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104年 - 104 台灣疼痛醫學會專科醫師考題#122433

科目：台灣疼痛醫學會專科醫師 | 年份：104年 | 選擇題數：50 | 申論題數：0

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所屬科目：台灣疼痛醫學會專科醫師

選擇題 (50)

1. 關於催眠(hypnosis)及催眠止痛(hypnotic analgesia)，何者敘述錯誤？ (A) 不只是一種魔術，催眠可能有效止痛 (B) 利用的是「暗示」(suggestion)的技巧，與心理層面有關，不影響生理功能 (C) 可以造成精神放鬆，注意力轉移，對人、時、地的錯誤判斷，及改變個人經驗 (D) 催眠止痛要達到長期的效果，需要以暗示方法改變(或主導)病人的疼痛經驗 (E) 催眠止痛改變病人的疼痛經驗的方式有：解離式想像法(dissociated imagery)、集中注 意力法(focused analgesia)、重新詮釋法 (reinterpretation)
2. Which of the following statement concerning the treatment of cancer pain is least likely? (A) Obeying the principles of the analgesic ladder approach, 71% of patients will achieve good in relief without further intervention. (B) Oral morphine remains the drug of choice according to the analgesic ladder of the WHO. (C) The most common use of radiotherapy is for metastases abdominal pain. (D) The patient with advanced cancer is in the dynamic state with changing pathology. (E) About 60% of patients who receive radiotherapy will achieve at least 50% pain relief.
3. 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，marcophages 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。
4. Which of the following statement concerning “animal models of pain” is least likely? (A) When applying Von Frey filaments for identifying mechanical hyperalgesia, one of the drawbacks is that different application speed may generate different forces. (B) The writhing test is frequently referred to as a somatic pain model. (C) The injection of capsaicin is thought to activate TRPV1-expression nociceptors. (D) The injection of Freund’s complete adjuvant (FCA, or CFA) is a model for inflammatory pain. (E) The chronic constriction injury (CCI) model is a partial nerve lesion model.
5. 關於鴉片 類藥物的敘述，以下何者最為正確？ (A) 嗎啡可能使肥胖細胞(mast cell)釋放組織胺(histamine) (B) Methadone 具有 NMDA 受體拮抗劑的特性，且不會被 naloxone 拮抗 (C) 鴉片類藥物作用在腦幹會降低呼吸中樞對缺氧(low PO2)的敏感性 (D) 使用鴉片類藥物造成便秘是屬於中樞性副作用(central side effect) (E) 嗎啡的代謝產物 M3G 與 M6G 均有微弱的止痛效力
6. The effect of placebo will be enhanced by the followings except (A) conditioning by treatment context (B) suggestion by verbal (C) expectation of response (D) desire of pain relief (E) attention to pain
7. 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.
8. Which of the following drug is not suggested to be prescribed to prevent migraine? (A) beta blocker (B) anticonvulsant such as gabapentin (C) tricyclic antidepressant such as amitriptyline (D) SSRI (Selective serotonin re-uptake inhibitors), such as Fluoxetine (prozac) (E) all of the above can be prescribed as preventive medications
9. 關於疼痛臨床研究與止痛方式的統計，下列何者正確？ (A) 一般而言，某種止痛方式的 number need to treat 介於 8-12 之間，表示該方式是有效的 (B) 統計結果 Number need to treat 數值愈大，表示該止痛方式效果越好 (C) 統計結果 Number need to harm 不適合用以表達副作用或併發症的的發生率 (D) 比較不同止痛方式的效果時，病人自控式止痛的嗎啡用量是很好的指標，比 pain score 更為客觀 (E) 以上皆不正確
10. 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
11.關於嗎啡類藥物成癮的機轉敘述，下列何者錯誤： (A) 大腦中 ventral tegmental area (VTA) 及 nucleus accumbens (NA)為最重要影響腦區 (B) 此兩個腦區藉由系統中的 mesolimbic pathway 連接 (C) 與神經傳遞物血清素(serotonin)的分泌有關 (D) 此中樞神經網路代表了動物行為的「獎懲系統」(reward system) (E) 與酒精成癮的機制是同一套神經興奮系統
12. 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) Thrombangiitis obliterans (E) Radiation-induced plexopathy
13. When will you make a surgical suggestion as you manage a patient with neck or low back pain? (A) Intractable symptoms for one week (B) No changes in physical findings and no response to conservative management for two weeks (C) Obvious radicular sign without findings of correctable anatomical problem for more than one month (D) No improvement with progressive neurologic deficit in two weeks (E) Mild improvement for more than one month but less than three months
14. Which of the following statement concerning “phantom limb pain” is most likely: (A) Phantom pain is the painful sensations referred to the amputation stump (B) Phantom pain may enhance with time (C) Preamputation pain increases the risk of phantom pain (D) Phantom pain can be prevented by a preoperative epidural blockade (E) Postamputation pain can be easily treated by analgesia
15. Regarding antidepressant analgesics, which of the following statement is least likely: (A) According to NNT data in treating postherpetic neuralgia, imipramine has slightly better analgesic effect than oxycodone. (B) Desipramine (25-300 mg/day, oral) has low potency of anticholinergic effect and sedation. (C) Fluoxetine (5-40 mg/day, oral) has no anticholinergic and sedative effects. (D) Venlafaxine is relatively free of muscarinic cholinergic, histaminic and alpha-adrenergic receptor effects. (E) The analgesic effect of antidepressants in treating neuropathic pain is dependent of its antidepressant action.
