SAER 2008 Flashcards
The most common clinical manifestation of Lyme disease is
(a) monoarticular or oligoarticular arthritis.
(b) facial-nerve palsy.
(c) atrioventricular block.
(d) erythema migrans.
(d) Erythema migrans (EM) is a skin lesion that is erythematous, and may be round or oval, flat or raised,
and possibly have central clearing. Of persons with untreated EM, sixty percent will have monoarticular
or oligoarticular arthritis. Ten percent will have a neurologic presentation, such as facial-nerve palsy.
Approximately 5 percent will have a cardiac manifestation such as atrioventricular block.
You are consulting on a 28-year-old woman with metastatic cervical cancer. She is married with
one young child. At this time, she requires minimum to moderate assistance with her mobility and
activities of daily living. The oncology service is debating whether to discharge the patient to home
with hospice care or to give her inpatient rehabilitation. You inform them that acute inpatient
rehabilitation
(a) improves function and quality of life despite the patient being
at the end of her life.
(b) is too much of a physical demand for her and agree with
hospice care.
(c) takes time away from the patient being with her family, so
hospice is preferable.
(d) will help the patient to some extent, but not as much as a
patient without cancer.
(a) When consulted on a patient with cancer, the physiatrist must balance the need to maximize the
patient’s independence through rehabilitation with the desire to have the patient return home as soon as
possible. Inpatient rehabilitation is useful to improve the patient’s quality of life. Functional gains have
been demonstrated to be significant and comparable to those gained by patients without cancer. The
presence of metastatic disease does not influence functional outcome and should not preclude
participation.
Cyclobenzaprine is a medication that is used to treat acute musculoskeletal pain. While the exact
mechanism of action is unknown, its structure and side effects are similar to what class of drug?
(a) Central alpha2-adrenergic agonist
(b) Tricyclic antidepressant agent
(c) Antihistamine
(d) γ-aminobutyric acid agonist
(b) Cyclobenzaprine is structurally similar to tricyclic antidepressants and was first studied as an
antidepressant. While its exact mechanism of action is unknown, it is presumed to work at the level of
the brainstem or higher with a generalized sedative effect. Tizanidine is a central alpha2-adrenergic
agonist. Orphenadrine is an antihistamine. Benzodiazepines, such as diazepam, and baclofen are γ-
aminobutyric acid agonists.
You are asked to evaluate a 1-year-old patient who is not yet walking but is developmentally
appropriate. Which reflex would you expect to find?
(a) Asymmetric tonic neck
(b) Symmetric tonic neck
(c) Palmar grasp
(d) Plantar grasp
(d) The asymmetric tonic neck reflex (ATNR) and symmetric tonic neck reflex (STNR) are usually
integrated by 6 to 7 months. Palmar grasp disappears by 5 to 6 months. Plantar grasp is integrated when
walking is achieved. The normal age of walking varies, but may be as late as 18 months.
Individuals with diabetes are at high risk of amputation despite ankle pressures greater than 55
mmHg because
(a) the ankle brachial pressure index must be greater than or equal to 0.3 to prevent limb
threatening ischemia.
(b) ankle pressures seldom correlate with severity of symptoms and are unreliable.
(c) calcification of the arterial media results in a spuriously high pressure.
(d) transcutaneous oxygen partial pressures and not ankle pressures correlate with ischemia.
(c) In patients with diabetes, amputation is a strong possibility, even with ankle pressures higher than 55
mmHg because spuriously high pressures can be present in these patients as a result of calcification of
the arterial media. The ankle brachial pressure index (ABPI) is the patient’s brachial pressure compared
to the ankle pressure. A resting ABPI greater than 1.0 is considered normal. Patients with intermittent
claudication have an ABPI in the range of 0.5 to 0.7, and patients with rest pain or other symptoms of
severe ischemia have an ABPI of less than or equal to 0.3. A pressure less than 50 mmHg at the ankle
is associated with limb threatening ischemia.
