Archive for September 2020

A 59-year- old woman has been told by her orthopedist that the preferred treatment for her debilitating pain in both knees is knee replacement surgery. She agrees to have the surgery in one month when she will have time for rehabilitation. In the interim, the physician prescribes a medication for pain relief and to reduce inflammation. The woman is otherwise healthy, takes no medication, and has no known drug allergies. The physician decides on a nonsteroidal anti- inflammatory drug that has a high affinity for cyclooxygenase-2 (COX-2) and no affinity for COX-1. Compared to other NSAIDs, this drug is less likely to cause:

Naim 13:15

A 59-year- old woman has been told by her orthopedist that the preferred treatment for her debilitating pain in both knees is knee replacement surgery. She agrees to have the surgery in one month when she will have time for rehabilitation. In the interim, the physician prescribes a medication for pain relief and to reduce inflammation. The woman is otherwise healthy, takes no medication, and has no known drug allergies. The physician decides on a nonsteroidal anti- inflammatory drug that has a high affinity for cyclooxygenase-2 (COX-2) and no affinity for COX-1. Compared to other NSAIDs, this drug is less likely to cause:



A. Allergy
B. Blood clots
C. Elevated blood pressure
D. Gastric ulcer
E. Peripheral vasoconstriction


Answer: D

A 69-year-old male presents to your office complaining of pain in his neck that extends bilaterally over his shoulders. He also complains of an aching sensation in both of his arms and loss of fine motor control of his hands. This has been progressing over the past six months. He worked in construction and had multiple small neck injuries during college wrestling and football. His overall health is quite good. On X-rays studies of his cervical spine you would expect to find?

Naim 13:15

A 69-year-old male presents to your office complaining of pain in his neck that extends bilaterally over his shoulders. He also complains of an aching sensation in both of his arms and loss of fine motor control of his hands. This has been progressing over the past six months. He worked in construction and had multiple small neck injuries during college wrestling and football. His overall health is quite good. On X-rays studies of his cervical spine you would expect to find?



A. Normal findings
B. Nothing abnormal except for the loss of the cervical lordotic curve
C. Narrowing of multiple disc spaces, with osteophytes and loss of cervical lordosis
D. An anterior wedge deformity is present at C5
E. A large lytic lesion in the body of C4


Answer: C

A 54-year-old male construction worker has had low back pain for about two months. He has had previous episodes of low back pain. Now, the pain is more intense than it was on prior episodes and seems to be getting worse rather than improving over time. He does remember lifting very heavy steel beams and the pain is now unbearable. He complains of numbness in both legs and across his buttocks. He is embarrassed to report that he was incontinent of urine and stool this morning. You should plan on:

Naim 13:14

A 54-year-old male construction worker has had low back pain for about two months. He has had previous episodes of low back pain. Now, the pain is more intense than it was on prior episodes and seems to be getting worse rather than improving over time. He does remember lifting very heavy steel beams and the pain is now unbearable. He complains of numbness in both legs and across his buttocks. He is embarrassed to report that he was incontinent of urine and stool this morning. You should plan on:



A. Admitting him to the hospital immediately
B. Arranging for outpatient physical therapy
C. Giving him a prescription for acetaminophen
D. Recommending him for an outpatient lumbar spine MRI
E. Recommending for him bed rest and a return visit in a week


Answer: A

A 25-year-old female medical student comes to your office asking for an MRI of her neck to confirm her suspicion that she has a herniated cervical disc. On exam, her triceps reflex is absent, and she has weakness of elbow extension and numbness on her long finger. You both expect the MRI to reveal a disc herniation at:

Naim 13:14

A 25-year-old female medical student comes to your office asking for an MRI of her neck to confirm her suspicion that she has a herniated cervical disc. On exam, her triceps reflex is absent, and she has weakness of elbow extension and numbness on her long finger. You both expect the MRI to reveal a disc herniation at:



A. C3
B. C4
C. C5
D. C6
E. C7


Answer: E

A 57-year-old physician presents to his doctor complaining of neck pain that radiates down the lateral aspect of his right arm. He also complains of numbness in his right thumb with weakness on resisted thumb extension. You suspect a herniated disc compression which nerve root?

Naim 13:14

A 57-year-old physician presents to his doctor complaining of neck pain that radiates down the lateral aspect of his right arm. He also complains of numbness in his right thumb with weakness on resisted thumb extension. You suspect a herniated disc compression which nerve root?



A. C3
B. C4
C. C5
D. C6
E. C7



Answer: D

A 54-year-old male construction worker has had low back pain for about two months. He has had previous episodes of low back pain. Now, the pain is more intense than it was on prior episodes and seems to be getting worse rather than improving over time. He does remember lifting very heavy steel beams and the pain is now unbearable. He complains of numbness in both legs and across his buttocks. He is embarrassed to report that he was incontinent of urine and stool this morning. You should plan on:

Naim 13:14

A 54-year-old male construction worker has had low back pain for about two months. He has had previous episodes of low back pain. Now, the pain is more intense than it was on prior episodes and seems to be getting worse rather than improving over time. He does remember lifting very heavy steel beams and the pain is now unbearable. He complains of numbness in both legs and across his buttocks. He is embarrassed to report that he was incontinent of urine and stool this morning. You should plan on:



A. Admitting him to the hospital immediately
B. Arranging for outpatient physical therapy
C. Giving him a prescription for acetaminophen
D. Recommending him for an outpatient lumbar spine MRI
E. Recommending for him bed rest and a return visit in a week


Answer: A

A 35-year-old male presents to your office with complaints of back pain and some weakness in his left leg. It has been present for a few weeks and the back and leg pains have been increasing in intensity. You are concerned about a herniated lumbar disc. His left ankle jerk reflex (achilles tendon reflex) is absent and you find numbness on the lateral aspect of the lower leg and sole of his left foot. This is most commonly caused by a:

Naim 13:14

A 35-year-old male presents to your office with complaints of back pain and some weakness in his left leg. It has been present for a few weeks and the back and leg pains have been increasing in intensity. You are concerned about a herniated lumbar disc. His left ankle jerk reflex (achilles tendon reflex) is absent and you find numbness on the lateral aspect of the lower leg and sole of his left foot. This is most commonly caused by a:



