MSK SAEs Flashcards
A 72-year-old woman underwent right total knee arthroplasty 2 days ago. When you see her in
consultation, she tells you that she has numbness along the lateral portion of the incision site.
What is the most likely cause?
(a) Femoral or peroneal nerve injury
(b) Deep vein thrombosis
(c) Cutaneous nerve injury
(d) Temporary side effect from anesthesia
Answer: (c)
Commentary: Cutaneous sensory loss is a very common complication following primary total
knee arthroplasty. One study from 1995 found that 100% of patients had lateral skin flap
numbness, and more recent studies in 2004 and 2009 found 81%-86% of patients had lateral skin
flap numbness.In most cases, the numbness does improve with time (50% recovered in 2 years in the 2009study). Deep vein thrombosis (DVT) and common peroneal nerve palsy are other known
complications of total knee arthroplasty.
Imaged with musculoskeletal ultrasound, normal tendon structure looks
a) hypoechoic, with hyperechoic septa.
b) hypoechoic , with fascicular pattern.
c) hyperechoic, with fibrillar echotexture.
d) hyperechoic, with posterior acoustic shadowing.
Answer:(c)
Commentary: Musculoskeletal ultrasound is an imaging modality that is able to identify and
characterize various soft tissue structures. Normal tendons appear as hyperechoic(bright echo)
structures with fibrillar or fiber-like pattern. Normal muscle appears as a hypoechoic(low echo)
structure with hyperechoic septa. Bone appears as a very hyperechoic structure with posterior
acoustic shadowing. Posterior acoustic shadowing is an artifact that refers to the anechoic
region(no echo) deep to the bone surface.
The third occipital nerve innervates which structure?
(a) C2-3 zygapophysial joint
(b) C2-3 intervertebral disc
(c) C3-4 zygapophysial joint
(d) C3-4 intervertebral disc
Answer:(a)
Commentary: The third occipital nerve(TON) innervates the C2-3 zygapophysial joint. The C3-4
zyagpophysial joint is innervated by the C3 and C4 medial branches. Innervation to the cervical
discs involves the sinuvertebral nerve, vertebral nerve and sympathetic trunk.
SAER-2011
- Injured workers with acute low back pain treated with high-dosage opioids compared to low-dose
or nonopioid medications demonstrated which outcome?
(a) Lower overall medical costs
(b) Same duration of disability
(c) Higher risk for surgery
(d) Shorter duration of opioid use
Answer: (c)
Commentary: Injured workers with acute low back pain who received higher dosages of opioids
in early treatment had adverse outcomes compared to patients given no or low-dose opioids. In
the high-dose opioid group, adverse outcomes included higher medical costs, prolonged
disability, higher risk for surgery, and continued use of opioids. The high-dose opioid group was
disabled 69 days longer than the non-opioid group, had a 3 times greater risk for surgery, and a 6-
times-greater risk of receiving long-term opioids. The severity of the low back injury was a strong
predictor of all outcomes.
- Hamstring injuries occur most commonly
a) at the proximal attachment of the lateral hamstrings to the pelvis.
b) during concentric contraction of the medial hamstrings.
c) at the distal attachment of the medial hamstrings to the tibia.
d) during eccentric contraction of the lateral hamstrings.
Answer: (d)
Commentary: The majority of hamstring injuries occur from indirect forces during running and
sprinting activities. Most injuries occur at the myotendinous junction, not at the osseous
attachments, during eccentric contraction of the hamstring. The lateral hamstrings (biceps
femoris) are affected more than the medial hamstrings (semitendinous and semimembranosus).
- For injured workers with chronic low back pain, which outcome is associated with better
performance during a functional capacity evaluation (FCE)?
(a) Shorter usage of temporary disability benefits
(b) Lower subjective reports of perceived disability
(c) Higher likelihood of sustainable work tolerance
(d) Fewer recurrences of low back pain over the next 12 months
Answer: (a)
Commentary: Functional capacity evaluations (FCEs) are commonly used to determine readiness
for return to work. These evaluations measure the injured worker’s functional abilities relative to
the physical demands required by the job. The clinical assumption is that workers who perform
better during FCEs will have a lower risk of reinjures and less pain exacerbation upon return to
work. One-year follow-up of patients with chronic low back pain whose FCE demonstrated
performance that met or exceeded physical job requirements did not demonstrate a reduction of
recurrent low back pain, improved occupational sustainability, or improved perception of
disability. Better FCE performance was mildly associated with faster return to work and shorter
duration of temporary disability benefits.
- Which statement regarding an independent medical examination (IME) is TRUE?
(a) The traditional physician-patient relationship is not maintained, and confidentiality is not
guaranteed.
(b) The examiner is exempt from potential liability since the purpose of the evaluation is to
assess medical-legal issues, not clinical issues.
(c) Treating providers may conduct an IME as long as records from other providers are also
reviewed.
(d) Because of potential conflicts of interest, only providers no longer in clinical practice
should conduct IMEs.
Answer: (a)
Commentary: In the IME context, a traditional physician-patient relationship does not exist, since
the evaluation does not include “intent to treat.” Confidentiality is not guaranteed, since the
examiner is expected to share certain medical information and findings with the referring party.
Because a “limited doctor-patient relationship” exists during an IME, the physician is responsible
for disclosing in the IME any medical findings that could affect the patient’s health, and he or she
is potentially liable for any harm, direct or indirect, that may be sustained by the person
examined. Only a provider who is uninvolved with an examinee’s treatment may conduct an
IME, although a treating provider may be an “expert witness.” Legal requirements for
qualification as an expert witness vary from state to state. There is no restriction regarding a
provider’s clinical status and eligibility to conduct IMEs.
- Comparing the functional outcomes at 1-year post treatment of 2 groups of patients with
nonspecific low back pain greater than 12-months’ duration and no prior history of lumbar fusion,
which finding regarding structured rehabilitation with cognitive behavioral therapy (CBT) versus
lumbar fusion is TRUE?
(a) Better functional outcomes in the surgical group versus the CBT group
(b) Improvements in both groups with similar functional outcomes
(c) Better functional outcomes in the CBT group versus the surgical group
(d) Poor functional outcomes in the CBT group, but no consistent outcome in the surgical Group
Answer: (b)
Commentary: Randomized trials for surgery are difficult to conduct, particularly those that
compare surgical to nonsurgical treatment. While available studies do not allow a general
statement regarding the efficacy of fusion over nonsurgical care for discogenic back pain, 4 trials
suggest any advantage of surgery over nonsurgical care is modest, on average near or below the
minimally important change in the disability score. Both groups demonstrated improvement
compared to baseline. Highly structured rehabilitation with a cognitive-behavioral component
seems nearly equivalent to surgery in efficacy at 1 year, with fewer complications.
- A firefighter who is now 5 days postsurgery for a rotator cuff and labral tear is in significant pain, but is concerned about opioid use for pain control. He is concerned about becoming “addicted to the pain killers.” In educating the patient about opioids and the issues of addiction, dependence and tolerance, which statement is correct?
(a) While all 3 terms have subtle differences, they are essentially identical in meaning and
can be used interchangeably.
(b) Since he is a firefighter, he should avoid use of any opioids at all times since he is subject
to toxicology screening.
(c) Addiction is predictable and avoidable, and since he already concerned about it, he is
unlikely to have problems with addiction.
(d) Addiction is characterized by behavioral issues, whereas dependence and tolerance are
characterized by physiologic adaptation.
