HISTORY TAKING AND GENERAL EXAMINATION

There are two basic steps in clinical examination of a patient/subject.

I. HISTORY TAKING

The patient is asked for a description of what has happened. The history taking
includes
a. Name, age and address
b. Marital status
c. Occupation(including type of work)
d. Chief complaints (in patient‟s own words and in chronological order)
e. History of present illness
f. History of previous illness, accidents, operations
g. Family and Social history – state of health of parents and siblings or cause of
death. History of intake of drugs, alcohol and smoking
h. Treatment history

II. GENERAL PHYSICAL EXAMINATION

1. Posture and attitude.

Posture of a patient may give valuable information

2. Body build and nourishment:

Note the height, weight and musculature and note whether the person is poorly,
moderately or well built and nourished.

3. Pallor:
It gives a rough assessment of degree of anaemia of the patient. It is looked for
by retracting the lower eyelids and seeing the colour of palpebral conjunctiva. It
will be normally reddish in colour. Pallor is also noted by colour of skin, especially
of palms, nail bed, mucosa of tongue and oral cavity.
Anemia is defined as a reduction in hemoglobin content or RBC count or both for
the age and sex of the individual

4. Jaundice or Icterus:
It is a yellowish discoloration of skin, sclera and mucous membrane due to
deposition of bilirubin in tissues. It is clinically obvious when serum bilirubin level
exceeds 2 mg/dl. Normal bilirubin level is 0.02-1 mg/dL of plasma. Jaundice is
looked for in upper sclera by asking the patient to lower his eyeballs.

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 5. Cyanosis:
It is the bluish discoloration of skin and mucous membranes due to reduced
Hemoglobin more than 5g% in capillary blood.
Cyanosis can be divided into
1. Central cyanosis
2. Peripheral cyanosis
Central cyanosis results from imperfect oxygenation of blood as in certain lung
diseases or from mixing of arterial and venous blood,as in congenital cyanotic
heart disease It is more generalized. Central cyanosis is seen in the tongue,
nose, lips and in severe cases it can be seen in extremities also (fingertips, ear
lobes etc..)
Peripheral cyanosis is due to stagnation of blood in the peripheral capillaries
leading to increased extraction of oxygen from hemoglobin. It is seen in
conditions like exposure to severe cold, shock. Peripheral cyanosis is looked for
at the extremities (fingertips, ear lobes, toes etc..)
In central cyanosis extremities are warm whereas in peripheral cyanosis
extremities are cold. Methemoglobinemia and sulphhemoglobinemia also give
rise to bluish discoloration.

6. Clubbing:
It is thickening of tissues at base of nail associated with obliteration of angle
between nail base and adjacent skin of the finger and an increase in convexity of
the nail. Clubbing is seen in lung diseases like lung cancer, congenital cyanotic
heart disease.

7. Lymphadenopathy:
It is the enlargement of lymph nodes. Different groups of lymph nodes are
palpated eg. cervical, axillary, inguinal etc. Presence of generalized or localized
lymphadenopathy are noted. Generalized lymphadenopathy is seen in conditions
like lymphatic leukemia.

Lymph node examination:

I. Cervical lymph nodes : With the subject sitting on a stool, examiner should stand
behind to examine for submental, submandibular, preauricular, tonsillar, deep
cervical lymphnodes in anterior triangle of neck, supraclavicular and scalene
lymph nodes. Standing in front, palpate for deep cervical lymph nodes on
posterior triangle of neck. Patient’s head and neck is passively flexed towards the
side of the node by placing one hand of examiner on patient’s head and the
other hand is used for palpating the node.

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II. Axillary lymph nodes:
a. Pectoral, central and apical group: Palpated with the examiner standing in
the front and using the right hand to palpate the nodes on left side.
Patient’s arm should be made to rest on examiner’s forearm.
b. Lateral or brachial group: Palpated with the examiner standing in front and
using left hand to palpate the left side and vice versa.
c. Posterior or subscapular group: Palpated with the examiner standing behind
the patient and nodes on the right side are examined with right hand of the
examiner and vice versa.
III. Inguinal lymph nodes: With the patient in supine position palpate the inguinal
region.
IV. Popliteal lymph nodes: With the patient in supine position knee is flexed to less
than 45degrees and palpate the popliteal fossa.

8. Oedema:
Excess accumulation of fluid in interstitial space. Oedema is seen in conditions
where there is increased hydrostatic pressure of capillaries (e.g: cardiac failure,
intravascular volume expansion, pregnancy, pelvic tumours, deep vein thrombosis
etc..) or any conditions that produces decreased oncotic pressure in capillaries
(liver disease, renal disease, malnutrition, malabsorption of proteins etc..) or
conditions causing increased capillary permeability (inflammation, sepsis, drug
related) or lymphatic obstruction (filariasis, malignancy, radiation injury). In
myxoedema oedema is due to accumulation of hyaluronic acid, proteoglycans and
mucopolysaccharides which retain water. Presence of dependent oedema in
ambulant persons is usually detected by applying sustained firm pressure (for at
least 30 sec) with the thumb just above the medial malleolus or shaft of tibia and
see for pitting or depression at pressure point.
In bed ridden patients and infants it is important to see for dependent oedema at
sacral region. Presence of generalized or localized oedema is also noted. There are
two types: Pitting oedema (seen in conditions in which plasma protein
concentration is low- eg: congestive cardiac failure) and non-pitting oedema
(chronic filariasis, myxoedema).

9. Skin, hair & nails:

Texture of skin, abnormal pigmentation, texture and distribution of body and scalp
hair are also noted. Nails are examined for pitting, ridges, spooning, hemorrhagic
spots, nodules etc.

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10. Other features:
Obvious deformities in appearance and gait, presence of thyroid swelling or any
other abnormal swelling, varicosities of veins etc. are noted if present.

11. Pulse:
Definition: The blood is forced into the aorta during ventricular systole sets up a
pressure wave that travel along the arteries. This expands he arterial wall as it travels
which is palpable as pulse.
Pulse rate, rhythm, volume, character and condition of vessel wall are to be noted.
Radial pulse is generally felt at the wrist with tip of middle three fingers over radial
artery compressing it over radius with the subject’s arm slightly pronated and wrist
joint slightly flexed.

a. Rate: Pulse is counted for 1 minute. Rate is expressed as number of beats/min.

Normal pulse rate-average - 72/min. Normal range 60 - 100/min. Increased pulse rate
more than 100 beats/min is called tachycardia E.g: Hyperthyroidism, shock etc..
Decreased pulse rate below 60 beats/min is called bradycardia E.g: trained atheletes,
sleep, myxoedema, increased intracranial tension).

b. Rhythm is the regularity with which one beat follows the other. Pulse rhythm is
noted as being regular, regularly irregular (extrasystole) or irregularly irregular (atrial
fibrillation). Rate and rhythm are assessed by palpating the radial artery.

c. Volume: is the amplitude of expansion of vessel wall. Assess if it is of normal, low,

or high volume. Volume of pulse gives an assessment of pulse pressure.

d. Character: Form or pattern of pulse is also noted. Pulse volume and character are
best noted by palpating carotid artery.
• Collapsing or water hammer pulse- Aortic regurgitation
• Anacrotic or slow rising pulse- Aortic stenosis
• Pulsus alternans- Left ventricular failure
• Pulsus paradoxus- Cardiac tamponade, severe asthma

e. Condition of vessel wall: whether normal or thickened. It is noted by trying to roll

the artery over the bone by palpating with finger after occluding it proximally. It is
thickened in elderly due to atherosclerosis

e. Radio femoral delay: simultaneous palpation of radial or brachial artery along with
femoral artery is done to see any asynchrony or delay.

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12. Blood pressure:
It is recorded as a routine in sitting position from the right arm.

13. Respiration:
Rate, rhythm, and type of respiration are noted

14. Temperature:
Body temperature is measured using the clinical thermometer. Usually the oral
temperature is measured. The subject is asked to hold the thermometer under the
tongue, gently supported by the lips for one minute. The procedure should not be
done immediately after taking hot or cold drinks. Normal oral temperature is 37 0C
(98.60F) [36.60C-37.20C (980F-990F)].

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 The rectal temperature is representative of the temperature of the core of the
body and varies least with changes in the environmental temperature. The rectal
temperature is usually 0.5oC higher than the oral temperature. Axillary
temperature is 0.5oC lower than oral temperature. Nowadays, mercury
thermometers have been replaced by electronic devices which are safe and more
accurate.

Report:

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 EXAMINATION OF CARDIOVASCULAR SYSTEM

AIM:
To examine the cardiovascular system of the given subject.

APPARATUS: Stethoscope, measuring tape.

PROCEDURE:
Note the biodata of the patient. Do the general examination and then the examination
of the cardiovascular system.

GENERAL EXAMINATION:
Points to be noted are:

1. Posture and attitude

2. Body build and nourishment.

3. Pallor

4. Jaundice or Icterus

5. Cyanosis.

6. Clubbing

7. Lymphadenopathy

8. Oedema

9. Skin, hair & nails

10. Other features

11. Vital signs:

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i) ARTERIAL PULSE:

Pulse rate, rhythm, volume, character and condition of vessel wall are to be noted.

a. Rate: Pulse is counted for 1 minute. Normal pulse rate-average - 72/min. Normal
range 60 - 100/min. Increased pulse rate (tachycardia) occurs in fever, during and after
exercise, emotion, thyrotoxicosis etc. Decrease in pulse rate (Bradycardia) is seen in
athletes, hypothyroidism etc.

b. Rhythm: Pulse rhythm is noted as being regular, regularly irregular or completely

irregular. Occasional irregularities may be due to extra systole. Completely irregular in
atrial fibrillation.

c.Volume: whether of normal, low, or high volume. Volume of pulse gives an

assessment of pulse pressure. Low volume pulse is seen after severe hemorrhage. High
volume is seen in aortic regurgitation.

d. Character: pattern of pulse is also noted. Pulse volume and character are best
noted by palpating carotid artery. It is best felt with the thumb pressing backward at
the medial border of sternocleidomastoid at the level of thyroid cartilage.

A normal arterial tracing has an upstroke and down stroke. In certain diseases
character is detectably abnormal. For eg collapsing or water hammer pulse (rapid
upstroke and descend) occurs in aortic regurgitation

e. Condition of vessel wall: whether normal or thickened. It is noted by trying to roll

the artery over the bone by palpating with finger after occluding it proximally. It is
thickened in elderly due to atherosclerosis

f. Radio femoral delay: simultaneous palpation of radial or brachial artery along with
femoral artery is done to see any asynchrony or delay. Radio femoral delay is seen in
coarctation of aorta

g. Other peripheral pulsations: Other main peripheral arteries are also palpated
bilaterally. Superficial temporal artery, carotid artery, brachial artery, femoral artery,
popliteal artery, posterior tibial artery, dorsalispedis artery. Pulsations are compared
with those of opposite side and inequalities of volume of pulse present are noted.

a) Superficial temporal artery is felt just in front of the tragus of the ear.
b) Carotid artery is best felt with the thumb pressing backward at the medial border
of sternocleidomastoid at the level of thyroid cartilage.
c) Brachial artery is felt in front of elbow just medial to tendon of biceps.

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 d) Femoral artery is felt at the groin just below the inguinal ligament midway
between the anterior superior iliac spine and the symphysis pubis.
e) Popliteal artery is felt by flexing the knee to 40 degrees with the heel resting on
the bed, so that the muscles around the popliteal fossa are relaxed. The clinician
places his fingers over the lower part of popliteal fossa and the fingers are
moved sideways to feel the pulsation of the popliteal artery against the posterior
aspect of the tibial condyles.
f) Posterior tibial artery is felt just behind the medial malleolus midway between it
and the tendoachilles.
g) Dorsalispedis artery is felt just lateral to the tendon of the extensor hallucis
longus, proximally in the first metatarsal space.

ii) BLOOD PRESSURE

iii) RESPIRATION

iv) TEMPERATURE

EXAMINATION OF CARDIOVASCULAR SYSTEM

Examination of a system is carried out in 4 different steps.

1. Inspection 2. Palpation 3.Percussion 4.Auscultation.

INSPECTION:

1. Shape of chest is noted. Presence of deformities like kyphosis, scoliosis are

looked for.

2. Shape of precordium - Precordium is the anterior aspect of chest wall overlying

the heart. Presence of sternal deformities if any are noted.

3. Jugular Venous Pulse : The internal jugular veins are in direct continuity with
right atrium. So the jugular vein show pulsations and hence observation of jugular
venous pulsations give direct information about pressure changes in right atrium and is
an important guide to cardiovascular function. There is a mean upper level above which
the vein remains collapsed. To look for neck veins, patient should be reclining at an
angle of about 45°. The neck is supported so that neck muscles are relaxed. There
should be good light. In healthy patients pulsation are invisible because upper level of
venous pulsation is at the same level as that of sternal angle and is hidden behind the
sternum. Sometimes it may be just visible above the clavicle.

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Differences between arterial and venous pulsation in the neck

Jugular venous pulse Carotid arterial pulse

1. More lateral 1. More medial

2. Can be easily occluded 2. Cannot be easily occluded
3. Better seen than felt(not palpable) 3. Better felt than seen(palpable)
4. Definite upper level present 4. No definite upper level
5. Level falls during inspiration 5. Not affected by respiration
6. Different waves seen 6. Single wave pattern
7. Upper level rises with gentle abdominal 7. No change during the
pressure (Hepato jugular reflux) procedure

4. Site of apex beat – if visible, noted.

Apex beat: is the lowermost and outermost point of the precordium where definite
cardiac pulsations can be seen or felt. It corresponds to the 5th left intercostal space
1 cm medial to the mid clavicular line. Even in healthy adults especially when
recumbent, apex beat may not be visible. It is also not visible in persons with thick
chest wall due to fat or muscle or breast tissue or when it is behind the rib.
Pathologically invisible in pericardial effusion, lung emphysema.

Displacement of apex beat :

a) In pleural effusion and pneumothorax, the heart is pushed towards the opposite
side

b) Pulmonary fibrosis and collapse of the lung pulls the heart towards the same
side.

c) Enlargement and hypertrophy of the left ventricle results in downward and

outward shift of apex beat

d) Dextrocardia – apex beat is seen on the right side of the chest.

5. Presence of any other pulsations over or around precordium are noted.

a) Suprasternal pulsations are visible in –thin persons, aneurysm of arch of aorta

b) In the neck –aortic regurgitation ,anxious persons

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 c) Epigastric pulsations –tricuspid regurgitation ,aneurysm of abdominal aorta

d) Pulsations in 2nd left intercostal space –pulmonary hypertension

6. Presence of any enlarged veins is noted. –engorged veins over the chest
wall –in superior and inferior venacaval obstruction

PALPATION:

1. Jugular venous pressure to be measured if elevated. The sternal angle is taken as

the reference point to measure it. The vertical height from this angle to upper
level of pulsation is measured with patient lying at an angle of 45°. It is raised in
right heart failure. Sternal angle or angle of Louis is an important landmark
over the chest, which corresponds to the level where 2nd costal cartilage
articulates with the sternum. Counting of intercostal spaces is done with the help
of this landmark
2. Position of apex beat: Localise apex beat with the palm and note its exact
position with tip of the middle finger. Position of apex beat is noted with
reference to intercostal space by counting down from 2nd intercostal space and
laterally with reference to mid clavicular, anterior axillary, mid axillary and
posterior axillary lines

3. Character of apex beat whether normal, tapping, forceful or

heaving. Normal – the apex beat gently raises the palpating finger

Tapping – mitral stenosis

Forceful, less sustained – aortic regurgitation

Heaving (forceful & sustained) – hyperkinetic circulation, aortic stenosis, Left

ventricular hypertrophy

4. Palpability of heart sounds: eg: 2nd heart sound is palpable in pulmonary area in
pulmonary hypertension.

5. Left parasternal heave: Medial aspect of palm is kept over the chest just to the
left of sternum to feel for an impulse termed as left parasternal heave. This is
obtained in right ventricular hypertrophy.

6. Thrills: A palpable murmur is called a thrill. It is a vibratory sensation transmitted

to the palpating hand through the chest wall from the heart and simulates the
purring of a cat. Feel for the presence of thrill over all areas of precordium.

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 7. Other pulsations: pulsations in suprasternal, epigastric, scapular region or other
areas of precordium and neck are palpated

PERCUSSION

Method of Percussion:

Middle finger of the left hand is pleximeter finger. Middle finger of the right hand
is plexor finger. Pleximeter finger is placed firmly over the part to be percussed. With
the tip of the plexor finger strike the middle phalanx of the pleximeter finger. The
movement should come from the wrist joint.

Rules of percussion:

1. Always percuss from resonant to dull area

2. Plexor should be at right angles to the pleximeter

3. Pleximeter should be kept parallel to the organ percussed

4. The stroke should be delivered from the wrist and finger joints and not from the
elbow or shoulders.

5. As soon as the blow is given the plexor must be raised

Percussion of Heart border:

This is not very reliable and has been replaced by chest x-ray and echocardiography

1. Heart borders: are percussed out to see for any shifting or obliteration of
normal cardiac dullness and to see for any enlargement of heart.

Left border: Place the pleximeter finger in the space parallel to the rib.

Start percussion in the 5th intercostal space well beyond the mid axillary line and
continue towards the right till the dullness is obtained. Repeat the same procedure in
the 4th, 3rd and 2nd intercostal spaces.
Right border: Pleximeter finger is placed on the right side of the chest in the 2 nd
intercostal space 4 -5 cms away from the sternum and note the resonance. Then
percuss and note the resonance in the same vertical line in each lower intercostal space
till the liver dullness is obtained. Then percuss from the right axilla to the right sternal
border in a line just above the liver dullness. Right border corresponds to the right
sternal border from the 3rd to 6th intercostals space.

