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Hong Kong College of
Anaesthesiologists Intermediate
Fellowship Examination February /
March 2004
Examiners' Report
General
Six out of 15 candidates successfully passed this examination. The overall
performance in the oral section was better than the written exam. The performance in the
physiology written paper was the least satisfactory.
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 a viva voce examination of
20 minutes. 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. 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
will significantly affect the overall mark of the paper adversely.
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.
Candidates are encouraged to use the diagrams to help them with their answers. Whenever
diagrams are required, they should be drawn to the proportion and correctly labelled.
Written Paper:
Physiology Section
Four out of 15 candidates (27%) achieved a pass mark in the written section and 7 (47%)
were successful in the oral section. Overall, 6 (40%) candidates passed the physiology section
of the examination. In the written paper, questions on carbon dioxide production, non-
respiratory role of the lungs, and the effects and changes in inadequate potassium intakes
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were poorly dealt with.
Written Paper
Q1. Define osmosis and describe its role in two body systems.
Passing rate was 27%. Most candidates used the kidney as the example. However, the role of
osmosis in the other parts of body was poorly dealt with like the one in hypothalamus and
brain. Osmotic diuresis due to glycosuria or other osmotic active substances were acceptable.
Osmotic pressure due to plasma proteins is called oncotic pressure and this process could be
described in a capillary or in the glomerular capillaries in the kidney.
Q2. Draw a set of arterial blood gases for a pregnant woman at term. Describe the
reasons for these values.
Passing rate was 53%. Candidates should describe about the causes of respiratory alkalosis
and its effects on the partial pressure of arterial oxygen and the changes in bicarbonate and
base excess level as a result of metabolic compensation.
Q3. Describe the factors that determine intracranial pressure.
Passing rate was 80%. Munroe Kelly doctrine was mentioned by majority of candidates. A
few mentioned about the change in ICP with respiration.
Q4. What factors determine the composition and volume of glomerular filtrate in a
normal person?
Passing rate was 47%. As most candidates described about the influence of the surface area,
permeability, and the balance between the hydrostatic and oncotic pressure in the glomerular
capillaries, very few gave further details of how the sympathetic nerves, angiotensin II and
tubuloglomerular feedback affects the GFR.
Q5. Describe the production of carbon dioxide in the body and the physiological reasons
why the PaCO2 may be raised.
Passing rate was 13%. The production of carbon dioxide was poorly addressed. Simple facts
like the place, rate, substrates, enzymes and by-products should help the candidates to give a
better answer. The second part was better answered.
Q6. Describe the change in functional residual capacity, and the possible causes and
consequences of this change, in a supine healthy adult patient under general anaesthesia.
Passing rate was 53%. Normal value and magnitude of change were the things that examiners
looked for. The part on causes and mechanisms was incomplete and candidates rarely
mentioned about the change in A-aO2 gradient as a consequence of reduction in FRC.
Diagrams were rarely given which may help to better illustrate the changes.
Q7. Outline the pathway of pain perception and describe all the mechanisms that would
modulate the perception of pain.
Passing rate was 53%. The pathways involving the A+ C fibers were usually covered but
the descending pathways were often missed. Sensors other than skin receptors were seldom
mentioned. Very little was mentioned about the 1˚ hyperalgesia, gate control theory, winding,
plasticity, central desensitization, and clinical methods of modulating the pain perceptions.
The role of larger peripheral fibers and descending inhibitory fibers in the gate theory was
rarely mentioned.
Q8. Outline the functions of the liver
Passing rate was 73%. This is a straight-forward question. Organized answers with clear
explanation earned higher marks.
Q9. Give an account of synthesis, storage, release and regulation of thyroid hormones.
Passing rate was 67%. This question was generally handled well. The part on storage and
release was covered more poorly. Many candidates did not mention the attachment to the
thyroglobulin during storage and the proteolysis of thyroglobulin during release. The normal
range of plasma concentration of thyroxine was seldom mentioned.
Q10. Give an account of the non-respiratory role of the lung.
Passing rate was 13%. This question was generally answered poorly. Most candidates failed
to recognize the different non-respiratory cell types and their functions in the. Again most
candidates did not appreciate the concept of the unique position of the pulmonary circulation
as the first capillary bed where the entire venous return will pass through and therefore
ideally placed for metabolism of drugs, hormones and mediators.
Q11. Define preload of the heart. Discuss the use of central venous pressure for the
assessment of preload of the heart.
Passing rate was 53%. Most candidates provided a reasonable definition of preload. However
most answers failed to discuss adequately the limitations of using CVP to monitor the preload.
It was disappointing to see some candidates were confused about the concepts of preload and
contractility and made comments such as change in preload would change contractility
according to Starling’s Law as well as the CVP could be used to monitor contractility. Some
candidates gave a wrong CVP waveform drawing though this question did not require such a
drawing. Anyway candidates were not penalized for this.
Q12. Describe the effects of inadequate potassium intake and the subsequent
compensatory changes.
None passed. The direct effects of hypoK were handled better than the compensatory
mechanisms by most candidates. The important response of decreased insulin secretion
during hypoK was not mentioned by many candidates. Few described correctly the ECG
changes associated with hypoK. However it was surprised to see many candidates cited
correctly the highly complex Nerst equation. A recurrent problem with many candidates
answering questions related to membrane potential is to use the words “increase” and
“decrease”. Because the RMP is negative, for instance an increase in RMP may mean it is
becoming less negative or may mean the exact opposite that is an increase in absolute value.
It will be clearer if candidates described the changes as more/less negative or hyper-
/depolarization.
Viva Voce Examination
Candidates often gain a better impression from the examiners if they can volunteer the
definition and support the discussion or diagrams with appropriate values or reference ranges.
Diagrams were drawn too small for some candidates. It is much clearer and facilitates further
discussion if the diagrams can be drawn carefully using at least half the size of an A4 paper
provided.
Measurement of blood pressure using invasive method
Monitoring of PaCO2
PA catheter waveform
Acute respiratory failure
Renal reabsorption of HCO3-
V/Q ratio in the lung
Diffusion
pH and buffers
Afterload of the heart
Exponential equation
Measurement of osmolality
Cellular hypoxia
ICP & PaCO2
Hypoxic hypoxia
Lactate metabolism
Cerebral blood flood and resistance measurement
Hormonal change associated with position change
Diabetic ketoacidosis
Pulse oximetry
Lung compliance
Structure of haemoglobin molecule and oxygen-Hb dissociation curve
