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99年 - 99 台灣疼痛醫學會專科醫師考題#122437

科目：台灣疼痛醫學會專科醫師 | 年份：99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. 以下針對超音波影像引導之疼痛治療中，各式使用的探頭(probes)敘述，何者為非?
(A)弧形探頭的頻率最低，所引導針尖到達之標的治療組織最深。 (B)微型探頭的頻率最高，所引導針尖到達之標的治療組織最淺。 (C) 線型探頭的頻率約在 5~12MHz 左右。 (D)腰椎小面關節注射(facet joint injection)因範圍很小，故以使用微型探頭最為適當。 (E)通常組織穿透力高的探頭，解析度會較為遜色。

2. 在施行上背部菱型肌(rhomboideus muscle)之筋膜激發點注射(myofascial trigger point injection)時，常會有肋膜穿透的疑慮；在進針時，往往因為避免 副作用發生，反而常因深度不足而使療效降低。藉由超音波引導，便可避免此疑慮之產生。以下圖為例，請問進針的深度適當範圍為何(右方刻度單位為公分)?
(A) 0.5 cm ~ 1.0 cm (B) 1.0 cm ~1.5 cm (C) 1.5 cm ~ 2.0 cm (D) 2.0 cm ~ 2.5 cm (E) 2.5 cm ~ 3.0 cm

3. 此超音波顯像圖示中，針尖位置於何處是最合適於星狀神經節注射？
(A) 1 (B) 2 (C) 3 (D) 4 (E) 5。

4. 此超音波顯像圖示乃臂神經叢(Brachial Plexus)區域性麻醉中，乃一區域之圖示？
(A) Interscalene block (B) Supraclavicular block (C) Infraclavicular block (D)Axillary block (E) Femoral nerve block。

5. 此超音波顯像圖乃腰椎哪一種部位之介入性疼痛處置術式？
(A) Trigger Points Injection (B) Epidural Injection (C) Facet Joint Injection (D) Intra-thecal Injection (E) Psoas Compartment Block
6. 目前對 Chronic tension-type headache (CTTH) 的認識，下列何者不正確？ (A) 發作時，在腦血流中有明顯的 CGRP 增加 (B) 與 myofascial pain 有關，可以用注射 botulinum 治療 (C) 以 Beck’s depression scale 評分，可以發現頭痛頻率與 depression 程度有關 (D) 以 pressure-pain threshold 測量，可以發現疼痛閾值改變不大 (E) TCA (Tricyclic antidepressant) 可以當第一線用藥
7. 周邊神經切除會形成 neuroma 引起疼痛，下列敘述何者不正確： (A) 是因為 axon 不正常的 regenerative sprouting (B) 疼痛發生大多與 C-fiber 出現不正常的 ectopic firing 有關 (C) 糖尿病或神經炎，也會出現 microneuroma，引起疼痛 (D) 在新生兒周邊神經損傷，反而少出現神經瘤 (E) Tineal sign 可以作為診斷 ectopic firing 的依據
8. 以下敘述何者為非? (A) 有關疼痛治療之臨床試驗，研究者除須保持中立、盡量減少偏見及增加實驗可信度外，其實驗設計、執行及數據分析亦應盡量依據 the Consolidated Standards of Reporting Trials (CONSORT) guidelines for clinical trial reporting 及 the Initiative on Methods, Measurements, and Pain Assessment in Clinical Trials (IMMPACT) statement for chronic pain 等相關研究之規範進行 (B) Randomized controlled trials, double blinding, paralleled groups and cross over， 等均是可行的實驗設計 (C) 實驗設計常併用安慰劑控制 (placebo control)，而安慰劑之疼痛緩解療效與 受試者之背景、受試者是否被條件訓練 (conditioning)、受試者是否被暗示， 等情形有關 (D) 研究個案數 (sample size) 可參考 powering trials for statistical significance、臨床效度 (clinical efficacy)，及 the number needed to treat (NNT) 等因素來決定 (E) 疼痛治療之臨床試驗除測量疼痛程度外，亦應測量其它面向如功能、壓力、 及副作用；而副作用如以病患日記形式紀錄，其發生率通常會低於其它形式 之紀錄
9. 下列何者不具有 Na channel blocker 的作用： (A) lidocaine (B) carbamazepine (Tegretol) (C) gabapentin (Neurontin) (D) mexiletine (Mexitil) (E) amitriptyline