A. Herniated nucleus pulposus at the L1-L2 level
B. Herniated nucleus pulposus at L2-L3 level
C. Herniated nucleus pulposus at L3-L4 level
D. Herniated nucleus pulposus at L4-L5 level
E. Herniated nucleus pulposus at L5-S1


Answer: E

A 35-year-old male presents to your office with complaints of back pain and some weakness in his left leg. It has been present for a few weeks and the back and leg pains have been increasing in intensity. You are concerned about a herniated lumbar disc. His left ankle jerk reflex (achilles tendon reflex) is absent and you find numbness on the lateral aspect of the lower leg and sole of his left foot. These findings are typical of compression of:

Naim 13:13

A 35-year-old male presents to your office with complaints of back pain and some weakness in his left leg. It has been present for a few weeks and the back and leg pains have been increasing in intensity. You are concerned about a herniated lumbar disc. His left ankle jerk reflex (achilles tendon reflex) is absent and you find numbness on the lateral aspect of the lower leg and sole of his left foot. These findings are typical of compression of:



A. L2 nerve root
B. L3 nerve root
C. L4 nerve root
D. L5 nerve root
E. S1 nerve root

Answer: E

A 25-year-old medical student comes to your office asking for an MRI of her neck to confirm her suspicion that she has a cervical disc herniation. On exam, her triceps reflex is absent. She has weakness of elbow extension and numbness on her long finger. You expect the MRI to reveal a disc herniation at at which of the following levels?

Naim 13:13

A 25-year-old medical student comes to your office asking for an MRI of her neck to confirm her suspicion that she has a cervical disc herniation. On exam, her triceps reflex is absent. She has weakness of elbow extension and numbness on her long finger. You expect the MRI to reveal a disc herniation at at which of the following levels?



A. C3-C4 level
B. C4-C5 level
C. C5-C6 level
D. C6-C7 level
E. C7-T1 level

Answer: D

A patient sustained a cervical sprain/strain (somatic dysfunction) secondary to trauma. She complains of non radiating neck pain in absence of shoulder pain. Given this scenerio, which of the following signs/symptoms would more likely be present than any other?

Naim 13:13

A patient sustained a cervical sprain/strain (somatic dysfunction) secondary to trauma. She complains of non radiating neck pain in absence of shoulder pain. Given this scenerio, which of the following signs/symptoms would more likely be present than any other?



A. Hyper-reflexia in the lower extremities
B. Loss of bowel control
C. Loss of urinary bladder control
D. Numbness in the hands in a dermatomal pattern
E. Occipital headaches

Answer: E

What is the treatment for pseudoaddiction?

Naim 13:13

What is the treatment for pseudoaddiction?



A. Discharge your patient from the practice secondary to drug seeking behavior
B. The patient has demonstrated a genetic tendency for addition and should be monitored carefully
C. To redesign the analgesic regimen so that analgesics are provided at an appropriate dose and dosing interval
D. To call a family intervention and address the problem from a psychosocial protocol
E. Taper the patient off of their current pain medication and change to a different analgesic


Answer: C

What are the 4 A's for pain management?

Naim 13:12

What are the 4 A's for pain management?



A. Analgesia, Activities of daily living, Adverse events and Aberrant drug-taking behaviors
B. Alcoholism, Addiction, Anatomical changes, Adversity
C. Abnormal character, Avoidance, Apoplectic, Association with past trauma
D. Abdominal pain, Alcoholics Anonymous, Assistance seeking, Associated behaviors
E. Addiction Medicine, Anorexia, Abdominal pain, Anhidrosis


Answer: A

Which of the following are side effects from chronic opioid use?

Naim 13:10

Which of the following are side effects from chronic opioid use?



A. Fatigue and decreased libido from low levels of testosterone and DHEA
B. Diarrhea and dilated pupils
C. Hyperactivity from increased adrenal secretions
D. Insomnia and nocturia
E. Increase 5HT secretions in the central nervous system


Answer: A

A 42-year-old nurse presents to the office to see if OMM can be helpful for her long-standing foot pain. The patient had sustained her foot injury five years prior when a car ran over her foot while trying to cross the street. She sustained multiple fractures at that time and the injury healed subsequent to multiple surgeries. There is no back pain and no pain in the legs. She is currently on morphine 60mg every twelve hours. Physical examination reveals relatively normal lumbar range of motion, normal straight leg raise, and reveals normal muscle tone, strength and sensation throughout both lower extremities. The foot and ankle are painful to touch on the surface. There is decreased range of motion of the ankle with erythema and skin dystrophic/atrophic changes. Which of the following pain management approaches is indicated:

Naim 13:10

A 42-year-old nurse presents to the office to see if OMM can be helpful for her long-standing foot pain. The patient had sustained her foot injury five years prior when a car ran over her foot while trying to cross the street. She sustained multiple fractures at that time and the injury healed subsequent to multiple surgeries. There is no back pain and no pain in the legs. She is currently on morphine 60mg every twelve hours. Physical examination reveals relatively normal lumbar range of motion, normal straight leg raise, and reveals normal muscle tone, strength and sensation throughout both lower extremities. The foot and ankle are painful to touch on the surface. There is decreased range of motion of the ankle with erythema and skin dystrophic/atrophic changes. Which of the following pain management approaches is indicated:



A. Addition of another opioid medication
B. Celiac block
C. Lumbar epidural steroid injection at L5 and S1 levels
D. Lumbar sympathetic block
E. High velocity/low amplitude OMM to the subtalar join


Answer: D

A 40-year-old male presents with a one-week history of low back pain without radiation. The symptoms started after he was carrying some luggage. There is no tingling, numbness in the legs, nor any reported weakness. There is minimal spasm in the paravertebral muscles in the lumbo-sacral spine, straight leg raising test is negative and the neurological examination is normal. There are somatic dysfunctions in form of neutral dysfunctions L1-L5 NSleftRright. Which of the following statements is most appropriate?

Naim 13:10

A 40-year-old male presents with a one-week history of low back pain without radiation. The symptoms started after he was carrying some luggage. There is no tingling, numbness in the legs, nor any reported weakness. There is minimal spasm in the paravertebral muscles in the lumbo-sacral spine, straight leg raising test is negative and the neurological examination is normal. There are somatic dysfunctions in form of neutral dysfunctions L1-L5 NSleftRright. Which of the following statements is most appropriate?



