Another exam done and dusted

Amazing porcelain starlings by Cai Guo-Qiang at the NVG

A quick post today to congratulate all of those candidates who presented for the viva exam in Melbourne over the past three days.

It was lovely to speak with many of you after the exam at the celebratory drinks. Regardless of your result, you all deserve to be proud of yourselves.

I have popped a link below to a post I wrote a couple of years ago now, but the sentiments remain unchanged. Let this exam experience shape you for the better.

Best wishes for a relaxing weekend for all of you and we will see you back here very soon…

https://primarydailylo.wordpress.com/2017/04/08/the-primary-exam-does-not-define-you/

A comedian walks into a bar

This clip from Radio National’s Ockham’s Razor https://www.abc.net.au/radionational/programs/ockhamsrazor/when-anaesthetists-cant-sleep/11187656 is well worth 11 minutes of your time if you have a viva next week. It’s also worth a listen if you intend to have, or ever have had, an ANZCA primary viva.

I think I remember him! At least, I remember examining a candidate with an Olympic pin who used my favourite, and generally underappreciated, word (you don’t get any extra marks for using the examiner’s favourite word though you may star in a blog post years later). The word is homeostenosis, and it refers to the narrowing, or stenosing, of the physiological range over which someone can maintain homeostasis. Namely, the ‘good 90 year old’. A more irreverent definition – irreverent as only those who need to cope with constant exposure to suffering and death can manage – comes from another examiner – ‘the wheel nuts are only hand tightened’.

Anaesthetists practise quite a different type of medicine to most other doctors in that core to our role we deliberately stress our patients’ physiology, and need the tools to assess and aid their compensation. The mental tools for this are assessed in the primary examination. So it’s disappointing (and surprising even :P) that I found it in Harrison’s not an anaesthesia tome.

The top five posts for PLOOTD

Having achieved the herculean task of posting for every single learning objective for the Primary exam curriculum it is time to reflect on this body of work.

I thought I might start with a post on the top five posts in terms of number of times they have been visited. I have excluded all the hits on the home page and list of LOs and subject headings etc.

The top 5 most visited posts – insert drum roll here- are:

1. A Primer for the Primary Examination    March 9, 2018
2. BT PO 1.50 Describe the cardiovascular changes that occur with morbid obesity June 19, 2017
3. The primary exam does not define you   April 8, 2017
4. Study Tip- doing effective revision   Jan 27, 2017
5. Dynamic airway closure   December 15, 2016

Unsurprisingly aGasgal wrote three of these (2,3,5) and Vallecula wrote number 4.

Mark Reeves, former Chair of the Primary Exam Subcommittee, wrote Primer for the Primary Examination. Here is another link to this great resource here.

primer for the primary

The section at the start titled “HOW TO FAIL THE PRIMARY” is essential reading.

 

 

Mission accomplished!

Almost three years ago PLOOTD was conceived by one of my colleagues (his tag is PRIMARYLOS) with a mission to assist candidates in preparing for the primary examination. By means of a daily post it was hoped to address every learning objective (LO) in the curriculum for the Primary examination. For each LO a series of TRUE/ FALSE statements was provided as an impetus for candidates to read around the topic and gain an understanding of the topic. This was thought to be a better way of acquiring and consolidating knowledge as opposed to finding the answer to a remembered MCQ on a black bank.

In addition to this there was also provided a plethora of posts on supplemental aspects of exam preparation such as study technique, exam technique and recommended resources. And if that was not enough there were also posts about historical aspects of anaesthesia as well as examiner humour. Our original contributor really upped the ante by writing a pharmacokinetic simulator program in association with some posts to help candidates understand this important topic which is poorly dealt with in the texts.

At the time of writing there are 333 LOs (half the devil’s number)  that are potentially assessable in the Primary Examination. As of yesterday there has been a post written for every single one of them. For most of the LOs there are more than one post that has been written. Indeed for some of the more comprehensive LOs there are multiple posts. BT SQ 1.6 I am thinking of you in particular.*

This has been a huge effort by primarylos in terms of conceiving, building and refining the website- collating all the LOs, past SAQs and topic weightings is a monumental task in itself. I would also like to acknowledge the efforts of  two of our stellar contributors: aGasgal and Vallecula. aGasgal has written so much stuff that she has a supplementary website to fit all her contributions in!

aGasgal

To date we have clocked up over 63,000 views by over 13,000 people from over a hundred different countries.

If you look at a post for a different LO each day you can cover the entire curriculum in under a year! Okay, this might be stretching the friendship a bit.

Stay tuned to learn what PLOOTD will do in the future.

 

*This LO is the one about methods of measurement applicable to anaesthesia and by my count has no less than 16 posts devoted to it.