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Upper border: of heart cannot be defined accurately by percussion. First percuss
directly over the clavicle. Resonant note is obtained. Then percuss the 1st and 2nd inter
coastal space. Normally 2nd inter coastal space shows resonance.
Lower border: of the heart is in relation with diaphragm and left lobe of liver below it.
Hence it cannot be defined by percussion.

2. Pulmonary area: is percussed to see for dullness, which is seen in pulmonary

artery dilation.

AUSCULTATION:

Auscultatory areas of heart: Auscultatory areas are certain areas of precordium

where haemodynamic events occurring at each of the cardiac orifices are best
appreciated. These areas are not directly over the valves themselves.

Mitral area -corresponds to position of apex beat.

Pulmonary area -is situated over 2nd left intercostal space close to sternum.
Aortic area -is in 2nd right intercostal space close to sternum.
Tricuspid area -is situated at lower end of sternum to the left.

1. Heart sounds: Using a stethoscope heart sounds are auscultated over each of the
auscultatory areas. Diaphragm is used for soft high pitched sounds whereas bell picks
up low pitched sounds better. Absolute and relative intensities of heart sounds are
compared. Normally in young and healthy people 2nd heartsound is best heard at
pulmonary area and aortic area and 1st heart sound better heard in mitral and tricuspid
area.

1st heart sound is longer, soft in quality and low pitched .It resembles the word “lub”. It
is due to closure of atrioventricular valves
2nd sound is shorter, high pitched and sharp in quality. It resembles the word “dup”. It
is due to closure of semilunar valves

A 3rd heart sound may be heard in normal young individuals eg: during exercise and in
pregnancy. It may also be heard in abnormal conditions like Left ventricular Failure and
Mitral regurgitation. This occurs in the first rapid filling phase of the ventricle.

The 4th heart sound is usually heard in abnormal conditions with non-complaint left
ventricle like Chronic hypertension and Aortic stenosis.

2. Splitting of heart sounds: As aortic valve closes a fraction of a second earlier than
pulmonary valve, normally splitting of 2nd heart sound may be heard even in healthy
young adults and in children in pulmonary area. This physiological splitting is wider and
is better appreciated during inspiration. See for any abnormal splitting.

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 3. Murmurs: are caused due to turbulent blood flow at or near a valve or an
abnormal communication within the heart. Presence of murmurs is looked for in all
auscultatory areas. Timing, character, behaviour during respiration, point of maximum
intensity and direction of propagation of a murmur if present is noted.

Systolic murmurs –heard in aortic stenosis and mitral regurgitation

Diastolic murmurs –heard in mitral stenosis and aortic regurgitation

4. Other sounds: Look for any additional sounds like clicks, opening snap, pericardial
rub etc.

REPORT:

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 EXAMINATION OF RESPIRATORY SYSTEM
AIM:
To examine the respiratory system of the given subject.

APPARATUS: Stethoscope, measuring tape.

PROCEDURE:
Note the bio data of the patient. Do the general examination and then the
examination of the respiratory system.

EXAMINATION OF RESPIRATORY SYSTEM

I. INSPECTION

a. Nasal alae: Nasal alae do not move usually. Exaggerated movement indicates
difficulty in breathing.

b. Position of trachea: Usually central in position. A slight shift towards right is

normal.

c. Shape of chest: Normally it is bilaterally symmetrical with no hollows or bulges. It is

elliptical in shape, the normal ratio of antero-posterior to transverse diameter is 5:7
(Hutchinson’s index)

Abnormalities:

1. Pigeon chest (Pectus carinatum) is a common sequel to chronic respiratory

disease in childhood. It consists of a localized prominence of the sternum and adjacent
costal cartilages, often accompanied by in drawing of the ribs to form symmetrical
horizontal grooves (Harrison‟s sulci) above the costal margins. Rickets also produce this
type of deformity.

2. Barrel chest -Seen in chronic bronchitis and emphysema. Here the Anteroposterior
diameter is equal to transverse diameter. Chest assumes barrel shape.

3. Kyphosis- forward bending of the vertebral column.

4. Scoliosis- lateral bending of vertebral column.

Combination of these two - Kyphoscoliosis produced by either disease of spine or lung

tissue.

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 5. Funnel chest deformity (Pectus excavatum) is a developmental defect in which
there is either a localized depression of the lower end of the sternum or depression of
the whole length of the body of the sternum and of the costal cartilage attached to it.

d. Respiratory movements:

Normal rate - 14-20/min

Increased rate is called tachypnoea. Seen in children, exertion, fever, thyrotoxicosis,

nervous excitement, hypoxia. Decreased rate is called bradypnoea. Seen in narcotic

poisoning.

e. Rhythm of respiration: Normally regular. The rhythm of respiration is varied in

Biot‟s and Cheyne Stokes breathing.

f. Types of respiration: Usually abdomino thoracic in male and thoraco abdominal in

female. Children have mainly abdominal type. Purely thoracic in diaphragmatic
paralysis, ascitis and also in later stages of pregnancy. Purely abdominal in painful
lesions of chest.

g. Movements of chest wall: Normally chest moves equally and simultaneously on

both sides.

h. Apex beat: It is defined as the lowermost and outermost point on precordium

where definite cardiac impulse can be seen or felt. In adult normally it is seen or felt in
5th left intercostal space 1 cm medial to midclavicular line. Position of apex beat is
observed.

II. PALPATION

1. Position of trachea: Place the middle finger of the right hand over the laryngeal
prominence and the index and ring finger on the sternoclavicular joints on either side.
Trace the trachea down towards the suprasternal notch. Note whether it is placed
centrally or deviated to one side by noting its relation to the suprasternal notch and
insertion of sternocleidomastoid.

In fibrosis and collapse of lung, trachea is pulled towards the affected side. In pleural
effusion and pneumothorax, trachea is pushed towards the opposite side.

2. Position of the apex beat: Palpate the apex beat. Displacement of trachea and apex
beat indicates shifting of the mediastinum

3. Movement of chest wall: To make sure that the two sides of chest move
approximately to the same extend. This is done by placing the fingertips of both hands

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on either side, so that the tips of the thumbs just meet in the midline in front of the
chest. The subject is directed to take a full inspiration. Then the distance of movement
of the thumb from the midline is noted, which indicate the extent of expansion of either
half of the chest. Similarly movements on the back of the chest is also examined.
Diminished movement is seen in pleural effusion, pneumothorax, consolidation, fibrosis
collapse of the lung. For assessing the expansion of apices of lung, place the fingers
over the shoulder from behind, the thumbs meeting over the lower cervical vertebrae.

4. Expansion of chest:Using a measuring tape at the level of nipple, measure during

inspiration and expiration. In males, expansion is about 5-8 cm. Decreased in chronic
lung diseases

5. Tactile vocal fremitus.It is the vibration transmitted from the trachea and bronchus to
the chest wall, which is appreciated with the ulnar border of hand. Here, ask the patient
to say “one, one”, or “99” repeatedly while placing the ulnar border of the palm over
the chest wall on corresponding areas on either side of chest.

The areas to be examined are:

1. Supraclavicular area 6. Infra axillary area

2. Infraclavicular area 7. Suprascapular area

3. Mammary area 8. Interscapular area

4. Inframammary area 9. Infrascapular area

5. Axillary area

Normally the vocal fremitus will be equal on both sides. It is increased in consolidation
and cavity of lung. It is diminished in bronchial obstruction and absent in pleural
effusion.

III. PERCUSSION

Percuss the different lung areas (given above) and compare symmetrical areas on
both sides. While percussing on the back, ask the subject to keep his hands on the
opposite shoulders and while percussing the axillary areas, ask him to keep his hand
over the head .Normally, resonance is heard over lung areas and dullness over liver and
heart areas.

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 Hyper resonance is common in pneumothorax as well as in emphysema. Dullness is
seen in fibrosis, consolidation, collapse of lung, and effusion. In pleural effusion we get
stony dullness.

Normally the lower border of right lung lies over the liver. Normally liver dullness is
obtained in the 5th Right Intercostal space in the midclavicular line. Lower border of left
lung lies over the stomach. So there is transition from lung resonance to tympanic
stomach resonance.

IV. AUSCULTATION

Using stethoscope auscultate the corresponding areas of either side, character of

breath sound, duration of various phases of respiration and intensity of breath sound.
Normally all over the chest vesicular breath sound is heard.

1. Vesicular breath sound: This is characterized by inspiratory phase, which is

continuous with a short expiratory phase. In vesicular breathing inspiration is fairly
intense, low pitched and audible throughout. Expiratory sound is less intense, audible
only in early part. There is no gap between the inspiratory and expiratory phase. The
vesicular breath sounds are produced when air passes in and out of lung tissue.
Vesicular breathing with prolonged expiration is heard in airway obstruction.

2. Bronchial breath sound: Bronchial breathing is heard over trachea and bronchi. It is
more loud and harsh with almost equal inspiratory and expiratory phase with a pause in
between. Inspiration sound is moderately intense, audible only in early part, harsh and
high pitched. Expiratory sound is more intense than inspiration audible in all phase high
pitched and harsh. A definite gap between inspiratory and expiratory phase.

Bronchial breath sounds are produced by passage of air through main respiratory
tubes. It is not heard in normal lung tissue, if heard it is abnormal. Bronchial breath
sound from lung tissue is heard in consolidation.

Vocal resonance:

Ask the subject to say „one, one‟ repeatedly and auscultate different areas in
corresponding areas of both sides. It is heard with equal intensity on both sides. If it is
increased, the sounds appear to be nearer to earpiece of the stethoscope. Then it is
known as bronchophony. Still higher intensity, words become clear and sound as if
spoken into the examiners ear, it is called whispering pectoriloquy. This occurs in
consolidation of lung and large cavities. Vocal resonance is diminished in pleural
effusion and pneumothorax.

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Adventitious sounds or added sounds:

Rhonchi or Wheeze: It is prolonged uninterrupted sounds arising in bronchi due to

partial obstruction of lumen. Partial obstruction can be produced by mucosal swelling,
viscid secretion or bronchial smooth muscle spasm resulting in turbulent outflow.
Rhonchi are usually heard in bronchial asthma. Rhonchi are musical in character.

Crackles (Crepitations or Rhales): This are discontinous, typically inspiratory

sound created when alveoli and small airways open and close with respiration. They are
often associated with pneumonia and interstitial lung disease.

Pleural rub: Seen in pleurisy. Pleural rub is unchanged following cough. They occur
during late part of inspiration and early part of expiration.

REPORT:

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 EXAMINATION OF ABDOMEN
AIM:
To examine the abdomen of the given subject.

APPARATUS: Stethoscope, measuring tape

PROCEDURE:
Note the biodata of the patient. Do the general examination and then the examination
of the abdomen.

EXAMINATION OF ABDOMEN
I. INSPECTION

a) Skin and surface of the abdomen

1. Whether stretched or not
-in marked distension, skin is smooth and shiny
-white or pink linear marks are produced by gross stretching of skin with
rupture of the elastic fibres. Eg: Pregnancy, ascites, cushing syndrome
2. Note for scars (recent or old) that may indicate previous surgeries
3. Pigmentation Eg: Linea nigra seen in pregnancy

b) Shape of the abdomen

Observe the normal abdominal contour. Normal contour is flat (the rib margins and the
abdominal wall are about the same level).
Abnormalities:
- Sunken (scaphoid) abdomen is seen in severe malnutrition, starvation and
malignant diseases – carcinoma of oesophagus or stomach
- Generalized fullness or distension due to fat, fluid, flatus, faeces or foetus (5F’s)

c) Abdominal Symmetry
Normal abdomen is symmetrical.
-Localized fullness due to gross enlargement of liver, spleen or any other organ or
tumors may result in asymmetry

20
d) Umbilicus
Normally the umbilicus is slightly retracted and inverted or level with the skin surface;
everted or ballooned out in umbilical hernia due to raised intra abdominal pressure;
transversely stretched in ascites.

e) Movements during respiration

In males, the diaphragm is more freely used than intercostal muscles and its free
movement causes a free outward movement of abdomen – abdominothoracictype.The
abdomen moves freely with respiration, rising gently during inspiration and falling
during expiration. In females, respiration is mainly thoracoabdominal. The abdominal
movements may be restricted in generalized peritonitis, tense ascites, inflammation of
diaphragm or injury of abdominal muscles.

f) Presence of visible pulsation

Presence of visible pulsation of abdominal aorta in the epigastrium can be seen in
nervous, thin individuals. Pulsations from a pulsating liver or right ventricle can also be
seen in the epigastrium.

g) Visible peristalsis
Peristalsis may be seen visible as a movement of slow wave on the abdomen in persons
with thin abdominal wall, malnourished children or cachexia. It may also indicate pyloric
and small and large intestinal obstruction.

h) Presence of prominent veins

- Small thin veins over the subcostal margin are common in thin
individuals -distended veins around umbilicus indicate portal
hypertension
- Prominent veins over the abdominal wall and chest wall indicate obstruction of
inferior venacava

i) Hernial sites
The hernia sites in the groin should be looked for any swelling on straining or
coughing.

II. PALPATION

Method of palpation:

The right hand is placed flat on the abdomen, with the wrist and the forearm in the
same horizontal plane.

21
The relaxed hand is moulded to the abdomen with the fingers almost straight with
slight flexion at the metacarpophalangeal joints.

On palpation, the normal abdomen is soft, gives an elastic or doughy feeling and there
is no tenderness. Peritonitis produces rigidity from a reflex contraction of the muscles of
abdominal wall.

1. Palpation of liver
a) The palpation for the liver starts in the right iliac fossa and gradually worked up
to the right costal margin
b) As the patient inspires deeply, the fingers are pressed firmly inward and upward.
c) If the liver is palpable, it meets the radial aspect of the index finger as a sharp
regular border.
Normally, liver is not palpable. Liver becomes palpable, it is
enlarged(hepatomegaly) and sometimes in children.
Causes: Congestive liver failure, hepatitis, liver abscess, malignancy. If palpable,
the character of its surface is noted- whether soft and smooth, very firm or hard,
irregular.

2. Palpation of Spleen
a) The flat of the right hand is placed on the right iliac fossa and the left hand is
placed over the left lowermost ribcage posterolaterally.
b) The left hand presses medially and downward while the right hand presses
deeply toward the left costal margin to feel for the spleen.
c) If the enlargement of spleen is suspected and it is not still palpable, turn the
subject onto his right side and repeat the whole procedure.
Normally, the spleen is not palpable. Spleen becomes palpable,when it is
enlarged two to three times its normal size(splenomegaly).
Causes: Malaria, kalaazar, typhoid, portal hypertension, some anemias, acute
leukemias, chronic myeloid leukemia.

3. Palpation of Kidney

Left Kidney

a) The right hand is placed anteriorly in the left lumbar region while the left hand is
placed posteriorly under the costal margin.
b) As the subject takes a deep breath, the left hand presses forward and the right
hand presses backward, upward and inward; and an attempt is made to feel for
the kidney between the pulp of the fingers of the two hands.

22
 The left kidney is usually not palpable unless enlarged or low in position.

Right Kidney
a) The right hand is placed anteriorly in the right lumbar region with the left hand
placed posteriorly in the right loin.
b) As the subject takes a deep breath, the left hand presses forward and the right
hand pushes inward and upward; an attempt is made to feel for the kidney
between the fingers of the two hands.
c) The lower pole of the right kidney is commonly palpable in thin subjects as a
smooth, rounded swelling which descends on inspiration.

III. PERCUSSION

Using light percussion, all the nine regions of the abdomen are percussed
systematically. A resonant note is heard all over the abdomen except over the liver
where it is dull. The percussion note varies depending on the amount of gas in the
intestines. Ascites, tumors, enlarged liver or spleen give a dull note.

IV. AUSCULTATION

Auscultation is done by placing a stethoscope (diaphragm) on different areas of

abdomen for bowel sounds, peristaltic rub and bruit in the abdominal aorta and other
vessels.
Bowel sounds may be normal, absent or increased.
Normal bowel sounds are heard every 5-10 sec as intermittent gurgles, low or medium
pitched give an occasional high pitched noise. In simple mechanical obstruction of small
bowel, the bowel sounds are excessive or exaggerated, frequent loud low pitched
(borborygmi), while in peritonitis, bowel sounds are absent.

REPORT:

23
 EXAMINATION OF THE NERVOUS SYSTEM

The following are to be tested after bio data and general examination

1. Higher functions
2. Cranial nerves
3. Sensory system
4. Motor system
5. Reflexes

EXAMINATION OF HIGHER FUNCTIONS

1. Appearance and behaviour

Does the patient look well or ill? Cleanliness, mode of dressing, his interest in
surroundings etc should be watched. Look for any behavioral abnormalities.

2. Level of consciousness

Is there any clouding of consciousness? This is very important in cases of head injury or
raised intracranial tension
- fully conscious, drowsy, stuporous (person can be aroused by painful
stimuli),comatose (cannot be aroused even by painful stimuli)

3. Mental and emotional state

Look for any restlessness, anxiety, lowered mood, inability to concentrate, apathy or
depression. Enquire about sleep and dreams.

4. Orientation in place, time and person

Does the patient appreciate his surroundings and know where he is. Can he estimate
time without looking at the watch? Ask the subject about date, month and year. Can he
identify individuals who were previously familiar to him?