A. Bed rest for one to two weeks is indicated
B. Imaging studies including X-rays, MRI and bone scan should be ordered immediately
C. Neurodiagnostic studies including an EMG are indicated as the studies of choice
D. NSAIDS and muscle relaxants together with OMM would be appropriate
E. Opioid medications are indicated to be started within one week


Answer: D

Which of the following is correct about the various pain types?

Naim 13:10

Which of the following is correct about the various pain types?



A. A viscero-somatic reflex is an example of nociceptive pain
B. Neuropathic pain is an example of nociceptive pain
C. Somatic pain is an example of non-nociceptive pain
D. Sympathetic pain is an example of nociceptive pain
E. Visceral pain is an example of non-nociceptive pain

Answer: A

A 64-year-old school superintendent with known rheumatoid arthritis presents to the office with a recurrent episode of significant hand and wrist pain after having been virtually pain-free for about eight months on DMARD therapy as closely monitored by her rheumatologist. She questions the doctor as to how it could be that she has these painful chronic-recurrent flare-ups alternating with pain-free periods, all the while it seems that the "arthritis is getting better" with the medications. What would be the best explanation, based on the article by D. Marcus: "Treatment of Nonmalignant Chronic Pain?"

Naim 13:08

A 64-year-old school superintendent with known rheumatoid arthritis presents to the office with a recurrent episode of significant hand and wrist pain after having been virtually pain-free for about eight months on DMARD therapy as closely monitored by her rheumatologist. She questions the doctor as to how it could be that she has these painful chronic-recurrent flare-ups alternating with pain-free periods, all the while it seems that the "arthritis is getting better" with the medications. What would be the best explanation, based on the article by D. Marcus: "Treatment of Nonmalignant Chronic Pain?"



A. Central block of pain transmission along the spino-thalamic tract to the limbic system
B. Central neural plasticity
C. Near complete loss of nociception at the joints in the hands
D. Patient is emotionally more stable as she has accepted the disease
E. Significant atrophy of interneurons in the spinal cord


Answer: B

A 56-year-old female with a known history of seropositive rheumatoid arthritis maintained on etanercept injections presents complaining of right knee pain and swelling for two days. She has been in good health otherwise and denies fevers and chills. She reports stiffness in the right knee that lasts for longer than 1 hour. Her other joints are doing well. You perform an arthrocentesis and remove 30cc of clear fluid. You send the sample to the lab, and 24 hours later no organisms are seen. The patient follows up later that day. The best course of management for this patient is:

Naim 13:08

A 56-year-old female with a known history of seropositive rheumatoid arthritis maintained on etanercept injections presents complaining of right knee pain and swelling for two days. She has been in good health otherwise and denies fevers and chills. She reports stiffness in the right knee that lasts for longer than 1 hour. Her other joints are doing well. You perform an arthrocentesis and remove 30cc of clear fluid. You send the sample to the lab, and 24 hours later no organisms are seen. The patient follows up later that day. The best course of management for this patient is:



A. Biofeedback
B. Fentanyl patch
C. Intra-articular steroid injection to the right knee
D. Opiod "lollipop"
E. Referral to orthopedist for consideration of knee replacement

Answer: C

A 64-year-old woman diagnosed with gout has been taking chronic treatment for over one year. The prescribed medication enhances the excretion of uric acid. Her physician cautions her to contact him before starting any prescription or nonprescription medication. The antigout medication and many other drugs can compete for tubular transport. Examples include aspirin and other nonsteroidal anti-inflammatory drugs, loop and thiazide diuretics, certain anti-infective medications, and certain diabetes drugs. The chronic antigout medication prescribed for this patient is most likely:

Naim 13:08

A 64-year-old woman diagnosed with gout has been taking chronic treatment for over one year. The prescribed medication enhances the excretion of uric acid. Her physician cautions her to contact him before starting any prescription or nonprescription medication. The antigout medication and many other drugs can compete for tubular transport. Examples include aspirin and other nonsteroidal anti-inflammatory drugs, loop and thiazide diuretics, certain anti-infective medications, and certain diabetes drugs. The chronic antigout medication prescribed for this patient is most likely:



A. Colchicine
B. Febuxostat
C. Indomethacin
D. Pegloticase
E. Probenecid


Answer: E

A 57-year-old man with chronic gout is given a prescription for a uricosuric agent. He is cautioned to avoid aspirin, NSAIDs, and other drugs that are secreted into the proximal tubule. The mechanism of action of the anti-gout medication is most likely direct inhibition of:

Naim 13:07

A 57-year-old man with chronic gout is given a prescription for a uricosuric agent. He is cautioned to avoid aspirin, NSAIDs, and other drugs that are secreted into the proximal tubule. The mechanism of action of the anti-gout medication is most likely direct inhibition of:



A. Absorption of dietary purines
B. AMP deaminase
C. Microtubule polymerization
D. Organic anion transporter
E. Xanthine oxidase


Answer: D

A patient with a history of hyperuricemia and three gouty flares in the past six months is placed on an anti-gout regimen that includes a drug to prevent gouty flare. He is cautioned that nausea, vomiting, abdominal pain, and diarrhea are early signs of drug toxicity; if these symptoms occur, he should stop taking the drug and call the office. The drug produces its action by binding to:

Naim 13:06

A patient with a history of hyperuricemia and three gouty flares in the past six months is placed on an anti-gout regimen that includes a drug to prevent gouty flare. He is cautioned that nausea, vomiting, abdominal pain, and diarrhea are early signs of drug toxicity; if these symptoms occur, he should stop taking the drug and call the office. The drug produces its action by binding to:



A. Cyclooxygenase
B. Dihydrofolate reductase
C. Organic anion transport protein
D. Tubulin
E. Xanthine oxidase

Answer: D

A 45-year-old patient with a history of HIV/AIDS and mildly impaired renal function presents with signs/symptoms of acute gouty arthritis. His antiretroviral regimen includes a strong inhibitor of CYP3A4. Which one of the following medications is effective in the treatment of the pain and inflammation of acute gouty flare but contraindicated in this patient?

