OSTEOCHONDRITIS

osteochondritis 

Paediatrics: Head Examination: Differential Diagnoses

Delayed Dentition

Causes of Delayed Dentition 

>>Various Anthrometric values at various ages and methods to calculate them.

Delayed Closure of Sutures

Causes of Delayed Closure of suture

Bossing of Skull

Causes Of  Bossing Of Skull

Bulging Anterior Fontanelles

Causes of Bulging Anterior Fontanelle

Craniotabe (Ping Pong Ball)

Causes Of Craniotabes

Microcephaly (<-3SD for Age, Sex, Height and Weight)

Causes of Microcephaly

>>Know the normal head circumference and its rate of growth.

Macrocephaly (> 2 SD or > 2.5cm of mean for age)

Causes of Macrocephaly

Macroglossia

Causes of Macroglossia

Hyperplasia of Gums

Causes of Gum Hyperplasia

APPLYING FOR NMC EXAM : THE ADMIT CARD, EXAM AND RESULT

THE ADMIT CARD AND EXAM

How to get admit card?

Once you have submitted all your documents and made the payment, your application will be processed. After the last day of submission of application form, when you login into your account it will show it as processed.

Then you will get  “get the Admit card” option. On clicking that your admit card will come.

How many copies to print ?

Two copies

Which photo to paste?

Hard copy of the one which you have uploaded in the website while applying. It need not be same as that you pasted while getting your provisional form.

What else need to be done?

Sign over the designated location and also over the original photograph you have pasted.

Put the thumb print over the designated place.

How does it look like?

Still having trouble registering yourself? Make sure you got things done correctly.

What is important in this card?

Bar code is the most important thing. They will scan it and check it while you appear for exam. So if bar code is not printed may be try again with better printer.

What is your ID ?

The number beneath the barcode is your id.

What else do I need to take while appearing for exam?

Nothing. Just one id card (Citizenship certificate original) if possible along with the admit card.

Where is the centre?

Generally at Nepal Army Medical College at sanobharyang.

Follow link for map.

What is the timing ?

If they follow the same schedule as done previously then Reach there by 07:30 as far as possible. Exam starts at 0900 am. Earlier you reach more advantage you have in processing, finding seats and such things. Better verify venue and timing before every exam by asking at NMC or viewing its main page. nmc.org.np

How is the exam ?

There are enveloped sealed with your names printed over it.

How many sets?

I found there were a total of 5 sets at the time appeared. But you can not be sure any one around you will have the same set.

Know about MALARIA treatment protocol in Nepal before you appear your NMCLE.

Will your friends be around you ?

If you are lucky and have submitted the forms together. Because there was issue with our PROVISIONAL certificate every one of my batch mate submitted on the extended date and hence all were in same room with just one extra person in between. if you want to be together make sure you guys submit in some random day together and not on the last day .

How many people in a class ?

My class and classes surrounding me had 15 in each. If your room is in poly technical institute then surely there will be not more than 15 of them in a single class.

Dos and don'ts (As stated in admit card)

You must...

1. bring admit card to the examination centre.

2. leave the personal belonging outside the hall at own risk.

3. arrive test centre well ahead of scheduled exam time so that you will be able to find out that you seat location.

4. fill the answer sheets as per instruction on them.

5. sign the attendence sheet showing admit card.

6. handover the question booklet and answer sheet to the invigilator before leaving the hall.

You must not...

1. be late for more than 15 minutes after the commencement of exam, if you arrive late:

 - you may not be admitted to the hall.

 - you may not allowed to take any of the test components.

 - you may not be eligible for refund.

2. carry any type of electronic device(e.g. mobile, calculator, pager, Ipod, pen drive, etc.)

3. bring any paper (blank/ written), instrument box and carry bags.

4. talk or disturb any candidate.

5. lend anything to, or borrow anything from, another candidate during the examination.

6. remove any pages from question booklet.

7. write name, symbol no. in any other page than where required. Any type of indication mark places elsewhere will be breach code of conduct.

8. engage in any form of mal practice which may damage the integrity and security of NMC Licensing Examination.

9. violate the rule of NMC Licensing Examination. Candidate violating the rule will face expulsion from exam hall and may be liable for legal action.

Passed your NMCLE. May be you got to collect your Provisional certificate.

