109年 - 109 台灣疼痛醫學會專科醫師考題#120915

1. The innervation of deep somatic tissue like muscle and joint is quite complex. Which of the following description is not appropriate? (A) The nociceptors are predominantly activated by non-physiological stimuli which may cause damage to the structures (e.g. overload, twisting, strong pressure, ischemic contraction). information within the central nervous system. (B) During inflammation or after trauma, nociceptors of joint and muscle show pronounced sensitization, in particular for mechanical stimuli. (C) Descending inhibition is enhanced during chronic inflammation but seems to be normalized during acute inflammation. (D) Both primary afferent fibers as well as sympathetic reflexes may aggravate inflammatory lesions. (E) Reduced release of hormones from the hypothalamic-pituitary-adrenal (HPA) axis such as cortisol, adrenal androgens and testosterone may cause a relative loss of anti-inflammatory activity..

2. Which of the following description about autonomic, endocrine and immune interactions in pain is correct? (A)Signaling from the immune system to the CNS via vagal afferents and possibly small-diameter afferents innervating somatic tissues to induce sickness behavior (B) Modulation of the immune system and the inflammatory response by CNS circuits that control the production and release of neuroendocrine hormonal mediators in the sympathoadrenal stress axis (C)Coupling of the sensory nociceptive and sympathetic efferent components of the peripheral nervous system in the setting of inflammation and nerve injury to produce sympathetically maintained pain (D) All of above

3. Which one of the following statements is wrong? (A) All nociceptors are myelinated. (B) Following a cutaneous injury, enhanced pain in response to cutaneous stimuli, called hyperalgesia, develops at the site of injury (primary hyperalgesia) and in the surrounding uninjured skin (secondary hyperalgesia). (C) Tissue injury leads to enhanced responsiveness of nociceptors, called sensitization, which accounts for primary hyperalgesia. (D) When nerves are severed, spontaneous activity and ectopic mechanical, thermal, and chemical sensitivity develop in the injured nociceptors.

4. Which one of the following statements is wrong? (A) The perception of pain arising from a noxious stimulus starts with conversion of the energy of the stimulus into an electrical signal in the primary afferent neurons innervating the site of the stimulus. (B) This process of energy conversion is called transduction. (C) The three general modalities of noxious stimuli that impinge on the body are chemical, thermal, and mechanical. (D) Specific proteins or groups of proteins called transducers underlie the process of transduction. (E) All of the above are correct.

5. Which one of the following statements is wrong? (A) Pain and hyperalgesia arise in part from the action of inflammatory mediators on the peripheral terminals of nociceptive neurons. (B) The list of inflammatory mediators may include arachidonic acid metabolites, bradykinin, adenosine triphosphate and nitric oxide. (C) A series of inflammatory cytokines and chemokines, such as tumor necrosis factor-α and interleukin-1β, and growth factors, particularly nerve growth factor, are capable of changing the response properties of pain-signaling neurons. (D) The inflammatory mediators may activate nociceptive terminals or regulate gene expression of nociceptors. (E) All of the above are correct.

6. Which one of the following statements is wrong? (A) Neuron–glial interactions are increasingly recognized as being key for physiological and pathological processes in the central nervous system. (B) Microglia in the spinal dorsal horn respond to injury to peripheral nerves by adopting a specific response state characterized by up-regulation of the purinergic receptor P2X4. (C) In this P2X4R+ state, microglia release brain-derived neurotrophic factor, which disinhibits neurons in the spinal nociceptive processing network. (D) The transformation in processing caused by signaling of P2X4R+ microglia to nociceptive transmission neurons may account for the main symptoms of neuropathic pain in humans. (E) All of the above are correct.

7. Which one of the following statements is wrong? (A) The spinal dorsal horn receives input from a wide variety of primary afferent axons, including nociceptors, which respond to tissue-damaging stimuli from the skin, muscles, joints, and viscera. (B) The patterns of termination of primary afferents within the spinal cord are related to axonal diameter and receptive field modality. (C) Most nociceptive primary afferents have slowly conducting fine myelinated or unmyelinated axons, and they terminate mainly in the deep part of the dorsal horn. (D) Primary afferents release a variety of chemical mediators and on entering the dorsal horn they form excitatory synapses with neurons located within it.

