Hong Kong College of Anaesthesiologists
Intermediate Fellowship Examination
February/April 2005
Examiners' Report
General
The format of the examination for the Pharmacology and the Physiology are the same.
Each consists of a written paper of 12 short answer questions, and 2 twenty minutes viva voce
examinations. Candidates are required to achieve a minimum of 48 marks (passing mark 60)
in both the physiology and pharmacology paper before they can present for the oral
examination.
A total of 16 candidates presented for the written paper examination. Five candidates
did not fulfill the minimum criteria for the oral examination (3 of them failed in both subjects,
2 failed in pharmacology alone). Out of the 11 candidates, the passing rate for the viva
examination was 73% (8 candidates) in pharmacology and 82% (9 candidates) in physiology.
Overall, the passing rate in pharmacology was 64% (7 candidates) and 82% (9 candidates) in
physiology. Seven candidates passed both subjects (passing rate 44% out of 16 candidates).
For the written paper, this is not an examination of essay style. Whilst not wrong,
writing out or rewording the question, writing a detailed introduction or conclusion, or
including other extraneous information take time away from answering the question, and are
unlikely to score extra marks. It is quite acceptable to answer the question in point form, as
long as it is possible for the examiner to follow what has been written. Values should be given
wherever appropriate. Candidates are advised to spend equal timing on each question and
make sure they have answered all the questions. They should not leave any question
unanswered as this may prove detrimental to the overall marks.
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:
Topics for the Oral Examination
Morphine: structure-activity relationship
Aspirin
Tramadol
Physiology Section
Ten candidates (63%) achieved a pass mark in the written section while 3 failed to
attain the minimum standard required for the oral examination. After all, 9 candidates passed
this section.
Written Paper
1. Define the term “anion gap”. Why does it exist? List the circumstances that give rise
to abnormalities of the anion gap.
Only 31 % of the candidates passed this question. The performance was the least satisfactory
among the twelve questions. Many of the answers showed a poor grasp of the definition and
concept behind the anion gap. Very few candidates could point out the relationship of anion
gap with the presence of unmeasured cations (eg calcium and magnesium) or anions in the
plasma. The list on conditions leading to an elevated anion gap was far better than that of a
lower anion gap.
2. How does the respiratory system respond to exercise? Outline how the ventilatory
changes are initiated.
Fifty-six percent of the candidates passed the question. Few candidates could give a complete
account on the respiratory response to exercise. It should include the magnitude and duration
of changes in ventilation, maximum breathing capacity, oxygen diffusion capacity, oxygen
consumption, arterial and venous oxygen partial pressure and content, as well as carbon
dioxide tension. The second part of the question was better answered though omissions on the
motor centre activities, afferent impulses from proprioceptors of the limbs, joints and muscles,
as well as the rise in body temperature were common.
3. Compare and contrast the electrophysiology of the cardiac action potential at the
sino-atrial node to that of the ventricular myocyte.
Fifty-six percent of the candidates passed the question. Majority of the candidates were able
to draw and label the diagrams of change in action potential with time for the SAN and
ventricular muscle correctly. Explanation on how these changes take place were satisfactory
apart from some candidates often confused the directions of change in membrane potentials
relative to the flow of potassium and calcium ions.
4. Outline the physiology and factors affecting the airway humidification in the
normal adult. List the advantages of artificial humidification in the ventilated
patient.
Fifty percent of candidates passed the question. The essence of the human humidification
system involves the development of turbinates, nasal hair, and the countercurrent system.
While nose breathing at rest, inspired gases become heated to 36°C and are about 80% to 90%
saturated with water vapour by the time they reach the carina, largely due to heat transfer in
the nose. Heat and moisture content falls from carina to nares, so that the nose is typically at
30°C. A countercurrent mechanism of heat and moisture exchange in the airways maximises
efficiency, with nasal cooling on inspiration and warming on exhalation. Tracheal temperature
and humidity fall with increased ventilation particularly when the inspired gases are cold and
dry. Mouth breathing reduces this to 60% to 70% relative humidity. The second part of the
question was better answered. Apart from heat and water losses, impairment of ciliary
movement and formation of dry mucsoal plug are frequent complications of breathing dry
gases.
5. Outline the production of carbon dioxide and factors affecting the arterial carbon
dioxide tension in the body.
Fifty six percent of candidates passed the question. There were very few good answers for a
very straight forward question. Not many candidates provided a clear explanation of the
importance of dead space & the difference between alveolar and minute ventilation. The
influence of the type of fuel (i.e. respiratory quotient) was seldom discussed, nor did many
candidates provide a rough value of rate of CO2 production (approx 200 ml/min at rest). The
formula PaCO2 approx CO2 production/ alveolar ventilation was not mentioned by most. The
discussion of pathology e.g. COPD was again irrelevant.
6. Briefly comment on factors that determine cardiac contractility of the left ventricle.
Outline how this may be quantitatively assessed in man.
Forty four percent of candidates passed the question. Some candidates just put down headings
(e.g. “afterload”) without explanation. The assessment part of the question was generally
more poorly covered. Very few candidates produced the ventricular function curve which was
required in this question. Discussion of pathology e.g. MI, cardiomyopathy was irrelevant.
