MCQS Practice FINAL FRCA Pain Study Day
11th May 2012
Dr Deepak Malik
Advanced Pain Fellow
Leicester
Chronic pain problems in children and young people
1. Chronic pain in children is most likely to:
(a) Be recognized as a significant health problem in developed countries.
(b) Be attributable mainly to psychological factors.
(c) Be more frequent in adolescent girls than boys.
(d) Respond well to nerve blocks.
(e) Lead to defined patterns of co-morbidity.
2. Childhood neuropathic pain is most likely to:
(a) Occur in children of at least 5 yr of age.
(b) Be associated with nerve injury rather than nerve dysfunction.
(c) Have a poor prognosis when compared with neuropathic pain in adults.
(d) Be associated with joint hypermobility.
(e) Be implicated when there is a history of surgery and administration of
cytotoxic drugs.
3. Complex regional pain syndrome is most likely to:
(a) Occur after physical trauma.
(b) Occur in teenage girls.
(c) Require urgent referral for physiotherapy.
(d) Affect the upper and lower limbs with equal frequency.
(e) Be difficult to manage successfully when there is a relapse.
4. Management of chronic pain in children is most likely to adhere to the
following principles:
(a) Recent onset headache is managed mainly with simple analgesics.
(b) Migraine in childhood is similar to that in adults.
(c) Functional abdominal pain (FAP) responds to peppermint oil supplements.
(d) Stresses of daily life can lead to increased symptoms associated with
inflammatory bowel disease.
(e) Adjunctive pain treatments in palliative care comprise diazepam, antiemetics
Radiofrequency therapies in chronic pain
5. Continuous radiofrequency (CRF) procedures for pain:
(a) Use alternating current with a frequency of 500 Hz.
(b) Produce an effect by coagulating target nerves.
(c) Produce heat energy in tissue distal to the active tip of the electrode.
(d) Produce differential lesioning of target nerves.
(e) Can be associated with deafferentation syndromes.
6. Pulsed radiofrequency (PRF) procedures for pain:
(a) Use a 50 kHz alternating current delivered in 20 ms pulses at a frequency
of 2 Hz for 120 s.
(b) Cause significant heating of target tissue.
(c) Lead to heat dissipation by convection, conduction and radiation.
(d) Are associated with increased markers of cellular stress in target tissue.
(e) Have a mechanism of effect that is not clear.
7. In chronic pain management:
(a) Percutaneous radiofrequency trigeminal rhizotomy is a first line treatment
for trigeminal neuralgia.
(b) Potential side-effects of trigeminal rhizotomy include diplopia.
(c) Selection criteria for radiofrequency neurotomy in somatic spinal pain
include placebo-controlled diagnostic blocks.
(d) Radiofrequency neurotomy of the dorsal ramus of C3 is used in
management of cervicogenic headache.
(e) CRF treatments are associated with fewer side effects than pulsed
radiofrequency treatments.
Transdermal drug delivery in pain Management
8. Physicochemical characteristics of a drug that decrease its transdermal
penetration include:
(a) Molecular weight below 500 Da.
(b) High melting point.
(c) Non ionic form.
(d) High concentration.
(e) High partition coefficient between skin and drug patch.
9. The fentanyl transdermal patch:
(a) Is available only in matrix form.
(b) Has an elimination half-life of 20 h after patch removal.
(c) Delivers more drug with exposure to heat.
(d) Forms a depot within skin layers.
(e) Has increased elimination when administered with CYP3A4 inhibitors.
10. An EMLA patch:
(a) Should be applied for at least 1 h prior to venous cannulation.
(b) Can be left in place for up to 4 h.
(c) Can be used for surface anaesthesia for minor procedures.
(d) Is safe in patients with congenital methaemoglobinaemia.
(e) Can be used in children aged 6 months.
11. The fentanyl ITS system:
(a) Uses ultrasound waves to drive drug molecules across the skin.
(b) Gives a peak plasma fentanyl concentration in approximately
40 min.
(c) Has the disadvantage of being very bulky.
(d) Delivers a maximum of 40 mg of fentanyl every 10 min.
(e) Causes a slow fall in plasma fentanyl concentrations after its removal,
because of skin deposition.
Anaesthetic implications of psychoactive Drugs
12. Tricyclic antidepressants (TCAs):
(a) May cause arrhythmias.
(b) Enhance uptake 1.
(c) May cause hypotension.
(d) Raise the seizure threshold.
(e) May cause anticholinergic side-effects.
13. Drugs that should be avoided in patients taking monoaminoxidase
inhibitors (MAOIs) include:
(a) Ephedrine.
(b) Pethidine.
(c) Morphine.
(d) Bupivacaine with 1:200 000 adrenaline.
(e) Ketamine.
14. Selective serotonin reuptake inhibitors:
(a) May impair platelet function.
(b) Are a contraindication to use of pethidine.
(c) May cause the serotonergic syndrome when administered with tramadol.
(d) Inhibit presynaptic serotonin reuptake.
(e) Are generally not stopped before elective surgery.
15. The following are known side-effects of antipsychotic drugs:
(a) Tardive dyskinesia.