8. Which of the following description about spinal cord plasticity and pain is incorrect? (A) Some spinal nociceptive neurons receive convergent input from high- and low- threshold sensory fibers thus called wide–dynamic range neurons (B) Glutamate is the major fast excitatory neurotransmitter in all nociceptive afferent nerve fibers. Glutamate can bind to three types of ionotropic glutamate receptors and to G protein–coupled metabotropic glutamate receptors to modify neuroexcitability. (C) Hyperalgesia and allodynia can even be induced in humans in the absence of any sensory stimuli, such as during prolonged application of opioids or on abrupt withdrawal of opioids.. (D) Spinal nociception is under powerful control from descending inhibitory and facilitatory pathways. Under normal conditions, descending facilitation appears to prevail over inhibitory pathway.

9. About epidural steroid injection, which one of following statements is wrong? (A) Spinal stenosis is an indication for epidural steroid.. (B) Do not use for non-specific low back pain. (C) Do not repeat more than three times per year. (D) May cause pain from chronic arachnoiditis. (E) Efficacy is less with radicular pain that has lasted longer than 3 months.

10. Adjuvant analgesics are often prescribed for managing caner pain, but which of the following drug – indication is not considered ? (A) NSAIDs for Soft tissue pain (B) Anticonvulsants for Neuropathic pain (C) Steroids for Soft tissue pain (D) Baclofen for Muscle spasm (E) Benzodiazepines for Muscle spasm

11. The innervation of deep somatic tissue like muscle and joint is quite complex. Which of the following description is not appropriate? (A) The nociceptors are predominantly activated by non-physiological stimuli which may cause damage to the structures (e.g. overload, twisting, strong pressure, ischemic contraction). (B) During inflammation or after trauma, nociceptors of joint and muscle show pronounced sensitization, in particular for mechanical stimuli. (C) Descending inhibition is enhanced during chronic inflammation but seems to be normalized during acute inflammation. (D) Both primary afferent fibers as well as sympathetic reflexes may aggravate inflammatory lesions. (E) Reduced release of hormones from the hypothalamic-pituitary-adrenal (HPA) axis such as cortisol, adrenal androgens and testosterone may cause a relative loss of anti-inflammatory activity.

12. Pain disorder may result in the sleep problem, and which of the sleep pattern is not often seen in patients: (A) acute pain following surgical procedures is associated with reduced and fragmented sleep (B) acute postsurgical pain may result in diminished amounts of slow wave and rapid eye movement (REM) sleep (C) patients with chronic pain may suffered from reduced sleep efficiency and altered sleep architecture (increased wakefulness and stage 1 non-REM sleep) (D) subjects subjected to noxious stimuli during all stages of sleep will demonstrate a sleep awakening response and a moderate level of cortical arousal. (E) all of the above are common found in pain patients

13. 治療 Postamputation pain 下列用藥，何者最不適合？ (A) Imipramine (B) Gabapentine (C) Pregabalin (D) Memantine (E) Tramadol

14. 有關 Post-Herpetic neuralgia (PHN) 導致相關症狀，下列何者描述最不適合？ (A) Ongoing pain at rest (B) Brush-evoked pain (C) Joint hyperalgesia (D) Heat-hyperalgesia (E) Cold-hyperalgesia

15. 有關 Post-stroke pain 之疼痛症狀類型中，下列描述何者最不適合？ (A) Central post-stroke pain 屬於 neuropathic type (B) Shoulder pain 不屬於 neuropathic type (C) Musculoskeletal pain 不屬於 neuropathic type (D) Headache 屬於 neuropathic pain (E) Spasticity 不屬於 neuropathic type

16. 有關 Common Types of Acute and Chronic Neuropathic Pain 下列敘述，何者最不適合？ (A) Trigeminal neuralgia (TN)(tic douloureux) 屬於 central neuropathic pain (B) Compressive myelopathy from spinal stenosis 屬於 central neuropathic pain (C) HIV myelopathy 屬於 central neuropathic pain (D) Multiple sclerosis-related pain 屬於 central neuropathic pain (E) Syringomyelia 屬於 central neuropathic pain

