SAER 2004 Flashcards
According to the Consortium for Spinal Cord Medicine’s Clinical Practice Guidelines for the
Prevention of Thromboembolism in Spinal Cord Injury, individuals with motor incomplete (ASIA
class C or D) spinal cord injury should receive
(a) warfarin (Coumadin), international normalized ratio target: 2–3.
(b) low molecular weight heparin.
(c) inferior vena cava filter.
(d) unfractionated heparin, 5000 units every 12 hours.
(d) According to the guidelines for the prevention of thromboembolism in spinal cord injury, patients
with low risk motor incomplete injuries require only compression hose and compression boots;
those with intermediate risk require unfractionated heparin, 5000 units every 12 hours. Patients
with a motor complete injury should receive either unfractionated heparin to a high normal
activated partial thromboplastin time (aPTT) or low molecular weight heparin twice daily. Persons
with a motor complete injury with other risk factors including lower limb fracture, risk of
thrombosis, cancer, heart failure, or other compromising factors may require an inferior vena cava
filter in addition to the prescribed drugs.
In order to minimize myocardial oxygen requirements in a patient with known coronary artery
disease during low intensity resistive exercise it is best to prescribe
(a) isometric supine exercises.
(b) isometric standing exercises.
(c) isotonic supine exercises.
(d) isotonic standing exercises.
(d) With low intensity exercise the rate pressure product (RPP), a valid surrogate measure for
myocardial oxygen consumption, is higher for supine than standing activities. At higher exercise
intensities the situation is reversed and the RPP is higher for standing activities. Isometric
contractions greater than 15% of maximum cause continued increase in the RPP until fatigue limits
the duration of contraction. For patients at risk for cardiac ischemia, low intensity, isotonic,
standing exercises should be prescribed to avoid elevation of the RPP.
A 45-year-old auto mechanic with a history of low back pain and a herniated disc presents to you
with 2-day history of leg pain, numbness in the lower extremity, stumbling, and 2 episodes of
urinary incontinence. Your recommendation includes
(a) Ibuprofen, ice, relative rest, pelvic tilts, and repeat magnetic resonance imaging this week.
(b) Lumbar epidural steroid injection and physical therapy.
(c) Immediate magnetic resonance imaging and referral to a spine surgeon.
(d) Acetaminophen, ultrasound, light duty for 5 days, and physical therapy.
(c) In this patient with known herniated disc now with urinary incontinence the primary concern should
be to evaluate for cauda equina syndrome. The MRI is necessary to determine if an extruded disc is
causing the current symptoms. Surgery in the acute setting is essential to achieve neurologic
recovery.
A 2-year-old patient with spinal muscular atrophy type 2 (intermediate form) presents with a 25°,
C-shaped scoliosis. What is the best treatment option at this time?
(a) Muscle strengthening
(b) Electrical stimulation
(c) Spinal fusion
(d) Spinal orthosis
(d) Muscle strengthening will not reduce the curve or prevent it from progressing and is not easily
accomplished in 2-year-old children. Posterior or anterior spinal fusion is not indicated with a
curve of this size and is to be avoided in a young child if at all possible. Spinal orthotics are used in
young children with spinal muscular atrophy to improve sitting balance and to attempt to halt curve
progression.
Which knee component is preferred in the prosthetic prescription for an 80-year-old debilitated,
dysvascular, diabetic transfemoral amputee?
(a) Single axis
(b) Polycentric
(c) Pneumatic
(d) Manual locking
(d) A manual-locking knee is indicated for new unstable amputees and those who need utmost stability
because of muscular weakness or poor coordination. The other components are generally used in
persons with less risk of falling.
prolonged extrication from his vehicle and lost consciousness at the scene of the accident. Head
computed tomography (CT) scan was notable for a small subarachnoid hemorrhage. He has had
several episodes of hypotension and hypoxemia since admission. What information in this clinical
case makes diffuse axonal injury highly likely?