Applying for Nepal Medical Council (NMC):The Online Form

Sorry for the fact that i can not uplaod all the necessary photo graph from the website because while i was applying i had no idea taht i will be writing about this. So what ever is possibel to be posted as photograph i have done it . 

Which website?

Go to exams.nmc.org.np if you go to www.nmc.org.np you will never find any section named as examination as I was bewildered among the tabs and could not find anything where I can fill my details.

How to register?

Fill in the basics as you fill up the first page when you join facebook. Please fill in a functioning email id with a password you know.

Once you submit you will receive a mail in your inbox. Open the mail and follow the link to open the NMC website. Then only you will be able to login in the NMC site.

If you have not opened your mail, no matter how many times you retry applying for new login account it will report as your account has been used.

 

I have made my account in NMC Website. Now What ?

Login in this site: https://exam.nmc.org.np/login.html

Now fill in the details

First page : Name, address, marital status.

Here you need to upload your PP sized photograph and your citizenship Certificate.

Learn what next after you get yourself registered? How to get admit card ? What else you need to know before exams.

What documents do I need? 

All the document you have presented to NMC while acquiring NMC Provisional Certificate. 

Extra: 

1.       Six months completion letter

2.       Letter of declaration.

Which photo to upload?

Make a note that the photo you upload here, needs to be reproduced while you appear in the exam.

So better don’t snap from your mobile and upload it. It would be easy if your upload the scanned copy / digital copy of PP sized photograph

How do I upload my Citizenship Certificate ?

Better Scan or shoot the both side of your citizenship and merge. If you upload one side of the citizenship and uploaded the other side in the extra boxes you get in last, may be the last photo is deleted because the last extra space is only for the certificates.

Is it necessary to scan all documents?

I don’t know. I had upload the photograph of each taken from my own mobile phone. But Scanned one looks good and are better comprehensible than photos.

Can I go to Next step without filling this page ?

NO. All the things with asterisk mark need to be filled before you can go to next step.

How to fill other pages ?

Second page is related to your Schooling. I don’t think it is necessary to keep the accurate date, just keep the tentative date. I don’t think anyone is going to go to your school to verify the date and prove you a fake doctor. Just make sure it falls on the month of Baishak and is not Saturday. The date of complete can be mentioned as stated in the Transcript.

Third page is your higher secondary education. Do the same as you did in Schooling section. Here you upload the transcript and not the marks sheet of class 11 and 12.

Last page is about your MBBS.  Here you need to upload all things all your marks sheets from basic, minors and majors. They say attested copy of marks sheet so may be it is necessary to attest the copy of marks shit and publish it.

Other things needed in this section also include letter of declaration, provisional certificate for intership,  6 months completion letter and other documents if you a foreign student.

Convert Nepali date to English in this site : http://www.ashesh.com.np/nepali-date-converter.php

What is the letter of declaration?

This is a page mentioning what you have posted in this site is true to the best of your knowledge and  will bear any charge if turn out to be false and deceitful. Just go this page and download and print this page. Duly sign it and put your thumb print, scan it and upload it.

https://exam.nmc.org.np/self-declaration-form.html

What is MUST to complete the last page ?

1.       Six months completion letter

2.       Letter of declaration.

3.       Provisional certificate issued by University mentioning you are eligible to do INTERNSHIP.

They say character certificate is must (there is an asterisk ) but you can upload all without that as well because college won’t give you character certificate before you complete your internship.

Provisional Number and Provisional Certificate is only necessary when you are about to apply for exams. Just to upload the details it is not so necessary.

The number of days of internship can be calculated as per the letter provided to you by the college. The interval can be measured from this site.

http://www.timeanddate.com/date/timeduration.html

Can I reedit ?

Yes, you can. You can reedit datas,, value and even uploaded photographs. But once you go to apply for exam and click on payment section what ever you have posted is full and final and cannot be reedited. 

Learn what next after you get yourself registered? How to get admit card ? What else you need to know before exams.

How to apply for exam ?

After you fill all the documents, go to the exam section in the content bar and open it. There will be list (usually one date) when you can apply for. And press apply for exams in the button in the right hand side.

Now there will be a list of all the information posted by you.

How to pay ?

At the end of this table there is a button in the right hand corner saying GO FOR PAYEMENT or something like that. After this there will be an option where there will be two menus.