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5. Delusions and hallucinations

Delusions are false beliefs continued to be held despite evidence to the contrary.
Hallucinations are false impressions referred to the organs of special senses for
which no cause can be found. It can be auditory, olfactory or visual

6. Memory
It is the ability to grasp and retain images and ideas .Ask the patient questions to
test immediate and remote memory

7. General intelligence –can be assessed approximately by noting the

educational status, nature of work and work record

8. Speech –note whether speech is normal or not. Ask him to read a given
passage. Disorders of speech include dysarthria or aphasia.
Dysarthria denotes defect of articulation
Aphasia indicate disturbances in the structure and organization of language itself,
whether in speaking, writing or comprehending. It may be sensory or motor.

REPORT :

25
 24

EXAMINATION OF CRANIAL NERVES

AIM:
To examine the cranial nerves of the given subject.
Biodata :
General Examination :
Vital signs:

EXAMINATION OF NERVOUS SYSTEM:

HIGHER FUNCTIONS:
Examination of higher functions include
1. Appearance and behaviour of the subject
2. Level of consciousness
3. Emotional state
4. Orientation in time place and person
5. Delusion and Hallucination
6. Memory i.e. Long term and short term
7. General intelligence
8. Speech.

EXAMINATION OF CRANIAL NERVES:

I. Olfactory Nerve:
Olfactory receptor cells are modified bipolar neurons present in the olfactory epithelium.
The central processes of the neurons pass through the cribriform plate to the olfactory
bulb where the cells of the second order neurons lie. From there, nerve fibres are
projected to the olfactory area of cerebral cortex, the uncus and the
parahippocampalgyrus.

To Test sensation of smell: Take three bottles containing oil of clove, oil of
peppermint and tincture of asafoetida. Ask the subject to close his eyes and present
these to each nostril of the subject separately. Ask him to recognize them. Avoid using
irritant substances as these may partially stimulate the trigeminal nerve.

26
 Anosmia: Absence of smell. It may be due to neurological defects or due to local
changes in the nose itself eg. Catarrh (common cold). Parosmia is perversion of the
sense of smell eg. offensive substances may seem to have a pleasant smell and vice
versa. Enquire about hallucinations of smell also. This is characteristically seen in
temporal lobe epilepsy.

II. Optic nerve:

Purely sensory - Fibres of the optic nerve from the retina pass back to the optic
chiasma. Here the fibres from the inner nasal half of each retina which represents the
temporal field decussate. Fibres from the outer temporal half which represent the nasal
field remain on the same side without crossing. Each optic tract formed after this
chiasmal decussation consists of fibres from the outer half of the retina of the same
side and inner half of retina of the opposite side. Each optic tract then passes
posteriorly to the lateral geniculate body of the same side. From these optic radiations
originate, pass through the posterior limb of the internal capsule and then projects
posteriorly to the calcarine cortex of occipital lobe.
Three functions. of optic nerve have to be tested.
1. Visual acuity 2. Visual fields 3.Colour vision.
1. Visual acuity :
Far vision is measured with Snellen’s chart. In this a series of letters of varying size
are constructed so that the top letter is visible to the normal eye at 60m and
subsequent lines at 36m, 24m, l8m, 12m, 9m, 6m, and 5m, respectively. Visual acuity
(V) is recorded according to the formula.
v = d where
D
d = distance at which letters are read
D = distance at which they should be normally read.

The subject is placed at a distance of 6m from the chart (d = 6). Each eye is tested
separately, the other one being kept closed. The subject reads down the chart as far as
he can. If only the top letter is visible, the visual acuity is 6/60. A normal person will
read at least up to the 7th line i.e. visual acuity is 6/6. If the visual acuity is less than
6/60 the subject should be moved towards the chart, until he can read the top letter. If
the top letter is visible at 2m, the visual acuity is 2/60. If acuity is less that 1/60 it is
tested by (1) counting fingers, (2) hand movements, (3) perception/ no perception of
light.

27
 Test for near vision: Visual acuity at reading distance is assessed by using reading
text types of varying sizes based on Printers’ point system. The smallest print is N5.
Near vision is recorded as the smallest type, which the person can read comfortably.
2. Visual fields:

It is the extent of vision while the eye is fixed on any object. The simplest method of
assessing the visual field is the confrontation method. It consists of comparing the
extent of the subject’s visual field with that of the examiner’s. Each eye must be tested
separately (for monocular vision)
Confrontation test: The subject is seated opposite the examiner at a distance of
about 1 m from him If the subjects right eye is to be tested his left eye is covered and
he is asked to look steadily at the examiner’s left eye. The examiner should cover his
right eye with the hand and gaze steadily at the subject’s right eye. Then the examiners
left hand is held up in a plane midway between the patient’s face and his own at almost
a full arm’s length to the side. The hand is brought nearer while moving the fingers
until the examiner can just see the movements of the fingers with the tail of his eye.
Ask the subject whether he can see the movements while fixing his gaze on examiners
eye. If he fails to see the fingers, keep bringing the hand nearer until he can see them.
Test the field in this manner in each direction, upwards, downwards to the right and to
the left. Test the other eye in the same way.
Perimetry: Instrument used to measure the monocular field of vision and can be
used to assess the visual fields.
Changes in field of vision: Central scotoma is a zone of loss of vision confined to the
centre of the field. The visual field may be constricted all around its periphery when it is
called concentric constriction of visual field.
Loss of sight in one half of visual field is called hemianopia. When the same half of
both visual fields is lost, hemianopia is described as homonymous. In right
homonymous hemianopia the right half of the field of each eye is affected. Bitemporal
and binasal hemianopia are described as heteronymous. If vision is lost only in one
quadrant of the eye it is called quadrantanopia.

3. Colour vision :

Most easily tested using Ishihara’s charts. People with defective colour vision confuse
certain colours. Ishihara’s charts are so constructed that a person with abnormal colour
vision will read a different number from a normal person on the same colour plate. Most
common abnormality of colour vision are various types of red green colour blindness.

4. Light reflex and accommodation reflex- also to be tested for optic nerve

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III, IV, VI: Oculomotor, Trochlear and Abducent Nerves :
These three nerves are tested together because they function as a physiological unit
in the control of ocular movements (purely motor). The trochlear nerve innervates the
superior oblique muscle and abducent nerve innervates the lateral rectus. All the other
extra ocular muscles, sphincter pupillae and levator palpebrae superioris are supplied by
the oculomotor nerve. To assess the function of these nerves the things to be looked
for are
1. Ocular movements
2. Presence of squint or ptosis
3. Pupillary abnormalities.
Ocular movements: Look for horizontal movements adduction and abduction and
vertical movements elevation and depression. Intorsion and extorsion are involuntary
and so can‟t be tested. Recti act as depressors and elevators when the eye is in
abduction and the oblique act as elevators and depressors when the eye is in
adduction. Medial and lateral recti act directly in single plane.
Look for the presence of squint or ptosis: In abducent nerve lesion the person is
unable to move the eye outwards and diplopia will be present on looking in that
direction. In trochlear nerve lesion downward movements of eye in adducted position is
lost. In complete oculomotor palsy there is ptosis and eye is displaced downwards and
outwards.
Pupil: Size, shape and mobility of pupils are studied.
Size: Compare the size of the pupils first in bright light and then in dim light. Normally
they are of equal size, but slight inequality may be seen even in perfectly healthy
subjects.
Shape: Note whether the pupil is circular or whether its contour is irregular.
Mobility: Reaction to light is a reflex action. The afferent fibres travel in the optic
nerve, leaves it before reaching the lateral geniculate body to enter the brain stem in
the pretectal region. These fibres then synapse in the oculomotor nuclei. Efferent fibres
reach the pupillary sphincters in the IIIrd nerve after synapsing again in the ciliary
ganglion at the orbit.

Reaction to light
Direct light reflex: The subject is seated in an indirectly illuminated place. Ask him to
look into the distance. Each eye is examined separately. Shine a bright light into the eye
taking care to bring in the light from the side. The pupil should constrict almost

29
immediately. When the light is switched off, the pupil will rapidly dilate to its previous
diameter.
Indirect Light relex : (Consensual light reflex) -Keep one eye shaded. Shine a bright
light into the other eye. The pupil of the shaded eye is also seen to contract due to
crossing of fibres to the opposite side in optic chiasma as well as in the brain stem.
Reaction to accommodation: The subject is asked to look at a far object. The
examiner brings his finger, holding it vertically, about 15 cm in front of the subject’s
nose and subject is asked to looked at it. As the eyes converge to accomplish this, the
pupils become smaller. During accommodation there is also increase in anterior
curvature of the lens (3C‟s – Convergence of eyeball, constriction of pupil, Change of
anterior curvature of lens).
Afferent is optic nerve and efferent is oculomotor nerve.
Pupillary abnormalities :
Argyll Robertson pupil: The pupil is small and irregular. Reacts briskly to
accommodation, but does not react to light directly or consensually. Classically seen in
Neurosyphilis.
Hippus is a rhythmic dilatation and constriction of the pupil either in response to light or
occurring spontaneously. Seen in retrobulbar neuritis.
Adie’s pupil: Absent or delayed pupillary constriction to light or to accommodation. Once
constricted, the pupil dilates only very slowly either in response to darkness or to far
gaze.

V. Trigeminal Nerve:
Has a sensory and a motor root (Mixed nerve).
Sensory root: Origin is from nerve cells in the Gasserian or trigeminal ganglion. It has
sensory distribution through its three branches -ophthalmic, maxillary and mandibular.
It supplies the skin of the face excluding the angle of the jaw. It also supplies the
cornea, sinuses, mucous membrane of the nose, teeth, tympanic mem- brane and
common sensations other than taste to the anterior 2/ 3rd of tongue.
Tests :
I. Test for touch, pain and temperature sensations on both sides of the face.

2. Corneal reflex: Tested using a bit of cotton twisted into a fine hair. Ask the subject
to gaze into a distance and lightly touch the lateral end of the cornea at its conjunctival
margin with the cotton wisp. If the reflex is present, the subject blinks. The cornea
should not be wiped with cotton and central part of cornea should never be touched. To
do so carries the risk of corneal ulceration and subsequent visual impairment. The two

30
sides can be compared more easily by lightly blowing a puff of air into each cornea in
turn. Afferent for corneal reflex is 5th nerve and efferent is 7th nerve.
3. Conjuctival reflex: A bit of cotton is used to touch the conjunctiva. This results in
blinking of both eyes. Afferent is 5th nerve and efferent is 7th nerve.

Motor root: Supplies muscles of mastication -pterygoids, temporalis and masseter.

Tests :
I. Ask the subject to clench his teeth. Feel for the contraction of the masseter and
temporalis muscles on both sides. They stand out with equal prominence on both sides.
If there is paralysis on one side, the muscles on that side will fail to become prominent.
2. Ask the subject to open his mouth. If there is paralysis on one side, on opening the
mouth, the jaw will deviate towards the paralysed side. This is because the paralysed
side is being pushed over by the healthy lateral pterygoid muscle.
VII. Facial Nerve :
Mixed nerve - This nerve is attached to the brain stem by motor and sensory roots
(Nervus intermedius). The two roots run laterally and downwards to reach the internal
acoustic meatus and fuses at the bottom of meatus and leaves the skull by passing
through the stylomastoid foramen. The nerve crosses the styloid process, enters the
parotid gland and divides into 5 terminal branches. Supplies most of the muscle of facial
expression and stapedius.Sensory to external auditory canal and taste sensation to
anterior two third of the tongue.

Tests :
1. Ask the subject to look upward without moving his head. Look for wrinkling of
the forehead (occipitofrontalis)
2. Ask the subject to shut his eyes as tightly as he can. Then examiner tries to
open the eyes while the subject attempts to keep them closed. If the orbicularis
oculi is acting normally, it is impossible to make the eyes open with normal
effort.
Bell’s phenomenon- When one tries to shut eyes tightly, eyes roll upwards- a
normal response. In bell’s palsy when the patient closes his eyes, the upward
movement of the eyeball become obvious because closure of affected eye is not
possible
3. Look for the presence of nasolabial fold.
4. Ask the subject to smile or show his upper teeth. In facial nerve lesion, there is
deviation of angle of mouth to normal side.
5. Ask the subject to whistle.

31
 6. Ask the subject to inflate his mouth and blowout his cheeks (Buccinator). The
examiner tries to press on the cheeks. Air escapes easily on the weak or paralysed
side.
7. Test the sense of taste on the anterior 2/3rd of tongue by placing strong solution
of sugar or salt using a rod on the surface of the tongue. Ask the person whether
he can appreciate its taste before withdrawing the tongue to his mouth.
8. History of hyperacusis will be present in paralysis of stapedius.

Abnormalities :

1. Supranuclear lesion (upper motor neuron lesion): Only the lower part of face is
affected because of bilateral innervation of upper part.

2. Nuclear or Infranuclear lesion (lower motor neuron lesion): Here both the upper
and lower parts of face are equally affected. .
3. Bell’s palsy: Is a case of isolated infranuclear lesion, of unknown cause. May be
caused by oedema of facial nerve in the facial canal.

VIII. Vestibulo cochlear nerve

Purely sensory nerve - Cochlear part is concerned with hearing while vestibular part
is concerned with equilibrium. Auditory receptors are the hair cells of the organ of Corti
situated in the cochlear duct of internal ear .The central processes of the neurons
innervating the receptors form the cochlear nerve which ends in dorsal and ventral
cochlear nuclei. Vestibular receptors are the maculae of saccule and utricle and cristae
of the ampullae of the semicircular canals. The central process of the neurons which
innervate the vestibular receptors form vestibular nerve which ends in vestibular nuclei.
Tests:
1. Watch test :
Ask the subject to shut his eyes. Close the opposite ear. Place a sound source such
as wrist watch at the probable range of hearing. Bring it gradually nearer to the ear.
Ask the subject to tell whether he can hear it or not.
2. Tuning fork test :

The hearing impairment can be either due to defect of the nerve or of middle ear.
Differentiation can be made by tuning fork test. The tuning fork has a frequency of 256
or 512 Hz.
a. Rinne’s test: Place the base of the vibrating tuning fork firmly over the mastoid
process. When it becomes inaudible, bring it close to the ear with the vibrating prongs
parallel to the ear and ask the subject whether he can hear the sound. Normally it can
be heard i.e., air conduction is better than bone conduction- Rinne Positive (normal). In

32
middle ear diseases bone conduction is greater than air conduction (Rinne negative). In
neurological damage, both bone and air conduction are impaired.
b. Weber’s test: Place the base of a vibrating tuning fork at the middle of the
forehead. The sound is heard equally on both sides or it is centralised. If there is middle
ear disease, the sound islateralised to the side of lesion. In sensorineural deafness it is
referred to the better hearing ear.
c. Schwabach test: This test compares subject’s bone conduction with examiner’s
bone conduction. It is assumed that examiner’s hearing is normal. Place the base of the
sounding tuning fork on the mastoid process of the subject. Ask him to tell when the
sound dies off. Immediately place the base of the tuning fork on the examiner’s mastoid
process. If the examiner can still hear the sound, the bone conduction is reduced in the
subject, there is some sensorineural loss.

Abnormal auditory sensations -

I. Any history of tinnitus -ringing sensation in the ear.
2. Any history of Auditory Hallucinations

Abnormal vestibular sensations

1. Any history of Vertigo(giddiness)

2. Nystagmus

IX. Glossopharyngeal Nerve

Mixed nerve- The fibres of the nerve pass forwards and laterally between the
olivary nucleus and inferior cerebellar peduncle, through the reticular formation of the
medulla. The filaments unite to form a trunk and passes forwards and laterally, leaves
the skull by passing through the middle part of the jugular foramen. It descends
between internal jugular vein and internal carotid artery, turns around the lateral aspect
of the stylopharyngeus muscle and reaches the side of the pharynx. It is motor to
stylopharyngeus, secretomotor to parotid gland, gustatory to the posterior 1/3rd of the
tongue and sensory to the pharynx, palatine tonsil and posterior 1/3rd of the tongue.

Tests :
1. Test the taste sensation on the posterior 1/3rd of tongue.
2. Test the gag reflex or pharyngeal reflex by touching the posterior part of the pharynx
with a swab. There will be reflex contraction of the pharyngeal muscles. Afferent is the
IX Nerve and efferent is the X Nerve.
3. Test for palatal reflex. Touch the palate with the tip of a twisted cotton wool. Reflex
contraction of palate results. Afferent -IX Nerve. Efferent X Nerve.

33
X. Vagus Nerve
Mixed nerve - The nerve is attached by about ten rootlets to the posterolateral sulcus
of medulla. The rootlets unite to form a large trunk and leave the skull through the
jugular foramen. Supplies the muscles of larynx and pharynx, heart and viscera of
abdomen.
Tests :
1. Ask the patient whether there is nasal regurgitation or history of dysphagia
2. Observe whether there is any nasal tone to the voice. Check the ability to say words
like ’egg’ and ‘rub’, which require complete closure of nasopharynx.

3. Ask the subject to open his mouth. See the position of uvula. Normally it is in the
midline.
4. Ask the subject to say “ah” and see if the palate arches up wards. If the vagus on
one side is affected the palate on that side and the median raphe is pulled towards the
healthy side. In bilateral vagal nerve paralysis, both sides remain motion less.
5.Test for palatal and pharyngeal reflex.
XI. Spinal Accessory Nerve
Purely motor nerve. It has a cranial and spinal root. The cranial root is distributed
through its branches to the muscles of the pharynx and larynx. Spinal part arises from
the upper five segments of the spinal cord. In the vertebral canal, the filaments unite to
form a single trunk and enters the cranium through foramen magnum behind the
vertebral artery. Within the cranium the nerve runs upwards and laterally, crosses the
jugular tubercle and reaches the jugular foramen. It leaves the skull through the middle
part of jugular foramen and fuses with a short length of cranial root. It soon separates
from the latter and passes out of the foramen. The nerve crosses the sternomastoid,
enters the posterior triangle of the neck and supplies the trapezius and sternomastoid
muscles.