(a) High-speed motor vehicle collision
(b) Subarachnoid hemorrhage on head CT scan
(c) Episodes of hypoxia and hypotension
(d) Prolonged extrication from vehicle
(a) Diffuse axonal injury is most commonly seen after high-speed motor vehicle collisions, particularly
when immediate loss of consciousness occur
A 13-year-old boy presents with waddling gait and difficulty in climbing stairs. On examination, he
demonstrates significant weakness in his proximal lower extremity muscles, especially the
quadriceps, and some calf hypertrophy. What is the genetic inheritance of this disorder?
(a) Autosomal dominant
(b) X-linked recessive
(c) Autosomal recessive
(d) No genetic linkage
(b) The abnormal gene for Duchenne and Becker muscular dystrophy (DMD, BMD, respectively) is on the
short arm of the X chromosome at position Xp21Reference. Both DMD and BMD are inherited Xlinked
recessive diseases affecting primarily skeletal and myocardial muscles. Dystrophin is a large
cytoskeletal protein in the subsarcolemmal lattice, the protein that stabilizes the plasma membrane
during muscle contractions.Mutations in the dystrophin gene that result in a complete loss of
dystrophin lead to the DMD phenotype. Mutations that cause a reduced, truncated, or dysfunctional
form of dystrophin to be produced lead to the BMD phenotype. Both DMD and BMD are progressive
myopathies, although DMD is much more severe and is universally fatal. BMD shows a similar pattern
of muscle weakness to DMD but with later onset and much slower rate of progression.
Compared to persons with traumatic spinal cord injury, persons with non-traumatic spinal cord injury are more likely to be (a) under the age of 35 years. (b) female. (c) tetraplegic. (d) single.
(b) Persons with nontraumatic spinal cord injury (SCI) are older, more likely married, female, retired,
and have significantly more paraplegia and incomplete injury than persons with SCI of traumatic
etiology, with neoplasm (53%) and cervical spondylosis (25%) as the leading causes of
nontraumatic injury.
A pulmonary rehabilitation patient has a temperature of 101.5° and is breathing at a rate of 10
breaths per minute. In order to optimize his percent hemoglobin saturation at a given O2 partial
pressure, it would be best to
(a) administer an antipyretic and encourage him to breathe more rapidly.
(b) not treat his fever, but encourage him to breathe more rapidly.
(c) administer an antipyretic and encourage him to maintain his current respiratory rate.
(d) not treat his fever and encourage him to maintain his current respiratory rate.
(a) A number of different factors have the capacity to shift the hemoglobin-oxygen dissociation curve.
Acidosis, elevated temperature, and increased PCO2 all cause the curve to shift to the right. Thus,
controlling this patients fever and encouraging him to expire more rapidly thereby reducing PCO2
and acidosis and would increase the degree of hemoglobin saturation at a given O2 partial pressure.
The owner of a landscape business is interested in implementing a program to reduce low back
injuries in his workers. Which therapeutic exercise program has been shown to reduce the risk of
low back injuries?
(a) Lumbar extension exercises
(b) Lumbar flexion exercises
(c) Lumbar spine stabilization exercises
(d) No specific group of exercises reduces risk
(d) No specific lumbar spine strengthening program has been shown to prevent low back pain in the
work place. Spine strength is not a predictor of reduced risk for onset of low back pain.
The most common spinal problem seen with achondroplasia during childhood is
(a) kyphosis.
(b) scoliosis.
(c) spinal stenosis.
(d) low back pain.
(a) While scoliosis may occur in children with achondroplasia, it is less common than kyphosis, which
begins in infancy. Spinal stenosis occurs frequently in individuals with achondroplasia, with 38
years being the average age of symptom onset. Low back pain is extremely frequent in adults with
achondroplasia, but rare in children. Progressive kyphosis that occurs in infants and young children
with achondroplasia is treated with a spinal orthosis.
How much knee flexion is required to descend stairs step over step after a total knee replacement?
(a) 45°
(b) 70°
(c) 90°
(d) 110°
(d) Descending stairs requires 110° knee flexion.
What is the pathophysiology of Duchenne muscular dystrophy?