1.   Pay via esewa: If you have e-banking activated in e-sewa compatible banks then you can transfer your amount to e-sewa and then pay via e-sewa.
2.  Get a token of ESEWA : if you are new to e-sewa, apply this option. Find an e-sewa centre nearby you by calling in the toll free number of E-sewa (977-1660-01-02121). Then when you find the center and give the token number along with your phone number. It will verify your number and will send you a message in the mobile.

If you are going to NMC anyways, there is an esewa counter in the nearest proximity of NMC office in Bansghari. So Get the token and pay out there.

Once you go for the pay section there will a bar mentioning whether you have paid or your application is still unpaid. Once you receive the SMS in your mobile phone it has to change to PAID.

How much to Pay ?

Nrs 2500 in normal days

NRs 3500 in the extended days with extra charge. It is not double, just be happy . I paid this unfortunately. 

Applying for Nepal Medical Council (NMC): The Provisional Certificate

This is solely based upon my personal experience and all things may not be correct It is just to make your job hassle free and easy and it is not an official guide. Being a medical student from Nepal I have posted all what I have actually done and don't know what International student or Nepali Student studying in Foreign need to do.

THE PROVISIONAL CERTIFICATE

When do you qualify ?

After you pass your final year exam (including Basics, Minor and Major)

What is Provisional Certificate ?

A certificate that gives you permission to practice under supervision (That is you can do your internship under this certicficate)

When to apply for Provisional Certificate ?

As soon as you join your internship.

Once you pass your exam, make sure that your college has sent necessary documents to NMC stating all these students have started internship in the college.

Still having trouble registering yourself? Make sure you got things done correctly.

What document you need to apply for Provisional Certificate?

Total 10 documents (all attested photocopies)

	1.       Citizenship Certificate
School	2.       SLC Marksheet	3.       Character Certificate
College:	4.       10+2 marksheet	5.       character Certificate
University	6.       all 3 marksheets Basics, 7.        Minor 8.        Major	9.       document from university stating you are eligible to do internship
	10.   Recent passport Sized Photo (Atleast 4)

Why 4 photos?

One to fix to form .

Three photos to be provided along with form. They will fix the same photo in all the certificates they will provide you in future (I guess, because the same photo was there in my provisional Certificate)

Sign or write name behind each photo to be on safe side. (my experience)

Better have 8-10 printed because though you fill an online form, real photos need to be fixed in your admit cards (two in number).

Who can attest your documents?

Any Medical Officer with PERMANENT registration number. (Consultants who have their permanent number, or medical Officer or Residents who have worked for atleast 2 years and have their permanent certificates)

Better put on the stamp from the organization of the doctor where s/he is working. So better get it done from some one in your own college and get the stamp of the college to be on  the safe side.

Do I need to verify the duplicate and original are equivalent ?

Better sign behind every photocopied document stating gSsn adf]lhd ;Ssn l7s 5 . (the duplicate is same as the original.) So that you dont have any trouble.

Where to get the forms?NMC office at bansbari, Kathmandu

Who can Collect ?

Any one collect that for you. So better collect for the entire batch at once.

What Forms to fill up ?

There are a total of 3 forms

1.       In Nepali Paper (Nepali kagaz) all your personal details with a photograph

2.       One declaration form stating all statements are true

3.       Third one also stating personal details

How to fill the form?
Fill in your details. You need to fill up your fathers name, mother name and even grand fathers name.
Citizenship certificate number, place and date of issue as well.

There are several places where you need to sign. I actually do not remember. But i think every paper has 1 place to sign and one has 2/3 places to sign so make sure all things are signed properly. (NMC called two of my friends back because they forget to sign in some of the place)

You are applying for provisional so tick on the provisional option where ever needed. Don't tick on
temporary, permanent or special.

Still stuck with filling the registration form, adit card and exams?

How much to pay ?

Rs 525 worth Bank Voucher of SBI Bank. The bank is near to NMC office at Mahargunj.

Can be paid in anyone's name and just need to attach along with your form.

How much time does it take to process this document?

They can take as far as 2-3 months to make your provisional certificate. So better don’t take chance. We turned out unfortunate as our college didn’t guided us adequately for this and we submitted it just 30 days prior to our NMC exams. We just had our Certificate 1 day prior to the last day of form submission and had to pay the extra charge on the extended deadline. It happened in 16^th day, however we had to use all our sources(from within college) to get it done in time.

What do i get finally ?

NMC Provisional Certificate

The written document giving you the permission to practice.