17. 有關 Post-Herpetic Neuralgia (PHN) 治療，就目前已經發表的 Clinical Trials 下列何者藥物，效果最不明顯(negative results)？ (A) Nortriptyline (B) Carbamazepine (C) Gabapentin (D) Oxycodone (E) Lidocaine-topical

18. Which of the following site of lesion with its referral site of pain is not common? (A) Diaphragmatic irritation with Shoulder (B) Urothelial tract with Inguinal region and genitalia (C) L1–2 with Sacroiliac joint and hip (D) Pharynx with Ipsilateral ear (E) all of the above are common patterns of pain referral

19. Which of the following patterns of pain is not attributed to a typical breakthrough pain syndrome? (A) pain is exacerbated by volitional actions of the patient (B) pain is exacerbated by non-volitional events (C) exacerbations of pain associated with failure of anlagesia (D) Neuropathic non–movement-related pain (E) Visceral pain—volitional or non-volitional

20. Which of the followings is not suggested for the use of opioids for cancre pain in children? (A) Treat opioid side effects promptly. (B) Use the transdermal route first in most circumstances. (C) If side effects are bothersome with one opioid, consider switching to another one. (D) Treat constipation pre-emptively. (E) all of the above should be suggested for prescription of opioids in cancre pain in children

21. Which of the following adjuvant analgesic is not suggested for its following indication in the management of cancer pain? (A) Non steroidal anti-inflammatory/analgesic drugs (NSAIDs) for Musculoskeletal pain (B) Antidepressants for Neuropathic pain (C) benzodiazepines for Muscular spasm (D) Phenothiazines or Butyrophenones for Hallucinations (E) all of the above adjuvant analgesic are suggested for its following indication in the management of cancer pain.

22. Which of the following practice in the management of cancer pain and associated events for the dying patients in the last hours and days of life is not advisable? (A) Non-essential drugs should be discontinued (B)If the insight of the patient, family, and carers into the patient’s condition is identified, high dose of opioids should be discontinued to avoid respiratory depression (C)”As-required” subcutaneous medication is prescribed according to an agreed protocol to manage pain (D) Decisions are made to discontinue inappropriate interventions. (E) all of the above are acceptable practices.

23. Which of the following is not true about the properties of visceral pain? (A) It is diffuse in character and poorly localized. (B) It is typically referred rather than being felt at the source. (C) It is produced by stimuli different from those adequate for activation of somatic nociceptors. (D) Distention of hollow organs may induce adequate stimuli for production of visceral pain. (E) It is associated with emotional and autonomic responses but much less than those associated with somatic pain.

24. Which of the following is not true about chronic pelvic pain without pathology (CPP)? (A) CPP is defined as non-menstrual pelvic pain of 6 or more months’ duration that is severe enough to cause functional disability or to require medical or surgical treatment. (B) CPP is common and estimated to account for 40% of all gynecologic diagnostic laparoscopies. (C) A history of childhood physical and/or sexual abuse has been correlated with the development of CPP. (D) The best evidence-based management of patients with CPP is multidisciplinary care.. (E) All of the answers above are correct.

25. Which of the followings is probabaly a less predictive addition indicator? (A) Selling prescription drugs (B) Multiple episodes of loss of prescriptions (C) Repeated resistance to changes in therapy despite clear evidence of adverse physical or psychological effects from the drug (D) Resistance to a change in therapy associated with “tolerable” adverse effects with expressions of anxiety related to the return of severe symptoms (E) Concurrent abuse of alcohol or illicit drugs

26. Which of the following oral opioids is not recommended for padiatric patients with cancer pain? (A) morphine (B) hydromorphone (C) oxycodone (D) meperidine (pethidine) (E) all of the above can be prescribed for pediatric patients with cancre pain

27. Which of the following cell type sense the initial “endanger signal” and participates in the initial phase of pathogenesis of the nerve injury induced neuropathic pain? (A) Microglia (B) Spinal lamina I and II neuron (C) Astrocyte (D) oligodendrocyte

28. Pain is a frequent consequence of spinal cord injury (SCI). Which of the following statement is least likely: (A) Below-level neuropathic pain is most likely described as severe or excruciating months or years following initial injury. (B) Damage to the spinothalamic tracts is an important ingredient in the development of neuropathic pain following SCI. (C) Chronic musculoskeletal pain is common in tetraplegic patients after SCI. (D) Patients with cervical SCI are at risk of developing CRPS affecting upper limbs. (E) Below-level neuropathic pain is also referred to deafferentation pain.

