Pain Management — MCQs
Anaesthetic agent causing analgesia?
Intravenous regional anesthesia is suitable for :
A nondiabetic, nonhypertensive patient has occasional extra heartbeats. The doctor informed them it is benign, but the patient continues to seek investigations from doctor to doctor. This is a type of:
Perception of normal (non-painful) sensory stimuli as painful is called
Which of the following pain medications requires the MOST caution in a patient with a history of opioid addiction?
Which nerve is targeted in the nasociliary nerve block?
A malnourished 60-year-old man underwent emergency surgery for Strangulated Sigmoid Volvulus. After resection of the sigmoid colon, a colostomy was fashioned. The postoperative period was stormy and he developed a painful calf swelling in right lower limb. The most probable diagnosis is :
A patient developed breathlessness and chest pain, on second postoperative day after a total hip replacement. Echocardiography showed right ventricular dilatation and tricuspid regurgitation. What is the most likely diagnosis?
A patient comes with a complaint of shoulder pain after laparoscopic surgery. What should be the next step in management?
A female patient who underwent surgery for abdominal intestinal perforation presents on the 5th postoperative day with serous discharge and a gap in the wound. What is the most likely diagnosis?
Pain Management Indian Medical PG Practice Questions and MCQs
Question 1: Anaesthetic agent causing analgesia?
- A. Thiopentone
- B. Ketamine (Correct Answer)
- C. Propofol
- D. Etomidate
Explanation: ***Ketamine*** - Ketamine provides excellent **analgesia** by acting as an **NMDA receptor antagonist**, making it unique among commonly used intravenous anesthetics [1]. - It induces a state of **dissociative anesthesia**, where the patient is conscious but detached from painful stimuli, maintaining cardiovascular stability [1]. *Thiopentone* - Thiopentone is a **barbiturate** that causes rapid **induction of anesthesia** and profound **sedation** but has no analgesic properties. - Its primary action is through potentiation of GABA-A receptor activity, leading to central nervous system depression. *Propofol* - Propofol is a widely used intravenous anesthetic known for its rapid onset and short duration of action, but it lacks significant **analgesic effects** [3]. - It primarily works by enhancing GABA-A receptor function, leading to **sedation** and hypnosis. *Etomidate* - Etomidate is an intravenous anesthetic characterized by its minimal cardiovascular depression, making it suitable for patients with **hemodynamic instability**, but it provides **no analgesia** [1], [2]. - Its anesthetic effect is mediated through GABA-A receptor potentiation, resulting in rapid loss of consciousness.
Question 2: Intravenous regional anesthesia is suitable for :
- A. Caesarian section
- B. Head and neck surgery
- C. Orthopedic manipulation on the upper limb (Correct Answer)
- D. Vascular surgery on the lower limb
Explanation: ***Orthopedic manipulation on the upper limb*** - **Intravenous regional anesthesia (IVRA)**, also known as a Bier block, is ideal for **short-duration procedures on the extremities**, especially the upper limb. - The technique involves isolating the limb with a **tourniquet** and injecting a local anesthetic intravenously, making it suitable for procedures like **orthopedic manipulations** that are typically less than an hour. *Caesarian section* - A Caesarian section requires **widespread anesthesia** to the lower abdomen and uterus, which cannot be achieved with IVRA. - It is typically performed under **spinal or epidural anesthesia**, or general anesthesia. *Head and neck surgery* - **IVRA** is a regional technique limited to the extremities below the tourniquet; it cannot provide anesthesia for the **head and neck region**. - Procedures in this area usually require **general anesthesia** or sometimes regional blocks like cervical plexus blocks. *Vascular surgery on the lower limb* - While IVRA can be used on the lower limb, **vascular surgery** often involves **longer durations** and may require more profound muscle relaxation and sensory blockade than IVRA can reliably provide. - Additionally, the use of a **tourniquet for extended periods** in vascular surgery patients can be contraindicated due to potential ischemic complications.