Complete Obstetrics history (points not to be missed)

List of items in Obstetrics history

This page is dedicated to writing history of a Obstetrics case for medical students.

The following points should always be included in any obstetrics history. These form the basis of Obstetrics history. The patient particulars followed by the presenting complains are the first things to be listed. Unlike any other history writing, obstetric history doesn't have history of present illness immediately after the chief complains. The menstrual and obstetrics history gets the priority ahead of that. Similarly, history of present pregnancy must be included before the elaboration of presenting complains because menstrual, obstetrics and history of present pregnancy is the basis of history writing in any obstetric case.

Menstrual History : Points to include

Learn about the indications of Cesarean Section 

 Previous Obstetrics history: Points to be included

Learn more about the parity index. Para, Gravida, Living and Abortion and solve some problems. 

History of present pregnancy: things you need to ask in 1st trimester

History of present pregnancy: things you need to ask in 2nd trimester

History of present pregnancy: things you need to ask in 3rd trimester 

Elaborate the presenting symptoms to support your provisional diagnosis, rule out the differential diagnoses with negative history and always rule out the complications associated with these problems in the history of present illness. And identify any other symptoms present that may support your diagnoses from any other systems in the body.

Things to elaborate for the presenting complains.

Past history, Personal history, family history and socio-economic history are equally relevant and important in any history taking and so does in obstetrics.

Past medical and surgical history that needs to be taken care.

Personal habits and history that can affect your current pregnancy.

Family and socioeconomic history that matters in pregnancy.

Including all these points mentioned in the diagram makes your history informative and complete.

Lets us see an example of a case

Congenital heart diseases and Xray signs

Long standing ASD : Handle of jug appearance
Transposition of great vessels: Egg on string sign
Type I TAPVR : figure of eight sign
TAPVR : Snowmans Heart
Partial APVR : Schmitar sign
Ebstein Anamoly: Box shaped heart
Endocardial cushion defect : Gooseneck heart
Coarctation of Aorta: figure of 3 sign
Tetralogy of Fallot: Boot shaped heart


For more reading visit http://pubs.rsna.org/doi/full/10.1148/rg.275065148

Plantar Reflexes and its equivalents with youtube video

The Normal Plantar Reflex

Nocireceptive relfex
Root value : S1

Stroking the lateral aspect of the sole with a sharp object produces (In increasing order of stimulus)

1. Flexion of all five toes 
2. Dorsiflexion and inversion of foot (with stronger stimuli)
3. Contraction of adductors of thigh, sartorius and tensor fascia lata.

Different resposnses

Normal: Flexor/Downgoing plantar reflex  (as mentioned above)

Babinski Sign (Extensor/ upgoing plantar reflex)

Components of extensor reflex are 

1. Dorsiflexion of great toe (precedes all other movements)
2. Fanning (outspreading) and extension of remaining four toes 
3. Dorsiflesion of ankle. flexion of knee and hip joint 
4. Contraction of fascia tensor lata 

Equivocal/incomplete/variable response

No Response 

Withdrawal reflex

Preparing for Exam : Check if you have all necessary instruments necessary for CNS examination 

Plantar Equivalents 

Oppenhiems sign 

Heavy pressure applied by thumb and index finger over the medial aspect of tibial (shin) from above down ward

Gordon Reflex

Squeezing or applying pressure over the calf muscle 

LMN UMN lesion of bladder 

?Shefer sign/?Schaefer Sign 

Squeezing the Achilles tendon 

Know the physiology behind the upper motor and lower motor neuron lesion.

Chaddock Sign 

Striking the skin just below lateral malleolus and moving anterior /in circular fashion 

Bing sign 

Prinking the dorsum of foot or great toe by a pin

Moniz sign 

Forceful passive flexion of ankle 

Gonda sign 

Forceful stretching or snapping of distal phalanges of euther the 2nd or the 4th toe 

Brissauds reflex

Contraction of tensor fascia lata in amputated/absent great toe patients or complete paralysis of extensors of toe

Rossimillo Sign 

Tap the ball of the foot or flick the distal phalages of toe into extension nad allow them to fall back to their normal position produces  PLANTIFLEXION of ALL phalanges. (Only sign with Plantiflexion of great toe)

Equivalent of Hoffmann's Sign 

Hoffmann sign 

Flex the distal interpalangeal joint of the middle finger and now flick it down suddenly, response is brisk flexion and abduction of thumb as well as flexion of the other fingers.

