Chapter 50. Principle of Pain Management Flashcards
Question 50-1: Testicular pain of neuropathic or referred origin suggests localization at which level? A. Diaphragm B. Gastric C. Renal D. Ovarian Jawab:C
Answer 50-1: c.
Neuropathic pain is frequently referred to as a
site spatially distant from the origin, but
anatomically appmpriate. Testicular pain
which is referred from neural irritation would
most likely be of renal or adrenal origin, with
the afferents in the Tl2-L2 nerve roots.
Abscess or tumor would be likely causes.
Diaphragmatic and gastric lesions usually
produce more rostral pain. On the other hand
ovarian neoplasms and infections produce
lower quadrant, back, or hip pain. (p925)
Question 50-2:
Which of the following summarizes the current concepts of neuropathic pain syndromes?
A. Complex regional pain syndrome 1 is due to sympathetic-mediated maintenance of the pain
B. CRPS-1 is associated with dystrophic changes in bone and soft tissues of the affected extremity
C. Definitive treatment of CRPS-1 is sympathetic ablation
D. Migration of the distribution of the pain indicates psychogenic pain
Answer 50-2: B.
CRPS type-l was formerly called RSD
whereas CRPS type-2 was forme-rly called
causalgia. Sympathetic mediation of the
dystrophic changes and pain has been a theory
which does not have much support - only a
minority of patients with CRPS type I have
sympathetically-maintained pain .. Migration
with change in the field of distribution of the
pain is common, and does not necessarily
indicate psychogenic pain syndrome.
Alteration in nociceptive fields likely occurs
at spinal and cerebral levels. (p927)
Question 50-3:
Which statement best describes the difference between conversion reaction and malingering?
A. Patients with malingering are unaware of the secondary gain of their complaints, whereas patients with conversion reaction are consciously aware of the etiology of their symptoms
B. Patients with conversion reaction have symptoms due to defined structural pathology whereas patients with malingering have psychogenic symptoms
C. Patients with conversion disorder are not consciously aware of the absence of organic pathology, whereas malingering patients are making a conscious effort to deceive the examiner
D. Malingering and conversion reaction have the same psychologic foundation
Answer 50-3: C.
Patients with conversion reaction are not
consciously aware of the secondary gain.
Malingering patients are aware of the nature
of their condition and are making an
intentional effort to deceive the examiner.
(p929)
Question 50-4: For patients with chronic pain related to cancer, which would be the best starting treatment? A. NSAIDs B. Opiates C. Tricyclic antidepressants D. Antiepileptic drugs
Answer 50-4: A.
NSAIDs are recommended as the lowest rung
of the analgesic ladder. TCAs and AEDs are
used as adjuvant treatment, however. they are
not often used alone without any analgesic.
Many patients can have tolerable pain merely
with the analgesics alone. (p930)
Question 50-5:
A patient presents with limb pain without objective deficit on examination. Psychogenic pain is considered, and a placebo is administered, which results in moderate pain relief. Which of the following statements are true?
A. The placebo response suggests psychogenic pain
B. The placebo response indicates sympathetically-maintained pain
C. Repeated placebo response suggests psychogenic pain
D. The placebo response can be seen in organic and psychogenic pain
Answer 50-5: D.
A placebo response cannot differentiate
organic from psychogenic pain. Pain is a
perceptual problem, and even with serious
organic cause, there may be a beneficial effect
of placebo due to the anticipation of relief.
(p929,931)
Question 50-6:
Chronic neuropathic pain can be appropriately treated by which of the following?
1. Carbamazepine
2. Oxycodone
3. Amitriptyline
4. Meperidine
Selett: A = 1, 2, 3. B = 1, 3. C = 2, 4. D = 4 only. E = All
Answer- 50-6: B.
Anticonvulsants and tricyclic antidepressants,
are effective for treaUDent of chronic
neuropathic pain including deafferentation
pain.Oxycodone should be avoided, although
it is effective, and should be considered along
with other opiates for last-line therapy.
Meperidine can be used safely for acute pain,
but there is an increased incidence of serious
adverse effects with long-term use, including
myoclonus, seizures, and encephalopathy_
These effects are due to a normeperidine
metabolite which makes chronic use
inadvisable. (p933)
Question 50-7:
A patient maintained on chronic sustained morphine treatment for “failed back” is admitted to the emergency department because of abdominal pain, unrelated to his chronic back pain. The ED physician administers pentazocine (Talwin) and shortly thereafter the patient becomes irritable, agitated, has severe nausea and vomiting, and has chiIIs. Which of the following most likely explains the sudden change in symptoms?
A. The patient had an allergic reaction to pentazocine
B. Pentazocine has precipitated opiatewithdrawal
C. The underlying intra-abdominal pathology worsened
D. This is an expected reaction to pentazocine
Answer 50-7: B.
Pentazocine is a mixed opiate agonistantagonist.
The most likely scenario is that the
antagonist effect precipitated acute opiate
withdrawal. The other possibilities have to be
considered, but are much less likely. (p933)
Question 50-8:
A patient with severe post-operative pain is treated with morphine. Which is the best regimen?
A. Nursing administration of prnmorphine intramuscular injections
B. Nursing administration of prn morphine intravenous injections
C. Continuous release morphine tablets
D. Continuous infusion of morphine with patient controlled analgesia for supplemental drug
Answer 50-8: D.
Postoperative pain may be associated with
disordered gastrointestinal absoIption, so
parenteral administration is preferable. Of the
potential parenteral routes, intravenous
administration is preferable. Of the modes of
intravenous administration. continuous
administration with PCA. may afford the best
pain coverage. Nursing administration of
analgesic is fme. but the delay in
administration and hesitancy on the part of the
patient in contacting the nurse for a shot may
cause pain levels to increase to the point that
needless suffering is present. (p935)
Question 50-9:
Which of the following statements are true regarding the use of intrathecal and epidural opioid analgesia?
1. Therapy is directed mainly to patients with headache and meningeal pain
2. Systemic absorption of opiate is prominent
3. Respiratory suppression does not occur with these routes of administration
4. Epidural opiates are less likely to produce weakness than local anesthetics
Select: A = 1, 2 , 3. B = 1.3. C = 2, 4. D = 4 only. E = All
Answer 50-9: D.
Intrathecal and epidural opiates are used
predominantly for pelvic and lower extremity
pain. They are less likely to produce weakness
than similarly injected local anesthetics.
Respiratory suppression can occur, especially
with high intrathecal doses and water-soluble
agents such as morphine. (p936)
Question 50-10:
Which of the following statements are true regarding capsaicin for neuropathic pain?
1. Used mainly for localized pain
2. Can be helpful for postherpetic neuralgia
3. Works by depleting substance P from nociceptive afferents
4. Burning produced by the agent can prevent use
Select: A = 1, 2, 3. B = 1, 3. C = 2, 4. D = 4 only. E = All
Answer 50-10: E.
All are true. Capsaicin is commonly used for
patients with postherpetic neuralgia and other
localized pain syndromes. However, capsaicin
is considered relatively weak, so most
physicians prescribe anticonvulsants and
tricyclics fIrst line. (p937)