Naim 13:06

A 45-year-old patient with a history of HIV/AIDS and mildly impaired renal function presents with signs/symptoms of acute gouty arthritis. His antiretroviral regimen includes a strong inhibitor of CYP3A4. Which one of the following medications is effective in the treatment of the pain and inflammation of acute gouty flare but contraindicated in this patient?



A. Abatacept
B. Colchicine
C. Febuxostat
D. Prednisone
E. Probenecid

Answer: B

A patient with a history of hyperuricemia and three gouty flares in the past six months is placed on hypouricemic therapy. He is also prescribed a concomitant oral drug for prophylaxis of gouty flare. The second drug interferes with microtubule and spindle formation but its anti-gout actions are not well defined. One of this drug's early signs/symptoms of toxicity is:

Naim 13:06

A patient with a history of hyperuricemia and three gouty flares in the past six months is placed on hypouricemic therapy. He is also prescribed a concomitant oral drug for prophylaxis of gouty flare. The second drug interferes with microtubule and spindle formation but its anti-gout actions are not well defined. One of this drug's early signs/symptoms of toxicity is:



A. Diarrhea
B. Fever
C. Hyperthermia
D. Hypotension
E. Tachypnea


Answer: A

A 68-year-old obese African-American woman with severe polyarticular chronic gout with tophi and urate nephrolithiasis refractory to oral anti-gout therapy discusses therapeutic options with her rheumatologist. Intravenous pegylated recombinant uric acid oxidase (uricase) may cause hemolysis and methemoglobinemia in this patient and the drug is contraindicated in her case because she has the X-linked recessive genetic disease:

Naim 13:05

A 68-year-old obese African-American woman with severe polyarticular chronic gout with tophi and urate nephrolithiasis refractory to oral anti-gout therapy discusses therapeutic options with her rheumatologist. Intravenous pegylated recombinant uric acid oxidase (uricase) may cause hemolysis and methemoglobinemia in this patient and the drug is contraindicated in her case because she has the X-linked recessive genetic disease:



A. Down syndrome
B. Glucose-6-phosphate dehydrogenase deficiency
C. Osteogenesis imperfecta
D. Sickle cell anemia
E. Turner syndrome


Answer: B

The above-referenced patient, HK, returns now to the family practice clinic for a follow-up visit. The pain and inflammation from the gout flare has resolved and he is taking the ß-tubulin inhibitor twice daily prophylactically and tolerating it well. Clinical laboratory results are consistent with hyperuricemia > 9 mg/dL and overproduction of uric acid. Creatinine clearance is within the normal range; uric acid stones are present. The doctor prescribes an oral medication that reduces serum urate levels in overproducers and is an appropriate drug for urate stone formers. The direct mechanism of action of this drug is most likely:

Naim 13:05

The above-referenced patient, HK, returns now to the family practice clinic for a follow-up visit. The pain and inflammation from the gout flare has resolved and he is taking the ß-tubulin inhibitor twice daily prophylactically and tolerating it well. Clinical laboratory results are consistent with hyperuricemia > 9 mg/dL and overproduction of uric acid. Creatinine clearance is within the normal range; uric acid stones are present. The doctor prescribes an oral medication that reduces serum urate levels in overproducers and is an appropriate drug for urate stone formers. The direct mechanism of action of this drug is most likely:



A. Formation of allantoin
B. Inhibition of thymidylate synthase
C. Prevention of neutrophil chemotaxis
D. Transrepression of gene expression
E. Xanthine oxidase inhibition


Answer: E

HK is a 64-year-old man with a history of hypertension and gout who presents to the family practice clinic with complaint of 48 hours of acute pain in his right elbow. He has taken indomethacin without relief. He denies trauma, but admits to drinking "more than I should" on a trip to Atlantic City during the previous weekend. He has had 3 gout flares in the past year that were relieved by indomethacin. The diagnosis of gout has been previously confirmed by aspiration and crystal examination. Chart review shows that HK's renal function is within normal limits. To control the acute pain, the doctor prescribes an oral medication that acts by inhibiting ß-tubulin polymerization thus interfering with microtubule formation. The doctor cautions the patient not to take any other medication or herbal products without checking with doctor because the prescribed drug is a substrate of:

Naim 13:05

HK is a 64-year-old man with a history of hypertension and gout who presents to the family practice clinic with complaint of 48 hours of acute pain in his right elbow. He has taken indomethacin without relief. He denies trauma, but admits to drinking "more than I should" on a trip to Atlantic City during the previous weekend. He has had 3 gout flares in the past year that were relieved by indomethacin. The diagnosis of gout has been previously confirmed by aspiration and crystal examination. Chart review shows that HK's renal function is within normal limits. To control the acute pain, the doctor prescribes an oral medication that acts by inhibiting ß-tubulin polymerization thus interfering with microtubule formation. The doctor cautions the patient not to take any other medication or herbal products without checking with doctor because the prescribed drug is a substrate of:



A. CYP2D6
B. CYP3A4
C. N-acetyltransferase
D. OATP1B1
E. UGT1A1

Answer: B

A 64-year-old woman diagnosed with gout has been taking chronic treatment for over one year. The prescribed medication enhances the excretion of uric acid. Her physician cautions her to contact him before starting any prescription or nonprescription medication. The antigout medication and many other drugs can compete for tubular transport. Examples include aspirin and other nonsteroidal anti-inflammatory drugs, loop and thiazide diuretics, certain anti-infective medications, and certain diabetes drugs. The chronic antigout medication prescribed for this patient is most likely:

Naim 12:34

A 64-year-old woman diagnosed with gout has been taking chronic treatment for over one year. The prescribed medication enhances the excretion of uric acid. Her physician cautions her to contact him before starting any prescription or nonprescription medication. The antigout medication and many other drugs can compete for tubular transport. Examples include aspirin and other nonsteroidal anti-inflammatory drugs, loop and thiazide diuretics, certain anti-infective medications, and certain diabetes drugs. The chronic antigout medication prescribed for this patient is most likely:



A. Colchicine
B. Febuxostat
C. Indomethacin
D. Pegloticase
E. Probenecid


Answer: E

A 55-year-old female with a history of lung cancer, protein C deficiency, currently on hormone replacement therapy for post menopausal symptoms, presents with bilateral lower extremity swelling after a prolonged plane ride from Asia. She reports that the swelling decreases when she elevates her legs at night when she goes to sleep. Which of the following would indicate a decreased risk for thrombosis?

