Manual of Medical Standards for AFMS Entry PDF

1 Tele: 2309328 41187/2(V)/DGAFMS/DG-3A 23 July 2024 MINISTRY OF DEFENCE OFFICE OF THE DGAFMS/DG-3A MANUAL ON MEDICAL EXAMINATION AND MEDICAL STANDARDS FOR UNDERGRADUATE ENTRIES INT...

1 Tele: 2309328 41187/2(V)/DGAFMS/DG-3A 23 July 2024 MINISTRY OF DEFENCE OFFICE OF THE DGAFMS/DG-3A MANUAL ON MEDICAL EXAMINATION AND MEDICAL STANDARDS FOR UNDERGRADUATE ENTRIES INTO ARMED FORCES MEDICAL COLLEGE PUNE, COLLEGE OF NURSING, SSC ENTRY IN THE ARMED FORCES MEDICAL SERVICES AND ARMY DENTAL CORPS INCLUDING CIVILIAN POST GRADUATE AND SUPERSPECIALTY CANDIDATES JOINING AFMS TEACHING HOSPITALS/ AFMC 1. Pl ref Manual of Medical Examination and Medical Standards for Undergraduate entries into Armed Forces Medical College Pune, College of Nursing and SSC Officers joining the AFMS and Civilian Post Graduate and Superspeciality candidates joining AFMS teaching hospitals/ AFMC: Priority V candidates promulgated vide note No 41187/2(V)/DGAFMS/DG- 3A dt 03 Nov 2021 and subsequent addendums to the same dt 11 May 2022 & 18 Oct 2022. 2. Over the past two and a half years policies w.r.t. medical stds have undergone several revisions, thereby necessitating revision of the AFMS entry standards in its entirety. Accordingly, the AFMS policy has been revised, duly incorporating all addendums, Common Medical Standards and relevant policies promulgated by the O/o DGAFMS. 3. Policy letters issued in this context by the O/o DGAFMS in the past are hereby superseded. 4. A copy of the manual is forwarded herewith as an enclosure to this note. 5. This has the approval of DGAFMS. Sd /- x x x x (S Ghosh) Col Col AFMS (Health) Encl: - As above AFMC, Pune DGMS (Army)/5A : For info of all SMB, AMB & RMB Centres DGMS (Navy)/Med-II For info of all AMB Centres DGMS (Air)/Med-5 Internal: DGAFMS/DG-1D  2 MANUAL ON MEDICAL EXAMINATIONS AND MEDICAL STANDARDS FOR UNDERGRADUATE ENTRY INTO ARMED FORCES MEDICAL COLLEGE, COLLEGE OF NURSING, SSC ENTRY IN THE ARMED FORCES MEDICAL SERVICES AND ARMY DENTAL CORPS INCLUDING CIVILIAN POST GRADUATE ENTRY & SUPERSPECIALTY COURSES IN AFMS HOSPITALS/AFMC VERSION II  3 TABLE OF CONTENTS SR NO TOPIC PAGE NO a Section – 1 4 General Considerations and Principles of Medical Examinations b Section – 2 10 Anthropometric Standards c Section – 3 17 Detailed Methodology of Examination for Specialists Medicine & Allied d Section – 4 27 Detailed Methodology of Examination for Specialists Surgery & Allied e Section – 5 66 Medical Examination of Women Candidates f Section – 6 69 Dental Fitness Standards  4 SECTION - 1 GENERAL CONSIDERATIONS AND PRINCIPLES OF MEDICAL EXAMINATIONS  5 GENERAL CONSIDERATIONS AND PRINCIPLES OF MEDICAL EXAMINATIONS 1. The Armed Forces Medical Services (AFMS) is one of the largest employers in the Armed Forces. All AFMS personnel regardless of occupational specialty, unit assignment, age or gender should have a basic level of general physical and medical fitness, when inducted into service. This basic level of fitness can then be used as a springboard to train personnel for further physically demanding occupational specialties or unit assignments and deployable combat readiness. 2. The AFMS selects doctors for commissioning as Medical Officers in the Army Medical Corps (AMC), dental surgeons for commissioning in Army Dental Corps (ADC) and nurses for joining the Military Nursing Services (MNS). Medical Cadets are selected for entry to the Armed Forces Medical College (AFMC). Nursing Cadets are selected for entry to the College of Nursing (CON) at AFMC as well as other colleges of Nursing run by the Army. Civilian doctors are selected for various post-graduate and superspecialty courses at AFMC and other AFMS teaching hospitals with the mandate of getting commissioned in the AFMS on completion of the course. 3. It is imperative on the part of every examining Medical Officer (MO) and Specialist to ensure selection of medically fit individuals into the Armed Forces. It must be borne in mind by all MOs and specialists that a candidate once selected as medically fit, if found unfit during trg at AFMS institutions stage due to a disability that could have been discovered during initial medical examination, causes considerable embarrassment to authorities and avoidable financial burden to State. In case of any doubt about any disease/ disability/ injury/ genetic disorder etc. noticed during entry, the benefit of doubt will be given to the State. 4. The aim of this manual is to provide guidelines to MOs, Specialist Officers, and Medical Boards involved in medical examination of candidates at Armed Forces Medical establishments as regards their medical fitness standards based on the criteria laid down in subsequent pages. The following aspects are emphasized: (a) The guidelines enumerated in this manual are meant to be applied in conjunction with the standard methods of clinical examination. (b) These guidelines are not exhaustive and any deformity/ disease/ injury/ impairment or any abnormality in function of any part of the body/system may be a cause for rejection even if not mentioned here. (c) Fitness of a candidate for commissioning or entry to teaching establishments of the AFMS will be determined by duly constituted Medical Boards. 5. To be deemed ‘Medically Fit’ for these courses, a candidate should be: - (a) Free of contagious diseases that might endanger the health of self and other personnel. (b) Free of medical conditions or physical limitations that would entail excessive absence from duty for treatment and hospitalization. (c) Capable of undergoing highly demanding training activities. (d) Adaptable to military environment without the necessity of geographical limitations and capable of performing military tasks without access to specialized  6 medical care. He/ she should be able to serve in any climate and terrain under austere conditions within the country as well as abroad. 6. Applicability. These medical standards will be applicable to Medical, Dental and Nursing candidates selected for commissioning in the AFMS; Medical Cadets and Nursing Cadets selected for entry to AFMC and other Colleges/ Schools of Nursing in the AFMS and to all Civilian candidates who join Post Graduation and Super Specialty courses at AFMC / other AFMS Teaching Institutions/ Hospitals. 7. Evaluation for medical fitness in respect of all candidates for commissioning into the AFMS as well as entry to AFMS teaching establishments will be conducted by duly constituted Medical Boards {designated as ‘Special Medical Boards (SMB)} and recorded on AFMSF-2. (a) MOs will ensure that the Medical Examination Form (AFMSF-2) is correctly filled by the candidate, required declarations are given, relevant investigations are carried out and results obtained before the candidates are referred to the concerned Specialists. The examining MO is responsible for recording concisely and clearly the identification marks in the space allotted for the purpose in AFMSF-2 to facilitate candidate’s future identification. The presence of a lady attendant will be ensured while examining a female candidate. (b) Specialist Officers from Medicine, Surgery, Eye, ENT, Dental, and Gynecology (in case of female candidates) will record their findings and comment on fitness at defined columns/ paras of AFMSF-2. (c) The President of the Medical Board will clearly mark FIT or UNFIT as the findings of the board. 8. The following investigations will be carried out for all candidates as part of the Medical Examination: Mandatory investigation to be carried out at entry medicals Complete Haemogram Blood Sugar Fasting & HbA1C Liver Function Test Renal Function Test Lipid Profile Urine RE & ME Resting ECG USG Abdomen& Pelvis X- Ray Chest PA view X- Ray LS Spine AP & Lateral view  7 9. Specialists will endorse detailed justification for declaring a candidate unfit. The President of the Board will inform unfit candidates the reasons for his/ her unfitness. Candidates will be informed about the appeal process. 10. Candidates found UNFIT may appeal against the findings of the Special Medical Board on payment of requisite fees. 11. Medical Examination at the time of Admission to AFMC. Initial medical examination /SMB for candidates joining as Medical Cadets to AFMC, will be carried out at the time of reporting for interview for admission to the MBBS course in AFMC. (a) SMB proceedings will be recorded in AFMSF-2 in triplicate. The composition of the Board will be as follows: - Presiding Officer : 01 x Col or equivalent from the faculty at AFMC Members : 01 x Med Spl : 01 x Surg Spl (b) The specialist endorsing the opinion will not be a part of the Medical Board. The approving authority for SMB will be the Dean & Dy Comdt, AFMC. Candidates declared medically unfit by the SMB will be provided an opportunity to appeal against the findings of the Medical Board, by means of an Appeal Medical Board (AMB) if they desire, on deposit of Rs 40 as MRO. (c) Candidates declared Unfit during SMB will report for the AMB within 24 hours. Such candidates will invariably be examined by Senior Advisor in the concerned specialty. All suitable investigations will be carried out to assess the fitness status. This examination will be carried out on a fresh AFMSF-2 (in triplicate). In case a specialist finds another abnormality related to his/her own specialty, which is not mentioned in the SMB, he will mention the same and give opinion for the same too in AFMSF-2. In case while examining the candidate, the specialist finds another abnormality that is not related to his/her own specialty which is not mentioned in SMB, then he/she will mention the same on a clinical case sheet and refer the candidate to the concerned specialist for further necessary action. The approving authority of such AMBs will be Dir & Commandant, AFMC. The composition of AMB will be as follows: - (i) HoD, Dept of Surg (ii) HoD, Dept of Med (iii) HoD, Dept of Radiodiagnosis & Imaging (The senior most will be the Presiding Officer) There is no option for a Review Medical Board (RMB) in respect of candidates joining AFMC as Medical Cadets. 