Question 3: A nondiabetic, nonhypertensive patient has occasional extra heartbeats. The doctor informed them it is benign, but the patient continues to seek investigations from doctor to doctor. This is a type of:
- A. Depression
- B. Conversion disorder
- C. Somatoform pain
- D. Illness Anxiety Disorder (Correct Answer)
Explanation: ***Illness Anxiety Disorder*** - This condition is characterized by **preoccupation with having or acquiring a serious illness**, despite minimal or no somatic symptoms, or an excessive preoccupation if symptoms are present. - The patient's repeated seeking of investigations despite medical assurance of a benign condition aligns with the diagnostic criteria of **illness anxiety disorder**, where reassurance has little effect. *Depression* - While **depressive symptoms** (e.g., low mood, anhedonia) can coexist with health anxieties, the primary driver here is the fear of serious illness rather than pervasive sadness or loss of interest. - Patients with depression typically report a **generalized dysphoria** or lack of energy, which is not the central issue described. *Conversion disorder* - Involves **neurological symptoms** (e.g., paralysis, blindness, seizures) that are incompatible with recognized neurological conditions and are not intentionally produced. - The patient's concern is about a benign cardiac finding, not the sudden onset of **functional neurological deficits**. *Somatoform pain* - This term is older and has largely been replaced by **Somatic Symptom Disorder with predominant pain**, where psychological factors play a significant role in the onset, severity, exacerbation, or maintenance of pain. - The patient's main concern is about the **implication of a benign symptom** rather than experiencing overwhelming pain itself.
Question 4: Perception of normal (non-painful) sensory stimuli as painful is called
- A. Causalgia
- B. Hyperpathia
- C. Hyperalgesia
- D. Allodynia (Correct Answer)
Explanation: ***Allodynia*** - This is the experience of **pain from stimuli that are not typically painful**, such as light touch or brushing against the skin. - It arises from abnormal processing of sensory signals in the central nervous system, often seen in conditions like **neuropathic pain** and **fibromyalgia**. *Causalgia* - This term refers to **complex regional pain syndrome type II**, which is characterized by **burning pain** and often involves nerve injury. - While it involves severe pain, it typically results from a noxious stimulus becoming excessively painful, rather than a non-painful stimulus being perceived as painful. *Hyperpathia* - This describes an **exaggerated pain reaction to a painful stimulus**, often involving a raised threshold for pain alongside an increased and persistent response. - Unlike allodynia, the initial stimulus is already painful; hyperpathia simply makes the response more intense and prolonged. *Hyperalgesia* - This is an **increased pain response to a stimulus that is normally painful**, meaning a painful stimulus is perceived as even more painful than expected. - The key difference from allodynia is that the stimulus itself is already nociceptive (pain-producing), whereas in allodynia, a non-nociceptive stimulus elicits pain.
Question 5: Which of the following pain medications requires the MOST caution in a patient with a history of opioid addiction?
- A. Morphine (Correct Answer)
- B. Oxycodone
- C. Methadone
- D. Buprenorphine
Explanation: ***Morphine*** - Morphine is a **full mu-opioid agonist** with the highest potential for **abuse, dependence, and relapse** in patients with a history of opioid addiction due to its strong **euphoric effects**. - It carries the greatest risk of triggering **addictive behaviors** and relapse in recovering patients, making it require the MOST caution in this population. - Use should be avoided if possible, or limited to short-term use under strict supervision with alternative analgesics preferred. *Oxycodone* - Oxycodone is another **potent full opioid agonist** with very high abuse potential, nearly equivalent to morphine. - While requiring extreme caution, morphine remains the prototypical high-risk opioid in addiction-prone patients. *Methadone* - Methadone is a **long-acting full opioid agonist** used in opioid maintenance therapy with significant abuse potential. - However, when used appropriately in supervised programs, it has a role in addiction treatment, though acute pain prescribing requires caution due to its **long half-life and QTc prolongation risk**. *Buprenorphine* - Buprenorphine is a **partial mu-opioid agonist** with a **ceiling effect** that limits respiratory depression and euphoria. - It is the **standard medication for opioid use disorder treatment** and has LOWER abuse potential than full agonists. - While it requires careful timing to avoid precipitated withdrawal in opioid-dependent patients, it is actually SAFER than full agonists in patients with addiction history due to reduced relapse risk.