(a) merosin deficiency
(b) abnormally low levels of dysferlin
(c) absence of dystrophin
(d) mutations of alpha-sarcoglycan
(c) The absence of dystrophin is the basis of the pathophysiology of Duchenne muscular dystrophy
(DMD). Most genes in the affected area of the X chromosome encode for components of the
dystrophin-glycoprotein complex (DGC), an assembly of transmembrane and membrane-associated
proteins that form a structural linkage between the F-actin cytoskeleton and the extracellular matrix in
muscle. The proteins that comprise the DGC are organized into 3 subcomponents, the cytoskeletal
proteins, the sarcoglycans and the sarcospan. Many of the different types of muscular dystrophies arise
from primary mutations in genes encoding components of this complex. However, the other choices
noted above are not involved in DMD or Becker MD. Deficiencies in those proteins are associated
with forms of limb girdle muscular dystrophy
What is the leading cause of traumatic spinal cord injury in the United States?
(a) Falls
(b) Sports related injury
(c) Gunshot wound
(d) Motor vehicle crash
(d) The leading cause of traumatic spinal cord injury in the United States is motor vehicle crash. The
incidence of spinal cord injury from gunshot wounds is decreasing nationally; falls are now the
second most common cause nationwide, followed by sports related injuries.
Electrophysiologic findings of compound muscle action potential conduction block and temporal
dispersion, prolonged minimum F-wave latency, and reduced conduction velocity would most
likely be seen in
(a) Charcot-Marie-Tooth disease.
(b) myasthenic syndrome.
(c) Guillain-Barré syndrome.
(d) amyloidosis.
(c) All the findings mentioned are features associated with an acquired demyelinating condition such as
Guillain-Barré syndrome or acute inflammatory demyelinating polyradiculoneuropathy (AIDP).
Hereditary motor sensory neuropathies do not usually have temporal dispersion of compound
muscle action potentials. Myasthenic syndrome is a neuromuscular junction disorder and
amyloidosis is associated with a form of axonal peripheral neuropathy.
What acquired upper extremity amputation is most common in adults?
(a) Dominant extremity at the transradial level
(b) Dominant extremity at the transhumeral level
(c) Non-dominant extremity at the transradial level
(d) Non-dominant extremity at the transhumeral level
(a) Acquired upper limb amputations in adults occur most commonly in males between the ages of 21
and 64 years. These amputations result frequently from work-related accidents or trauma and are
most common in the dominant limb at the transradial level. In contrast, congenital upper limb
deficiencies occur most commonly on the left side at the transradial level.
A 30-year-old man with a recent traumatic brain injury has frequent episodes of emesis with
gastrostomy tube bolus feedings despite receiving agents to facilitate gastric emptying. The most
appropriate next course of action is to
(a) switch the tube feeding formula.
(b) switch to continuous tube feedings.
(c) order a gastric endoscopy.
(d) place a jejunostomy tube.
(b) Intolerance to feeding can be related to increased gastric distention, and adjusting from bolus to a
slower rate with longer feeding time may provide relief. Converting to a jejunostomy is appropriate
if simpler measures fail
A 35-year-old man with history of psoriatic arthritis complains of localized low back pain
insidious in onset. The pain is worse in the morning and improves as the day progresses. What is
the most likely cause of his back pain?
(a) Piriformis strain
(b) Sacroiliitis
(c) Quadratus lumborum strain
(d) Discitis
(b) Sacroiliitis occurs in patients with spondyloarthropathies such as psoriatic arthritis, reactive
arthritis, enteropathic arthritis, and ankylosing spondylitis
The circulatory system’s response to exercise is characterized by
(a) parasympathetically mediated vasoconstriction of the skin.
(b) vasodilatation in active muscle groups mediated by local factors.
(c) sympathetically mediated vasodilatation of viscera.
(d) an increase in total peripheral vascular resistance.
(b) During vigorous exercise, sympathetically mediated vasoconstriction occurs in the skin and viscera.