Tests :
1. Stand behind the subject and ask him to shrug his shoulders against resistance. Then
trapezius
becomes prominent.
2. Ask the subject to turn his face towards the opposite side, while resistance is offered
to the chin. The sternocleidomastoids become prominent.

34
XII. Hypoglossal Nerve
Purely motor. The nerve is attached to the anterolateral suclus of medulla by 10-15
rootlets, which run laterally behind the vertebral artery and join to form two bundles
which pierce the duramater separately near the hypoglossal canal and leaves the skull
through it. It supplies the muscles of the tongue.
Tests :

1. Ask the subject to put out his tongue as far as possible. In XII Nerve palsy, tongue
will deviate to the paralysed side.
2. Ask the subject to move his tongue from side to side and push each cheek with it.
Also do it against resistance.
3. See whether there is any wasting of tongue.

4. Look for fibrillation and fasciculations of the tongue. The fasciculations should be
noted with the tongue relaxed in the mouth.

REPORT :

35
 EXAMINATION OF SENSORY SYSTEM

AIM: To examine the sensory system of the given subject.

PROCEDURE:
Sensory system is a part of Central nervous system. It is concerned with perception,
mediation and appreciation of various sensations. It includes
1. Tactile sensibility
a. Light touch
b. Pressure touch
c. Tactile localization
d. Tactile discrimination

2. Pain sensations
a. Superficial pain
b. Deep pain
3. Thermal sensibility
a. Warmth
b. Cold
4. Sense of position and appreciation of passive movements
5. Stereognosis
6. Vibration sense
7. Abnormal sensations
Precautions:
1. Explain to the subject the nature of the test going to be conducted and proceed with
the intelligent cooperation of the subject.
2. Ask the subject to close his eyes before the test whenever necessary
3. Corresponding points on both sides should be compared while testing, whether
perceived equally on both sides
4. Every now and then, negative tests should be employed to prevent the patient from
giving random answers.

36
Note the biodata. Do the general examination, examination of higher
functions.

EXAMINATION OF SENSORY SYSTEM

Sensory part of Cranial Nerves should be examined before proceeding to the
examination proper of the sensory system.
I. Tactile sensibility
a. Light touch or fine touch
A wisp of cotton wool is used to test fine touch. Ask the subject to say “yes‟ each
time he feels the touch sensation. Test all over the body on both sides starting from
face downwards. This sensation is carried by dorsal column tract to the brain.
b. Pressure touch or crude touch
It is tested with a blunt object like a pencil or fingertip carefully, without applying too
much pressure to avoid pain or any discomfort. Ask whether he can appreciate it or not.
Afferent pathway is through anterior spinothalamic tract.
c. Tactile localization
It is tested in the same way as above. But ask the subject to localize the point of
application of the stimulus either by describing or pointing out the spot. Pathway -
dorsal column tract.
d. Tactile discrimination or two point discrimination
Ability to discriminate between two points touched simultaneously is called tactile
discrimination. This can be tested using dividers or weber’s compass. A minimum
separation of 2mm is needed between the 2 points to be appreciated in highly sensitive
areas like fingertips where touch receptors are more in number. A wider separation is
needed in less sensitive areas like back, pulp of toes etc. Keep the limbs of the dividers
at a distance of 5 mm and touch with it on different parts of the body. Ask whether he
can appreciate it as a single point or two. Increase the distance till he can appreciate it
as two points. The receptors are touch receptors. It depends on touch and also has a
cortical component. Afferent pathway is dorsal column tracts.
If any area of decreased or absent touch sensation is detected, mark out the
boundaries of that area. Receptors for touch are Meissner’s corpuscles, Merkel’s disc,
Ruffini’s nerve endings or basket like network around hair follicles.
Alterations in touch sensibility:
Hypoaesthesia -reduced tactile sensation

Hyperaesthesia - touch stimulus produces a painful impression like pricking or burning.

It is seen in hysteria.

37
Anaesthesia -loss of all sensations including pain.

38
II. Pain sensation
a. Superficial pain
Tested by using the point of a pin. See that the subject is not confused with pain
sensation and sharpness of the object. Even in the absence of pain sensation subject
can recognize the sharpness of the object.
b. Pressure pain or Deep pain
Tested by squeezing the muscle or pinching the Achilles tendon.
Pathway- Lateral spinothalamic tract
Receptors -Unmyelinated free nerve endings

Alterations :
Analgesia - absence of appreciation of pain sensation
Hypoalgesia - decreased appreciation in pain sensation
Hyperalgesia - increased sensitivity to pain. This occurs in some patients with
spinal cord disease and deep seated parietal or thalamic lesion.

III. Thermal sensibility

Tested by using test tubes containing hot and cold water touched in turn on the part
to be tested. The subject is asked to say whether he feels hot or cold. Too hot or too
cold water should not be used. It will provoke only pain sensation. This is the first
sensation to be lost in leprosy.
Pathway- Lateral spinothalamic tract Receptors -Modified nerve ending, separate for
cold and warmth
IV. Sense of position and appreciation of passive movements
Sense of position: It implies the ability to imitate on the opposite side of the body
with eyes closed or patient looking away, the same position in which the limb or its part
has been placed. Ask the subject to close his eyes. One of his limbs is held in examiners
hand and moved passively in different directions. Finally keep it in any definite position.
Ask him to imitate the position on the opposite side. While the sense of position is being
tested, the part being tested should not touch any other part of the body.
Appreciation of passive movement or joint sense: any digit or limb is held by
the examiner and moved gradually to another position. While moving ask the subject to
say “yes‟ when he can recognize the movement. At the same time ask the subject to
say in which direction the movement is carried out. Normally 100 movement is enough
to be recognized in all normal joints. The position and joint senses are lost in conditions
affecting posterior column of spinal cord.
Receptors- muscle spindle and Golgi tendon organ in muscles, free nerve endings
around the joints and Ruffini’s end organs, Pacinian corpuscle
Pathway - dorsal column tract

39
V. Stereognosis
It is the ability to recognize common objects like pen, pencil, key etc., with eyes
closed from their size, shape and form. This ability obviously depends upon relatively
intact touch and pressure sensation, but it also has a large cortical component. To test
this, take some familiar objects in the palm and ask to identify them with eyes closed.
Two objects differing only in size are placed on the palm and ask the subject to say
which is smaller or larger. Absence of this sensation is called astereognosis. This occur
in parietal lobe and posterior column lesions
Receptors- Touch and pressure receptors
Pathway - Dorsal column tract
VI. Vibration sense
It is a tingling sensation felt when the foot of a vibrating tuning fork is applied on the
skin over an underlying bone. Strike the arms of the tuning fork (128 Hz) firmly and
make it vibrate. Place the foot of the tuning fork over the sternum to make the subject
understand what vibration sense is. Then the foot of the vibrating tuning fork is placed
on different bony prominences and tested. Ask the subject to say at once when
vibrations stop. Immediately place the foot of the fork over the examiner’s body over
the same bony prominence and see whether the examiner can perceive the vibration. If
vibration sense is lost the subject cannot feel the vibration. If the vibration sense is
decreased, the examiner can perceive the vibration after taking the tuning fork from the
subject’s body. A pattern of rhythmic pressure stimuli is interpreted as vibration.
Receptors- touch receptors mainly Paccinian corpuscle.
Pathway- Dorsal column tract.
Vibration sense is lost in Tabes dorsalis, peripheral neuritis, Pernicious anaemia,
posterior column lesions.
VII. Abnormal sensations: are called paraesthesia. Consists of various sensation
experienced by the subject in the absence of any sensory stimulus. Eg: numbness,
itching, pins and needles sensation, feeling of insect crawling over the body etc.
Sensory inattention: seen in patients with parietal lobe lesions. To demonstrate
this, ask the patient to close his eyes. Corresponding points on two sides of the body
are tested simultaneously with identical stimulus- either pain, tactile or thermal stimuli.
Ask the patient to say which side is tested. Subjects with sensory inattention cannot
appreciate the stimulus on affected side, the lesion being on the opposite side of the
brain.
Romberg’s sign: The subject is asked to stand with his feet close together. If he
can do this he is asked to close his eyes. If Romberg’s sign is present he begins to sway
about or may even fall as soon as his eyes are closed that is, the patient is more

40
unsteady standing with eyes closed than open. This sign is positive in posterior column
disorders (Sensory ataxia).

REPORT:

41
 EXAMINATION OF MOTOR SYSTEM
AIM: To examine the motor system of the given subject.
Examination of Motor system has to be carried out under the following headings.
1. Bulk of muscles
2. Tone of muscles
3. Strength of muscles/power
4. Reflexes
5. Coordination of movements

6. Gait

7. Involuntary movements

Note the biodata. Do the general examination, examination of higher

functions and motor part of cranial nerves.

EXAMINATION OF MOTOR SYSTEM

1. Bulk of muscle can be assessed by inspection and palpation. Circumference of
different parts of the limbs can be measured with a tape and compared with the
opposite side. Measurements should be taken at definite distances from definite bony
prominences. If there is wasting or atrophy, the muscles are smaller, softer and more
flabby than normal. When wasting is accompanied by fibrosis, the muscle feels hard
and inelastic and difficult to stretch passively. This is called contracture. Generalised
wasting maybe due to chronic debilitating diseases. Localised atrophy may be due to
injury or disease at a joint. In such cases strength is preserved. The main neurological
cause of muscle wasting is lower motor neuron lesion. In upper motor neuron lesion
wasting may occur due to prolonged disuse (Disuse atrophy).

2. Tone: Muscular tone is a state of tension or partial contraction or resistance offered

by muscle to stretch. It is found in healthy muscles. The degree of tone is estimated
by handling the limbs and moving them passively at various joints. Note the resistance
offered and compare both sides. Hypertonia is increase in tone and hypotonia is
decrease in tone.

42
Hypotonia: There is little or no resistance to passive movements of the limbs and when
the limb is lifted and let go, limb falls down inertly. They are also abnormally soft and
flabby to palpation. Hypotonia is seen physiologically in sleep and on treatment with
certain drugs. Pathologically it is seen in LMN lesions, lesions of afferent pathways &
cerebellar lesions.
Hypertonia is of different types.
1. Spasticity - Hypertonia is seen following UMN lesions. Eg.lesions of corticospinal
tract. This type of spasticity is referred to as clasp knife spasticity, This is characterised
by increased resistance to passive movement which is maximal at the beginning of
movement and suddenly decreases as the passive movement is continued. It occurs
predominantly in flexor muscles of upper limb and extensor muscle of lower limb.
2. Rigidity - Increase in resistance to passive movement is uniformly present through
out the range of movement and is known as “lead pipe” rigidity. This is seen in
parkinsonism. Sometimes, there is a series of “catches” during passive motion, due to
tremor being superimposed on rigidity. This is known as “Cog Wheel Rigidity”.
3. Strength of muscle: A quick and reliable method of making preliminary
assessment of strength of muscle is to watch the subject performing his routine
activities. eg: walking. Strength of the individual muscles can be assessed more
formally by active movements against resistance, offered by the examiner.
Grading of Muscle power
The Medical Research Council Scale is usually used to grade muscle weakness.
Grade 0 - Complete paralysis
Grade I - A flicker of contraction only.
Grade II - Muscle power detectable only when gravity is excluded by
appropriate postural adjustments
Grade III - Limbs can be held against the force of gravity but not against the
Examiner’s resistance.
Grade IV - There is movement against resistance but not to normal extent.
There is some degree of weakness.
Grade V - Normal power is present.

MOTOR PART OF CRANIAL NERVES

Motor part of Cranial Nerves should be examined before proceeding to the
examination proper of the motor system.

43
MUSCLES OF UPPER LIMB
Abductor Pollicis Brevis: The subject is asked to abduct his thumb in a plane at right
angles to the palmar aspect of index finger against resistance of examiner’s own thumb.
The muscles can be seen and felt.

Opponens Pollicis: Ask the subject to touch the tip of his little finger with the point of
his thumb. Oppose the movement with your thumb or index finger.

First dorsal interosseus: Ask the subject to abduct his index finger against your
resistance
The interossei and lumbricals:
1. Ask the subject to flex the metacarpophalangeal joints and extend the interphalangeal
joints.
2. Ask him to adduct and abduct his fingers.
3. Give the subject a piece of paper or a card and ask him to grip it between the
fingers-card test. When the muscles are weak the subject will either be unable to grip it
or will offer poor resistance to its withdrawal. When these muscles are paralysed, a
claw hand deformity is produced. The first phalanges are over extended and the distal
ones are flexed.
Flexors of fingers: Ask the subject to squeeze examiner’s index and middle fingers
and assess the strength of the grip.
Flexors of wrist: Ask him to bring the tips of his fingers towards the front of the
forearm.
Extensors of wrist: Ask the subject to make a fist, which results in contraction of
both extensor and flexors of the wrist. Then forcibly try to extend the wrist against
resistance. The wrist flexors can also be tested similarly by forcibly trying to flex the
wrist against resistance. Radial nerve palsy leads to weakness of the extensors,
resulting in a condition called wrist drop.
Brachioradialis: Place the arm midway between prone and supine positions. Ask the
subject to bend up the forearm while the examiner opposes the movement. The
healthy muscle will be seen and felt to stand out prominently.
Biceps: Ask the subject to bend up the forearm against resistance with the forearm
in full supination. The muscle will stand out prominently.
Triceps: Ask the subject to extend the forearm against your resistance.
Supraspinatus: Ask the subject to lift his arm straight out at right angles to his side.

44
 Deltoid: The next 600 of shoulder abduction is by the middle fibres of deltoid. The
anterior and posterior fibres help to draw the abducted arm forwards and backwards.
Infraspinatus: Ask the subject to tuck his elbow into his side with forearm flexed to a
right angle. Then ask him to rotate the limb outwards against the examiner’s
resistance, the elbow being held against the side throughout. The muscle can be
seen and felt to contract.
Pectorals: Ask the subject to stretch his arm out in front of him and then to clasp his
hands together while the examiner tries to hold them apart.
Serratus anterior: Elevating the arm above right angles or pushing forwards with the
hands against resistance result in winging of scapula, if the muscle is paralysed.
Latissimus Dorsi:
1. Subject is asked to raise the arm laterally upto the horizontal level and is then
asked to adduct the arm against resistance exerted by the examiner.
2. The subject is asked to clap his hands at his back while the examiner (standing
behind the subject) offers passive resistance in backward and downward
direction.

MUSCLES OF THE TRUNK

(1) Make the subject to lie on his back with legs extended. Ask him to rise up
without using hands. If there is weakness of abdominal muscles, the subject is unable
to do it. In spastic paralysis of the leg, the affected limb will rise first - Babinski’s
rising up sign.
(2) Ask the subject to lift up his head from the pillow against resistance. With paralysis
of lower region of anterior abdominal wall the umbilicus moves upwards. When the
upper segment is affected, the umbilicus is pulled downwards -Beevor’s sign.
(3) To test erector spinae and muscles of the back, make the subject to lie on his face
and try to raise his head from the bed by extending the neck and back. The muscles, if
healthy, will stand out prominently during this effort. The trapezius is tested by asking
the subject to shrug his shoulders while the examiner tries to press them down from
behind.

MUSCLES OF LOWER LIMBS

Dorsiflexion and plantar flexion of feet and toes: are tested by asking the subject to
elevate or depress the part against resistance.
Extensors of knee: Bend up the subject‟s knee. Ask him to try to straighten it out
again.

45
 Flexors of knee: Raise the leg up from the bed supporting the thigh with your left
hand and holding the ankle with your right. Ask the subject to bend his knee against
resistance.
Flexors of the thigh: Ask the subject to raise his leg from the bed with the leg
extended against resistance.
Adductors of thigh: Abduct the limb and ask the subject to bring it back to the
midline against resistance.
Abductors of thigh: Place the subject’s legs together and ask him to separate them
against resistance.
Rotators of the thigh: With the lower limb extended on the bed ask the subject to
roll outwards or inwards against resistance.
Extensors of hip: Lift the subject’s foot off the bed with his knee extended. Ask him
to push it down against resistance.
Patterns of weakness
Hemiplegia - Paralysis of one side of the body.
Paraplegia - Paralysis of both legs
Monoplegia - Paralysis of one limb
Quadriplegia - Paralysis of all four limbs.

4. Reflexes
5. Co-ordination of movements
In order to accomplish a definite motor activity, coordination of groups of muscles is
required. If such co-ordination is imperfect, motor activities become difficult or even
impossible.
TESTS OF CO-ORDINATION
Upper Limbs :
Finger nose test: Ask the subject to fully extend the arm. Then he is asked to touch
the tip of his nose and then your finger with his index finger. Repeat with the other
hand also. If he performs the movement naturally and without making errors,
coordination is normal. In persons with cerebellar ataxia, this is not possible.
Dysdiadochokinesia: Impaired ability to execute rapidly repeated movements. The
subject is asked to flex his elbow to a right angle and then alternately supinate and
pronate his fore arm as rapidly as possible. When dysdiadochokinesia is present the
movements are slow, awkward, incomplete, irregular and impossible after a few
attempts. This is seen characteristically in cerebellar ataxia.
Lower limbs :
1. Ask the subject to walk along a straight line. If incoordination is present he will soon
deviate to one side or the other.