(b) Parkinsonian symptoms.
(c) Urinary retention.
(d) Diarrhoea.
(e) Precipitation of neuroleptic malignant syndrome.
Chronic pain and prescription opioid Misuse
16. Regarding routes of administration of prescription opioids:
(a) The parenteral route is preferred for breakthrough non-cancer pain.
(b) The oral or transdermal routes should always be used.
(c) There is a greater risk of misuse with the intranasal route.
(d) The transdermal patch provides a rapid increase in opioid blood levels.
(e) Morphine and oxycodone are available in sustained release preparations.
17. Pethidine:
(a) In equipotent doses causes less smooth muscle spasm than other opioids.
(b) Has an active metabolite nor-pethidine with a shorter half life.
(c) Should be prescribed in an oral sustained release formulation.
(d) Is contraindicated in patients who have received monoamine oxidase
inhibitors (MAOIs) in the previous 14 days.
(e) Is particularly unsuitable when given by injection for patients with chronic
pain.
18. Oral opioid therapy:
(a) Can cause tolerance, the phenomenon where identical doses of an opioid
result in an increasing level of effect.
(b) Can lead to pseudoaddiction that describes patient behaviour that may
occur when their pain is under treated.
(c) Usually leads patients to develop tolerance.
(d) Can be associated with opiophobia i.e. reluctance of patients to take
opioid medication.
(e) Leads to physical dependence, which means that a patient has an
addiction.
Paravertebral block
19. The following structures form part of the contents of the paravertebral
space:
(a) Spinal nerves.
(b) Sympathetic rami communicantes.
(c) Dorsal root ganglia.
(d) Sympathetic ganglia.
(e) Fat.
20. Absolute contraindications for paravertebral blocks include:
(a) Patient refusal.
(b) Tumours in the paravertebral space.
(c) Cellulitis over the posterior chest wall.
(d) Previous thoracic surgery on the same side.
(e) Ankylosing spondylitis of the thoracic spine.
21. Complications reported after paravertebral blocks include:
(a) Pneumothorax.
(b) Severe disabling neurological injury.
(c) Hypotension.
(d) Vascular puncture.
(e) Failure.
22. Thoracic paravertebral blocks can be used for analgesia following:
(a) Nephrectomy.
(b) Shoulder replacement.
(c) Pulmonary lobectomy.
(d) Mastectomy.
(e) Open cholecystectomy.
Nerve blocks of the anterior abdominal Wall
23. Regarding abdominal wall anatomy:
(a) The nerve supply to the umbilicus is the posterior rami of T10.
(b) Transversus abdominis is the most superficial muscle.
(c) The transversus abdominis plane is between the transverses abdominis
muscle and the external oblique muscle.
(d) The arcuate line is found one third of the distance from the umbilicus to the
pubic crest.
(e) The rectus abdominis is divided by the linea alba.
24. Regarding rectus sheath block:
(a) The depth of the rectus sheath can be accurately predicted.
(b) Local anaesthetic is placed at the posterior wall of the rectus abdominis.
(c) Local anaesthetic will not spread through the sheath due to tendinous
intersections.
(d) Complications include puncture of inferior epigastric vessels.
(e) It is suitable for catheter insertion to provide prolonged analgesia.
25. Regarding ilioinguinal nerve block:
(a) The ilioinguinal nerve originates from the L1 nerve root.
(b) The iliohypogastric nerve originates from the L2 nerve root.
(c) The ilioinguinal nerve supplies the skin over the umbilicus.
(d) It has a success rate of over 90%.
(e) Femoral nerve block may be a complication.
26. Regarding transversus abdominis plane (TAP block):
(a) Ultrasound cannot be used for this block.
(b) It provides analgesia for visceral abdominal pain.
(c) Injection into the peritoneal cavity may result in a prolonged block.
(d) Low volume and high concentrations of local anaesthetic are
recommended.
(e) The triangle of Petit is bounded by the external oblique, the iliac crest and
lattissimus dorsi muscle.
Sympathetic blocks
27 Sympathetic blocks are used in the following conditions:
(a) Reynaud’s syndrome.
(b) Herpes zoster.
(c) Chronic pancreatitis.
(d) Migraine.
(e) Fracture pain of the lower limb.
28The following drugs can be used for sympatholysis:
(a) Lidocaine.
(b) Alcohol.
(c) Phenol.
(d) Guanethedine.
(e) Clonidine.
29The immediate effects of a sympathectomy include:
(a) Increased skin temperature.
(b) Contracted blood vessels.
(c) Decreased sweating.
(d) Muscle atrophy.
(e) Hair loss.
Epidural steroids
30Radicular pain is related to:
(a) Compression of the nerve alone.
(b) Effects of the leakage of contents of the nucleus pulposus.
(c) Disruption of the nerve supply of the annulus fibrosus.
(d) The production of hyperalgesic prostaglandins, thromboxanes and
leukotrienes.
(e) Suppression of production of phospholipase A2.
31.Regarding delivery of steroids to the epidural space:
(a) The caudal route is the most common technique used.
(b) The caudal route has the lowest incidence of dural puncture.