An 11-year-old baseball player presents to your clinic complaining of elbow pain. X-rays of the affected side reveal an 8-mm separation of the medial epicondyle. What should be the next step in management?
(a) Relative rest for at least 6 weeks
(b) Long arm cast for at least 4 weeks
(c) Refer to pediatric orthopedic surgeon
(d) Physical therapy for strengthening
(c) “Little league elbow,” seen in throwing athletes with immature skeletons, is a conglomeration of
different diagnostic entities caused by valgus and extension-overload. Medial epicondylar avulsion can
frequently occur. Separation from 3–5mm can be managed nonsurgically. However, separations greater
5mm usually require surgery.
Which of the brain tumors listed is a benign tumor?
(a) Medulloblastoma
(b) Astrocytoma
(c) Glioblastoma
(d) Craniopharyngioma
(d) The only benign brain tumor listed is craniopharyngioma
Myositis is defined as
(a) muscle aching.
(b) muscle aching with weakness.
(c) muscle symptoms with creatine kinase elevation.
(d) muscle symptoms with creatine kinase and creatinine elevations.
(c) Myopathy refers to a disease or an abnormal condition of striated muscle, whereas myalgia is defined as
muscle aching or weakness without serum creatine kinase (CK) elevations. Myositis implies muscle
symptoms accompanied by CK elevations. Rhabdomyolysis signifies muscle complaints with CK
elevations 10 times the upper limits of normal (ULN) with creatinine elevation. Clinically important
myopathy with CK elevations greater than 10 times ULN is estimated to occur in approximately 0.1%
of patients who receive statin monotherapy. Clinically important myopathy and rhabdomyolysis have
been reported with all statins with an overall death rate of .15 per 1 million prescriptions.
Based on the revised edition of the American Spinal Injury Association (ASIA) Impairment Scale,
published in 2000, which condition would be sufficient to categorize a spinal cord injury as motor
incomplete?
(a) Some motor function more than 1 level below the motor level
(b) Voluntary anal sphincter contraction
(c) A well-defined zone of partial preservation
(d) An anterior spinal artery syndrome
(b) For an individual to receive an ASIA classification of motor incomplete (ASIA C or D), he/she must
have either voluntary anal sphincter contraction or sensory sacral sparing with sparing of motor
function more than 3 levels below the motor level. The zone of partial preservation is used only in
complete injuries. Individuals with anterior spinal artery syndrome are often motor complete.
Lambert-Eaton myasthenic syndrome is most commonly associated with cancer in the
(a) prostate.
(b) breast.
(c) lung.
(d) brain.
(c) Lambert-Eaton myasthenic syndrome is most commonly associated with small-cell lung cancer, but it
may also be seen in kidney and rectal cancer, malignant thymoma, basal cell carcinoma, and leukemia.
You have evaluated a 50 year old man for lower extremity muscle pain and discomfort. The pain increases with jogging. You have reviewed his medications, which include simvastatin (Zocor). Baseline laboratory studies were normal 6 months ago. The creatine kinase level is mildly elevated at 185 units/L. The next most appropriate step is to
(a) check thyroid stimulating hormone levels.
(b) order electrodiagnostic study.
(c) switch to a different class of lipid lowering medications.
(d) continue the medication with close monitoring of the creatine kinase levels.
(d) If a patient on a statin presents with muscle complaints, with or without creatine kinase (CK) elevations,
other causes, including strenuous exercise or hypothyroidism, must be considered. If a patient initially
has normal or only moderately elevated CK levels, the statin may be continued with close monitoring of
symptoms and CK levels; however, if symptoms become intolerable or if the CK level is 10 times the
upper limits of normal (ULN) or greater, the statin must be discontinued. If myositis is present or
strongly suspected, the statin should be discontinued immediately. Early diagnosis and treatment of
symptomatic CK elevations, including cessation of drug therapies potentially related to myopathy, can
prevent progression to rhabdomyolysis. Symptoms and CK levels should resolve completely before
reinitiating therapy, at a lower dose if possible. Asymptomatic elevation of CK at 10 times the ULN or
greater should also prompt discontinuation of the statin. Consideration should also be given to
discontinuation of statins before events that may exacerbate muscle injury, such as surgical procedures
or extreme physical exertion.Needle electromyography abnormalities are uncommon in statin-induced
myopathy. An EMG does not exclude statin-induced myopathy, because it primarily affects type 2
muscle fibers. Electromyography is not routinely performed or recommended unless the clinical
presentation does not improve with statin discontinuation or if concern exists about other diagnoses.
