Pain Test Flashcards by B -

Which if the following drugs are Schedule II agents?
Levophanol
Codeine
Oxycodone
Hydrocodone
a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

B✔
Codeine is a Schedule V drug
Levophanol, Oxycodone, and Hydrocodone areSchedule II drugs
Hydrocodone recently change from ScheduleIII to II drug October 2014.

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Which of these statements are true about opioid metabolism and clearance?
Normeperidine toxicity occurs only in patients with decreased creatinine clearances
Morphine is metabolized to Dextromathorphan, which is an NMDA antagonist
Morphine-3-Glucuronide can accumulate in patients with decreased creatinine clearance and cause sedation and respiratory depression.
Myoclonus can occur acutely after continuous administration of meperidine because of accumulation of normeperidine.
a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

.B? 4 is true as well
Dextromathorphan is an NMDA antagonist. – Dextromethorphan is an antitussive found in many cough medications

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Methadone
The d-isomer is an NMDA receptor antagonist
The l-isomer ia a mu opioid agonist
Is a Schedule II agent.
Accumulates in renal failure
a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

BX
A✔
Methadone unlike morphine is metabolized through N-demethylation by the liver cytochrome P-450 enzyme (CYP1A2), caution in patients receiving multiple medications, specifically antivirals and antibiotics.
Excreted exclusively in the feces and can be given in patient with renal dysfunction

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With regard to opiate receptors, which of the statements are true?
At present, there are three principal opiate receptors delta, kappa, and mu, and the actions of agonists_all three are reversed by naloxone.
The mu opioid receptor has been isolated, cloned, and characterized, and has been shown to be a G protein that acts to hyperpolarize the cell membrane
The common opiate agonists, such as fentanyl, morphine, and sufentanil, exert their action upon the opioid receptor.
The drug, buprenorphine, binds to receptors as follows delta, kappa, mu

a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

EX
A✔
Opioids have been proposed to inhibit neurotransmitter release by inhibiting calcium entry, by enhancing outward movement of potassium ions, or by inhibiting adenylate cyclase (AC), the enzyme which converts adenosine triphosphate (ATP) to cyclic adenosine monophosphate (cAMP).

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Which of the following statements are generally true about the mechanisms of action of drugs classified as “NSAIDs”?
Serve to inhibit the synthesis of arachidonic acid metabolites.
Action has been demonstrated within the spinal cord as well as at s peripheral site.
COX-2 inhibitors have the same risk of cardiovascular complications as non-selective agents.
Close correlation between “anti- inflammatory” activity of NSAID and “analgesic” potency.
a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

C✔?

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It has been shown that epidural clonidine has analgesic actions. Which of the following statements best characterize this action?
Clonidine exert its analgesic effects by an interaction with an alpha 2 receptor that is antagonized by naloxone.
The spinal alpha 2 effect is mediated by a receptor that is coupled by G protein to a K+ channel that serves to increase K+ conductance. This leads to a hyperpolarization of the membrane.
Transdermal clonidine (TTS) produces more significant hypotension than does epidural clonidine
Spinally delivered clonidine exerts its hypotensive effects by redistribution to supraspinal systems that result in a reduction in preganglionic outflow.
a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

D✔

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An isolated C-5 nerve root lesion typically affects the following muscles:
a. Deltoid, Brachialis, Biceps
b. Triceps, Flexor Carpi Ulnaris, Biceps
c. Deltoid, Supraspinatus, Infraspinatus
d. Deltoid, Brachialis, Pronator teres
e. All of the above

A✔

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A posterior herniated nucleus pulposus at the L4-5 level most frequently impinges upon the ___ nerve root.
a. L3
b. L4
c. L5
d. S1
e. None of the above

B✔

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Fifteen minutes after completing a stellate ganglion block using an anterior approach at C-7 using 12ml of 0.25% Bupivacine without epinephrine administered via a 22-G, 1.5 inch needle, your patient complains of difficulty breathing. Oxygen saturation on room is 95% and heart rate is 72 beats per minute. The most likely diagnosis is:
a. Pneumothorax
b. Recurrent laryngeal nerve block
c. Epidural injection of local anesthetic
d. Unilateral phrenic nerve block
e. None of the above

D✔

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Which of the following intra-abdominal organs is innervated by the celiac plexus?
Pancreas
Liver
Gallbladder
Omentum
a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

E✔

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______ is proportional to the terminal elimination half-life of an opioid after administration into the lumbar epidural space.
a. pKa
b. Hydrophilicity
c. Hydrophobicity
d. Molecular weight
e. Reynold’s number

BX
bioavailability of opioids in the cerebrospinal fluid and epidural space is determined primarily by their hydrophobicity, with less hydrophobic drugs having greater bioavailability.

