AAPMR - Patient Evaluation and Diagnosis
Examination.
A 35-year-old woman presents with a 3-4 week history of numbness in the right little finger and ulnar
aspect of the right hand and weakness with handgrip strength compared to the other side. Her
electrodiagnostic studies show the following.
Figures show:
-Normal sensory NCV
-Motor NCV with slight side-to-side amplitude difference (R<L) with median and ulnar studies but
normal CV and latencies.
-Needle study shows reduced recruitment and abnormal spontaneous activity in EDC, PQ, ECU, FDI, APB,
and cervical paraspinals on the right.
These findings are most consistent with right:
A.Ulnar and median mononeuropathies
B.Lower trunk plexopathy
C.Ulnar mononeuropathy
D.C8/T1 radiculopathy - ANS >> D.C8/T1 radiculopathy 83.82%
The electromyographic findings are localized to muscles supplied by the C8/T1 roots. The triceps can
have some C8 innervation but frequently tests normal in C8/T1 radiculopathies. The normal sensory
studies make it less likely that this is a plexopathy or peripheral nerve injury. The median and ulnar
motor amplitudes are in the normal range but smaller compared to the left side. Finally, the
involvement of the lower cervical paraspinal muscles is consistent with a cervical radiculopathy.
Which of the following is a typical feature of seronegative spondyloarthropathies?
A.Symmetric arthritis
B.Bursitis
C.Enthesitis
D.Vasculitis - ANS >> C.
Enthesitis
81.72%
Seronegative spondyloarthropathies (SpA) are commonly asymmetric and have familial patterns. Less
than 5% of patients are HLA-B27 negative. In order to identify patients with SpAs, symptoms of LBP
lasting ≥ 3months should be present, and occur before age 45 years. In addition, the following criteria
should be met: Sacroiliitis on imaging plus one or more of the SpA features listed below. Or,
alternatively, HLA-B27 positivity plus two or more of the following SpA features listed: inflammatory
back pain; arthritis; enthesitis (e.g., heel); uveitis; dactylitis; Psoriasis; Crohn's/colitis; good response to
NSAIDs; family history of SpA; elevated C-reactive protein (CRP).
A 23-year-old with C5 AIS-A tetraplegia admitted to inpatient rehabilitation was noted to have significant
weight loss and vomiting after meals. X-rays with barium contrast show abrupt termination of the
barium in the area of the duodenum. This clinical scenario is most likely related to
A.Superior mesenteric artery syndrome
B.Cholecystitis
C.Chronic pancreatitis
D.Neurogenic bowel - ANS >> A.
,Superior mesenteric artery syndrome
78.62%
Superior mesenteric artery (SMA) syndrome is seen mostly in patients with tetraplegia who present with
abdominal distention, discomfort, and recurrent emesis following eating. It is caused by obstruction in
the distal part of the duodenum as it passes behind the SMA and in front of the spine and aorta. It often
occurs in patients who are immobilized and have lost a significant amount of weight and retroperitoneal
fat. It is worse in the supine position and in patients who are in a body jacket. Upper GI series reveal an
abrupt cessation of barium in the third part of the duodenum. Treatment includes sitting the patient in
upright or positioning them in left side-lying after meals, nourishment to restore weight, and applying a
lumbosacral corset to push the abdominal contents upward. Surgery is rarely indicated.
Which of the following is true regarding running and the gait cycle?
A.Stance and swing phases each occur for 50% of the cycle
B.Double stance does not occur
C.Initial contact occurs exclusively with the heel
D.Center of gravity is at its highest point during midstance - ANS >> B.
Double stance does not occur
78.62%
Running is the bipedal locomotion at a cadence sufficient such that a period of double stance does not
occur. Double stance is replaced by a period of double limb float, when both limbs are in swing phase.
As opposed to normal (walking) gait, stance phase occurs for 40% of the gait cycle, while swing phase
occurs for 60%. Additionally, the center of gravity reaches its lowest point in the cycle during midstance,
whereas this is its highest point during walking. Initial contact can occur with either the heel or forefoot,
as is common in sprinters, or those running uphill.
Which measure evaluates patients' self-perception of disability specifically for low back pain?
A.Fear-avoidance beliefs questionnaire (FABQ)
B.Oswestry Disability Index (ODI) questionnaire
C.Minnesota multiphasic personality inventory (MMPI)
D.Short Form 36 (SF-36) - ANS >> B.