A 24-year-old man with T6 complete paraplegia whose injury occurred 16 weeks ago. He is concerned he can no longer reach down to put on and tie his right shoe. Upon evaluation, he has significant loss of range of motion in the right hip with mild warmth at the hip. There is no swelling at the knee, lower leg, ankle, or foot. The most likely diagnosis is
(a) hip dislocation.
(b) deep vein thrombosis.
(c) heterotopic ossification.
(d) iliopsoas abscess.
(c) Heterotopic ossification (HO) may develop as early as 17 days after a neurologic injury. However, it typically takes up to 6 weeks to begin to mineralize and decrease range of motion at the affected joint. Persons with spinal cord injury are prone to develop HO below their level of injury. This patient’s progressive loss of range of motion accompanied by a loss of function points toward HO. With no history of trauma, early fracture is unlikely, lack of systemic signs such as fever render an abscess unlikely, and with a deep vein thrombosis (DVT) one would expect edema distal to the clot. Persons with spinal cord injury are at highest risk for DVT within the first 6 to 8 weeks after injury.
A patient with a history of cancer treated with chemotherapy complains that her feet feel swollen, cold, and painful. The pain is described as shooting and is rated 10/10. On examination, there is no swelling and no temperature changes, but there is hypesthesia and dysesthesia. Of the following choices, which is the most appropriate pain management for this patient?
(a) MS Contin (extended release morphine sulfate) 15 mg every
12 hours
(b) Prednisone taper starting at 60 mg daily
(c) Neurontin (gabapentin) 300 mg 3 times a day
(d) Naprosyn (naproxen) 500 mg twice daily
(c)
Many chemotherapeutic agents can cause a peripheral neuropathy. Treatment for neuropathic pain includes membrane-stabilizing medications such as Neurontin. Opiates like MS Contin and non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen are not the first line treatment for neuropathic pain. Prednisone is appropriate for complex regional pain syndrome (CRPS), but CRPS is not common in cancer patients after chemotherapy. Further, this patient probably does not have CRPS, considering the absence of swelling, color changes, or temperature changes.
A 50-year-old construction worker has received a 30% whole person impairment rating because of
his pericardial heart disease. According to the fifth edition of the American Medical Association
Guides to the Evaluation of Permanent Impairment, this worker’s status indicates that
(a) he is 100% disabled from performing his work activities.
(b) his general functioning and ability to perform activities of daily living is reduced by 30%.
(c) he has a 30% reduction in work capability.
(d) he should receive 30% of his future wages and benefits in a disability payment.
(b)
According to the AMA guides, a 30% whole person impairment rating indicates a 30% reduction in general functioning, excluding work. The whole person impairment rating does not directly correlate to the patient’s work abilities and it does not determine the disability compensation.
