Chronic Pain Management — MCQs
A patient with nocturnal enuresis and depressive symptoms was started on an antidepressant. What is the drug?
Psychodynamic model of disease explains the psychopathologic cause of all mental illness to be
What is the first-line drug used for painful diabetic neuropathy?
Which of the following is the most appropriate pharmacological treatment for neuropathic pain in a diabetic patient?
Which of the following is/are characteristic features of chronic inflammation?
Match the following: A) Glossopharyngeal nerve B) Spinal accessory nerve C) Facial nerve D) Mandibular nerve 1) Shrugging of shoulder 2) Touch sensation from the posterior one-third of the tongue 3) Chewing 4) Taste from the anterior two-thirds of the tongue
Best therapy suited to teach daily life skills to a child with intellectual disability:
Sensations of pain from teeth and temperature are carried by
All are first rank symptoms of schizophrenia, except:
A patient delivered at home with a complete perineal tear came to the hospital after 2 weeks. What is the most appropriate management for this patient?
Chronic Pain Management Indian Medical PG Practice Questions and MCQs
Question 1: A patient with nocturnal enuresis and depressive symptoms was started on an antidepressant. What is the drug?
- A. clomipramine
- B. sertraline
- C. amitriptyline
- D. imipramine (Correct Answer)
Explanation: ***Imipramine*** - **Imipramine (Tofranil)** is a **tricyclic antidepressant (TCA)** [1] historically used for **nocturnal enuresis** due to its anticholinergic and alpha-adrenergic effects, which increase bladder capacity and sphincter tone. While it treats **depressive symptoms** [2], its use in enuresis has declined due to newer therapies with fewer side effects. *Clomipramine* - **Clomipramine (Anafranil)** is primarily used for **obsessive-compulsive disorder (OCD)** but also has antidepressant effects. While it shares some properties with imipramine as a TCA, it is **not the primary choice for nocturnal enuresis** and is more known for its serotonin reuptake inhibition. *Sertraline* - **Sertraline (Zoloft)** is a **selective serotonin reuptake inhibitor (SSRI)** commonly used for depression, anxiety disorders, and OCD. It **does not have a recognized role in treating nocturnal enuresis** and can sometimes even worsen urinary symptoms or cause nocturnal polyuria. *Amitriptyline* - **Amitriptyline (Elavil)** is a TCA effective for **depression**, **neuropathic pain**, and **migraine prophylaxis**. While it has strong anticholinergic properties that could theoretically affect bladder function, it is **not the preferred TCA for nocturnal enuresis**; imipramine has a more established history for this indication.
Question 2: Psychodynamic model of disease explains the psychopathologic cause of all mental illness to be
- A. Structural and functional defect in CNS
- B. Maladaptive
- C. Cognition difficulties
- D. Unconscious conflict (Correct Answer)
Explanation: **Correct: Unconscious conflict** - The **psychodynamic model**, largely based on Freudian theory, posits that psychopathology arises from unresolved **unconscious conflicts** or repressed urges and experiences. - These conflicts typically stem from early childhood experiences and defense mechanisms used to cope with them, leading to symptomatic behavior. - This is the fundamental explanatory mechanism of the psychodynamic framework. *Incorrect: Structural and functional defect in CNS* - This explanation aligns with the **biomedical model**, which attributes mental illness to biological factors like **neurotransmitter imbalances**, genetic predispositions, or brain abnormalities. - While biological factors are crucial in understanding some mental illnesses, they are not the primary explanatory mechanism in the psychodynamic framework. *Incorrect: Maladaptive* - While psychopathology often involves **maladaptive behaviors** or thought patterns, the psychodynamic model views these as symptoms or manifestations of the underlying unconscious conflict, rather than the root cause itself. - Other models, like **behavioral psychology**, focus more directly on maladaptive learning as the primary cause. *Incorrect: Cognition difficulties* - **Cognitive difficulties** and distortions are central to the **cognitive model** of psychopathology, which suggests that mental illness results from faulty thinking patterns or dysfunctional schemas. - The psychodynamic model acknowledges intellectual functions, but it primarily sees disturbances in cognition as driven by deeper, unconscious emotional processes.
Question 3: What is the first-line drug used for painful diabetic neuropathy?