Answer: (d)
Commentary: Physical dependence, tolerance, and addiction are discrete and different phenomena
that are often confused. Addiction is characterized by behaviors that include one or more of the
following: impaired control over drug use, compulsive use, continued use despite harm, and
craving. Addiction is not a predictable drug effect, but represents an idiosyncratic adverse
reaction in biologically and psychosocially vulnerable individuals. Physical dependence is a state
of adaptation characterized by specific withdrawal symptoms that can be produced by abrupt
cessation, rapid dose reduction, and/or administration of an antagonist. Tolerance is a state of
adaptation that results in a decreased effect of a drug over time.
- You are asked to provide a brief synopsis of workers’ compensation benefits to the hospital’s case management department. Which statement about the benefits and services provided in the
workers’ compensation system is correct?
(a) The employer has to be at fault in order for the injured employee to seek medical care.
(b) Injured workers continue to receive their full wages as long as they are unable to work.
(c) Workers’ compensation programs are designed and administered by each individual state.
(d) Workers’ compensation is primarily financed by federal and state funds.
Answer: (c)
Commentary: Workers’ compensation provides benefits to workers who are injured on the job or have a work-related illness, regardless of who is at fault for the injury or illness. Benefits include medical treatment for work-related conditions and cash payments that partially replace lost wages. In the event that symptoms do not completely resolve, financial compensation is also provided. In exchange, an injured worker gives up the right to sue the employer because of a work-related injury or illness. Workers’ compensation programs are designed and administered by each state, and programs and policies vary from state to state. Workers’ compensation is financed almost exclusively by employers, not federal or state funds.
- A 22-year-old man who is right hand-dominant presents to your office with acute onset of right shoulder pain. He is a former college tennis player without a previous history of shoulder
pathology. Which test would you perform to evaluate for pathology involving the labrum of the
shoulder?
a) Hawkin test
b) Bowstring sign
c) O’Brien active compression test
d) Apley scratch test
Answer: (c)
Commentary: The O’Brien active compression test is used to evaluate and differentiate labral
tears (superior labrum anterior posterior – SLAP tears) from acromioclavicular joint pathology
and pain. The Hawkin test is an impingement test of the shoulder and is not intended to evaluate
tears of glenoid labrum. The bowstring sign is used to identify lumbar nerve root compression.
The Apley scratch test is used to assess the range of motion of the shoulder.
- A 30-year-old woman began running 2 weeks ago. She runs 4 miles a day, twice a week. She began experiencing bilateral lower leg pain. On physical examination, she reports diffuse pain along the medial tibia at the start of her run with improvement during the run. The most likely diagnosis is
a) stress fracture.
b) medial tibial stress syndrome.
c) anterior tibialis tendinitis.
d) tarsal tunnel syndrome.
Answer: (b)
Commentary: This woman presents with symptoms most consistent with medial tibial stress
syndrome (MTSS) or what has been termed “shin splints.” Pain from MTSS occurs along the
lower third of the posteromedial border of the tibia. A stress fracture is unlikely in this low
mileage runner who has had only 2 weeks of running activity. Stress fractures generally have a
focal area of pain and are not relieved with further running. Anterior tibialis tendinitis presents
with anterolateral pain along the dorsal aspect of the ankle. Tarsal tunnel syndrome is associated
with numbness and tingling in the foot.
- A man presents to your clinic complaining of buttock pain that radiates posteriorly down the thigh. On exam you note that he has a leg length discrepancy, symptoms are provoked by placing the affected limb in the FAIR position (hip in flexion, adduction and internal rotation), and he has a positive straight leg raise test. He has normal nerve conduction studies and a normal needle electromyography test. Treatments that may be beneficial include
(a) stretching exercises of the iliotibial band and corticosteroid injection of the greater trochanteric bursae.
(b) a lumbar stabilization exercise program and coricosteroid lumbar epidural spinal injection.
(c) a lumbar stabilization exercise program and botulinum toxin injection of the lumbar paraspinals.
(d) stretching exercises in the FAIR position and botulinum toxin injection to the piriformis.
Answer (d)
Commentary: This is a description of piriformis syndrome. Although some positive findings on
needle examination may be seen with piriformis syndrome, electrodiagnostic studies are often
normal. On the other hand, positive findings are expected in cases of lumbar radiculopathy.
Conservative treatment of piriformis syndrome begins with piriformis stretching (FAIR position
is a good position for this) and nonsteroidal anti-inflammatory drugs (NSAIDs), followed by
lumbosacral stabilization, hip strengthening, and myofascial release. Botulinum toxin relieves
pain via multiple mechanisms and is increasingly used in the treatment of myofascial dysfunction.
A lumbar stabilization exercise program and botulinum toxin injection of the lumbar paraspinals
may help relieve some of this patient’s pain if he also has low back pain, but would not address
the main issue, piriformis syndrome. Stretching exercises of the iliotibial band and corticosteroid
injection of the greater trochanteric bursae would be the treatment for greater trochanteric
bursitis. A lumbar stabilization exercise program and corticosteroid lumbar epidural spinal
injection would treat a lumbar radiculopathy.
- 20-year-old football player reports anterior shoulder pain during a game. He completes the game, but radiographs after the game revealed a type 2 acromioclavicular (AC) joint sprain. How is a type 2 acromioclavicular (AC) joint injury defined?
(a) Acromioclavicular and coracoclavicular ligaments are both disrupted.
(b) Acromioclavicular and coracoclavicular ligaments are both intact.
(c) Acromioclavicular ligament is disrupted, but the coracoclavicular ligament is intact.
(d) Acromioclavicular ligament is intact, and the coracoclavicular ligament is disrupted.
Answer: (c)
Commentary: Acromioclavicular joint injuries are classified into 6 types according Rockwood
classification. A type 1 injury describes a mild injury to the AC joint without disruption of either
the acromioclavicular or the coracoclavicular ligaments. A type 2 injury describes disruption of
the acromioclavicular ligament, but the coracoclavicular ligament remains intact. A type 3 injury
describes disruption of both ligaments whereas a type 4 injury entails complete disruption of both
ligaments with posterior displacement of the distal clavicle into the trapezius muscle.
- Which statement is TRUE regarding the rehabilitation of anterior cruciate ligament (ACL)
reconstruction/repair?
(a) Immediate postoperative weight bearing adversely affects subsequent knee function.
(b) A self-directed program is not as effective as regular physical therapy visits.
(c) Use of a continuous passive motion machine improves outcome.
(d) Postoperative functional bracing does not improve outcome.
Answer: (d)
Commentary: The use of postoperative functional bracing does not improve outcome. Immediate postoperative weight bearing does not adversely affect subsequent knee function. A self-directed program is as effective as regular physical therapy visits in a motivated patient. The use of a continuous passive motion machine does not improve outcome.
- Compared to a younger individual, an older worker who suffers a musculoskeletal injury is more likely to
(a) return to work sooner.
(b) have a recurrent injury.
(c) have the injury treated nonsurgically.
(d) sustain a less serious injury.
Answer: (b)
Commentary: Compared to a younger individual who suffers a musculoskeletal injury, an older
individual is more likely to have a recurrent injury, a decreased likelihood of returning to work
after the injury, increased time lost from the job as a result of the injury and a more serious injury.
Also, an older individual with a spine injury is more likely to have surgery than is a younger
individual.
- A 40-year-old woman reports left-sided facial pain for the past month along with difficulty in
moving her jaw. She hears a clicking noise with chewing along with constant tinnitus. Upon
examination, she has tenderness to palpation along her muscles of mastication on the left with
deviation of the mandible upon jaw opening. She would like to have pain relief. You suggest
(a) referral to an oral surgeon.
(b) that she perform jaw isometric exercises in a closed position with massage.
(c) a 2-week trial of an oral nonsteroidal anti-inflammatory medication.
(d) an ultrasound-guided intra-articular injection with steroids.