(c) Fluoroscopic guidance may improve the efficacy of steroid delivery.
(d) The transforaminal route can be performed without fluoroscopic guidance.
(e) The transforaminal route allows use of lower doses of steroids.
32. Concerning indications and contraindications for epidurals:
(a) Spinal stenosis can be treated with epidural steroids.
(b) Patients with post-lumbar laminectomy syndrome cannot be treated with
epidural steroids.
(c) Systemic infection is a relative contraindication.
(d) Congestive heart failure is a relative contraindication.
(e) Immunosupressed patients may require antibiotic prophylaxis before
procedure.
33. Concerning risks, evidence and controversies:
(a) Failure rates are negligible and patients do not need to be warned of this
outcome.
(b) Postdural puncture headache is ,1% for caudal injection.
(c) Evidence for caudal epidural steroids is strongest for lumbar spinal pain
with disc herniation and radiculitis.
(d) There is only very weak evidence for the use of interlaminar epidural
steroids in lumbar spinal stenosis.
(e) Particulate steroids have been implicated as a cause of anterior spinal
artery syndrome in transforaminal injections.
Chronic post-surgical pain
34. The following are risk factors for the development of chronic post-surgical
pain (CPSP):
(a) Increasing age.
(b) Severe postoperative pain.
(c) Laparoscopic surgery.
(d) Short operations.
(e) Primary surgical repair.
35. The following may help reduce the incidence of CPSP:
(a) Pre-emptive analgesia.
(b) Preventative analgesia.
(c) Aminoglycoside antibiotics.
(d) Steroids.
(e) Gabapentin following amputation.
36. The following are associated with the development of chronic pain:
(a) Reduced sodium channel expression.
(b) Microglial inactivation.
(c) Reduced glutamate release.
(d) Central sensitization.
(e) Reduced spontaneous neuronal discharge.
Pain and fibromyalgia
37. Regarding fibromyalgia:
(a) Terms like neurasthenia have been used in the past.
(b) It affects more than 10% of the population in the US.
(c) It is usually diagnosed between 20–50 years of age.
(d) There are 4 diagnostic criteria laid down by The American College of
Rheumatology.
(e) It can be confused with chronic fatigue syndrome.
38. Clinical features of fibromyalgia include:
(a) Localized pain.
(b) Fatigue.
(c) Sleep disturbance.
(d) Additional features like stiffness, headaches and restless legs.
(e) Diarrhoea.
39. In fibromyalgia:
(a) Levels of 5-HT and norepinephrine are high.
(b) The levels of substance P are low.
(c) The hypothalamic-pituitary-adrenal axis is disturbed.
(d) Trauma may be a trigger factor.
(e) Specific diagnostic tests are available to confirm the diagnosis.
40. Regarding management of fibromyalgia:
(a) Educating the patient regarding the condition plays an important role.
(b) Tri-cyclic agents are not beneficial in treating pain.
(c) There is evidence that strong opioids are beneficial.
(d) There is evidence that steroids are beneficial.
(e) Cognitive behavioural therapy is recommended.
Transcutaneous electrical nerve stimulation
Choose one single best answer, from (a) to (e), for each question for
questions 21-25:
41. For patients with normal skin sensation transcutaneous electrical nerve
stimulation (TENS) should initially be given to generate:
(a) A strong painful paraesthesiae over acupuncture points.
(b) A strong non-painful paraesthesiae over vertebrae segmentally related to
the pain.
(c) A strong painful paraesthesiae over the site of pain.
(d) A strong non-painful paraesthesiae over the site of pain.
(e) A paraesthesiae that is barely perceptible over the site of pain.
42. The purpose of conventional TENS is to:
(a) Stimulate large diameter, low threshold afferents (A-b) and small diameter,
high threshold afferents (A-d).
(b) Stimulate large diameter, low threshold afferents (A-b) without
simultaneously stimulating small diameter, high threshold afferents (A-d).
(c) Generate muscle twitches in order to activate small diameter muscle
afferents.
(d) Stimulate small diameter, higher threshold afferents (A-d)
without simultaneously stimulating large diameter, low threshold afferents
(A-b)
(e) Directly stimulate neurones in the spinal cord.
43. The mechanism of action of conventional TENS is predominantly by:
(a) Activating structures on the descending pain inhibitory pathways.
(b) Resetting central sensitization and reorganizing aberrant neuronal
pathways.
(c) Blocking impulses travelling in peripheral nociceptive afferents.
(d) Long-term depression of central nociceptor cell activity.
(e) Inhibiting second order central nociceptor cell activity in somatic receptive
fields.
44. Clinical research on TENS demonstrates that:
(a) TENS is definitely effective for the relief of all chronic pains.
(b) TENS has no value as an adjunct for the relief of acute pain.
(c) TENS may be effective for the relief of chronic pain although evidence is
often inconclusive due to methodological shortcomings.
(d) TENS should be used as a stand alone treatment for moderate to severe
pain.
(e) TENS is definitely not effective for the relief of chronic pain.
45. Suitable choice for electrode placement may include:
(a) Anterior and posterior over chest wall to treat angina pain.