46
2. Heel knee test: If the person cannot walk, ask him as he lies on the bed to lift one
leg high in the air to place the heel of his leg on the opposite knee and then slide the
heel down his shin towards the ankle with his eyes open. In cerebellar ataxia, irregular
side to side errors in the direction of movements occur.
6. Gait
The legs should be adequately exposed for examining the gait. The feet should be
bare. The subject is asked to walk away from the observer, to turn around at a point
and come towards him again. If there is any abnormality exclude local causes like old
injury of a joint or local pain. Certain well recognised abnormal types of gait are:
1. Spastic gait eg: hemiplegia
2. Stamping gait eg: sensory ataxia
3. Reeling gait (or drunken gait) eg: cerebellar lesion
4. Festinant gait eg: parkinsonism
5. Waddling gait eg: Myopathies, muscular dystrophies.
6. High stepping gait eg: common peroneal nerve palsy
7. Involuntary Movements
In certain diseases of the nervous system, involuntary unintended movements occur
either at rest or during voluntary movement. Most of them are due to diseased basal
ganglia and extrapyramidal system.
1. Epilepsy :The movement is complex and repetitive
2. Tremor: Regular or irregular distal movements having an oscillatory character.
Seen in thyrotoxicosis,Parkinsonism,cerebellar disease.
3. Athetosis: seen in lesions of basal ganglia.
4. Chorea

REPORT :

47
 EXAMINATION OF REFLEXES
The basis unit of integrated neural activity is the reflex arc. This arc consists of the sense
organ, afferent neuron, one or more synapses in a central integrating station or
sympathetic ganglion, an efferent neuron and an effector organ. In mammals the
connections between afferent and efferent somatic neurons is generally in brain or spinal
cord. Damage to any part of the arc may cause disturbance of reflex action.
Reflexes are classified into
1. Superficial reflexes
2. Deep reflexes or tendon reflexes
3. Visceral or sphincteric reflexes
1. Superficial reflexes: These are polysynaptic, elicited by stimulating the skin or
mucus membrane, resulting in the contraction of the muscle or a group of muscles.
a. Conjuctival reflex
Afferent for this reflex -Ophthalmic division of trigeminal nerve
Efferent -Facial nerve
Centre -in Pons
Effector organ - orbicularis oculi.
b. Corneal reflex
Afferent and efferent are same as that of conjuctival reflex
c. Palatal reflex
Afferent- IX Cranial Nerve
Efferent -X Cranial Nerve
Centre: medulla
d. Superficial abdominal reflexes
Ask the subject to lie relaxed in the supine position with abdomen uncovered. A light
stimulus like a key is passed over the abdominal skin from outer aspect towards the
midline. Contraction of underlying musculature is seen. It is difficult to elicit this in anxious
persons, in elderly or obese and in multiparous women.
Spinal segments concerned are T7-T12. These reflexes are absent in upper motor
neuron lesion above the spinal level. In diseases of thoracic spine they may indicate the
segmental level of lesion by their absence below this level.

48
e. Plantar reflex: (Root value L5, S1 )- Muscles of the lower limb are relaxed.
Outer segment of the sole of foot is stimulated by gently scratching with a key or stick from
the heel towards the little toe and medially across the metatarsals up to the base of the big
toe. In healthy adults even a slight stimulus produces contraction of the tensor fascia lata,
often accompanied by a slighter contraction o f adductors of thigh and of the sartorius.
With a slightly stronger stimulus, flexion of outer four toes appears which increases with
the strength or stimulus, till all the toes are flexed and drawn together, the ankle being
dorsiflexed and inverted. This is called the flexor plantar response.
Abnormalities: Extensor plantar response is known as Babinski’s sign (Babinski’s extensor
plantar response) and was first described by Babinski. It is seen in patients with
corticospinal tract lesion. In this, dorsiflexion or extension of the great toe is followed by
spreading out and extension of other toes, by dorsiflexion of the ankle and by flexion of hip
and knee. In children below one year the extensor response is the normal response. Flexor
response appears in the subsequent 6-12 months as myelination of corticospinal pathways
is completed.
f. Anal reflex (Root value S3, S4)
Stroking or scratching of skin near anus produces contraction of anal sphincter.

g. Cremasteric reflex (Root value L1, L2)

Movements of testicle upwards when skin on the medial side of thigh is stroked.

h. Bulbocavernosus reflex (Root Value -S3 , S 4)-Pinching of glans penis produces

contraction of the muscle.

2. Deep reflexes
Tendon reflexes: If the tendon of a lightly stretched muscle is struck with a knee hammer,
(so as to suddenly stretch the muscle), the muscle contracts briefly. This is a monosynaptic
stretch reflex. Stimulus initiates stretch in the muscle. Response is contraction of the
muscle that is being stretched.
Sense organ is the muscle spindle. Impulses originating in muscle spindle are conducted
by fast sensory fibres that pass directly to motor neurons which supply the same muscle.
1. Knee jerk: Best tested with the subject supine. Examiner’s hand is passed under
the knee of subject and placed upon the opposite knee, knee to be tested is on the dorsum
of examiner’s wrist. Patellar tendon is struck midway between origin and insertion with
knee hammer. Following the blow, there will be a brief extension of knee caused by
contraction of quadriceps. Sometimes the reflex can be conveniently elicited
with the subject sitting up, legs dangling freely over the edge of the seat. L2, L3 and L4 are
involved. Sometimes reinforcement will have to be applied to elicit the reflex -
Jendrassik’s manoeuvre. This is done by asking the subject to make a strong voluntary
muscle contraction with upper limbs like locking the fingers of the two hands together and

49
then trying to pull them apart as forcefully as possible and simultaneously eliciting the knee
jerk. Reinforcement acts by increasing the excitability of anterior horn cells and by
increasing sensitivity of muscle spindle primary sensory endings, to stretch (by increased
gamma fusimotor drive).
2. Ankle jerk: Patient in the lying position such that knee is slightly flexed and foot
everted. Then with one hand slightly dorsiflex the foot so as to stretch the Achilles tendon.
With the other hand strike the tendon on its posterior surface with a knee hammer. The
response is a sharp contraction of calf muscles. This depends on S 1 and S2 segments. This
reflex can also be conveniently elicited when the subject is kneeling on a chair.
3. Triceps jerk: Flex elbow and allow the forearm to rest on the subject’s chest
(lying position). Tap triceps tendon just above the olecranon. Triceps contracts causing
extension of elbow. Segments: C6 and C7
4. Biceps jerk: Elbow is flexed to a right angle with forearm placed in a semi-pronated
position and supported on the examiners forearm. Examiner places the thumb or index
finger on biceps tendon and strikes it with a knee hammer. Biceps contracts, resulting in
flexion of the elbow and supination of forearm Segments involved
- C5, C6.

5. Supinator jerk: The muscle concerned for this reflex is Brachioradialis. Strike the
tendon of Brachioradialis just above the styloid process of radius with the forearm
semipronated and semi flexed at the elbow. There is sudden flexion and supination of
forearm. Segments - C5 & C6.

6. Jaw jerk: Ask the subject to open the mouth a little. Place one finger firmly on his
chin. Then tap it with the other hand as in percussion. Contraction of the muscles that close
the jaw occurs.

Afferent: Trigeminal nerve

Efferent: Trigeminal nerve
Centre: Pons

This may be absent in health and increased in UMN lesion above the trigeminal nerve
nuclei.

Clonus-

When a muscle is subjected to a sudden continued stretch, a regular oscillation of

contraction and relaxation occur, which is called clonus. Sustained clonus is abnormal and is
an evidence of UMN lesion. Phenomenon is elicitable, especially at the ankle.

50
Ankle clonus
To test for ankle clonus, bend the subject’s knee slightly and support it with one hand,
grasp the forepart of foot with the other hand and suddenly dorsiflex the foot. Look for
alternate contraction and relaxation of calf muscles.
Patellar clonus
Patellar clonus is elicited by sharply pushing the patella towards the foot while the subject
lies supine and relaxed with his knee extended and supported by the bed. Alternate
contraction and relaxation of quadriceps muscles occur if clonus is present.

Unsustained clonus may occur in healthy persons, especially in those who are tense and
anxious.
Grading of reflexes

Tendon reflexes are graded as

0 -absent
1 -Present ( as in normal ankle jerk)
2 - Brisk (as in normal knee jerk )
3 - Very brisk
4 - Clonus

Abnormal tendon reflexes:

Tendon reflexes are diminished or absent in LMN lesion.
Hyper reflexia- Is seen in upper motor neuron lesion. May also occur in nervousness,
thyrotoxicosis etc. In cerebellar diseases, reflexes may have a pendular quality .In
myxoedema; the reflexes may be sluggish with prolongation of contraction and relaxation
phases.

3. Sphincteric reflexes: Concerned with swallowing, micturition, defaecation. They

depend upon complex muscular movements excited by increased tension in the wall of the
viscera concerned. It involves striated and non-striated muscle. Ask the subject whether he
has any difficulty in swallowing, micturition, defecation etc.

51
REPORT:

UMN Lesion LMN Lesion

Site Above the level of anterior At the level of anterior horn

horn cell cell and below it

Power Reduced to normal Spastic Severely decreased Flaccid

Tone Hypertonia Paralysis Hypotonia or Atonia Paralysis

Deep tendon Reflex Exaggerated Reduced or absent

Clonus Present Absent

Plantar reflex Babinski sign(Extensor plantar) Absent

Bulk of the muscle Slight disuse atropy Marked wasting

Fasciculation Not present Absent

52
 BASIC LIFE SUPPORT
Basic Life Support (BLS) refers to the care healthcare providers and public safety
professionals provide to patients who are experiencing respiratory arrest, cardiac arrest
or airway obstruction. BLS includes psychomotor skills for performing high-quality
cardiopulmonary resuscitation (CPR), using an automated external defibrillator (AED)
and relieving an obstructed airway for patients of all ages.

As a healthcare professional, you have a duty to respond in an emergency. Your actions

during emergency situations are often critical and may determine whether a seriously ill
or injured patient survives.

Cardiac arrest

Triad of 1) Unresponsiveness 2) No pulse 3) No breathing or no normal breathing

CARDIAC ARREST HEART ATTACK

Sudden cardiac arrest occurs when the Heart attack occurs when the blood flow to
heart develops an abnormal rhythm the part of the heart muscle is blocked by
a clot
It is often a “rhythm‟ problem It is a “clot‟ problem
Death occurs within minutes if the victim Signs of heart attack may appear
does not receive immediate lifesaving immediately or last weeks or longer, may
treatment Include
Severe discomfort in the chest or other
areas in the upper body
Shortness of breath
Cold sweats
Nausea/vomiting

ADULT – 1 RESCUER BLS SEQUENCE

1. VERIFY SCENE SAFETY, CHECK FOR RESPONSIVENESS, AND GET HELP
a) Verify the scene is safe for you and the victim.
b) Check for responsiveness. Tap the victim’s shoulder and shout, “Are you OK?”
c) If the victim is not responsive, shout for nearby help
d) Activate the emergency response system as appropriate in your setting
depending on your work situation

53
 e) If you are alone, get the AED/defibrillator. If someone else is available, send that
person to get it.

2. ASSESS FOR BREATHING AND PULSE

To minimize delay in starting CPR, you may assess the breathing at the same
time as you check the pulse. This should not take more than 10 seconds.

Breathing
To check for breathing, scan the victim‟s chest for rise and fall for no more than
10 seconds
- If the victim is breathing, monitor the victim until additional help arrives
- If the victim is not breathing or is only gasping, this is not considered normal
breathing and is a sign of cardiac arrest

Check pulse

To perform a pulse check in an adult, palpate a carotid pulse

If you donot definitely feel a pulse within 10seconds, begin high-quality CPR

3. BASED ON THE PRESENCE OR ABSENCE OF NORMAL BREATHING AND

PULSE

IF THEN
➢ If the victim is breathing normally ➢ Monitor the victim
and pulse is present
➢ If the victim is not breathing ➢ Provide
- rescue breathing
normally but a pulse is present ➢ Confirm that the emergency
response system is activated
- Continue rescue breathing and
check pulse about every 2 minutes.
Be ready to perform high quality
CPR if you do not feel the pulse
- If opioid use is suspected, consider
naloxone
➢ If the victim is not breathing ➢ Begin high quality CPR
normally or is only gasping and has
no pulse

54
HIGH-QUALITY CHEST COMPRESSIONS

Single rescuers should use compression-to-ventilation ratio of 30 compressions to 2

breaths when giving CPR to victims of any age.

- Start compressions within 10 seconds of recognition of cardiac arrest.

- Push hard, push fast: Compress at a rate of 100 to120/min with a depth of
o At least 5 cm for adults
o At least one third the depth of the chest, about 5 cm for children
o At least onethird the depth of the chest, about 4 cm, for infants
- Allow complete chest recoil after each compression
- Minimize interruptions in compressions (try to limit interruptions to less than 10
seconds)
- Give effective breaths that make the chest rise
- Avoid excessive ventilation

OPENING THE AIRWAY

Two methods for opening the airway

1) Head tilt- chin lift

2) Jaw thrust (if spinal injury is suspected)

Head Tilt- Chin lift Jaw thrust

1. Place one hand on the victim‟s 1. Place one hand on each side of the
forehead and push with your palm victim‟s head. You may rest your
to tilt the head back elbows on the surface on which the
2. Place the fingers of the other hand victim is lying
under the bony part of the lower 2. Place your fingers under the angles
jaw near the chin of the victim‟s lower jaw and lift
3. Lift the jaw to bring the chin with both hands, displacing the jaw
forward Forward
3. If the lips close, push the lower lip
with your thumb to open the lips

Barrier devices

Standard precautions include using barrier devices such as pocket mask. If available
bag and mask devices.

55
 ELECTROCARDIOGRAPHY
Electrocardiography is the graphic recording of variations in electrical potential
produced by the heart. Electro cardiograph is the apparatus used and
Electrocardiogram is the recording.

AIM:
To record ECG by standard and unipolar leads.

APPARATUS:
There are two types of electrocardiographs.

1. String galvanometer (oldest)

2. Direct writing electrocardiograph (modern).

An electrocardiograph assembly essentially consists of:

a. Electrodes to be applied and fixed on body surface. They conduct electric current.
Electrodes are applied after applying non-corrosive jelly to decrease skin impedance.

b. An appliance to measure the direction and strength of electric current or cathode ray
oscillograph.

c. An arrangement to record the deflection of galvanometer or CRO.

d. An arrangement to run the recording paper at a desired speed (usually 25 mm/sec).

Paper is heat sensitive. The stylus is heated and writes as the paper moves. The heat
movement of stylus and paper can be controlled by amplifiers.

ECG paper: ECG paper has a black background on which wax is coated which is erased
by the heated system producing the markings. ECG paper is divided into 1mm 2 squares
by thin lines. Every fifth line is thickened both horizontally and vertically. Horizontal
small squares represent 0.04 sec so that time relation between two thick lines is 0.2
sec. Vertically amplitude is measured in mV and 1mV produces a deflection of 10 small
divisions. 1 small square represents 1mV.

Method: Subject is asked to lie down on a bench (wooden only, not metallic) in a
completely relaxed state. Rub small amounts of jelly and connect electrodes. Electrode
is tied on limbs by means of rubber strap. Lead wires are connected according to
marking

56
 - Red for right arm

- Yellow for left arm

- Green for left leg

- Black for right leg (earthing)

Bipolar limb leads: Bipolar limb lead connections record potential difference between
two electrodes. They are:

Lead I -between right arm and left arm

Lead II -between right arm and left leg

Lead III -between left arm and left leg

Unipolar limb leads -These record potentials from a single region of the body.
Indifferent electrode is kept at zero potential by connecting the electrodes on right arm,
left arm and left leg to a central terminal through 5000 ohm resistance. This is achieved
automatically in the machine. Current from the three leads neutralize and there is no
current change in the indifferent electrode during cardiac cycle. Exploring electrodes
can be placed on any region of the body. Unipolar limb leads, which are used these
days, are augmented limb leads.

aVR - for right arm

aVL - for left arm

aVF - for left foot

Unipolar Precordial Leads or Unipolar chest leads.

6 positions are used V 1 to V 6
V1 - right 4th intercostal space at the sternal border.
V2 - left 4th intercostal space at the sternal border
V3 - between V 2 and V 4
V4 - left 5th intercostal space midclavicular line
V5 - left 5th intercostal space in anterior axillary line.
V6 - left 5th intercostal space in mid-axillary line.

Chest electrode is a small metal cup with a rubber bulb.

57
 With the electrodes in position

1. Switch on the ECG machine. Adjust sensitivity to calibration control so that

standard 1 mV will produce 10 mm deflection.
2. Enter the name, age of the patient and date and time.
3. Record electrical potential of heart with the help of lead selector. Record in
standard order namely lead I, lead II, lead III, aVR, aVL, aVF and V1 to V6. Tear
off the paper from machine and label the leads recorded.

PRECAUTIONS

1. Instrument should be correctly standardized.

2. Working electrical appliances should not be nearby.

3. Patient should be completely relaxed and should not be under emotional stress.

4. Loose connection to skin should be avoided.

5. Patient and instrument should be completely earthed.

USES

1. To determine heart rate.

2. To determine the mean electrical axis of heart.

3. To diagnose cardiac diseases like ischemia, myocardial infarction, arrhythmia, heart

block etc.

DISCUSSION

Normally P wave, QRS complex and T wave are seen. QRS complex actually has 3
components - Q wave, R wave and S wave.

1. P wave - due to depolarization of atria before contraction (atrial component)

2. QRS complex - due to depolarization of ventricle prior to contraction.

3. T wave due to repolarization of ventricle.

58
 Duration Voltage

P wave 0.08 to 0.12 sec 0.1 to 0.3 Mv

Average 0.1 sec

QRS complex 0.08 to 0.1 sec 1 mV

Average 0.08 sec

T wave 0.27 sec 0.2 to 0.3 mV

Intervals

P R interval (Conduction time from SA node to ventricle)

- Onset of P wave to the beginning of QRS Complex. Duration- 0.12 to 0.2 sec.

