110年 - 110 台灣疼痛醫學會專科醫師考題 #120829

科目：台灣疼痛醫學會專科醫師 | 年份：110年 | 選擇題數：50 | 申論題數：0

試卷資訊

所屬科目：台灣疼痛醫學會專科醫師

選擇題 (50)

1. Which of the following statement concerning “postoperative pain” is least likely? (A) Management of postoperative pain is challenging. (B) Management of postoperative pain is based on current understanding of the peripheral and central mechanisms involved in nociceptive transmission. (C) Chronic pain after surgery is an underdiagnosed condition (D) Advances in understanding the genetic profile of patients should help improve treatment of postoperative pain. (E) It is not essential that the neuronal response to surgery be blocked to achieve the task of optimal pain control.

2. 下列幾項關於疼痛名詞的定義或說明，依照 Bonica’s Management of Pain 5th ed 或疼痛學理，哪一項是錯誤？ (A) Anesthesia dolorosa: Spontaneous pain in an area or region that is anesthetic (B) Catastrophizing: A cognitive and emotional process which can be an important predictor of negative response to both acute and chronic pain (C) Chronic widespread pain includes nonradicular back pain, fibromyalgia, irritable bowel syndrome, pelvic pain, tension-type headache, and temporomandibular disorders (TMD). (D) Conditioned pain modulation: a mechanism can be assessed by measuring tonic pain response after a conditioned phasic pain stimulus (E) Hyperpathia: A painful syndrome characterized by an abnormally painful reaction to a stimulus

3. Which of the following statement concerning “muscle pain” is least likely? (A) Muscle pain is distinct from cutaneous pain. (B) Muscle pain is one of the most common pain complaints. (C) Muscle nociceptors are free nerve endings that are connected to the central nervous system. (D) Most nociceptors cannot be excited by algesic agents, including bradykinin, serotonin. (E) In damaged muscle, the nociceptors have a lowered mechanical threshold.

4. Which of the following diagnostic tests that aid in the diagnosis of complex regional pain syndrome? (A) Bone scintigraphy (B) Plain radiography and X-ray bone densitometry (C) Quantitative sensory testing (D) Skin temperature measurement (E) All of above

5. Which of the following is the acceptable statement about pathogenesis of FMS? (A) There is evidence to suggest that FMS is a disorder of abnormal processing of sensory information within the central nervous system. (B) Several neurochemical mediators of pain, substance P, nerve growth factor, dynorphin A, glutamate, nitric oxide, serotonin and noradrenaline are viewed as pronociceptive because they carry or amplify afferent signals, leading to the brain perception of increased pain. (C) The elevation of cerebrospinal fluid substance P in FMS is due to lowered activity of cerebrospinal fluid substance P esterase because the rate of cleavage of libeled substance P by FMS cerebrospinal fluid was lower than normal. (D) In different subtypes of FMS, it is believed that nerve growth factor may be responsible for the elevated cerebrospinal fluid substance P through its effects on central sensitization and neuroplasticity. (E) A specific Gi-protein–coupled receptor in peripheral blood leukocytes was found to be dysfunctional in patients with FMS. This resulted in lower baseline, also depressed intracellular levels of cyclic AMP and proposed as a diagnostic test for FMS.

6. Which drug below is less likely an option for inhibiting central sensitization following acute postoperative pain: (A) NMDA antagonist (B) Opioid (C) COX2-inhibitor (D) Pre-emptive analgesia (E) Gabapentin

7. A 61-year-old woman presents to the pain clinic with a chief complaint of left shoulder and arm pain 3 years after undergoing radiation therapy for breast cancer. Physical examination reveals lymphedema of the left axilla with noticeable skin changes. Examination of the left supraclavicular area precipitates a sharp pain that radiates down her left arm. Which of the following is her likely diagnosis? (A) Tumor metastasis (B) Cervical radiculopathy (C) Reflex sympathetic dystrophy (D) Thrombangitis obliterans (E) Radiation-induced plexopathy

8. 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%.