(b) Over an area of diminished skin sensation to treat neuropathic pain.
(c) On the contralateral site in the treatment of phantom pain.
(d) Over the abdomen for pain relief during childbirth.
(e) Over the anterior neck for acute tonsillitis.
Spinal cord stimulation and its anaesthetic Implications
46. Mechanisms of action of spinal cord stimulators include:
(a) Stimulating GABA release.
(b) Stimulating lateral spinothalamic tracts.
(c) Stimulating nitric oxide release.
(d) Stimulating opioid release.
(e) Stimulating adenosine release.
47. In patients with an implanted pacemaker:
(a) Spinal cord stimulators can trigger pacemaker malfunction.
(b) Pacemakers should be in bipolar mode.
(c) Spinal cord stimulators should be in unipolar mode.
(d) Spinal cord stimulators are an absolute contraindication.
(e) Pacemakers can interfere with spinal cord stimulator function.
48. Indications for spinal cord stimulation include:
(a) Complex regional pain syndrome.
(b) Post-spinal cord transection pain.
(c) Failed back surgery syndrome.
(d) Post-amputation pain.
(e) Postoperative pain.
Assessment of neuropathic pain
49. Chronic neuropathic pain should be suspected in a patient reporting pain
with the following features:
(a) Dynamic mechanical allodynia.
(b) No evidence of neurological dysfunction.
(c) Pain related to a 3-week-old injury.
(d) Sensory loss.
(e) Hyperalgesia.
50. Accepted causes of neuropathic pain include:
(a) Post-thoracotomy pain.
(b) Diabetic neuropathy.
(c) Irritable bowel syndrome.
(d) Persistent low mood.
(e) Multiple sclerosis.
53. Recognized neuropathic pain mechanisms include:
(a) Nociceptor sensitization.
(b) Reduced serotonin receptor activity.
(c) NMDA receptor activation.
(d) Mast cell activation.
(e) Increased expression of sodium channels.
Headache and chronic facial pain
54. Regarding migraine:
(a) It predominately affects males.
(b) 30% of migraineurs have a positive family history.
(c) Migraine with aura is the most common type.
(d) Unilateral headache is more common.
(e) Ataxia may be a feature.
55. Cluster headaches:
(a) Affect males predominately with a M:F ratio of 9:1.
(b) Have a peak age of onset in the 20–40 year olds.
(c) Have a prevalence of 1–4%.
(d) Nausea and vomiting is common.
(e) There is a preceding aura.
56. Regarding trigeminal autonomic cephalagias:
(a) Short-lasting, unilateral neuralgiform headache attacks with conjunctival
injection and tearing syndrome (SUNCT) attacks last for 20 min.
(b) SUNCT attacks occur up to 100 times a day.
(c) SUNCT attacks mostly occur at night.
(d) Paroxysmal hemicrania is more common in men.
(e) Paroxysmal hemicrania is unresponsive to indomethacin.
57. Regarding trigeminal neuralgia (TGN):
(a) Diagnosis requires radiological imaging.
(b) Peak onset is in the fifth and sixth decade.
(c) 20% of patients with multiple sclerosis have TGN.
(d) Carbamazepine is the drug of choice.
(e) Microvascular decompression surgery has a 5% mortality.
58. Persistent idiopathic facial pain:
(a) Has an estimated incidence of 1%.
(b) Predominantly affects females.
(c) Simple analgesics are effective.
(d) Radiological investigation demonstrates relevant abnormality.
(e) Inflammatory bowel disease is a common association.
Intrathecal opioids in the management of acute postoperative pain
59. When administering intrathecal morphine:
(a) Onset of analgesia can be expected within the first thirtyminutes.
(b) Parenteral morphine formulations may be used.
(c) Patients on long term opioids should receive their prescribed dose before
intrathecal opioid administration.
(d) Combination with hyperbaric bupivacaine reduces baricity.
(e) Neurotoxicity is a risk with repeated administrations.
60. With reference to the physicochemical properties of lipophilic intrathecal
opioids:
(a) Longer duration of action can be expected with low pKa values and higher
octanol: water coefficients.
(b) Ionised amine groups within the morphine molecule are responsible for its
enhanced water solubility over other opioids.
(c) The potency ratio of fentanyl: morphine is greater following intrathecal
administration compared to systemic administration.
(d) Increasing pKa leads to a faster onset of action.
(e) Fentanyl is predominantly unionised within the dorsal horn.
61. Concerning pharmacokinetics of intrathecal opioids.
(a) Fentanyl demonstrates significant rostral spread in the CSF.
(b) Morphine has a low volume of distribution in the spinal cord.
(c) ‘Ion trapping’ facilitates fentanyl binding to receptor sites in the spinal cord.
(d) CSF concentration falls rapidly following injection of fentanyl.
(e) Diamorphine is eliminated more rapidly from the CSF than morphine.
62. Following administration of intrathecal opioids:
(a) Binding to G protein linked opioid receptors results in hyperpolarisation of
dorsal horn neurones.
(b) Fentanyl reduces C fibre sensory transmission.
