain is diffi cult to manage. Opioids
have not been successful in managing CPSP for at least
100 years. Some authors recommend detoxifi cation. The
mainstays for treatment include anti-dysrhythmics, anticonvulsants,
and antidepressants.
Carbamazepine, doxepin, propanolol, and Mexilitene have
been demonstrated to have benefi t in CPSP
Source: Shah RV, Board Review 2004
98
Q
- A 66 year old woman presents with pain in the posterior
cervical region for the last 1 year. It radiates to the right
shoulder, lateral upper arm, and right index fi nger. She
also complains in the medial part of the right scapula
and anterior shoulder. On physical examination, she has
numbness to the index and middle fi ngers of the right
hand and weakness of the triceps muscle. The cause of
her pain is most likely:
A. Herniated nucleus pulposus of the C5 to C6 disk causing
compression of the C5 nerve root
B. Herniated nucleus pulposus of the C5 to C6 disk causing
compression of the C6 nerve root
C. Herniated nucleus pulposus of the C6 to C7 disk causing
compression of the C7 nerve root
D. Herniated nucleus pulposus of the C6 to C7 disk causing
compression of the C6 nerve root
E. Herniated nucleus pulposus of the C7 to T1 disk causing
compression of the C8nerve root
A
- Answer: C
Explanation:
The pattern of pain helps identify the cervical disk causing
the most problems. Herniated nucleus pulposus (HNP)
are more common in the lumbar region.The cervical nerve
roots exit above the vertebral body of the same segmentthe
C7 nerve root exits between the C6 to C7 vertebra.
Source: Chopra P. 2004
99
Q
- Trigeminal neuralgia
A. is also called tic doloureux
B. is characterized by sudden, sharp, stabbing facial pain
C. often has a specifi c “trigger zone”
D. may be treated with surgery, medications, or injections.
E. all of the above
A
- Answer: E
Explanation:
Trigeminal neuralgia is a devastating facial pain
characterized by sudden facial pain, and may be treated
with surgery, medications, or injections.
Source: Trescot AM, Board Review 2004
100
Q
545. A 22 year old healthy woman with a history of migraine headaches develops an intense frontal headache after eating ice cream at a party. The pain is sharp and intense. What is the most likely diagnosis? A. Frontal sinusitis B. Cold stimulus headache C. Conversion headache D. Chronic paroxysmal hemicrania E. Intractable Migraine without Aura
A
- Answer: B
Explanation:
A. A frontal sinusitis is a persistent frontal headache and
does not have an abrupt onset.
B. Cold stimulus headache start with exposure of the head
to very cold temperatures as in diving into cold water. An
intense focused pain develops in the frontal region when a
very cold food ingested. The pain lasts for a short duration
of a few minutes. It maybe in the frontal or
retropharyngeal region.
C. Conversion headaches are associated with severe
behavioral abnormalities.
D. Chronic paroxysmal hemicrania is very similar to a
cluster headache in the form that it is similar in intensity
and location. The attacks are short and frequent. They
respond well to indomethacin.
E. Intractable migraine with aura is associated with one or
more fully reversible symptoms.
Source: Chopra P, 2004
101
Q
- Which of the following is true about spinal stenosis
A. Spinal stenosis can only be diagnosed if a patient has
neurogenic claudication
B. Spondylolysis of the pars interarticularis is the most
common etiology of spinal stenosis
C. Classically, patients develop pain after walking and
must stop and stand, in order to obtain pain relief
D. Patients typically have relief of symptoms when walking
downhill
E. Urinary dysfunction is common among patients with
spinal stenosis
A
- Answer: E
Explanation:
A subset of patients with spinal stenosis have neurogenic
claudication, but most patients present with aching low
back and thigh pain. Degenerative arthritic changes of the
L4-5 facet joints and spondylosis of the L4-5 disc are the
most common etiologies of spinal stenosis.
Spondylolisthesis is also associate with these changes.
Classically, patients must sit or stoop forward in order to
obtain pain relief. Patients with vascular claudication have
to stop walking and just stand in order to get relief.
Patients have an exacerbation of symptoms when walking
downhill, due to relative spine extension.
Patients with spinal stenosis frequently have urinary
dysfunction, as evidenced by urodynamic abnormalities
(Inui Y. Spine 2004; 29(8): 869-873)
Source: Shah RV, Board Review 2004
102
Q
- A 12-year old boy complains of neck and jaw pain. He
underwent tonsillectomy 6 months ago. The pain is
exacerbated by swallowing, talking, or turning his head.