Vasodilatation in active muscle groups is mediated by local factors including potassium ion
concentrations, increases in osmolarity, changes in adenosine nucleotide concentrations, and
decreasing pH. Muscle blood flow may increase up to 15-20 times baseline. The vasodilatation in
muscle groups causes a reduction in total peripheral resistance by up to 50%.
In which activity should a 16-year-old girl with C5 ASIA class A spinal cord injury be
independent with the use of assistive devices?
(a) Self catheterization
(b) Transfers to level surfaces
(c) Self feeding
(d) Bathing
(c) While boys with C5 spinal cord injury (SCI) may learn to perform bladder self-catheterization with
assistive devices, girls do not. Level transfers require active elbow and wrist extension, which
would not be present in a person with C5 SCI. Self-feeding with assistive devices such as a palmar
band can usually be done by persons with C5 tetraplegia.
A 26-year-old mail handler is sent to you for management of her severe sensorimotor carpal tunnel
syndrome confirmed by electrodiagnostic evaluation. She was given a splint for her presumed
carpal tunnel syndrome 3 months ago, which she has worn 24 hours a day since that time without
relief. She notes severe tingling in her fingers that is worse at night, and she also notes difficulty
with gripping the mail, because of subjective weakness. She is now having severe pain, which
radiates up her hand into her forearm. You consider that a corticosteroid injection might benefit
this patient. Which statement is most correct regarding this injection?
(a) The risk of intraneural injection is too high, and the patient should not be injected.
(b) So that intraneural injection can clearly be recognized, do not dilute the corticosteroid with
anesthetics.
(c) Persisting or worsening pain and numbness or swelling normally last for more than 48
hours postinjection.
(d) Local tenderness and superficial hematomas are rare after this injection
(b) The risk of intraneural injection is real, but in experienced hands this injection is safe. Anesthetics
mixed with the corticosteroid can mask the pain associated with needle placement into the nerve
and should not be used. Numbness is anticipated with this injection without use of anesthetics, and
helps to confirm proper placement. Local tenderness and hematomas are common with this
injection and do not represent a complication. Persistent or worsening pain or swelling lasting more
than 48 hours are signs of nerve injection or neurotoxic injury.
A 28-year-old woman, who is 35 weeks pregnant, complains of right thigh and groin pain with
weight bearing. You diagnose her with idiopathic transient osteoporosis of the femoral neck.
What is the course of treatment?
(a) Recommend labor induction
(b) Prescribe protected weight bearing
(c) Recommend bedrest until delivery
(d) Prescribe alendronate (Fosamax)
(b) Patients with idiopathic transient osteoporosis of the femoral neck may ambulate as tolerated but
may need protective weight bearing for pain relief. Symptoms and pathology resolve within 6
months
Regarding the epidemiology of neurogenic thoracic outlet syndrome,
(a) it is a commonly occurring syndrome.
(b) it occurs equally in men and women.
(c) it occurs more frequently in the young and middle-aged.
(d) it is highly associated with repetitive motion.
(c) Neurogenic thoracic outlet syndrome is rare, occurs most frequently in young to middle-aged
women, and involves the lower trunk of the brachial plexus. Pain is the most common sensory
symptom, and is usually in the medial forearm and ulnar aspect of the hand.
A patient with advanced ankylosing spondylitis complains of increasing dyspnea. You order
pulmonary function tests. Which parameter do you anticipate will deviate the most from normal,
age-adjusted values?
(a) Functional residual capacity
(b) Expiratory reserve volume
(c) Vital capacity
(d) Tidal volume
(c) Spinal flexion and extension are necessary for full thoracic expansion. Limited spinal mobility, as
occurs in diffuse skeletal hyperostosis and ankylosing spondylitis, will directly affect full
respiratory capability. Functional residual capacity, residual volume, and tidal volume may be
decreased. However, vital capacity is related to inspiratory capacity and will therefore be more
significantly affected by reduced spinal mobility.
Your 6-month-old patient had burns to his head and both arms in a house fire. What approximate
percent of his total body surface area (TBSA) was burned?