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Which of the following opioid- related side effects are similar incidence regardless of whether the opioids are administered via an epidural or systemic route?
Respiratory depression
Pruritus
Nausea and Vomiting
Urinary retention
a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

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With respect to brachial plexus avulsion, which statements are true?
CT myleography can be used to demonstrate the presence of pseudomeningoceles.
DREZ lesioning is the treatment of choice
Avulsion is associated with increased spontaneous activity in dorsal horn neurons
DREZ lesioning is not associated with a risk of motor impairment.

a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

C X

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Which statement are true regarding tic douloreux:
Most commonly caused by an aneurysmal compression of Cranial Nerve V by the posterior inferior cerebellar artery
Causes continuous pain most commonly in V1 distribution
Associated with sensory loss in the painful trigeminal distribution
The treatment of choice is sub-occipital craniectomy (Janetta procedure)
a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

B✔

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With respect to multiple myeloma, which is false?
It is best detected by bone scan because of its osteoblastic activity.
Hypercalcemia can occur
It is most often a polyclonal gammopathy of multiple classes of immunoglobulins
Often detected by urine electrophoresis by detection of light chains
a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

EX
C✔
Bone lesions and hypercalcemia (high blood calcium levels) are also often encountered.

Diagnostic Criteria
Clonal plasma cells >10% on bone marrow biopsy or (in any quantity) in a biopsy from other tissues (plasmacytoma)
A monoclonal protein (paraprotein) in either serum or urine (except in cases of true non-secretory myeloma)
Evidence of end-organ damage felt related to the plasma cell disorder (related organ or tissue impairment, ROTI, commonly referred to by the acronym “CRAB”):
HyperCalcemia (corrected calcium >2.75 mmol/L)
Renal insufficiency attributable to myeloma
Anemia (hemoglobin

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Which of these statements are true regarding spinal cord compression due to tumor?
Most often due to hematogenous metastases to bone in breast and lung cancer.
Most cord compression occur in the thoracic cord
Steroid and radiation therapy are useful therapies
Loss of primitive reflexes like the “anal wink” is the earliest sign of compression
a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

E✔

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Which of the following statements about afferent encoding are true?
First pain is mediated by C-fiber nociceptor
First pain is mediated by A-delta nociceptor
The sensation produced by capsaicin is mediated by TRPV receptors on A- delta axons
After local inflammation there is an increase in the spontaneous activity of C- fibers.
a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

C✔

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The wide dynamic range (WDR) neuron is characterized by the following characteristics
Discharge frequency proportional to stimulus intensity, from innocuous to noxious✔
High degree of selectivity for specific modality and organ systems
Displays windup✔
Respond primarily to NMDA receptos antagonists, such as Ketamine and Dextromethorphan ✔
a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

E ✔?

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19. Based on the current thinking about the mechanism of facilitated processing (for example, windup or the "2nd phase of the formation test"), which of the following agents would block the facilitation, but not the primary excitation or first phase?
Clonidine (an alpha 1 agonist )
Ibuprofen (a cyclooxygenase inhibitor)
L-NAME (a nitric oxide synthetase inhibitor)
MK- 801 (an NMDA receptor anatgonist)
Morphine (a mu receptor agonist opioid)
a. Clonidine, Ibuprofen, L-Name
b. Ibuprofen, L-Name, MK-801
c. L-Name, MK 801, Morphine
d. Clonidine, MK 801, Morphine
e. L-Name, MK 801, Morphine

MK-801
L-Name,
Clonidine
morphine 
L- NAME

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All of the following contribute to the mechanism underlying the increased receptor field size after peripheral injury, EXCEPT:
a. Generation of ongoing C fibers activity from the injured dermatome
b. Sensitization of the neurons receiving imput from the injured dermatome
c. Input from collateral projecting from adjacent dermatomes
d. Release of glutamate
e. Sprouting of afferent innervating the adjacent dermatomes

E X

The first major mechanistic insight was that the induction and maintenance of acute activity-dependent central sensitization was dependent on NMDA receptors,379 revealing a key involvement of glutamate and its receptors

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Following nerve injury in humans, there is evidence that components of the pain state may develop a dependency upon sympathetic activity, as evidenced by the reversal of the pain state after sympathetic blockade. This suggests some interaction between sympathetic nervous system and the injured sensory nerve. Which of the following statements best describes our current understanding of the site or mechanism of that interaction?

A. Follow and peripheral nerve injury, there is sprouting of postganglionic sympathetic if efferent into the dorsal root ganglia and into the Neuroma.

B. While injury may cause sympathetic terminal to sprout, there is no physiological evidence that such sprouting affects the spontaneous activity of injured afferents.

C. Injury leads to an increase in sympathetic terminal activity, and this increase in circulating catecholamines accounts for the increased sensory terminal activity

D. Sympathetic blockade actually serves to block transmission in the sympathetic afferent the travels with the sympathetic efferents. It is a blockade of a transmission in these afferent that is in fact accounts for the observed pain relief produced, for example by regional sympathectomies.

E. Peripheral injury lead to an increased sympathetic innervation of spinal dorsal horn, neurons leading to a facilitation of their response to otherwise innocuous stimulation.