Videos

All reflexes in one video

Sources
http://www.ncbi.nlm.nih.gov/books/NBK397/
www.youtube.com
Harrisons Text Book Of Medicine
Bedside Clinics In Medicine 6e (Arup Kumar Kundu)

Strawberry Sign In Medicine

Strawberry cervix:  trichomoniasis. (Trichomonas vaginalis)

erythematous cervix with pinpoint areas of exudation

Strawberry gallbladder: cholesterolosis

Change in the gall bladder bladder wall due to excessive Cholesterol

Strawberry gingivitis/gums:  

Wegener's granulomatosis: immunologically mediated uncommon multisystemdisorder affecting aerodigestive tract

Sarcoidosis

Strawberry nevus/hemangioma: capillary hemangioma
benign condition appearing after birth characterized by endothelial prolifeartion 

Find all the terms named after Kocher 

Strawberry tongue:

Glossitis with hyperplastic fungiform Papillae
Scarlet Fever :GABH Streptococcus Infection
kawasaki disease: Vasculitis seen in Children
Toxic Shock Syndrome: Fatal illness caused by toxins of Staphylocccus aureus and streptococcus Pyogenes

Strawberry Shaped Nasal Mass: rhinosporidiosis

Chronic granulomatous disease caused by Rhinosporidium seeberi, characterised by production of polyps and other manifestations of hyperplasia of nasal mucosa

Strawberry skin : sarcoidosis

Strawberry shaped skull: 
Edward syndrome 

Trisomy 18

KOCHERS- All terms named after Theodor Kocher

Emil Theoder Kocher was a 1909 Nobel laureate who was a swiss researcher and physician. many instruments, surgical procedures, incision used to open various parts of the body and many clinical signs has been named after him to commemorate his outstanding achievement in the field of medicine. The following are some of the terms named after him 

Kocher's forcep/Clamp

It is a strong hemostatic forceps with serrated blades with interlocking teeth at the tip.

Kocher's sign

When clinician places his hands on patient’s eye and lifts it higher, patients eyelids springs up more quickly than the eyebrow, seen in Graves' Ophthalmopathy.

Kocher's incision

1.     In abdomen, it is an oblique  incision in right upper quadrant for open cholecystectomy. 

2.     In neck, it is  a transverse, slightly curved incision about 2 cm above the sternoclavicular joints

All other surgical incisions in the abdomen. 

Kocher's Maneuver:

1.     Kocherisation is a surgical maneuver to expose structures in the retroperitoneum behind the duodenum and pancreas; for example to control hemorrhage from the inferior vena cava or aorta, or to facilitate removal of a pancreatic tumor.

2.     In shoulder dislocation it is a maneuver used to reduce dislocations by externally rotating the shoulder, before adducting and internally rotating it.

Kocher's Reflex:

It is a sign elicited as contraction of abdominal muscles, in response to testicular compression.

Kocher's vein

The middle thyroid vein is named as Kocher's vein.

All the conditions with Strawberry signs 

Kocher's Test: 

The test to elicit obstruction is trachea is named as Kocher's test. Slight compression of the lateral lobe of thyroid gland produces stridor. If the test is positive, it signifies that the patient has an obstructed trachea.

Kocher's Point:

Common entry point for an intraventricular catheter to drain cerebral spinal fluid from the cerebral ventricles. It is located 2.5 centimeters from the midline (at approximately the mid-pupillary line) approximately 11 cm posterior to the nasion

Kocher–Debre–Semelaigne syndrome

A type of Hypothyroidism in infancy or childhood is named as Kocher-Debre-Semelaigne Syndrome. The components of which are: lower extremity or generalized muscular hypertrophy, myxoedema, short stature and cretinism.

Exception

Though named as Kocher, the following are totally different Kochers and not to be confused with Emil Theoder Kocher.

Kocher Criteria

It is a criteria to differentiate Septic Arthritis from transient synovitis in children with hip joint inflammation .It is named after Mininder S. Kocher, who was an orthopedic surgeon.

Kocher Approach

It is a incision on the skin and deep down the muslces to elbow. It is a Posterolateral Approach to Elbow allowing the  exposure of the entire distal humerus as well as radial head, radial neck, and biceps tuberosity.

Kocher's interval

It is a interneural interval between the ANCONEUS and the Extensor carpi Ulnaris

Sources (SRB Textbook of surgery, Wikipedia and online resources)