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Flashcards in SAER 2012 Deck (52):

Which clinical examination finding increases the likelihood that a stroke patient has had an
ischemic stroke and NOT a hemorrhagic stroke?
(a) Neck stiffness
(b) Cervical bruit
(c) Diastolic blood pressure greater than 110 mm Hg
(d) Headache

Answer: (b)
Commentary: There are two fundamental types of stroke and differentiating the two types of
stroke has become more important as the use of thrombolytics in the acute management of stroke
has become more important. Runchey and McGee in a review of 19 prospective articles with
data from 6438 patients found that the following clinical findings increased the probability of
hemorrhagic stroke: coma, neck stiffness, seizures, diastolic blood pressure greater than 110 mm
Hg, vomiting and headache. While other findings (cervical bruit and prior transient ischemic
attack) decreased the probability of hemorrhagic stroke and made ischemic stroke more probable.
However, no specific finding or combination of findings was definitively diagnostic.


A 22-year-old male with C6 ASIA B tetraplegia secondary to a motor vehicle accident 2 months
ago is undergoing inpatient rehabilitation. His bladder is managed with a suprapubic catheter and
he is on a daily bowel program using digital stimulation and a bisacodyl (Dulcolax) suppository.
While resting supine in bed one evening, he suddenly develops a pounding headache. His blood
pressure is found to be 180/100 and his heart rate is 56. His face is flushed. What is the first step
in the initial management of this patient?
(a) Flush his suprapubic catheter.
(b) Using a well lubricated finger, check his lower rectum for fecal impaction.
(c) Sit him up and loosen any restrictive clothing.
(d) Apply ½ inch of nitropaste to his anterior chest wall.

Answer: (c)
Commentary: This patient is presenting with autonomic dysreflexia (AD). Once diagnosed, the
first step in the management of AD is to sit the patient up, if supine, and loosen any restrictive
clothing. If the blood pressure remains elevated, the urinary system should be evaluated. In this
case, therefore, the second step would be to flush the suprapubic catheter. If the blood pressure
continues to be elevated after bladder distention has been ruled out, the lower bowels should be
evaluated for fecal impaction, but only after the systolic blood pressure is reduced to less than
150 mmHg, using medications if necessary. Medications, such as nitroglycerin paste (nitropaste),
should be used only after these first 3 steps are taken. In the acute setting the need is unlikely, but
to avoid life threatening hypotension in chronic SCI and AD avoid using nitrates with sildenafil
(Viagra) and other phosphodiesterase type 5 inhibitors.


Which clinical tool BEST measures and predicts the safety of ambulation in older adults?
(a) Berg Balance Scale (BBS)
(b) Braden Scale
(c) Timed Up and Go (TUG) test
(d) Katz Index

Answer: (c)
Commentary: The Berg Balance Scale (BBS) is a 56-point scale to evaluate performance during
14 common activities, such as standing, turning and reaching for an object on the floor. It does
not rate walking. The Braden Scale is for predicting pressure sore risk, and is used to help
determine the risk of skin breakdown or decubitus ulcer. In the Timed Up and Go (TUG) test, a
patient is asked to rise from an armchair, walk 3 meters (10 feet), turn around, walk back to the
chair, and sit down again (the score is the time in seconds it takes to complete these tasks). This
test has high interrater and content reliability, and predicts whether a patient can safely walk
outside alone. The Katz Index is widely used to measure independence in activities of daily living
(ADLs), but does not include measures of mobility, such as walking or stair climbing.


A 67-year-old man who had a stroke is being discharged from the hospital. His 32-year-old
nephew plans to care for him at home, but is unfamiliar with the Family Medical Leave Act
(FMLA). How does FMLA apply to the nephew?
(a) He does not qualify since he is not the spouse or an immediate family member.
(b) FMLA only applies to the patient, not to the caregiver.
(c) He will be paid 66% of his usual salary while he is taking FMLA.
(d) If he takes FMLA, he may lose his employer-sponsored health insurance.

Answer: (a)
Commentary: The Family Medical Leave Act (FMLA) entitles eligible employees of covered
employers to take unpaid, job-protected leave for specified family and medical reasons with
continuation of group health insurance coverage. Eligible employees are entitled to 12 work
weeks of leave in a 12-month period for any of the following reasons:
1. the birth and care of the newborn child of an employee
2. the placement with the employee of a child for adoption or foster care
3. to care for an immediate family member (spouse, child, or parent) with a serious health
4. to take medical leave when the employee is unable to work because of a serious health
Employees are eligible for leave if they have worked for their employer at least 12 months, have
worked at least 1250 hours over the past 12 months, and work at a location where the company
employs 50 or more employees within 75 miles.


One advantage of a concentric needle compared to a monopolar needle is its
(a) higher amplitude of motor unit action potentials(MUAPS).
(b) decreased likelihood of electrical interference.
(c) ability to vary the recording surface size.
(d) longer duration of the MUAPs.

Answer: (b)
Commentary: The shaft of a concentric needle serves as the reference electrode, whereas an
additional electrode (typically a surface electrode) is needed as a reference when using a
monopolar needle. MUAPs recorded from monopolar needles are slightly longer in duration and
have higher amplitude, since they record from the entire area around the needle tip rather than
only from the fibers facing the bevel. Because the concentric needle shaft serves as the reference
electrode, the recording surface size is fixed and interference from surrounding muscles is


Botulinum toxin injections into the hip adductors, hamstrings and gastrocsoleus in children with
spastic cerebral palsy are shown to
(a) have greater effect in children older than 10 years.
(b) be better than serial casting in management of spastic equinus.
(c) be ineffective in management of spastic equinus gait.
(d) delay progression of hip displacement.