A/E ✔?

The key question is how and where does the sympathetic nervous system become coupled to the sensory nervous system to produce the pain observed in the clinical situation? The basic observation must be that activity in the sympathetic nervous system initiates abnormal impulse traffic in sensory neurones that leads to pain perception.

numerous studies demonstrating that peripheral nerve injury leads to sympathetic sprouting in the DRG

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Tactile allodynia is a common component of post nerve injury pain state (causalgia). Based on our current appreciation of the effects produced by nerve injury, which of the following statements describe the mechanism that are believed to account for this allodynia?
Lost of intrinsic modulation by enkephalinergic projections
Sprouting of A-beta afferents from Lamina III into Lamina II✔
Stalk cell degeneration and regeneration into Lamina I
Loss of dorsal horn GABA/ Glycine modulatory neurons✔
a. 1,2,3 only
b. 1,3 only
c. 2,4 only
d. 4 only
e. All are correct

D ?
C✔

Understanding of the peripheral and central mechanisms of the mechanical allodynia has been perceived as follows:

1) increased excitability of peripheral and central terminals and their cell bodies, including local paracrine mechanisms; 2) The reduction in inhibition (disinhibition) in the spinal cord (i.e. the decreased inhibitory activity of GABA/glycinergic interneurons;
3) The reorganization of synaptic connections in the spinal dorsal horn (Aβ-afferents sprout into the superficial layer

The allodynia and hyperalgesia associated with neuropathic pain may be best explained by:

1) the development of spontaneous activity of afferent input 2) the sprouting of large primary efferents (eg. A-beta fibers from lamina 3 into lamina 1 and 2),
3) sprouting of sympathetic efferents into neuromas and dorsal root and ganglion cells,
4) elimination of intrinsic modulatory systems and
5) up regulation of receptors in the dorsal horn which mediate excitatory processes

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Which of the following nerves does NOT exhibit the superior orbital fissure?
a. Ophthalmic division trigeminal
b. Oculolmotor
c. Trochlear
d. Maxillary division trigeminal
e. Abducens

C ?
D✔

Lazy French Tarts Sit Nakedly In Anticipation

The order of the nerves passing through the superior orbital fissure from superior to inferior:

L: lacrimal nerve
F: frontal nerve (a branch of the ophthalmic nerve)
T: trochlear nerve (CN IV)
S: superior division of the oculomotor nerve (CN III)
N: nasociliary nerve (a branch of the ophthalmic nerve)
I: inferior division of the oculomotor nerve (CN III)
A: abducens nerve (CN VI)

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A 66-year-old white male presents with deep-seated pain in the tonsillar area triggered by swallowing. Imaging study should include:
a. Foramen spinosum
b. Foramen lacerum
c. Internal acoustic meatus
d. Jugular foramen
e. Hypoglossal canal

E ?

D✔

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25. Chronic daily headaches is most often associated with: a. Analgesic rebound b. Chronic cluster headache c. Hemicrania continua d. Orgasmic headache e. Transformed migraine

E? E✔ Transformed migraines are chronic (long-lasting), daily headaches that originate from episodic migraine headaches. Most patients who experience transformed migraines have a history of intermittent migraines, usually beginning in childhood or early adolescence. The onset of daily transformed migraine headaches generally occurs in people during their 20s and 30s.

26. All of the following are indomethacin responsive headaches EXCEPT: a. Hemicrania continua ✔ b. Paroxysmal hemicrania ✔ c. Ice pick headache ✔ d. Sexual headache e. Transformed migraine

D ? E ✔ Indomethacin-responsive headache syndromes represent a unique group of primary headache disorders characterized by a prompt and often complete response to indomethacin to the exclusion of other nonsteroidal anti-inflammatory drugs and medications usually effective in treating other primary headache disorders. Because these headache disorders can easily be overlooked in clinical practice, they likely are more common than previously recognized. Indomethacin-responsive headache syndromes can be divided into several distinct categories: a select group of trigeminal-autonomic cephalgias, valsalva-induced headaches, and primary stabbing headache (ice-pick headache or jabs and jolts syndrome). Each category can be differentiated clinically and by the extent to which the individual headache disorders respond to indomethacin. The paroxysmal and continuous hemicranias invariably respond in an absolute manner to indomethacin, whereas valsalva-induced and ice-pick headaches may respond in an equally dramatic, but somewhat less consistent fashion. Hypnic headache recently has been described as another primary headache disorder that may respond to indomethacin.