A 14-year-old girl is sent to you for electrodiagnostic evaluation of a left foot drop. The mother reports that the left foot drop has been present for about 2 months and that her daughter has lost about 40 pounds in the last 6 months. Nerve conduction studies and needle electromyography show the following data: MOTOR NERVE CONDUCTION STUDIES Nerve Stimulation Site Distal Latency (ms) Amplitude (mV) NCV (m/s) L Peroneal Ankle 4.2 1 Below knee 0.5 35 Above knee NR R Peroneal Ankle 4.5 5.4 Below knee 5.0 47 Above knee 4.8 52 L Tibial Ankle 4.4 9 Knee 8.5 53 SENSORY NERVE CONDUCTION STUDIES Nerve Stimulation Site Distal Latency (ms) Amplitude (μV) L Sural Ankle - 14 cm 3.6 17 L Superficial peroneal Ankle - 12 cm NR R Superficial peroneal Ankle - 12 cm 3.1 15 Needle Electromyography Muscle Abnormal Spontaneous Activity Recruitment L Vastus medialis 0 Normal L Semimembranosus 0 Normal L Short head of biceps femoris 0 Normal L Tibial anterior 3+ Reduced L Medial gastrocnemius 0 None L Peroneus longus 2+ Reduced L Lumbar paraspinals 0 -- NCV = Nerve Conduction Velocity NR = No response The patient’s symptoms are most likely due to left (a) peroneal nerve injury at the fibular head. (b) deep peroneal nerve injury. (c) sciatic nerve injury. (d) lumbosacral plexopathy.
(a)
The electrophysiologic findings are consistent with common peroneal nerve compression at the fibular head. The normal study of the short head of the biceps femoris points to a lesion distal to the innervation of this muscle, and hence a lesion at or below the level of the knee. Lack of involvement of muscles innervated by other nerves points away from a plexopathy or sciatic nerve injury. Excessive weight loss can often be a factor in patients with peroneal nerve compression lesions.
The most common reason for prescribing a plastic leaf-spring ankle-foot orthosis is to
(a) overcome ankle spasticity.
(b) reduce lower-extremity edema.
(c) prevent plantar flexion deformity.
(d) support weak ankle dorsiflexors.
(d)
A plastic leaf-spring orthosis (PLSO) is probably the most commonly prescribed type of ankle-foot orthosis (AFO). It substitutes for weak ankle dorsiflexors and provides some medial lateral stability. Severe spasticity of the ankle may require prescription of a solid AFO. A plastic spiral AFO may be prescribed for concomitant weakness of both the ankle dorsiflexors and plantar flexors when spasticity is absent.
A 67-year-old man with Parkinson disease is experiencing more falls. These falls usually occur shortly after getting up in the morning, or after a large meal. You suspect his falls are due to
(a) vestibular dysfunction.
(b) orthostatic hypotension.
(c) increased lower extremity weakness.
(d) increased rigidity.
(b)
The majority of patients with Parkinson disease experience orthostatic hypotension (OH) as the disease progresses. The patient’s history suggests falls related to postural changes and situations that lower blood pressure. Educating your patient to avoid or mitigate these situations (slow postural changes, small meals, and avoidance of high heat exposure and alcohol) is the best initial treatment.
The most significant risk factor for continued structural destruction of the knee in osteoarthritis is
(a) joint malalignment.
(b) obesity.
(c) prior surgery.
(d) occupational bending and lifting
(a)
Joint malalignment is the most significant risk factor for further joint deterioration, since it creates uneven focal loading.
Cognitive deficits are common in
(a) Duchenne muscular dystrophy.
(b) inclusion body myositis.
(c) fascioscapulohumeral dystrophy.
(d) Becker muscular dystrophy.
(a)
A brain isoform of dystrophin exists and there are documented mildly decreased Intelligence Quotient scores in people with Duchenne muscular dystrophy. These lower scores may be specific to deficits with tasks requiring attention to complex verbal information.
Which statement is correct regarding the management of labor and delivery for women with cervical spinal cord injuries?
(a) Pre-eclampsia is 3 times more likely to occur than in able-bodied women.
(b) Vaginal delivery is contraindicated.
(c) Autonomic dysreflexia occurs 60%–80% of the time.
