Abdominal Pain Distribution

Haemorrhoids/ Piles

Piles= a ball or mass
Haemorrhoids= flowing blood

Hemorrhoids are painful, swollen veins in the lower portion of the rectum or anus.

Types:
1. Internal - above dentate line and covered by mucosa only.
2. External - below dentate line and covered by skin.

Classification of Internal piles:
Primary Hemorrhoids: 3,7 and 11 o'clock in lithotomy position. Hemorrhoids in other places are called secondary.

1st degree- doesn't come out
2nd degree- return back spontaneously
3rd degree- returned back by manual help
4th degree- doesn't return back

Clinical Features:
Bleeding
Mass per anum
Pain if infected
Visualized on inspection if prolapsed
Proctoscopically visualized

Treatment:
1: Non operative:
Sitz bath
Fiber diet + plenty water +
Laxatives
Antibiotics
2: Sclerotherapy
3: Banding
4: Cryosurgery
5: Stapled Haemorrhoidopexy
6: Open operation
Ligation and excision
Submucosal haemorrhoidectomy

What is hamartoma???

Hamartano means i miss or fault or misfire. From here has been derived the word hamartoma which infact is a faulty growth. Hamartoma is a benign mass of mature specialized tissue or tissue indigenous to that particular site arranged in a disorganized manner due to aberrant differentiation. ExAmples are haemangioma, lymphangioma, AVM and neural malformation.

Classification & Management of dehydration in children with diarrhea

1. Signs of Severe dehydration
Unconsciousness
Sunken eyes
Unable to drink or drinks poorly
Skin pinch goes back in >= 2 sec

How to manage?
Rehydrate with Cholera Saline or Hartman's solution @ 100ml per kg IV stat. DNS but not DS can be used.
If child <1year give total volume i.e 100ml * wt. of child in kg in 6 hours with 30ml/kg in 1hour (repeat if radial pulse absent) and 70ml/kg in next 5 hours.
If child >1year give total volume in 3 hours with 30ml/kg in 30mins and 70ml/kg in 2&half hours. (half of above durations).

After treatment if signs persist repeat ; if signs of some dehydration or no dehydration follow below given protocol.

2. Signs of Some dehydration
Restless
Sunken eyes
Drinks eagerly
Skin pinch goes back < 2 sec

How to manage?
Rehydrate with ORS @ 75ml/kg by 4hours at your clinic/OPD. After 4 hours assess, if still some dehydration present, repeat or follow protocol for no dehydration.

3. Diarrhea but no dehydration
No signs

How to manage?
After ever motion give 50-100ml of ORS for child <2years. For >2years give as per demand.


Also give zinc supplement @10mg/day for 10to14 days for children < 6months. For > 6 months 20mg/day for 10 to 14 days.

Continue breast feeding if child is breastfed and increase number of meals to 6times a day at least up to 2 weeks after diarrhea.

Breastfeeding...How Long How Often ???

There are many myths about breast feeding as when to stop , how mant times a day you can breastfeed your child. As medical students its really important for us to know what exactly should we advice to a mother about breast feeding. As of the latest recommendations from Americn Ascademy of Paediatrics , they have recommended to exclusively breastfeed a child for 6 months. This means the only source of nutrition for an infant upto 6 months would be breast milk, not even water is to be given. Breastfeeding should start soon after birth usually within 1 hour of birth without any food being given before breast milk (no pre-lacteal feeding). After 6 months solid foods (complimentary foods) may be added slowly in a step wise manner. Breast feeding should be continued for at least 12months. However as per a WHO report breastfeeding should be continued for 24 months at least. Well the golden rule for how many times you should feed your baby is that feed it whenever it shows signs of hunger. the amount of time feeding should continue each time in first few weeks is 10-45 minutes.