Answer: (c)
Commentary: This woman has a temporomandibular joint (TMJ) disorder most likely myofascial
in origin, which is the most common etiology. It is usually self-limited, and is managed
conservatively with relative rest (eg, avoiding jaw clenching, gum chewing), heat, and
nonsteroidal anti-inflammatory agents. Intra-articular steroid injections are not needed with a
myofascial origin of pain. She also does not need a referral to an oral surgeon at this time.
- The current workers’ compensation system in the United States is a “no fault” system. This
means that the
(a) employee does not have to prove that the employer is at fault for the injury.
(b) employer does not have to prove they are at fault for the employee’s injury.
(c) employee and employer do not have to prove that the other is at fault for the injury.
(d) employer does not have to prove that the employee is at fault for the employee’s injury.
Answer: (c)
Commentary: In the United States workers’ compensation system the injured worker does not
have to prove that the employer is at fault for the employee’s injury. Similarly, the employer
does not have to prove that the injured worker is at fault for his/her injury. If the injury occurred
at work, the medical costs and partial payment of lost income are covered.
- An 87-year-old man on your inpatient rehabilitation unit was found on the therapy mat in much pain after hearing a loud “cracking” noise when he transferred himself. What position of his right lower limb would suggest hip fracture?
(a) Internal rotation and lengthened
(b) Internal rotation and shortened
(c) External rotation and lengthened
(d) External rotation and shortened
Answer: (d)
Commentary: In most cases, the lower limb of the fractured hip would be held in external rotation
(rotated outward) and would appear shortened relative to the unaffected lower limb.
- You are seeing a 79-year-old gentleman with chronic right shoulder pain. For the past several years he has had limited shoulder movement and is diffusely tender around the shoulder. Magnetic resonance imaging demonstrates a partial tear of the supraspinatus and infraspinatus tendons with degenerative changes of the glenohumeral joint. You recommend
(a) rotator cuff repair.
(b) total shoulder arthroplasty.
(c) intra-articular viscosupplementation injection.
(d) flexibility and progressive strengthening exercises.
Answer: (d)
Commentary: The nonsurgical management of shoulder osteoarthritis (OA) with a chronic,
massive rotator cuff defect requires flexibility exercises and gentle progressive strengthening
exercises to increase shoulder function. Surgical repair involves humeral hemiarthroplasty.
Rotator cuff repair in partial thickness tears consists of surgical smoothing of the humeroscapular
motion interface with cuff curettage. Reverse total shoulder arthroplasty is used for
anterosuperior escape rotator cuff lesions. There is no role for shoulder viscosupplementation,
since it has not been shown to be beneficial.
- Which clinical scenario is most consistent with a L4-5 foraminal disc herniation?
(a) Weakness of the extensor hallicus longus, decreased sensation of the web space between
the first and second toes, absent hamstring reflex
(b) Weakness of the gastrocnemius, decreased sensation of lateral foot, absent Achilles reflex
(c) Weakness of the anterior tibialis, decreased sensation of the web space between the first
and second toes, absent hamstring reflex
(d) Weakness of quadriceps and anterior tibialis, decreased sensation of medial lower leg,
absent patellar reflex
Answer: (d)
Commentary: A foraminal disc herniation at L4-5 level would most likely affect the exiting L4
nerve root. A nerve root lesion could result in muscle weakness in the affected myotomes,
sensation loss in the affected dermatomes, and deep tendon reflex changes. The physical
examination findings most consistent with a lesion to the L4 nerve root would be weakness of
the quadriceps (L2-4), decreased sensation in L4 dermatomes, and decreased or absent patellar
deep tendon reflex (L4).
- A 67-year-old man presents to your clinic with weakness and frequent falls. You suspect cervical stenosis. Calculating anteroposterior (AP) ratios to other anatomical structures, which ratio would enable you to assess for bony cervical spinal stenosis on lateral radiographs?
(a) AP diameter of the vertebral body to the height of vertebral body.
(b) AP diameter of the vertebral canal to the AP diameter of the vertebral body at the same level.
(c) Vertebral height to the AP of the vertebral canal at the same level.
(d) Distance from the anterior border of the vertebral body to the tip of the spinous process.
Answer: B
Commentary: Assessment of cervical spinal stenosis on lateral radiograph can be made by calculating the ratio of the anteroposterior (AP) diameter of the vertebral canal to the AP diameter of the vertebral body at the same level. This ratio is called the Pavlov ratio. A normal ratio is 1.0 with less than 0.82 indicating stenosis. The Torg ratio is the same as Pavlov ratio.
- A 47-year-old woman injures her back on the job. Her supervisor inquires about the injury and creates a document with the employee’s name, outlining how the injury occurred and where the employee is experiencing pain. The information in the document is protected by the
(a) Health Insurance Portability and Accountability Act (HIPAA).
(b) The Joint Commission (JC).
(c) Americans with Disabilities Act (ADA).
(d) United States Supreme Court.
Answer: A
Commentary: Once the document was created by the supervisor and it contained individually identifiable health information it became information that is protected by HIPAA. The term ‘individually identifiable health information’ means any information, including demographic information collected from an individual, that: (A) is created or received by a health care provider, health plan, employer, or health care clearinghouse; and (B) relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual, and identifies the individual.
- Repeatedly lifting the shoulder past which degree of flexion or abduction is associated with an increased prevalence of shoulder disorders?
(a) 10o
(b) 30o
(c) 45o
(d) 60o
Answer: D
Commentary: Repeatedly lifting the shoulder past 60 degrees of flexion or abduction is associated with an increased prevalence of shoulder disorders.
- Which factor is associated with increased risk for occupational injury in an older individual?
(a) White collar occupation
(b) Female gender
(c) Impaired hearing
(d) Self employment
Answer: C
Commentary: Predictors of increased injury risk in an older worker include male gender, less education, obesity, alcohol abuse, disability, self report of impaired hearing or sight, and several specific job requirements. Service workers, mechanics, machine operators, and laborers are at increased risk for occupational injury compared to people in white collar occupations. Individuals who are self-employed have a lower risk of injury.
A 35-year-old man presents to your clinic with a 3-month history of groin pain exacerbated by activity. He is an avid skier and runner. He has been taking anti-inflammatories with minimal relief. Anteroposterior films of the hip were normal. The magnetic resonance imaging of the hip reported a bony prominence at the femoral head-neck junction. What clinical exam finding is most likely to correlate with these radiographic “abnormalities”?
(a) Pain with resisted straight leg raise
(b) Pain with hip flexion, external rotation, and abduction
(c) Pain with sacral thrust
(d) Pain with hip flexion, internal rotation, and adduction
Answer:D
Commentary: This patient has radiographic evidence of femoroacetabular impingement. Two types have been described, cam impingement and pincer impingement. Cam impingement is described more commonly in active males and describes a non-spherical femoral head or osseous abnormalities of the femoral head-neck junction. These bony abnormalities have abnormal contact with the acetabulum in hip flexion, adduction, and internal rotation. Pincer impingement describes abnormal contact between the femur and the acetabulum due to overcoverage of the femoral head from an abnormally deep or retroverted acetabulum.
- A recent study of individuals undergoing a single knee or hip replacement surgery who were treated at an inpatient rehabilitation facility (IRF) compared to those treated at a skilled nursing facility (SNF) found that those treated in an IRF were more likely to
(a) need the use of a walker to ambulate.
(b) require home care services.
(c) be discharged home.
(d) ambulate a shorter distance.
Answer: C
Commentary: Patients undergoing single knee or hip replacement surgery who were treated at an IRF were more likely to be discharged home, less likely to require home care services upon discharge, and were able to ambulate farther distances compared to those treated in an SNF.