(c) Kappa receptor activation mediates calcium channel closure.
(d) Uptake of morphine occurs into the posterior radicular artery
(e) Diamorphine is metabolised to morphine 6 glucuronide in the spinal cord.
63. With reference to the side effects of intrathecal morphine:
(a) All patients should be monitored in a high dependency area.
(b) The incidence of nausea is related to the dose administered.
(c) Morphine-6-glucuronide is the principal cause.
(d) Antihistamines reduce opioid induced pruritus due to selective antagonism
at H1 receptors in the spinal cord.
(e) The diagnosis of respiratory depression should be confirmed with blood
gas analysis.
Serotonin and anaesthesia
64. Serotonin (5-HT):
(a) Is produced from tryptophan.
(b) Is found in platelets and mast cells.
(c) Has only 3 receptor subtypes.
(d) Acts at both the chemoreceptor trigger zone and the vomiting centre.
(e) Is devoid of effect on the heart.
65. Selective Serotonin-Reuptake Inhibitors (SSRIs):
(a) The mechanism of serotonin syndrome is overstimulation of central 5-HT
receptors.
(b) Must always be stopped in the perioperative period.
(c) Are safe in combination with high doses of tricyclic antidepressants.
(d) Hyperreflexia and clonus are manifestations of CNS toxicity.
(e) Neuroleptic malignant syndrome is a consequence of overdose.
66. 5-HT receptor agonists and antagonists:
(a) 5-HT3 antagonists must always be given as sole agents for PONV.
(b) Triptans are 5-HT1 receptor agonists.
(c) Triptans are indicated for the prodromal phase of migraine.
(d) 5-HT4 agonism has anti-anginal utility.
(e) Ketanserin is a 5-HT2 receptor antagonist.
67. In pre-eclampsia:
(a) Trophoblastic fragmentation may trigger serotonin release from platelets.
(b) The disease process is limited to the cardiovascular system.
(c) Ketanserin has an antihypertensive effect similar to that of hydralazine.
(d) Ketanserin reduces the incidence of the syndrome of haemolysis, elevate
liver enzymes and low platelets (HELLP).
(e) Ketanserin is licensed in the UK.
Transdermal drug delivery systems
68. Regarding the skin:
(a) The epidermis is the thickest layer.
(b) The stratum corneum is the greatest barrier to transdermal transport.
(c) The dermis has a rich capillary blood supply.
(d) Skin hydration is a cause of inter-individual variation in drug absorption.
(e) Increasing body temperature increases the transdermal absorption of
fentanyl.
69. Properties of a drug suitable for transdermal use include:
(a) High molecular mass.
(b) Low lipophilicity.
(c) Low required daily dose.
(d) Low potency.
(e) High partition coefficient.
70. Problems with opioid TDDS include:
(a) Poor patient compliance.
(b) Allergy.
(c) Constipation.
(d) Respiratory depression.
(e) Cognitive dysfunction.
Epidural drug delivery and spinal infection
71. The risk of spinal infection after epidural drug delivery (EDD)
is increased by:
(a) Diabetes.
(b) Increasing age.
(c) Alcoholic liver disease.
(d) Pregnancy.
(e) Renal failure requiring haemodialysis.
72. Spinal infection after lumbar epidural drug delivery:
(a) Presents with back pain in 90% cases.
(b) Presents with fever in about 2/3 cases.
(c) Can be excluded by finding a normal CRP.
(d) Leads to motor block late in its presentation.
(e) Should be investigated by lumbar spine MRI scan.
73. The prognosis for neurological recovery after spinal infection:
(a) Is worse after infection at thoracic levels.
(b) Is worse in those with spinal stenosis.
(c) Is worse in children.
(d) Is better in those with tuberculous infection.
(e) Is worse if diagnosis is delayed for more than 36 hours.
Acupuncture in pain management
74. Electro acupuncture:
(a) Encephalins are released at 1–2 Hz.
(b) Encephalins are released at 12–15 Hz.
(c) Encephalins are released at 100 Hz or above.
(d) Endorphin is released at 100 Hz or above.
(e) Dynorphin is released at 100 Hz or above.
75. Acupoints and meridians:
(a) A meridian is a predetermined anatomical point where an acupuncture
needle is positioned.
(b) A meridian describes a channel for energy flow in the body.
(c) Meridians exceed 400 in number.
(d) There are 20 known acupoints on the body.
(e) Energy flow (Qi) can be easily measured.
76. The mechanism of action of acupuncture:
(a) Needling attenuates the release of opioids in the body.
(b) Local blood flow is reduced at the acupoint, thereby reducing
inflammation.
(c) Acupuncture is thought to block the meso-limbic loop in the brain.
(d) Acupuncture is thought to attenuate the serotinergic system in the brain.
(e) Acupuncture is thought to augment the noradrenergic system in the brain.
77. Acupuncture has a proven role in the treatment of:
(a) Trigeminal neuralgia.
(b) Cervico-brachial syndrome.
(c) Dental pain.
(d) Post operative nausea.
(e) Pregnancy-related nausea.
78. The following are absolute contraindications to acupuncture:
(a) Systemic sepsis.