29. Which of the following painful disorder is more common in male patients than in female patients? (A) migraine (B) rheumatoid arthritis (C) irritable bowel syndrome (D) cornary artery disease ( older than 60 years old) (E) all of the above are more common than in female patients.

30. Which of the following statement concerning painful polyneuropathies with prevalent loss of small fibres is most likely: (A) Chronic renal failure neuropathy. I. (B) Diabetes mellitus neuropathy. (C) Alcoholic neuropathy. (D) Myeloma neuropathy.. (E) soniazid neuropathy.

31. 叢發性頭痛(cluster headache)急性發作時，下列何種藥物不具治療角色? (A)皮下注射 sumatriptan (B)經鼻給予 zolmitriptan (C)經鼻給予 lidocaine 至翼齶窩(pterygopalatine fossa) (D)靜脈注射 dihydroergotamine (E)口服 verapamil

32. 下列何者不是偏頭痛(migraine)常見症狀？ (A)單側性疼痛 (B)搏動性疼痛 (C)痛到眼窩後方 (D)噁心嘔吐 (E)對光與聲音敏感

33. 下列何者不是典型三叉神經痛(classic trigeminal neuralgia)的臨床特徵? (A)發作前常無預兆 (B)表淺的、尖銳的、針刺樣或撕裂樣的劇烈疼痛 (C)持續超過 10 分鐘以上 (D)在個別患者發作型態變化不大 (E)無神經缺陷

34. 下列何者為最常見的頭痛型態？ (A)偏頭痛(migraine) (B)緊張性頭痛(tension-type headaches) (C)叢集性頭痛(cluster headaches) (D)頸因性頭痛(cervicogenic headache) (E)次發性頭痛(Secondary headaches)

35. 下列關於原發性口腔灼熱症候群(burning mouth syndrome)的描述，何者為非? (A)症狀局限於舌頭處 (B)表現灼熱及感覺異常 (C)常伴隨味覺功能障礙 (D)涉及對感覺神經元和自主神經元的損害 (E)藥物治療包含三環類抗抑鬱藥、抗癲癇藥或鴉片類藥物

36. Which of the following statement concerning painful polyneuropathies with prevalent loss of small fibres is most likely: (A) Chronic renal failure neuropathy. I. (B) Diabetes mellitus neuropathy. (C) Alcoholic neuropathy. (D) Myeloma neuropathy.. (E) soniazid neuropathy.

37. Which of the following is the acceptable statement about neurodestructive RF lesions? (A) These temperatures are resulted from friction heat. (B) The size of RF lesion with 22 gauge RF needle is around with a radius of 5 mm (C) The heat is generated on the tip of RF needle. The RF needle then heat up the tissues. (D) The RF pernanent neuro-destructive lesion is formed when neural temperatures exceed 42 C (E) All of the above

38. Which of the following suggestion is not advisable for the use of opioids in children with cancre pain? (A) Use the oral route first in most circumstances (B) Treat constipation pre-emptively. (C) If side effects are bothersome with one opioid, consider switching to another one. (D) Use sufficient doses to keep the patient comfortable should be avoided due to the possible occurrence of adverse effects (E) Use the oral route first in most circumstances.

39. Which of the following is not a common manifestation of the myofascial pain syndrome? (A) Regional body pain and stiffness (B) Abnormal findings on neurological examinationl (C) Limited range of motion of the affected muscle (D) One or more trigger points (E) Referral (triggering) pain from a trigger point to a zone of reference .

