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Question One
A 34-year-old woman with fibromyalgia, generalized anxiety disorder, and depression is currently taking several psychotropic medications, including alprazolam, duloxetine, hydrocodone/acetaminophen, and pregabalin. She continues to have residual pain, anxiety, and mood symptoms. Her clinician is considering simplifying her medication regimen and plans to discontinue the medication with the least evidence of efficacy for her disorders. Which of the following should be discontinued?
A. Alprazolam
B. Duloxetine
C. Hydrocodone/acetaminophen
D. Pregabalin
The correct answer is C.
| Choice | Peer answers |
|---|---|
| A. Alprazolam | 24% |
| B. Duloxetine | 0% |
| C. Hydrocodone/acetaminophen | 71% |
| D. Pregabalin | 5% |
A Incorrect. Alprazolam is an effective treatment for generalized anxiety disorder.
B Incorrect. Duloxetine is an effective treatment for both depression and for fibromyalgia.
C Correct. Hydrocodone/acetaminophen does not have evidence of efficacy for the treatment of fibromyalgia, nor is it an appropriate treatment for her other illnesses.
D Incorrect. Pregabalin is an effective treatment for fibromyalgia and also has evidence of efficacy in anxiety.
References
Question Two
A 35-year-old woman complains of widespread pain so debilitating that she has been unable to work for the last several weeks, though she did not experience any significant injury that seems to account for the pain. Specifically, she states that even the mild pressure of being touched causes such significant pain that she cringes when her 2-year-old daughter tries to hug her. This type of pain is called:
The correct answer is B.
| Choice | Peer answers |
|---|---|
| A. Acute pain | 2% |
| B. Allodynia | 49% |
| C. Hyperalgesia | 44% |
| D. Neuropathic pain | 5% |
A Incorrect. Acute pain refers to pain that resolves after a short duration and that is usually directly related to the healing of tissue damage. In this case the patient has had significant pain for several weeks despite the lack of any apparent injury; thus, this does not appear to be acute pain.
B Correct. Allodynia is a painful response to a stimulus that does not normally provoke pain, such as pain in response to light touch. This is consistent with what the patient describes.
C Incorrect. Hyperalgesia is an exaggerated pain response to something that is normally painful (for example, extreme pain in response to a pin prick). Mild pressure from being hugged by one’s child would not normally elicit pain, and thus this particular complaint does not represent hyperalgesia.
References
Question Three
A young man arrives at the emergency room in great pain after receiving a chemical burn during an accident at work. Which primary afferent neurons would have responded to the chemical stimulus to produce nociceptive neuronal activity?
The correct answer is C.
| Choice | Peer answers |
|---|---|
| A. A beta fiber neurons | 10% |
| B. A delta fiber neurons | 35% |
| C. C fiber neurons | 55% |
A Incorrect. A beta fibers respond to non-noxious small movements such as light touch, hair movement, and vibrations, and do not respond to noxious stimuli.
B Incorrect. A delta fibers fall somewhere in between A beta fibers and C fiber neurons, sensing noxious mechanical stimuli and subnoxious thermal stimuli.
C Correct. C fiber peripheral terminals are bare nerve endings that are only activated by noxious mechanical, thermal, or chemical stimuli. Thus C fiber neurons are the primary afferent neurons responsible for nociceptive conduction following this patient’s injury.
References
Question Four
A 29-year-old woman has just been diagnosed with major depressive disorder and is being prescribed a selective serotonin reuptake inhibitor (SSRI). In addition to depressed mood, lack of interest in her work or friends, and difficulty sleeping, she has been experiencing aches and pains in her arms, shoulders, and torso. She asks if the SSRI is likely to alleviate her painful physical symptoms as well as her emotional ones. Which of the following statements is true?
A. SSRIs may have inconsistent effects on pain because serotonin can both inhibit and facilitate ascending nociceptive signals
B. SSRIs may worsen pain because serotonin can facilitate but not inhibit ascending nociceptive signals
C. SSRIs generally alleviate pain because serotonin can inhibit but not facilitate ascending nociceptive signals
D. SSRIs generally have no effect on pain because serotonin neither facilitates nor inhibits nociceptive signals
The correct answer is A.
| Choice | Peer answers |
|---|---|
| A. SSRIs may have inconsistent effects on pain because serotonin can both inhibit and facilitate ascending nociceptive signals | 53% |
| B. SSRIs may worsen pain because serotonin can facilitate but not inhibit ascending nociceptive signals | 0% |
| C. SSRIs generally alleviate pain because serotonin can inhibit but not facilitate ascending nociceptive signals | 26% |
| D. SSRIs generally have no effect on pain because serotonin neither facilitates nor inhibits nociceptive signals | 21% |
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