(a) 37
(b) 18
(c) 27
(d) 49
(a) An infant’s head is approximately 19% and each arm constitutes 9% of the total body surface area
(TBSA). In adults and older children the head is approximately 9% of the TBSA.
In patients with osteoporosis, which treatment reduces incidence of vertebral compression fracture? (a) Weight reduction (b) Cash brace (c) Strengthening of spinal extensors (d) Strengthening quadriceps
(c) Weak extensor muscles increase risk of compression fracture. Risk increases with immobilization
longer than 2 days. There is no association between osteoporotic compression fractures and weight
or family history
The occurrence of renal calculi during the first 3 months after spinal cord injury is related to
(a) level of injury.
(b) immobilization hypercalciuria.
(c) method of bladder management.
(d) number of urinary tract infections.
(b) Renal calculi occur in approximately 8% of patients with spinal cord injury. Approximately 98% of
renal calculi in persons with spinal cord injury are composed either of calcium phosphate or
magnesium ammonium phosphate. These stones are typically associated with urinary tract
infections (UTIs). Early stone formation is likely secondary to immobilization hypocalcemia,
whereas later stone formation is secondary to repeated UTIs and long term use of an indwelling
catheter.
Which of the following medications exerts its analgesic effect by increasing the influence of the
descending spinal tracts on nociceptive processing in the dorsal horn?
(a) Valproic acid (Depakote)
(b) Mexiletine (Mexitil)
(c) Amitriptyline (Elavil)
(d) Baclofen (Lioresal)
(c) Tricyclic antidepressants are believed to exert their analgesic effects through modulation of the
descending inhibitory pathways the arise in various brain stem centers and synapse within the
dorsal horn of the spinal cord. Neurons within these tracts are principally serotonergic and
noradrenergic. By influencing the reuptake of these monoamines, amitriptiyline and other tricyclic
antidepressants, enhance the inhibitory influence exerted by the descending tracts.
The presence of nonorganic physical signs in low-back pain patients as described by Gordon
Waddell is intended to
(a) alert the examiner that psychological issues may be contributing to pain.
(b) identify patients and workers that are malingerers.
(c) determine which workers would benefit from low back and abdominal exercises.
(d) indicate which patients require examination by a psychiatrist.
(a) Nonorganic physical signs in patients with low back pain was described by Gordon Waddell. His
original paper describes the physical signs that correlated with psychological data and were
distinguishable from standard clinical signs of physical pathology. Waddell’s signs should be used
to determine if nonorganic issues may be contributing to the patient’s complaints. Not all patients
with nonorganic physical signs are malingerers or require psychiatric evaluation. The signs are not
indicators for therapeutic modalities.
Which joints are most commonly involved in juvenile rheumatoid arthritis?
(a) Shoulder, hip, fingers
(b) Atlantoaxial, costomanubrum, hip
(c) Sternomanubrum, shoulder, sacroiliac
(d) Elbow, hip, temporomandibular
(d) The elbow is involved 90% of the time in juvenile rheumatoid arthritis (JRA), the
temporomandibular and hip 50% each. The shoulder is involved about 8% of the time in early JRA
and about 33% later.
Which type of stroke typically results in the best overall outcome?
(a) Pontine hemorrhage
(b) Embolic cortical infarction
(c) Anterior cerebral artery aneurysm rupture
(d) Internal capsule lacune
(d) Lacunar strokes are typically small and very localized and, in general, have the best prognosis
40-year-old woman with irritable bowel syndrome and tension headaches complains of
increasing fatigue and diffuse muscle soreness in her neck, shoulders, and low back. She has a
nonfocal neurologic examination. She does not feel rested in the morning. The most appropriate
initial recommendation is
(a) lorazapam (Ativan) at bedtime.
(b) amitriptyline (Elavil) at bedtime.
(c) zolpidem (Ambien) at bedtime.
(d) acetaminophen with codeine (Tylenol #3 ) at bedtime.
(b) This patient has fibromyalgia. Neuropathic medications such as trycyclic antidepressant
medications are recommended.