- A 55-year-old woman presents to the clinic with a 6-week history of right wrist pain. She is an administrative assistant and has been working extra hours for the past 3 months. She has been taking anti-inflammatory medications without relief. You diagnose her with de Quervain tenosynovitis. What is the next most appropriate step in treatment?
(a) Trial of a higher dose of anti-inflammatory medication
(b) Surgical consultation
(c) Corticosteroid injection
(d) Splinting the wrist
Answer: C
Commentary: Corticosteroid injection for de Quervain tenosynovitis has been shown to be more effective treatment than splinting and anti-inflammatory medications.
- Which structure is required by the American with Disabilities Act (ADA) to have adequate accessibility for individuals with disabilities, so long as the modifications to it are readily achievable?
(a) House of worship
(b) Physician’s office within a private residence
(c) Commercial airplane
(d) Residential private apartments
Answer: B
Commentary: If a publicly accessible office is present within a single family home, it is required to be accessible under the ADA, so long as the necessary modifications are readily achievable. Accessibility of commercial airplanes is covered under the Air Carrier Access Act, not the ADA.
Access to houses of worship or strictly residential private apartments is not required under the ADA.
22-year-old female volleyball player fell on an outstretched right hand 3 weeks ago and complains of continued wrist pain. On examination, she has minimal swelling of the distal limb and is tender to palpation distal to the ulnar styloid between the flexor carpi ulnaris and extensor carpi ulnaris tendons. A plain radiograph was normal except for an ulnar plus variant. She failed conservative treatment with splinting and activity modification. The most appropriate imaging study to obtain would be
(a) computed tomography scan of the wrist.
(b) repeat plain films in 10 days.
(c) triple phase bone scan.
(d) magnetic resonance imaging with arthrogram.
Answer: D
Commentary: This patient sustained an injury to her triangular fibrocartilage complex. This structure is a stabilizer of the distal radioulnar joint and is composed of an avascular articular disc and radioulnar ligament complex. It is often injured with repetitive wrist activities or compressive loads. Tears to it are best imaged by MRI arthrogram. Injury to this complex would not be optimally evaluated on plain films, bone scan, or computed tomography scan.
- You recommend work hardening for a worker recovering from a shoulder injury. You explain to the worker to expect a therapy program that
(a) builds aerobic conditioning and will be performed 2 hours daily.
(b) simulates work duties and will be performed approximately 4 hours daily.
(c) simulates a heavy manual labor job and will be performed 6 hours daily.
(d) improves aerobic conditioning while simulating a light duty job and will be performed 8 hours daily.
Answer: B
Commentary: Work hardening is a rehabilitation program designed to simulate the individual worker’s job. It can be performed at a center or at the worker’s jobsite. These programs are often recommended to be done 5 days a week. The worker performs an individualized program based
on his/her specific job requirements. Physician follow-up is needed to determine if goals have been achieved. Work conditioning is a program used to enhance aerobic conditioning but does not attempt to replicate the tasks of a specific job.
- A 60-year-old man with left total knee arthroplasty 5 days prior continues to have difficulty with ambulation during rehabilitation. On exam, he has 70oof active knee flexion, a 20oextensor lag, and a distal lower limb normal to palpation. You then notice that he has trouble clearing his toes during swing phase. You suspect the major cause of his difficulty walking is due to
(a) weak quadriceps strength.
(b) inadequate knee flexion range.
(c) commonperoneal nerve palsy.
(d) tibialis anterior tendon tear.
Answer: C
Commentary: The patient has a common peroneal nerve palsy which can occur after total knee arthroplasty. Weak quadriceps strength and inadequate knee flexion may cause difficulty with ambulation, but not the loss of ankle dorsiflexion. Tibialis anterior tendon tear will cause difficulty with ankle dorsiflexion, but is not a common complication after knee arthroplasty. Also, acute tendon tears present with sudden pain and palpatory defect.
- A 28-year-old man returns to clinic after failing conservative management for clinical medial epicondylitis. In order to determine the appropriateness of a surgical referral, what is the most cost effective diagnostic test to localize the site of pathology?
(a) Plain radiographs of the elbow and forearm
(b) Magnetic resonance imaging of upper extremity
(c) Real time ultrasound
(d) Electrodiagnostic studies
nswer: C
Commentary: Real time ultrasound is less costly than magnetic resonance imaging (MRI) and has similar sensitivity and specificity in diagnosing medial epicondylitis. Plain radiographs and electrodiagnostic studies will not help localize or confirm your diagnosis of medial epicondylitis, but may help with diagnosing a fracture or nerve injury, respectively.
- Disability as defined by the Americans with Disabilities Act (ADA) is
(a) a physical or mental impairment that substantially limits 1 or more major life activities.
(b) abnormality of the physiologic or anatomic structure or function.
(c) the barriers society places on the individual interacting in his/her community.
(d) a rating based on an independent medical examination.
Answer: A
Commentary: The Americans with Disabilities Act defines disability as a physical or mental impairment that substantially limits 1 or more of a person’s major life activities. The person has a record of such impairment, or is regarded as having such impairment. Impairment is the actual physiologic, anatomic, or psychologic abnormality. Handicap refers to the barriers society places on an individual to perform function in the community. A permanent disability rating is used to determine financial compensation for an injury.
- The validity of a functional outcome measurement tool is defined as the ability
(a) of two different raters to obtain the same conclusion.
(b) of the tool to measure what it is designed to measure.
(c) to minimize random error.
(d) to measure several different outcomes simultaneously
Answer: B
Commentary: The validity of a functional outcome measurement tool is defined as the ability of the tool to measure what it is designed to measure. The ability to measure different outcomes simultaneously does not impact the validity of the instrument, but the validity of the tool would need to be established for each of the outcomes being measured. The ability of two different raters to obtain the same conclusion is referred to as inter-rater reliability. Freedom from random error is also related to the reliability of the instrument.
. A 23-year-old postgraduate student presents to your office with bilateral knee pain. She just began training for a half marathon but has been limited by her knee pain. She reports pain in the anterior aspect of the knee and describes it as “beneath the knee cap.” The pain is worse when arising after sitting for a prolonged period of time. Which physical examination finding might you expect in this patient?
(a) Pes cavus
(b) Strong hip abductors
(c) Negative Ober test
(d) Tight quadriceps muscles
Answer: D
Commentary: Patellofemoral arthralgia is thought to result from tracking problems of the patella within the trochlear groove. Several biomechanical issues, such as tight and inflexible quadriceps, pes planus, tight iliotibial band, weak and ineffective vastalis medialis, and weak hip abductors, may contribute to incorrect tracking of the patella. The Ober test assesses the tensor fascia lata and iliotibial band for contracture and inflexibility.
. According to the American Medical Association Code of Ethics Opinion, which statement is TRUE?
(a) Individual gifts of minimal value from pharmaceutical representatives to physicians are permissible so long as the gifts are related to the physician’s work.
(b) It is acceptable for physicians to request free pharmaceuticals for personal use or use by family members.
(c) Subsidies to underwrite the costs of continuing medical education are permissible when provided directly from the pharmaceutical company to the physician.
(d) Faculty presenting at conferences cannot accept honoraria and reimbursement for travel, lodging, and meal expenses.
Answer: A
Commentary: According to the AMA Code of Ethics Opinion, individual gifts of minimal value from pharmaceutical representatives to physicians are permissible, so long as the gifts are related to the physician’s work. It is not acceptable for physicians to request free pharmaceuticals for personal use or use by family members. Subsidies to underwrite the costs of continuing medical education are permissible when they are accepted by the conference’s sponsor and are not provided directly to the physician. It is acceptable for faculty at conferences to accept reasonable honoraria and reimbursement for travel, lodging, and meal expenses.