Answer: (d)
Commentary: Younger children with fewer physical limitations have more potential for
improvement than older children with more physical limitations. Serial casting and botulinum
toxin injections appear to have similar benefit. Spastic equinus gait is effectively improved with
botulinum toxin injections into gastrocsoleus and hamstrings. Hip displacement can be delayed
with botulinum toxin injections into hip adductors and hamstrings but does not affect long-term


Comparing lower limb amputations to upper limb amputations in the United States, lower limb
amputations are
(a) most often due to trauma.
(b) expected to significantly increase over the next 20 years due to increasing rates of
diabetes mellitus.
(c) less common than upper extremity amputations.
(d) expected to decrease over time due to improved prenatal care leading to less congenital

Answer (b)
Commentary: The prevalence of diabetes mellitus continues to increase in the United States and
this trend is expected to cause increasing rates of lower extremity amputation. Lower extremity
amputations are more common than upper extremity amputations and are more likely to be
related to dysvascular causes. Despite improvements in prenatal care enabling more births, rates
of amputations due to congenital defects have not changed significantly. The most common cause
of upper extremity limb loss is trauma-related injury.


When applying cryotherapy in the treatment of musculoskeletal disorders, which of the following
events is NOT a contraindication to its use?
(a) Paroxysmal cold hemoglobinuria
(b) Impaired sensation
(c) Arterial insufficiency
(d) Spasticity

Answer : (d)
Commentary: Contraindications for the use of cryotherapy include paroxysmal cold
hemoglobinuria, impaired sensation and arterial insufficiency. Other contraindications are cold
hypersensitivity, cryopathies, cold intolerance, cryotherapy-induced neurapraxia, and Raynaud
disease. Spasticity is one of the general uses of cryotherapy in addition to musculoskeletal
injuries and pain syndromes, postoperative conditions and emergency treatment of minor burns.


Which barrier is perceived by older individuals to be the LEAST significant obstacle to physical
(a) Time, money, family commitments
(b) Illness and injury
(c) Fear of injury
(d) Availability of an exercise partner

Answer: (a)
Commentary: Perceived barriers are a powerful negative predictor of physical activity in the
elderly. Although individual variation is the rule, overall obstacles to physical activity tend to
change with age, and seem to increase for many aging individuals. Elderly patients report that
time, money and family commitments are less significant barriers as they age. Availability of an
exercise partner, illness, injury and fear of injury become more prominent concerns as they grow


Which antispasticity drug used to treat a 3-year-old child with cerebral palsy binds to GABA
receptors in the spinal cord to inhibit reflexes that lead to increased tone?
(a) Clonidine
(b) Tizanidine
(c) Dantrolene
(d) Baclofen

Answer: (d)
Commentary: Baclofen binds to GABA receptors in the spinal cord to inhibit the reflexes that
lead to increased tone. Clonidine is an alpha 2 agonist, as is tizanidine. Dantrolene works in the
striated muscle at the level of the sarcoplasmic reticulum. All these drugs have pediatric
application. Baclofen can be used beginning at age 2 years.


Which deep heat method recommends the use of protective eyewear to prevent the formation of
(a) Ultrasound
(b) Short wave diathermy
(c) Fluidotherapy
(d) Microwave diathermy

Commentary: Microwave diathermy is another form of electromagnetic energy that uses
conversion as its primary form of heat production. Temperature distribution in a particular tissue
is affected largely by its water content. In general, tissues with high water content absorb greater
amounts of energy and are selectively heated. General heat precautions should be observed with
microwave procedures. Metal implants, pacemakers, sites of skeletal immaturity, reproductive
organs and brain, and fluid-filled cavities (eye, bullae, effusions, etc.) should be avoided.
Microwaves can cause cataracts and protective eye wear should be worn by both patient and
therapist to reduce risk.


An 18-year-old female with a history of depression and C2 ASIA A spinal cord injury acquired in
a diving accident requires continuous ventilation. She is diagnosed with a major depressive
disorder 8 weeks after her injury. Which factor has increased her risk for developing depression
after her spinal cord injury?
(a) Ventilator use
(b) Prior history of depression
(c) Level of injury
(d) Traumatic nature of injury

Answer: (b)
Commentary: Prior history of depression is a general risk factor for depression after a spinal cord
injury. Etiology, level of injury and ventilator use are not risk factors.


A 67-year-old man with chronic obstructive lung disease (COPD) is about to start a pulmonary
rehabilitation program. Which option is an appropriate breathing retraining technique for the
patient to learn?
(a) Diaphragmatic breathing
(b) Localized expansion exercises
(c) Rapid, shallow breathing
(d) Head up and bending backward postures

Answer: (b)
Commentary: Breathing retraining techniques for COPD include pursed lips breathing, head
down and bending forward postures, slow deep breathing, and localized expansion exercises (also
known as segmental breathing, wherein the patient is asked to inspire while the clinician applies
pressure to the thoracic cage to resist respiratory excursion in a segment of the lung). These
techniques maintain positive airway pressure during exhalation and help reduce overinflation.
Although diaphragmatic breathing (done by expanding one's belly and thereby allowing the
diaphragm to move down creating more room for the lungs to expand) is widely taught, it has
been shown to increase the work of breathing and dyspnea compared with the natural pattern of
breathing in the patient with COPD.