10. 哪一種神經疼痛的動物模型可以代表糖尿病變性神經痛： (A) chronic constriction injury (CCI) or Bennett model (B) spinal nerve ligation (SNL) or Chung model (C) spared nerve injury (SNI) or Decosterd model (D) Streptozocin-induced neuropathy (E) Vincristine-induced neuropathy
11. 下列哪一項病人可能的主訴，較不屬於神經病變性疼痛的症狀： (A) ongoing pain, touch-evoked pain (B) tingling, spontaneous pain (C) pin-prick hyperalgesia, burning sensation (D) numbness, edema, trophic changes (E) Joint stiffness, soreness, pulling
12. 下列哪一項病理現象，不代表周邊神經損傷後引起的脊髓中樞敏感化 (central sensitization)： (A) Wallerian degeneration (B) Windup, after-discharge (C) Receptive field alteration (D) microglial activation (E) Descending dis-inhibition
13. 有關 hyperalgesia 的描述何者為非？ (A) 組織受傷會導致許多促進發炎反應的化學物質的釋放，包括 bradykinin， prostaglandins，leukotrienes，serotonin，histamine，substance P，thromboxanes， platelet-activating factor，adenosine，ATP， protons 以及 free radicals 等等 (B) Hyperalgesia 不僅發生在受傷的區域，也會發生在周圍未受傷的區域 (C) 在周圍未受傷害的區域產生的 hyperalgesia 稱之為 primary hyperalgesia. (D) 在發炎反應的時候，marcopharges 會釋放 cytokines 來調節發炎反應。 (E) 促進發炎反應之因子，如 cytokine 會促進神經生長因子之產生，再直接或 間接地加強疼痛現象。
14. 有關微膠細胞 (microglia) 的敘述何者為非？ (A) 中樞神經系統中有三腫膠細胞，分別是 astrocytes, oligodendrocytes 及 microglia. (B) 中樞神經系統中，膠細胞的數量大約與神經元相等 (C) 微膠細胞功能類似於 marcopharge (D) 微膠細胞一旦被激發，外形會改變，細胞表面的 complement receptor-3 分子 會大量表現。 (E) 變形的微膠細胞會放出一些 cytokines，造成發炎。
15 腰椎或頸椎部位最常見需要手術的原因，且手術比其他治療方式預後較好的 是? (A) Herniated intervertebral disc (HIVD) (B) Degenerated discs (C) Spinal stenosis (D) Osteoporosis (E) Facet arthropathy
16. 下列有關多發性肌痛症(Fibromyalgia syndrome； FBS)之敘述，何者較不正確? (A) 流行病學研究顯示有至少 2%的族群有 FBS (B) 女性多於男性 (C) 診斷的依據之一為 widespread pain 達 6 個月以上 (D) 診斷的依據之一為 18 個特定解剖位置之壓痛點當中，至少有 11 個壓痛點 (E) 壓痛點的產生是指以 4kg 之指壓力道所誘發產生，亦可用 standard algometer 測之
17. 以下敘述何者為非? (A) 認知-行為模式治療 (The cognitive-behavior model approach) 目前已知對頭 痛、關節炎、顳顎關節疼痛、纖維肌痛、腸躁症、等症狀有效 (B) 認知-行為模式治療常用之方式包含問題解決、認知重建、注意力轉移、放鬆、目標設定及逐步面對引發疼痛之活動、等方式 (C) 認知-行為模式治療依進度可區分為評估、教育及觀念重整、技巧訓練、診間及在家練習、等階段 (D) 認知-行為模式治療對成人效果較好，對兒童效果較差 (E) 認知-行為模式治療可能有成效不佳及起伏之情況，應教育病患如何面對上 述情況
18. 以下敘述何者為非? (A) 疼痛刺激活化 c-fiber 後會導致 P 物質 (substance P)、血管活性腸肽 (vasoactive intestine polypeptide, VIP)、體抑素 (somatostatin)、三磷酸腺苷 (ATP)及穀氨酸鹽 (glutamate) 等物質之釋放 (B) P 物質 (substance P) 之受體 (receptor) 為 COX-2 受體 (C) 穀氨酸鹽 (glutamate) 之受體包括 APMA 及 NMDA 等受體 (D) 體抑素 (somatostatin) 之受體為 SST1-3 等受體 (E) 三磷酸腺苷(ATP)之受體為 P2X 受體
19. 下列有關多發性肌痛症之臨床常見表現症狀，除 widespread pain 外，下列何 者最常見? (A) Depression (B) Sleep disorder (Insomnia) (C) Fatigue (D) Irritable bowel syndrome (E) Irritable bladder syndrome