9. 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)

10. 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

11. 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.

12. 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

13. 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

14. Which one of the following statement about the pathophysiology of herpes zoster is wrong? (A) Herpes zoster most commonly manifests in the distribution of a single dorsal sensory or cranial nerve ganglion. (B) Why the reactivation of virus occurs in one ganglion when latent virus is present throughout the patient’s sensory ganglia is clear. (C) Declining cellular immunity is a major risk factor for reactivation of the virus, which is thought to occur when cell-mediated immunity falls below a critical level. (D) This impression is supported by evidence that even individuals with adequate levels of serum antibodies to varicella-zoster virus (VZV) antigen can, over time, exhibit T cells with reduced ability to proliferate and defend against VZV infections. (E) Cell-mediated immunity appears to play a crucial role in preventing reactivation of latent VZV.

15. 關於 cordotomy 的敘述，下列何者錯誤？ Ablation 目標是 spinothalamic tract (A) Indication 是 bilateral 的 pelvic、flank、chest wall pain (B)因為 opioids treatment 的進步以及 intrathecal pain pump 的發展，cordotomy 的施行比以前減少 (C)手術方式通常是在 C1/2 level 經皮施行 (D)手術也可在 mid-to-upper thoracic level(T4)施行

16. 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

17. 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.

18. 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.

19. 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.

20. 下列有關常用疼痛評估量表的敘述何者正確? (A)常用的疼痛強度量表是 Visual analogue scale, 是用 0 分到 10 讓病患挑選 (B) Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) 用以偵測 neuropathic 的好處是方便病患自己選答 (C) DN4 雖然項目不多, 但需要 clinician 執行 examination (D) Brief Pain Inventory (BPI) 中有關 Pain Interference 的部分共有 9 個 item, 包括 general activity, mood, walking ability, lifting heavy object, normal work (both housework and work outside the home), relation with other people, language processing, sleep 及 enjoyment of life (E)以上皆正確

21. 下列有關進行 Diagnostic block 預期 Diagnostic confidence 之 specificity and sensitivity 計算公式，下列選項何者是錯誤？ (A) posttest odds = pretest odds × positive likelihood ratio (B) positive likelihood ratio = sensitivity / (1 − specificity) (C) pretest odds = prevalence / (1 − prevalence) (D) diagnostic confidence = [(posttest odds) / (1 −posttest odds)] × 100% (E)若 specificity 是 65%, 以及 prevalence 是 40%, 則 diagnostic confidence of positive comparative blocks 大約是 66%

22. 下列有關 Painful neuropathy 的敘述何者錯誤？ (A) Fabry disease 雖然以 neuropathic pain 為主要症狀, 但仍有全身性的影響包括心臟與腎臟 (B) Inherited erythromelagia 的成因與鈉離子通道的變異有關 (C) Postherpetic neuralgia 是因為 spinal cord dorsal horn neuron 內 dormant 的 Varicella-zoster virus reactivation 造成神經元破壞而產生 (D) 抗癌化學治療藥物, 例如 cisplatin 或 vincristine 可能會造成 painful neuropathy (E) Alcoholic neuropathy 未必與 thiamine 或其他維生素 B 群 deficiency 相關

23. 疼痛科醫師在面對非癌症患者需要開立 strong opioids 時，常會擔心成癮、濫用等問題。曾有研究建議以Five As of treatment success來評估治療成效，以下何者非為Five As之一？ (A) Analgesia or pain score (B) Acceptance of interventional treatment (C) Adverse events (D) Aberrant behavior (E) Adherence to the treatment plan

24. 生氣(Anger)等情緒反應在慢性疼痛病人當中可能較為頻繁出現，下列何者並非評估 Anger 的量表？ (A) State-trait anger expression inventory (STAXI-2) (B) Short form 36 (SF-36) (C) Targets and reasons for anger in pain sufferes (TRAPS) (D) Multi-dimensional anger inventory (MAI) (E) Anger disorders scale (ADS)