27. The most commonly involved trigeminal dermatomes and Trigeminal neuralgia are: a. I b. II c. III d. II & III e. I & III

E ? D ✔

28. A 24-year-old female presents with flashing pain lasting 5 to 10 seconds many times daily and the ophthalmic division of the right trigeminal distribution. The most likely diagnosis is: a. Trigeminal neuropathy b. Diabetic Neuropathy c. Multiple Sclerosis d. Raeder's Syndrome e. Cavernous sinus thrombosis

A? C ✔

29. The following plexus involve sensory fibers that transmit nociceptive and Paul says from the uterus and cervix: a. Pudendal nerves b. Pelvic plexus c. Superior hypogastric plexus d. Celiac plexus e. greater and lesser splanchnic nerves

B ✔

30. Which of the following Peripheral nerves are associated with the appropriate nerve root of origin? 1. Ilioinguinal T12-L1 2. Obturator L2-L4 3. Genitofemoral L1-2 4. Iliohypogastric T12- L1 a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

E ✔

31. The most common gynecological cause of chronic pelvic pain is: a. Primary dysmenorrhea b. Endometriosis c. Ovarian remnant syndrome d. Adenomyosis e. Salpingo- oophoritis

B ✔

32. MRI with contrast should be obtained to visualize what pathologic processes? 1. Infections 2. Disk herniatoins 3. Cancer 4. Abnormal CSF Flow a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

B X E✔

33. Features associated with lumbar spine stenosis are: 1. Age> 50 years old 2. Neurogenic claudication 3. Decreased pain with flexion of the spine 4. Loss of proprioception a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A X E ✔ Romberg's test is not a test of cerebellar function, as it is commonly misconstrued. Patients with cerebellar ataxia will, generally, be unable to balance even with the eyes open;[6] therefore, the test cannot proceed beyond the first step and no patient with cerebellar ataxia can correctly be described as Romberg's positive. Rather, Romberg's test is a test of the proprioception receptors and pathways function. A positive Romberg's test has been shown to be 90% sensitive for lumbar spinal stenosis. The Romberg test is a test of the body's sense of positioning (proprioception), which requires healthy functioning of the dorsal columns of the spinal cord

34. Which one of the following statements about pain in multiple sclerosis patient is NOT true? A. it's almost always related to spasticity. B. Central pain has a high incidence. C. Burning pain it's quite common. D. Trigeminal neuralgia may occur in the first division of the trigeminal. ✔ E. Lhermitte's Sign is a painful electric shock sensation going down the spine, often brought on by neck or trunk flexion. ✔

C X Central pain is thus an important symptom in MS (around 30%) and causes much suffering The sign suggests a lesion of the dorsal columns of the cervical cord or of the caudal medulla. Although often considered a classic finding in multiple sclerosis, it can be caused by a number of conditions,

35. The best prophylaxis against development of the phantom limb phenomenon is: a. Therapeutic bombardment of the limb pre-operatively b. Cingulotomy c. A course of steroids intrathecally d. Topiramate pre-op e. Amitriptyline pre-op

E X

36. A patient presents with back pain accompanied by unexplained fever, episodic infection, bloody stool and urine. The history revealed several admissions for similar problems. The nurses' notes indicate the discovery of contaminated syringe in the trash can. One should have a high index of suspicion for: 1. Bordeline personality 2. Factitious disorder 3. Major depression with psychotic features 4. Muchausen Syndrome a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

C X C ✔?

37. Altered patterns of sleep, decreased energy, appetite, and conversation, when found in combination with pain are most likely to indicate: 1. Panic disorder 2. Somatization disorder 3. Malingering 4. Depression a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

D X D✔?

38. Which are features of discography? 1. Manometry of disc pressure on injection 2. Determination of concordant or discordant pain 3. Interpretation of contrast image of injected disc 4. Injection of steroids into disc a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A ✔

39 . Disease states that have been definitely shown to respond to Botulinum toxin Serotype A injection include: 1. Cervical dystonia 2. Headache 3. Spasticity 4. Cervical Myofascial Pain a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A ✔

40. Polymyalgia Rheumatica 1. Is a disease of the young 2. Can be associated with temple arteritis and blindness 3. Is associated with a normal erythrocyte sedimentation rate 4. Is usually very responsive to systemic steroids a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A ? C ✔ Most people who develop polymyalgia rheumatica are older than 65. It rarely affects people younger than 50. Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are linked inflammatory conditions that affect different parts of the body

41. Rheumatoid arthritis is NOT associated with: 1. Ulnar deviation. 2. Carpal tunnel syndrome 3. Swan-neck deformity of the fingers. 4. Heberden's nodes a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

C ? D✔ Carpal tunnel syndrome (CTS) is a common result of the inflammation caused by rheumatoid arthritis. Heberden's nodes are hard or bony swellings that can develop in the distal interphalangeal joints (DIP) (the joints closest to the end of the fingers and toes). They are a sign of osteoarthritis and are caused by formation of osteophytes (calcific spurs) of the articular (joint) cartilage in response to repeated trauma at the joint.

42. Which are true regarding the innervation of the pleura and peritoneurm.? 1. The central diaphragm innervated by the phrenic nerves.. 2. The peripheral diaphragm is innervated by the intercostal nerves. 3. The converge – projection theory explains referred pain.. 4. Pain is referred from the central diaphragm to C6. a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A X A✔? The diaphragm is primarily innervated by the phrenic nerve which is formed from the cervical nerves C3, C4 and C5.While the central portion of the diaphragm sends sensory afferents via the phrenic nerve, the peripheral portions of the diaphragm send sensory afferents via the intercostal (T5-T11) and subcostal nerves (T12).