Oswestry Disability Index (ODI) questionnaire
77.59%
ODI is used to track patient perception of disability over the course of treatment, specifically for low
back pain. In addition to being used as an outcome measure in research, physician offices are also
utilizing this tool for outcome tracking.
According to the Americans with Disabilities Act (ADA), an individual with a T12 AIS A spinal cord injury
would likely be able to perform the essential job functions of which of the following positions without
accommodation?
A.Truck driver
B.Plumber
C.Software developer
D.Warehouse worker - ANS >> C.
Software developer
98.97%
Accommodation would be needed for someone with paraplegia to work as a commercial truck driver.
The individual presumably has no training as a plumber and would therefore be unable to work as
plumber. An analyst is a sedentary clerical position that could be done by a person with paraplegia with
readily available computer interface approaches. A warehouse clerk is a physically demanding job that
would likely require some type of accommodation for a person with paraplegia (e.g., a robotic
exoskeleton), if any were available.
,A 70-year-old presents with hip pain 3 months after a total hip joint arthroplasty. Laboratory values
reveal mildly elevated inflammatory markers (ie, ESR and CRP) without a leukocytosis. X-rays reveal a
hybrid total hip prosthesis with a partially cemented femoral component with lucent zones at the
proximal portion of the prosthesis-to-bone interface. The most likely etiology to account for the
patient's pain and radiographic findings is:
A.Polyethylene osteolysis
B.Infection
C.Trauma
D.Hip girdle muscle weakness - ANS >> A.
Polyethylene osteolysis
78.97%
Osteolysis in total joint replacements is usually caused by foreign body granulomatous reactions.
Mechanical friction on polyethylene components abrade microscopic plastic particles into joint tissues.
Ultimately, gross loosening of the prosthesis may occur. Infection is less likely in this case given the lack
of a leukocytosis. There is no history of post-operative trauma. Hip girdle muscle weakness can
contribute to the development of post-operative bursitis and tendinitis, but would not explain the
patient's x-ray findings.
A 5 year-old boy with spina bifida has full hip flexion against gravity and his knee extension strength is at
least 4/5. The child has ankle dorsiflexion but not plantarflexion. His feet are in neutral position. Hip
examination is symmetric. What will most likely be this child's primary means of mobility as he grows
older?
A.Community ambulation without assistive device
B.Household ambulation with a cane
C.Use of bilateral crutches for all mobility
D.Independent manual wheelchair mobility - ANS >> A.
Community ambulation without assistive device
43.45%
This child has a strong quadriceps muscle and no deformities noted at 6 months of age. He is reported to
be healthy. Sitting balance and neurologic level were good predictors of ambulation potential. The best
early predictor of ambulation in children with spina bifida is a strong quadriceps muscle. Negative
predictors are spine and lower extremity deformities and obesity. Children do not typically learn to use
crutches until 3 to 5 years of age or older.
In which of the following conditions would a unilateral absent tibial H reflex most likely be seen?
A.Polyneuropathy
B.Lumbar plexopathy
C.S1 Radiculopathy
D.Myelopathy - ANS >> C.
S1 Radiculopathy
95.52%
In polyneuropathy, the H reflex may be delayed or absent bilaterally. Upper motor neuron pathology
such as myelopathy alone would not affect the H reflex. Lumbar plexopathy is not associated with H
reflex abnormalities, though a lumbosacral plexopathy could demonstrate abnormalities. A unilaterally
absent H reflex is most indicative of S1 radiculopathy.
A 47-year-old male with a right MCA stroke status post hemicraniectomy with left hemiparesis and right
gaze preference has become aggressive with therapies over the past two days. What is the appropriate
next step?
A.Start a mood stabilizing agent
B.Check a lumbar puncture
, C.Check serum chemistries
D.Modify environmental factors - ANS >> C.
Check serum chemistries
47.24%Electrolyte abnormalities and infections need to be ruled out in this patient with a change in
mental status. A lumbar puncture is not the appropriate next step. Modification of environmental
factors or the initiation of a mood stabilizing agent should not be considered until a physiologic cause
has been eliminated.
Which measure often used to identify the existence of comorbid psychological problems present in
chronic pain patients and to help tailor treatment?