(b) Concurrent anticoagulant drugs.
(c) Cellulitis.
(d) Burns.
(e) Pregnancy.
Opioids in persistent non-cancer pain
79. Chronic pain:
(a) Is an uncommon medical condition
(b) Usually requires medical attention
(c) Is associated with a reduction in the levels of physical, psychological and
social functioning
(d) Is usually treated appropriately with strong opioid medication
(e) Has minimal therapeutic options besides pharmacotherapy
80. With regard to strong opioids:
(a) The number of prescriptions for strong opioids has increased by
approximately 70% since 1998
(b) Strong opioids have excellent long-term efficacy and
safety data, relating to their use in persistent non-cancer pain
(c) There is evidence for efficacy in the treatment of neuropathic pain
(d) Long-term use rarely leads to physical dependence
(e) Continued use can lead to tolerance, probably mediated by the N-methylD-aspartate receptor system
81. Concerning the side effects of strong opioids:
(a) Side-effects occur in approximately 80% of patients
(b) The most commonly experienced adverse effects relate to
cognitive function
(c) Strong opioids are better tolerated when delivered via the
transdermal route, rather than orally
(d) The use of strong-opioids is a contraindication to driving a
motor vehicle
(e) The prescribing doctor has a legal responsibility to inform the
DVLA if he or she thinks a patient is unfit to drive
Complex regional pain syndrome
82. The following are recognised signs and symptoms of CRPS:
(a) Burning pain.
(b) Osteoarthritis.
(c) Atrophy of the skin, hair and nails.
(d) Vasodilatation.
(e) Allodynia.
83. Concerning the treatment of CRPS:
(a) A graduated exercise programme that does not aggravate the pain is
essential.
(b) The mode of action of calcitonin and bisphosphonates is unknown.
(c) Amputation should be considered if the pain is refractory.
(d) The treatment regimen does not require a multidisciplinary approach.
(e) Opiates are the first-line treatment option.
84. Concerning sensory changes:
(a) The sensory deficit is dermatomal.
(b) All patients suffer from hyperalgesia to mechanical stimuli.
(c) The pain is continuous burning, aching, shooting or prickly in nature.
(d) All patients suffer from severe allodynia.
(e) Temperature and proprioception deficits are the first symptoms to appear.
85. With regard to neuromodulation:
(a) Spinal cord stimulation affects sensory dorsal nerve roots as well as the
descending inhibitory pathways within the spinalcord.
(b) Neuromodulation involves spinal cord stimulation and peripheral nerve
stimulation.
(c) Spinal cord stimulation may induce the endogenous release of opioids.
(d) Invasive treatments offer acceptable results and good value for money.
(e) Spinal cord stimulation with no other treatment modalities, has a significant
effect on pain at 6 months.
86. The following are recognised causes of CRPS:
(a) Myocardial infarction.
(b) Frostbite.
(c) Crush injury.
(d) Sprain.
(e) Burns.
87. In patients with simple mechanical back pain:
(a) Pain arising from facet joints is more common in the elderly than
in young adults.
(b) Referred leg pain is well localized.
(c) Neuropathic pain is common.
(d) Investigation by plain radiographs is recommended.
(e) Discogenic pain accounts for 40% of cases.
88. Red flag markers for serious spinal pathology include:
(a) Previous history of spinal trauma.
(b) Pain persisting for >1 yr.
(c) History of steroid use.
(d) History of depression.
(e) Presentation under the age of 20 yr.
89. In patients with mechanical low back pain:
(a) Epidural injection is a useful treatment.
(b) Rest and not exercise should be advised.
(c) Complete pain relief is the primary goal.
(d) Psychological treatments should be used after all other treatments have
failed.
(e) Strong opioids should be avoided.
90. The management of acute postoperative pain in patients with chronic or
cancer pain on high dose opioids before surgery:
(a) Is entirely predictable.
(b) Is the same as for the opioid addicted patient requiring surgery.
(c) Should include a preoperative analgesic plan.
(d) Should not include the neuraxial administration of opioids.
(e) Requires regular reassessment of their analgesic requirements.
91. A patient who presents for surgery and uses transdermal fentanyl 75 mg
h_1 for the control of chronic pain:
(a) Will require _225--314 mg oral morphine (or parenteral equivalent) per 24
h in the postoperative period.
(b) Should remove their patch before surgery.
(c) Should be managed with intravenous fentanyl postoperatively.
(d) Is less likely to experience itching or nausea and vomiting in response to
an i.v. morphine infusion than an opioid-naive patient.
(e) Should be recommenced on a fentanyl patch 75 mg h_1 before discharge
from hospital.
92. Oral morphine 10 mg is equivalent to:
(a) Intramuscular morphine 5 mg.
(b) Intravenous morphine 3.3 mg.
(c) Subcutaneous diamorphine 2.5 mg.
(d) Intravenous morphine 1 mg.
(e) Epidural morphine 0.1 mg.
93. Neuropathic pain:
(a) Is rare in diabetics.
(b) Is always controllable with opioids.
(c) Involves peripheral nociceptors.
(d) Can be produced by peripheral nerve damage.