16. Based on clinical situations, which kind of opioids owns the highest oral bioavailability: (A) Hydromorphone (B) Morphine (C) Pethidine (meperidine) (D) Oxycodone (E) Tramadol
17. 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.
18. Among the following pain disorders, which will produce the highest pain rank index (PRI) by the McGill Pain Questionnaire? (A) Trigeminal neuralgia (B) Pericoronitis (C) burning pain syndrome (D) Reversible pulpitis (E) Temporomandibular disorders (TMD)
19. If we apply light touch stimulus to lesion side in painful neuropathies, it will evoke neuropathic pain, which afferent fiber is involved among the followings? (A) A-alpha fiber (B) A-beta fiber (C) A-delta fiber (D) C fiber (E) A-delta and C fiber
20. 關於鴉片類藥物的敘述，下列何者最不正確？ (A) Hydromorphone 效力比 morphine 強 3-5 倍(口服)，且具有 NMDA 受體拮抗劑與血 清素再吸收抑制(serotonin reuptake inhibitor)的特性 (B) Buprenorphine 具有 μ receptor partial agonist 及 κ antagonist 之性質 (C) Meperidine(pethidine)具有高度親脂性，容易引發「尋藥行為」(drug-seeking behavior) (D) Tapentadol 具有 μ agonist 與 noradrenaline reuptake inhibitor 之性質 (E) 以皮下作為給藥路徑可以提供緩慢穩定的吸收，唯給藥量不宜超過 5 mL/hr
21. 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
22. What is the following description about tension-type headache is FALSE? (A) may be associated with stress (B) associated with vomiting (C) bilateral (D) most common in adolescence (E) pain may involve teeth, forehead & neck
23. Which neurological signs and symptoms of complex regional pain syndrome (CRPS) among the followings is the highest? (A) Hyperesthesia/allodynia (B) Coordination deficits (C) Tremor (D) Muscle spasm (E) Paresis
24. Which following statement about pain assessment is true? (A) The McGill Pain Questionnaire (MPQ) has become the most widely used clinical and research tool for measuring pain. (B) The McGill Pain Questionnaire is designed to assess the multidimensional nature of pain experience and has been demonstrated to be a reliable, valid and consistent measurement tool. (C) Descriptors in the McGill Pain Questionnaire fall into 4 major groups, including: sensory, affective, evaluative, and miscellaneous (D) The main disadvantage of VAS is the assumption that pain is a unidimensional experience that can be measured with a single-item scale. (E) All the above are true.