20. 下列何種慢性疼痛病患接受 spinal cord stimulation 的治療效果最好？ (A)refractory angina pectoris (B) complex regional pain syndromes (C) phantom pain (D) postherpetic neuralgia (E) complete nerve root avulsion
21. 有關硬脊膜穿破後引起頭痛 (post-dural puncture headache) 的陳述，何者為真？ (A)Using large gauge “cutting” needles is the best preventive measure when performing a spinal anesthetic (B) It results from decreased cerebrospinal fluid (CSF ) pressure secondary to loss of CSF at the puncture site (C) Gender has no influence upon incidence (D)Early ambulation will increase the incidence (E) An epidural blood patch is always indicated
22. 一位末期肝癌疼痛的病患，因口服嗎啡已經造成嚴重的嘔吐，考慮改由脊髓 腔內(intrathecal) 持續給藥，因其每天劑量達 600 mg，經換算後脊髓給藥劑量 應為每天約： (A) 1 mg (B) 2 mg (C) 6 mg (D) 10 mg (E) 20 mg
23. 下列對 CRPS (complex regional pain syndrome) 的敘述何者不正確？ (A)有灼熱痛 (burning pain) (B)合併持續疼痛(ongoing pain)及突發性疼痛(breakthrough pain) (C)對嗎啡類止痛藥的反應不錯，常須合併這類藥物使用 (D)疼痛也會合併肌痛點的表現 (E)治療的首要目標為恢復正常生活作息
24. 腰椎交感神經叢神經阻斷術 (lumbar sympathetic blockade) 的適用症，下列 何者不包括? (A) acute herpes zoster (B) phantom limb pain (C) reflex sympathetic dystrophy (D) lumbar facet syndrome (E) vascular insufficiency
25. 下列哪種癌症病人最不易出現骨骼轉移的疼痛？ (A)乳癌 (B)前列腺癌 (C)肺癌 (D)肝癌
26 抗憂鬱劑常被用在治療慢性神經病理性疼痛緩解，以下有關於此類藥物之敘述何者為非? (A)三環抗憂鬱劑是慢性疼痛治療的首選藥物。 (B)Amitriptyline 可同時抑制 Serotonin 和 Noradrenaline 兩神經傳遞物質之回收，效果較其他選擇性回收抑制劑之治療效果佳，其 NNT 為 14 左右。 (C)三環抗憂鬱劑之止痛效果，主要並非來自於其鎮靜或是抗焦慮之作用。 (D)近來之研究發現三環抗憂鬱劑也具有抑制鈉離子通道及 NMDA 受體之作用。 (E)青光眼及攝護腺肥大是使用三環抗憂鬱劑的禁忌症。
27. 類鴉片藥物目前仍是臨床上用於疼痛控制的最主要藥物，以下有關於類鴉片 藥物使用之注意事項何者為是? (A) 類鴉片藥物是作用於類鴉片受體而產生止痛作用，各受體間有 Cross tolerance 存在，故使用 opioid rotation 和替代性並不能降低其相關之副作 用 並增強其止痛效果。 (B) 慢性疼痛病人在使用嗎啡時最擔心的就是所謂的被貼標籤(stigmatization)。 (C) 長期使用嗎啡時，其代謝產物 M6G 具有止痛作用，而另一代謝產物 M3G 則會產生副作用。 (D) Buprenorphine 的 first pass 較低，故口服錠效果佳。 (E) Codeine 之主要作用是經由肝臟之 glucuronidation、N-demethylation 和 D-demethylation 而轉化成約 2-10％的嗎啡而產生止痛作用。
28. Which of the following treatment is NOT the indication for limbs pain induced by increased spasticity after C7 incomplete spinal cord injury? (A) Joint positioning and range-of-motion (ROM) exercises. (B) Treat underlying spasticity-triggering events (infection, pressure ulcer, etc). (C) Serial casting or dynamic splinting to relieve already-occurred contractures. (D) Oral narcotics, like codeine or tramadol. (E) Anti-spasticity blocks via Botulinum toxins, phenol, or ethanol.