Naim 12:34

A 55-year-old female with a history of lung cancer, protein C deficiency, currently on hormone replacement therapy for post menopausal symptoms, presents with bilateral lower extremity swelling after a prolonged plane ride from Asia. She reports that the swelling decreases when she elevates her legs at night when she goes to sleep. Which of the following would indicate a decreased risk for thrombosis?



A. Her history of lung cancer
B. Her protein C deficiency
C. Prolong immobilization from a long trip
D. Reversible lower extremity swelling
E. Taking hormone replacement therapy


Answer: D

Which of the following correctly pairs the technique and its action on lymphatic drainage?

Naim 12:34

Which of the following correctly pairs the technique and its action on lymphatic drainage?



A. Doming the diaphragm - increases pressure gradient changes from respiration
B. Pedal pump - increases lymph flow by decreasing parasympathetic tone
C. Rib raising - constricts larger lymphatic vessels by increasing sympathetic tone in the long term
D. Splenic pump - decreases antibody production of immune cells in circulation
E. Thoracic pump - assists in removing abdominal diaphragm restrictions


Answer: A

A 25-year-old woman presents with increased swelling and pain of her left ankle after tripping and spraining her ankle 2 days ago. Which one of the following techniques would most directly help to remove obstruction of lymph drainage from her left ankle?

Naim 12:33

A 25-year-old woman presents with increased swelling and pain of her left ankle after tripping and spraining her ankle 2 days ago. Which one of the following techniques would most directly help to remove obstruction of lymph drainage from her left ankle?



A. A left popliteal fossa spread
B. A liver pump for 2 minutes
C. A right 1st rib FPR technique
D. A right plantar fascia inhibitory technique
E. A suboccipital release


Answer: A

A 50-year-old woman status post a small bowel resection 5 days ago is hospitalized and bed bound and complains of pain and increased swelling in both her legs. Which of the following factors is most likely contributing to her leg swelling?

Naim 12:33

A 50-year-old woman status post a small bowel resection 5 days ago is hospitalized and bed bound and complains of pain and increased swelling in both her legs. Which of the following factors is most likely contributing to her leg swelling?



A. A decrease in lymphatic flow secondary to a lack of muscle contraction
B. A decrease in lymphatic flow secondary to increased doming of her abdominal diaphragm
C. A decrease in lymphatic flow secondary to increased parasympathetic tone
D. An obstruction to lymph flow secondary to postsurgical scarring affecting the right thoracic duct
E. An overproduction of lymphatic fluid secondary to liver failure


Answer: A

A 35-year-old male patient presents with the chief complaints of a sore throat and left nasal congestion he has had for three days as well as moderately painful swelling of his right knee after twisting it while jogging one week ago. If somatic dysfunction were present, treatment of which of the following regions would most likely benefit both his complaints?

Naim 12:33

A 35-year-old male patient presents with the chief complaints of a sore throat and left nasal congestion he has had for three days as well as moderately painful swelling of his right knee after twisting it while jogging one week ago. If somatic dysfunction were present, treatment of which of the following regions would most likely benefit both his complaints?



A. Right hip
B. Occipito-mastoid suture
C. Left clavicle
D. T10-T11
E. Right rib 1


Answer: C

Which of the following is the most accurate description regarding lymphatic fluid formation?

Naim 12:33

Which of the following is the most accurate description regarding lymphatic fluid formation?



A. Lymph formation continues to increase as the interstitial fluid pressure increases
B. Hydrostatic pressure is the primary force driving the interstitial fluid into the lymph vessels
C. Oncotic pressure drives the majority of interstitial fluid into the lymph vessels
D. Anchoring filaments keep the lymphatic capillaries open but do not affect lymph absorption
E. Changes in the shape of the interstitial matrix affect the movement of fluid into lymph vessels


Answer: E

A 34-year-old female presents to your office with right ankle pain after spraining her ankle 3 days ago. She complains of increased swelling and pain in the region. An x-ray was taken on the day she sprained her ankle and was negative for any fractures. She denies any other past medical history or taking any other medication other than ibuprofen prescribed in the emergency room. You perform an osteopathic structural exam and find the following: C3-5 flexed, rotated and sidebent left, a right 1st rib inhalation dysfunction, T2-6 neutral, sidebent right and rotated left, and a right posterior fibular head. You decide to treat the patient with OMT. Which of the following statements is true?

Naim 12:33

A 34-year-old female presents to your office with right ankle pain after spraining her ankle 3 days ago. She complains of increased swelling and pain in the region. An x-ray was taken on the day she sprained her ankle and was negative for any fractures. She denies any other past medical history or taking any other medication other than ibuprofen prescribed in the emergency room. You perform an osteopathic structural exam and find the following: C3-5 flexed, rotated and sidebent left, a right 1st rib inhalation dysfunction, T2-6 neutral, sidebent right and rotated left, and a right posterior fibular head. You decide to treat the patient with OMT. Which of the following statements is true?



A. You should treat the thoracic group curve as it would help improve thoracic cage excursion
B. You should treat the right 1st rib dysfunction first since that is the region of terminal lymphatic drainage of the right ankle
C. You should avoid treatment of C3-5 since it would adversely affect the diaphragm and decrease lymph drainage
D. You should advise complete bed rest to allow the lymph to return naturally
E. You should avoid any osteopathic manipulative treatment as it is contraindicated in her case


Answer: A

A 24-year-old female presents to the office with complaints of bilateral lower extremity swelling that has been on and off for the past two years. She denies any leg pains or any other symptoms. Her vital signs are as follows: BP: 118/85 mm Hg, HR: 60 bmp, RR: 18 bmp, Temp: 98.8°F, BMI: 21. On osteopathic structural exam you note suboccipital muscle spasms, ribs 1-4 inhalation dysfunction on the left, and increased left anterior diaphragm motion restriction. Which of the following techniques would you perform first in order to address this patient's edema?