25. Which statement of the followings is wrong? (A) Pain cannot be explained purely by a simple perception-action model. (B) Pain is unlikely be underpinned by a single unified motivation value system. (C) Pain is likely to be underpinned by a number of distinct systems of action, including innate, habit-like, and goal-directed systems. (D) Understanding decision making is likely to be critical for understanding the complexity of intrinsic pain modulation pathways. (E) All the above are correct
26. 關於纖維肌痛症 (fibromyalgia) 的定義，下列哪一項為 1990 年 ACR 的舊定義，而不屬於2010 年的新定義： (A) 廣泛性疼痛(widespread pain index, WPI)為計算疼痛分布在身體 19 個區塊的數量 (B) 疼痛部位需分布在身體的上、下、左、右、及中軸等部位 (C) 症狀嚴重度 (Symptom Severity Scale, SSS)包括疲憊程度、記憶力減弱、睡眠不足 (D) SSS 還包括身體症狀，如頭痛、下腹痛、憂鬱等症狀 (E) 身體症狀是指過去半年內曾發生的病史
27. Which of the drugs below is the most useful prophylactic drugs for chronic tension type headache (CTTH) in clinical practice ? (A) beta blocker (B) anticonvulsant such as gabapentin (C) tricyclic antidepressant such as amitriptyline (D) SSRI (Selective serotonin re-uptake inhibitors), such as Fluoxetine (prozac) (E) weak opioids such as tramadol
28. 關於鴉片類藥物的敘述，下列何者最不正確？ (A) Codeine 在肝臟中經 cytochrome P450 2D6 進行 O-demethylation 後會產生 morphine (B) Tramadol 屬於 weak opioid 類藥物，口服生物利用率(oral bioavailability)差，對 neuropathic pain 和 fibromyalgia 效用不佳 (C) Tramadol 造成嚴重呼吸抑制的風險極低，但嚴重腎功能障礙或嚴重藥物過量時仍可能 發生 (D) Oxycodone 的口服生物利用率比 morphine 高，且比較沒有 active metabolite 的疑慮 (E) 肝腎功能障礙對於 methadone 的代謝清除率(clearance)並沒有明顯的影響

29. 下列對於肌筋膜疼痛及纖維肌痛的比較，何者錯誤：
30. From the viewpoint of clinical manifestations, structures responsible for generating pain in the nociceptive process from within the head does not inlcude: (A) large intracranial vessels and dura mater (B) peripheral terminals of the trigeminal nerve innervating these structures (C) cortex of brain (D) central terminals and second-order neurons of the trigeminal nucleus (E) all of the above are responsible in perception of nociceptive pain within the head
31. Differentiation between cluster headache and other trigeminal autonomic cephalalgias such as paroxysmal hemicranias, SUNCT syndrome and hemicrania continua includes: (A) less severe pain (B) less frequent pain attacks (C) effective prophylactic treatment by methysergide and prednisolone (D) no autonomic features (E) with migrainous features
32. Which of the following statement concerning autonomic- endocrine-immune interaction in pain” is least likely? (A) Cytokines are involved in the sensitization of nociceptors during inflammation and may lead to hyperalgesia. (B) Proinflammatory cytokines are synthesized and released by macrophages and other immune-related cells. (C) IL-4 is categorized as an anti-inflammatory interleukin (D) IL-1, IL-10 and TNF-α are categorized as proinflammatory cytokines. (E) TNF-α induces synthesis and release of IL-8, which activates sympathetic terminals that synthesize nociceptors via β2-adrenoceptors.
33. Which of the description below is not included in the simple diagnostic criteria for migraine? (A) unilateral pain (B) numbness (C) throbbing pain (D) nausea/vomiting (E) photophobia and phonophobia
34. Which of the following statement concerning “spinal cord plasticity and pain” is least likely? (A) A strong and/or sustained activation of nociceptive C fibers may induce the plasticity in spinal cord. (B) Neurotrophic factors BDNF and NGF are thought to be able to induce hyperalgesia on spinal application. (C) In nociceptive pathways, long-term potentiation (LTP) may be triggered by enhanced synaptic activity. (D) LTP may be induced by electrical stimulation and nerve injury, but not hindpaw injection of formalin. (E) In nociceptive pathways, long-term potentiation (LTP) may be triggered by abrupt withdrawal from opioids.
35. During peripheral sensitization of nociceptors, which of the coupling is wrong? (A) prostaglandin E2 (PGE2) --- EP receptor (B) bradykinin --- B2 receptor (C) heat --- TRPV1 receptor (D) ATP --- P2Y receptor (E) all of the above are right
36. Arrange the pain intensity of the following conditions from the strongest to the least according to long form McGill Pain Questionnaire. 1 Labor pain, 2 Amputation of digit, 3 Male low abdominal surgery, 4 Fracture: (A) 1＞2＞3＞4 (B) 2＞1＞4＞3 (C) 2＞1＞3＞4 (D) 1＞2＞4＞3 (E) None of above is right
37. Regarding the actions of spinal and supraspinal analgesia for opioids, which of the following statement is most likely: (A) Opioid receptors are mostly located at a predominantly 70% postsynaptic location on the central terminals of only small diameter nociceptive primary afferents. (B) The contribution of kappa, delta and mu receptors to the total opiate binding throughout the spinal cord is estimated to be delta ＞ mu ＞kappa.(C) Opioids inhibit OFF cells via GABA neurons and activate ON cells in the rostromedial medulla (RVM) leading to changes in spinal descending controls. (D) Nitric oxide (NO) is required for the 5-HT-mediated inhibition of PAG output and reversal of antinociception. (E) Fibers descending from the PAG to the dorsal horn of the spinal cord are mostly enkephalinergic, glycinergic and GABAergic.