25. Effects on postoperative morbidity of regional anaesthetic or analgesic techniques compared with those of general anaesthesia and systemic postoperative analgesics may reduce the following complications, except: (A) pulmonary embloism (B) myocardial complications (C) pulmonary infectious complications (D) cerebral complications (E) other thromboembloic complications

26. A 52-year-old man complains of a sudden onset of severe, stabbing pain in the left jaw and cheek that subsides in less than a minute. He is pain-free during the intervals between attacks. Activities such as combing his hair and shaving can cause the onset of this facial pain. He is otherwise healthy. The most likely diagnosis is (A) trigeminal neuralgia (B) atypical facial pain (C) postherpetic neuralgia (D) vascular facial pain

27. 下列何者非為催眠(Hypnosis)在疼痛醫學中可能的應用範圍？ (A) Cancer pain management (B) Perioperative anxiolysis (C) Chronic low back pain (D) Local anesthetic systemic toxicity (E) Headache

28. In neuropathic pain, the hyperexcitability demonstrated by wide-dynamic range cells in the dorsal horns seems to be related to increase basal release of excitatory amino acids, such as (A) Dopamine (B) Glutamate (C) Acetylcholine (D) GABA (E) Norepinephrine

29. 關於癌症相關的骨頭疼痛，下列敘述何者不適當 (A) 癌症骨轉移最常見的位置是脊椎骨，一旦發現有骨轉移後，對於病患的產生癌症相關併發症和存活時間會有明顯的改變 (B) 在動物癌症骨轉移模型，無論是 osteolytic 或是 osteoblastic model，都可以看到骨頭有 destructive injury。 (C)過去研究發現 periosteum(骨膜)有豐富的交感與感覺神經纖維，另外 bone marrow 和 mineralized bone 也是有交感與感覺神經纖維分布，所以 bone pain 也就是 neuropathic pain。 (D) Cyclooxygenase (COX)-2-specific inhibitors 對於 bone pain 病患的使用上是比 nonselective NSAIDs 安全，此外抑制 COX-2 也可以抑制 tumor burden，osteoclastogenesis，以及 bone destruction。 (E) Intravenous zoledronic acid 已被證實對於 solid tumor 病患，可以降低骨骼相關併發症。

30. 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

31. epidural steroid injection 治療邏輯是針對椎間盤 nucleus pulposus 所釋放的發炎物質，下列數種發炎物質何者與椎間盤突出最沒有直接相關性？ (A) phospholipase A2 (B) caspase (C) interleukins ( 1α, 1β, 6) (D) tumor necrosis factor (E) nitric oxide

32. 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.

33. 關於頭頸癌症病人的的敘述，下列何者不恰當？ (A) 頭頸癌病人的疼痛問題，可能是腫瘤本身、化學治療、放射治療、或是手術造成的 (B) 粘膜炎(mucositis)的疼痛機制可能是黏膜產生潰瘍，暴露出神經末梢，使得黏膜表面變得對疼痛敏感。 (C) 可以用來處置粘膜炎(mucositis)產生的疼痛，包括 topical benzydamine、乳狀鎂(milk of magnesia)、口服 acetaminophen, NSAIDs，甚至是嗎啡類藥物。 (D) 住院的癌症病患如果有嚴重的粘膜炎(mucositis)，可以考慮使用 Intravenous Patient-controlled analgesia (IVPCA) with morphine。 (E) 粘膜炎(mucositis)在頭頸癌病人很常發生，常會造成疼痛問題，是無法預防的 p.