12. Candidates joining BSc Nursing. SMB of BSc Nursing candidates will be conducted at Base Hospital Delhi Cantt. Approving Authority for SMB will be Deputy Commandant Base Hospital Delhi Cantt. All candidates declared Unfit during SMB can appeal against the findings of the Medical Board on payment of requisite fees and report within 24 hours for Appeal Medical Board at Army Hospital (R&R). Deputy Commandant, Army Hospital (R&R), Delhi Cantt will be the Approving Authority for AMB. Board Members for both SMB and AMB will be at the discretion of Commandant BHDC and AH (R&R). However, it will be ensured that no Board Member is below the rank of Lt Col/ equivalent. There is no option for holding Review Medical Boards (RMB) for candidates joining BSc Nursing as Nursing Cadets.  8 13. Candidates joining as AMC (SSC) & MNS(SSC). (a) Candidates joining as SSC (AMC) entry will undergo SMB at AH(R&R) and AFC. Comdt AFC will be the approving auth for SMB carried out at AFC. Those joining MNS (SSC) will undergo SMB at Base Hospital Delhi Cantt. Candidates (Both AMC & MNS) declared Unfit at SMB will undergo AMB at the respective AMB centers within a period of 42 days from the date of SMB. All suitable investigations will be carried out to assess the fitness status. Such candidates will invariably be examined by Senior Advisor in the concerned specialty. Where Senior Adviser is not available, they will be examined by a Classified Specialist in the discipline and the findings countersigned by Senior Adviser in allied specialty. This examination will be carried out on a fresh AFMSF-2 (in triplicate). In case a specialist finds another abnormality related to his own specialty, which is not mentioned in the SMB, he will mention the same and give opinion for the same too in AFMSF-2. In case while examining the candidate, the specialist finds another abnormality that is not related to his/her own specialty which is not mentioned in SMB, then he/she will mention the same on a clinical case sheet and refer the candidate to the concerned specialist for further necessary action. The approving authority of such AMBs will be Commandant of the Hospital/ AMB Centre. When such candidates are declared unfit by AMB and approved by the competent auth, the result will be communicated to him/her by the Presiding Offr of AMB. The candidate can seek a Review Medical Board (RMB) against the decison of AMB within 24 hours of the same being communicated. RMB will be granted at the discretion of DGAFMS, based on merit of individual cases and unlike AMB, should not be construed as a matter of right by the candidate. RMB will be conducted at AH(R&R) and at AFMC, Pune. Validity of SMB will be for a period of 180 days only. (b) Candidates who have been declared fit at SMB/AMB/RMB will not undergo another SMB on AFMS-2 before the validity period of 180 days. Candidates reporting to hospitals for commissioning within 180 days of SMB will undergo a Medical Inspection by the Staff Surgeon/ MOI/C MI Room for any overt/ visible disability. Only those candidates with overt/ visible disabilities will be referred to the concerned specialist for detailed investigation/ evaluation. Specialist opinion will be rendered on AFMSF-3A and Fit/ Unfit status would be endorsed by the Med Bd at the concerned hospital and approved by Comdt/CO hospital. (c) Candidates with no overt/ visible disability will be declared Fit and endorsement made in the Health Record Card. Lady candidates will be subject to an ultrasound pelvis only for ruling out pregnancy. (d) In all cases where the specialist feels that the detected disability is likely to resolve within a period, not exceeding 180 days from the date of SMB, candidates will be declared Temporary Unfit and directed to report to the hospital within a time frame as deemed appropriate by the specialist. The period of remaining Unfit shall in no way exceed 180 days from the date of SMB. Candidates in whom the said disability or impairment has resolved on follow up shall be declared Fit for joining and commissioned.  9 (e) Candidates in whom the disability is not likely to resolve within 180 days of SMB or who are still found to be suffering from the detected disability after the initial period of follow up, shall be declared Temporarily Rejected and endorsement made to the effect on AFMSF-3A, which will be fwd to DGMS (Army)/ DGMS-4B (For MNS candidates) and DGAFMS/DG-1A (For AMC SSC candidates). These candidates can seek an Appeal Medical Board at a centre of their choice within 42 days of being declared Temporarily Rejected, with a further scope of RMB. (f) Candidates who report to concerned hospitals after a period of 180 days of SMB, would be subject to a fresh SMB on AFMSF-2 with the provision of AMB and RMB. 14. Medical Examination for Civilian Candidates having Service Liability selected for undergoing Post Graduation and Super Specialty courses at AFMS Teaching Institutions/ Hospitals. Extreme diligence will be exercised in carrying out medical examination of these candidates. The MOs/ Specialists will be fully conversant with the rules, regulations and policy letters on the conduct of such examination. Initial Medical Examination for civilian post graduate candidates will be carried out at the respective institutions where such candidates are joining. The institution will maintain records and fwd one copy of the same to DGAFMS/DG-1D. Initial Medical Examination will be carried out on AFMSF-2. It is preferable that junior specialists and basic specialists (Med, Surg, ENT, Ophth and Gynae) perform the Initial Medical Examination. Appeal against the Initial Medical Examination will be preferred within 24 hrs of being granted Temporary Rejection and candidates examined by Sr Adv/ Super Specialist for the purpose of undergoing Appeal Medical Board. For civilian candidates joining in superspecialty courses at AHRR, Initial Medical Examination will be carried out at BHDC and AMB at AHRR. For civilian candidates joining superspecialty courses at AFMC, Initial Medical Examination will be carried out at CH(SC) and AMB carried out at AFMC. There is no provision for RMB for these categories of candidates.  10 SECTION – 2 ANTHROPOMETRIC STANDARDS  11 General Considerations 15. Armed Forces personnel are required to conform to minimum height requirements based on standards laid down by administrative authorities. Standards of weight for height are, however, specified based on medical considerations. Methods of Examination 16. Three basic measurements are required to be carried out for all candidates for commission into the Armed Forces Medical Services or for entry into AFMS training establishments. These are height, weight, and chest circumference. In certain instances, two more measurements, namely waist circumference and hip circumference, may be required to be carried out for further assessment. These measurements will be required to be taken only for conditions specified in para 18 below. The method of recording these measurements is given below: (a) Height. The measurement of height requires a vertical board with an attached metric rule and a horizontal headboard that can be brought into contact with the uppermost point of the head. The individual to be measured should be bare foot and wearing little clothing so that the positioning of the body can be seen. He or she should stand on a flat surface, with weight distributed evenly on both feet, knees straight, heels together, and the head positioned so that the line of vision is perpendicular to the body. The arms hang freely by the side, and the head, back, buttocks, and heels are in contact with the vertical board. The individual is asked to inhale deeply, and the body should maintain a fully erect position. The movable headboard is brought onto the topmost point on the head with sufficient pressure to compress the hair. The height is recorded to the nearest cm. (b) Weight. The individual must stand still on the center of the weighing scale with the body weight evenly distributed between both feet, wearing only briefs or underwear, or a light smock over underwear. Weight is to be recorded to the nearest Kg. As far as possible electronic weighing scales should be used for medical boards and zero should be checked before the measurement. (c) Chest Circumference. The chest should be bare. The arms are abducted slightly to permit the passage of the tape around the chest. When the tape is snugly in place the arms are lowered to their natural position at the sides of the trunk. Chest circumference is measured at the level of the fourth costosternal joints counting the ribs from above. The measurement is made in the horizontal plane at the end of normal expiration and again at full inspiration. The difference between the two measurements is to be recorded to the nearest 0.1 cm. (d) Abdominal Circumference. The subject stands comfortably with his weight evenly distributed on both feet and being about 25-30cms apart. The measurement is taken midway between the inferior margin of the last rib and the crest of the ileum, in a horizontal plane. Each landmark should be palpated and marked, and the midpoint determined with a tape measure and marked. The observer sits by the side of the subject and fits the tape snugly but not so tightly as to compress underlying soft tissues. The circumference is measured to the nearest 0.1 cms at the end of normal expiration.  12 (e) Hip (Buttocks) Circumference. Wearing underwear, or a light smock over underwear, the subject stands erect with the arms at the sides and feet together. The measurer sits at the side of the subject so that the maximum level of the diameter of the buttocks can be seen and places the tape measure around the buttocks in a horizontal plane. The tape is snug against the skin but does not compress the soft tissues. The measurement is recorded to the nearest 0.1cms. Height Standards 17. Male cadets. The minimum height required for entry into the AFMS for male cadets is 157 cm. Candidates from Hill and Northeastern States will be accepted with a minimum height of 152 cm. An allowance for growth of 02 cm will be made for candidates below 18 yrs at the time of examination. 