(d) Spinal and epidural anesthesia are contraindicated
(c)
Women with paraplegia or tetraplegia can give birth vaginally and caesarean delivery is rarely necessary. Patients with neurologic levels above T6 are at risk for autonomic dysreflexia during pregnancy, labor, and delivery. Autonomic dysreflexia is reported to occur in 60% to 80% of women with SCI with lesions above T6. Preeclampsia occurs with the same frequency in able-bodied women and women with disabilities. Complications from autonomic dysreflexia may be severe and include encephalopathy, cerebrovascular accidents, death of the mother, and severe fetal asphyxia. Spinal or epidural anesthesia extending to the T10 level is the treatment of choice and the most reliable method of preventing and treating autonomic dysreflexia during labor and delivery.
In assisting patients returning to their previous level of work, work hardening programs can achieve return-to-work rates of
(a) less than 25%.
(b) 25%–49%.
(c) 50%–75%.
(d) more than 75%.
(d)
Return-to-work rates of 77% can be achieved with work hardening programs. Poor outcome was associated with an increased number of treatments before the program, an increased length of time off from work; the patient’s having lower satisfaction with the program, and a lawyer being involved in the case.
gambar gelombang mulai defleksi sampai naik ke netral lagi = 2 kotak, mulai defleksi pertama sampai netral = hampir 2 kotak, 1 kotak = 10 ms
What is the total duration of the motor unit action potential shown above?
(a) 8 ms
(b) 12 ms
(c) 18 ms
(d) 22 ms
(c)
The total duration of a motor unit is measured from the initial deflection from baseline to the final return to baseline.
A 35-year-old man with history of psoriatic arthritis complains of localized low back pain of insidious onset. The pain is worse in the morning and improves as the day progresses. What is the most likely cause of his back pain?
(a) Piriformis strain
(b) Sacroiliitis
(c) Quadratus lumborum strain
(d) Discitis
(b)
Spondylonegative spondylarthropathies, such as psoriatic arthritis, are often associated with sacroiliitis. The Gelling phenomenon, characterized by stiffness after prolonged immobility, occurs with many inflammatory arthropathies.
During the initial, acute evaluation of a young spinal cord injury patient, which factor would make you suspicious of a concomitant brain injury?
(a) Fall as the mechanism of injury
(b) Female patient
(c) Higher level spinal cord injury
(d) African-American patient
(c)
The following factors, evidenced at the time of a spinal cord injury, place an individual at higher risk for a concomitant traumatic brain injury: Male sex and a higher level of spinal cord injury. Up to the age of 74 years-old, a transportation accident is the major source of traumatic brain injury (TBI) and not falls. Studies have shown a potential relationship between race and the incidence of TBI, but there are too many confounding variables and no study has shown a clear evidence of a relationship.
A forty-year-old woman with rheumatoid arthritis (RA) complains of right wrist pain that limits her ability to use her computer and phone at work as a computer analyst. On exam, she has metacarpal phalangeal ulnar deviation, wrist radial deviation, and several boutonniere deformities in her fingers. There is no active synovitis. You suggest occupational therapy and
(a) oral prednisone.
(b) short forearm cast.
(c) a resting wrist orthotic.
(d) finger splints.
(c)
Resting wrist splints provide light support for a painful joint and are well tolerated. They are the most commonly prescribed orthotic in RA.
All hereditary sensory motor neuropathies are characterized by
(a) decreased Intelligence Quotient scores.
(b) absent spinal deformities.
(c) muscle weakness.
(d) joint contractures.
(c)
All types of hereditary sensory motor neuropathies (HSMN) are characterized by weakness. The residual muscle force in the later stages of disease is 20%–40% less than normal. Intelligence Quotient reduction, significant joint contractures, pulmonary/cardiac abnormalities and spinal deformities are not typical of these diseases.
If a man injures his low back while on the job and is off work for 6 months, then the chance that he will return to work is
(a) 25%.
(b) 35%.
(c) 50%.
(d) 75%.
(c)
There is about a 50% chance of return to work when a worker who injures his low back on the job is off work for 6 months. The rate drops to 25% when the worker is off for 1 year, and is minimal is he is off for 2 years.
Acquired subluxation or dislocation of the hips in spastic cerebral palsy is usually due to muscular imbalance with excessive tone of which muscles?