43. Splanchnic Nerves: 1. Are derived from T5-T12 spinal segments 2. Synapse with the celiac and aorticorneal ganglia. 3. Connect the thoracolumbar outflow to prevertebral ganglia 4. Carry parasympathetic fibers. a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

B X All carry sympathetic fibers except for the pelvic splanchnic nerves, which carry parasympathetic fibers.

44. Fitz- Hugh- Curtis Syndrome: 1. Is associated with pelvic inflammatory disease. 2. Is associated with RUQ tenderness and rebound 3. Can be associated with radiation to the shoulder 4. Is often associated with gonococcal infection . a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A ? E✔

45. Acute cholecystitis is best diagnosed by: 1. HIDA Scan 2. Oral Cholecystography 3. ERCP 4. Ultrasound a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

D ? E ✔ Ultrasound (US) is the preferred initial modality in the investigation of right upper quadrant pain. It is more sensitive than HIDA scintigraphy and CT in the diagnosis of acute cholecystitis, and more readily available MRI is sensitive in the detection of acute cholecystitis, with findings similar to those seen on ultrasound and CT. MR cholangiopancreatography (MRCP) may show an impacted stone in the gallbladder neck or cystic duct

46. Fibromyalgia differs from myofascial pain syndrome in: 1. Having at least 11 tender points 2. Fatigue is more prevalent 3. Sleep disturbance are more prevalent 4. There is a great association with headaches syndromes a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

B X E✔

47. Pain and lateral epicondylitis is commonly precipitated by: a. Fraction of the forearm on the arm by the biceps b. Extension of the wrist c. Extension of the middle finger d. Flexion of the wrist e. Pronation of the forearm

E X B ✔ Lateral epicondylitis is usually precipitated by repetitive contraction of the wrist extensors and is characterized by aching pain that is worsened with activity.

48. Pain afferent fibers from the uterus, lower uterine segment and cervix travel in which of the following nerves? 1. Uterine and cervical plexus 2. Plexus (inferior hypogastric) plexus 3. Middle hypogastric plexus or nerve (hypogastric nerve) 4. Superior hypogastric and aortic plexuses a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A ? E ✔?

49. Pain fibers supplying the vagina travel by which of the following structures? 1. Pelvic plexus 2. Pudendal nerve 3. Uterovaginal plexus 4. Superior hypogastric plexus a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A ? E✔

50. NSAID- use during the third trimester may be associated with: 1. Oliogohydramnios. 2. Increased risk of intracranial hemorrhage. 3. Constriction of the ductus arteriosus . 4. Increased incidence of cardiac defects a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A X A✔ In the third trimester, NSAIDs and aspirin are usually avoided because of significant fetal risks such as renal injury, oligohydramnios, constriction of the ductus arteriosus (with potential for persistent pulmonary hypertension in the newborn), necrotizing enterocolitis, and intracranial hemorrhage.

51. In general, medicines that are safe for lactating mothers are: 1. Highly protein bound 2. Very lipid soluble 3. Largely ionized 4. Low molecular weight a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

B X B✔

52. Which of the following are true? 1. Full term infants habituate to repeated stimuli 2. Premature infants demonstrate sensitization to noxious stimuli 3. Neonates have well developed nociceptive afferent systems 4. Newborns are more sensitive to painful stimuli than adults a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

C ? E

53. Which os the following are true regarding drug pharmacokinetics in the newborn? 1. Albumin levels are lower than in the adult 2. Local anesthetics are less protein bound 3. Drugs have decreased affinity for fetal hemoglobin 4. Drugs free fractions are increased a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

C ? E ✔ protein binding of drugs is lower in newborns than in older children and adults—the result of lower albumin values, the lower affinity of fetal albumin for drugs, and the presence of endogenous compounds, such as bilirubin, that compete for protein binding.

54. The major factor causing poor compliance with medical advice by the elderly is: a. Drug costs b. Race issues c. Number of drugs d. Communications e. Insurance

D ? C ✔

55. Pharmacokinetic changes in the elderly include: 1. Increased volume of distribution 2. Prolonged elimination 3. Increased lipid content 4. Decreased lean body mass a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

C ? E ✔

56. A 39 year old computer entry worker is sent for exam. Findings include weakened thumb pinch, opposition, and abduction. Wrist extension and DTRs are WNL. Likely diagnoses include pathology at which nerve (s)? a. Radial b. Axillary c. Median d. Ulnar e. Lower cord of brachial plexus

C X E ✔

57. A motorcycle rider fell from his Harley. Cervical MRI was negative; he is having trouble with sustained use of his right arm. Exam shows decreased DTR at biceps and branchioradialis, weakness of elbow flexors and wrist extensors. His likely diagnosis includes which of the following? a. Carpal Tunnel Syndrome b. Neuro- foraminal stenosis at C5-6 c. Brachial plexus lower trunk injury d. Lumbar plexus injury e. Brachial plexus upper trunk injury

E X C ✔

58. Referred pain describes a pain which is generally "felt" at different site than the pathology. Which is/ are not characteristic of referred pain? a. Radiation does not follow known spinal segmental pathways b. Referral is toward distal dermatome c. Perception and pathology ipsilateral d. Localization is generally deep. e. Pathology site is tender, not necessarily perceived as pain.