Naim 12:32

A 24-year-old female presents to the office with complaints of bilateral lower extremity swelling that has been on and off for the past two years. She denies any leg pains or any other symptoms. Her vital signs are as follows: BP: 118/85 mm Hg, HR: 60 bmp, RR: 18 bmp, Temp: 98.8°F, BMI: 21. On osteopathic structural exam you note suboccipital muscle spasms, ribs 1-4 inhalation dysfunction on the left, and increased left anterior diaphragm motion restriction. Which of the following techniques would you perform first in order to address this patient's edema?



A. Thoracic pump
B. Doming of the diaphragm
C. Pedal pump
D. Indirect thoracic outlet myofascial
E. Suboccipital release


Answer: D

A 42-year-old woman with chronic lower back pain had fallen off a horse and broken her right tibia at age 16, causing her right tibia to be shorter than her left tibia. You also diagnose side bending and rotation changes in her lumbar spine, with a radiologically-documented sacral base unleveling of ½ inch. Your patient agrees to try heel lift therapy. How much of a heel lift does she need, and on which side?

Naim 12:32

A 42-year-old woman with chronic lower back pain had fallen off a horse and broken her right tibia at age 16, causing her right tibia to be shorter than her left tibia. You also diagnose side bending and rotation changes in her lumbar spine, with a radiologically-documented sacral base unleveling of ½ inch. Your patient agrees to try heel lift therapy. How much of a heel lift does she need, and on which side?



A. 3/4 inch, right side
B. 3/8 inch, left side
C. 3/8 inch, right side
D. 1/6 inch, left side
E. 1/6 inch, right side


Answer: E

You are evaluating your 27-year-old male patient who presented to your office with a complaint of lower back pain, and you have completed your history. You are performing your physical and osteopathic structural examination, and as you ask your standing patient to bend one knee at a time, allowing the ipsilateral innominate to drop inferiorly (or lower), you find an asymmetry of motion between the sides. He can easily bend his right knee, allowing his right innominate to lower. However, when you ask him to bend his left knee, he has limited motion, and the innominate does not lower very much. What is the name of this particular test, and what other anatomical region are you assessing with this test?

Naim 12:32

You are evaluating your 27-year-old male patient who presented to your office with a complaint of lower back pain, and you have completed your history. You are performing your physical and osteopathic structural examination, and as you ask your standing patient to bend one knee at a time, allowing the ipsilateral innominate to drop inferiorly (or lower), you find an asymmetry of motion between the sides. He can easily bend his right knee, allowing his right innominate to lower. However, when you ask him to bend his left knee, he has limited motion, and the innominate does not lower very much. What is the name of this particular test, and what other anatomical region are you assessing with this test?



A. Hip Drop test, hip joint involvement
B. Hip Drop test, lumbar involvement
C. Hip Drop test, sacral involvement
D. Stinchfield test, hip joint involvement
E. Stinchfield test, lumbar involvement


Answer: B

A 35-year-old man with chronic lower back pain has leg length inequality that began to appear around age 10, and resulted in his right femur being shorter than his left femur. You also diagnose side bending and rotation changes in his lumbar spine, with a radiologically-documented sacral base unleveling of ¾ inch. Your patient agrees to try heel lift therapy. How much of a heel lift does he need, and on which side?

Naim 12:32

A 35-year-old man with chronic lower back pain has leg length inequality that began to appear around age 10, and resulted in his right femur being shorter than his left femur. You also diagnose side bending and rotation changes in his lumbar spine, with a radiologically-documented sacral base unleveling of ¾ inch. Your patient agrees to try heel lift therapy. How much of a heel lift does he need, and on which side?



A. 1/4 inch, left side
B. 1/4 inch, right side
C. 3/4 inch, left side
D. 3/8 inch, left side
E. 3/8 inch, right side


Answer: B

A patient has radiologically documented lumbar vertebral degenerative changes, including wedging, facet hypertrophy, and spurring. According to David Heilig's formula for determining heel lift therapy, what is the name of the category for the described findings and what number would be assigned for the particular findings described?

Naim 12:31

A patient has radiologically documented lumbar vertebral degenerative changes, including wedging, facet hypertrophy, and spurring. According to David Heilig's formula for determining heel lift therapy, what is the name of the category for the described findings and what number would be assigned for the particular findings described?



A. Compensation, 2
B. Compensation, 3
C. Duration, 2
D. Duration, 3
E. Sacral base unleveling, 2


Answer: A

A 40-year-old woman with chronic lower back pain had fallen off a ladder and broken her left tibia at age 15. Her left tibia healed, such that it was longer than her right tibia. You also diagnose side bending and rotation changes in her lumbar spine, with a radiologically-documented sacral base unleveling of ¾inch. Your patient agrees to try heel lift therapy. How much of a heel lift does she need, and on which side?

Naim 12:31

A 40-year-old woman with chronic lower back pain had fallen off a ladder and broken her left tibia at age 15. Her left tibia healed, such that it was longer than her right tibia. You also diagnose side bending and rotation changes in her lumbar spine, with a radiologically-documented sacral base unleveling of ¾inch. Your patient agrees to try heel lift therapy. How much of a heel lift does she need, and on which side?



A. 3/4 inch, left side
B. 3/8 inch, left side
C. 3/8 inch, right side
D. 1/4 inch, right side
E. 1/4 inch, left side


Answer: D

You are evaluating your 52-year-old female patient who presented to your office with a complaint of lower back pain. You have completed your history and are performing your physical and osteopathic structural examination. As you ask your standing patient to bend one knee at a time, allowing the ipsilateral innominate to drop inferiorly (or lower), you find an asymmetry of motion between the sides. She can easily bend her left knee, allowing her left innominate to lower. However, when you ask her to bend her right knee, she has limited motion, and the innominate does not lower very much. The special test results described would lead you to which of the following physical examination assessments for this patient?

Naim 12:31

You are evaluating your 52-year-old female patient who presented to your office with a complaint of lower back pain. You have completed your history and are performing your physical and osteopathic structural examination. As you ask your standing patient to bend one knee at a time, allowing the ipsilateral innominate to drop inferiorly (or lower), you find an asymmetry of motion between the sides. She can easily bend her left knee, allowing her left innominate to lower. However, when you ask her to bend her right knee, she has limited motion, and the innominate does not lower very much. The special test results described would lead you to which of the following physical examination assessments for this patient?