- QT interval- beginning of QRS complex to end of T wave Duration- 0.4 sec.

Segments

Normally two segments are present - PR segment and ST segment. They are isoelectric
segments.

Determination of Heart Rate

1. Look for R-R interval

Heart rate = 60 .

R-R interval

2. Count the number of small divisions between two adjacent R wave. Divide 1,500 by
the number of small divisions

Heart rate = 1,500 .

Number of small divisions between 2 adjacent R waves.

59
ABNORMAL ECG CHANGES

In Myocardial ischemia, ST segment is depressed

In Myocardial infarction, ST segment is elevated and T wave is inverted.

- In anterior wall infarction, ST segment is elevated in leads aVL, lead I and

precordial chest leads
- In inferior wall infarction, ST segment is elevated in leads aVF, lead II and lead
III
- Old infarction shows prominent Q wave

REPORT:

60
61
 ARTERIAL PULSE TRACING

AIM:
To record and study the arterial pulse.

PROCEDURE :
This is done using a Pulse –Respiration coupler (Physiograph) or using finger
plethysmography. The photoelectric transducer is fixed on the tip of the index finger or
ear lobe. The transducer should not be fixed too tightly and no outside light should fall
on the photocell.

A normal pulse wave shows the following components

a. Percussion wave or the anacrotic limb

This is the sharp upstroke. It is due to expansion of the artery due to ventricular
systole and corresponds to the rapid ejection phase of ventricular systole.

b. Catacrotic limb
This is the downstroke and it has two components
i) Tidal wave (T) : It is due to falling blood column during reduced ejection
phase.
ii) Dicrotic Notch and Wave : These are seen on the descending limb.
The dicrotic notch (N) or the negative wave is due to the falling blood
column during reduced filling phase. Dicrotic wave (D) is due to the
closure of aortic valve and marks the end of ventricular systole.
The systolic and diastolic wave of the ventricle can be indicated on the arterial
pulse tracing.
The maximum ejection phase lasts from the upstroke to the peak of the
percussion wave, while the reduced ejection phase lasts from the peak to dicrotic
notch. Thus, systole is approximately from the upstroke to the dicrotic notch.

Types of Abnormal Arterial Pulse Waves

a. Corrigan’s , Water Hammer, or Collapsing Pulse:

Characterized by an abrupt Rise, and sudden fall of the pulse wave in early
diastole

62
 It is most commonly seen in Aortic Regurgitation also found in Patent Ductus
Arteriosus or a large arterio-venous fistula
In aortic regurgitation, the incompetent valve fails to close properly leading to
back flow of blood from aorta back into the ventricle.
The rapid upstroke is due to the greatly increased and vigorous stroke volume
while the collapsing is caused by two factors: -
- Diastolic run off of blood back into the left ventricle
- The rapid run off of blood towards the periphery due to low pressure
resistance which results from arteriolar dilatation.

b. Pulsus Parvus or Slow–rising Pulse (Anacrotic pulse):

It is a small weak pulse which rises slowly and has a slow systolic phase. The
weak upstroke is due to decreased stroke volume and a narrow pulse pressure.
It is seen in Aortic Stenosis, Left Ventricular Failure and Hypovolemia.

c. Alternating Pulse(Pulsus Alternans):

The pulse beats are regular but alternately large and small in amplitude. It is
seen in Left Ventricular Failure when the ventricle is severely diseased.

d. Pulsus Paradoxus:
Normally, there is a slight fall of blood pressure by 8-10mm Hg during
inspiration. The term “Pulsusparadoxus‟ describes the marked decrease in pulse
volume (and blood pressure) which occurs on deep inspiration. The paradox is
that while the pulse may not be felt at the wrist, heart sounds may still be heard
at the precordium. It occurs in large pericardial effusion.

e. Thready pulse:
It is characterized by low volume and increased pulse rate. Thin, thready pulse is
a feature of shock due to the decrease in stroke volume.

63
 HUMAN ARTERIAL BLOOD PRESSURE
AIM:
To record the blood pressure of a normal individual in sitting, standing, recumbent
position and after exercise.

Blood Pressureis defined as the lateral pressure exerted by the column of blood on
the walls of the containing vessel. The maximum pressure exerted during systole is the
Systolic pressure and the minimum pressure exerted during diastole is the Diastolic
pressure.

Pulse pressureis the difference between systolic pressure and diastolic pressure.

Mean arterial pressure is the average pressure throughout the cardiac cycle. As the
duration of systole is shorter than diastole,

the mean arterial pressure = diastolic pressure + 1/3 pulse pressure

APPARATUS:
Sphygmomanometer and Stethoscope

Sphygmomanometer has 3 important parts,

1. A Mercury manometer

2. A rubber bag with linen cuff

3. An air pump

Mercury manometer: has a long limb graduated from 0 - 300 and each division
corresponds to 2mm of Hg. The lower end of the glass is connected to a mercury
reservoir and the upper end is closed with the help of metal cap. The mercury column
rises and falls in the glass tube lume with increase or decrease of pressure in the
reservoir, respectively

Rubber bag (Riva- Rocci cuff): The Riva Rocci cuff consists of a soft elastic rubber
bag which has got two rubber tubes – 1) connecting it to the mercury reservoir 2) the
other to a rubber bulb(air pump) and a linen cuff covers the entire bag. Width of the
cuff varies for adults and children.

As per American Heart Association guidelines, the width of the bag should be atleast 40%
and length of rubber bag should be 80% of the arm circumference. Recommended

64
width for adults -12.5 cm, children below 8years – 8 cm, below 4years – 5cm, infants –
2.5cm.

Air pump: It is a thick but flexible rubber pump, which has 2 openings guarded by
valves and allows airflow only in one direction. Cuff can be inflated to the desired
pressure by means of this air pump. Air can escape by means of screw attached to the
pump.

Sphygmomanometeris enclosed in a metallic box.

Stethoscope: It has got 2 earpieces and a chest piece. The chest piece has a
diaphragm on one side and a bell on the other side. By turning the chest piece either
the diaphragm or bell can be used. Chest piece is connected to the earpieces by means
of a Y-shaped tube. When the stethoscope is being used the earpieces are placed into
the ears such that they face forward and medially. Bell is used to auscultate low pitched
sounds and diaphragm for high pitched sounds

Methods of determination of BP

I. Direct: used only for investigations and experimental purposes.

2. Indirect: We do the indirect method using sphygmomanometer.

This is safe and convenient. Principle is that pressure in the brachial artery is balanced
with pressure inside the BP cuff. Cuff pressure necessary to balance the arterial
pressure is measured directly from the manometer.

PROCEDURE:
Check the apparatus for any leak. Seat the subject comfortably. He should be
relaxed mentally and physically. Place the arm and the apparatus in such a way that it
is almost at the level of the heart. The Hg level in the manometer should be at zero. Tie
the cuff in the right upper arm so that the lower border of the linen cuff is one inch
above the cubital fossa. Measurement is done by 2 methods.

1. Palpatory method 2. Auscultatory method.

Palpatory Method:

Introduced by Riva Rocci. Here the radial pulse is palpated. Pressure in the cuff is
slowly inflated and the point at which pulse disappears is noted. It is slightly elevated
and deflated until pulse reappears. The manometer reading should be noted. Reading
at which the pulse reappears corresponds to the systolic BP.

65
Advantage of palpatory method is it avoids the pitfall of the auscultatory method in
missing the auscultatory gap.

Disadvantage of this method is that diastolic BP cannot be recorded.

Auscultatory Method:

Introduced by Korotkoff known as Korotkoff’s method. Here brachial artery is

auscultated during the measurement. Brachial artery is located and auscultated. Cuff is
inflated 20-30 mm of Hg above the systolic BP got by palpatory method. If palpatory BP
is 120, we elevate it to 140 - 150. Slowly deflate the cuff until a tapping sound is heard.
Observe the manometer reading when first tapping sound is heard which corresponds
to systolic BP. Then slowly deflate the cuff listening to the serial changes in the sound.
Note the manometer reading when the sound completely disappears. This corresponds
to the diastolic BP; Series of sounds heard during deflation are called Korotkoff sounds.
It is divided into 5 phases:

Phase I: Sudden appearance of a clear tapping sound. It becomes louder during 10

15 mm Hg fall of pressure.

Phase II: Sound becomes soft and murmuring in the next 10-15 mm Hg fall of
pressure.

Phase III: Murmuring character continues but becomes louder and clear in the next
12- 14 mm Hg fall of pressure.

Phase IV: Sound becomes soft and muffled lasting for next 5 mm Hg fall in pressure.

Phase V : Sound completely disappears.

Basis of Korotkoff Sounds:

Normal blood flow is laminar and stream lined and is always silent. Flow through a
partially occluded vessel is turbulent and it produces a sound. There is no sound in a
completely occluded vessel. When the vessel is partially occluded by the pressure cuff
there is turbulence. These sounds due to turbulence are transmitted and heard by
auscultation. Appearance and disappearance of sounds are observed which corresponds
to systolic and diastolic BP respectively.

66
Precaution:

1. The subject should be mentally and physically relaxed.

2. Initial Hg level must be at zero.

3. Palpatory method should always be done first to prevent missing the

auscultatory gap.

Auscultatory gap may sometimes be found in hypertensive patients. Here

Korotkoffs sounds temporarily disappears and then reappear. So if pressure in
auscultatory method is raised only up to this gap, systolic BP may be underestimated.
To avoid this auscultatory gap, palpatory method should always be done first.

Normal Values:

Systolic BP varies between 100-140 mm of Hg.

Diastolic BP varies between 60-90 mm of Hg.

Average BP:

Systolic - 120 mm Hg.

Diastolic - 80mmHg.
It is expressed as 120/80 mm Hg.
Pulse pressure -30 -60 mm Hg
Mean arterial pressure -100 mm Hg

Factors maintaining blood pressure

1. Cardiac output

2. Peripheral resistance

3. Elasticity of vessel wall

4. Viscosity of blood

5. Blood volume

Variations:

Physiological:

1. Diurnal: lowest in the morning and highest in the afternoon

2. Age: Minimum at birth. As age increases, BP increases.

67
 3. Sex: Less in females in the reproductive age group. It increases after
menopause.

4. Body build: BP is high in obese people.

5. Meals: Systolic BP shows changes with meal.

5. Sleep: Systolic BP falls in undisturbed sleep. If sleep is disturbed by dreams,

systolic BP increases.

7. Emotion: anxiety, worries etc. increases BP.

8. Gravity: Pressure is high in vessels below heart level.

9. Posture: Systolic BP is maximum in the supine position. In the supine position

venous return increases which leads to increase in cardiac output and increase in
systolic BP.

Diastolic pressure is maximum in standing position. On standing up, there is a fall in

arterial pressure in the upper part of body. This cause less stimulation of baroreceptors
which in turn causes strong sympathetic discharge and elevates the diastolic BP.

10. Exercise: Systolic BP moderately rises. Diastolic BP remains unchanged or it may

fall in severe exercise. Increased systolic BP is due to sympathetic stimulation. Fall in
diastolic BP is due to peripheral vasodilatation.

Pathological

1. Increased BP - Hypertension

A. Primary or idiopathic- essential hypertension

B. Secondary- due to many causes.

a) Arterial - arteriosclerosis

- coarctation of aorta

- renal artery stenosis

b) Renal diseases like acute glomerulonephritis

c) Endocrine diseases like pheochromocytoma and Cushing’s syndrome

2. Decreased BP- hypotension

68
RESULT:

Posture BP by Palpatory method BP by Auscultatory method

Sitting

Standing

Recumbent

After exercise

69
 EFFECT OF EXERCISE ON BLOOD PRESSURE AND
HEART RATE
AIM:
To record the effect of exercise on bood pressure and heart rate.

Effect of exercise on blood pressure and heart rate depends on the following:

1. Type of Exercise – Isotonic or Isometric

Isotonic exercise Isometric exercise

Change in muscle length present No change
SBP rises moderately SBP, DBP rise sharply
DBP varies
CO increases markedly due to increase in Stroke volume change very little
heart rate, stroke volume
Blood flow to exercising muscle increases Blood flow to contracting muscle is
decreased as a result of compression of
their blood vessel

2. Intensity of exercise –mild, moderate, heavy, severe(WHO grading)

Grade Level HR/min O2 Trained Untrained

Consumption individuals individuals
L/min SBP DBP SBP DBP
I Mild <100 0.4-0.8 - - ↑ ↓
II Moderate 100-124 0.8-1.6 - - ↑↑ ↑
III Heavy 125-150 1.6-2.4 ↑ - ↑↑↑ ↑↑
IV Severe >150 >2.4 ↑ - ↑↑↑ ↑↑

Maximum heart rate = 220- age (in years)

SBP, DBP both increase on mild, moderate, severe exercise. There is continuous
increase in CO with increase in severity of exercise. DBP remains unchanged in
mild exercise or it may fall slightly during moderate exercise. During severe
exercise, the DBP may increase slightly as sympathetic vasoconstrictor activity
supersedes the vasodilator influence on the cutaneous blood vessels.

70
3. Effect of training

Training of an individual results in lower basal heart rate (because of higher vagal and
a lower sympathetic tone), lower submaximal heart rate with exercise, increased
stroke volume and lower peripheral resistance than they had before training. During
exercise, the maximal heart rate of a trained individual is same as that in the
untrained persn, but it is attained at a higher level of exercise.

APPARATUS
Sphygmomanometer, Stethoscope, Harvard/ Master step, Hand grip dynamometer

PROCEDURE

Make the subject comfortable and record the BP and HR after 5minutes of rest. Ask
the subject to perform any of the following exercise
1. Spot running with thighs brought up to horizontal, alternately for 3-5 minutes.
2. Hopping on each foot for 3minutes raising the feet 12-15inches off the ground, for
20times on each foot.
3. Climbing up and down the stairs.
4. Jogging
5. Master Two step test or Harvard step test.
a) In Two step exercise test or Harvard step test, the subject ascends to the top
of 2 steps and walks down the other side. This is counted as one trip. He
should then turn and start the second trip. The rate of ascent and descent
should be controlled by the metronome. The exercise is performed for 4-
5minutes.
b) Usually the test is conducted at 30 double steps/min for 5minutes in a 20 inch
step(for male) or 16 inch step(for female)
c) This is a test for physical fitness and should not be used in patients.
d) The exercise is discontinued if , the subject feels
- Intolerably breathless
- Fatigue in legs
- Giddiness or pain
- Constriction or suffocation in chest
e) Record the BP and HR immediately after the stoppage of exercise and
continued every minute and until the resting values are obtained
f) The time of recovery is also noticed.

71
OBSERVATIONS

A) Effect of posture on BP

Posture Heart SBP/DBP Pulse pressure

rate(per (mmHg) (mm Hg)
minute)
1. Lying (after 5-10min
rest)
2. On sitting
Immediate after 1
minute
After 2 minutes
After 3 minutes
3. On standing
Immediate
After 1 minute
After 2minutes
After 3 minutes

B) Effect of exercise on BP
Heart SBP/DBP Pulse pressure
rate(per (mmHg) (mm Hg)
minute)
1. Resting
2. Immediately after 4-
5min of exercise
3. Recovery
1 min after exercise
2 min
3 min
4 min
5 min

72
 CARDIOVASCULAR AUTONOMIC FUNCTION TESTS
Changes in blood pressure are monitored for assessing the sympathetic function, while
heart rate changes are monitored for assessing parasympathetic function

Tests for sympathetic functions:

1. QT: QS2 ratio

2. Cold pressure response
3. Hand-grip test [BP response to isometric exercise]

Tests for parasympathetic functions:

1. Standing test [30:15 RR ratio]

2. Standing to lying ratio
3. Valsalva ratio test
4. Tacycardia ratio
5. Deep breathing test

APPARATUS REQUIRED:
ECG machine, BP apparatus, hand grip spring dynamometer

TESTS FOR SYMPATHETIC FUNCTIONS

1. QT-QS2 ratio This test is an index of sympathetic excitation of the heart

Procedure:

1. Ask the subject to lie down supine on the couch and relax. Attach ECG leads and
place the contact microphone on the carotid artery to record heart sounds
[phonocardiogram]
2. Record lead II of ECG and phonocardiogram simultaneously at a paper speed of
50mm/sec
3. Measure QT interval from the beginning of QRS complex to the end of T wave.
Measure QS2 from the beginning of QRS to the first major vibration of aortic
component of second heart sound in phonocardiogram. Determine the QT/QS2
ratio.

Note: QS2 is the total electromechanical systolic interval. A high value indicates greater
sympathetic tone, while a low value represents low sympathetic tone.

73
 2. Cold pressor response

Physical or mental stress causes stimulation of sympathetic system. Plunging a hand in

cold water act as a pain stimulus and causes rise in BP

Procedure:

1. Explain the test to the subject and seat him/her in a chair. Record the baseline
BP
2. Ask the subject to immerse one hand in cold water at 4-5o C for 2 minutes.
Record the BP from the other arm at 30 seconds intervals
3. note the maximum increase in SBP and DBP and compare with the pretest
readings. The systolic BP may increase by 20 mmHg, while the diastolic BP rises
by 10 mmHg

Results:

Reduced sympathetic activity is indicated by a smaller rise of BP. In some normal

persons, there may be no significant rise in BP.

3. Handgrip test [isometric test]

Sustained handgrip causes a rise in HR and BP. An ECG machine, a sphygmomanometer

and a handgrip spring dynamometer will be required for this test.