18. Female Cadets. The minimum height required for entry into the Armed Forces for female cadets is 152 cm. Candidates from Hill and Northeastern States will be accepted with a minimum height of 148 cm. An allowance for growth of 02 cm will be made for candidates below 18 yrs at the time of examination. Weight Standards 19. Weight for height charts given at Appendix ‘A’ for males and Appendix ‘B’ for females will be the standards for all categories of entries. The charts specify the minimum acceptable weight that candidates of a particular height must have. Weight below the minimum specified will not be acceptable in any case. The maximum acceptable weight for height has been specified in three age categories. Weights higher than the acceptable limit will be acceptable only in exceptional circumstances like in the case of candidates with documented evidence of bodybuilding, wrestling, and boxing. In such cases the following criteria will have to be met: (a) Body Mass Index should be below 27. (b) Waist Hip ratio should be below 0.9 for males and 0.8 for females. (c) Waist Circumference should be less than 94 cm for males and 89cms for females. (d) All biochemical metabolic parameters should be within normal limits. Chest Circumference 20. Minimum chest circumference should be 77 cm. Chest expansion should be 05 cm or more for all categories of candidates.  13 Appendix ‘A’ (Refers to para 15) WEIGHT FOR HEIGHT CHART: MALES Height Minimum Maximum Weight (Kg) Weight (cm) (kg) Age below 20 Age 20 to 25 Age above 25 Yrs Yrs Yrs 150 40 52 54 56 151 40 52 55 57 152 40 53 55 58 153 40 54 56 59 154 40 55 57 59 155 41 55 58 60 156 41 56 58 61 157 42 57 59 62 158 42 57 60 62 159 43 58 61 63 160 44 59 61 64 161 44 60 62 65 162 45 60 63 66 163 45 61 64 66 164 46 62 65 67 165 46 63 65 68 166 47 63 66 69 167 47 64 67 70 168 48 65 68 71 169 49 66 69 71 170 49 66 69 72 171 50 67 70 73 172 50 68 71 74 173 51 69 72 75 174 51 70 73 76  14 175 52 70 74 77 176 53 71 74 77 177 53 72 75 78 178 54 73 76 79 179 54 74 77 80 180 55 75 78 81 181 56 75 79 82 182 56 76 79 83 183 57 77 80 84 184 58 78 81 85 185 58 79 82 86 186 59 80 83 86 187 59 80 84 87 188 60 81 85 88 189 61 82 86 89 190 61 83 87 90 191 62 84 88 91 192 63 85 88 92 193 63 86 89 93 194 64 87 90 94 195 65 87 91 95 196 65 88 92 96 197 66 89 93 97 198 67 90 94 98 199 67 91 95 99 200 68 92 96 100  15 Appendix ‘B’ (Refer Para 15) WEIGHT FOR HEIGHT CHART: FEMALES Minimum Height Maximum Weight (Kg) Weight Age below 20 Age 20 to 25 Age above 25 (cm) (kg) Yrs Yrs Yrs 145 37 46 48 50 146 37 47 49 51 147 37 48 50 52 148 37 48 50 53 149 37 49 51 53 150 37 50 52 54 151 37 50 52 55 152 37 51 53 55 153 37 51 54 56 154 38 52 55 57 155 38 53 55 58 156 39 54 56 58 157 39 54 57 59 158 40 55 57 60 159 40 56 58 61 160 41 56 59 61 161 41 57 60 62 162 42 58 60 63 163 43 58 61 64 164 43 59 62 65 165 44 60 63 65 166 44 61 63 66 167 45 61 64 67 168 45 62 65 68  16 169 46 63 66 69 170 46 64 66 69 171 47 64 67 70 172 47 65 68 71 173 48 66 69 72 174 48 67 70 73 175 49 67 70 74 176 50 68 71 74 177 50 69 72 75 178 51 70 73 76 179 51 70 74 77 180 52 71 75 78 181 52 72 75 79 182 53 73 76 79 183 54 74 77 80 184 54 74 78 81 185 55 75 79 82 186 55 76 80 83 187 56 77 80 84 188 57 78 81 85 189 57 79 82 86 190 58 79 83 87 191 58 80 84 88 192 59 81 85 88 193 60 82 86 89 194 60 83 87 90 195 61 84 87 91  17 SECTION – 3 DETAILED METHODOLOGY OF EXAMINATION FOR SPECIALISTS MEDICINE AND ALLIED  18 21. History. A detailed history is to be elicited as per declaration form in AFMSF-2 History of illness not covered in the questionnaire may be elicited if examination findings indicate presence of a condition. 22. General Physical Examination. A diligent general physical and systemic examination will be carried out for all candidates by the MO/ Specialist. (a) Record temperature, pulse and blood pressure (details of examination of pulse and blood pressure are covered under cardiovascular examination). (b) Examine conjunctiva for pallor and icterus. (c) Study the appearance of the face and distribution of facial hair. (d) Examine lymph nodes in all the groups (cervical, axillary, inguinal, submandibular, occipital, epitrochlear etc.) and look for size, consistency, matting and overlying skin. (e) The candidate should be asked to protrude his/her tongue and examined for any growth, discoloration, tremors or cyanosis. (f) Lips should be examined for fissures and angular stomatitis. (g) Examine oral cavity for colour of mucosa, condition of gums and teeth. (h) The nails will be examined for any clubbing, infection, haemorrhage and abnormal colour changes. (j) Inspect and palpate the thyroid gland. Look for enlargement (Goitre), consistency/nodularity and movement with deglutition. (k) Skin will be examined for presence of any chronic skin disorders, features of leprosy or sexually transmitted infections. (l) Look for presence of peripheral edema. 23. Cardiovascular System (a) Pulse. Rate, rhythm, volume, regularity of the pulse and condition of the arterial wall will be assessed. Thickening and hardening of the arteries are noted by rolling the brachial artery under the examiner’s fingers. The pulsation of both the radial and femoral arteries should always be compared and difference, if any, recorded. The pulse should be counted for one full minute. In addition, pulsation of carotid, popliteal, posterior tibial and dorsalis pedis arteries on both sides should be palpated and difference, if any, should be noted. For persistent tachycardia, the candidate’s pulse rate should be checked twice. Pulse should be checked second time after a rest period of five minutes and both measurements should be endorsed in AFMSF-2. (b) Examination of Blood Pressure (BP). The individual should be sitting or lying comfortably at the time of recording of BP. Recording should be done after allowing the individual to relax. If first recording is abnormal two readings atleast 5 minutes apart should be taken and the lower of the two be recorded. (c) Examination of Heart. Examine the precordium along classical lines with special emphasis on detecting deformities, pulsations abnormal heart sounds, murmurs and added sounds.  19 24. Respiratory System. (a) The position of the trachea and apex beat should be determined. The candidate will be asked to take deep breaths to determine symmetry of thoracic movements. Further clinical examination on classical lines namely, inspection, palpation, percussion and auscultation, will be carried out. A careful clinical auscultation for crackles in all regions of the chest including post-tussive auscultation must be done. (b) All candidates will be subjected to a radiograph of the chest (PA view). 25. Gastrointestinal System (a) Examine the abdomen on classical lines with emphasis to detect scars, organomegaly, lumps or free fluid. (b) USG Abdomen and Pelvis. It will be carried out for all candidates during the Medical Examination prior to entry. Disposal of cases with incidental ultrasonographic findings like fatty liver, cysts, hemangiomas, septate gallbladder etc. will be based on existing guidelines. 26. Endocrine System. Examine the candidate for findings suggestive of endocrine disorder (macroglossia, acromegaly, striae over abdomen, shoulders, chest and thigh, proximal muscle weakness, eye signs suggestive of thyroid disorder, pretibial myxedema, hyperpigmentation of skin or oral mucosa) and for features suggestive of hypogonadism. 27. Hematopoietic System. Hemoglobin estimation, total and differential leucocyte count, platelet counts are to be routinely performed on an automated hematology cell counter. 28. Dermatological System. (a) Examination. Skin will be carefully examined in good daylight after removing all clothes to exclude any skin disease, features of leprosy or sexually transmitted disease. (b) Skin will be examined for dryness, excessive sweating, elasticity, abnormal pigmentation, extensive erythema, purpura, keloids, bullae, pustules, nodules, ulcers, sinuses, large naevi and infections. Special care will be taken to look for warts, hesitation cuts, areas of depigmentation or hypo pigmentation, claw hand, foot drop or facial palsy. 29. Central Nervous System Examination (a) Mental Status Examination. The candidate will be assessed by clinical examination consisting of observation and brief mental state examination, which will be carried out by a Medical Specialist who will especially evaluate for signs and symptoms enumerated below. Any substantial doubt about the presence of psychiatric illness shall be grounds for rejection. Appeal in case of rejection will be reviewed by Psychiatrist after exclusion of medical/ other disorder, if any. In case of marks on skin arising from suspected self-harm the candidate will be reviewed by Dermatologist prior to Psychiatrist. Possible self-inflicted injuries will be evaluated by the MO conducting medical examination. Presence of scar(s) on extremities and/ or other body parts accessible to dominant hand, indicative of being deliberately inflicted, will be grounds for declaring unfit. The medical specialist conducting medical examination will look for the following signs which will be grounds of rejection.  20 (b) General Examination. (i) Prominent tremors (ii) Bradykinesia (iii) Rigidity (indicating usage of antipsychotics) (iv) Excessive restlessness/ fidgeting (v) Evidence of drug use (scarred and/collapsed veins, multiple puncture marks) (vi) Excessive sweating over palms and soles (vii) Tics (viii) Stereotyped behaviors (rocking, hand-flapping etc.) (c) Appearance and behavior. (i) Poor grooming (ii) Odd or eccentric behavior (iii) Hallucinatory behavior (talking/ muttering to self) (iv) Persistent downcast gaze/ avoiding eye contact (d) Speech. (i) Non-spontaneous/ monotonous (ii) Prominent stammering (iii) Mute (iv) Abnormally low or high volume (v) Not understandable/ incomprehensible (vi) Vocal Tics (e) Mood. (i) Appearing unusually depressed or cheerful (ii) Appearing apathetic  21 (f) Neurological Examination. Each candidate will undergo an orderly neurological examination. (i) Evaluate speech (articulation, fluency, verbal comprehension, naming, repetition, reading and writing). (ii) Examine cranial nerves. (iii) Examine motor and sensory system examination of upper limbs, trunk and lower limbs. (iv) Examine spine and skull. (v) Examine peripheral nerves for thickening. (vi) Test for coordination of lower limbs by asking the candidate to tandem walk. The test is done by asking the candidate to walk along a straight line placing the heel of one foot immediately in front of the toe of the one behind. Ask the candidate to turn around and walk back to the examiner. Look for swaying to either side and in-coordination while turning around. (vii) Examine for tremors of hands, tongue, and eyelids The candidate should stand with his eyelids slightly closed and with his arms stretching out before him at shoulder level. The fingers should be separated and fully extended. If tremors are found to be significant, the candidate should be made unfit. In recording eye lid tremors, the normal blinking movements should be ignored. 