A. Left lumbar convexity
B. Right lumbar convexity
C. Left thoracic convexity
D. Right thoracic convexity
E. Decreased lumbar lordosis


Answer: A

A 19-year-old man with chronic lower back pain has leg length inequality that began to appear around age 11 and resulted in his right femur being shorter than his left femur. You also diagnose side bending and rotation changes in his lumbar spine, with a radiologically-documented sacral base unleveling of ½inch. Your patient agrees to try heel lift therapy. How much of a heel lift does he need, and on which side?

Naim 12:31

A 19-year-old man with chronic lower back pain has leg length inequality that began to appear around age 11 and resulted in his right femur being shorter than his left femur. You also diagnose side bending and rotation changes in his lumbar spine, with a radiologically-documented sacral base unleveling of ½inch. Your patient agrees to try heel lift therapy. How much of a heel lift does he need, and on which side?



A. 1/2 inch, left side
B. 1/4 inch, left side
C. 1/4 inch, right side
D. 1/6 inch, right side
E. 1/6 inch, left side


Answer: C

You suspect that your patient has an axonal injury to the nerve in his leg. You perform a nerve conduction study. You would expect to see a change with which aspect of the nerve conduction study?

Naim 12:29

You suspect that your patient has an axonal injury to the nerve in his leg. You perform a nerve conduction study. You would expect to see a change with which aspect of the nerve conduction study?



A. Amplitude
B. Latency
C. Conduction velocity
D. Distance
E. Intensity


Answer: A

Which of the following patients would be most appropriate for EMG/NCS testing?

Naim 12:29

Which of the following patients would be most appropriate for EMG/NCS testing?



A. A patient with a six month history of paresthesia in the hands and feet
B. A patient with a six week history of pain in the right hip joint
C. A patient with a stroke two weeks ago who has had weakness of the right arm and leg since the stroke
D. A patient with pain in the foot immediately after fracturing his metatarsal
E. A patient with a one day history of arm numbness


Answer: A

A 60-year-old male presents to your office with low back pain after doing some gardening. The pain is localized to the right paraspinal muscle and does not radiate down the right leg. There is no incontinence and reflexes are normal. There is localized spasm of the right lumbosacral paraspinal muscles. MRI shows a mild right S1 disc bulge. The most likely reason for his back pain is:

Naim 12:28

A 60-year-old male presents to your office with low back pain after doing some gardening. The pain is localized to the right paraspinal muscle and does not radiate down the right leg. There is no incontinence and reflexes are normal. There is localized spasm of the right lumbosacral paraspinal muscles. MRI shows a mild right S1 disc bulge. The most likely reason for his back pain is:



A. Fibromyalgia
B. L5 radiculopathy
C. Muscle spasm
D. S1 radiculopathy
E. Spinal stenosis

Answer: C

A student celebrates a successful examination by imbibing too much. The student passes out with the arm slung over the back of a couch and in the morning, notes an inability to extend the wrist. The most likely reason is:

Naim 12:28

A student celebrates a successful examination by imbibing too much. The student passes out with the arm slung over the back of a couch and in the morning, notes an inability to extend the wrist. The most likely reason is:



A. Axonotmetic lesion of the ulnar nerve
B. Neurapraxic lesion of the radial nerve
C. Neurapraxic lesion of the ulnar nerve
D. Neurotmetic lesion of the axillary nerve
E. Neurotmetic lesion of the radial nerve


Answer: B

A 25-year-old press-operator sustained a crush injury to his left hand and was referred by the emergency physician directly for electrodiagnostic testing. There is no fracture upon the initial CT-scan performed in the Emergency Department, but the patient reports reduced sensation in the thumb, and digits two and three. The pain is getting worse but he is able to "shake it out," on occasion. Which of the following findings would you expect on the EMG/NCS test that was performed the following day?

Naim 12:27

A 25-year-old press-operator sustained a crush injury to his left hand and was referred by the emergency physician directly for electrodiagnostic testing. There is no fracture upon the initial CT-scan performed in the Emergency Department, but the patient reports reduced sensation in the thumb, and digits two and three. The pain is getting worse but he is able to "shake it out," on occasion. Which of the following findings would you expect on the EMG/NCS test that was performed the following day?



A. Distal, generalized neuropathy
B. Median nerve involvement
C. Normal study
D. Radial nerve involvement
E. Ulnar nerve involvement


Answer: C

A person has been bitten by a venomous snake in his lower leg and is transported by helicopter to the regional trauma center. The doctors suspect a lower leg compartment syndrome. Which of the following finding would you expect to be present upon examination?

Naim 12:27

A person has been bitten by a venomous snake in his lower leg and is transported by helicopter to the regional trauma center. The doctors suspect a lower leg compartment syndrome. Which of the following finding would you expect to be present upon examination?



A. Painless passive motion of his ankle and toes
B. Normal sensation of his foot and leg
C. His lower leg is soft and easily compressible
D. No complaints of pain
E. Intact dorsalis pedis and posterior tibial pulses


Answer: E

A 25-year-old medical student sustained a mid-shaft fracture of his tibia after falling from his motorcycle. He has sustained skin abrasions but there is no evidence of an open fracture. He begins to complain of increasing pains in his leg with passive flexion of his first toe, weakness on attempted active dorsiflexion of his ankle and numbness in the dorsal part of the first web space. You suspect which of the following:

Naim 12:27

A 25-year-old medical student sustained a mid-shaft fracture of his tibia after falling from his motorcycle. He has sustained skin abrasions but there is no evidence of an open fracture. He begins to complain of increasing pains in his leg with passive flexion of his first toe, weakness on attempted active dorsiflexion of his ankle and numbness in the dorsal part of the first web space. You suspect which of the following:



A. This is normal and expected after a tibia fracture
B. A compartment syndrome of the anterior compartment
C. A lateral compartment syndrome of the leg
D. A superficial posterior compartment syndrome
E. A deep posterior compartment syndrome


Answer: B

The medial and lateral menisci serve an important function by:

Naim 12:26

The medial and lateral menisci serve an important function by:



