Thursday, March 1, 2012

What the hell is PM&R, Part 2

When I was studying for the PM&R boards, they had some practice questions online. It's bad enough that nobody outside of my field seems to know what a physiatrist does, but after doing some of these questions, I was no longer certain what I do.

Some examples:

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. What is the most likely diagnosis?

OK, this is a reasonable question. We deal with spinal cord injury, so this makes sense.

What is the most common reason for prescribing a plastic leaf-spring ankle-foot orthosis?

Also very reasonable, since we deal a lot with bracing.

Which of the brain tumors listed is a benign tumor?

OK, this question makes less sense, but I guess sometimes we get a brain tumor patient on our brain injury unit. And somehow we wouldn't be able to figure out that information from the person who diagnosed the tumor.

A 47-year-old man with human immunodeficiency virus (HIV) presents with fever, headache, and memory loss. What is the most likely diagnosis?

This question makes no sense to me. I mean, I can come up with an answer based on my med school and internship training, but we very rarely deal with HIV. I suppose we could have a patients now and then with HIV so we should be able to manage complications, but I think I would call medicine or ID in that sort of situation. (That wasn't an option in the answers.)

A 70-year-old man underwent a 2-vessel coronary artery bypass graft and mechanical mitral valve replacement five days ago. You note that he is presently taking Coumadin (warfarin). What is the primary reason to put this patient on Coumadin after this procedure?

I give up. I really don't know what we do if we're somehow supposed to be deciding whether a patient should get coumadin right after cabg. I mean, why not just copy and paste the Medicine boards into our board exam and call it a day.


  1. There was a question on my IM boards about valve pathology. As I was reading the question stem I predicted the answer would be "refer for valve replacement". Ha. As I read the answer choices it became clear I was suppose to know the appropriate surgical approach to the valve replacement. Excuse me? After three years of IM training?

  2. The reason why you put the patient on Coumadin is to avoid clotting from the mechanical mitral valve. Goal INR 2.5-3.5.
    But, I wouldn't expect you to be managing that.

  3. The HIV patient likely has HIV dementia or encephalopathy. If you're dealing with brain tumors, I can see where that might come into play, but yeah... I wouldn't exactly expect a PM&R person to get that right off.

  4. By putting the patient on Coumadin you ensure that he will fall, break his hip, and suffer a subdural hematoma, therefore ensuring a stay on the rehab floor.

  5. @LtP, Fizzy clearly knows why the pt requires warfarin, but it clearly is not a PM&R-specific question -- docs in all fields ought to know this one cold.