- A. Venlafaxine
- B. EMLA cream
- C. Carbamazepine
- D. Duloxetine (Correct Answer)
Explanation: ***Duloxetine*** - **Duloxetine**, a serotonin-norepinephrine reuptake inhibitor (SNRI), is recommended as a **first-line agent** for the management of **painful diabetic neuropathy**. - Its efficacy in reducing neuropathic pain has been demonstrated in multiple clinical trials, leading to its approval for this indication. *Carbamazepine* - **Carbamazepine** is an **antiepileptic drug** primarily used for seizure disorders and trigeminal neuralgia, but it is not a first-line treatment for painful diabetic neuropathy. - While it can be used for neuropathic pain, its efficacy in diabetic neuropathy is **limited**, and it has a narrower therapeutic index with potential for significant adverse effects. *Venlafaxine* - **Venlafaxine** is another SNRI, similar to duloxetine, and can be used for neuropathic pain. However, **duloxetine** is generally preferred as a first-line agent specifically for **diabetic neuropathy** due to more robust evidence and specific FDA approval for this indication. - While it has similar mechanisms of action, it is often considered a **second-line** or alternative agent for painful diabetic neuropathy. *EMLA cream* - **EMLA cream** (eutectic mixture of local anesthetics) contains lidocaine and prilocaine and is a **topical agent** used for localized pain or before minor procedures. - It is **not suitable for diffuse or widespread neuropathic pain**, such as that seen in painful diabetic neuropathy, and would not be considered a first-line systemic treatment.
Question 4: Which of the following is the most appropriate pharmacological treatment for neuropathic pain in a diabetic patient?
- A. Acetaminophen
- B. Tramadol
- C. Aspirin
- D. Gabapentin (Correct Answer)
Explanation: ***Gabapentin*** - **Gabapentin** is a widely recommended first-line treatment for diabetic neuropathic pain due to its efficacy in modulating neuronal excitability. - It works by binding to the **α2δ subunit of voltage-gated calcium channels**, reducing calcium influx and thereby decreasing the release of excitatory neurotransmitters involved in pain signaling. *Acetaminophen* - **Acetaminophen** is primarily an analgesic and antipyretic, effective for mild to moderate non-neuropathic pain. - It has no significant efficacy against **neuropathic pain**, which involves distinct neurobiological mechanisms. *Tramadol* - **Tramadol** is an opioid analgesic with some serotonin and norepinephrine reuptake inhibition, offering moderate pain relief. - While it can be used for moderate to severe pain, it is generally considered a **second-line agent** for neuropathic pain due to its opioid nature and potential side effects. *Aspirin* - **Aspirin** is a nonsteroidal anti-inflammatory drug (NSAID) primarily used for its anti-inflammatory, analgesic, and antiplatelet effects. - It is **ineffective for neuropathic pain**, which does not typically involve peripheral inflammation as its primary mechanism.
Question 5: Which of the following is/are characteristic features of chronic inflammation?
- A. Infiltration of neutrophils
- B. Tissue fibrosis and lymphocyte infiltration (Correct Answer)
- C. Increased blood flow (hyperemia)
- D. Presence of fluid accumulation (edema) in tissues
Explanation: ***Tissue fibrosis and lymphocyte infiltration*** - **Chronic inflammation** is characterized by the persistent presence of lymphocytes, plasma cells, and macrophages as the predominant inflammatory cells [1]. - **Tissue fibrosis** (scarring) and destruction are hallmarks of chronic inflammation as the body attempts to repair ongoing damage, often leading to loss of organ function [1]. *Infiltration of neutrophils* - **Neutrophils** are the primary inflammatory cells seen in **acute inflammation**, being the first responders to injury or infection [2]. - Their presence typically signifies an active, recent inflammatory process, usually resolving within hours to days. *Increased blood flow (hyperemia)* - **Hyperemia** is a classic sign of **acute inflammation**, contributing to the **redness and warmth** observed at the site. - While some vascular changes can persist in chronic inflammation, pronounced and primary hyperemia is characteristic of the acute phase. *Presence of fluid accumulation (edema) in tissues* - **Edema** primarily results from increased vascular permeability, a key feature of **acute inflammation**, causing swelling [2]. - While some edema may be present in chronic inflammation due to persistent vascular leakage, it is a dominant feature of acute inflammatory responses. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Inflammation and Repair, pp. 109-110. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Inflammation and Repair, pp. 103-104.
