Hong Kong College of Anaesthesiologists

Intermediate Fellowship Examination

Jul/Aug 2005

Examiners' Report

General

Fourteen candidates out of a total of 17 candidates passed this examination - the

highest passing rate (82%) so far in the history of this examination. Of the 17 candidates who
had attended the written examination, only one did not qualify for the oral examination. The
overall passing rate in pharmacology was 82% (14 candidates) and 88% (15 candidates) in
physiology. The passing rates for the individual sections were listed below. The examiners
generally felt that the candidates were of high standard and the performance in the written and
oral sections were satisfactory.

The comments in the written section below show the basic requirement for each
question. Additional marks will be given to the answers which are relevant to the questions.
Irrelevant answers will not be given marks.

Candidates are examined on a variety of topics during the viva examination. Most of
these questions are structured. Only the introductory viva questions are listed in this report.
Improvements are seen in the use of clear and correctly labeled diagram to help with the
answer. Whenever diagrams are required, they should be drawn to the proportion and clearly
labelled.

Written Paper:

Question 1

Question 2

Question 3

Question 4

Question 5

Question 6
Question 7

Question 8
Question 9
Question 10

Question 11

Question 12

Viva Topics

Physiology Section

Twelve candidates (71%) achieved a pass mark in the written section while 1 out of
the 17 candidates failed to attain the minimum standard required for the oral examination. The
viva examination was well attempted with 15 candidates (94%) passing this section. After all,
15 candidates (88%) passed the physiology section.

Written Paper

Question 1
List and explain the differences in physiological effects between 1 Litre of Normal Saline
and 1 Litre of Ringer’s Lactate Solution infused over 1 hour.
65% of candidates passed this question. Besides the electrolyte contents and
subsequent changes in plasma concentrations, examiners looked for whether
candidates understood about the concept of hyperchloraemic acidosis, metabolism of
lactate, osmolarity changes and fluid shift. Since only the differences were required,
no points would be given for answers on similarities.

Question 2
Explain the physiological effects associated with peri-operative fasting from solids for 5
days.
76% of candidates passed this question. Candidates were expected to explain how the
body is able to generate glucose from different sources during different stages of
fasting. In general, most of the candidates described about the glycogen store in
different organs quite well. The sequence of utilizing glycogen, amino acids and fatty
acids and the corresponding enzymes involved were also well mentioned.

Question 3
Briefly describe the role of the muscle spindle in the myotatic (muscle stretch) reflex and
indicate its significance.
53% of candidates passed this question. The question requires a clear idea of the myotatic
reflex and its significance. In order to gain a pass candidates should be able to describe the
reflex and provide at least one function/purpose.

Question 4
Describe how the plasma calcium ion concentration is regulated in the body.
82% of candidates passed this question. This is a straight-forward question. The
interplay between the parathyroid, vitamin D and calcitonin hormones were required.
Additional points were given to the candidates who had described about the effects of
pH, albumin concentration, liver and renal diseases.

Question 5
Briefly describe the events at a molecular level of myocardial muscle contraction and
relaxation. Explain the role of calcium in these events.
82% of candidates passed this question. This is a question requires facts. How well
the candidates performed depends on how much they have read into and remembered
about this topic. Candidates were expected to describe the role of actin, myosin,
troponin, calcium, ATP and sacroplasmic reticulum during myocardial muscle
contraction and relaxation.

Question 6
Briefly describe the endocrine manifestations you might expect in a patient with chronic
renal failure as a result of bilateral renal artery stenosis.
53% of candidates passed this question. This question required interpretation skill of
candidate to demonstrate the effect on rennin angiotensin system as a result of renal
artery stenosis and accompanied hormonal changes (ie, production of calcitriol,
erythropoietin, and prostaglandins; actions of atrial naturietic peptides, aldosterone,
antidiuretic and parathyroid hormones on the kidneys) secondary to chronic renal
failure. Most candidates mentioned about the changes in the renin-angiotensin system
but few mentioned about the rest.

Question 7
Describe the haemodynamic effects of 30 degrees of Trendelenberg position.
47% of candidates passed this question. This question required the candidates to think
laterally and broadly. Candidates who gave clinical examples, eg. in laparoscopic
surgery, scored better. One candidate did not know what a Trendelenburg position is
and answered wrongly by focusing on the reverse Trendelenburg position. A
reasonable answer should include the effects on venous return from dependent and
non-dependent parts of the body, as well as raised intrathoracic pressure and
subsequently to deduce of change in cardiac output. The effect of raised cerebral
venous pressure on intracranial pressure, duration of the position, advantages and
disadvantages of its clinical use should also be addressed.

Question 8
Briefly describe how blood pressure is derived using an oscillometric blood pressure
machine and list the sources of inaccuracies.
76% of candidates passed this question. Most candidates had a reasonable idea how
the oscillometric BP machine works but were not so knowledgeable when came to
listing sources of inaccuracies.

Question 9
What is the difference between the terms “heat” and “temperature”? Briefly explain the
principles of a thermistor and list its advantages and disadvantages.
88% of candidates passed this question. Well answered by majority of candidates.
Definition of heat and temperature understood by most, but few mentioned how they
were related by specific heat capacity. A few had the relationship between temperature
and resistance inverted. None mentioned time constants.

Question 10
Describe the physiological effects of positive pressure mechanical ventilation on the
respiratory system.
29% of candidates passed this question. Surprisingly poorly answered for a topic that
is fundamental to clinical practice. Few described the loss of physiological control
over CO2 levels, which is determined by the set minute ventilation. There was
confusion over the effects of general anaesthesia as opposed to IPPV, especially with
respect to effects on the FRC. Very few appreciated that patients may be ventilated
without being anaesthetized. Some candidates gave long accounts of West’s zones or
effects of spontaneous ventilation, which were not directly relevant. One even gave an
answer to the cardiovascular effects of IPPV. Dead space and V/Q mismatch were
well understood.
Question 11
Define preload of the heart. Briefly explain the rationale and limitations in the use of
central venous pressure for the assessment of preload of the heart.
82% of candidates passed this question. Long accounts of factors affecting preload
were not directly relevant. Effect of valvular lesions and compliance was well
discussed. Few mentioned the ease of CVP measurement as a rationale. Not many
appreciated that RAP may not correspond to transmural pressure, e.g. with tamponade.
There could have been better discussion of technical limitations, e.g. posture, zeroing
etc.

Question 12
Indicate the results of a set of arterial blood gases for a pregnant woman at term. Give
reasons for these values.
82% of candidates passed this question. Overall well answered. Wide leeway was
given for typical arterial blood gas levels, but some gave internally inconsistent values,
e.g. bicarbonate and base deficit changes in opposite directions, pH, pCO2 and
bicarbonate values that were incompatible. Some answers indicated poor
understanding of acid base physiology, not just in pregnancy.

Topics of the Oral Examination

Lung compliance
Lung volumes and capacities
Oxygen saturation
Ventilation and pregnancy
Clinical glass thermometer
General concepts of hormonal function
Growth hormone
Thyroid hormone
Insulin and glucagons
Invasive BP measurement
Valsalva manoeuvre
ECG
Hypersensitivity
Mean arterial pressure
Frank starling’s law
Complement system
Cerebral blood flow
Intracranial pressure
Blood brain barrier
Neuromuscular junction