A 47-year-old woman with T8 ASIA A spinal cord injury (SCI) applied for a position as a store
clerk. She felt that she was being discriminated against because of her SCI. Under the Americans
with Disabilities Act (ADA), she may have a right to file a complaint if
(a) the employer requested a pre-employment physical to see if she qualified.
(b) the employer hired her, but then requested a pre-placement physical to determine the
most appropriate position for her.
(c) the job description required climbing ladders and working from heights.
(d) the employer did not make all accommodations to allow her to work from her wheelchair.

Answer: (a)
Commentary: The Americans with Disabilities Act (ADA) is a federal law designed to help
protect the rights of disabled citizens. Employers must not discriminate against hiring a disabled
applicant if that person is able to perform the key components of the job. Pre-employment
physicals are not allowed under the ADA, but a pre-placement physical can be used after an
individual is hired to help determine the most appropriate job for that person. An employer may
decline to hire a disabled individual if that person is unable to perform the essential functions of
the job, so long as the employer has attempted to make reasonable accommodations to allow the
disabled individual to perform these job functions. This individual would not be able to climb
ladders or work from heights because of her SCI, despite any accommodations.


A 55-year-old postal worker with a 1-year history of increasing left knee pain and decreasing
ability to ambulate arrives at your office. Her history is significant for 30 minutes of morning
stiffness and a left medial meniscal tear that was repaired arthroscopically 5 years ago. Her exam
is significant for a body mass index of 35, left knee varus deformity, and mild quadriceps
weakness. Her radiograph demonstrates medial compartment narrowing and bony sclerosis. She
(a) rheumatoid arthritis.
(b) osteoarthritis.
(c) parvovirus infection.
(d) pseudogout.

Answer: (b)
Commentary: Osteoarthritis (OA) is the leading cause of impaired mobility in elderly persons.
Risk factors include obesity, malalignment, prior trauma or surgery, and occupational bending or
lifting. Radiographs of knee OA demonstrate joint space narrowing, osteophytes, bony sclerosis
and cysts.


A 42-year-old woman with multiple sclerosis comes to you describing profound afternoon
fatigue. You recommend
(a) tizanidine (Zanaflex).
(b) amantadine (Symmetrel).
(c) azathioprine (Imuran).
(d) glatiramer acetate (Copaxone).

Answer: (b)
Commentary: Many medications are indicated for multiple issues relating to multiple sclerosis
(MS). Medications for fatigue include amantadine (Symmetrel) and modafinil (Provigil).
Medications for use in exacerbations include prednisone, ACTH and Solu-Medrol. These drugs
are supposed to decrease the length and severity of exacerbation. Disease altering medications
including the interferons beta 1A and beta 1B as well as glatiramer acetate (Copaxone) can
decrease the number of exacerbations. Medications for chronic MS include cyclophosphamide
(Cytoxan), azathioprine (Imuran), and cyclosporine (Sandimmune), which are supposed to slow
progression in chronic MS. Medications for spasticity include baclofen (Lioresal), dantrolene
(Dantrium), tizanidine (Zanaflex), and diazepam (Valium). Medications for ataxia can include
clonazepam (Klonopin) as well as isoniazid (Nydrazid).


Two medical experts (Drs. A and B) have differing opinions in a medical-legal case. Dr. A
accuses Dr. B of citing “junk science,” and states that Dr. B’s testimony fails to meet the Daubert
standard. Which statement supports the opinion that Dr. B has not met the Daubert standard?
(a) Dr. B’s research experience and publications are less than Dr. A’s.
(b) Dr. B’s peer-reviewed references are all more than 10 years old
(c) Dr. B’s cited references did not have a known error rate.
(d) Dr. B’s opinions are not fully accepted by the medical community.

Answer: (c)
Commentary: The Daubert standard refers to a federal Supreme Court decision to prevent “junk
science” from influencing juries. Information given by expert testimony must meet certain
criteria, and if these criteria are not met the expert can be barred from testifying. The information
provided by medical experts must meet the following four criteria:
1. Generally well accepted in the medical community
2. Published in peer-reviewed literature
3. Have a scientific basis
4. Have a known error rate
In the scenario presented, Dr. B satisfied the Daubert standard except for his failure to provide a
known error rate in his research.


In patients with steroid myopathy, the needle electromyographic study usually reveals
(a) small motor unit action potentials (MUAPs) with early recruitment.
(b) small MUAPs with reduced recruitment.
(c) positive waves and fibrillation potentials in proximal muscles.
(d) normal MUAPs and normal recruitment.

Answer: (d)
Commentary: Needle examination in patients with steroid myopathy usually reveals normal
insertional activity and no abnormal spontaneous activity. Motor unit potential morphology and
recruitment do not reveal any abnormalities. This combination occurs because in steroid
myopathy the type 2 muscle fibers are preferentially affected, in contrast to the first-recruited
type 1 fibers.


What is the primary benefit of using a postoperative, rigid, non-removable dressing in a new
transtibial amputee?
(a) Improved monitoring of postoperative wounds
(b) Protection of the wound and edema control
(c) Prevention of hip flexion contractures
(d) Improved strength in the residual limb

Answer (b)
Commentary: The primary benefits of a rigid dressing include wound protection, edema control
and prevention of knee flexion contractures (not hip flexion contractures). Monitoring the wound
may be more difficult with a non-removable rigid dressing. The dressing should be removed for
wound check regularly and if there is a concern for infection. Type of postoperative dressing has
no effect on residual limb strength.