- A 50-year-old administrative assistant presents with low back pain. After taking her history, performing a physical examination, and reviewing her imaging studies, you determine that her pain is likely discogenic. She asks if there are any positions which would be better for her back while at work. Which position exerts the most pressure on the lumbar discs?
(a) Standing erect
(b) Standing erect and flexed forward
(c) Seated in a chair
(d) Seated in a chair and flexed forward
Answer: D
Commentary: Nachemson measured the relative pressure changes within the third lumbar disc with changes of position. Standing erect was the reference position and pressures decreased with lying supine and increased in the seated position. Seated and flexed forward further increased disc pressures. Several other positions were evaluated.
- Which statement is TRUE when comparing a functional restoration program to active individual therapy for chronic low back pain?
(a) Flexibility is increased to a greater extent with active individual therapy program.
(b) Pain intensity is reduced to a greater extent with active individual therapy.
(c) Functional restoration programs have a greater effect on flexibility and pain than do active individual therapy programs.
(d) Functional restoration programs produce greater improvements in endurance than do active individual therapy programs.
Answer: D
Commentary: Functional restoration programs produce a greater improvement in endurance, but no differences are noted between functional restoration programs and active individual therapy programs.
- 20-year-old college basketball player was seen in the training room after practice. He reports “twisting” his ankle while attempting to rebound a missed shot. On further questioning, he describes an inversion-type injury. He has swelling along the lateral aspect of the ankle. He is tender to palpation over the anterior talofibular ligament and calcaneofibular ligament as well as the 5th metatarsal base. He has no pain over the lateral or medial malleolus or proximally over the fibular head. You obtain plain radiographs, which show a nondisplaced avulsion fracture of the 5th metatarsal base. What is the next step in treating this individual?
(a) Provide clearance for return to playing basketball without immobilization.
(b) Obtain a surgical consult for possible screw or pin fixation.
(c) Recommend immobilization with a postoperative shoe for 1-2 weeks.
(d) Prescribe non-weight bearing with crutches for 6-8 weeks or until radiographically verified healing occurs.
Answer: C
Commentary: Nondisplaced or minimally displaced avulsion fractures of the 5th metatarsal base can occur with inversion ankle sprains. These generally are treated nonsurgically with a short course of immobilization (1-2 weeks) with a postoperative shoe or a short walking boot. Displaced fractures may require screw or pin fixation. It is important to differentiate an avulsion fracture of the base from a fracture of the metaphyseal-diaphyseal junction (Jones fracture), since treatment is different.
- You have evaluated a 50 year old man for lower extremity muscle pain and discomfort. The pain increases with jogging. You have reviewed his medications, which include simvastatin (Zocor). Baseline laboratory studies were normal 6 months ago. The creatine kinase level is mildly elevated at 185 units/L. The next most appropriate step is to
(a) check thyroid stimulating hormone levels.
(b) order electrodiagnostic study.
(c) switch to a different class of lipid lowering medications.
(d) continue the medication with close monitoring of the creatine kinase levels.
(d)
If a patient on a statin presents with muscle complaints, with or without creatine kinase (CK) elevations, other causes, including strenuous exercise or hypothyroidism, must be considered. If a patient initially has normal or only moderately elevated CK levels, the statin may be continued with close monitoring of symptoms and CK levels; however, if symptoms become intolerable or if the CK level is 10 times the upper limits of normal (ULN) or greater, the statin must be discontinued. If myositis is present or strongly suspected, the statin should be discontinued immediately. Early diagnosis and treatment of symptomatic CK elevations, including cessation of drug therapies potentially related to myopathy, can prevent progression to rhabdomyolysis. Symptoms and CK levels should resolve completely before reinitiating therapy, at a lower dose if possible. Asymptomatic elevation of CK at 10 times the ULN or greater should also prompt discontinuation of the statin. Consideration should also be given to discontinuation of statins before events that may exacerbate muscle injury, such as surgical procedures or extreme physical exertion.Needle electromyography abnormalities are uncommon in statin-induced myopathy. An EMG does not exclude statin-induced myopathy, because it primarily affects type 2 muscle fibers. Electromyography is not routinely performed or recommended unless the clinical presentation does not improve with statin discontinuation or if concern exists about other diagnoses.
- In assisting patients returning to their previous level of work, work hardening programs can achieve return-to-work rates of
(a) less than 25%.
(b) 25%–49%.
(c) 50%–75%.
(d) more than 75%.
(d)
Return-to-work rates of 77% can be achieved with work hardening programs. Poor outcome was associated with an increased number of treatments before the program, an increased length of time off from work; the patient’s having lower satisfaction with the program, and a lawyer being involved in the case.
. If a man injures his low back while on the job and is off work for 6 months, then the chance that he will return to work is
(a) 25%.
(b) 35%.
(c) 50%.
(d) 75%.
(c)
There is about a 50% chance of return to work when a worker who injures his low back on the job is off work for 6 months. The rate drops to 25% when the worker is off for 1 year, and is minimal is he is off for 2 years.
- What percentage of patients with whiplash-associated disorders develop chronic symptoms?
(a) less than 25%
(b) 25%–49%
(c) 50%–75%
(d) more than 75%
(b)
Up to 33% of individuals with symptoms from whiplash-associated disorders have chronic symptoms. Symptoms associated with whiplash-associated disorders include neck pain, arm pain, paresthesias, temporomandibular joint dysfunction, headache, dizziness, visual disturbances, and difficulty with memory and concentration.
Ref: Panagos A, Sable AW, Zuhosky JP, Irwin RW, Sullivan WJ, and Foye PM. Industrial medicine and acute musculoskeletal rehabilitation. 1. Diagnostic testing in industrial and acute musculoskeletal injuries. Arch Phys Med Rehabil 2007;88(3 Suppl):S5.
- Which factor is most likely to be associated with the development of a work-related, repetitive-strain injury?
(a) Normal body weight
(b) Warm work environment
(c) Younger age
(d) Rheumatoid arthritis
(d)
Risk factors associated with a repetitive strain injury include obesity, cold temperature, older age, diabetes, smoking, pregnancy, rheumatoid arthritis, and psychologic stress.
Ref: Panagos A, Sable AW, Zuhosky JP, Irwin RW, Sullivan WJ, Foye PM. Industrial medicine and acute musculoskeletal rehabilitation. 1. Diagnostic testing in industrial and acute musculoskeletal injuries. Arch Phys Med Rehabil 2007;88(3 Suppl):S5.
- A 17 year old woman was involved in a motor vehicle crash 4 months ago. She suffered a shoulder dislocation. Electromyographic studies have confirmed a brachial plexus injury to her posterior cord and indicate nerve continuity (Sunderland 2 injury). Although she has completed 4 weeks of occupational therapy, she has had no improvement in her strength from baseline. Your next step would be to
(a) reassure the patient and continue to monitor for improvement.
(b) continue occupational therapy for 4 additional weeks.
(c) initiate neuromuscular electrical stimulation to the affected muscles.
(d) refer the patient to neurosurgery for exploratory surgery.
(d)
With closed nerve injury as described, early active and passive range of motion (ROM) therapy of the affected joints is begun. The value of electrical stimulation is uncertain. The purpose of surgical repair is to improve peripheral nerve recovery and eventual function. Therefore, surgery is done when the patient has an incomplete loss of function but shows no improvement over several weeks, or no return of function at 2 months for peripheral nerve and 4 months for a brachial plexus injury. Findings at the time of surgery help establish a prognosis. However, the chances of successful surgical repair begin to decline by 6 months after the injury. By 18–24 months, the denervated muscles usually are replaced by fatty connective tissue, making functional recovery impossible.