For additional info. click here

PCI/Coronary Angioplasty/Angioplasty

Percutaneous coronary intervention (PCI),also known as coronary angioplasty or angioplasty, is a therapeutic procedure used to treat the stenotic (narrowed) coronary arteries of the heart found in coronary artery disease like Myocardial Ischamia (inadequate blood supply to the heart) and Myocardial Infarction (heart attack; death of heart muscle due to ischemia) . Stenosis of coronary arteries occurs due to the build up of cholesterol-laden plaques in the intima which protrude into the lumen (atherosclerosis). PCI helps to improve the blood supply to the affected parts.

For more info read the JAMA article 

"USMLE: Know-how" for foreign graduates

Most of the medical students all around the world dream about practicing in the United States. But the common problem everyone faces is how to make it the US. Here I try to explain the procedure by which a non-USA medical student/graduate can pursue higher education in the States. Through out this post emphasis will be on the candidates who will be taking USMLE Step 1 and Step 2 CK for the first time.

Introduction:

The main idea is that you have to get ECFMG certification before you can do Residency or Fellowship Programs in the United States. And for getting the ECFMG certification you have to pass the USMLE Step 1 and Step 2 tests. Certification also enables you to take the USMLE Step 3 which then gives you an unrestricted license to practice medicine in the United States.

About USMLE

The United States Medical Licensing Examination(USMLE) is a three-step examination for medical licensure in the United States which every foreign medical student/graduate and American medical student/graduate has to take to practice as a physician in the United States. Foreign medical students/graduates known as International Medical Graduates (IMGs) are students/graduates from medical schools outside USA and Canada even if they are USA/Canada citizens.

Steps of USMLE

It consists of three steps

Step 1: It tests your pre-clinical knowledge which includes Anatomy, Physiology, Biochemistry, Pharmacology, Pathology, Microbiology, Behavioral Science.

Step 2: This step mainly judges if you can apply medical knowledge, skills and understanding of clinical science for patient care under supervision. It includes two parts CK and CS. In CK (Clinical Knowledge) your knowledge about clinical subjects will be judged. In CS (Clinical Skills) you have to deal with the patients, communicate with them, take notes of histories, presentation etc.

Step 3: This steps assesses whether you can apply your medical knowledge and clinical skills for unsupervised practice. 

Eligibility Criteria for foreign students (IMGs):

A medical student

•  Officially enrolled in a medical school outside USA/Canada and his medical school should be listed in the International Medical Education Directory (IMED) of the Foundation for Advancement of International Medical Education and Research and that the graduation year should be current at the time of applying and exam.. Check your eligibility here 
(As soon as you graduate and receive your medical diploma, you must send two photocopies of your Final Medical Diploma and one full-face, passport-sized, color photograph to ECFMG).
• Completed at least two years of medical school ( you must have completed the basic medical science component of the medical school curriculum by the beginning of your eligibility period)

A Medical graduate

• Officially graduated from a medical school outside USA/Canada and his medical school should be listed in the International Medical Education Directory (IMED) of the Foundation for Advancement of International Medical Education and Research and that the graduation year should be current at the time of applying and exam.. Check your eligibility here 
• Two photocopies of your final medical diploma. The name of the final medical diploma for India, Pakistan, Bangladesh and Nepal is MBBS Diploma. 
• Documents that are not in English must be accompanied by an official English translation

Procedure:

• Get ECFMG ID: Before applying for USMLE you need to get ECFMG ID from the ECFMG website.  Get your ID here. Fill all the information accurately, make sure your name is same as the one which is on marksheets/degree and try to get a passport with same name.

• Apply for ECMFG certification: Now you have to apply for the certification process on the ECFMG website. Go to ECMFG site and Login into IWA section. (Apply Here). Check your email to confirm receipt of your application. To check the status of your application you can use OASIS.