(e) Occurs in all patients with peripheral neuropathy.
94. The following drugs are used as first-line treatments in neuropathic pain:
(a) Amitriptiline.
(b) Carbamazepine.
(c) Oxycodone.
(d) Gabapentin.
(e) Transdermal fentanyl.
95. Common clinical features of neuropathic
pain are:
(a) Allodynia.
(b) Hyperalgesia.
(c) Reduced skin sensation.
(d) Changes in skin colour.
(e) Dysaesthesia.
96. NMDA receptor antagonists:
(a) May be effective in somatic pain.
(b) May be effective in neuropathic pain.
(c) Have significant side-effects.
(d) Are commonly used in the management of neuropathic pain.
(e) Cannot be given orally.
Pain management programmes
97. Pain management programmes:
(a) Aim primarily to reduce the intensity of the pain that the patient feels.
(b) May involve the patient’s family.
(c) May be in-patient or out-patient based.
(d) Usually involve increasing the patient’s analgesic medication.
(e) Primarily rely on physical therapies to bring about behavioural change.
98. People with chronic pain:
(a) May have fear of movement that exacerbates their disability.
(b) Are generally very similar in terms of their pre-morbid coping strategies
and personality.
(c) Can commonly be managed successfully by a sole practitioner.
(d) Need psychological assessment before entering a PMP.
(e) Often benefit functionally from taking the opportunity to
considerably increase their level of activity when symptoms are quiescent.
99. Cognitive behavioural intervention for chronic pain patients:
(a) May go on for many years.
(b) Is a form of psychoanalysis.
(c) Is known to have lasting effects over many decades.
(d) Involves encouraging patients to challenge their beliefs about their
condition.
(e) Involves getting the patient to understand that emotions are not related to
thoughts and behaviour.
100. During a pain management programme:
(a) Educational sessions are usually delivered by a doctor and a
physiotherapist.
(b) Patients are introduced to a graded exercise programme.
(c) ‘Pacing’ involves activity level being predicted by pain intensity.
(d) Patients are encouraged to regularly visit their GP or hospital doctor for
advice.
(e) Patients are discouraged from planning ahead for possible exacerbations
in pain because it may depress their mood.
101. Concerning epidural entry:
(a) The interlaminar approach enters the anterior epidural space.
(b) The ‘hanging drop’ technique is useful with a difficult lumbar spine.
(c) Maximal flexion of the cervical spine aids safe cervical entry.
(d) The T5--6 space is best approached by a paramedian route.
(e) Piercing the sacrococcygeal ligament is a reliable method of providing
lumbo-sacral anaesthesia in the adult.
102. With respect to the anatomy of the epidural space:
(a) Superiorly it is limited by the sacro-coccygeal ligament.
(b) The posterior venous plexus is generally largest at the lumbar level.
(c) Laterally is the pedicle of the vertebra and the intervertebral foramen.
(d) The spinal cord ends at L4.
(e) The dural sac ends by forming the cauda equina.
103. The following statements are true:
(a) The first ‘recognizably typical’ vertebra is C2.
(b) Cervical entry should not be attempted until lumbar techniques have been
mastered.
(c) Cervical spinal nerve C7 exits the spinal canal in the intervertebral
foramen between C6 and C7.
(d) In everyday use, if difficulty is encountered in the thoracic region with a
paramedian approach, a transforaminal approach is reasonable.
(e) X-ray screening is necessary for safe catheterisation of the thoracic
epidural space.
104. Concerning the anatomy and pathophysiology of postoperative pain after
thoracic surgery:
(a) Posterolateral thoracotomy is the most common incision and gives rise to
the worst pain.
(b) A posterolateral thoracotomy incision usually crosses about six
dermatomal levels.
(c) A median sternotomy is the least painful incision.
(d) The muscle-sparing thoracotomy reduces post-operative acute pain
without affecting access.
(e) Stimuli from the skin and intercostal muscles are mediated via the vagus
nerves.
105. The following factors contribute to acute post-thoracotomy pain:
(a) Skin and muscle trauma.
(b) Posterior costovertebral ligament damage.
(c) Shoulder pain.
(d) Chest drains.
(e) Anxiety.
106. The following produce reliable dynamic analgesia after thoracotomy:
(a) Thoracic epidural local anaesthetic and opioid combinations.
(b) Paravertebral nerve blockade.
(c) I.V. opioid infusions.
(d) Intrathecal morphine.
(e) Lumber epidural local anaesthetics with opioids.
107. Concerning the delivery of a pain service for post-thoracotomy pain:
(a) The aim of pain control is to achieve low pain scores at rest.
(b) Ordinal pain scores are the most reproducible.
(c) A balanced technique and multidisciplinary input provides the best overall
pain relief.
(d) Dynamic analgesia is defined as when a patient is able to move freely and
cough effectively with a low pain score.
(e) Only dynamic analgesia decreases post-thoracotomy respiratory
complications.
108. In the treatment of chronic pain, tricyclic antidepressants:
(a) Enhance ascending inhibitory activity in the spinal cord.