Which nerve does NOT innervate the outer annulus of the lumbar intervertebral disc?
(a) sinuvertebral nerve
(b) lumbar medial branches of dorsal rami
(c) grey rami communicantes
(d) lumbar ventral rami
(b)
The lumbar medial branches of the dorsal rami supply the facet joints as well as the deep paraspinals, such as the rotators and multifidi. The sinuvertebral nerve, also termed the recurrent meningeal nerve is the primary source of nerve supply to the lumbar intervertebral disc. It is derived from portions of the ventral rami and grey rami communicantes (sympathetic input). Accordingly, the referral pattern seen with intrinsic disc pain is vague and diffuse.
- A 22-year-old female gymnast with chronic low back pain is diagnosed with spondylolysis of the right L5 pars interarticularis. Spondylolisthesis is not identified on plain x-rays. What is the best test to determine fracture healing?
(a) magnetic resonance imaging
(b) single photon emission computed tomography
(c) computed tomography scan
(d) flexion and extension lateral x-rays
(c)
Computed tomography (CT) scans with thin cuts through the area of the pars interarticularis can identify the healing pattern of a pars stress fracture.
Ref: Standaert CJ, Herring SA. Expert opinion and controversies in sports and musculoskeletal medicine: the diagnosis and treatment of spondylolysis in adolescent athletes. Arch Phys Med Rehabil. 2007. Apr;88(4):537-40.
- Which factor increases the risk for long-term symptoms after a whiplash-type injury?
(a) Male gender
(b) Eastern European descent
(c) Preexisting hyperlordosis of cervical spine
(d) Presence of radiating pain into the limb
(d)
Risk factors for chronic whiplash-associated pain include presence of preexisting degenerative disc disease, preexisting loss of cervical lordosis, female gender, awkward head position at time of impact, presence of radiating pain into upper limbs, and prior history of headache. A famous Lithuanian study showed no incidence of long-term whiplash pain in a country that had no compensation system for whiplash.
Ref: Seroussi RE, Ferrari R. Curve/countercurve: Whiplash. SpineLine 2001:12-9.
You see the significant other of a close friend in your office for knee pain. As part of her past medical history you note that she has a congenital heart defect. She says she has not yet told your friend that she has this condition. You decide to tell your friend about her congenital heart defect even though the patient did not give you permission to do so. What penalty do you face for knowingly disclosing individually identifiable health information, which is in violation of HIPAA rules?
(a) $50,000 and up to 1year of imprisonment
(b) No penalty
(c) $250,000 and up to 10 years imprisonment
(d) $100,000 and up to 5 years imprisonment
(a)
A person who knowingly discloses individually identifiable health information in violation of HIPAA faces a fine of $50,000 and up to a 1-year imprisonment. The criminal penalties increase to $100,000 and up to 5 years imprisonment if the wrongful conduct involves false pretenses, and to $250,000 and up to 10 years imprisonment if the wrongful conduct involves the intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or malicious harm.
- Which route of epidural steroid administration is most likely to deliver steroid to the junction of the posterior disc and anterior dura?
(a) Transforaminal
(b) Caudal with catheter
(c) Interlaminar
(d) Caudal
(a)
The subpedicular transforaminal route of epidural steroid delivery places the needle at the anterior portion of the intervertebral foramen. The retroneural route of delivery purposefully terminates needle placement at the posterior edge of the intervertebral foramen to avoid injuring radicular vasculature. The caudal and interlaminar approaches are of limited utility in delivering steroid anteriorly due to raphe within the epidural space.
Ref: Irwin RW, Zuhosky JP, Sullivan WJ, et al. Interventional procedures for work-related lumbar spine conditions. Arch Phys Med Rehabil 2007;88(Suppl):S22-3.
Under the Health Insurance Portability and Accountability Act (HIPAA) Protected Health Information is data that
(a) a physician can withhold from a patient.
(b) a patient’s job supervisor can obtain from a physician.
(c) can be used to identify a patient.
(d) can be shared with family without permission.
(c)
Protected Health Information includes individually identifiable health information. This is information, including demographic data, that relates to any of the following particulars: the individual’s past, present or future physical or mental health or condition; the provision of health care to the individual; or the past, present, or future payment for the provision of health care to the individual. It can also be information that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number).
- Which statement describes the natural history of lumbar spinal stenosis (LSS)?
(a) The majority of individuals with LSS will develop focal weakness.
(b) Of patients treated nonsurgically, 25%–50% have satisfactory outcomes.
(c) Ambulation worsens in the majority of individuals with LSS.
(d) Early surgery improves long-term outcome.
(b)
The natural history of spinal stenosis is generally benign. While decompressive surgery achieves satisfactory results in the great majority of individuals, the difference in outcomes with their nonsurgical cohorts becomes narrower with time.
- In 2003, which diagnosis-related group (DRG) had the most admissions to inpatient rehabilitation facilities?
(a) Stroke
(b) Unilateral joint replacement in a lower extremity
(c) Amputation for circulatory disorders except upper limb and toe
(d) Hip or pelvis fracture
(b)
In fiscal year 2003, the number of admissions to an inpatient rehabilitation facility with the diagnosis related group unilateral joint replacement in a lower extremity was 124,754, stroke was 54,433, amputation for circulatory disorders except upper limb and toe was 7,200, and hip or pelvis fracture was 5,863.
Ref: US Government Accountability Office. Medicare: more specific diagnoses needed to classify inpatient rehabilitation facilities. April 2005. Report GAO-05-366. Available at: http://www.gao.gov/new.items/d05366.pdf. Accessed July 4, 2007.
- You are called onto a football field immediately after a defensive player involved in a spearheading tackle complains of neck pain and right greater than left arm tingling. What should be the next step?
(a) Call for an ambulance and stabilize the neck.
(b) Remove the athlete’s football helmet and palpate for any neck tenderness.
(c) Return the athlete to the game if his strength exam is normal.
(d) Walk the athlete to the locker room and perform a thorough neurologic examination.
A telltale sign of cervical cord involvement is bilateral symptoms. In this case, the athlete should be treated as having a potential spinal cord injury and should have his cervical spine immobilized. The football helmet should not be removed, since the cervical spine may fall into extension in the act of removing the helmet. If the airway needs to be accessed, then the face guards should be removed using special equipment. If the athlete suffered and recovered from a temporary “stinger,” involving 1 limb, he may return to play as long as his neurologic examination is normal.
- A 42-year-old car mechanic with a 3-week history of low back pain and lower limb pain after lifting equipment at work is referred to you for management. He has been taking ibuprofen 800mg 4 times daily without improvement. He is unable to flex through the lumbar spine or sit without pain. Your recommendations to his employer regarding work include
(a) modified duty to allow no repetitive twisting or bending and no push/pull heavier than 20 lbs.
(b) return to sedentary work 8 hours daily for 1 week, and no push/pull heavier than 10 lbs.
(c) light duty to include no pushing/pulling, or lifting more than 25 lbs for 1 month.
(d) remain off work until lumbar flexion, sitting, and lifting are no longer painful.
Returning the employee to modified duty that fits the impairment and avoids provocative activities is important from several aspects. One, behavioral management with the employee allows early goals to be set, so that the employee can work with restrictions. It also establishes that simply being off work until pain free is not always a logical goal. Second, the employer can fully understand the employee’s capabilities during recovery. This management approach hones in on the employer to comply with the restrictions. Third, starting with reasonable restrictions allows the physician to guide the employee back to the work place by making adjustments as the worker’s rehabilitation progresses.
- A 55-year-old paramedic is under your care for a work-related shoulder injury. She has completed physical therapy, no longer requires pain medications, and wants to return to work. She does not have full shoulder abduction and has some pain with overhead activities. Ideally, you recommend
(a) return to work without restrictions.