Which is the most significant risk factor for a stroke?
(a) Smoking
(b) Hypertension
(c) Age
(d) Diabetes

Answer: (c)
Commentary: Age is the single most important risk factor for stroke, worldwide. The incidence
of stroke for both males and females doubles for each decade after age 55. Stroke is more
prevalent in men than women, except for the age cohort of 35-44 (a finding considered to be due
to the use of oral contraceptives and pregnancy) and among persons over age 85. Hypertension is
the most important modifiable risk factor for both ischemic and hemorrhagic stroke regardless of
age. A family history of stroke increases the risk of stroke by about 30%. Cigarette smoking is
an important risk factor and doubles one’s risk of ischemic stroke and triples the risk of
subarachnoid hemorrhage. Other well-documented risk factors include diabetes, dyslipidemia,
and atrial fibrillation.


A 72-year-old woman underwent right total knee arthroplasty 2 days ago. When you see her in
consultation, she tells you that she has numbness along the lateral portion of the incision site.
What is the most likely cause?
(a) Femoral or peroneal nerve injury
(b) Deep vein thrombosis
(c) Cutaneous nerve injury
(d) Temporary side effect from anesthesia

Answer: (c)
Commentary: Cutaneous sensory loss is a very common complication following primary total
knee arthroplasty. One study from 1995 found that 100% of patients had lateral skin flap
numbness, and more recent studies in 2004 and 2009 found 81%-86% of patients had lateral skin
flap numbness.
In most cases, the numbness does improve with time (50% recovered in 2 years in the 2009
study). Deep vein thrombosis (DVT) and common peroneal nerve palsy are other known
complications of total knee arthroplasty.


Which pulmonary parameter is predictive of mortality in a child with Duchenne muscular
(a) Maximal expiratory pressure
(b) Peak flow rate
(c) Cough peak flow
(d) Forced vital capacity

Commentary: One simple method of assessing the interplay between pump function and load is
the measurement of the forced vital capacity (FVC) and fractional lung volumes. In boys with
Duchenne muscular dystrophy (DMD), the relationship between the absolute value of FVC and
age can be divided into 3 epochs: one of gradual increase coincident with their ambulatory period,
followed by a plateau phase at 10 to 12 years when they become confined to wheelchairs, and
then a gradual but persistent decline thereafter. However, when the FVC is described as a percent
of the predicted value, it is lower than normal and diverges from the normal curve over time. The
decline in FVC to a value of less than 1 liter may also predict mortality in patients who do not
receive assisted ventilation.


A 47-year-old woman with secondary progressive multiple sclerosis is applying for Social
Security Disability Insurance (SSDI). She asks her primary care physician for help. His correct
response to her is that
(a) SSDI benefits and policies vary from state to state.
(b) SSDI benefits include medical insurance.
(c) he will make the final determination of disability and employability.
(d) she must satisfy non-medical criteria before medical factors are considered.

Answer: (d)
Commentary: The Social Security Administration (SSA) provides both Social Security Disability
Insurance (SSDI) and Supplemental Security Income (SSI). SSDI and SSI are federal programs
with identical benefits and policies from state to state. SSDI and SSI provide financial assistance
to disabled individuals, but do not provide medical insurance. Final determination of SSDI or SSI
is made by the SSA, not the treating provider. However, medical information is usually requested
from treating providers in order to make a determination of disability. An applicant must first
meet certain non-medical (eg, economic) criteria before medical factors are considered.


A 45-year-old man with a history of transtibial amputation secondary to trauma presents to your
office 6 months following surgery. He is successfully ambulating independently with his
prosthesis. His chief complaint today is new mild phantom limb pain. Evaluation does not reveal
any significant problems with his prosthesis or gait. What treatment would you recommend to
decrease his phantom limb pain?
(a) Cryotherapy
(b) Ultrasound
(c) Desensitization
(d) Paraffin wax

Answer (c)
Commentary: First line treatment for phantom limb pain should include use of desensitization
techniques (massage, friction rubbing, wrapping, etc.) The other types of therapeutics listed
would not be effective in phantom limb pain management. Phantom limb pain is one of many
sources of pain in an amputee and is difficult to treat. It affects anywhere from 67% to 79% of
amputees. For patients whose pain interferes with function and quality of life, a biopsychosocial
approach to pain management is crucial.


A 25-year-old man with a history of plantar fasciitis complains of low back and buttock pain.
The pain is worse at rest and better with activity. Schober test (signifying restricted lumbar
flexion) is positive. The laboratory or radiology result that would help confirm your most likely
diagnosis is a positive
(a) antinuclear antibody (ANA).
(b) human leukocyte antigen (HLA) B27.
(c) discogram.
(d) myelogram.

Answer: (b)
Commentary: The patient may have ankylosing spondylitis (AS). Enthesitis, such as plantar
fasciitis, is common in patients with AS. HLA B27 is usually positive in this condition, which is
a seronegative spondyloarthropathy. Schober test is performed by marking a point 5 cm below
the iliac crest line and 10 cm above. On forward flexion, the line should increase by more than 5
cm. An ANA test, discogram and myelogram would not help to diagnosis AS.