There was no evidence of infection. The most likely cause
of his persistent pain is
A. Riedel’s struma
B. Eagle’s syndrome
C. Ludwig’s angina
D. Post traumatic stress disorder
E. Infection of tonsillar bed
A
- Answer: B
Explanation:
Eagle’s syndrome, also known as stylohyoid syndrome,
occurs after tonsillectomy, rarely. This is secondary to
fi brosis developing around an elongated styloid process,
impinging on the carotid sheath. It causes pain in the
upper neck, jaw, face, ears, sternocleidomastoid, or
temporal region. Pain may be exacerbated by swallowing,
talking, or turning the head. Surgical removal of the
styloid may be necessary
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
103
Q
548. Patients with sickle cell disease can experience episodic painful crises, which are characterized by A. Hypothermia B. Normoxemia C. Acidosis D. Dehydration E. Cocaine addiction
A
- Answer: B
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition
104
Q
549. What sign is classical for multiple sclerosis? A. Hoffman’s sign B. Homan’s sign C. Lhermitte sign D. Koenig’s sing E. Brudzinski’s sign
A
- Answer: C
Source: Day MR, Board Review 2004
105
Q
550. A 62-year-old woman complains of limb discomfort and trouble getting off the toilet. She is unable to climb stairs and has noticed a rash on her face about her eyes. On examination, she is found to have weakness about the hip and shoulder girdle. Not only does she have a purplishred discoloration of the skin about the eyes, but she also has erythematous discoloration over the fi nger joints and purplish nodules over the elbows and knees. The most likely diagnosis is: A. Systemic lupus erythematosus B. Psoriasis C. Myasthenia gravis D. Dermatomyositis E. Rheumatoid arthritis
A
- Answer: D
Explanation:
This woman presents with proximal muscle weakness and
pain and a heliotrope rash about her eyes. The term
heliotrope refers to the liliac color of the periorbital rash
characteristic of dermatomyositis. This rash surrounds
both eyes and may extend onto the malar eminences, the
eyelids, the bridge of the nose, and the forehead. It is
usually associated with an erythematous rash across the
knuckles and at the base of the nails and may be associated
with fl at-topped purplish nodules over the elbows and
knees. Men with dermatomyositis are at higher than
normal risk of having underlying malignancies. Psoriatic
arthritis may be associated with reddish discoloration of
the knuckles and muscle weakness, but the heliotrope rash
would not be expected with this muscle weakness, but the
heliotrope rash would not be expected with this disorder.
The age of onset for a psoriatic myopathy is also atypical.
Similarly, the patient’s rashes are not suggestive of lupus
erythematosus, although a myopathy may occur with this
connective tissue disease as well.
Source: Anschel 2004
106
Q
551.The most common organism identified in spinal infections is A. Staphylococcus aureus B. Staphylococcus epidermidis C. Mycobacterium tuberculosis D. Pseudomonas aeruginosa E. Escherichia coli
A
- Answer: A
Explanation:
Gram positive aerobic bacteria are most commonly
isolated, and staph aureus is the most common organism.
Source: Boswell MV, Board Review 2005
107
Q
552. The most common source of spine infection is A. Genitourinary B. Dermatologic C. Respiratory D. Bowel E. Dental
A
- Answer: A
Source: Boswell MV, Board Review 2005
108
Q
553. Delayed onset of central pain after spinal cord injury is most commonly due to A. Infl ammation B. Fibrosis C. Infection D. Syrinx E. Tumor
A
- Answer: D
Source: Boswell MV, Board Review 2005
109
Q
- A 52-year-old man presents with locked-in syndrome. On neurologic examination, the patient is quadriplegic with
sensory loss and cranial nerve involvement. He is able to
respond to questions using his eyes. Choose appropriate
diagnosis:
A. Basilar artery stroke
B. Middle cerebral stroke
C. Anterior cerebral stroke
D. Transient ischemic attack
E. Posterior cerebral stroke
A
- Answer: A
Explanation:
(Tierney, 42/e, pp 962-963.) Basilar artery stroke causes
quadriplegia, sensory loss, and cranial nerve involvement;
patients may present with coma or locked-in syndrome.
Wallenberg syndrome or lateral medullary syndrome
causes an ipsilateral weakness of the palate and vocal
cords,ipsilateral ataxia, ipsilateral Horner syndrome, and
ipsilateral loss of facial pain and temperature but
contralateral loss of body pain and temperature sensation.
There is no limb weakness in Wallenberg syndrome.