Question 6: Which nerve is targeted in the nasociliary nerve block?
- A. Greater palatine nerve
- B. Sphenopalatine nerve
- C. Anterior ethmoidal nerve
- D. Nasociliary nerve (Correct Answer)
Explanation: ***Nasociliary nerve*** - A nasociliary nerve block specifically targets the **nasociliary nerve** itself. - This block is used to anesthetize the sensory innervation of structures supplied by the nasociliary nerve, such as parts of the **nasal cavity**, **eyeball**, and **skin of the nose**. *Greater palatine nerve* - The **greater palatine nerve** supplies sensation to the posterior hard palate and is targeted in a **greater palatine nerve block**. - This nerve is a branch of the **maxillary nerve** and is primarily involved in dental and palatal anesthesia. *Sphenopalatine nerve* - The **sphenopalatine nerve**, or pterygopalatine ganglion, contains sensory fibers for the nasal cavity, palate, and pharynx, and its block is distinct from a nasociliary block. - A **sphenopalatine ganglion block** is mainly used for conditions like cluster headaches and facial pain, not for direct eyeball sensation. *Anterior ethmoidal nerve* - The **anterior ethmoidal nerve** is a branch of the nasociliary nerve, but a nasociliary nerve block targets the main trunk, which includes all its branches. - While the anterior ethmoidal nerve supplies the anterior part of the nasal septum and lateral wall, it is a **component** of the nasociliary innervation rather than the sole target.
Question 7: A malnourished 60-year-old man underwent emergency surgery for Strangulated Sigmoid Volvulus. After resection of the sigmoid colon, a colostomy was fashioned. The postoperative period was stormy and he developed a painful calf swelling in right lower limb. The most probable diagnosis is :
- A. Myocardial failure due to fluid overload
- B. Deep vein thrombosis (Correct Answer)
- C. Oedema of renal failure
- D. Hypoproteinaemia
Explanation: ***Deep vein thrombosis*** - Postoperative patients, especially those undergoing **abdominal surgery** and those with **malnutrition**, are at high risk for **deep vein thrombosis (DVT)** due to Virchow's triad (venous stasis, endothelial injury, hypercoagulability). - A **painful calf swelling** is a classic symptom of DVT, indicating clot formation within the deep veins of the leg. *Myocardial failure due to fluid overload* - While fluid overload can occur post-surgery, it typically leads to **generalized edema**, shortness of breath, and signs of cardiac dysfunction, not isolated painful calf swelling. - The primary presentation here is a localized, painful swelling, which is less consistent with systemic cardiac issues. *Oedema of renal failure* - **Renal failure** can cause **edema**, but it tends to be **pitting, bilateral, and generalized**, often affecting the ankles and sacral areas. - It would not typically present as a painful, unilateral calf swelling without other signs of kidney dysfunction. *Hypoproteinaemia* - **Hypoproteinaemia**, common in **malnourished** individuals, can cause **generalized non-pitting edema** due to decreased oncotic pressure, not specifically a painful calf swelling. - It would manifest as widespread edema rather than a localized, painful swelling indicative of a thrombotic event.
Question 8: A patient developed breathlessness and chest pain, on second postoperative day after a total hip replacement. Echocardiography showed right ventricular dilatation and tricuspid regurgitation. What is the most likely diagnosis?