Some candidates mentioned use of echo to calculate stroke volume during echo estimation of
EF, which is not possible. Candidates should read the question more carefully before
answering as some candidates write down contractility as a factor which affects contractility!
7. Explain the differences in the effects of true shunt versus scatter of
ventilation/perfusion (V/Q) ratio on arterial oxygenation.
Forty four percent of candidates passed the question. A definition of the two conditions i.e.
shunt is an area where v/q ration =0 & scatter of v/q referred to areas where v/q ratio was low
but >0 was expected but not provided by many candidates. Some candidates omitted the
difference in response to O2 supplement in these two conditions which is of great importance.
There is frequently insufficient explanation of why v/q scatter should lead to poor
oxygenation, particularly many candidates seemed not to appreciate the significance of
inhomogenicity of v/q scatter and explain the concept why impairment in oxygenation caused
by low v/q areas cannot be compensated for by high v/q areas. Some candidates stated
hypoxaemia due to true shunt would not improve with O2 supplement which was not true. It
actually depends on the shunt fraction and oxygenation will still be improved with
supplemental O2 if the shunt is small. A more appropriate way to discuss this is that true
shunt will not be FULLY compensated by O2 supplement. This may reflect the difficulties
some candidates have when trying to express a complicated concept with a foreign language.
8. Use a table to compare and contrast skeletal and smooth muscle.
Sixty three percent of candidates passed the question. This question was generally well
answered. Many candidates mentioned short/ long contraction in skeletal and smooth muscle
respectively which the difference in contraction should actually be referred to as tonic/ phasic
contraction. Most candidates knew sarcoplasmic reticulum was an important source of Ca++
is skeletal but not smooth muscle but few pointed out that this explained the difference in
clinical behaviour of the 2 types of muscles, i.e. skeletal muscle contraction is less sensitive to
alterations in ECF Ca++ concentration. Very few mentioned differences in resting membrane
and action potentials in these two muscle types.
9. Describe the circulatory changes that occur at birth.
Eleven candidates passed. In general, candidates had problems organizing the sequence of
events leading to the transition from foetal to neonatal circulation. More than half of the
candidates did not give an account for the closure of the ductus venosus. A number of
candidates were uncertain of the mechanisms leading to the closure of the ductus arteriosus. A
few even omitted the significance of the first few breaths that lowered pulmonary vascular
resistance and increased pulmonary blood flow. Better candidates were able to point out the
changes resulted in transition from parallel to serial circuits, and that the changes could be
reversed in the few days after birth.
10. Where is aldosterone produced in the body? What are its physiological effects
and how is its secretion controlled?
Nine candidates passed. In general, candidates were able to describe the physiological effects
of aldosterone on the kidney. However, only better candidates explained mechanisms of
actions on intracellular receptors. Only 3 candidates mentioned that aldosterone caused Na
reabsorption in salivary glands and colonic mucosa. Most candidates did not mention the role
of ACTH on aldosterone secretion. Candidates also showed haphazard understanding of
circulating blood volume and the rennin-angiotensin system on aldosterone secretion.
11. Define the terms “accuracy” and “precision”. Briefly comment on some of the
important properties of a continuous measuring system.
Only seven candidates passed. Most candidates showed understanding on the term "accuracy",
whereas only four candidates were able to define the term "precision". Only two candidates
used a diagram to illustrate the terms. Overall, candidates showed deficient knowledge on the
properties of a continuous measuring system, particularly on signal to noise ratio and
hysteresis. Poor candidates described in general and vague terms whereas better candidates
showed understanding of more technical terms such as drift, gain, and damping.
12. Discuss with examples the factors determining the movement of fluid across the
intravascular and interstitial compartments.
Nine candidates passed. Most candidates were able to state the Starling's equation. However,
there were errors in a few of the answers, mostly related to the filtration and the reflection
coefficients. Candidates showed better understanding of the effects hydrostatic pressures than
those of the oncotic pressures. Most candidates used the systemic capillaries as example.
However, almost half were unable to give typical values of the Starling forces. The better
candidates discussed the differences in microcirculation in the kidney, lung and brain.
Topics of the Oral Examination
Cerebral blood flow measurement
Factors affecting cerebral blood flow
Basis of RMP
Haemodilution and application of the exponential washout concept
Control of erythropoietin secretion and conditions required for successful erythropoiesis
Physiology of CSF
ICP waveforms
Alveolar oxygen tension
Paramagnetic oxygen analyzer
Capnogram
Arterial and mixed venous oxygen content
Dead space
Carbon dioxide analyzer
Cardiac cycle
Atrial contraction
Effects of pregnancy on the cardiovascular system
Sequence of complement activation
Determinants of myocardial oxygen supply and demand
Cardiac output measurement
Physiology of transplanted heart
Types of allograft reaction
Control of the major intracellular functions
Concept of total body water
Normal body pH and its maintenance
Magnesium
Osmolality
Renal blood flow
Motor and secretory activities of the digestive system
Mechanisms of cellular response to external stimuli