(a) Hip flexors and tensor fascia lata
(b) Hip flexors and hip adductors
(c) Rectus femoris and hip abductors
(d) Tensor fascia lata and hip extensors
(b)
Progressive changes associated with hip subluxation in patients with cerebral palsy result from the effects of neuromuscular imbalance on the growth and development of the hip joint. The primary problem is spasticity and muscular imbalance, and the musculoskeletal manifestations are secondary. Soft tissue abnormalities include a muscular imbalance between the stronger flexors and adductors, and the weaker extensors and abductors. A flexion-adduction contracture also shifts the center of rotation of the hip from the femoral head to the lesser trochanter, and the proximal femur is gradually displaced upward and outward.
A 19 year-old male is seen after a traumatic brain injury. The patient’s mother is at the bedside and is asking you questions about the patient’s prognosis for recovery. As you consider your response, which statement is TRUE?
(a) Severe disability is unlikely if the length of coma is less than 1 month.
(b) Good recovery is unlikely if posttraumatic amnesia (PTA) lasts longer than 3 months.
(c) An initial Glasgow Coma Scale score of less than 8 is associated with a poor outcome.
(d) Neuroimaging studies are not helpful to determine a patient’s prognosis
(b)
Multiple studies have shown that age, initial Glasgow Coma Scale (GCS) score, duration of coma, duration of posttraumatic amnesia (PTA), and neuroimaging findings are correlated with outcome. All provide valuable information that the clinician can use to mark milestones, and help with prognosis, but the most powerful of these is the duration of PTA. The longer the duration of the PTA, the worse the outcome. It is unlikely for a person with PTA lasting less than 2 months to have a serious disability; however, the likelihood of a good recovery is poor if the PTA extends beyond 3 months. Length of coma is determined by the time from coma onset to the time when the patient can follow commands. On average only 7%–8% will make a good recovery if the coma lasts longer than 4 weeks, and severe disability is unlikely if the coma lasts less than 2 weeks. Although the GCS score provides a general idea about the severity of the injury, it does not by itself yield a definitive prognosis.
The arthropathy in persons with systemic lupus erythematosus (SLE) generally is in the wrists, knees and small joints of the hands. It is also
(a) symmetric and non-erosive.
(b) symmetric and erosive.
(c) asymmetric and non-erosive.
(d) asymmetric and erosive.
(a)
The arthritis in SLE is symmetric and non-erosive. It is also generally non-deforming and reducible due to its involvement of the para-articular tissues.
A 52-year-old woman with a history of non-alcoholic steatohepatitis underwent a recent liver transplant. Her protein and albumin levels are very low and, on exam, she has anasarca. Your inpatient rehabilitation admission orders should include
(a) referral for paracentesis.
(b) nursing orders to avoid use of an abdominal binder.
(c) high protein diet with high protein oral supplements.
(d) oxandrolone and monitoring of liver enzymes.
(c)
Malnutrition is significant in patients with liver disease. Ascites can promote excessive protein loss. Patients should receive a high protein diet with high protein oral supplements when they are in rehabilitation. Paracentesis would be required only if the patient was having symptoms from the ascites and would probably not be appropriate in the admission orders. Oxandrolone carries a risk of liver damage and therefore should not be prescribed in this patient. Abdominal binders may be used to help with ascites, particularly if the patient has an umbilical hernia from it.
According to current guidelines, for the injured factory worker with acute low back pain, what is the recommendation?
(a) >6
(b) 4-5
(c) 2-3
(d) <1
(d)
In a systematic review of patients with acute low back pain, resting in bed was found to be less effective than staying active.
In children with spastic cerebral palsy, which approach strengthens weak muscles?
(a) Ankle-foot orthotics
(b) Tendon transfer surgery
(c) Intrathecal baclofen
(d) Functional training
(d)
Children with cerebral palsy often have weakness as part of their disorder. Treatments such as bracing, tendon lengthening or transfers, and medications such as botulinum toxin or intrathecal baclofen add to this weakness. Strengthening programs or functional training programs can help to strengthen weak muscles.