A 75-year-old patient with metastatic breast cancer, hypertension, and diabetes is admitted to the
hospital for radiation of a pathological femoral fracture. Her severe osseous pain was controlled
during the initial 72 hours of admission with intravenous morphine, 5 mg/hour. Eager to facilitate
discharge, a well-meaning house officer converts her to oral sustained-release morphine sulfate,
120 mg tid. Twenty-four hours after receiving the first dose of oral morphine, the patient becomes
increasingly confused and somnolent. The most likely explanation for this change in mental status
is
(a) the dose of oral morphine is excessive (not an accurate IV to PO conversion).
(b) radiation-induced hypersomnolence.
(c) accumulation of morphine metabolites.
(d) hypercalcemia.
(c) Morphine sulfate is glucoronidated in the liver to produce two metabolites; morphine-6-glucoronide
and morphine-3-glucoronide. Both of these compounds are renally excreted and can accumulate in
elderly patients with compromised renal function. Morphine-6-glucoronide is a m-receptor agonist
and is believed to contribute to morphine-induced analgesia. Morphine-3-glucoronide has been
implicated in the undesirable neuropsychological side effects of morphine therapy and does not
provide significant analgesia. Due to first-pass effect, the serum concentration of morphine
metabolites is much higher when morphine is administered orally.
Which of the following is part of neurodevelopmental therapy (NDT)?
(a) Promotion of primitive reflexes
(b) Use of taping and icing
(c) Strengthening exercises
(d) Facilitating automatic reactions
(d) Neurodevelopmental therapy, developed by Bobath, emphasizes inhibition of reflex patterns,
normalizing tone, and facilitating automatic reactions. The therapy does not include strengthening
exercises.
When applying a static resting hand splint to a person who had a stroke with upper limb paralysis,
what is the appropriate joint position to maintain the hand in a functional position?
(a) 20° of wrist flexion
(b) 90° of metacarpophalangeal flexion
(c) Neutral position or slight flexion of the distal interphalangeal joints
(d) 30° of thumb opposition across the palm
(c) A resting hand splint is designed to maintain a position of function in a hand that is weak or
paralyzed. It is applied on the volar surface and extends from the fingertips to the proximal third of
the forearm. The wrist is typically placed in slight extension. The metacarpophalangeal joints are
placed in slight flexion and the interphalangeal joints are placed in a neutral position or in slight
flexion. The thumb is supported in a position between palmar and radial abduction
How does a weighted kypho-orthosis (Posture Training Support®) improve function in patients with chronic thoracic kyphosis? (a) Improves posture (b) Strengthens spinal extensors (c) Promotes bone formation (d) Helps activate rectus abdominus
(a) A weighted kypho-orthosis improves posture without any effect on pain.
You prescribe a work-hardening program for a 36-year-old assembly-line worker. Work-hardening
programs are most effective when
(a) focused on upper limb function.
(b) the patient’s job functions are simulated.
(c) combined with a physical therapy program.
(d) prescribed by a physiatrist
(b) Work-hardening programs are most effective when essential job duties are simulated.
Your 14-year-old patient with spastic diplegic cerebral palsy has increasing problems with
spasticity. He walks with ankle-foot orthoses (AFOs) and crutches and is independent in his
activities of daily living. Which medication would reduce his spasticity while minimizing
undesirable side effects?
(a) Diazepam (Valium)
(b) Baclofen (Lioresal)
(c) Dantrolene (Dantrium)
(d) Oxybutynin (Ditropan)
(b) Diazepam has lethargy and sleepiness as major side effects. Dantrolene works at the level of the
muscle and often causes weakness, which can interfere with function. Oxybutynin relaxes the
muscles of the bladder, not skeletal muscles.
A person with diabetes presents with an area of nonblanching erythema on the plantar surface of
the foot at the first metatarsal head. Recommendations for footwear would include
(a) custom-molded shoe insert.
(b) narrow toe box shoe.
(c) heel lift on the affected side.
(d) calcaneal bar added to the sole of the shoe.