38. 當病人一再來門診或急診要求注射成癮性止痛藥時，下列哪些現象暗示病患可能有「成癮」 現象？ (A) 病人抱怨最近的處方的止痛時間不夠久，藥效變差 (B) 病患抱怨最近疼痛加重厲害，發作頻繁，他把三天的藥一天吃完 (C) 病人自述出現嗜睡、噁心、性欲降低、便秘，但是疼痛都沒有減輕 (D) 病人自述沒吃止痛藥會睡不著，希望睡前加重劑量輔助睡眠 (E) 病人最近反覆敘述藥物遺失，而且發生很多次
39. Which one of the following intervention provides the worst therapeutic effect of pain relief for lumbar spinal radicular pain? (A) transforaminal epidural steroids injection (B) radiofrequency denervation (C) spinal cord stimulation (D) lumbar sympathetic block (E) caudal steroids injection
40. 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) Hypnotic analgesia can be understood as the result of a placebo manipulation, and it is not more than just relaxation. (C) Increases in hypnotic relaxation are associated with increases in regional cerebral blood flowin the occipital cortex. (D) Deep relaxation, dissociated imagery and focused analgesia produced significant reductions on all pain-related measures. (E) Descending projections from amygdale, PAG and locus coeruleus contribute to modulate nociceptive processes in the brain stem and the spinal cord.
41. A parturient 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
42. Which of the following is the unacceptable statement about peripheral nerve block? (A) Occipital nerve block is indicated for occipital and posterior auricular neuralgia. (B) Lateral cutaneous nerve of the thigh: local anaesthetic block of this nerve is indicated for diagnosis and treatment of meralgia paresthetica. (C) Sacral plexus block, transforaminal through the sacral foramina, may be indicated for temporary relief of sciatic pain. (D) Suprascapular nerve block is indicated for postsurgical pain relief, for assessment of shoulder pain and to facilitate physical therapy of the shoulder joint in painful shoulder stiffness and pain secondary to CRPS. (E) For classical trigeminal neuralgia, blocks of the Gasserian ganglion with glycerol or radiofrequency are now the commonly used alternatives when microvascular decompression is not available or cannot be used.
43. 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) Post laminectomy failed back syndrome without radiculopathy
44. 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.
45. 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) Atypical facial pain (B) Vascular facial pain (C) Postherpetic neuralgia (D) Trigeminal neuralgia
46. 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 involves 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 gold standard of treatment.
47. When the administration of opioids failed to manage pain or the dose of opioids is noted to escalate, the following differential diagnosis should be considered, except: (A) Limited absorption of oral preparations—vomiting or gastric stasis. (B) Pain poorly responsive to opioids alone- such as Neuropathic pain (C) Pharmacological factors: Opioid-induced hyperalgesia and allodynia (D) Psychological factors: Distress, Anxiety or Depression (E) All of the above should be considered
48. Which statement about trigeminal autonomic cephalgias (TAC) is wrong? (A) Oxygen inhalation is a safe and effective method for acute treatment of cluster headache (B) Midbrain and pontine activation play a pivotal role in either initiation or termination of the acute attack of migraine (C) The forehead, temporal, orbit and occiput are the most frequent sites of hemicrania continua. (D) Paroxysmal hemicrania responds in a dramatic and absolute fashion to indomethacin. (E) Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) syndrome is usually maximal in the ophthalmic distribution of trigeminal nerve.
49. As we know, bone scan is the most common diagnostic tool for bone metastasis. Which limitation is incorrect? (A) Bone scan is characterized by high sensitivity and high specificity (B) Any positive findings should be corresponded to painful sites with further evaluation of CT or plain radiographs(C) Bone scan doesn’t evaluate the structural integrity (D) Most common pattern of metastasis in bone scan is “hot spot” with radioisotope accumulation for new bone reaction (E) Some cancers may not show “hot spot” pattern, such as melanoma and multiple myeloma
50. Choice a right equianalgesic factors compared to subcutaneous morphine. (A) Morphine (oral) 0.50 (B) Codeine (oral) 0.20 (C) Alfentanil (subcutaneous) 1.0 (D) Oxycodone (parenteral) 5.0 (E) None of above is right.

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