29. Which one of the following neuropathic pain conditions is not likely responded to spinal cord stimulation? (A) CRPS type I (B) CRPS type II (C) Central post-stroke pain (D) occlusive peripheral vascular disease (E) diabetic neuropathy.
30. 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) glutamate. (B) GABA. (C) dopamine. (D) acetylcholine (E) norepinephrine.
31. A typical symptoms of a) myocardial ischemia； b) dyspnea on exertion； c) ST segment elevation or depression in the ECG； d) Q wave in the ECG. The above items included in criteria for acute myocardial infarction are: (A) a and b (B) a, b, and c (C) a, c, and d (D)b, c, and d (E) all of them
32. Which of the following statement concerning hypnotic analgesia is least likely: (A) Hypnosis has been highly associated with theta activity (4~8 Hz) using EEG methods. (B) Increases in hypnotic relaxation are associated with increases in regional cerebral blood flow in the occipital cortex. (C) Deep relaxation, dissociated imagery and focused analgesia produced significant reductions on all pain-related measures. (D) Hypnotic analgesia can be understood as the result of a placebo manipulation, and it is not more than just relaxation. (E) Descending projections from amygdale, PAG and locus coeruleus contribute to modulate nociceptive processes in the brain stem and the spinal cord
33. Which following item is not a criterion for the diagnosis of migraine? (A) Throbbing/stabbing quality (B) Aggravation by or causing avoidance of routine physical activity (C) Unilateral location (D) Moderate or severe pain intensity (E) All are criteria for diagnosis of migraine
34. Which of the following is the unacceptable statement about paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) : (A)To treat acute postoperative pain and in the chronic situation for treatment of osteoarthritis, there are differences in efficacy between NSAIDs and paracetamol. (B) To treat acute postoperative pain and in the chronic situation for treatment of osteoarthritis, the efficacy of classical NSAIDs and Coxibs (cyclooxgenase-2-inhibitory non-steroidal anti-inflammatory drugs) is similar. (C) If oral NSAIDs are taken for at least 6 months, the risk of an endoscopic ulcer is 1 in 5, of a symptomatic ulcer is about 1 in 70, of a bleeding ulcer is about 1 in150, and of a death from a bleeding ulcer about 1 in 1300. (D)Coxibs reduce the gastrointestinal bleeding risk compared with NSAIDs. The risk of congestive heart failure is twice as high with chronic NSAID therapy, and increases to over 20 in patients with a previous history. (E) Paracetamol acts as a Cox inhibitor in the brain, explaining both its analgesic and its antipyretic actions
35. Which of the following is the acceptable statement about the local anaesthetic blocks and epidurals? (A) In the management of chronic pain, diagnostic nerve blocks may help in locating the origin of pain, but are unreliable as prognostic aids for neurolytic or neurodestructive procedures. (B) Pain originating from malfunctioning CNS pain modulation may also be relieved by a peripheral nerve block. (C) Epidural local anaesthetic blocks cannot reliably predict the effect of spinal cord stimulation. (D)“Pulsed radiofrequency” treatment: lower temperature applied； less effective； fewer adverse effect compared with conventional radiofrequency denervation. (E) All of the above
36 Which of the following statements regarding trigeminal neuralgia is FALSE? (A) It affects the fifth cranial nerve. (B) It is usually bilateral and is more common in men under the age of 50. (C) Etiology includes idiopathic, demyelination, or vascular malformations. (D) The majority of patients describe the classic high-intensity, triggerable pain in association with activities such as eating or talking. (E) Even simple things, such as a cold breeze, can trigger a pain episode.