(b) work conditioning for 4 weeks.
(c) a week of work hardening.
(d) functional capacity evaluation.
(d) The paramedic has a high demand job. A functional capacity evaluation would best determine the employee’s ability to return to her job. If deficits are noted, work hardening over a period of weeks will best ensure return to work. Work hardening for 1 week may not be sufficient. Work conditioning enhances aerobic fitness and conditioning but is not job specific. The paramedic is at high risk for recurrent injury. Returning the employee to work without testing the her ability to perform her job duties may precipitate premature return and reinjury.
- An 18-year-old, right-handed hockey player presents to you after experiencing 3 right shoulder anterior dislocations in the prior season after falls on ice. Magnetic resonance imaging shows supraspinatus tendonitis but no other lesions or tears. After 6 sessions of physical therapy, he is pain free. He has been invited to play professionally in 6 months. What is your next recommendation?
(a) Tell him that he will likely dislocate again and that he should relocate the shoulder by forcefully pushing the anterior shoulder against a wall.
(b) Refer him to a surgeon to consider shoulder stabilization surgery.
(c) Tell him he should not return to any sports because of his increased chance of dislocating again.
(d) Stress the importance of compliance with his home exercise program.
B
Recurrent dislocations should be treated with surgery at some point if the athlete would like to return to contact sports. Various anterior shoulder dislocation techniques that can be applied to reduce the shoulder, most by external rotation of the shoulder or by using gravity.
- [ITEM WAS NOT SCORED ON 2007 SAE-R]
You have evaluated a 50-year-old man for lower extremity muscle pain and discomfort. The pain increases with jogging. You have reviewed his medications, which include simvastatin (Zocor). Baseline laboratory studies were normal 6 months ago. The creatine kinase level is mildly elevated at 185 units/L. The next most appropriate step is to
(a) discontinue the medication and check creatinine and thyroid stimulating hormone levels.
(b) order electrodiagnostic study.
(c) switch to a different class of lipid lowering medications.
(d) continue the medication with close monitoring of the creatine kinase levels.
(d) If a patient on a statin presents with muscle complaints, with or without creatine kinase (CK) elevations, other causes, including strenuous exercise or hypothyroidism, must be considered. If a patient initially has normal or only moderately elevated CK levels, the statin may be continued with close monitoring of symptoms and CK levels; however, if symptoms become intolerable or if the CK level is 10 times the upper limits of normal (ULN) or greater, the statin must be discontinued. If myositis is present or strongly suspected, the statin should be discontinued immediately. Early diagnosis and treatment of symptomatic CK elevations, including cessation of drug therapies potentially related to myopathy, can prevent progression to rhabdomyolysis. Symptoms and CK levels should resolve completely before reinitiating therapy, at a lower dose if possible. Asymptomatic elevation of CK at 10 times the ULN or greater should also prompt discontinuation of the statin. Consideration should also be given to discontinuation of statins before events that may exacerbate muscle injury, such as surgical procedures or extreme physical exertion.
Needle electromyography (EMG) abnormalities are uncommon in statin-induced myopathy. An EMG does not exclude statin-induced myopathy, because it primarily affects type 2 muscle fibers. Electromyography is not routinely performed or recommended unless the clinical presentation does not improve with statin discontinuation or if concern exists about other diagnoses.
- Under the prospective payment system for inpatient rehabilitation facilities, which item is used in assigning a patient to a case-mix group?
(a) Mini Mental Status Examination
(b) Disability Rating Scale
(c) Previous hospitalization
(d) FIM instrument motor score
D
The prospective payment system for inpatient rehabilitation facilities requires that all patients admitted for inpatient rehabilitation be assigned to an impairment group code category. Payment to the rehabilitation facility is further determined by the patient’s subclassification into a case-mix group. The FIM instrument motor score is used to help determine the case-mix group designation under the prospective payment system for inpatient rehabilitation facilities. None of the other options listed are used in this process.
- The interdisciplinary approach to patient care emphasizes
(a) common patient and team goals.
(b) discipline-specific goals.
(c) concentration on specific clinical problems.
(d) treatment by multiple team members.
A
The interdisciplinary approach to patient care emphasizes common patient and team goals rather than discipline-specific goals. The patient and family members should be included in the goal setting process. All team members must work in a collaborative way to facilitate achievement of goals. Team members must have an appreciation for all the issues that affect the patient rather than focusing on an isolated problem. Team communication is essential at all points in the rehabilitation process, not just when problems occur.
A case manager comes to your office accompanying the injured worker you are managing. The front desk person asks if you will see the case manager with the patient. You respond that
(a) case managers inhibit patient care and you don’t wish to speak with them.
(b) as requested by the patient you will see the case manager following the interview and examination.
(c) you will speak with the case manager after the patient signs a release of information.
(d) the case manager should always be present at the time of the patient’s interview and examination despite the patient’s request to avoid the case manager.
B
Case managers are shown to be beneficial liaisons between the physician and workers compensation carrier and their presence facilitates patient care. To be treated as a workers compensation case, the patient must give the carrier full access to his/her medical record. The employee treated under workers compensation cannot restrict the access of the case manager to the physician; however, discussions with the case manger should be done in the environment that the patient requests.
The purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to
(a) ensure that a patient’s medical record is available to health care providers as directed by the patient.
(b) allow qualified physicians access to the patient’s medical record.
(c) allow a lawyer access to a medical record only if litigation is pending.
(d) prohibit the release of confidential health information to insurance carriers.
AThe purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to ensure that a patient’s medical record remains private, but is available to health care providers as directed by the patient. A non-treating physician, lawyer, or insurance company may have access to the record with written authorization by the patient or guardian. There are no stipulations about a physician’s qualifications with regards to medical information access.
(a) Office for Civil Rights-HIPAA Privacy. Incidental uses and disclosures. Revised April 2003. [cited 2006 July 13] Available from URL: http://www.hhs.gov/ocr/hipaa/guidelines/incidentalud.pdf
A 55-year-old long-distance truck driver is recovering from a work related low back injury that occurred during lifting. The worker has completed 2 weeks of physical therapy and continues to have low back pain, lower extremity pain, and paresthesias. The employer calls you and is upset that you have restricted the worker from truck driving during the treatment phase, citing that “driving is sedentary work.” You recommend that the driver refrain from truck driving because
(a) a minimum of 4 weeks of physical therapy will be necessary to facilitate recovery.
(b) low back pain has been found to be more frequent in people exposed to whole body vibration.
(c) workers with low back pain should not sit while symptoms of radiculopathy are present.
(d) the employer is unlikely to follow the restrictions you recommend
B
Whole body-vibration is associated with increased frequency of low back pain. Some studies have found a correlation between increased frequency of disc protrusion and occupational driving. The exposure to vibration will likely facilitate continued symptoms in this worker, and relative rest is indicated during the initial stages of recovery. There is no predetermined length of physical therapy that is associated with recovery. Workers with low back pain and leg pain must learn to sit without increasing symptoms. Complete avoidance will not necessarily improve recovery and is not practical. The driver can likely perform some duties with restrictions. The employer has the responsibility to provide a job that meets the restrictions set by the physician. If the employer is unable to provide a job with these restrictions then the employee must remain off work.
To allow pronation of the foot, which 2 joints must have their axis of rotation in parallel?
(a) Lisfranc and talonavicular
(b) Subtalar and calcanocuboid
(c) Talocrural and subtalar
(d) Talonavicular and calcaneocuboid
D
The transverse tarsal joint, namely the talonavicular and calcaneocuboid joints, must have their joint axes in parallel to allow for a flexible midfoot and pronation. If the axes intersect, the midfoot becomes rigid, which enables proper supination.