Your patient is having difficulty writing or performing tasks in certain positions. He has an
asymmetric tremor that is present only with movement. You suspect which type of tremor?
(a) Essential
(b) Primary orthostatic
(c) Cerebellar
(d) Dystonic

Answer: (d)
Commentary: Suspect a dystonic tremor if it is very asymmetrical and shows postural
dependence. There may be associated dystonia elsewhere in the body. The tremor may have task
specificity, such as writing or postural dependence. A cerebellar tremor will often have other
cerebellar signs present and often improves if the patient performs movement with eyes closed.
Essential tremor is symmetrical and best seen with an outstretch hand. Primary orthostatic tremor
presents as unsteadiness or tremor in the legs that increases with prolonged standing, and the
symptoms are relieved by sitting or walking.


A 48-year-old woman had an acute myocardial infarction (MI) 2 weeks ago. The referring
cardiologist informed you that she had a small MI and an uncomplicated hospital course. In a
situation such as this, which statement is TRUE?
(a) Combined aerobic and resistance training, compared to aerobic training alone, has a
higher risk of adverse outcomes.
(b) Beta blocker agents will attenuate the benefits of exercise training.
(c) A change in left ventricular (LV) dimensions (remodeling) is associated with improving
LV function.
(d) Cardiac rehabilitation will improve both myocardial perfusion and LVelectrophysiologic

Answer: (d)
Commentary: After a myocardial infarction (MI), exercise training is initiated within 2-4 weeks.
Combined resistance and aerobic training improves aerobic fitness and muscle strength more than
aerobic training alone, without adverse outcomes. Beta blockers, which are a standard of care to
reduce mortality after an MI, do not attenuate the benefits of exercise training. Following an MI,
a change in left ventricular (LV) dimensions (remodeling) is associated with deteriorating LV
function, ventricular arrhythmias, aneurysm formation, and higher mortality. Cardiac
rehabilitation improves both myocardial perfusion and LV electrophysiologic parameters,
reducing the risk for malignant ventricular arrhythmias and sudden cardiac death after MI.


Imaged with musculoskeletal ultrasound, normal tendon structure looks
a) hypoechoic, with hyperechoic septa.
b) hypoechoic , with fascicular pattern.
c) hyperechoic, with fibrillar echotexture.
d) hyperechoic, with posterior acoustic shadowing.

Commentary: Musculoskeletal ultrasound is an imaging modality that is able to identify and
characterize various soft tissue structures. Normal tendons appear as hyperechoic(bright echo)
structures with fibrillar or fiber-like pattern. Normal muscle appears as a hypoechoic(low echo)
structure with hyperechoic septa. Bone appears as a very hyperechoic structure with posterior
acoustic shadowing. Posterior acoustic shadowing is an artifact that refers to the anechoic
region(no echo) deep to the bone surface.


A neurologist refers a patient to you with Parkinson disease and poor gait. What treatment
strategy is recommended to prevent frequent falls?
(a) Methylphenidate medication trial to increase attention and concentration
(b) Physical therapy with balance training and cueing strategies
(c) Referral to a neurosurgeon for implantation of a deep brain stimulator
(d) Maximized levodopa medication to improve balance control

Answer: (b)
Commentary: Physical therapy with cueing strategies, such as rhythmic auditory stimulation with
a metronome and balance and strength training are shown to be useful in improving gait and
decreasing falls. Treadmill training is still in its infancy and its role in improving gait is unclear,
although early studies are positive. The use of methylphenidate in initial trials was positive but a
recent randomized, double blinded study using methylphenidate showed no improvement in gait.
The use of deep brain stimulation is very inconsistent in its effect on balance and gait and further
study is needed to optimize type of stimulation and to define new targets for stimulation.
Levodopa can improve gait, but can also cause a worsening of gait and balance, possibly due to
drug-induced dyskinesias.


A 60-year-old man has first metatarsophalangeal joint pain. Joint fluid analysis confirms your
suspected diagnosis. What lifestyle or medication changes would reduce flare-ups of his
(a) Increase seafood intake
(b) Decrease alcohol intake
(c) Increase diuretic use
(d) Decrease vitamin C use

Answer: (b)
Commentary: Alcohol increases uric acid production and can provoke an acute gout attack.
Seafood and red meat contain purines which increase serum uric acid levels and thus increase
gout flares. Gout can also be provoked by trauma and drugs such as thiazide diuretics. In
contrast, vitamin C has been found to decrease gout attacks.


In persons with traumatic spinal cord injury (SCI), which statement regarding employment is
(a) The majority of patients are unemployed at the time of injury.
(b) Education is most strongly associated with postinjury employment.
(c) Employment status is similar between different ethnic groups.
(d) Employment status is highest within the first 5 years postinjury.

Answer: (b)
Commentary: The National Spinal Cord Injury (SCI) Statistical Center database states that at the
time of injury, 63% of people injured were employed, 19% were students, and 17% were
unemployed. While unemployment at the time of injury is a negative predictor for postinjury
employment, education has been found to be the factor most strongly associated with postinjury
employment, with only 5% of persons with less than 12 years of education being employed, and
69% of persons with doctoral degrees being employed. Overall, only about 25% of all persons
with SCI were employed. African Americans and Hispanics with SCI fared worse in employment
outcomes compared to Caucasians with SCI. Employment status increased over time, with the
odds of being employed at 1, 5 and 10 years after injury being 1.58, 2.55, and 3.02, respectively.