30. Standards for Fitness (a) History. When the answer to any question in self-declaration in AFMSF 2 is ‘YES’, the candidate will be suitably evaluated by a Conslt/ Sr Adv in the concerned specialty/ sub-specialty before being accepted/ rejected. (b) General Examination. UNFIT. (i) Presence of icterus, cyanosis. (ii) Moderate to severe hirsutism in females. (iii) Lymph nodes more than one cm in size (more than 1.5 cm for inguinal group) and involving more than two groups or fixed/ confluent nodes. (iv) Presence of any growth, ulceration, cracks/ fissures in the corner of mouth (angular stomatitis). (v) Tongue: - Presence of macroglossia, tremors, cyanosis, tongue tie, leukoplakia. (vi) Nails: - Presence of clubbing, platynychia, koilonychia, fungal infections in more than one nail, thimble pitting, separation of nails from nail bed, splinter haemorrhages. (vii) Presence of peripheral edema. (viii) Thyroid: - Any enlargement, nodularity, or lack of movement with swallowing.  22 (c) Dermatological System. (i) UNFIT. (aa) Presence of more than five CALM (Café-au-lait macules) or any other associated neuro-cutaneous syndromes. (ab) Xanthomata and Xanthalesma if associated with hyperlipidemia. (ac) Palmar and plantar warts, corns and extensive callosities. (ad) Chronic skin diseases like psoriasis, lichen planus, bullous diseases, eczema, ichthyosis, palmoplantar keratoderma (thickening of palms and soles), recurrent urticaria, angioedema, dermographism. (ae) Skin infections such as Tinea cruris, Tinea corporis, Intertrigo, Pityriasis versicolor, Impetigo, Folliculitis, Furunculosis, Scabies, warts, Molluscum contagiosum, Herpes simplex or zoster if extensive. (af) Acne on the face or trunk of grade III and IV or with abscess, cysts, hypertrophic scars etc.). (ag) Rosacea (Redness of face with dilated blood vessels and pustules). (ah) Moderate to severe hirsutism in females. (aj) More than 01 patch of alopecia areata characterized by circular/ oval patches of non-scarring hair loss/ solitary patch >2cm. (ak) Loose or unduly elastic skin. (al) Keloid (even if single). (am) Large hypertrophic scars which interfere with normal functioning. (an) Clinical evidence suggestive of leprosy. (ao) Any evidence of STD, present or past. (ap) Evidence of severe hyperhidrosis/ skin changes as sequel to hyperhidrosis. (aq) Vitiligo (ar) Palmo-plantar keratoderma manifesting with hyperkeratotic and fissured skin over the palms, soles and heels (ii) FIT. (aa) Vitiligo limited to glans penis.  23 (ab) Mild acne vulgaris (ac) Scabies on completed treatment and full recovery (ad) Scrotal dermatitis on full recovery (ae) Tinea cruris, tinea corporis and Intertrigo after complete treatment and full recovery (af) Folliculitis or sycosis barbae after complete recovery (ag) Single corn/ wart/ callosity after 03 months of successful treatment and no recurrence (ah) Localized congenital mole/ naevus of size 18 g/dl, irrespective of sex. (ac) Any significant abnormality detected in PBS (ad) Hereditary hemolytic anaemias (due to red cell membrane defect or due to red cell enzyme deficiencies) and Haemoglobinopathies. (ae) Current bleeding disorders to include but not limited to Hemophilias, von Willebrand’s Disease, Idiopathic Thrombocytopenia. (af) Absolute Monocyte count > 1000/cu mm or more than or equal to 10% of total WBC count. (ag) Absolute eosinophil count >500/cu mm.  26 (k) Central Nervous System (i) UNFIT. (aa) A candidate giving a history of mental illness/psychological afflictions requires detailed investigation and psychiatric referral. Such cases should normally be rejected. (ab) History of insomnia, phobias, nightmares or frequent sleepwalking, when recurrent or persistent. (ac) A candidate with migraine, which was severe enough to make him consult his doctor, should normally be a cause for rejection. Even a single attack of migraine with visual disturbance or MSigrainous epilepsy will be unfit. (ad) History of epilepsy (ae) History of severe head injury (af) The presence of stammering, tic, nail biting, excessive hyperhydrosis or restlessness during examination which are indicative of emotional instability. (ag) All candidates suffering from psychosis (ah) Any evident neurological deficit (aj) Tremors of eyelids, tongue and digits (ak) Presence of scar(s) on extremities and/or other body parts accessible to dominant hand, indicative of being deliberately inflicted. (al) Any abnormality not mentioned above but likely to interfere with performance of duty will also be rendered unfit. (ii) FIT. Fracture of the skull, unless there is a history of associated intracranial damage or any residual bony defect in the calvaria.  27 SECTION - 4 DETAILED METHODOLOGY OF EXAMINATION FOR SPECIALISTS SURGERY AND ALLIED  28 31. History. A detailed history will be obtained from the candidate regarding all previous surgical procedures, injuries, ailments and treatment obtained for the same. These will be documented, which will be signed by the candidate. 32. Method of General Surgical examination. (a) General physical examination of the candidate will be carried out in good illumination in a well-lit room, after removal of all clothes. (b) For female candidates, examination should always be carried out in the presence of a lady attendant. 33. Steps of examination. (a) As soon as the patient walks in, gait must be assessed. (b) The candidate is asked to walk towards and away from the medical examiner. (c) Spinal curvature is assessed when the candidate bends forward trying to touch his feet. Any abnormal curvature of the spine needs to be evaluated further. (d) The candidate is then asked to fan out the fingers and a note is made of any deformity or any absence of/ supernumerary digits. (e) The candidate is then asked to stand on his/ her toes and a note is made of any abnormal plantar arch, curvature and any absence of/supernumerary digits. (f) Candidate is then asked to extend the forearm and abnormal curvature/ carrying angle is assessed. (g) All the movements are assessed at neck/shoulder/ elbow/ wrist and joints of hands. (h) All the hernial orifices are assessed after asking the candidate to cough facing away from the examiner. (j) External genitalia are assessed in standing position to look for undescended testis/ any scrotal swelling/ mass. (k) Movements and deformities are then assessed at the hip/ knee/ ankle and small joints of the feet. (l) Patient is then examined in the left lateral position lying on the couch with right knee flexed and touching the chest and left leg extended. Candidate is asked to cough to look for hemorrhoids. During this process, visual assessment for fissure/fistula/skin tags/ previous scars and pilonidal sinus are made. (m) Candidate is then asked to lie supine on the examination couch and general examination of the abdomen is done to look for any organomegaly, scar, sinuses, fistula/ dilated veins/ any other abnormal findings.  29 34. Head & Neck. (a) Any craniofacial abnormality. (b) Cleft lip/ palate. (c) Previous scars of craniotomy or any head and neck surgery 35. Chest & spine. (a) Visible Pulsations. (b) Amazia, Polymazia, Polythelia, Gynecomastia, discharge from nipples, lump/abscess in the breast. (c) Chest symmetry. (d) Dilated vessels. (e) Respiratory movements. (f) Deformities of rib cage, scapula, shoulder, spine. (g) Congenital abnormalities. (h) Hypertrichosis, dimpling of skin, vascular tumors, pigmented naevi, sinuses, tuft of hair over spine, kyphosis, and scoliosis. (j) Any scar of previous surgery. 36. Abdomen (a) Size, distention, symmetry. (b) Movements of abdominal wall, surgical scars, dilated vessels. (c) Visible peristalsis. (d) Hernia, impulse on coughing. (e) Tenderness, lump/ fluid, liver, gallbladder, kidneys. (f) Inguinal lymph nodes. (g) Hemorrhoids, prolapse of rectum/ uterus, skin tags. (h) Fistulae, pilonidal sinus, condyloma, fissures, sinuses.  30 37. Urogenital (a) Penis, scrotum, spermatic cord, epididymis, meatus (location), urethra. (b) Hydrocele, varicocele, undescended testis, atrophic testis. (c) External genitals in females. (d) Visible lesions indicative of Sexually Transmitted Infections. 38. Extremities and Musculoskeletal system. (a) Upper limbs: (i) Fingernails - Splinter hemorrhages, platynoychia, separation from nail bed and absence of nails. (ii) Deformities of elbows & digits. (iii) Axillary lymph nodes, warts, corns, callosities, abnormal growth. (iv) Joint swelling, Cubitus varus/valgus. (v) Deformities of shoulder/elbow/wrist joints, abnormal/restricted movements. (vi) Complete/ partial amputation of digits/ polydactyly/ syndactyly. (vii) Evidence of recurrent dislocation of shoulder. (viii) Neuro-vascular deficits. (ix) Muscles wasting, reflexes, coordination. (b) Lower Limbs. (i) Stance, gait, balance. (ii) Oedema, varicose veins, ulcers, warts, corns, callosities, growths. (iii) Muscle wasting, reflexes, coordination. (iv) Knock knee, bow legs, flat feet, hammer toes. (v) Joint swelling, Genu varus/ valgus/ recurvatum. (vi) Flat feet, deformities of arch of foot, clubfoot. (vii) Complete/ partial amputation of toes/ Polydactyly/ Syndactyly. (viii) Neurovascular deficit. (ix) Hallux valgus/varus.  