• Apply for the USMLE: Application can be usually sent at any time of the year.It consists of applying online through the IWA and at the end of online application you willl be presented two forms viz. Certification of Identification Form (Fom 186) if you are a medical graduate or Certification Statement (form 183) if you are medical student. Print the appropriate form and send it to ECFMG by courier or post. Other documents (such as photocopies of Medical Diploma & Final Medical School transcript) as mentioned on IWA of ECFMG website must also be dispatched along with Form 187.  You must pay all applicable fees at the time you apply for examination. You can check status of your application on OASIS.

Eligibility period: When you apply for Step 1 or Step 2 CK, you must select a three-month period, such as January-February-March, February-March-April, etc., during which you would like to take the exam. Remember that it takes 3weeks to process the application after they receive it and there may be postal delays before that, so choose your eligibility period smartly. 

• Scheduling permit : Next you will receive a scheduling permit if your application is accepted. Scheduling permits are issued in electronic format and can be accessed using ECFMG’s IWA after you receive a notification email about it.

• Appointment with Prometric: Next you go to Prometric website (who will be eventualy conducting your exam) and schedule your testing appontment within the eligibility period (upto 6 months in advance) using your scheduling permit details. Contact Prometric. You will receive your Prometric Confirmation Number. Be sure to keep this number. If you need to reschedule your testing appointment, you will need your Prometric Confirmation Number.

• Take the test: You should arrive at the Prometric test center 30 minutes before your scheduled testing appointment with Scheduling permit and photo identity document (Passport,Driver’s license with photograph, National identity card or Other form of dated, unexpired, government-issued identification that meets all of these requirements). Take the test and get your scores in 3 to 4 weeks time on a Wednesday!

Minimum pass score on 2 digit scale is 75 and on 3 digit scale 188 and 189 for S1 and S2 CK respectively.

When to apply

The best time to apply for Step 1 is just after you have finished pre-clinical classes. 

Number of attempts and time limit

• You will be allowed to take each Step or Step Component no more than six times, including incomplete attempts.
• You have to get your certification within 7 years or else all previous passing performance will be invalid. This seven-year period begins on the exam date for the first Step or Step Component passed and ends exactly seven years from this exam date.
• You can take a test 3 times in a calendar year. The 4th attempt should be 6 months after the latest attempt.

Fee Structure

Application for ECFMG certification = $50

Step 1 = $790 (Examination Fee) + (International test delivery surcharge: $140 for India)

Step 2 CK= $790 (Examination Fee) + (International test delivery surcharge: $140 for India)

Step 2 CS = $1,375 (Examination Fee)

Format of the Exams

Step 1 and Step 2 CK are each one-day multiple-choice exams. Step 1 exam consists of 350 multipe choice questions divided into 7 blocks of 50 questions each to be done in 60-minutes. Each question will be followed by 3 to 11 response options with only one best answer. The Step 1 testing session lasts approximately eight hours. The Step 2 CK testing session lasts approximately nine hours. Step 2 CK has.370 questions divided in 8 blocks of 48 questions each. Each block has to be done in 60 minutes.

Step 2 CS is a one-day exam that consists of 12 simulated patient cases. The Step 2 CS testing session lasts approximately eight hours.You get 15 mins for history and examination of the patient, 10 mins for writing patient notes.

Preparation Materials

Practice materials on USMLE official site:  STEP 1 STEP 2 CK STEP 2 CS

NBME self assessment service (paid service) : Click Here

Practice Session at a Prometric Test Center after receiving scheduling permit (paid service)

USMLE Test Contents

STEP 1 

Anatomy

Behavioral sciences

Biochemistry

Microbiology

Pathology

Pharmacology

Physiology

Interdisciplinary topics, such as nutrition, genetics, and aging.

STEP 2 CLINICAL KNOWLEDGE (CK)

Internal medicine

Obstetrics and gynecology

Pediatrics

Preventive medicine

Psychiatry

Surgery

For more info.

ECFMG Homepage   USMLE Homepage   NBME Homepage   Prometric  

Download USMLE 2012 Bulletin        ECFMG 2012 Informaton Bulletin

http://www.usmleguide.co.nr/