The third occipital nerve innervates which structure?
(a) C2-3 zygapophysial joint
(b) C2-3 intervertebral disc
(c) C3-4 zygapophysial joint
(d) C3-4 intervertebral disc

Commentary: The third occipital nerve(TON) innervates the C2-3 zygapophysial joint. The C3-4
zyagpophysial joint is innervated by the C3 and C4 medial branches. Innervation to the cervical
discs involves the sinuvertebral nerve, vertebral nerve and sympathetic trunk.


Which finding would you expect in a 35-year-old man with type 1 hereditary motor sensory
(a) Absence of ankle reflexes
(b) Pes planus
(c) Motor nerve conduction velocity slowing, with evidence of temporal dispersion
(d) Absence of electromyographic spontaneous activity

Answer: (a)
Commentary: Hereditary motor sensory polyneuropathy type 1 (HMSN-1, the demyelinating
form of Charcot-Marie-Tooth disease) presents in young adult life with insidious onset of distal
weakness and sensory loss. Clinically, it typically presents with pes cavus, hammertoes and foot
drop. Ankle reflexes are absent. Temporal dispersion would indicate an acquired, not hereditary,
process. Secondary axonal loss is expected, which would result in positive waves and


Which ethnicity has the highest prevalence of neural tube defects?
(a) Eastern European
(b) Asian
(c) African American
(d) Hispanic

Answer: (d)
Commentary: Even though neural tube defects have declined across all ethnicities, because of
increased folate intake, the disparity between Hispanics and other ethnicities remains. While
50%-70% of neural tube defects can be prevented by adequate folic acid, genetic influences


Which finding is most closely associated with favorable motor recovery after a traumatic spinal
cord injury?
(a) Recovery from spinal shock in less than 4 weeks after injury
(b) ASIA B classification with retained pinprick sensation in the sacral dermatomes
(c) Detection of somatosensory evoked potentials in the first 2 weeks after injury
(d) Hemorrhage in the spinal cord of less than 1cm on MRI

Answer: (b)
Commentary: ASIA B patients with preservation of sacral pinprick sensation have a 70% to 90%
chance of motor recovery sufficient to ambulate. The concept of spinal shock has been poorly
defined and is generally not helpful to clinicians in predicting recovery. The detection of
somatosensory evoked potentials is not always associated with motor recovery. Hemorrhage of
any amount is generally associated with a poorer prognosis.


Personality changes and/or aphasia are typical of which dementia?
(a) Alzheimer
(b) Frontotemporal
(c) Parkinson’s disease with dementia
(d) Vascular

Answer: (b)
Commentary: Frontotemporal dementia is a neurodegenerative disease of unknown etiology with
atrophy and neuronal loss in the frontal and temporal lobes of the brain resulting in a gradual and
progressive decline in behavior and/or language. Overuse of stock phrases, lack of
conversational initiation and echolalia are more common in frontotemporal dementia. Alzheimer
disease is primarily associated with memory and visuospatial loss of function, and speech is more
fluent than in persons with frontotemporal dementia. Parkinson disease with dementia is
associated with symptoms of memory loss, fluctuating cognition, and visual hallucinations with
spontaneous parkinsonism motor features. Persons with vascular dementia usually have a history
of stroke or have focal neurologic deficits, early gait disturbance, changes in personality and
mood and a history of frequent falls or unsteadiness.


A 35-year-old woman sustained an ischemic stroke and is currently undergoing workup in the
acute care hospital. Systemic lupus erythematosus (SLE) is suspected. An immunoglobulin G
(IgG) or IgM anticardiolipin antibody analysis is ordered to evaluate for which associated
(a) Antiphospholipid antibody syndrome
(b) Activated protein C resistance
(c) Antinuclear antibody
(d) Antithrombin III deficiency

Answer: (a)
Commentary: Antiphospholipid antibody is associated with systemic lupus erythematosus (SLE)
and can increase risk of thrombosis. SLE is diagnosed with an abnormal serum level of IgG or
IgM anticardiolipin antibodies, positive lupus anticoagulant, or false-positive serologic test for
syphilis. Activated protein C resistance and antithrombin III deficiency are risk factors for
thrombosis and stroke, but do not have the same association with SLE. Antinuclear antibody is
usually positive in SLE and is part of the diagnostic criteria, but is not associated with


What advice would you provide to a 22-year-old man with chronic T4 ASIA A paraplegia who
has ejaculatory dysfunction?
(a) Avoid ejaculation because of complications related to autonomic dysreflexia
(b) Use sildenafil (Viagra) 60 minutes before intercourse
(c) Consider a trial of vibratory stimulation
(d) Ejaculation dysfunction cannot be treated

Answer: (c)
Commentary: Men with an upper motor lesion (UMN) and an ejaculation reflex have a 30% to
96% ejaculation rate with vibratory stimulation, depending on the vibratory stimulator's
waveform amplitude and frequency. If vibratory stimulation is unsuccessful, ejaculation can be
accomplished and sperm collected using a rectal probe with electroejaculation. Sildenafil is an
option for management of erectile dysfunction rather than ejaculation dysfunction. Although
autonomic dysreflexia may occur with ejaculation, it is more commonly a transient phenomenon
and does not lead to complications.


Cooling can produce physiological changes in the body. One of these changes is an increase in
(a) nerve conduction rate.
(b) stretch receptor sensitivity.
(c) elasticity of connective tissue.
(d) general sympathetic activity.

Answer: (d)
Commentary: Nerve conduction rate is slowed by cooling. The stretch receptor sensitivity in
muscles and tendons is reduced, and the elasticity of connective tissue diminishes with cooling.
The general sympathetic activity is increased with cooling of the body, and this may affect the
responses of the stretch receptors in a beneficial way.