31 39. Vascular & lymphatic system. (a) Varicose veins (b) Peripheral Arterial Disease (c) Deep Vein Thrombosis (d) Thrombophlebitis (e) AV malformation 40. Fitness after Surgery. Candidates will be considered fit only after the minimum laid down period following surgery for the disease/disability is over and there are no complication or residual defect. (a) All open abdominal surgeries including midline laparotomies can be assessed for fitness after 24 weeks from the date of surgery. (b) For any other surgery, where the time period after minor surgical procedure is not mentioned in this manual, the candidate can be assessed for fitness after a minimum of 02 weeks and for other surgeries after 12 weeks of the surgery, provided the scar is well healed and there is no post op complication. (c) The final decision on fitness for these candidates presenting with previous surgeries shall depend upon the exact nature of surgery & indication for surgery as stated in the authentic medical documents, OT notes, histopathology reports, hospital discharge summary or case summary etc. signed & stamped by a registered medical practitioner or surgeon. Candidates who have undergone a surgical procedure will be declared unfit if the aforesaid supporting documents are nor produced, irrespective of the nature of the surgery. 41. Standards for fitness. Standards of fitness are described in detail in the following sections. 42. Abdomen. (a) Anterior abdominal wall hernia including Femoral hernia. (i) FIT. After 24 weeks of surgery (open as well as laparoscopic) provided there is no recurrence or post-op complications (ii) UNFIT. (aa) All current or operated cases of incisional hernia (ab) All cases of current anterior abdominal wall hernia (b) Inguinal hernia. (i) FIT. After 01 year of hernia repair surgery (open as well as laparoscopic) provided there is no recurrence or post-op complications. (ii) UNFIT. All cases of current inguinal hernia  32 (c) Anorectal Conditions. (i) FIT. (aa) Those with external skin tags and after rectal surgery for polyps, haemorrhoids, fissure, fistula, or ulcer provided 12 weeks of post op period is complete and there is no residual/recurrent disease. (ab) Well healed post op cases of pilonidal sinus when assessed after 12 weeks of surgery (ii) UNFIT. (aa) Those with current evidence of anal fistula, hemorrhoids, (internal or external), anal or rectal polyp, stricture, or fecal incontinence. (ab) Rectal prolapse even after operative correction (ac) Any anorectal surgery with post op complications. (ad) Current evidence of pilonidal sinus (d) Gallbladder. (i) FIT. (aa) Normal echotexture and anatomy of the gallbladder (ab) Cases of laparoscopic cholecystectomy with normal LFT, normal histopathology, well healed port sites and no incisional hernia when assessed 08 weeks post-op (ac) Cases of open cholecystectomy with normal LFT, normal histopathology, well healed scar and no incisional hernia when assessed 24 weeks post-op (ad) Agenesis of gall bladder in the absence of any other biliary tract abnormalities (MRCP to be done) (ii) UNFIT. (aa) Clinically palpable gall bladder (ab) USG evidence of cholecystitis/ cholelithiasis/ biliary sludge/ polyp/ choledochal cyst/gall bladder wall thickening > 05mm/ septate gall bladder/ any evidence of chronic cholecystitis/ gall bladder mass (f) Spleen. Candidates having undergone splenectomy will be declared UNFIT  33 (g) Pancreas. Candidates with any of the following conditions will be declared UNFIT: - (i) Any structural abnormality. (ii) Space Occupying Lesion/ Mass lesion. (iii) Features of chronic pancreatitis (calcification, ductal abnormality, atrophy). (h) Peritoneal Cavity. (i) UNFIT. (aa) Ascites. (ab) Solitary mesenteric or retroperitoneal lymph node >1 cm. (ac) Two or more lymph nodes of any size. (ad) Any mass or cyst. (ii) FIT. Single retroperitoneal LN 1.5cm (Unilateral). (ac) Multiple cysts of any size or any number (unilateral or bilateral). (c) Congenital defects. The following conditions will render a candidate UNFIT: - (i) Solitary kidney (ii) Horseshoe kidney (iii) Hydronephrosis (iv) Ectopic/ mal-rotated kidney (v) Hypoplastic kidney with length 20 degrees and IMT angle > 10 degrees between 1st and 2nd metatarsals. Hallux Valgus of any degree with bunion, corns or callosities. (ag) Symptomatic deformity of the toes (acquired or congenital), including but not limited to conditions such hallux varus, hallux rigidus, hammer toe(s), claw toe(s), or overriding toe(s) when associated with callosities, bunion, corns. (ah) Clubfoot, Pes cavus (high arch foot). (aj) Rigid or symptomatic Pes planus (acquired or congenital) - arches do not reappear on standing on toes, unable to skip on forefoot. (ak) Symptomatic neuroma. (al) Polydactyly (am) Syndactyly (>25%)  43 (an) All cases of complex syndactyly (ii) Foot (FIT conditions). (aa) Polydactyly can be assessed for fitness 12 weeks post-op and can be declared FIT if there is no bony abnormality on X-Ray, wound is well healed, scar is supple and there is no evidence of neuroma on clinical examination. (ab) Simple syndactyly can be assessed for fitness 12 weeks post-op and can be declared FIT if there is no bony abnormality on X-Ray, wound is well healed, scar is supple and webspace is satisfactory. (ii) Knee (Conditions that will render a candidate UNFIT). (aa) Current loose or foreign body in the knee joint. (ab) Anterior or posterior cruciate, medial and lateral collateral ligament injury with or without instability. (ac) ACL reconstruction surgery (Open or Arthroscopic). (ad) Symptomatic medial or lateral meniscal injury with limitation of activity. (ae) Meniscectomy, meniscal repair, meniscal transplant. (af) Dislocation of patella in past 02 years, or recurrent episodes with or without surgery. (ag) Dislocation of the knee, with or without surgery. (ah) Chondromalacia patellae, chronic patello-femoral pain syndrome and, osteoarthritis, or traumatic arthritis. (iii) Hip (Conditions that will render a candidate UNFIT). (aa) Developmental dysplasia (congenital dislocation) of the hip, osteochondritis of the hip (Legg-Calve-Perthes Disease) or slipped capital femoral epiphysis of the hip. (ab) Traumatic hip dislocation. (ac) Hip arthroscopy or femoral acetabular impingement. (iv) Angular deformities (Conditions that will render a candidate UNFIT). (aa) Genu Varum with Intercondylar distance >07 cm. Measure in standing posture, knees in full extension, thighs touching closely, measured at level of adductor tubercle. (ab) Genu Valgum with Intermalleolar distance > 5 cm in males and > 8 cm in females. Measure in standing posture, knees in full extension,  44 thighs touching closely, measured at level of tip of medial malleolus. (ac) Genu Recurvatum with Hyperextension of knee >10 degrees is unfit. Measure in standing posture, knees in full extension. (c) Upper Limb (Conditions that will render a candidate UNFIT). (i) Fingers and Thumbs: Inability to clench fist, pick up a pin, grasp an object, or touch tips of fingers with thumb. (ii) Absence/ deformity - Hand and Fingers: (aa) Absence of any part of either thumb or index finger. (ab) Any fixed deformity of fingers (ac) Loss of any finger or fingers or parts thereof (Except terminal phalanx of little finger). (ad) Partial loss of distal phalanx with functional disability. (ae) Amputation through the DIP joint or any other joint proximal to it. (af) Corrected or uncorrected congenital deformity of the hand, polydactyly or syndactyly. (ag) Any tendon injury, vascular injury, fractures and nerve injury(s), corrected or uncorrected, with functional deficit. (ah) Polydactyly/ syndactyly (aj) Hyper-extensible finger joints, (Extension of fingers beyond 900) including isolated presentations. (iii) Conditions for which a candidate may be considered as FIT: - (aa) Polydactyly can be assessed for fitness 12 weeks post-op and can be declared FIT if there is no bony abnormality on X-Ray, wound is well healed, scar is supple and there is no evidence of neuroma on clinical examination. (ab) Simple syndactyly can be assessed for fitness 12 weeks post-op and can be declared FIT if there is no bony abnormality on X-Ray, wound is well healed, scar is supple and webspace is satisfactory. (ac) Candidates with mild fixed deformities i.e., less than 10 degrees of extension lag without any evidence of trauma, pressure symptoms and no functional deficit. (iii) Elbow (UNFIT conditions) (aa) Cubitus Valgus: -Carrying angle > 15 degrees in males and > 18 degrees in females (Carrying angle to be measured by goniometry).  45 (ab) Cubitus Varus > 05 degrees. (ac) Cubitus Recurvatum >10 degrees. (ad) Fixed flexion deformity of any degree. (d) Miscellaneous conditions of the extremities considered UNFIT (i) Symptomatic osteochondritis of the tibial tuberosity (Osgood-Schlatter Disease) within the past 12 months. (ii) Stress fractures, either recurrent or a single episode occurring during the past 12 months. (iii) Acromio-clavicular separation (iv) Joint replacement or resurfacing of any site. (v) Neuromuscular paralysis, weakness, contracture, or atrophy. (vi) History/clinical evidence of healed or current osteomyelitis. (vii) Osteochondral defects, osteochondritis dissecans. (viii) History of any cartilage surgery, including but not limited to cartilage debridement or chondroplasty, chondromalacia, microfracture, or cartilage transplant procedure. (ix) History of post-traumatic or exercise-induced compartment syndrome. (x) Osteonecrosis of any bone. (xi) Any joint laxity, unstable joint, ligamentous injuries, any surgery of the joint for any disease/disability, malformation/deformity, cysts, arthritis. (e) FRACTURES (i) UNFIT. (aa) All intra-articular fractures of large joints with or without surgery, with or without implant. (ab) All extra-articular fractures with post-op implant in situ. (ac) Current malunion or non-union of any fracture. Any sequalae of extra-articular fractures (Nuro-vascular deficit. Soft tissue loss, functional deficit, osteomyelitis/ sequestrae formation) (ad) Healed fractures with significant cosmetic deformity, any angulation, rotational deformity or shortening. (ae) Healed Fractures of long bones, less than 09 months old.  46 (ii) FIT. (aa) Current retained hardware (including plates, pins, rods, wires, or screws) will be considered for fitness after minimum of 12 weeks of implant removal. (ab) Candidates with extra-articular fractures of long bones, who have been treated conservatively, can be assessed for fitness after 09 months of injury. They can be declared FIT is there is no evidence of mal- alignment/ malunion, neuro-vascular deficit, soft tissue loss, functional deficit, osteomyelitis/sequestra formation. 