34. Choice a right description about treatment of cancer pain. (A) Because of the complexity of cancer pain, 3 analgesic ladder from WHO was not useful. (B) Surgery, Chemotherapy and radiotherapy are not the analgesic titration for cancer pain. (C) Only 10-20% of patients ultimately require regular strong opioids. (D) Constipation is common for opioid use, but laxative can be used only when symptom exists. (E) None of above is right

35. About the intrathecal drug delivery system, which of the following statements is NOT correct? (A) It places medication directly into the cerebrospinal fluid that surrounds the spinal cord. (B) Morphine delivered directly to the intrathecal space is particularly effective because it does no have to circulate systemically to reach the CSF and the dorsal horn of the spinal cord. (C) As a result, much smaller doses are needed (e.g., approximately 1/30 of an oral morphine dose), and the frequency of side effects is reduced. (D) Advantages of intrathecal therapy in pain includes effective pain relief, reduced side effects for patients, reduced consumption of systemic medication, improved ability to perform ADLs, and enhanced quality of life.

36. A patient suffered from chronic low back pain with radiating to buttock, poster lateral thigh and lateral aspect of lower leg. Muscle weakness was observed in the extensor hallucis longus and tibialis anterior. Which lumbosacral root compression is the most likely？ (A) L2 root compression (B) L3 root compression (C) L4 root compression (D) L5 root compression (E) S1 root compression

37. Which of the followings clinical indicators with its suspected pathology for spinal pain is suggested to receive X-ray for first line test? (A) fracture due to severe trauma (B) aortic aneurysm with cardiovascular risk factors (C) weight loss due to tumor (D) susecpted infection with fever, sweating (E) x-ray is not a first line test for the above causes of spinal pain

38. 關於｢The principles of pharmacotherapy endorsed by WHO｣，下列敘述何者不適當? (A)五大原則: by the mouth, by the clock, by the ladder, for the individual, and with attention to detail。 (B) Cancer pain 病患盡可能以口服止痛藥物為主，但如果病患有 dysphagia, uncontrolled vomiting, or GI obstruction 可以考慮改用其他途徑給予止痛藥物。 (C) By the clock 的用意在於止痛藥物是”around-the-clock”的方式給予，讓大多數癌症病患不再使用快速作用(immediate or rapid-onset)的嗎啡類止痛藥物。 (D) 沒有標準的嗎啡藥物使用劑量，理想的正確劑量是可以緩解病人疼痛，又能有最少的副作用。 (E)癌症疼痛病患的處方，是需要定期追蹤服藥順從性、藥物止痛效果、身體功能、副作用、或是有無服藥後異常行為。

39. Which one of the following statement about the pathophysiology of herpes zoster is wrong? (A) Herpes zoster most commonly manifests in the distribution of a single dorsal sensory or cranial nerve ganglion. (B) Why the reactivation of virus occurs in one ganglion when latent virus is present throughout the patient’s sensory ganglia is clear. (C) Declining cellular immunity is a major risk factor for reactivation of the virus, which is thought to occur when cell-mediated immunity falls below a critical level. (D) This impression is supported by evidence that even individuals with adequate levels of serum antibodies to varicella-zoster virus (VZV) antigen can, over time, exhibit T cells with reduced ability to proliferate and defend against VZV infections. (E) Cell-mediated immunity appears to play a crucial role in preventing reactivation of latent VZV.

40. 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 pe 口 nanent neurodestructive lesion is formed when neural temperatures exceed 42 C (E) All of the above

41. Which of the following drug is categorized as Agonist-Antagonist and should "Not" be used in opioid tolerant patients. (A) Morphine (B) Tramadol (C) Nalbuphine (D) Hydromorphone (E) Methadone

42. 關於 breakthrough pain (BTP)，下列敘述何者不適當 (A) BTP 的原因與發生的部位就是 baseline persistent pain 相同。 (B) BTP 可以是可預期，或是特定動作或生理反應而產生。 (C)在給予定時止痛藥物之後發生的 BTP，有可能是給予藥物的間距時間過長，通常這樣的 BTP 是可以預期，而且會在固定的期間發生。 (D) 發生 BTP 的時間可能是無法預期，跟特定動作或時間無關。 (E)典型的 BTP 通常在 3-5 分鐘發生，持續約 30 分鐘，每次發生的強度不一定相同。

43. Which of following description about opioid receptors is "Incorrect" ? (A) Opioid receptors belong to the superfamily of G protein–coupled receptors (GPCR) (B) Opioid receptors are coupled to Gs protein to trigger downstream signaling. (C) Overall opioid receptor activation leads to inhibit neuronal activity (D) In spinal cord level, opioid receptors are located mostly in the superficial dorsal horn (E) Endogenous opiates maybe released by immune cells and work on both central and peripheral opioid receptors.