Question 6: Match the following: A) Glossopharyngeal nerve B) Spinal accessory nerve C) Facial nerve D) Mandibular nerve 1) Shrugging of shoulder 2) Touch sensation from the posterior one-third of the tongue 3) Chewing 4) Taste from the anterior two-thirds of the tongue
- A. A-3 , B-1 , C-4 , D-2
- B. A-2 , B-3 , C-4 , D-1
- C. A-4 , B-1 , C-2 , D-3
- D. A-2 , B-1 , C-4 , D-3 (Correct Answer)
Explanation: ***A-2 , B-1 , C-4 , D-3*** - **A) Glossopharyngeal nerve (CN IX)** is responsible for **general sensation and taste from the posterior one-third of the tongue** [1]. (2). - **B) Spinal Accessory nerve (CN XI)** innervates the **sternocleidomastoid** and **trapezius muscles**, which are involved in shrugging the shoulders (1). - **C) Facial nerve (CN VII)** carries **taste sensation from the anterior two-thirds of the tongue** [1] (4) via the chorda tympani. - **D) Mandibular nerve (V3)**, a branch of the trigeminal nerve, innervates the muscles of mastication, enabling **chewing** (3). *A-3 , B-1 , C-4 , D-2* - This option incorrectly associates the **glossopharyngeal nerve** with chewing, which is a function of the mandibular nerve (V3). - It also incorrectly associates the **mandibular nerve** with touch sensation from the posterior one-third of the tongue, which is a function of the glossopharyngeal nerve [1]. *A-2 , B-3 , C-4 , D-1* - This option incorrectly links the **spinal accessory nerve** with chewing; this nerve primarily controls shoulder and neck movements. - It also incorrectly assigns shrugging of the shoulder to the **mandibular nerve** instead of the spinal accessory nerve. *A-4 , B-1 , C-2 , D-3* - This choice incorrectly attributes **taste from the anterior two-thirds of the tongue** to the glossopharyngeal nerve, which supplies the posterior one-third [1]. - It also incorrectly links **touch sensation from the posterior one-third of the tongue** to the facial nerve, which is involved in taste from the anterior two-thirds [1].
Question 7: Best therapy suited to teach daily life skills to a child with intellectual disability:
- A. Applied Behavior Analysis (ABA) (Correct Answer)
- B. Cognitive Behavioral Therapy (CBT)
- C. Social skills training
- D. Self-instructional training
Explanation: **Applied Behavior Analysis (ABA)** - **ABA** is a highly structured, evidence-based therapy that focuses on teaching specific skills by breaking them down into smaller steps and using **positive reinforcement**. - It is particularly effective for children with intellectual disabilities in acquiring **adaptive daily living skills**, communication, and social behaviors. *Cognitive Behavioral Therapy (CBT)* - **CBT** primarily targets changing negative thought patterns and behaviors, requiring a level of abstract reasoning that may be challenging for children with significant intellectual disabilities. - While it can be adapted, its core methods rely on cognitive processes that might not be the most direct approach for teaching basic daily life skills to a mentally challenged child. *Social skills training* - **Social skills training** focuses specifically on improving social interactions and communication within social contexts. - While important for overall development, it is a subcomponent of broader skill development and may not directly address all aspects of **daily living skills** in a comprehensive manner. *Self-instructional training* - **Self-instructional training** involves teaching individuals to guide themselves through tasks using internal speech or self-talk, which relies on a child's ability to internalize and follow complex verbal instructions. - This approach might be too cognitively demanding for a child with significant developmental delays when the primary goal is mastering basic, functional daily life skills.