Anterior cerebral stroke causes unilateral leg weakness and
sensory loss. Posterior cerebral artery stroke causes an occipital stroke and a homonymous hemianopsia. Middle
cerebral artery stroke causes hemiplegia or hemiparesis
greater in the arm than the leg, aphasia, unilateral sensory
loss, and eyes that deviate to the side of the hemispheric
lesion. Patients with lacunar infarcts may present with
different syndromes, such as dysarthria and mild
hemiparesis (clumsy-hand dysarthria). Lacunar infarcts
represent small artery occlusions; hypertension and
diabetes are risk factors for these infarcts. Patients in a
vegetative state from diffuse cortical damage have
spontaneous eye opening and movement without evidence
of awareness.
110
Q
- Acute Herpes zoster (shingles) involving the anterior
external ear canal, palate, tongue, and face is due to
reactivation of virus in which of the following ganglia?
A. Otic
B. Geniculate
C. Gasserian
D. Sphenopalatine
E. Pterygopalatine
A
- Answer: C
Explanation:
The virus involves the ganglion that forms the 5th nerve,
the gasserian ganglion. Ramsay Hunt syndrome involves
the ear, by reactivation in the geniculate ganglion, which
appears to have sensory fi bers from the pinna and
posterior external auditory canal.
111
Q
556.The mechanism of injury of a C2 traumatic spondylolisthesis is A. Flexion B. Flexion-rotation C. Compression D. Extension E. Other
A
- Answer: D
Explanation:
This fracture is also known as a hangman’s fracture; the
mechanism is hyperextension, such as might occur at the
end of a short rope tied around ones neck, with the knot
under the mandible.
Source: Boswell MV, Board Review 2005
112
Q
- A 41-year-old construction worker complains of the
sudden onset of severe back pain after lifting some heavy
equipment. He describes the pain as being in his right
lower back and radiating down the posterior aspect of his
right buttock to the knee area. He has no bladder or bowel
dysfunction. The pain has improved with bed rest. On
physical examination, the patient has tenderness in his
lumbar area with palpation. The straight-leg maneuver
with the right leg increases the back pain at 80°. The
straight-leg maneuver with the left leg also causes thigh
pain. Sensation, strength, and refl exes are normal. Which
of the following is the most likely diagnosis?
A. Nerve root compression
B. Paravertebral abscess
C. Lumbosacral strain
D. Osteoporosis compression fracture
E. Paget’s disease
A
- Answer: C
Explanation:
(Tierney, 42/e, pp 793-795.) Since the patient has no
neurologic compromise, the most likely diagnosis is back
strain. Strain is common in people in their forties. It is
exacerbated by activity and improves with rest. A straightleg
maneuver is positive for nerve root compression from
disk herniation when pain is produced at less than 70° of
elevation. Crossover pain (straight-leg maneuver of
nonpainful leg worsens pain of involved leg) is also a
strong indicator of nerve root compression, but only if
pain is produced below the knee. Paravertebral abscess
usually presents with fever and tenderness with percussion
of the affected back area. Risk factors for osteoporosis
include female gender, menopause, lack of activity, slim
body habitus, older age, inadequate calcium intake,
medications such as corticosteroids, and racial-ethnic
background (Asian and northern European descent).
Paget’s disease (osteitis deformans) is a slowly
progressing disease of bone that may be asymptomatic or
may cause bone pain, deformities (such as a large skull or
leg bowing), hearing loss, and fractures. It begins in
middle-aged men and is thought to be due to an inborn
error of metabolism causing the formation of poorly
organized bone.
113
Q
558. The hallmark that distinguishes ankylosing spondylitis from other forms of arthritis is: A. Synovitis B. Enthesitis C. Kyphosis D. Amyloidosis E. Osteoporosis
A
- Answer: B
Explanation:
Infl ammation at insertion of tendons, ligaments and fascia
on bone is an important mechanism of the spinal bony
changes
Source: Boswell MV, Board Review 2005
114
Q
559. A 61-year-old man presents with fl accid paralysis, atrophy, fasciculaions, and hyperrefl exia. Choose correct diagnosis: A. Upper motor neuron disease B. Lower motor neuron disease C. Myelopathy D. Radiculopathy E. Broca’s aphasia
A
- Answer: B
Explanation:
(Seidel, 5/e, p 798.) Upper motor neuron (UMN) disease
(above the level of the corticospinal synapses in the gray
matter) is characterized by spastic paralysis, hyperrefl exia,
and a positive Babinski refl ex (everything is up in UMN
disease). Lower motor neuron (LMN) disease (below the
level of synapse) is characterized by fl accid paralysis,
signifi cant atrophy, fasciculations, hyporefl exia, and a
fl exor (normal) Babinski refl ex (everything is down in
LMN disease). A radiculopathy occurs with root
compression from a protruded disk that causes sensory
loss, weakness, and hyporefl exia in the distribution of the
nerve root. Myelopathy causes severe sensory loss 0
posterior column sensation (position sense and vibration),
spasticity, hyperrefl exia, and positive Babinski refl exes.