E ✔

59. A 26-year-old woman was in the motor vehicle accident and sustain a cervical flexion extension injury recently. She complains of neck pain and stiffness, and tingling in her right arm. Your exam shows decreased sensation over the right shoulder, decreased biceps reflex and weakness in her forearm flexors. Wrist extensors are intact. Which diagnosis is MOST CONSISTENT with these findings: a. Shoulder impingement syndrome b. Brachial plexus stretch injury c. Brain stem stretch injury d. Cervical radiculopathy at C5 e. Axillary nerve injury

D ✔

60. Which of the following are true? a. The concept of disability refers to an impairment preventing occupational function b. The concept of impairment refers to a handicap that prevent function. c. The concept of handicap refers to an impairment preventing social function d. All of the above e. A & C

D ? A✔

61. Who determines Medicare disability? a. The doctor b. The patient c. The administrative law judge d. A&B e. Any/ all the above, depending on situation

E ? C✔

62. A 36 year old woman complains of numbness in the thumb and dropping things from the right hand. Median nerve entrapment positiveon EMG. Non surgical treatment includes which of the following: a. Wrist Brace b. Wrist Strengthening c. Injection to Median N or carpal tunnel d. Cold laser applied to the wrist e. A,C,D

B X E✔ Wrist splinting in a neutral position at night is recommended. A 1-mL combination of 0.5 mL of lidocaine 1% and 0.5 mL cc of triamcinolone is a common choice for injection in the area around the median nerve at the proximal wrist crease

63. A 45 year old woman with DeQuervain's syndrome requires a brace--- which joints are covered by the brace? a. CMC b. PIP and DIP c. AFO d. MCM and IP e. CMC and MP

B X E✔ Recommended for immobilization of MP and CMC joints, deQuervain's syndrome

64. The following muscles would be expected to be abnormal abnormal in an S1 radiculopathy: a. Iliopsoas b. Quadriceps c. Tibialis anterior d. Tibilias posterior e. Soleus

D X E✔

65. In an radiculopathy, which statements are true? 1. There may be denervation potentials, e.g. fibrillations and positive sharp waves. 2. There are small, polyphasic potentials at minimal voluntary effort. 3. There are large polyphasic potentials at minimal voluntary effort 4. There is a complete interference pattern at maximum voluntary effort. a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A X

66. Which of the following is NOT primarily a Na channel blocker: a. Carbamazepine b. Gabapentin c. Lamotrigine d. Oxcarbazepine e. Valproate

B ? B✔

67. Which of the following might be considered for mood stabilization in a pain patient? 1. CarbamazepineV 2. Valproate V 3. Topiramate V 4. Gabapentin a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A ? E✔

68. The incidence of herniated nucleus pulposus in asymptomatic patients is approximately ___% a. 10 b. 25 c. 37 d. 50 e. 95

A ? B✔

69. The most potent parenteral corticosteroid, on a weight basis, is a. Methylprednisolone (Depomedrol) b. Triamcinolone Acetonide (Kenalog) c. Triamcinolone Diacetate (Aristocort) d. Betamethasone Sod- Phosphate & Betamethasone Acetate (Celestone Soluspan) e. Dexamethasone Acetate (Decadron)

A ? D

70. The Minnesota Multiphasic Personality Inventory (MMPI) can be used to assess: 1. Personality variables 2. Depression 3. Anxiety 4. Functional vs. Organic pain a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A X E✔ Soon after it was developed, the MMPI was used in medical settings to help practitioners distinguish “functional” from “organic” pain, a distinction that is today seen as inadequate and has been replaced with the biopsychosocial approach.

71. The McGill Pain Questionnaire can be used to assess which of the following? 1. Sensory component of pain 2. Patient satisfaction 3. Affective component of pain 4. Patient perception of improvement. a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

D X | B✔

72. T.W. is a 41-year-old high school educated patient complaining of low back pain with some occasional right hip and lower extremity pain. Imaging study shows some minimal degenerative changes but no surgical lesion. Epidural and facet blocks have given limited relief. The patient appears motivated. According to the evidence-based clinical research, his best chance to improve his pain control and function is: 1. Comprehensive multidisciplinary program 2. Implantable therapies 3. Cognitive behavioral therapy plus functional restoration 4. Pharmacological therapy a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