What neurological level of spina bifida is associated with active plantar flexion, cavus foot
deformities and neurogenic bowel and bladder?
(a) thoracic (T2-12)
(b) upper lumbar (L1-3)
(c) lower lumbar (L4-5)
(d) sacral (S1-2)

Answer: (d)
Commentary: Bowel and bladder involvement is common at all levels, even in sacral lesions.
Plantar flexion and inversion causes development of the cavus foot in sacral lesions. Lower
lumbar lesions develop unopposed ankle dorsiflexion leading to a calcaneous foot. Upper lumbar
and thoracic lesions develop ankle plantar flexion contractures due to the inability to move the
ankle at all.


A significant improvement in quality of life for advanced ALS patients is attributed to
(a) having advanced directives.
(b) invasive ventilation to prolong life.
(c) earlier hospice transition.
(d) placement in long-term care

Commentary: Improved quality-of-life for advanced ALS patients is attributed to optimizing inhome
care and early hospice transition. Hospice can ease the burden of care by the family
members. Hospice organizations have guidelines for early entry into hospice during advanced
stages. Most patients who undergo invasive mechanical ventilation do so emergently and often
against their wishes. Invasive ventilation is not preferred in over 92% of ALS patients surveyed.
Often, there is a lack of advanced directives to guide the treating team. Lack of physician
communication with the patient about advanced directives is the major barrier to patients
developing their advanced directives.


A 49-year-old man is seen in your outpatient clinic 2 years after a stroke. You notice a
Trendelenberg gait and suspect weakness of which muscle?
(a) Gluteus maximus
(b) Quadratus lumborum
(c) Quadriceps
(d) Gluteus medius

Answer: (d)
Commentary: Weakness of the gluteus medius muscle, or reluctance to use the gluteus medius
muscle because of hip pain, can cause this gait pattern. It is a pattern of either excessive pelvic
obliquity during the stance phase of the affected side (uncompensated) or excessive lateral truncal
lean during the stance phase on the affected side (compensated).


Which burn patient has the highest risk of developing hypertrophic scars?
(a) Newborn baby
(b) Morbidly obese individual
(c) Heavily pigmented individual
(d) Elderly individual

Answer: (c)
Commentary: A hypertrophic scar is usually defined as a scar that is present at 3 or more
months after the burn injury and is greater than or equal to 2 mm in thickness. Heavily
pigmented patients tend to scar more than persons with less pigment. Little scarring has been
reported in neonates, newborns, elderly and the morbidly obese. Patients with wounds that take
longer than 2-3 weeks to heal, and persons requiring skin grafts, are also considered at risk for
developing hypertrophic scars


A 33-year-old woman who had a prolonged labor 6 weeks ago, reports pain in the groin radiating
along the medial aspect of the thigh. Needle electromyographic exam shows evidence of
denervation in the gracilis and adductor muscles. Most likely she has a lesion in the
(a) femoral nerve.
(b) obturator nerve.
(c) sciatic nerve.
(d) genitofemoral nerve.

Answer: (b)
Commentary: The nerve common to the affected muscles is the obturator nerve. There is some
innervation of the adductor magnus by a branch off the sciatic nerve, but the gracilis, adductor
brevis, and adductor longus are supplied by the obturator nerve. Injuries of the obturator nerve are
uncommon, but one cause in such cases is compression of the nerve between the fetal head and
the pelvic wall during prolonged labor.


In a transfemoral amputee, a circumducted gait pattern, on the prosthetic side, could be caused by
which factor?
(a) Insufficient prosthetic knee friction
(b) Long prosthetic limb
(c) Hip flexion contracture
(d) Poor balance

Answer (b)
Commentary: When observing gait deviations in an amputee, one should consider both the
prosthetic issues and amputee compensatory maneuvers as a potential cause for the deviation. A
circumducted gait pattern can have various causes, including a long prosthetic limb, excessive
prosthetic knee friction (making it difficult to bend the knee), and hip abduction contracture. Poor
balance is usually associated with excessive lateral trunk bending, uneven arm swing, and short
stance phase on the prosthetic side.


A 20-year-old female soccer player presents to your office with chronic low back pain. Her
computed tomography(CT) scan is seen in figure 1. What abnormality is seen on these CT
Fig. 1 (lumbar 5 dari lateral terlihat garis fraktur di corpus)
(a) Herniated disc
(b) Facet degeneration
(c) Pars interarticularis fracture
(d) Tarlov cyst

Answer: (c)
Commentary: Spondylolysis is a defect in the pars interarticularis. These CT images(sagittal and
axial) show evidence of an L5 pars interarticularis fracture. Spondylolysis is common in the
athletic population, particularly among athletes who perform repetitive flexion-extension.
Herniated discs and Tarlov cysts are not seen in these images and are more readily evaluated on
MRI. Facet degeneration is often diagnosed by CT scan but is not seen on these images.


Which pulmonary function parameters would you expect to increase in a child with advanced
neuromuscular disease?
(a) Total lung capacity
(b) Vital capacity
(c) Residual volume
(d) Expiratory reserve volume

Commentary: Patients with neuromuscular diseases (NMDs) demonstrate a restrictive pattern
when fractional lung volumes are measured. There is a reduction in total lung capacity, vital
capacity, and the expiratory reserve volume. In contrast, residual volume (the volume of air that
remains in the lungs after a maximal, complete expiratory maneuver) can actually be elevated
when the respiratory muscles are too weak to deform the chest wall inward to deflate the lungs
fully. These patterns will be exaggerated in children with NMDs who also develop scoliosis.
Forced expiratory flows are typically reduced in proportion to lung volume so that the ratio of the
forced expiratory volume in the first second (FEV1) to FVC is normal or high.