Which type of traumatic brain injury results in the most morbidity?
(a) Focal cerebral contusion
(b) Subarachnoid hemorrhage
(c) Epidural hematoma
(d) Diffuse axonal injury
(d)
After a traumatic brain injury, diffuse axonal injury (DAI) is the leading cause of morbidity, this morbidity includes impairments in cognition, behavior, and arousal.
In addition to routine weight-bearing exercises and calcium supplements, vitamin D is important in persons with osteoporosis because it
(a) decreases the amount of calcium supplementation needed.
(b) enhances muscle strength and reduces the risk of falling.
(c) decreases bone turnover.
(d) improves the mechanism of action of biphosphonates.
(b)
Vitamin D is essential for skeletal maintenance and has been shown to enhance muscle strength and reduce the risk of falling.
What percentage of patients with whiplash-associated disorders develop chronic symptoms?
(a) less than 25%
(b) 25%–49%
(c) 50%–75%
(d) more than 75%
(b)
Up to 33% of individuals with symptoms from whiplash-associated disorders have chronic symptoms. Symptoms associated with whiplash-associated disorders include neck pain, arm pain, paresthesias, temporomandibular joint dysfunction, headache, dizziness, visual disturbances, and difficulty with memory and concentration.
While recording an antidromic sensory nerve action potential, you increase the distance between the active and reference electrode from 1cm to 4cm by moving the reference electrode. What is the effect on the onset latency and peak latency? Onset Latency Peak Latency (a) No change Increase (b) Increase No change (c) Decrease Decrease (d) Increase Increase
(a)
Increasing the interelectrode distance from 1 cm to 4 cm does not alter the onset latency, but increases the peak latency and amplitude of the sensory response. The onset latency does not change because the active electrode position is not changed. The sensory nerve action potential amplitude increases because less of the information is eliminated by differential amplification. Similarly, the peak latency also is prolonged as less of the signal is eliminated.
The family of your 15-year-old patient who had a severe traumatic brain injury 6 weeks ago asks you if they may feed their son. You observe that the patient is agitated at times, has a hoarse voice, and drools. You try to feed him applesauce and notice that he seems to swallow part of it and does not cough. The most likely finding on the videofluoroscopic swallowing study will be
(a) Silent aspiration
(b) Reflux
(c) Coughing and gagging
(d) Normal swallow
(a)
The lack of coughing in a patient with neurologic impairment when presented with food may mean a normal swallow, but is more likely to mean silent aspiration. A normal videofluoroscopic swallowing study is unlikely in a patient with a TBI who is drooling and hoarse. Hoarseness may be a sign of reflux, but in a child with a TBI is more likely to mean vocal cord abnormality.
A 24-year-old man with T4 paraplegia has a sacral pressure ulcer measuring 2 cm by 2 without depth. The ulcer base has pink granulation tissue. Which dressing is LEAST appropriate in this case?
(a) Tegaderm (transparent adhesive dressing)
(b) Duoderm (hydrocolloid wafer dressing)
(c) Curasol (gel dressing)
(d) Accuzyme (enzymatic debridement)
(d)
This man has a stage II pressure ulcer. Debridement with an agent such as Accuzyme is indicated in wounds with necrotic tissue. Since no necrotic tissue is present in this patient’s wound, Accuzyme is not appropriate. A transparent adhesive dressing such as Tegaderm, a hydrocolloid wafer dressing such as Duoderm, and a gel dressing such as Curasol are all appropriate for clean wounds such as the ulcer described.
Which factor is most likely to be associated with the development of a work-related, repetitive-strain injury?
(a) Normal body weight
(b) Warm work environment
(c) Younger age
(d) Rheumatoid arthritis
(d)
Risk factors associated with a repetitive strain injury include obesity, cold temperature, older age, diabetes, smoking, pregnancy, rheumatoid arthritis, and psychologic stress.