B X E✔

73. Which are true regarding the effect of cognitive and behavioral factors on pain behavior and perception? 1. Operant learning can lead to "conditioned " pain and pain behavior 2. Distraction and selective attention have been shown to decrease the "pain" in response of a nociceptive stimulus 3. Modeling can be affective in altering pain behavior 4. Spousal responses can increase or decrease the perception of pain and/or pain behavior. a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A X

74. What is the correct order of increasing lipophilicity? | a. Morphine

A X A✔

75. Which is true with respect to the development and presence of catheter- associated intrathecal granulomas: a. Symptoms occur suddenly with motor changes and paroxysmal pain without a prodrome b. Occurs at drug concentrations of 10mg/ml or less c. Occurs at morphine doses of 10mg/ 24 hrs or higher d. Etiologically associated with concomitant indolent infection e. Has been reported with Hydromorphone, Baclofen, and Clonidine

A X | C ✔?

76. Ziconotide: 1. Is derived from a snail toxin. 2. Has a narrow therapeutic window 3. Is associated with psychosis and cognitive changes 4. Blocks sodium channels a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A X A✔ Ziconotide acts as a selective N-type voltage-gated calcium channel blocker.

77. Which is true of coxib pharmacology? 1. Beware of patients with sulfa allergies 2. Nephrotoxicity can be caused by COX-1 and COX-2 selective agents. 3. Less GI Bleeding occurs with COX-2 Inhibitors 4. COXIBS can be used for thromboembolic prophylaxis. a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

B X A✔ The selective COX-2 inhibitor celecoxib has a sulfonamide structure and is contraindicated for patients with known sulfa allergy.

78. NSAID gastropathy: 1. Is associated with significant mortality, particularly in the elderly 2. There is no correlation between the degree of symptoms and the extent of gastric disease. 3. Alcohol, caffeine, and smoking predispose to its development. 4. Misoprostol does not prophylaxis against its developement a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

B X | A✔

79. A disc herniation that extends above or below the level of the endplate is referred to as: a. Focal bulge b. Broad- based protrusion c. Herniated annulus fibrosis d. Extrusion e. Synovial Cyst

D ? | D✔

80. Endplate marrow signal changes that are defined as Modic Type 1 are: a. T1 isointense, T2 hypointense b. T1 Hyperintense, T2 Hypointense c. T1 Hypointense, T2 Hypointense d. T1 Hypointense, T2 Hyperintense e. T1 Hyperintense, T2 Hyperintense

D ? | D✔

81. The infraclavicular approach to brachial plexus block is a block anatomically of the ___of the plexus. a. Roots b. Trunks c. Divisions d. Cords e. Peripheral branches

B ? D✔

82. Using Seddon's Classification, list the following nerve injury types from least severe to most severe. a. Neurotmesis; axonotmesis; neurapraxia b. Axonotmesis; neurotmesis; neurapraxia c. Neurapraxia; neurotmesis; axonotmesis d. Axonotmesis; neurapraxia; neurotmesis e. Neurapraxia; axonotmesis; neurotmesis

B ? E ✔ Neuropraxia least severe Axonotmesis – more sevre Neurotmesis –most severe Classification Grade 1: Neuropraxia Conduction disruption with intact axon and preserved supportive structures Prognosis: Normally full recovery in days to weeks without surgical intervention Grade 2: Axonotmesis Disrupted axon with intact endoneurium; Wallerian degeneration takes place after 1-2 weeks Prognosis: Variable recovery, worse prognosis for proximal injuries and injuries that do not successfully re-implant in the muscle within 18 months Grade 3: Neurotmesis with preservation of perineurium Endoneurium is disrupted Prognosis: 60-80% recovery Grade 4: Neurotmesis with preservation of epineurium Prognosis: Nerve grafting is required Grade 5: Neurotmesis with complete transection of nerve trunk Prognosis: Bypass/jump grafting is required Explanation There are two classification schema used to describe nerve injuries. The first was published by Seddon in 1943, and separated injuries into three categories — neuropraxia, axonotmesis, and neurotmesis — largely based on the scale of injury from microscopic to macroscopic. In 1978, Sunderland expanded upon this idea, subdividing neurotmesis into three additional grades. The Seddon classification is useful to understand the anatomic basis for injury, while the Sunderland classification adds information useful for prognosis and treatment strategies.

83. Which of the following EMRs (Evoked Motor Response) of the sciatic nerve is associated with both the highest degree of successful blocking of both components of the nerve, as well as the shortest latency of onset of sciatic nerve block? a. Inversion b. Eversion c. Dorsiflexion d. Plantar flexion e. All are correct; any sciatic nerve response equally good.

B X | E✔

84. As a rule of thumb, following peripheral nerve injury where intact connective tissue continuity is preserved, a nerve will regrow at a rate of ___/day. a. 0.1mm b. 0.5mm c. 1.0 mm d. 10 mm e. 100 mm

AX C✔ Nerve regeneration occurs at a rate of 3-4 mm/day after crush and 2-3 mm/day after sectioning a nerve.