A 17-year-old female was involved in a motor vehicle crash 4 months ago. She sustained a shoulder dislocation. Electromyographic studies have confirmed a brachial plexus injury to her posterior cord and indicate nerve continuity. Although she has completed 4 weeks of occupational therapy, she has had no improvement in her strength from baseline. Your next step would be to
(a) reassure the patient and continue to monitor for improvement.
(b) continue occupational therapy for 4 additional weeks.
(c) initiate neuromuscular electrical stimulation to the affected muscles.
(d) refer her to neurosurgery for exploratory surgery.
D
With closed nerve injury as described, early active and passive range of motion exercise of affected joints is begun. The value of electrical stimulation is uncertain. Surgery is done when there is an incomplete loss of function but no improvement over several weeks or no return of function at 2 months for peripheral nerve and 4 months for a brachial plexus injury. The purpose of surgical repair is to improve peripheral nerve recovery and eventual function. Findings at the time of surgery help establish a prognosis. However, the chances of successful surgical repair begin to decline by 6 months after the injury. By 18 to 24 months, the denervated muscles usually are replaced by fatty connective tissue, making functional recovery impossible.
Which statement describes the chronic-pain concept of “central sensitization”?
(a) The evoked response of A-delta fibers to subsequent input is amplified.
(b) The influx of sodium is fundamental to electrical signaling and subsequent generation of action potentials and excitatory postsynaptic potentials.
(c) A complex set of activation-dependent post-translational changes occurs at the dorsal horn, brainstem, and higher cerebral sites.
(d) The so-called “inflammatory soup,” rich in algesic substances, causes a lowering of threshold for activation and subsequent evoked pain.
C
Central sensitization is a complex set of activation dependent post-translational changes occurring at the dorsal horn, brainstem, and higher cerebral sites that sensitizes the central nervous system to further perception of pain. Wind-up is an amplified evoked response to repeated afferent inputs at the level of the dorsal horn.
When using local steroid injections in patients with tendinopathies
(a) injection into the tendon substance is optimal.
(b) minimum interval between injections is 2 weeks.
(c) select the finest needle that will reach the area.
(d) early postinjection local anesthesia is a complication.
C
It is advisable to select the finest needle that will reach the area. The injection should be peritendinous with avoidance of the tendon to prevent rupture. The minimum interval between injections should be at least 6 weeks. Early postinjection local anesthesia is not a complication of steroids, but it will occur if local anesthetic is mixed with the steroid.
The activity established as most predictive of developing a low back disorder is
(a) carrying an object at an increased horizontal distance from the body.
(b) lifting an object repeatedly at 20% less than the individual’s maximum lift capacity.
(c) repetitive sit-to-stand transitions with a weighted back pack.
(d) bending at knees rather than at the waist to lift an object.
A
The work by Marras and colleagues showed that increasing the horizontal distance from the trunk of an object being carried increased the risk of developing a low back disorder. This increase in distance increased the forces consistently on the anterior column of the spine. Although the other options can all place the worker at risk for a low back injury, only the increased carrying distance from the trunk has been shown to be the most predictive of a low back injury.
Which term describes a maladaptive pattern of drug use marked by increasing doses to achieve a similar pain relieving effect and a withdrawal syndrome?
(a) Dependence
(b) Addiction
(c) Craving
(d) Tolerance
A
Dependence is a maladaptive pattern of drug use marked by tolerance and a drug-class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood levels of drug, or administration of an antagonist. Tolerance is a state of adaptation in which exposure to a drug induces changes that result in diminution of 1 or more of the drug’s effects over time. Addiction is a chronic biopsychosocial disease characterized by impaired control over drug use, compulsive use, continued use despite harm, and craving.
If the L3 and L4 medial branches of the dorsal rami are ablated, the patient will experience blocked afferents from the
(a) L5-S1 facet joint.
(b) L4-5 facet joint.
(c) L3-4 facet joint.
(d) L2-3 facet joint.
B
The medial branches of the dorsal rami supply innervation to the facet joints and the deep paraspinals, namely the segmental multifidi and rotators. The sacral multifidi are innervated by the sacral (rather than the lumbar) dorsal rami. Each lumbar medial branch innervates the facet joint at and below its derivation. The L4-5 facet joint is innervated by the L3 and L4 medial branches, derived from the L3 and L4 nerve roots.
In order to appropriately follow Medicare regulations for teaching physicians, when caring for a patient with a resident physician, the attending physician must
(a) review the chart and personally document his/her level of involvement in patient care, separate from documentation performed by the resident.
(b) examine the patient with the resident and co-sign the resident note.
(c) examine the patient and review the resident’s medical record documentation.
(d) examine the patient, review the resident’s documentation, and personally document involvement in the history, exam, and medical decision-making.
D
) In order to appropriately follow Medicare regulations for teaching physicians, when caring for a patient with a resident physician, the attending physician must see the patient, review the medical record documentation of the resident, and personally document involvement in key aspects of the history, exam, and medical decision-making. Documentation from the resident alone does not confirm the level of attending physician involvement. The attending physician documentation combined with the resident documentation can be used to determine the level of care provided and the appropriate level of billing.
Which spinal level has the greatest depth of posterior epidural space?
(a) C3-4
(b) C4-5
(c) C5-6
(d) C6-7
C
he C6-7 and C7-T1 epidural levels have the greatest amount of space. Interlaminar epidural injections should be performed with caution in the spaces that have a smaller diameter, such as those at stenotic levels or high cervical levels. Practitioners should also be aware that the ligamentum flavum may have defects in a high percentage of individuals.
Which condition is a cumulative trauma disorder that has been associated with intensive computer use?
(a) Herniated thoracic disc
(b) Shoulder adhesive capsulitis
(c) Post-traumatic stress syndrome
(d) Cervical myofascial pain
D
The United States Department of Labor has determined that computer work is associated with a significant number of musculoskeletal disorders, many of which are considered cumulative trauma disorders. Examples include cervical and thoracic myofascial pain, rotator cuff tendonitis, medial and lateral epicondylitis, de Quervain tenosynovitis, and carpal tunnel syndrome.
. Professionalism is the basis of medicine’s contract with society. Which item is a fundamental principle of medical professionalism?
(a) Social justice
(b) Physician paternalism
(c) Patient disclosure
(d) Free enterprise
A
According to the Charter on Medical Professionalism, there are 3 fundamental principles of medical professionalism. They are (1) the primacy of patient welfare, (2) patient autonomy, and (3) social justice.
Practice-based learning and improvement is considered by the Accreditation Council of Graduate Medical Education (ACGME) to be an aspect of medical practice in which all physicians need to achieve and maintain competency. Which characteristic is NOT a key aspect of practice-based learning and improvement?
(a) The ability to locate, appraise, and assimilate evidence from scientific studies related to their clinical practice
(b) The ability to access and use information technology to support their own education
(c) The ability to apply knowledge of study designs and statistical methods to the appraisal of medical literature
(d) The ability to advocate for quality patient care and assist patients in dealing with system complexities
D
All of the options listed are key aspects of practice-based learning and improvement, with the exception of the ability to advocate for quality patient care and assist patients in dealing with system complexities. This statement is a key aspect of systems-based practice as defined by the Accreditation Council of Graduate Medical Education.
Which treatment has NOT been shown to improve epicondylitis?
(a) Low intensity laser irradiation
(b) Wrist extension strengthening exercises
(c) Acupuncture
(d) Extracorporeal shock-wave therapy
A
Wrist strengthening, acupuncture, and shock wave therapy all help in the treatment of epicondylitis. However, low intensity laser treatment is not proven beneficial.