- A. Pulmonary embolism (Correct Answer)
- B. Cardiac tamponade
- C. Acute MI
- D. Hypotensive shock
Explanation: ***Pulmonary embolism*** - Postoperative state, sudden onset of **breathlessness**, and **chest pain** are classic symptoms of pulmonary embolism (PE). - **Right ventricular dilatation** and **tricuspid regurgitation** on echocardiography are strong indicators of acute right heart strain due to increased pulmonary artery pressure caused by the embolus. *Cardiac tamponade* - Characterized by muffled heart sounds, **pulsus paradoxus**, and **hypotension**, often due to fluid accumulation in the pericardial sac. - While it can cause breathlessness, the echocardiographic findings of **right ventricular dilatation** and **tricuspid regurgitation** are not typical of tamponade. *Acute MI* - Myocardial infarction typically presents with ischemic chest pain, often radiating, and is primarily diagnosed by **ECG changes** and **cardiac enzymes**. - While acute MI can cause breathlessness, the combination of a postoperative setting and the specific echocardiographic findings of **right heart strain** points away from an initial diagnosis of MI. *Hypotensive shock* - Hypotensive shock is a state of severe low blood pressure leading to organ hypoperfusion, with various underlying causes. - While PE can *lead to* hypotensive shock due to hemodynamic compromise, the question describes the specific pathology (right heart strain) rather than just the resultant shock state.
Question 9: A patient comes with a complaint of shoulder pain after laparoscopic surgery. What should be the next step in management?
- A. Intraarticular lignocaine injection
- B. USG of shoulder region
- C. Oral paracetamol for 2 - 3 days (Correct Answer)
- D. Diagnostic shoulder arthroscopy
Explanation: ***Oral paracetamol for 2 - 3 days*** - Post-laparoscopic shoulder pain is a common, self-limiting symptom caused by **diaphragmatic irritation from residual CO2 gas**, and typically resolves with conservative treatment. - **Oral analgesics** like paracetamol are the first-line treatment for managing this transient pain. *Intraarticular lidocaine injection* - This intervention is typically reserved for more severe or persistent **arthritic pain**, or for diagnostic purposes in the shoulder joint itself. - The pain described is referred pain from the **diaphragm**, not intrinsic joint pathology, making an intraarticular injection inappropriate as a first step. *USG of the shoulder region* - **Ultrasound** imaging is used to evaluate structural abnormalities within the shoulder joint (e.g., rotator cuff tears, tendinitis). - Since the pain is likely referred from **CO2 irritation of the diaphragm**, imaging of the shoulder joint is unlikely to reveal the cause and is not the appropriate initial step. *Diagnostic shoulder arthroscopy* - **Arthroscopy** is an invasive surgical procedure used for diagnosing and treating complex shoulder conditions. - Given that post-laparoscopic shoulder pain is generally benign and resolves spontaneously, such an invasive procedure is **unjustified** and carries unnecessary risks.
Question 10: A female patient who underwent surgery for abdominal intestinal perforation presents on the 5th postoperative day with serous discharge and a gap in the wound. What is the most likely diagnosis?
- A. Wound dehiscence (Correct Answer)
- B. Enterocutaneous fistula
- C. Peritonitis
- D. Seroma
Explanation: ***Wound dehiscence*** - This is the most likely diagnosis given the presentation of **serous discharge** and a **gap in the wound** on the 5th postoperative day. - **Abdominal intestinal perforation** surgery is a risk factor, and the timing is consistent with **fascial dehiscence**, which can lead to evisceration if left untreated. *Enterocutaneous fistula* - This involves a connection between the **bowel lumen** and the **skin surface**, typically discharging enteric contents (e.g., bile, stool), not just serous fluid. - While a possibility in complicated abdominal surgeries, the description of a "gap in the wound" and serous discharge is more indicative of a **structural failure** of the wound. *Seroma* - A seroma is a collection of **serous fluid** under the skin flap or surgical incision, presenting as a **fluctuant swelling**, but it typically does not involve a "gap in the wound." - It would not usually present with a wound **disruption** that exposes underlying tissue; instead, it's an intact pocket of fluid. *Peritonitis* - This is an **inflammation of the peritoneum**, usually caused by infection, and presents with **severe abdominal pain**, fever, and diffuse tenderness, which are not mentioned here. - While an intestinal perforation would initially cause peritonitis, the current presentation focuses on the **wound site** rather than systemic or diffuse abdominal symptoms.
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