85. Which of the following are the most important factors determining the spread of local anesthetics administered by the subarachnoid route? 1. Baricity 2. Level of injection 3. Positioning of the patient after injection 4. Barbotage a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A✔

86. An autologous epidural blood patch employing 20ml of blood results in an elevation of CSF pressure of approximately____mmHg that persists for up to __ hours. a. 7; 12 b. 70;6 c. 1.5; 24 d. 7;6 e. 15; 18

C ✔

87. The one ingredient NOT a part of the "The Four A's for Pain Treatment Outcome Assessment" is: a. Adverse events b. Aberrant drug-taking behavior c. Activities of daily living d. Average number of pills (controlled substance) needed in a given month e. Analgesia

D? | D✔

88. The following practices, when treating a pain patient who becomes non-compliant, are helpful EXCEPT: a. Have a system in place for identifying them b. Take no chances; dismiss them from your practice immediately c. If you have no pain treatment agreement with them, start over and get one! d. Do diligent F/U with them e. Carefully document all future interactions with them.

B? | C✔

89. Which of the following statements is false about the Controlled Substances Act of 1970: a. It introduced the concept of scheduling based on a drug's potential for abuse. b. Like the Harrison Act of 1914, it prohibits the recreational use of opiates (controlled substances), yet allows doctors to prescribe them in "good faith" for those in need. c. Its overall effect has been to clearly define whose job it is to "catch" the crooks and whose job it is to "treat' those who suffer pain d. It requires a license for both prescriber and dispensers of controlled substances. e. It results in an large influence for the DEA over a prescriber's practice of medicine.

C X

90. NASPER a. Eliminates prescriber's fear of licensure sanctions b. Stands for: National Alliance for Safe Prescriptions for use with Electronic Records c. Is mandated for all states by the year 2008 d. Is the first step in controlling the national epidemic of prescription drug abuse. e. Will be financed by the individual states that see the majority of drug abuse/ diversion.

B X D✔ The National All Schedules Prescription Electronic Reporting Act (NASPER) NASPER was signed into law on August 11, 2005, making it the only statutorily authorized program to assist states in combating prescription drug abuse of controlled substances through a prescription monitoring program (PDMP).

91. What percentage of discharge ICU patients described pain as the worst memory of the entire ICU experience? a. 10% b. 25% c. 50% d. 75% e. 100%

? B X | ????

92. What is the major coming complications of a completed dialysis run? a. Embolism b. Headache c. Hypotension d. Nausea and vomiting e. Gastroparesis

C? | C✔

93. In order to deafferent a facet using radiofrequency, how many levels must be blocked/lesioned? a. One b. Two c. Three d. Four e. Either two, or four, depending upon level

B✔

94. With respect to chemical neurolysis, which is true? 1. Alcohol neurolysis is preferred for craniofacial malignancies.✔ 2. Phenol possess local anesthetic properties✔ 3. Alcohol is hypobaric✔ 4. Both alcohol and phenol cause Wallerian degeneration.✔ a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

A? | E✔

95. Which of the following neurosurgical pain procedures is effective in the treatment of brachial plexus avulsion pain? a. Cordotomy b. DREZ lesion c. Sympathectomy d. Rhizotomy e. Medial Thalamotomy

EX | B✔

96. Which of the following procedures interrupt the spinothalamic tract in the treatment of pain? 1. Commissural myelotomy 2. DREZ lesion 3. Cordotomy 4. Dorsal Rhizotomy a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

EX E? Commissural myelotomy was designed as a surgical technique to produce bilateral analgesia by interrupting the decussating axons of the spinothalamic tract by means of a longitudinal incision extending over several spinal segments

97. Which of the following represents the best indication for spinal cord stimulation? a. Migraine headaches b. Axial low back pain c. CRPS d. Chronic pancreatitis e. Acute Herpes Zoster– related to pain

C? | C✔

98. Long-term success rates for pain relief with SCS in setting of chronic lumbar radiculopathy (or failed back surgery syndrome) are around: a. 50-60% b. 20-30% c. 90-100% d. 70-80% e. 25-30%

B? A ✔ Success rates for implanted neurostimulation has been reported to be 25% to 55%. Success is defined as a relative decrease in pain

99. A patient treated with intrathecal morphine for intractable low back pain receiving a 15 mg/day through an implanted pump, with a catheter tip lying at T11. Recently, the patient contacted your office with complaints of increased low back pain and left leg pain. Which of the following findings on physical examination would suggest an intrathecal granuloma? a. Absent ankle jerk on the left b. Left ankle clonus c. Straight leg raise test on the left d. Tenderness to palpation over thoracic spine e. + Faber test on the right.

D? | B✔

100. Which of the following are indications for L4/5 discectomy? 1. Radicular pain 2. L4/5 instability 3. Foot drop 4. Axial back pain. a. 1,2,3 only b. 1,3 only c. 2,4 only d. 4 only e. All are correct

✔ | A