44. Which of following description about non-steroidal anti-inflammatory drugs (NSAIDs) pharmacology is "Correct"? (A) NSAIDs work by inhibiting the inflammation associated enzyme cyclooxygenase and lipoxygenase (B) Perioperative use of NSAIDs will not increase the risk of surgical site bleeding (C) NSAIDs will not have drug-drug interaction with anticoagulant (such as warfarin) (D) Cyclooxygenase-2 (Cox-2) is the inducible isoform of cyclooxygenase but is constitutively expressed in certain tissues such as brain and kidney (E) Compared with non-selective NSAIDs, long term use of Cox-2 inhibitors will significantly reduce the risk of serious cardiovascular events, renal failure or congestive heart failure.

45. Which of following description about using anticonvulsants (used as Analgesic Drugs is "Correct"? (A) Most commonly used anticonvulsants as analgesics appear to work through potentiation of voltage-gated sodium and calcium channels (B) Sodium channel subtype 1.4 &1.5 are highly expressed in neuronal cell and could be the drug target for anticonvulsant medication (C) Gabapentinoid (Gabapentin & Pregabalin) works on GABA receptor (D) Topiramate works only on voltage-gated sodium channel (E) Lamotrigine and Phenytoin work on voltage-gated sodium channels

46. Which of the folllowing medication has a greater and long term effect for palliation of pain than placebo in treating chronic low back pain? (A) bezodiazepaine (B) antidepressants (C) pregabalin (D) opioids (E) none of the above medications can offter a greater and lon-term analgesic effect

47. Which of following description about "antidepressant analgesic" is "Correct"? (A) In terms of treatment efficacy (smaller number needed to treat NNT), pregabalin is much better than tricyclic antidepressant and listed as first line therapy for neuropathic pain (B) In terms of treatment efficacy (smaller number needed to treat NNT), SSRI is better than SNRI for common neuropathic pain such as postherpetic neuralgia or painful diabetic polyneuropathy (C) Venlafaxine is effective for treatment of neuropathic pain associated with beast cancer. (D) For painful diabetic neuropathy, comparison of amitriptyline and pregabalin showed no difference in pain relief but fewer adverse effects with pregabalin. (E) All of above

48. Which one of the following statement about central pain is wrong? (A) Central pain involves plasticity in a single area of CNS. (B)Sensitization of the CNS plays a major role in central pain and involves neuronal hyper-excitability resulting in an increased response to synaptic inputs, decreased threshold, expansion of receptive fields, and access of low-threshold Aβ mechanoreceptors to pain pathways. (C) The clinical consequences of central pain are allodynia, hyperalgesia, and after-sensations. (D) Central sensitization may also include spontaneous discharges. (E) Spontaneous discharges in damaged pain pathways or deafferented rostral neurons may be responsible for spontaneous ongoing or intermittent pain.

49. Which of the following diagnosis due to failed back surgery is not able to get evident diagnostic support from MRI? (A) lateral canal stenosis (B) painful disk (C) recurrent herniated nucleus pulposus (D) SI joint pain (E) MRI can help differential diagnois of all of the above causes of failed back surgery.

50. 見下圖，不同的傷害性刺激 (熱、酸或化學性、機械性刺激、冷) 所興奮的表皮傷害性接受器 (1, 2, 3, 4)，可對應左側四組 A, B, C, D，按 1, 2, 3, 4 正確排列依序為：
(A) A, B, C, D (B) A, C, B, D (C) B, C, A, D (D) C, B, D, A (E) D, C, B, A

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