BT_PO 1.70 Explain the renal responses to hypovolaemia

Several SAQs have been asked on this topic which is of obvious relevance to anaesthetists. It requires a sound understanding of renal sympathetic nerve activity, the mechanisms for autoregulation of renal blood flow as well as the role of the renin angiotensin system. I used Stoelting for this post as I find Vander a bit too wordy.

T/F intraoperative urine output correlates well with volume status

T/F noradrenaline preferentially constricts the afferent glomerular arteriole

T/F atrial natriuretic peptide preferentially constricts the afferent glomerular arteriole

T/F angiotensin II causes constriction of both the afferent and efferent  glomerular arterioles

T/F angiotensin II activates the thirst reflex

T/F when stimulated, renal sympathetic nerves decrease blood flow more than GFR

T/F a MAP above 70 indicates that renal perfusion will be adequate

T/F renin is released from the macula densa in response to decreased renal perfusion

T/F an increase in glomerular capillary oncotic pressure will increase net filtration pressure and increase GFR

 

Renal physiology BT PO 1.65 and 1.73

BT PO 1.65 Explain the mechanisms involved in the regulation of renal function

BT PO 1.73 Describe the mechanisms involved in the maintenance of fluid and electrolyte balance

To my mind these two LOs are about the same topic so I have taken the liberty of doing a single post for both of them. There is a lot of overlap between all the LOs that relate to the functions of the kidney.

Renal Physiology

This is a fairly core subject and you should find the correct responses to the statements below in any of the recommended texts. I used Miller predominantly.

T/F tubuloglomerular feedback refers to the feedback mechanism facilitated by the macula densa to autoregulate renal blood flow

T/F glomerulotubular balance accounts for a constant fraction of filtered sodium and water being reabsorbed in the proximal tubule

T/F the above two terms are often confused

T/F glomerulotubular balance bluntens the ability of changes in GFR to markedly alter urine production

T/F renin is the mediator involved in tubuloglomerular feedback

T/F the phenomenon of pressure diuresis results because of glomerulotubular imbalance

T/F the blood flow to the juxtamedullary nephrons is not autoregulated

T/F the urinary flow rate is autoregulated

T/F body sodium content, blood volume and blood pressure are closely interrelated with the kidney having a central role in their control

T/F intrarenal prostaglandins are the only important vasodilating substances that have a role in blood pressure control in the kidney

Can you pass the primary just using PLOOTD?

Probably.

If you use it well.

 

BT_PM 1.7 Outline the effects of pain and analgesia on injury-induced organ dysfunction

I freely admit I exclusively used the APM: Scientific Evidence for this LO. Section 1.6.3 on page 93 of the PDF file shares the title of this LO. The best part is it is only one page long and is possibly one of the shortest references for a LO in the curriculum.

Only three statements to consider:

T/F severe pain can contribute to myocardial ischaemia, ileus and atelectasis

T/F the adverse effects of pain can be clearly distinguished from those attributable to the surgical stress response

T/F there is convincing evidence that epidural analgesia prevents these adverse outcomes

The last one is probably more Final exam fare but certainly worth thinking about.

 

BT_PM 1.4 Describe the physiological mechanism of progression from acute to chronic pain

aGasgal has previously posted on several occasions regarding BT PM 1.3 which is about the basic physiological mechanisms of pain.

The next few LOs stay on the theme of pain physiology. Fortunately they are all dealt with in the appropriate section of ANZCA’s Acute Pain Management: Scientific Evidence. An unpalatable but comprehensive tome that is on the recommended reading list.

Section 1.4 is entitled “Progression of acute to chronic pain” and is seven pages long. Consult it to find the correct answer to the statements below.

T/F chronic postsurgical pain (CPSP) is very common

T/F CPSP frequently has a neuropathic component

T/F all pain developing in the postoperative environment that is prolonged is termed as CPSP

T/F preoperative and postoperative pain are the two most potent predictors of CPSP

T/F sensitisation of the peripheral and central nervous system is the mechanism that accounts for the development of CPSP

BT_PO 1.82 Describe the pharmacology of diuretics including mannitol, frusemide, thiazides, aldosterone antagonists and carbonic anhydrase inhibitors

aGasgal has already dealt with the other LO that relates to diuretics:

BT PO 1.81 Outline a physiological basis of classifying diuretics related to their site of action

This is also a fairly popular viva topic.

The statements below relate to the pharmacology of specific agents. I used Stoelting mainly but all the books cover this class of drugs well.

T/F frusemide is freely filtered at the glomerulus

T/F frusemide is ototoxic

T/F frusemide is nephrotoxic

T/F mannitol is an orally active diuretic

T/F thiazides can precipitate an acute attack of gout

T/F thiazides can impair glycaemic control in a diabetic patient

T/F spironolactone is used in the treatment of cardiac failure because of its diuretic action

T/F spironolactone doesn’t have to be in the glomerular filtrate to exert a diuretic effect