Broca’s aphasia (left inferior frontal gyrus) is a nonfl uent
expressive aphasia (Broca’s should remind you of broken
speech); Wernicke’s aphasia (left posterior-superior
temporal gyri) is a receptive aphasia because patients lack
auditory comprehension (Wernicke’s should remind you
of wordy speech that makes no sense).
115
Q
- A 30-year-old woman with a history of diabetes mellitus presents with a 3-week history of hand numbness that often awakens her from sleep. The symptoms resolve
after she shakes her hands for a few minutes. On physical
examination, there is no sensory or motor defi cit of her
hands but there is a positive Tinel sign. Which of the
following is the most likely diagnosis?
A. Thoracic outlet syndrome
B. Carpal tunnel syndrome
C. Dupuytren’s contracture
D. Mallet fi nger
E. Ganglion
A
- Answer: B
Explanation:
(Seidel, 5/e, p 735.) Carpal tunnel syndrome (CTS) is the
most likely diagnosis. It is due to median nerve
compression by the transverse carpal ligament. Risk
factors for this disorder include diabetes mellitus,
pregnancy, hypothyroidism, rheumatoid arthritis,
repetitive activity, and acromegaly. The Tinel sign
(paresthesias or pain reproduced with percussion of the
volar surface of the wrist) and Phalen sign (symptoms are
reproduced by holding the wrist in passive fl exion for 1
min)may be positive. Patients may complain of pain in the
forearm, the thenar eminence, and the fi rst three digits.
Thoracic outlet syndrome usually causes medial arm pain
and paresthesia when using the arms. The presence of a
cervical rib is a risk factor for this disorder. Dupuytren’s
contracture is a fi brotic process of the palmar fascia that
causes fi xed fl exion of the ring fi nger. Mallet fi nger is a
fl exion deformity of the distal interphalangeal joint and is
generally the result of traumatic rupture of the extensor
tendon of the distal phalanx. A ganglion is a painless, fi rm
cystic mass arising from any joint or tendon sheath. A
trigger fi nger may be seen in patients with rheumatoid
arthritis. It occurs when an enlarged fl exor tendon sheath
passes through the pulleys of the digits, causing locking or
catching.
116
Q
561. A 20-year-old man presents with complaints of pain in the left hip and left proximal femur. The pain has been present for approximately 3 weeks and is increasing in severity. It is worse at night and is relieved by aspirin. There is no history of trauma or previous hip or leg problems. Which of the following is the most likely diagnosis? A. Osteosarcoma B. Paget’s disease C. Osteoid osteoma D. Chondrosarcoma E. Muscle strain
A
- Answer: C
Explanation:
(Tierney, 42/e, p 835.)
C. A history of pain that increases in severity, worsens at
night, and is relieved by aspirin suggests the diagnosis of
osteoid osteoma. This benign tumor is more common in
males than females,and patients present between20 and 30
years of age. The proximal femur is the most common site
for this tumor. Other benign tumors of bone include giant
cell tumor (osteoclastoma), osteochondroma,
chondroblastoma, and osteoblastoma.
A & D. The most common malignant tumors of bone
include osteosarcoma (45%), chondrosarcoma (25%),
Ewing’s sarcoma (15%), and malignant fi brous
histiocytoma.
Osteosarcomas commonly involve the distal femur.
Chondrosarcomas are seen in older patients (40 to 50
years old).
Osteosarcomas may be seen later in life as a complication
of Paget’s disease.
117
Q
- Duchenne muscular dystrophy is a sex-linked disorder
involving the gene responsible for the synthesis of
A. Glucose-6-phosphatase
B. Hexosaminidase B
C. Myosin
D. Dystrophin
E. Actin
A
- Answer: D
Explanation:
Duchenne dystrophy has been incontrovertibly linked to
the gene, located on the X chromosome, that makes
dystrophin. The more profound the disturbance of this
gene, the earlier the disease becomes symptomatic. The
gene for dystrophin has single or multiple deletions in
affected children. Women who are probable carriers of the
defective gene can be checked for heterozygosity and given
genetic counseling. Chorionic villus biopsy at 8 to 9 weeks
can determine if a fetus that is at risk for the deletion
actually carries it.
Source: Anschel 2004