37. Which statement regarding complex regional pain syndrome (CRPS) is TRUE? (A) Causalgia, or burning pain, is now categorized as CRPS type I. (B) The term “reflex sympathetic dystrophy” (RSD), or CRPS type II, refers to a syndrome similar to causalgia but with a specific nerve lesion. (C) Etiology involve only peripheral over-reactions after nerve and/or soft tissue damage. (D) The signs and symptoms in CRPS are heterogeneous； which reflect underlying sensory, autonomic, and motor dysfunctions. (E) Sympathetic blockade is the golden standard of treatment
38. Which of the following statement concerning pain assessment is least likely: (A) Strong test-retest reliability coefficients do not exist for the MiGill Pain Questionnaire (MPQ) PRIs. (B) Rheumatoid arthritis showed a stable pattern of MPQ scores over a 6-year period. (C) MPQ has excellent distinction power between sensory and affective dimensons (D) MPQ is sensitive to interventions designed to reduce pain (E) MPQ can provide an aid in the differential diagnosis between various pain syndromes
39. Examination of a patient with neck and shoulder pain reveals referred pain in the lateral aspect of the forearm, with weakness and dysfunction of the biceps and brachioradialis, and hypoesthesia in the lateral aspect of the forearm and thumb. The patient most likely has a lesion of which nerve root? (A)C4 (B) C5 (C) C6 (D) C7
40. Indications for lumbar epidural steroid injections include all of the following, EXCEPT? (A) Radicular pain with corresponding sensory change (B) Radiculopathy due to herniated disc with failed conservative treatment (C) Acute herpes zoster in the lumbar dermatomes (D) Posterlaminectomy (failed back) syndrome without radiculopathy
41. For which of the following types of pain are antiepileptic drugs most commonly used？ (A)Acute pain (B) Cancer pain (C)Chronic pain syndrome (D)Neuropathic pain (E) Nociceptive pain
42. Descending inhibitory pathways typically involve which of the following neurochemical mechanisms EXCEPT? (A) Noradrenergic (B) Enkephalinergic (C) Serotonergic (D) Cholinergic
43. A parturitient of heroin abuse history ask for painless labor, which one is improper? (A) Meperidine (B) Continuous epidural analgesia (C) Nitrous oxide (D) Butorphanol (E) Intrathecal morphine
44. Which of the following statements regarding corticosteroid use is NOT true? (A) 30-50% of patients on chronic oral corticosteroid therapy suffer from osteoporotic fractures. (B) Corticosteroid users are at increased risk of NSAID-related GI bleeding. (C) Corticosteroid use can be associated with weight gain, hypertension and hyperglycemia. (D) Osteoporosis is only a concern in patients who have been on corticosteroids for over 12 months.
複選題
45. Which of the following statements concerning the difference between phenol and alcohol when used in neurolytic blocks is/are FALSE? (A) Phenol takes 15 minutes for neurolysis whereas alcohol’s neurolytic effect is immediate. (B) Phenol usually does not produce pain on injection. (C) Intrathecal alcohol is hypobaric, whereas phenol is hyperbaric. (D) Phenol is approximately twice as efficacious as alcohol.
46. Which of the following statements regarding morphine is true? (A) Its metabolite, morphine-3-glucuronide, is a potent analgesic. (B) In patients with renal failure, morphine-3-glucuronide may be accumulated and induce stronger analgesic effects. (C) Morphine is absolutely contraindicated in non-cancer pain management. (D) The constipation induced by morphine treatment can be reversed by naloxone
47. 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

48. About the following CT-guided intervention, which indication is NOT proper?

(A) Sympathetically maintained pain (B) Reflex sympathetic dystrophy (C) Chronic pancreatitis (D) Raynaud syndrome (E) Failed back surgery syndrome.
49. A 61-year-old woman presents to the pain clinic with a chief complaint of left shoulder and arm pain for 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 likely diagnosis for her clinical presentation ? (A) Radiation-induced plexopathy (B)Tumor metastasis (C) Reflex sympathetic dystrophy (D) Cervical radiculopathy (E) Thrombangiitis obliterans
50.Which of the following activities will exacerbate pain the most in an elderly patient with severe spinal stenosis? (A) Walking uphill (B) Walking downhill (C) Riding a bicycle (D) Bending forward Standing

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