Procedure:

1. Apply the BP cuff on the non-exercising arm and lead II of ECG for recording HR.
Record the resting BP and HR at 30 seconds intervals for 4 minutes. The ask the
subject to hold the dynamometer in the dominant hand and take a full grip on it
2. Ask the subject to exert maximum force and note the maximum tension
developed. Repeat three times at intervals of 2 minutes. Take the highest
reading and note it as a maximum isometric tension [Tmax]
3. Now ask the subject to maintain a tension of 30% of Tmax for 5 minutes. During
this procedure, record the BP ad ECG at 30 seconds intervals
4. Note the diastolic BP at the point just before the release of handgrip.
5. Note the mean resting value of diastolic BP readings during the last 3 minutes
before starting the exercise

Results:

The rise in diastolic BP in normal subjects is more than 15 mmHg but less than 10
mmHg in sympathetic insufficiency.

74
TESTS FOR PARASYMPATHETIC FUNCTIONS
1. Standing test

Upon sudden standing from supine, there is pooling of blood in the lower parts of the
body. This is followed by a sequence of events: fall of venous return → decrease in
cardiac output and BP → decreased baroreceptor activity → increase in sympathetic
tone and decrease in parasympathetic activity. This causes reflex increase in HR and
peripheral vasoconstriction after which the HR falls

The HR rises immediately on standing and continues to rise for the next 15-20 seconds,
after which it slows down to a maximum degree as a result of variations in vagal tone

Procedure

1. Ask the subject to lie supine on the couch and relax for 15 minutes. Apply ECG
leads and the BP cuff [or the wrist BP monitor]
2. Record ECG [lead II] for noting basal HR and BP. Then ask the subject to stand
[without support i.e not leaning against the wall] and remain motionless for 3
minutes, recording the ECG continuously. Record BP at the end of 1st and 3rd
minutes after standing. Mark the point of standing on the ECG paper.
3. Calculate the HR from R-R interval at 15th beat [fastest HR; shortest R-R
interval] and at 30th beat [slowest HR; longest R-R interval] after standing
4. Determine the 30:15 ratio, which is considered a cardiac vagal effect. Normal
value is more than 1.04. An R-R ratio of less than 1.0 indicates autonomic
insufficiency
5. In normal persons , the fall in systolic BP on standing should not be more than
10 mmHg.
a. In orthostatic hypotension, the systolic BP and diastolic BP fall more than 20
mmHg and 10 mmHg respectively
b. In vasovagal syncope, hypotension is accompanied by paradoxical bradycardia
because cardiac vagal supply is overactive

Note : Similar responses can be better studied by passive tilting the subject on a tilt table
from supine position to an inclination of 80o [head up] for a period of 3-4 minutes.
2. Standing to lying ratio [S/L ratio]

When a normal person lies down from a standing position, there is at first a rise in HR
which is followed by a slowing of the heart. This rise and fall of HR is due to changes in
vagal tone

75
Procedure:

1. Explain the procedure to the subject. Connect ECG leads for recording lead II.
Ask the subject to stand quietly for 2 minutes and then lie down supine without
any support
2. Record ECG for 20 beats before and for 60 beats after lying down. Note the point
of change of position on the ECG paper
3. Repeat three times at intervals of 5 minutes
4. Calculation of S/L ratio: take the average R-R interval during five beats before
lying down and shortest R-R interval during 10 beats after lying down. The
maximum ratio of the three trials is reported. Any abnormally low ratio indicates
parasympathetic insufficiency

3. Valsalva ratio

Valsalva maneuver [effort] is forced expiration against a closed glottis. This straining,
associated with changes in HR and BP, is a simple test for baroreceptor activity.

Procedure:

1. Seat the subject on a stool and explain the procedure. Connect ECG leads and BP
cuff on him/her and close the nostrils with a nose clip.
2. Disconnect the cuff from another BP apparatus and ask the subject to take a
deep breath, blow into the manometer and maintain the pressure of 40 mmHg
for 15 seconds
3. Record ECG [lead II] for 1 minute before the straining, for 15 seconds during
straining and for 45 seconds after the release of strain. It may also be calculated
as the ratio of longest R-R interval after the strain to the shortest R-R during the
strain.

Observations:

The valsalva maneuver has four phases:

1. Phase I : It is onset of strain. In this phase, there occurs transient decrease in

BP. Mechanical compression of the great vessels and increased intrathoracic
pressure contributes to this rise. There is not much change in HR.
2. Phase II : During straining, there is decrease in venous return, fall in cardiac
output and BP and inhibition of baroreceptors, followed by tachycardia and
vasoconstriction. The HR increases throughout straining due to vagal inhibition
initially and sympathetic activation later

76
 3. Phase III : at the release of strain, there is a transient fall of BP without
significant change in HR
4. Phase IV : After further release of strain, the BP slowly rises with decrease of
HR. These in turn stimulate baroreceptors causing bradycardia and drop in BP to
normal levels

The maximum valsalva ratio of three trials is taken as the index of autonomic activity. A
ratio of

a. Greater than 1.45 is normal

b. 1.20 – 1.45 is borderline
c. Less than 1.20 indicates autonomic disturbance

Clinical significance:

Failure of HR to increase during straining suggests sympathetic insufficiency, while

failure of HR to slow down after the effort suggests parasympathetic insufficiency.

4. Tachycardia ratio

It is defined as the ration of shortest R-R interval during valsalva effort to the
longest R-R interval before the effort. It is a better index of vagal activity.

5. Deep breathing test

The HR increases during inspiration [due to decreased cardiac vagal activity] and
decreases during expiration [due to increased vagal activity]. This is a normal
phenomenon and is called sinus arrhythmia

Procedure:

There are two methods to show the effect of breathing on HR. In one method, a single
deep breath is taken and its effect noted. In the other method, the subject breathes
deeply for 1 minute

1. Explain the procedure to the subject and ask him to lie down supine and relax,
with the head raised to 30o.
2. Attach the ECG leads for recording lead II. Then ask the subject to breathe eeply
and slowly at a rate of 6 breaths/min, with 5 seconds for inspiration and 5
seconds for expiration. Record ECG before and during deep breathing
3. Determine the maximum and minimum HR with each respiratory cycle and note
the average HR in inspiration and in expiration

77
4. Calculate the expiration to inspiration ratio [E:I ratio]. This is the mean of
maximum R-R intervals during expiration [slow HR] to the mean of minimum R-R
intervals during deep inspiration [fast HR]
5. In normal persons, the fall in HR should be more than 15 beats/min. In vagal
insufficiency, the HR slows less than 10 beats/min.

78
 RESPIRATORY MOVEMENTS IN MAN
AIM:
To record the respiratory movements in man during

1. Normal breathing

2. Deep voluntary breathing

3. After exercise

PRINCIPLE:
Pneumography or Stethography means the recording of the movements of the
chest occurring during respiration. If a rubber tube is tied around the chest, movements
of the thorax during respiration bring about a change in the pressure of air contained in
the tube. This change in pressure of air inside the rubber tube can be recorded by
connecting the tube to a suitable recording device.

APPARATUS:
1. Stethograph or Pneumograph

2. Marey’s Tambour with a lever

3. Kymograph

1. Stethograph or Pneumograph is a corrugated tube made of canvas impregnated with

rubber. It is closed at one end and the other end communicates through a rubber tube
and a glass T - tube to a recording tambour. The metal chains are attached at both
ends.

2. Marey’s tambour is a metallic cup with a side tube and a rubber diaphragm mounted
on the top. The side tube of the metallic cup can be connected to the Pneumograph by
the rubber tube and the glass T -tube. A writing lever is attached to a small disc, which
rests on the rubber diaphragm. Using this closed air system, changes in air pressure
inside can be transmitted to the tambour.

3. Kymograph - Electric kymograph with cylinder and smoked paper.

79
PROCEDURE:
Seat the subject on a stool near the worktable, facing away from the recording
drum. Tie the pneumograph around his chest at the level of the 4th intercostal space.
The rubber tube is connected to the Marey’s tambour. Adjust the position of the
stethograph and the amount of air inside it to get maximum response of the writing
lever to respiration. Allow the subject to relax and ask him to breathe regularly without
any effort. When the breathing is regular bring the writing lever in contact with the
recording surface and record a few normal movements on a slow moving drum. Then
ask the subject to breathe rapidly and deeply (voluntary hyperventilation) for 1-2
minutes. Here the rate as well as depth of breathing increases. Record the effect of
voluntary hyperventilation till it comes back to normal. Disconnect the pneumograph
and ask the subject to do moderate muscular exercise for 2 minutes. Reconnect the
pneumograph to the tambour and record the effect of exercise. Stop the Pneumograph
when the pneumogram becomes normal. Label the various events recorded.

OBSERVATION AND RESULT:

During inspiration the chest expands and the Pneumograph is stretched. As it is
corrugated tube there is no decrease in diameter of the tube on stretching. So the
volume of the interior space is increased during inspiration. But the space being closed
on all sides, the volume of air inside remains the same. So the pressure inside
decrease. This is transmitted to the tambour, there by the diaphragm of the tambour
gets depressed. This produces a down stroke of the lever. So the downward stroke of
the tracing represents inspiration and upward stroke, expiration. In voluntary
hyperventilation both rate and amplitude is increased. This is followed by a temporary
pause in breathing called apnoea. This apnoeic period is followed by normal breathing.

Causes of apnoea after voluntary hyperventilation

During voluntary hyperventilation excess amount of CO2 is washed off and Pco2
decreases which has a depressant action on respiration. This leads to apnoea. During
this period of apnoea CO2 is accumulated and a progressive fall in Po2 occurs. This fall
stimulates respiratory centers and normal respiration is resumed. After exercise there is
an increase in rate and amplitude in the pneumogram. But it is unaccompanied by
apnoea. It returns to normal without a period of apnoea.

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Causes of hyperventilation after exercise:
1. Increased rate of production of CO2 and other metabolites.
2. Decreased arterial blood concentration of O2
3. Increased production of H+
4. Impulses arising from the working muscle and joints
5. Increased body temperature
6. Increased secretion of adrenalin

Causes of lack of apnoea after exercise:

1. Impulses arising from working muscles and joints

2. Increased rate of production of CO2
3. Increased production of acid metabolites and H+ ions

Precautions:

1. Subject should avoid looking at the kymograph throughout the experiment

2. The voluntary hyperventilation should not be carried out for a long time as the
resulting alkalosis may precipitate an attack of tetany

3. The Pneumograph should be so adjusted that the, movements of the lever are
maximum

Periodic breathing:

This occurs in a number of different diseased conditions. Most common type of periodic
breathing is CheyneStoke’s breathing. Here the respiration is regularly irregular. There
is waxing and waning of respiration. There is gradual increase in respiration and it
attains a maximum, then it decreases gradually. Then the patient becomes apnoeic and
another cycle is repeated.

This type of breathing occurs

Physiologically in:

1. In newborn infants 2. In some people during deep sleep

3. At high altitude

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Pathologically in:

1. Uraemia 2. Brain damage. 3. Congestive cardiac failure

Another irregular type of breathing is Biot’s breathing. In this type there is no regularity
or periodicity. Apnoea occurs at varying intervals. Amplitude remains the same. There is
no waxing and waning. It is seen in diseases like meningitis.

RESULTS:

1. Effects of voluntary hyperventilation 2. Effect of exercise.

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 SPIROMETRY

APPARATUS:
Spirometer, Mouth piece, Nose clip, Wright’s peak flowmeter

I. SPIROMETER:
It is an instrument used routinely in physiological and clinical studies for the
determination of lung volumes and capacities.

It consists of:

1. A double walled cylindrical chamber containing water between the two cylinders,
water to maintain and airtight seal.

2. A Bell: It is cylinder of 9 litres capacity made of light weight metal which dips into
this water from above. The top of the bell carries a hook to which a chain is attached.
The chain passes over a frictionless pulley and carries a counterweight and a pen. This
pen moves up and down as the volume of air in the bell decreases or increases, thus
the bell displacements are recorded on the kymograph.

3. The Kymograph: It carries a millimeter square graph paper which is calibrated for
time as well as volume. The speed of the kymograph drum can be selected with the
help of selector lever that has marking of 60-0-1200.

(i) 60 mm /min for normal spirometric recordings,

(ii) 1200mm/min for recording of timed vital capacity, and

(iii) “zero‟ mark is neutral position, in which kymograph does not move .

4. Pilot lamp with power switch. It glows when the power switch is put in the “on‟
position.

5. Breathing assembly i.e. breathing valves with mouthpiece:

(i) There are two unidirectional breathing valves, one for inspiration and the other
for expiration. These are connected with the help of Y-shaped piece to a free breathing
valve.

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 (ii) Free breathing valve is 25mm bore metallic tube having bidirectional tap which
can be turned to allow the subject either to breath room air or spirometric air.

6. Soda lime absorber to remove carbon dioxide from the expired air.

7. Inlet for filling oxygen or any other gas into the bell.

8. Tap to drain the water from the apparatus.

9. Levelling screws.

10. Slot –present on the right side door of the apparatus provides an outlet for the
recorded paper.

11. Chart reverse knob is provided at the top of the cabinet; by turning it clockwise, the
recorded chart is wounded up again.

12. Chart paper: calibration

(i) Y-axis represents volume: 1mm = 30 ml.

(ii) X-axis represents time

(a) at drum speed : 60 mm /min;1mm= 1 sec.

(b) at drum speed : 1200mm/min;20mm=1 sec.

II. THEORY
A convenient way of measuring the lung volumes and capacities is by using a
spirometer, and the procedure of recording these is called spirometry. The various lung
volumes and capacities are shown on a spirogram and can be divided into two broad
headings: static and dynamic.

A. Static lung volumes and capacities (time factor is not involved, therefore,
expressed in ml or L)

Volumes

1. Tidal volume (TV)- it is the volume of air breathed in or out of lungs, during
quiet respiration. Normal: 500ml.
(i) decreases due to less contraction of respiratory muscles; causes:
respiratory muscle weakness or depression of respiratory centre.
(ii) Increases in muscular exercise.

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 2. Inspiratory Reserve Volume (IRV)- it is the maximal volume of air which can be
inspired after completing a normal tidal inspiration i.e inspired from the end-
inspiratory position. Normal:2000-3200ml
3. Expiratory Reserve Volume (ERV)- it is the maximal volume of air which can be
expired after a normal tidal expiration i.e, expired from the end- expiratory
position. Normal: 750-1000ml.
4. Residual Volume(RV)- it is the volume of air which remains in lung after a
maximal expiration. Normal:1200ml.
5. Closing Volume (CV)- It is the lung volume above residual volume at which
airways in the lower, dependent parts of the lungs begin to close off because of
the lesser transmural pressure in these areas.

Capacities:

1. Inspiratory Capacity (IC) - It is the maximal volume of air which can be inspired
after completing tidal expiration i.e. from the end –expiratory position. It can be
computed as: TV +IRV. Normal :2500-3700ml
2. Vital Capacity (VC) – It is the maximal volume of air which can be expelled from
lungs by forceful effort following a maximal inspiration (one stage VC). Normal:
4.8L in males and 3.2L in females. It can be computed as :TV+IRV+ERV
3. Functional Residual Capacity (FRC) - It is the volume of air which is contained in
the lungs at end-expiratory position i.e after completion of tidal expiration. It can
be computed as : RV+ERV. Normal:2.5L
4. Total Lung Capacity (TLC) - it is the volume of air contained in the lungs after a
maximal inspiration. It can be computed as: VC+RV. Normal:6L

B. Dynamic lung volumes and capacities (Time dependent, therefore

expressed in ml/min or L/min)

1. Timed Vital Capacity(TVC) or Forced Vital Capacity(FVC) - if VC is recorded on a

kymogragh (Spirograph) at the known speed, volume of air expelled can be
timed. Thus, FVC is the maximum volume of air which can be breathed out as
„forcefully‟ and „rapidly‟ as possible following a maximum inspiration. Thus TVC
is exactly similar to VC except that there is a special stress on rapid, forcible and
complete exhalation.

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 Components of TVC (FVC):

(i) FEV1 (Forced Expiratory Volume in l sec) i.e, volume of FVC expired in 1st sec of
exhalation.
Normal: 80% of FVC.

(ii) FEV2 (Forced Expiratory Volume in 2 sec) i.e, volume of FVC expired in first two
secs of exhalation.
Normal: 95% of FVC.
(iii) FEV3 (Forced Expiratory Volume in 3 sec) i.e, volume of FVC expired in first
three secs of exhalation.
Normal: 98-100% of FVC.

Clinical Significance of TVC (FVC): To distinguish between 'restrictive" and "obstructive'

Lung disorders

2. Forced Expiratory Flow during 25-75% of Expiration (FEF 25-75%).

This is the mean expiratory flow rate during middle 50% of FVC. Some workers call it
erroneously as Maximum Mid Expiratory Flow Rate' (MMEFR).Normal: 300 L/min.

It is a sensitive indicator of small airway disease where most of chronic obstructive

pulmonary disease (like bronchial asthma, emphysema) start.

The time taken for FEF 25-75% is called "Mid Expiratory Time (MET). Normal: MET 0.5
sec.

3. Minute Ventilation (MV) or Pulmonary Ventilation (PV) -This is the volume of air
expired or inspired out of the lungs in 1 minute. Therefore, PV=TVxRR per
min=500x12= 6L/min, normally.

4.Maximum Breathing Capacity (MBC) or Maximum Voluntary ventilation or Maximum

Ventilation Volume(MVV). It is the largest volume of air that can be moved into and out
of the lungs in one minute by maximum voluntary effort. Nrmal:90-170 L/min (average
100L/min)

5. Pulmonary Reserve (PR) or Breathing Reserve (BR)

It is the maximum amount of the air above the pulmonary ventilation , which can be
breathed in and out of the lungs in one minute.

It can be computed as: MVV – PV.