A.Fear-avoidance beliefs questionnaire (FABQ)
B.Oswestry Disability Index (ODI) questionnaire
C.Minnesota multiphasic personality inventory (MMPI)
D.Short Form 36 (SF-36) - ANS >> C.
Minnesota multiphasic personality inventory (MMPI)
36.21%
The MMPI and its variants (version 2 and 2RF) are the most widely used psychometric tests for adult
personality and psychopathology testing.
Which of the following anatomical locations is used to assess C6 level sensation?
A.At the dorsal surface of the proximal phalanx of the thumb
B.Over the medial epicondyle just distal to the elbow
C.At the dorsal aspect of the base of the middle finger
D.Over the lateral epicondyle at the elbow - ANS >> A.
At the dorsal surface of the proximal phalanx of the thumb
88.97%
This is a tested area for C6 sensation under the ASIA exam criteria. It correlates with wrist extensors,
which are the tested muscle for determining C6 motor impairment.
Which of the following is a provocative test for sacroiliac joint?
A.Gaenslen's test
B.Ortolani test
C.Log Roll test
D.Straight leg test - ANS >> A.Gaenslen's test
Fortin Finger, Patrick's, Ischial Compression, Gaenslen, and pubic compression tests are all known
maneuvers for provocation of sacroiliac joint pain. Three positive maneuvers have a specificity of 78%
for SIJ related pain
A 45-year-old patient with a history of hyperparathyroidism presents with recurrent episodes of knee
pain. X-rays reveal chondrocalcinosis of the medial and lateral menisci. The most likely diagnosis which
would account for the patient's pain and x-ray findings is:
A.Osteoarthritis
B.Gout
C.Paget's disease
D.Pseudogout - ANS >> D.
Pseudogout
76.9%
A definitive diagnosis of CPPD arthropathy (ie, pseudogout) requires the identification of CPPD crystals
from joint fluid; however, the radiologic findings in this case are diagnostic. CPPD deposition disease can
be associated with hyperparathyroidism, hemochromatosis, and amyloidosis. It is weakly associated
with hypothyroidism. Chondrocalcinosis is not seen in osteoarthritis, monosodium urate crystal
arthropathy (ie, gout), or Paget's disease.
Examination.
A 35-year-old woman presents with a 3-4 week history of numbness in the right little finger and ulnar
aspect of the right hand and weakness with handgrip strength compared to the other side. Her
electrodiagnostic studies show the following.
Figures show:
-Normal sensory NCV
-Motor NCV with slight side-to-side amplitude difference (R<L) with median and ulnar studies but
normal CV and latencies.
-Needle study shows reduced recruitment and abnormal spontaneous activity in EDC, PQ, ECU, FDI, APB,
and cervical paraspinals on the right.
These findings are most consistent with right:
A.Ulnar and median mononeuropathies
B.Lower trunk plexopathy
C.Ulnar mononeuropathy
D.C8/T1 radiculopathy - ANS >> D.C8/T1 radiculopathy 83.82%
The electromyographic findings are localized to muscles supplied by the C8/T1 roots. The triceps can
have some C8 innervation but frequently tests normal in C8/T1 radiculopathies. The normal sensory
studies make it less likely that this is a plexopathy or peripheral nerve injury. The median and ulnar
motor amplitudes are in the normal range but smaller compared to the left side. Finally, the
involvement of the lower cervical paraspinal muscles is consistent with a cervical radiculopathy.
Which of the following is a typical feature of seronegative spondyloarthropathies?
A.Symmetric arthritis
B.Bursitis
C.Enthesitis
D.Vasculitis - ANS >> C.
Enthesitis
81.72%
Seronegative spondyloarthropathies (SpA) are commonly asymmetric and have familial patterns. Less
than 5% of patients are HLA-B27 negative. In order to identify patients with SpAs, symptoms of LBP
lasting ≥ 3months should be present, and occur before age 45 years. In addition, the following criteria
should be met: Sacroiliitis on imaging plus one or more of the SpA features listed below. Or,
alternatively, HLA-B27 positivity plus two or more of the following SpA features listed: inflammatory
back pain; arthritis; enthesitis (e.g., heel); uveitis; dactylitis; Psoriasis; Crohn's/colitis; good response to
NSAIDs; family history of SpA; elevated C-reactive protein (CRP).