52. EAR NOSE AND THROAT (a) Examination of ear, nose and throat is required to exclude conditions which will impede optimal performance of Armed Forces personnel in various situations in peace and war. (b) History. History of otorrhoea, hearing loss, vertigo including motion sickness, tinnitus to be elicited. History suggestive of allergic rhinitis/ nasal polyps, ozoena, recurrent epistaxis, dysphonia, dyspnoea, dysphagia and history of any surgery of ear, nose, throat, neck is also required to be elicited. Family history of hearing loss is also required to be elicited. (c) Examination. To avoid overlooking or missing minor functional and anatomical abnormalities, the following points should be observed when examining the ears, nose and throat: - (i) A good illumination. (ii) A set pattern of examination. (iii) An adequate view of all parts under examination. (d) Nose and Paranasal Sinus. A Thudicum nasal speculum may be used to aid nasal examination. Septum will be assessed for deviation remarkable enough to cause persistent airway obstruction. Nasal airway assessment should be done by cold spatula test. It is important to look for perforations in the nasal septum. The nasal mucosa will be assessed for signs of inflammatory diseases of the nose/ paranasal sinuses like hyperemia, mucopurulent discharge, atrophy and crusting. Plain radiographic examination of the sinuses is fraught with inconsistencies and is not indicated. Presence of nasal polyps/growth/ulceration will be assessed. (e) Oral Cavity and Throat (i) Mouth. Look for submucous fibrosis, leukoplakia, erythroplakia, ulcerative or exophytic lesions in the oral cavity. (ii) Pharynx. Tonsils will be assessed for signs of chronic inflammation in the form of hyperemia of anterior faucial pillars and pus/debris in the tonsillar crypts. Presence of any ulcer/mass lesion should be looked for. Presence of  47 pooling of saliva indicating dysphagia to solids/ liquids will be noted. (f) Larynx. Presence of severe change in voice, stridor/ dyspnoea will be noted. (g) Ear. All candidates will be instructed to get ear wax removed under their own arrangements before reporting for medical examination. However, if wax is present on examination which is impeding adequate visualization of external auditory meatus/ tympanic membrane, the candidate will be given time to get the wax removed and will be re-examined. In case, it is not possible to re-examine the candidate, he/she should be referred to an ENT centre convenient to the candidate for re-examination without declaring him/ her unfit. The candidate will be specifically instructed to get the wax removed before reporting for this re-examination. (h) Auricle and Mastoid Region. The pinna will be assessed for gross deformity which will hamper wearing of uniform/ personal kit/protective equipment or which adversely impacts military bearing. The preauricular and postauricular regions should be carefully examined for scars and deformities due to past operations. Cauliflower ear for wrestlers and boxers may be accepted provided there is no functional deficit. (j) External Auditory Meatus. It is inspected by pulling the auricle upwards, backwards and outwards to straighten the external canal. Presence of wax, foreign body, exostosis, growth, otomycosis or discharge is noted. (k) Tympanic Membrane. Tympanic membrane must be inspected quadrant-wise by otoscopy. The ear is examined for perforation, scars, tympano-sclerotic plaques or retraction of membrane. Mobility of the tympanic membrane will be assessed by Valsalva maneuver. (l) Assessment of Hearing. Good hearing in both ears is a must. Assessment of hearing is to ensure adequate bilateral hearing acuity and freedom from any disease of the ear or upper respiratory passage. Unilateral deafness limits optimal sound perception and ability to locate the direction of sounds. (m) Auditory acuity is assessed without the use of any hearing aid. Testing for Conversational Voice (CV) is done for each ear separately. The candidate stands in a quiet room at a distance of 610 cm from the examiner with his back turned towards the latter. This prevents lip reading. An assistant will mask the non-test ear. Masking is done by placing a stiff piece of paper over the auricle and using the pulp of the fingertip to make a gentle circular rubbing motion producing a continuous rustling sound. CV test will be done using spondee words (bi-syllable words with equal phonetic emphasis on both components e.g., football). The distance at which the candidate can repeat fifty percent of the words correctly will be noted as CV. (n) Instructions for ENT Specialist. Detailed ENT examination by the Specialist is indicated in those cases where the candidate has been made unfit by a Recruiting MO. (o) Nose and Paranasal Sinus. (i) Nasal cavity and naso-pharynx may be assessed by nasal endoscopy. (ii) The septum will be assessed for deviation remarkable enough to cause persistent airway obstruction.  48 (iii) lt is important to look for perforations in the septum. The size of the perforation and presence of whistling noise on breathing will be noted. (iv) The nasal mucosa will be assessed for signs of inflammation of nose/para-nasal sinuses like hyperemia, mucopurulent discharge, atrophy and crusting. Presence of mucopus in the middle meatus will be noted. Presence of growth, polyps, granulomatous lesion and ulcer will be assessed. (p) Oral Cavity and Throat. (i) Mouth. Look for submucous fibrosis, leukoplakia, erythroplakia, ulcerative or exophytic lesions in the oral cavity. (ii) Pharynx. Tonsils will be assessed for signs of chronic inflammation in the form of hyperemia of anterior faucial pillars and pus/ debris in the tonsillar crypts. Presence of any ulcer/ mass lesion should be looked for. Presence of pooling of saliva indicative of dysphagia to solids/ liquids will be noted. (iii) Larynx. Presence of remarkable changes in voice, stridor/ dyspnoea will be noted and considered unfit. (q) Ear. If wax is present on examination which is impeding adequate visualization of external auditory meatus and tympanic membrane, the Specialist may attempt to remove the wax provided it is easily removable without possibility of injury to the external auditory meatus and tympanic membrane. If wax is not easily removable, the candidate will be advised to report after getting the wax removed. (i) Auricle and Mastoid Region. The pinna will be assessed for gross deformity which will hamper wearing of uniform/personal kit/ protective equipment or which adversely impacts military bearing. The preauricular and postauricular regions should be carefully examined for scars, sinuses and deformities due to past operations. (ii) External Auditory Meatus. Presence of wax, foreign body, exostosis, growth, otomycosis or discharge is noted. (iii) Tympanic Membrane. Tympanic membrane must be inspected quadrant-wise by otoscopy and if required by oto-endoscopy/ oto-microscopy. Perforations, scars, tympanosclerotic plaques or retraction of membrane will be carefully looked for. Mobility of the tympanic membrane will be assessed by Valsalva maneuver, Pneumatic Otoscopy and if required by Tympanometry. (iv) Assessment of Hearing. Good hearing in both the ears is a must. Assessment of hearing is to ensure adequate bilateral hearing acuity and freedom from any disease of the ear or upper respiratory passage. Unilateral deafness limits optimal sound perception and ability to locate the direction of sounds. Auditory acuity is assessed without the use of any hearing aid. (v) Free Field Hearing Tests. For Conversational Voice (CV) and Forced Whisper (FW) voice tests, each ear must be tested separately. It is necessary to standardize the technique, to make findings reproducible and comparable. The candidate should stand in a quiet room at 610 cm from the examiner with  49 his back turned towards the latter. This prevents lip reading. An assistant will mask the non-test ear. Masking is done by placing a stiff piece of paper over the auricle and using the pulp of fingertip to make a gentle circular rubbing motion producing a continuous rustling sound. CV will be done using spondee words (bi-syllable words with equal phonetic emphasis on both components). The distance at which the candidate can repeat 50% of the words correctly will be noted as CV. FW is carried out by whispering with the residual air at the end of an ordinary expiration. The candidate is asked to repeat the spondee words spoken by the examiner. The distance at which the candidate repeats 50% of the words correctly is recorded as FW. (vi) Tuning Fork Tests. Rinne test and Weber test may be employed to ascertain the type of hearing loss present. (vii) Pure Tone Audiometry (PTA). PTA will be performed for detailed assessment of hearing acuity wherever indicated. Audiometry will be done in a sound treated room and the audiometer will be calibrated as per standard guidelines. Thresholds will be noted for each octave interval from 0.5, 1, 2, 3, 4, 6, and 8 kHz for AC and from 0.5 to 4 kHz for BC, where indicated. (viii) Impedance Audiometry (Tympanometry). Tympanometry will be done to assess middle ear function and Eustachian tube function, where indicated. (r) Grounds of Rejection/ Acceptable standards. Candidates who suffer from any of the defects mentioned below will be declared unfit. However, any other condition in the ear, nose, throat and neck which is likely to hamper the individual in carrying out his military training/duties or adversely affects his military bearing will also be a cause for rejection. (s) Ear. (i) UNFIT. (aa) Gross deformity of pinna which hampers wearing of uniform/personal kit/protective equipment or which adversely impacts military bearing. (ab) Exostosis, Osteoma, Fibrous Dysplasia or any other bony growth in external auditory canal. Assessment of operated cases will be done after a minimum period of 4 weeks. Post surgery histopathology report and HRCT temporal bone will be mandatory. If the histopathological report is suggestive of a neoplasia or HRCT temporal bone is suggestive of partial removal or deep extension it would entail rejection. (ac) Current Otitis Externa (ad) Current Otitis Media of any type (ae) Evidence of healed Chronic Otitis Media in the form of Tympanosclerosis or scarring affecting more than 50% of the Pars Tensa of tympanic membrane (TM)  50 (af) All cases of Tympanoplasty and Myringoplasty/ Myringotomy for Chronic Otitis Media (ag) Any residual perforation. (ah) Any implanted hearing devices such as cochlear implants, bone anchored hearing aids etc, are not acceptable. (aj) Deafness due to any cause. Any reduction less than 610 cm in CV/FW is not acceptable. Wherever PTA is indicated, and thresholds are obtained, the hearing thresholds by air conduction at 500 Hz to 8000 Hz should be 25 dB or better. Isolated lower thresholds up to 30 dB may be accepted provided the ear is otherwise normal (ak) Peripheral vestibular dysfunction. History of motion sickness or any evidence or peripheral vestibular dysfunction due to any cause (ii) FIT. (aa) Tympanic membrane is mobile on pneumatic otoscopy. (ab) No hearing impairment on the Free Field Hearing Test (CV & FW). (ac) Pure Tone Audiometric thresholds (where required) are within normal limits. (ad) Tympanometry shows Type ‘A’ Tympanogram (where performed). (ae) Healed Otitis Media in the form of tympanosclerosis involving less than 50% of Pars Tensa with normal PTA and Tympanometry results. (t) Nose and Paranasal Sinuses. (i) FIT. (aa) Minor deformities of dorsum and nasal tip not interfering with nasal airway (ab) Asymptomatic anterior (cartilaginous) septal perforation less than 01 cm, provided it is not associated with nasal deformity, nasal crusting, epistaxis and granulation (ac) In cases of Deviated Nasal Septum (DNS), correction by septoplasty if reviewed four weeks after surgery and provided there is an adequate airway. (ad) Post-op intranasal adhesions not compromising airway (ae) Any infection of nose/paranasal sinuses after successful treatment, if there is no evidence of chronic rhino-sinusitis.  51 (ii) UNFIT. (aa) Gross external deformity of nose causing functional deformity will be rejected if it adversely impacts nasal airway. (ab) Obstruction to free breathing because of marked septal deviation. (ac) Nasal polyposis noted during examination or after any surgery for polyposis. (ad) Atrophic rhinitis. (ae) Vasomotor rhinitis (u) Oral Cavity (i) FIT. Completely healed oral ulcers and operated cases of mucus retention cyst only after surgery, with no recurrence and benign histology. Such evaluation will be done after a minimum four weeks post-surgery. (ii) UNFIT. All current and operated cases of leukoplakia, erythroplakia, submucous fibrosis, ankyloglossia, oral carcinoma, current oral ulcers/growth, mucus retention cysts and trismus due to any cause is unfit. Cleft palate is not acceptable even after surgery. (v) Pharynx (i) FIT. (aa) Bilateral symmetrical tonsillar enlargement, provided it is not a cause for persistent dysphagia / odynophagia. (ab) Post tonsillectomy cases can be reviewed for fitness after 04 weeks post-op. They may be accepted if histology is benign. (ii) UNFIT. (aa) Any ulcerative/ mass lesion of the pharynx (ab) Evidence of chronic tonsillitis is a cause for rejection. (w) Larynx. Following defects of Larynx will be declared UNFIT: - (i) Persistent hoarseness, dysphonia, chronic laryngitis, vocal cord palsy, laryngeal polyps, growths. (ii) Speech defects including stammering 53. OPHTHALMOLOGY (a) Introduction. To be declared fit for admission/ commission, the candidate must be in good visual health and free from any disability likely to interfere with the efficient performance of duty in the Armed Forces. Visual defects and systemic ophthalmic  52 conditions are among the major causes of rejection and hence a thorough and accurate eye examination is of great importance in selecting personnel into the Armed Forces Medical Services. To reduce inter-observer error and ensure maximum reliability, certain examination techniques are recommended. The examination is to be conducted in the following five stages: - (i) History and declaration by the candidate. (ii) Determination of visual acuity for distance and near vision and proper examination to assess colour vision. (iii) Ocular muscle balance tests. (iv) Slit Lamp examination. (v) Fundus examination, fields and other examinations, as required. (b) Family and Personal History (i) Specific questions should be asked for, to elicit family history of pathological myopia, night blindness, and any other relevant disease. Personal history should include: (ii) History of wearing spectacles/contact lenses, duration for which he has been wearing this correction and the number of times the refractive power was changed in the last 2 years. (iii) History of surgical correction of refractive errors such as (aa) Photorefractive Keratectomy (PRK) (ab) LASER in situ keratomileusis (LASIK) (ac) Small Incision Lenticule Extraction (SMILE) (ad) Collagen cross-linking (ae) Phakic IOLs etc. (iv) History of non-surgical refractive corrections such as Orthokeratology. (v) History of eyestrain, diplopia, frequent attacks of redness of the eyes, or having difficulty in seeing in the dark. Method Of Examination Distant Vision (c) Testing conditions. Distant visual acuity is judged by standard test types, read by each eye separately first, and then together without glasses at 6 meters. Digital, auto-projector charts should be used, if possible. The test type should be illuminated  53 to the minimum of 10-foot candles (9 - 18W standard company Tube light fitted). If the illumination is less, the visual acuity cannot be assessed correctly. Distance between the candidate and the test type should be exactly 6 meters. The lettering in the test should not be faded and must be against a clear white background. If the examination room is small, Snellen’s test type with standard illumination should be fixed to the wall above the seating position of the candidate and a mirror be placed at 3 metres from which the candidate is directed to read the chart. (d) Procedure of assessment (i) The eye that is not being tested should be occluded with an opaque card without pressure. (ii) In the Snellen’s test type of charts, the distance at which a particular letter should be read by a person with standard vision is given against that letter. For example, if a person at 6 meters can read only the letter that is to be read from 60 meters, his vision is recorded as 6/60. Similarly, 6/36, 6/24, 6/18, 6/12, 6/9 or 6/6 is recorded according to the number on the smallest line read. (iii) If he cannot even read the largest at 6 meters, the distance is reduced by a meter each time till he can read the top letter. If he reads it at 1 meter, his vision is recorded as 1/60. If his vision is less than 1/60 finger counting close to the face is checked. If even finger counting is not possible, then his ability to recognize hand movement (HM) is recorded. (iv) If even hand movements are not appreciated then his perception of light (PL) projected from four quadrants is tested and recorded. (v) Visual acuity should be assessed by all Optotypes of Snellen’s chart and randomly to minimize errors in recording vision. To prevent memorizing, the candidate can be asked to read any line in the reverse direction (right to left). (vi) Astigmatic individuals may be able to read letters indistinctly or may misidentify them because of indistinct images on the retina. There may be a desire to tilt the head to one side for better focus. Such individuals may be tested with cylindrical lens or stenopaic slit. (vii) In cases where refractive status needs to be assessed, manual retinoscopy under cycloplegia must be performed. (e) Common Errors in testing. Following are the common sources of error in testing distant vision: - (i) The chart is not 6 meters from the candidate. (ii) Too much light reduces visual acuity particularly if glare is reflected from the surface of the test type, or if extraneous light enters the candidate’s eye. (iii) The candidate views the chart with both eyes open, or memorizes letters before testing starts. (iv) The candidate is allowed to read the chart with glasses on before the  54 unaided acuity is determined. (v) The candidate or examiner presses on the occluded eye. (vi) The candidate is allowed to cover his own eye, and peeps from behind the occluder or between his fingers. (vii) The candidate is allowed to adjust his eye or adopt an unusual head posture. (viii) Candidates may be wearing fine contact lenses or may have undergone corneal refractive surgeries or orthokeratology which are not detected. (ix) Insufficient time for the candidate to relax his accommodation prior to making him read the charts. (x) The examiner’s inability to recognize guessing or memorizing on the part of the candidate. Near Vision (f) Standard Test types. For recording near visual acuity, Snellen’s or Jaegers test types are used. The candidate is seated in a chair with good light coming from behind the left shoulder and is asked to hold the card at approximately 33 cm distance and asked to read the words and sentences. The number of the smallest type printed on the card that he can read comfortably is the near vision. It is recorded as NV = N6 (Snellen’s), if he reads the smallest print marked 6. (g) Colour Vision (i) Color perception for entry into Armed Forces Medical Services will be assessed based on Ishihara Charts at SMB and Anomaloscope during AMB and RMB. (ii) Methods of Examination and assessment of Colour Vision by Ishihara Book and Anomaloscope. The book should be held at a distance of 75 cm from the candidate. The test should be carried out in ordinary daylight, but not directly in the sun. Artificial illumination, if used, will be a tube light with daylight filter. No candidate should be rejected unless tested in daylight. Each plate should be shown for 2 to 3 seconds only. Answers given should be noted. Next plate should be shown thereafter. Care should be taken that the charts are not unduly faded or otherwise marked. Candidates should not be allowed to touch the charts. No fixed sequence should be followed to guard against candidates memorizing the book. (aa) Color Perception (CP) Pass. Candidates who read plates 1-17 correctly, view nothing from plates 18-21 and reads plates 22-27 correctly. (ab) Candidates who are CP Fail will undergo CP testing by Anomaloscope during AMB and RMB. For candidates appearing for RMB at AFMC, testing with Anomaloscope will be carried out at CH(SC). Color Perception defect will be assessed, based on Anomaly Quotient in order to provide quantitative assessment.  