Question 8: Sensations of pain from teeth and temperature are carried by
- A. Lateral spinothalamic tract (Correct Answer)
- B. Trigeminal nerve pathway
- C. Ventral spinothalamic tract
- D. Corticospinal tract
Explanation: ***Lateral spinothalamic tract*** - The **lateral spinothalamic tract** primarily carries sensations of **pain and temperature** from the body to the brain. - This pathway is crucial for transmitting these somatosensory modalities from the periphery, including dental structures, up the spinal cord to the **thalamus** and then to the cerebral cortex. *Trigeminal nerve pathway* - The **trigeminal nerve (CN V)** is responsible for sensory innervation of the face, including teeth, and jaw motor function. - While it transmits sensory information from the teeth, its central pathway eventually synapses with the **trigeminal lemniscus** which then projects to the thalamus, rather than directly being the spinothalamic tract itself. *Ventral spinothalamic tract* - The **ventral (anterior) spinothalamic tract** primarily carries sensations of **crude touch and pressure**. - It does not significantly contribute to the transmission of pain and temperature, which are the main sensations from teeth and temperature described. *Corticospinal tract* - The **corticospinal tract** is a major **motor pathway** that originates in the cerebral cortex and descends to the spinal cord. - It is responsible for **voluntary fine motor control** of the limbs and body, having no role in carrying sensory information like pain or temperature.
Question 9: All are first rank symptoms of schizophrenia, except:
- A. Audible thoughts
- B. Thought broadcasting
- C. Voice arguing or discussing or both
- D. Perplexity (Correct Answer)
Explanation: ***Perplexity*** - **Perplexity** is a state of severe confusion, bewilderment, or puzzlement, which can be seen in various psychiatric conditions but is not specifically classified as a **first-rank symptom of schizophrenia** by Kurt Schneider. - While it may be present in schizophrenia, it is a non-specific symptom, meaning it can occur in conditions other than schizophrenia. *Audible thoughts* - **Audible thoughts** (Gedankenlautwerden in German) refers to the patient hearing their own thoughts spoken aloud, often as if by another voice. - This is considered a **first-rank symptom** as described by Kurt Schneider, highly indicative of schizophrenia. *Thought broadcasting* - **Thought broadcasting** is the delusional belief that one's thoughts are escaping from their mind and are somehow accessible to others. - This symptom is also a **first-rank symptom** of schizophrenia according to Schneider's criteria. *Voice arguing or discussing or both* - **Voices arguing or discussing** are a specific type of auditory hallucination where two or more voices are perceived to be talking to each other, often about the patient. - This phenomenon is considered a classic **first-rank symptom** of schizophrenia.
Question 10: A patient delivered at home with a complete perineal tear came to the hospital after 2 weeks. What is the most appropriate management for this patient?
- A. Repair 6 weeks post-delivery
- B. Repair 3 months post-delivery (Correct Answer)
- C. Repair within 1-2 weeks post-delivery
- D. Repair 3 weeks post-delivery
Explanation: ***Repair 3 months post-delivery*** - When a patient presents at **2 weeks post-delivery** with an **unrepaired complete perineal tear** (3rd or 4th degree), the optimal management is **delayed secondary repair at 3-6 months**. - At 2 weeks, the acute repair window has passed, and immediate repair carries high risks of **infection**, **wound breakdown**, and **poor healing** due to tissue edema, friability, and ongoing inflammatory changes. - Waiting **3 months** allows complete **resolution of inflammation**, **tissue maturation**, better **vascularization**, and optimal conditions for **secondary repair** with improved functional outcomes including continence. - This is the standard recommended approach per **RCOG** and **ACOG** guidelines for delayed presentation of complete perineal tears. *Repair within 1-2 weeks post-delivery* - While this would have been ideal if the patient presented immediately, she is **already at 2 weeks** when she comes to the hospital. - Primary repair should be done within **24 hours** of delivery or as soon as possible within the first few days for best results. - Since the patient is already at 2 weeks, this option is not feasible (cannot go back in time) and attempting repair at this point would have suboptimal outcomes. *Repair 3 weeks post-delivery* - At **3 weeks**, the tissues are still in a suboptimal state with ongoing inflammatory changes, edema, and risk of infection. - This timing falls in the **"danger zone"** where repair is neither early primary repair nor properly delayed secondary repair. - Attempting repair at this stage has higher rates of **dehiscence** and **poor functional outcomes** compared to waiting for full tissue healing. *Repair 6 weeks post-delivery* - While **6 weeks** is better than 3 weeks, it is still **too early** for optimal secondary repair of a complete perineal tear. - Tissues have not fully matured, and residual inflammation may persist, compromising surgical outcomes. - Standard practice recommends waiting **at least 3 months** (preferably 3-6 months) for best results in delayed secondary repair.
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