A 23-year-old with C5 AIS-A tetraplegia admitted to inpatient rehabilitation was noted to have significant
weight loss and vomiting after meals. X-rays with barium contrast show abrupt termination of the
barium in the area of the duodenum. This clinical scenario is most likely related to
A.Superior mesenteric artery syndrome
B.Cholecystitis
C.Chronic pancreatitis
D.Neurogenic bowel - ANS >> A.
,Superior mesenteric artery syndrome
78.62%
Superior mesenteric artery (SMA) syndrome is seen mostly in patients with tetraplegia who present with
abdominal distention, discomfort, and recurrent emesis following eating. It is caused by obstruction in
the distal part of the duodenum as it passes behind the SMA and in front of the spine and aorta. It often
occurs in patients who are immobilized and have lost a significant amount of weight and retroperitoneal
fat. It is worse in the supine position and in patients who are in a body jacket. Upper GI series reveal an
abrupt cessation of barium in the third part of the duodenum. Treatment includes sitting the patient in
upright or positioning them in left side-lying after meals, nourishment to restore weight, and applying a
lumbosacral corset to push the abdominal contents upward. Surgery is rarely indicated.
Which of the following is true regarding running and the gait cycle?
A.Stance and swing phases each occur for 50% of the cycle
B.Double stance does not occur
C.Initial contact occurs exclusively with the heel
D.Center of gravity is at its highest point during midstance - ANS >> B.
Double stance does not occur
78.62%
Running is the bipedal locomotion at a cadence sufficient such that a period of double stance does not
occur. Double stance is replaced by a period of double limb float, when both limbs are in swing phase.
As opposed to normal (walking) gait, stance phase occurs for 40% of the gait cycle, while swing phase
occurs for 60%. Additionally, the center of gravity reaches its lowest point in the cycle during midstance,
whereas this is its highest point during walking. Initial contact can occur with either the heel or forefoot,
as is common in sprinters, or those running uphill.
Which measure evaluates patients' self-perception of disability specifically for low back pain?
A.Fear-avoidance beliefs questionnaire (FABQ)
B.Oswestry Disability Index (ODI) questionnaire
C.Minnesota multiphasic personality inventory (MMPI)
D.Short Form 36 (SF-36) - ANS >> B.
Oswestry Disability Index (ODI) questionnaire
77.59%
ODI is used to track patient perception of disability over the course of treatment, specifically for low
back pain. In addition to being used as an outcome measure in research, physician offices are also
utilizing this tool for outcome tracking.
According to the Americans with Disabilities Act (ADA), an individual with a T12 AIS A spinal cord injury
would likely be able to perform the essential job functions of which of the following positions without
accommodation?
A.Truck driver
B.Plumber
C.Software developer
D.Warehouse worker - ANS >> C.
Software developer
98.97%
Accommodation would be needed for someone with paraplegia to work as a commercial truck driver.
The individual presumably has no training as a plumber and would therefore be unable to work as
plumber. An analyst is a sedentary clerical position that could be done by a person with paraplegia with
readily available computer interface approaches. A warehouse clerk is a physically demanding job that
would likely require some type of accommodation for a person with paraplegia (e.g., a robotic
exoskeleton), if any were available.
,A 70-year-old presents with hip pain 3 months after a total hip joint arthroplasty. Laboratory values
reveal mildly elevated inflammatory markers (ie, ESR and CRP) without a leukocytosis. X-rays reveal a
hybrid total hip prosthesis with a partially cemented femoral component with lucent zones at the
proximal portion of the prosthesis-to-bone interface. The most likely etiology to account for the
patient's pain and radiographic findings is:
A.Polyethylene osteolysis
B.Infection
C.Trauma
D.Hip girdle muscle weakness - ANS >> A.
Polyethylene osteolysis
78.97%
Osteolysis in total joint replacements is usually caused by foreign body granulomatous reactions.
Mechanical friction on polyethylene components abrade microscopic plastic particles into joint tissues.
Ultimately, gross loosening of the prosthesis may occur. Infection is less likely in this case given the lack
of a leukocytosis. There is no history of post-operative trauma. Hip girdle muscle weakness can
contribute to the development of post-operative bursitis and tendinitis, but would not explain the
patient's x-ray findings.