55 Anomaly Quotient Comments 0.7 to 1.4 Normal range < 0.7 to 0.1 Protanomaly >1.4 to ∞ Deuteranomaly (ac) Only those candidates with Anomaly Quotient between 0.7 to 1.4 will be labelled as CP PASS. (j) Night Vision Night Vision test is not done as a routine. In case the candidate gives family history of night blindness or gives symptoms of night blindness or shows signs suggestive of defective night vision, night vision capacity is tested to rule out organic pathology leading to night blindness. It can be assessed with an electroretinogram if required clinically. (k) Ocular Muscle Balance This examination is conducted to detect any manifest or Latent Squint. (i) Ocular Movements and Head Posture. The eyes should move fully and normally in all directions, and no diplopia should be elicited in any quadrant. Particular attention should be paid to candidates with torticollis, because to abolish diplopia and maintain binocular single vision, the individual may adopt an abnormal head posture. (ii) Nystagmus. In testing nystagmus, special care should be taken particularly to keep the fixation object inside the normal binocular field of vision. Physiological nystagmus can almost invariably be demonstrated in extreme positions of gaze. Latent nystagmus is demonstrated by covering one eye. Tests for squint. (iii) Hirschberg Test (HBT). It is used as an initial screening for the evaluation of squint and gives a rough estimate of manifest squint. (aa) Procedure. A pen torch light held at a distance of 33 cm is shone into the eyes of the candidate and he/she is asked to focus at it. The deviation of corneal light reflex from the centre of the pupil is noted in the squinting eye by the examiner. (ab) Inferences. If the corneal light reflex is seen in the centre of the pupil in both eyes, it is orthophoria. If light reflex is seen at the temporal part of cornea from pupillary border to limbus, it is esotropia while if it is seen at nasal part of cornea from pupillary border to limbus, it is exotropia. To estimate the amount of deviation, the position of light reflex is noted, at the border of pupil – 15° deviation, between the border of pupil and limbus – 30° deviation and at or outside limbus – 45° deviation. (iv) The Cover-Uncover Test. (aa) A pencil and a suitable cover such as a card are required. Both eyes must be tested separately.  56 (ab) Technique. Cover the apparently fixing eye completely. Hold the pencil vertically with the point 33 cm from the candidate’s face, between his eyes and level with the root of his nose. Ask the candidate to focus on the tip of the pencil. (ac) Cover test (Stage 1): When the fixing eye is occluded, the examiner may or may not observe the non-occluded eye move to pick up a fixation. This indicates the presence or absence of any tropia respectively. (ad) Uncover test (Stage 2): Now, quickly remove the cover, and observe any movement of the previously covered eye. It may not show any movement, or it may move either inwards or outwards. It indicates the absence or presence of any phoria respectively. (ae) Repeat the same test for distance vision, i.e., at 6m. Interpretation of Results (af) If there is no movement of the eyeball either in stage 1 or stage 2 of the test, it indicates that the muscle balance is normal, and fusion is achieved with effort. Such a stage is called orthophoria. (ag) However, if the movement is inwards or outwards in stage 1, the case is diagnosed to suffer from divergent or convergent squint, respectively. (ah) If no movement is observed in Stage 1, the cover is removed, and any movement seen in that eye is consistent with a latent squint (phoria). (aj) Not only the movement but the rate of recovery is also noted. The recovery can be rapid or slow, immediate, or delayed. Now the second eye is tested in similar fashion. The cover test is to be done for distant and near vision separately. (ak) Recording of Results. The degree of movement is recorded by letters ‘S’ if slight and ‘M’ if moderate. Second and third letters indicate lateral or medial deviation. Fourth and fifth letters show rate of recovery, and the last two letters indicate whether left or right or both eyes. Slight latent divergence with rapid recovery in both eyes will be recorded as “SLDRRBE” (v) Maddox Rod Test. This test only needs to be done when there is some suspicion in the cover-uncover test and is used to assess and quantify the amount of deviation. (aa) Technique and Inferences. The candidate, wearing a trial frame, is made to sit 6 meters from a spotlight in a dark room. The Maddox rod is placed in one eyepiece of the frame, the other eye being left uncovered. With the rod placed horizontally, a vertical beam of light is seen by one eye while the uncovered eye sees the spotlight. The position of the beam relative to be spotlight is noted, preferably on a scale  57 graduated in prism dioptres and mounted on the spotlight apparatus. (ab) To determine horizontal deviation, the rod is placed with grooves horizontally in front of the right eye so as to produce a vertical red line. The left eye fixes a spotlight at 6 meters distance. If the line is seen to the left of the spotlight, it indicates exophoria and if to the right of the light, esophoria. The amount of deviation can be measured by placing prisms of increasing strength in front of the right eye with bases in for exophoria and bases out for esophoria until the red line coincides with the spotlight. (ac) To determine vertical deviation, the rod is then placed vertically in front of the right eye, so as to produce a horizontal red line, which will pass through the spotlight if there is no vertical imbalance. If the red line is below the spotlight there is right hyperphoria, and if the red line is passing above there is left hyperphoria. The amount of deviation is measured by placing a prism of increasing strength in front of the right eye with bases down for right hyperphoria or up for left hyperphoria until the red light traverses the spot. (ad) If cyclophoria is present, when the Maddox rod is vertical, the line instead of running horizontally will run obliquely. Degrees through which the rod has to be tilted in order to make the line of light appear vertical, will indicate the amount of torsion. The obliquity is more easily recognized if two Maddox rods are used, one before each eye. Two lines seen are parallel to each other in the absence of cyclophoria. Great care must, of course, be taken that the rods are set vertically or horizontally in the trial frame. (ae) Instead of using prisms, the test may be used in conjunction with the Maddox tangent scale where the deviation is determined by asking the candidate to observe which number on the scale the red line traverses. (af) The test should also be done with the spotlight at 33 cm. If the Maddox rod is placed in front of the left eye the interpretation will change accordingly. (ag) Recording of results. To differentiate the two tests, results of the Maddox Rod test at 6 meters and at 33 cm are recorded separately. (Maddox Rod Test 6 m - Exo 2 D, 33 cm - Exo 10 D) (vi) Common Errors (aa) The candidate shuts one eye. (ab) The candidate does not relax to focus on the distant spotlight. Too high a degree of esophoria is indicated, which does not match the deviation detected by the cover test. (ac) Multiple red lines seen. Aberrant light sources are present if the examination room cannot be blacked out, the proper red line should be  58 indicated by flashing the spotlight on and off a few times. White Maddox Rods are available for use with a red spotlight, aberrant light leaks producing white lines and the spotlight, a red line. (ad) Falsification by the candidate. Heterophoria candidates who are familiar with the test may declare immediately that the line passes through the light. If following the cover test, this appears unlikely, a prism should be placed in an appropriate direction before the Maddox Rod. If orthophoria is still claimed, a closer check of the candidate’s responses is indicated. (vii) Worth 4 Dot Test. It consists of an illuminated box with four apertures for coloured glasses - one red, two green and one white. The candidate at 6 meters distance wears a red glass before right eye and green before left eye, so that he sees red with one eye, green with the other and white with both. If he/she sees four dots (one red, two green and one red-green) he/she has binocularity. If he/she sees five dots (two red and three green) he/she uses both the eyes but has diplopia. If he/she sees two reds, it is left eye suppression and if three greens only, it is right eye suppression. (viii) Convergence Tests. Convergence is divided into two – Objective convergence and Subjective convergence. (aa) Objective Convergence. The assessment of convergence is made without taking the help of the individual under examination. It is more reliable and more quickly done. (ab) Subjective Convergence. In assessment of subjective convergence, the assistance of the candidate is taken and it is a good corroborative finding to objective convergence. The test requires a special instrument called RAF rule. (ac) Measurement. Both objective and subjective convergence can be measured by RAF Near Point Rule. (ad) Objective Convergence. On the RAF rule, there is a scale with an attachment, a small box with a black dot on white background. The instrument is placed over the infra orbital margin and the candidate is asked to keep looking at the black dot. The box is then moved towards his nose and the examiner watches the ocular movements of the candidate. The point where one of the two eyes stops moving inwards or suddenly shoots out is taken as the point of convergence. The pointer reading on the scale is noted and is expressed as - convergence: 8 cm. If the reading is very high e.g., beyond 11 to 12 cm, the test should be repeated after explaining to the individual what is required of him/her. (ae) Subjective Convergence. Same technique as above but in this test, the candidate is asked to indicate when the dot becomes doubled and that point is considered the point of convergence. (ix) Measurement of Accommodation. On the RAF rule, there is a scale  59 with an a