A. Transferring forces from the femur to the tibia
B. Providing nutrition to articular cartilage
C. Transmitting nerve impulses across the knee joint
D. Increasing the length of the lower extremities
E. Being the primary restraints to varus and valgus forces

Answer: A

Displaced intracapsular hip fractures are usually treated with femoral head replacement surgery (prosthetic hip) because:

Naim 12:26

Displaced intracapsular hip fractures are usually treated with femoral head replacement surgery (prosthetic hip) because:



A. Complexity of fracture pattern makes it difficult to piece back together
B. Ease of replacement versus repair of femoral neck and head
C. Lower risk of infection with replacement compared to repair
D. Risk of non-union and avascular necrosis with this fracture
E. Shorter surgery time for replacement compared to repair


Answer: D

A 65-year-old female has undergone hip replacement surgery. She is a smoker and is obese. Her progress in postoperative physical therapy is poor. The team gets her to sit out of bed on the third post operative day but she begins to complain of difficulty breathing. Her pulse and respiratory rates are elevated. In your different diagnosis for her findings, the most urgent to address would be:

Naim 12:24

A 65-year-old female has undergone hip replacement surgery. She is a smoker and is obese. Her progress in postoperative physical therapy is poor. The team gets her to sit out of bed on the third post operative day but she begins to complain of difficulty breathing. Her pulse and respiratory rates are elevated. In your different diagnosis for her findings, the most urgent to address would be:



A. Acute post operative blood loss
B. Dislocation of the hip replacement
C. Pneumonia
D. Pulmonary embolism
E. Urinary tract infection


Answer: D

A 21-year-old female has been treated for a fracture of the right tibial shaft. The fracture was treated by fixation with an internally placed stainless steel rod. Four hours after the surgery, the patient complains to you of severe pain in her leg that was not controlled by large doses of pain medicine. On physical exam, you find that she has increased pain with passive flexion of her great toe. The lower leg is extremely swollen and she has profound numbness in the first web space of her foot. You suspect an acute compartment syndrome in which of the following compartments?

Naim 12:23

A 21-year-old female has been treated for a fracture of the right tibial shaft. The fracture was treated by fixation with an internally placed stainless steel rod. Four hours after the surgery, the patient complains to you of severe pain in her leg that was not controlled by large doses of pain medicine. On physical exam, you find that she has increased pain with passive flexion of her great toe. The lower leg is extremely swollen and she has profound numbness in the first web space of her foot. You suspect an acute compartment syndrome in which of the following compartments?



A. Anterior compartment of the leg
B. Deep posterior compartment of the leg
C. Lateral compartment of the leg
D. Superficial compartment of the leg
E. Deep dorsal compartment of the foot


Answer: A

On gait analysis, you notice your patient forcibly shifts her weight laterally to allow her leg to pass forward in swing phase. She has a history of poliomyelitis. She also has a positive Trendelenberg sign. Which of her muscles would you expect to be significantly weak?

Naim 12:23

On gait analysis, you notice your patient forcibly shifts her weight laterally to allow her leg to pass forward in swing phase. She has a history of poliomyelitis. She also has a positive Trendelenberg sign. Which of her muscles would you expect to be significantly weak?



A. Adductor magnus
B. Gluteus maximus
C. Gluteus medius
D. Rectus femoris
E. Vastus lateralis


Answer: C

As you watch a patient walk, you notice that he has difficulty moving his right foot from foot flat to toe-off. He seems to be dragging his foot at this phase. You ask him to stand on his toes, but he cannot do this with his right foot. On muscle strength testing, which of the following muscle would you expect to be weak?

Naim 12:23

As you watch a patient walk, you notice that he has difficulty moving his right foot from foot flat to toe-off. He seems to be dragging his foot at this phase. You ask him to stand on his toes, but he cannot do this with his right foot. On muscle strength testing, which of the following muscle would you expect to be weak?




A. Extensor digitorum brevis
B. Extensor hallucis longus
C. Flexor digitorum brevis
D. Gastrocnemius
E. Tibialis anterior


Answer: D

A 65-year-old female has undergone hip replacement surgery. She is a smoker and is obese. Her progress in postoperative physical therapy is poor. The team gets her to sit out of bed on the third post operative day but she begins to complain of difficulty breathing. Her pulse and respiratory rates are elevated. In your different diagnosis for her findings, the most urgent to address would be:

Naim 12:22

A 65-year-old female has undergone hip replacement surgery. She is a smoker and is obese. Her progress in postoperative physical therapy is poor. The team gets her to sit out of bed on the third post operative day but she begins to complain of difficulty breathing. Her pulse and respiratory rates are elevated. In your different diagnosis for her findings, the most urgent to address would be:



A. Acute post operative blood loss
B. Dislocation of the hip replacement
C. Pneumonia
D. Pulmonary embolism
E. Urinary tract infection


Answer: D

Which of the following statements about the "screw home" mechanism is true?

Naim 12:22

Which of the following statements about the "screw home" mechanism is true?


A. Hamstring muscle contraction leads to knee extension
B. Pes anserine muscle contractions leads to unlocking of the knee
C. Plantaris muscle contraction initiates knee rotation and flexion
D. Popliteus muscle contraction leads to rotation at the knee and the start of unlocking
E. Screw home mechanism cannot occur while the quadriceps muscles are relaxed


Answer: D

The "screw home" mechanism involves:

Naim 12:21

The "screw home" mechanism involves:



A. Hamstring muscle contracting, leading to knee extension
B. Plantaris muscle contraction initiates the knee rotation and flexion
C. Popliteus muscle contraction leading to knee rotation and the start of unlocking
D. Screw home cannot occur if the quadriceps are relaxed
E. The pes anserine muscles contracting to unlock the knee


Answer: C

Which of the following statements about the anterior cruciate ligament (ACL) is true?

Naim 12:21

Which of the following statements about the anterior cruciate ligament (ACL) is true?



A. A varus stress to the medial side of the knee tears the ACL in the Unhappy Triad
B. It is a primary restraint to anterior translation of the tibia on the femur
C. It is truly isometric throughout the range of motion of the knee
D. The ACL is extra-articular
E. To test it, the knee is placed in full extension


Answer: B
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