(b) Are less effective if they are mixed reuptake inhibitors compared with
those which specifically inhibit serotonin or norepinephrine.
(c) Are contraindicated in recent myocardial infarction.
(d) Are prescribed primarily to elevate mood.
(e) Initially produce sedative side-effects, which tend to wear off after a few
days.
109. Regarding antiepileptic drugs:
(a) Gabapentin acts on the GABA receptor.
(b) Carbamazepine is the treatment of choice for trigeminal neuralgia.
(c) Lamotrigine probably suppresses the action of glutamate at sodium
channels.
(d) Glutamate is an inhibitory amino acid.
(e) Sodium valproate decreases GABA levels in the central nervous system.
110. In selecting an antiarrhythmic treatment for chronic pain:
(a) Lidocaine is effective orally.
(b) Mexiletine has very few gastrointestinal side-effects.
(c) Lidocaine is used clinically to predict the utility of other membranestabilizing drugs.
(d) Studies support their long-term use.
(e) Generally, mexiletine and lidocaine are free from serious adverse effects.
111. Regarding neuronal hyperexcitability:
(a) Formation of neuromata from regenerating axonal sprouts may contribute
to the phenomenon.
(b) Spontaneous electrical discharge is seen in neuromata.
(c) It may be helped by the use of non-specific potassium channel blockers to
suppress activity.
(d) Low-dose lidocaine may block glutamate activity in the spinal cord.
(e) Anticonvulsants and antiarrhythmics have no role in treatment.
Opiods receptors
112. Which receptor--ligand pair is correct:
(a) NOP receptor--endomorphin.
(b) KOP receptor--dynorphin.
(c) MOP receptor--N/OFQ.
(d) DOP receptor--naloxone.
(e) Sigma receptor--naloxone.
113. Cellular mechanism elicited by N/OFQ at the NOP receptor include:
(a) Activation of voltage-sensitive calcium channels.
(b) Stimulation of potassium efflux.
(c) Inhibition of cAMP formation.
(d) Stimulation of adenylyl cyclase.
(e) Reduced neuronal cell excitability.
114. Supraspinally administered N/OFQ causes:
(a) Analgesia.
(b) Anti-analgesia.
(c) Detrusor muscle spasm.
(d) Potentiation of MOP receptor-induced analgesia.
(e) Antagonism of MOP receptor-induced analgesia.
115. With respect to drugs acting at opioid receptors:
(a) MOP receptor agonists produce analgesia.
(b) KOP receptor agonists produce euphoria.
(c) NOP receptor agonists applied supraspinally produce analgesia.
(d) DOP receptor agonists produce analgesia.
(e) NOP antagonists produce analgesia.
116. In a patient with burns, the amount of acute pain experienced:
(a) Is related but not directly proportional to the area of the burn.
(b) Is none or slight in burns in which a high percentage are full thickness.
(c) Can be reduced by cooling the burn with tap water.
(d) Is best treated with intramuscular opioids.
(e) May be influenced by psychological factors such as fear.
117. Burns dressings:
(a) Always require general anaesthesia.
(b) Can take 1--2 h in a major burn.
(c) Can be managed using intravenous sedation with midazolam alone.
(d) Are amenable to the use of ketamine, especially in children.
(e) May contribute to secondary hyperalgesia.
118. Rare, non-burn causes of pain in the burned patient may include:
(a) Colonic pseudo-obstruction.
(b) Heterotopic bone deposition.
(c) Compartment syndrome in a limb.
(d) Associated skeletal trauma.
(e) Donor site pain.
119. Phantom pain:
(a) After limb amputation has an incidence of 90%.
(b) Can be exacerbated by spinal anaesthesia.
(c) Occurs with the same frequency in both traumatically amputated limbs and
in congenitally absent limbs.
(d) Occurs only after limb amputation.
(e) Is characteristically localized in the proximal area of the amputated limb.
120. Risk factors for phantom pain include:
(a) Bilateral limb amputation.
(b) Persistent stump pain.
(c) Male gender.
(d) Lower limb amputation.
(e) Pre-amputation pain.
121. Treatment for phantom pain may include:
(a) Preoperative epidural analgesia.
(b) Provision of a well-fitting prosthesis.
(c) Surgery.
(d) Use of the mirror box, which has been successful in the treatment of
spasms in the phantom hand.
(e) Multimodal therapies.
122. With respect to analgesics used in the critically ill:
(a) The metabolites of morphine are excreted by the kidney.
(b) Morphine metabolites are removed by haemodialysis.
(c) The rate of alfentanil infusion should be reduced in patients with liver
dysfunction.
(d) Remifentanil is metabolised by red cell esterases.
(e) Dexmedetomidine is 6 times more potent than clonidine at the α1-receptor.
123. With respect to pain in critically ill patients:
(a) It is frequently overestimated.
(b) Epidural analgesia following major surgery has been shown to decrease
pulmonary complications in the postoperative period.
(c) Of clinically important spinal haematomas, 20% occur after removal of
epidural catheter.
(d) Pain during hospitalisation is the variable most associated with persistent
pain after discharge.
(e) Critical illness neuropathy involves both sensory and motor nerves.