40. 有關 Opioid 的敘述，下列何者為錯誤? (A) Codeine 與 tramadol 皆屬於 weak opioid，但二者不是同一級管制藥。 (B) 大約等效止痛劑量換算: 10mg morphine= 50mg tramadol= 7.5mg oxycodone。 (C) Opioid rotation(將一種 opioid 等效換成另一種 opioid)不會改善止痛強度。 (D) Opioid 可能會造成 muscle rigidity，myoclonus 與 delirium。 (E) 成癮性 opioid 用於慢性非癌疼痛，在台灣受到嚴格管控。

41. 有關 NSAID 的敘述，下列何者為錯誤? (A)NSAID 的副作用包含: Hypertension, Renal failure, Bleeding, Asthma。 (B) Cyclooxygenase(COX)的產物是 hyperalgesia 的 mediators。 (C) Topic NSAID 有被建議當作關節炎的第一線用藥。 (D) COX 的止痛機制與 prostaglandin 有關但與 endocannabinoids 無關。 (E) Paracetamol 的止痛會透過 TRPV1。

42. 有關 antidepressant 與 anticonvulsant 止痛藥的敘述，下列何者為非? (A) antidepressant 對帶狀庖疹後疼痛，糖尿病神經病變與中樞疼痛有治療效果。 (B) 三環抗憂鬱劑的副作用有口乾，姿態性低血壓，嗜睡與椎體外症候群。 (C) 抗憂鬱劑是同時具有疼痛改善與抗憂鬱的效果，而不是只透過抗憂鬱的效果來止痛。 (D) anticonvulsant 的止痛是透過鈉離子通道與 GABA pathway 等多重作用完成。 (E) 三叉神經痛，糖尿病神經病變也可用 anticonvulsant

43. 有關脊椎神經刺激術(SCS)的止痛敘述，下列何者為非? (A) SCS 是植入電極的疼痛治療方式，是 gate control 理論的應用。 (B)缺血性疼痛、複雜區域疼痛與糖尿病神經病變以 SCS 治療，成功機會較高。 (C)會陰部疼痛與脊椎部份傷害的疼痛，無效機會高。 (D) 病人存活時間要大於 6 個月。 (E) 有裝心臟節器的病人也適合。

44. 有關 complementary and alternative medicine(CAM)在疼痛的敘述，下列何者為非? (A) 針灸用於各種的疼痛，治療的結果不一。 (B) Chiropractic treatment (整脊)可用於治療背部的疼痛，但其結果並不一致。 (C) Massage therapy 在背部疼痛可能有效，但缺少嚴格的臨床試驗。 (D) Herbal medicine (中草藥)種類繁多，但多天然物，毒性低，但效果不一。 (E) 太極拳用於關節炎的治療，証據不明顯。

45. Which of the following is not true about post-mastectomy pain? (A) Mastectomy may result in chronic pain in as many as half of those patients. (B) This pain often starts immediately or a few days postoperatively. (C) This pain is usually neuropathic in character. (D) It is suspected that the intercostobrachial nerve is often damaged during axillary node dissection (E) The incidence of phantom breast syndrome 1 year after surgery is less than 5%.

46. According to the long-form McGill Pain Questionnaire (MPQ) pain rating index scores, which of the following acute pain status is rated the highest pain score? (A) Amputation of digit (B) Labor pain (C) Abdominal gynecological surgery (D) Fracture. (E) Lower abdominal surgery (males)

47. Which of the following symptom is not often seen in patients with physical dependence (abstinence syndrome -(withdrawal) ) ? (A) abdominal cramps (B) constipationn (C) vomiting (D) pupil dilatation (E) sweating

48. About chemical neurolytic nerve blocks, which one of following statements is wrong? (A) Phenol or ethanol is usually used for chemical denervation. (B) The duration of these blocks is often disappointingly brief. (C) They may induce deafferentation-neuropathic type pain. (D) They are often indicated for patients with chronic pain and a normal life expectancy. (E) They can be used in patients with advanced cancer disease.

49. Which of the following combination of lesion site with referral site describing pain referral is not common in cancer patients suffering from cancer pain? (A) (Diaphragmatic irritation) and (Shoulder) (B) (Urothelial tract) and (Inguinal region and genitalia) (C) (C7–T1 vertebrae) and (Interscapular) (D) (L1–2) and (Sacroiliac joint and hip) (E) all of the above are common found in patients with cancre pain

50. About image-guided lumbar sympathetic block, which the following indication is not proper? (A) Sympathetically maintained pain (B) Reflex sympathetic dystrophy (C) Phantom low limb pain (D) Raynaud’s disease (E) Chronic pancreatitis

109年 - 109 台灣疼痛醫學會專科醫師考題#120915

試卷資訊

選擇題 (50)

申論題 (0)