(a) Footwear for the person with diabetes and grade 1 skin changes on the plantar aspect of the foot
should be designed to relieve pressure over the affected site while evenly distributing pressure over
the remaining foot surface to prevent other skin breakdown. A typical prescription would include an
extra-depth shoe with a wide toebox and a total-contact, custom-molded insert with pressure relief
at the area of skin irritation. Further shoe modifications with a metatarsal bar and rocker bottom
sole could also be considered, especially if the patient had grade 2 skin changes or more severe foot
deformities. A calcaneal bar or heel lift would not be appropriate considerations in this case.
Which steroid compound has the longest half-life?
(a) Dexamethasone
(b) Prednisone
(c) Triamcinolone
(d) Hydrocortisone
(a) The least water-soluble compound will have the longest half-life.
A 22-year-old woman with a C5 ASIA class A spinal cord injury sustained in a car crash 2 weeks
ago complains of lightheadedness, dizziness, and nausea during her physical therapy session. In
response to her therapist’s call, you recommend
(a) sitting the patient up and loosening tight garments.
(b) placing the patient in Trendelenburg position.
(c) using elastic abdominal binders and elastic stockings.
(d) adjustment of HALO vest.
(c) Orthostatic hypotension (OH) is a decrease in blood pressure that results from a change in body
position toward the upright posture. Symptoms include lightheadedness, dizziness, nausea. This
form of hypotension is most likely to occur in persons with high levels of injury. Treatment
involves daily tilting with gradual change to upright posture. Elastic binders help compress the
abdomen, thus limiting blood accumulation in the abdominal vasculature. Elastic stockings limit
blood accumulation in lower extremities. Patients must be adequately hydrated. Salt tablets, 1
gram 4 times daily, ephedrine, 20–30mg up to 4 times daily, Florinef, and Midodrine may be used
as pharmacologic adjuncts.
A thrombocytopenic cancer patient has severe pain related to osseous metastases. Recognizing
that pain from osteolytic metastases is prostaglandin mediated, you choose to initiate therapy with
(a) Naproxen (Naprosyn, Aleve).
(b) Celecoxib (Celebrex).
(c) Valproic acid (Depakote).
(d) Acetaminophen (Tylenol).
(b) Nonsteroidal anti-inflammatory drugs reversibly inhibit cyclooxygenase, the enzyme responsible
for the conversion of arachadonic acid to prostaglandins. Given the importance of prostaglandins in
mediating metastatic bone pain, use of an NSAID represents appropriate first-line therapy for this
patient. For thrombocytopenic patients, use of a cyclooxygenase-2 specific inhibitor such as
celecoxib or refocoxib will place the patient at a much lower risk of hemorrhage.
A 32-year-old female cashier presents to you with a 2-week history of low back pain. She denies
specific trauma or activity with onset. She has no lower extremity pain, numbness, or tingling. She
denies night time pain, recent illness, or previous history of low back pain. Which radiological
diagnostic test would you recommend?
(a) Computed tomography scan
(b) Radiographic imaging
(c) No imaging
(d) Magnetic resonance imaging
(c) No imaging is necessary in this patient with no known medical risk factors. The low back pain can
be managed initially without the expense of CT or MRI. Recommendations for obtaining x-rays for
the patient with a first episode of low back pain for less than 7 weeks include: over age 65, history
of osteoporosis, history of urinary tract dysfunction, persistent sensory loss, progressive pain
despite treatment, night or rest pain, fever, chills, unexplained weight loss, history of trauma or
repetitive overuse, recurrent pain with no x-rays in 2 years, previous surgery, or fracture.
Which filter setting is usually considered to be appropriate for routine needle electromyography? Low frequency High frequency (a) 2–10Hz 10,000Hz (b) 2–10Hz 2,000Hz (c) 20–30Hz 10,000Hz (d) 20–30Hz 2,000Hz
(c) There is no universally accepted guideline for filter settings. However, based on clinical experience
certain ranges have been determined and are recommended. Each procedure has particular filter
settings, which are based on optimum frequency content of mean waveforms routinely observed.
The recommended filter setting for routine needle electromyography is 20–30 hertz for the low
filter and 10kilo hertz for the high filter.