A 5 year-old boy with spina bifida has full hip flexion against gravity and his knee extension strength is at
least 4/5. The child has ankle dorsiflexion but not plantarflexion. His feet are in neutral position. Hip
examination is symmetric. What will most likely be this child's primary means of mobility as he grows
older?
A.Community ambulation without assistive device
B.Household ambulation with a cane
C.Use of bilateral crutches for all mobility
D.Independent manual wheelchair mobility - ANS >> A.
Community ambulation without assistive device
43.45%
This child has a strong quadriceps muscle and no deformities noted at 6 months of age. He is reported to
be healthy. Sitting balance and neurologic level were good predictors of ambulation potential. The best
early predictor of ambulation in children with spina bifida is a strong quadriceps muscle. Negative
predictors are spine and lower extremity deformities and obesity. Children do not typically learn to use
crutches until 3 to 5 years of age or older.
In which of the following conditions would a unilateral absent tibial H reflex most likely be seen?
A.Polyneuropathy
B.Lumbar plexopathy
C.S1 Radiculopathy
D.Myelopathy - ANS >> C.
S1 Radiculopathy
95.52%
In polyneuropathy, the H reflex may be delayed or absent bilaterally. Upper motor neuron pathology
such as myelopathy alone would not affect the H reflex. Lumbar plexopathy is not associated with H
reflex abnormalities, though a lumbosacral plexopathy could demonstrate abnormalities. A unilaterally
absent H reflex is most indicative of S1 radiculopathy.
A 47-year-old male with a right MCA stroke status post hemicraniectomy with left hemiparesis and right
gaze preference has become aggressive with therapies over the past two days. What is the appropriate
next step?
A.Start a mood stabilizing agent
B.Check a lumbar puncture
, C.Check serum chemistries
D.Modify environmental factors - ANS >> C.
Check serum chemistries
47.24%Electrolyte abnormalities and infections need to be ruled out in this patient with a change in
mental status. A lumbar puncture is not the appropriate next step. Modification of environmental
factors or the initiation of a mood stabilizing agent should not be considered until a physiologic cause
has been eliminated.
Which measure often used to identify the existence of comorbid psychological problems present in
chronic pain patients and to help tailor treatment?
A.Fear-avoidance beliefs questionnaire (FABQ)
B.Oswestry Disability Index (ODI) questionnaire
C.Minnesota multiphasic personality inventory (MMPI)
D.Short Form 36 (SF-36) - ANS >> C.
Minnesota multiphasic personality inventory (MMPI)
36.21%
The MMPI and its variants (version 2 and 2RF) are the most widely used psychometric tests for adult
personality and psychopathology testing.
Which of the following anatomical locations is used to assess C6 level sensation?
A.At the dorsal surface of the proximal phalanx of the thumb
B.Over the medial epicondyle just distal to the elbow
C.At the dorsal aspect of the base of the middle finger
D.Over the lateral epicondyle at the elbow - ANS >> A.
At the dorsal surface of the proximal phalanx of the thumb
88.97%
This is a tested area for C6 sensation under the ASIA exam criteria. It correlates with wrist extensors,
which are the tested muscle for determining C6 motor impairment.
Which of the following is a provocative test for sacroiliac joint?
A.Gaenslen's test
B.Ortolani test
C.Log Roll test
D.Straight leg test - ANS >> A.Gaenslen's test
Fortin Finger, Patrick's, Ischial Compression, Gaenslen, and pubic compression tests are all known
maneuvers for provocation of sacroiliac joint pain. Three positive maneuvers have a specificity of 78%
for SIJ related pain
A 45-year-old patient with a history of hyperparathyroidism presents with recurrent episodes of knee
pain. X-rays reveal chondrocalcinosis of the medial and lateral menisci. The most likely diagnosis which
would account for the patient's pain and x-ray findings is:
A.Osteoarthritis
B.Gout
C.Paget's disease
D.Pseudogout - ANS >> D.
Pseudogout
76.9%
A definitive diagnosis of CPPD arthropathy (ie, pseudogout) requires the identification of CPPD crystals
from joint fluid; however, the radiologic findings in this case are diagnostic. CPPD deposition disease can
be associated with hyperparathyroidism, hemochromatosis, and amyloidosis. It is weakly associated
with hypothyroidism. Chondrocalcinosis is not seen in osteoarthritis, monosodium urate crystal
arthropathy (ie, gout), or Paget's disease.