A bladder neuroprosthesis applies electrical stimulation to intact sacral parasympathetic nerves
(S2-S4) to produce effective micturition and improve bowel function. A posterior rhizotomy from
S2-S4 is typically also performed at the same time in order to
(a) decrease pain and increase patient acceptance of the neuroprosthesis.
(b) improve bladder emptying and lower the postvoid residual.
(c) improve external urethral sphincter relaxation.
(d) decrease autonomic dysreflexia when the bladder is emptying.

Answer: (d)
Commentary: Micturition by electrical stimulation requires intact parasympathetic neurons to the
detrusor muscle. This stimulation is often combined with posterior sacral rhizotomy to increase
bladder capacity and decrease reflex incontinence and sphincter contraction. Detrusor sphincter
dyssynergia is avoided with rhizotomy, protecting the upper tracts and reducing autonomic
dysreflexia. The pudendal nerve controls the external sphincter via the somatic nervous system,
which is not affected by rhizotomy.


A 3-year-old boy with upper lumbar spina bifida has bilaterally dislocated hips on x-ray during a
routine follow up visit. You advise his parents that he
(a) needs surgery to relocate both his hips.
(b) should have at least one hip relocated, surgically.
(c) can still stand and walk despite the hip dislocations.
(d) will not be able to sit comfortably in a wheelchair.

Answer: (c)
Commentary: Due to the imbalance between hip flexors/adductors and hip extensor/abductors,
hip dislocation occurs in 30%-36% of children with upper lumbar spina bifida. Unilateral hip
dislocations tend to cause pelvic obliquity, difficulty with wheelchair positioning and standing,
and surgery is advocated. However, bilateral hip dislocations do not generally require surgical
intervention, because a level pelvis and good range of motion are more important for ambulation
than located hips.


A patient presents to your clinic with a 1-month history of mild hand numbness and clumsiness
without weakness. Electrodiagnosis confirms a primarily sensory median neuropathy at the wrist
without axon loss. Symptoms are not interfering with work. What is the most appropriate
treatment recommendation to provide short-term relief for this patient?
(a) Immediate referral to surgery for carpal tunnel release
(b) Neutral wrist splints to be worn at night
(c) Thumb spica splint
(d) Injection of platelet rich plasma into carpal tunnel

Answer (b)
Commentary: Wrist splints are shown to effectively decrease symptoms of carpal tunnel
syndrome in the short-term. Splints should be worn at night and during the day if possible. Brace
should place wrist in neutral (up to 5o of extension): note that many off-the-shelf carpal tunnel
braces place the wrist in excessive extensions. A thumb spica splint is not effective in treating
carpal tunnel syndrome. Conservative treatment is essential in mild to moderate cases of carpal
tunnel syndrome. Surgical referral should be considered for patients with weakness or worsening
symptoms not improved with conservative treatment. Platelet rich plasma injections are not an
effective treatment for carpal tunnel syndrome


A high school athlete sustains a suspected concussion during a football game. The player should
(a) removed from play, evaluated and, if asymptomatic, be allowed to return to the game on
the same day.
(b) able to continue playing if he or she is able to perform.
(c) immediately transported to the local emergency department for evaluation.
(d) evaluated on the sideline and should not return to play that same day.

Commentary: When an athlete sustains a concussion in a game or during practice, he or she
should not return to play on the same day of the injury. The athlete should be removed from play
and be evaluated on the sidelines. Standard emergency medical management principles should be
applied when appropriate; serial monitoring should be performed and the athlete’s disposition
should be determined. The athlete should follow up with an appropriate healthcare provider
before he or she is returned to play.


A 65-year-old woman with diabetes mellitus has been sent to your clinic for evaluation of
appropriate footwear. She had a diabetic foot ulcer 2 months ago over her first metatarsal head,
which is now healed. Examination reveals distal sensory loss and a mild claw foot deformity.
Which footwear/orthotic recommendation is the most appropriate?
(a) Since the wound is healed, no specialized footwear is needed.
(b) Well-fitting regular tennis shoes or sneakers are the best option.
(c) Off-the-shelf diabetic shoe with a custom molded orthotic based on severity of claw foot
deformity is indicated.
(d) Patellar tendon-bearing ankle-foot orthoses to help unload the metatarsal head should be

Answer (c)
Commentary: The patient is at high risk for future diabetic foot ulcers based on her history of
previous ulcers, claw foot deformity and peripheral neuropathy. Based on this risk profile,
specialized footwear is recommended. Patients with diabetes mellitus (DM) without risk factors
for ulcer could be counseled and educated regarding the use of well fitting tennis shoes and
sneakers. While a custom molded shoe could benefit this patient, they are very expensive and
usually needed for patients with severe foot deformity. At this point a prefabricated diabetic shoe
and custom orthotic would be clinically appropriate and more cost-effective. A patella tendon
bearing ankle-foot-orthosis is not indicated and would not effectively offload the metatarsal
heads. A metatarsal bar or pad placed proximal to the metatarsal head is an effective way to
offload the metatarsal head.