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 It is usually expressed as percentage of MVV i.e. (MVV-PV) x 100/MVV; and called as
percentage pulmonary reserve or Dyspnoeic Index (DI).

Normal % PR (DI) ≥ 60-70% (usually 90%) If

less than 60%, Dyspnoea is usually present.

III. PROCEDURE

1. Fill the space between the two cylindrical chambers 3/4th with water; put the
inverted bell from above so as to dip into this water.
2. With the free breathing valve open move the bell manually 3 to 4 times up and
down to wash it with the fresh room air, finally fill it with room air.
3. The subject is made to sit comfortably in a stool facing the spirometer, nose is
clipped and the mouthpiece is inserted between the teeth and the lips. Allow
him to breathe the room air; this is done to make him familiar to breathe
through the mouthpiece with the nose clipped.
4. After a gap of one minute, the free breathing valve is turned to connect the
subject to spirometer; immediately start the kymograph at a speed of
60mm/min and record normal breathing for about one minute. This is used for
computing the tidal volume, respiratory rate and the resting pulmonary
ventilation.
5. The subject is then instructed to breathe in with a maximum effort from the
end of resting expiration and subsequently to breathe out completely with
maximum effort. He is beforehand instructed not to breathe in while he is
breathing out. At least three such forced vital capacity (FVC) curves are
obtained and the maximum (best performance) of the three values is taken for
calculation purposes.
6. Change the speed of kymograph to 1200mm/min and repeat the whole
procedure (step 5) but with specific instructions to the subject to breathe out
completely as rapidly and forcibly as he can. Repeat this thrice and evaluate
the best record for calculating out timed vital capacity and its component.
7. Bring the speed of kymograph to 60mm/min, the subject is now instructed to
breathe in and out as rapidly and deeply as he can for a period of 15 seconds.
The pulmonary ventilation (tidal volume x respiratory rate) thus calculated
from the record, is called the maximum breathing capacity (MBC) or maximum
voluntary ventilation (MVV).
8. Peak expiratory flow rate (PEFR). It is the maximum velocity (litres/minute)
with which air is forced out of lungs in a single forced expiratory effort.
Normal: 350-400 L/min

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IV.CALCULATIONS

(A) Static lung volume and capacities

These are computed from the forced vital capacity (FVC) spirogram recorded at
60mm/min speed .

1. TV. Place a ruler across the record to cut maximum number of expiratory
tops(expiration being more stable); draw another line parallel to first to cut
maximum number of inspiratory tops.
The TV (ml) = the vertical distance between two lines x 30
2. IRV (ml) = the vertical distance between End Inspiratory and maximum
inspiratory Positions (mm) x 30.
3. ERV (ml) =The vertical distance between End Expiratory and maximum
expiratory Positions (mm) x 30
4. VC (ml) =the vertical distance between maximum Inspiratory and maximum
expiratory Positions (mm) x 30
=TV+IRV+ERV.
5. IC (ml) =TV+IRV

(B) Dynamic lung volume and capacities

1. TVC (FEVI, FEV2, FEV3). These are computed from TVC spirogram recorded at
1200 mm/min speed. Mark „zero‟ point (or time) (i.e. point where inspiration
ends and expiration begins), move 20 mm (= 1 sec) right to the point marked;
drop a perpendicular line from the second point on to the expiratory tracing. This
will give the volume of air expired in the first second of exhalation (FEV1) (Fig.
3.9.4). Express it either as absolute volume in ml or as percentage of FVC.
Similarly, determine FEV2 and FEV3 by moving 40 mm and 60 mm respectively.
to 3the right of ”zero‟ time.

2. FEF 25-75%. Divide expiratory tracing on TVC spirogram into 4 equal parts; draw
two perpendicular lines, one vertical from 75% mark and the other horizontal
from 25%”mark”. The vertical and horizontal distances from point of intersection
denotes the volume of air expired and time (MET) respectively. The flow rate
thus can be computed.

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3. Minute Ventilation (MV). Count either the number of inspiratory or expiratory
tops over a period of 15 seconds from FVC spirogram (Let it be N), then MV
(ml/min) = N x 4 x TV.
4. MBC. Calculate it from MBC graph like the MV; express in L/min.

5. Pulmonary reserve (PR). Calculate from the MV and MBC

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 PEAK EXPIRATORY FLOW RATE (PEFR)

Definition: The peak expiratory flow rate (PEFR) is the maximum or peak rate, in litres
per minute, with which air is expelled with maximum force after a deep inspiration.
Normal range = 350-650 liters per minute

Maximum Expiratory Flow Volume curve (MEFVC)

It represents the outflow of air from lungs during a forceful respiration after a deep
inspiration. Normal MEFVC starts at a TLC of about 6 L/min, quickly reaches a peak of
550 l/min and then falls gradually to a residual volume of 1.1L. The decline in the
expiratory flow rate is due to the compression of chest by the forced expiration.

APPARATUS

Wright’s peak flow meter, Mini Wright’s peak flow meter

Wright’s peak flow meter: It is a short cylinder made of plastic material. An indicator
moves in a slot alongside a scale with numbers on it which indicates L/min. There is a
handle provided near the mouth piece. The end opposite the mouthpiece, has holes in
it for allowing air to exit from the apparatus.

PROCEDURE

1. Ask the subject to hold the peak flow meter by its handle making sure that the
fingers are clear of the scale and the slot and are not obstructing the holes in it
for allowing the air to exit from the apparatus.
2. Ask the subject to take a deep breath, place the mouthpiece firmly between the
teeth and lips, then to blow out with a short sharp blast. Note the reading on the
scale. Bring the indicator back to zero by pressing the button located near the
mouthpiece.
3. Take 3-6 readings at intervals of 1minute and select the maximum value for
report.

Precautions:

Subject should be instructed to blow out rapidly, completely and forcefully into the
mouth piece

Questions:

What is PEFR and what is its significance

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 MOSSO’S ERGOGRAPHY
AIM:
To study the genesis of fatigue in hand muscles by Mosso‟sergography and the factors
that influence onset of fatigue.

APPARATUS:
MOSSO‟S ERGOGRAPH for isotonic exercise. It consists of

1. A flat wooden board fitted with two pairs of clamps and curved plates for
fixing the forearm of the subject and a pair of finger holders for fixing
index and ring fingers in position.
2. A hook (for suspending weights) attached to a cord is made to hangover
the pulley. The other end of the cord is attached to a sliding plate which
moves to and fro.
3. The sliding plate carries a lever system to record the movements on a
kymograph. The other end of the plate is connected through a sling to the
middle finger of the hand.
4. Alternatively, the sliding plate is fitted with a chart holder. A pencil or
ballpoint pen can be fitted vertically over the chart paper so as to record
the movements of the chart holder when it moves.

PROCEDURE:

1. Lay Mosso’s ergograph on its side and arrange the writing lever to write on a
very slow moving drum. Alternatively, arrange a spring loaded writing device or
ballpoint pen in the Mosso’s ergograph and a paper on the platform underneath.
2. Fix the forearm on the ergograph by means of clamps. Put the middle finger n
the loop to be pulled and insert the index and ring finger into the fixed metal
tubes provided in the ergograph.
3. Adjust the subject position and various adjustable points in the ergograph in
such a way that the forearm is properly fixed and at the same time the subject is
comfortable.
4. With the middle finger extended, suspend a weight (say 2 or 3 kg) according to
subject’s requirement on the ergograph. The weight should be such that the
subject must exert a real effort to lift it up.
5. Set the metronome at one beat per two seconds i.e. to a frequency of 30/min.

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 88

6. Ask the subject to make a series of maximal contractions without moving the
shoulder at regular intervals following the beat of the metronome. Continue the
contractions until fatigue is so great that weight can no longer be moved.
7. Study the effect of rest pause for 10-15minutes on the graph.

Precautions

1. The subject should be instructed properly to give her maximum effort.

2. The subject should move the finger according to the oscillations of the
metronome.
3. The subject should continue to do work till he/she is unable to lift the load.

DISCUSSION

Fatigue is defined as a temporary and reversible loss of the contraction of skeletal

muscles. There is also subjective feeling of tiredness so that the onset of fatigue can be
somewhat delayed by motivation. With rest, fatigue is completely reversible.

Site of fatigue

The fatigue developing in maximum voluntary muscular effort, first occurs in the central
nervous system, followed by neuromuscular junction and lastly in the muscle proper.

Factors that affect onset of fatigue

The degree, duration and type of work done are the important factors that general
affect the onset of fatigue.
1. The weight to be lifted: when the weight to be lifted increases, fatigue occurs
early.
2. Frequency of contractions: Fatigue occurs early when the frequency of
contraction increases.
3. Motivation: Encouragement delay onset of fatigue.
4. Blood supply to contracting muscles: Venous and arterial occlusion accelerate the
onset of fatigue
5. Training: Delay the onset of fatigue
6. Environmental factors – temperature, humidity

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REPORT:
The genesis of fatigue and the factors affecting the onset of fatigue are studied in the
given subject.

93
 PREGNANCY TESTS

AIM:

To confirm pregnancy by detecting HCG in the urine of the pregnant female.

REQUIREMENTS:

Urine Sample from the pregnant female, Antisera, HCG coated latex particles

METHODS FOR CONFIRMATION OF PREGNANCY

1. Biological tests
2. Immunological tests
a. Latex agglutination inhibition test/ Gravindex test
b. ELISA
c. Radioimmunoassay
3. Ultrasonography

BIOLOGICAL TESTS:

PRINCIPLE
It is based on the LH activity of HCG produced by the syncytiotrophoblast cells of the
placenta following implantation of the zygote which causes release of spermatozoa in
male animals and leutinizing or luteotrophic changes in a female animal.

PROCEDURE
Urine from a doubtful pregnant women is collected (around 60 to 70 days of
amenorrhea) and injected into the peritoneal cavity of the animals. Ovulatory changes
or release of ova in females and release of spermatozoa by males are observe for
confirmation of pregnancy.

Biological tests are 99% accurate however are costly and time consuming and are not
in practice.

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IMMUNOLOGICAL TESTS

PRINCIPLE
HCG secreted by syncytiotrophoblasts of placenta is antigenic and antibodies are
produced by injecting into the rabbits. These antibodies are used to detect the presence
of HCG in urine or serum of the female suspected to be pregnant.
Commercially available preparations are antisera containing antibodies against HCG and
HCG coated latex particles.

PROCEDURE:
Urine from a doubtful pregnant female is collected (as early as 10 th day of fertilization).
The subject is advised to restrict water intake 12-14hours and urine is collected in a
clean container in the morning.

a) LATEX AGGLUTINATION INHIBITION TEST (LAI)/ GRAVINDEX TEST

Urine of the suspected pregnant female containing HCG is mixed with antiserum to
HCG. This mixture is treated with HCG coated latex particles.
• If the urine contains HCG, then the antibodies in the antiserum are all used up
and hence no agglutination takes place. Therefore, “No agglutination” is positive
for pregnancy
• If the urine does not contain HCG, then the antibodies in the antiserum remain
free and hnce agglutination takes place. Therefore, “agglutination” is negative
for pregnancy.

The result is noted after 2min. The sensitivity level of HCG in urine is 1.5-3.5 IU/ml and
is 98% accurate.

b) RADIO IMMUNO ASSAY (RIA)

HCG radiolabelled with iodine (I135) is treated with fixed amount of antibodies and
urine sample.

c) ELISA

Same as RIA except an enzyme is used in place of radioactive substance.

False positive results are observed in

• Excess blood or protein in the urine sample

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 • Menopause
• At the time of ovulation

False negative results are observed in

• Low levels of HCG

Advantages

They are less costly, simpler and easy to carry out, take very little time for reporting
and can confirm pregnancy within 10days of conception.

ULTRASONOGRAPHY

The gestational ring is detected by ultrasound as early as 5th week, cardiac pulsation by
10th week and fetal movements by 12th week of pregnancy.

It is non invasive and gives details about morphology of fetus; detects abnormalities if
present.

UTILITY OF PREGNANCY TESTS

1. To diagnose pregnancy
2. Used in assessing and determining the course of action in cases of repeated
abortions.
3. In detecting hydatiform mole and chorioepithelioma,
Repeated tests show high and rising concentration of HCG(the urine diluted 1 n
500 may give a positive test) while, in normal pregnancy the HCG titer falls by
12th week.

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 SEMEN ANALYSIS

AIM:
To do semen analysis and to determine whether a male is fertile or not.

Characteristics of Normal semen

A sample of semen collected after 2-3 days of sexual abstinence has the following
features

1. Volume
Normal volume is 2.5 – 5ml.
It decreases in functional disorders or an inflammation of genital tract.
2. Motility
In a normal sample, at least 80% of sperms should show good forward motility
within first 3hours of collection.
Motility less than 60-80% is subnormal and less than 40% suggests infertility.
3. pH
Normal pH is 7.2-7.7.
pH below 7.0 indicates congenital absence of seminal vesicles or excessive
secretion of prostatic fluid.
4. Morphology
Normal sperms are actively motile and atleast 70% should have normal
morphology. They have a head, neck, body and tail.
Abnormalities in shape include: bifid or absent heads, bifurcated tails. If
present in more than 30% indicates pathology.
5. Count
Normal count is 40-200 million/ml; Average 100-120million/ml. Count between
20-40 million/ml indicate borderline sterility and counts below 20million/ml
indicate sterility.
6. Clotting and Liquefaction
Normal semen clots within 5minutes of ejaculation. It undergoes secondary
liquefaction due to the presence and activation of plasmin and other proteolytic
enzymes such as prostate specific antigen, pepsinogen, hyaluronidase and
amylase.

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 7. Fructose
Normal semen contains fructose. It is used by sperms for production of ATP by
Kreb‟s cycle.
Absence of fructose indicates obstruction or absence of ejaculatory ducts or
seminal vesicle.

SPERM COUNT

APPARATUS

Microscope, Neubauer chamber, WBC pipette, plasticine, 5% sodium bicarbonate

PRINCIPLE

Semen is collected from the subject, diluted 20 times in a WBC pipette and the sperms
are counted in Neubauer chamber.

PROCEDURE

1. Collect a fresh sample of semen (after two days of abstinence) in a petri dish.
2. Wait for 25-30 minutes for secondary liquefaction. Observe whether the
liquefaction is uniform. Measure its volume.
3. Assessing the sperm motility:
Place a drop of semen on a cover slip and invert it on the rim of a small circle of
plasticine previously made on a slide. Examine under low and high power. Assess
the percentage of motile to non-motile sperms. Note their morphology.
4. Counting the sperms.
Gently shake the sample to assure uniformity.
i) Draw semen to 0.5 mark in the WBC pipette, then draw the diluting fluid
to mark 11. Mix the contents of bulb for 2-3minutes.
ii) Discard the first few drops, charge the counting chamber and count the
sperms under high power in 4 WBC squares.
iii) Calculation:

Number of sperms in 64 squares (volume =2/5 mm3) = N

Number of sperms in 1 mm3 of undiluted semen = N x 5/2 x
20 Sperm count in 1ml = 50 N x 1000

98
REPORT:
Sperm count = million/ml
Morphology = % normal
Motility = % normal

99
 ELECTROENCEPHALOGRAM (EEG)

The record of electrical activity of the brain (cerebrum) is called Electroencephalogram

(EEG).

It can be recorded by placing two electrodes on the scalp and connecting them via a
suitable amplifier to a cathode ray oscilloscope (CRO).

Source of the EEG:

The activity recorded in the EEG is that of rhythmically discharging cell bodies in the
most superficial layers of the cortical grey matter.

The EEG is due to graded potentials which are summed postsynaptic potentials in the
brain neurons.

NORMAL EEG WAVES

EEG Rhythm Frequency Amplitude Associated features

(Hz) (µV)
1. Alpha (α ) 8-13 50-100 Present maximally in the occipital
and parieto-occipital areas
In all normal, waking and relaxed
adults with eyes closed(Rhythm of
inattention)
2. Beta (β ) 14-30 5-10 Generally seen in frontal region
Commonly seen in infants
When attention is focused on
something
3. Gamma (γ) 20-30 2-8 Persons working withrapt
attention
4. Theta (θ) 4-7 50-100 Parietal and temporal areas
Seen during sleep and deep
meditation
5. Delta (δ) 1-4 20-200 Appear during deep sleep
Produced by hyperventilation or
organic brain disease

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ALPHA RHYTHM (Synchronized EEG):

The synchronization is due to

1) the synchronizing effect of neighboring, densely packed, parallel-arranged fibers
(dendrites) in the cerebral cortex.
2) Rhythmic discharges from thalamus and other subcortical structures.

CHANGES IN ALPHA RHYTHM

Decreased in: Hypoglycemia, low body temperature, high arterial pCO2, low levels of
glucocorticoids, anesthesia and sleep

Increased in: Hyperglycemia, rise in body temperature, low arterial pCO2 and
hyperventilation

Desynchronization (Arousal response):

It refers to the replacement of a rhythmic EEG pattern by irregular, low voltage activity.
Ascending reticular activating system (ARAS) is responsible for this desynchronization
that follows any type of sensory stimulation.

ALPHA BLOCK: Any form of mental stimulation such as mental arithmetic or opening
the eyes leads to replacement of α-rhythm (alpha rhythm) by fast, irregular, high
frequency, low voltage waves. This is called α-block (alpha block).

CLINICAL APPLICATIONS OF EEG:

1. EPILEPSY
Grand mal epilepsy – In tonic stage, high voltage and high frequency
synchronous waves
In clonic stage, slower and larger waves
Petit mal epilepsy – Spike and dome pattern
Temporal lobe epilepsy – low frequency rectangular waves
2. Brain tumors and abscess
3. Head injuries and vascular lesions
4. Encephalitis, meningitis
5. Organic and functional disorders

101