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16
1 General History Taking andGeneral Examination
Dorsalis pedis pulse—The dorsalis
pedis artery runs on the anterior
aspect of the foot, lateral to the
extensor hallucis tendon. The dorsalis pedis pulse is generally felt
within 1cm of the bony prominence
of the navicular bone. The patient
being asked to extend his rst toe
which helps to elevate this landmark and make the pulse easier
(Fig.1.11d). It may be absent due to
an anatomical variation in 10% of
the general population.
Posterior tibial pulse—The posterior tibial artery is located posterior
to the medial malleolus of the tibia
(Fig. 1.11c). The posterior tibial
pulse may be the most difcult to
palpate, especially among less
experienced clinicians.
What to be measured
Type of pulse—Evaluation of pulse
begins with the type of pulse
whether it is bounding or weak, fast
or slow, irregular or regular, and
equal or unequal bilaterally.
The intensity of the pulse—The
intensity of the pulse is subjectively
graded on a scale of 0 to 4.
0 refers to a nonpalpable pulse.
1+ refers to a barely detectable pulse.
2+ refers to slightly diminished but greater
than 1+
3+ refers to a normal pulse and easily
palpable.
4+ refers to a bounding pulse (stronger than
normal).
Rhythm of pulse—After noting
intensity, the clinician will turn
their attention towards the rhythm,
feeling long enough to be certain
that the only variation in rhythm
may be the minor uctuation that
occurs with the respiratory cycle.
Rate of pulse—Finally, the rate of
pulse is to be measured and noted
while counting the total number of
palpable beats that occur during a pre-
determined amount of time. Generally,
30 s is the minimum amount of
acceptable time but more extended
periods provide greater accuracy.
– Tachycardia—Tachycardia is used for
a heart rate of over 100 beats per minute. Sometimes, it’s normal to have a
fast heartbeat, for example, during
exercise or as a response to stress,
trauma or illness. There are cardiac
and non-cardiac causes of tachycardia
(Tables 1.5 and 1.6).
Table 1.5 Cardiac causes of tachycardia
Cardiac causes of tachycardia
1. Atrial brillation—Atrial brillation is the most
common type of tachycardia
2. Atrial utter—The heart’s atria beat very fast but at
a regular rate
3. Supraventricular tachycardia—It is an abnormally
fast heartbeat that starts somewhere above the lower
chambers of the heart
4. Ventricular tachycardia—Ventricular tachycardia is
a rapid heart rate that starts with abnormal electrical
signals in the lower chambers (ventricles) of the
heart. VT more than a few seconds is lifethreatening emergency
5. Ventricular brillation—Most people who have
ventricular brillation have an underlying heart
disease or have experienced serious trauma, such as
being struck by lightning
Table 1.6 Non-cardiac causes of tachycardia
1. Anaemia
2. Drinking too much alcohol
3. Drinking too many caffeinated beverages
4. Exercise
5. Fever
6. High or low blood pressure
7. Imbalance of electrolytes, mineral-related
substances necessary for conducting electrical
impulses
8. Medication side effects (such as cocaine or
methamphetamine)
9. Hyperthyroidism
10. Smoking
11. Sudden stress, such as fright
1.2 Examination ofPatient
17
Table 1.7 Causes of bradycardia
1. Old age (aging) due to heart tissue damage
2. Congenital heart defect
3. Myocarditis
4. Hypothyroidism
5. Imbalance of serum electrolyte such as potassium or
calcium
6. Obstructive sleep apnoea causes repeated disruption
of sleep
7. Inammatory disease—Rheumatic fever or lupus
8. Medications used to treat high blood pressure and
psychosis
Common types of tachycardia
include:
Non-cardiac/other causes of
tachycardia
– Bradycardia—If heart beats are less
than 60 times a minute which is a
slower than normal heart rate. It can be
a serious problem if the heart doesn’t
pump enough oxygen-rich blood to the
body (Table1.7).
Causes of bradycardia
Assess for radio-femoral delay—
To assess radio-femoral delay, both
femoral pulse and radial pulse are to
be palpated simultaneously in healthy
individuals, and the pulses should
occur at the same time. If the pulses
are not synchronized, this indicates
radio- femoral delay.
(e) Respiration—The respiration is the move-
ment of oxygen from the outer environment
to lung alveoli, as well as removal of carbon
dioxide in the opposite direction.
Physiological respiration involves the mechanisms that ensure that the composition of
the functional residual capacity is kept con-
stant, and equilibrates with the gases dis-
solved in the pulmonary capillary blood, and
thus throughout the body. The act of breathing is evaluated on various parameters like
rate, rhythm, depth, breathing pattern.
• Respiratory Rate—The respiratory rate
dened as number of breaths a person
takes per minute. The rate is usually measured when a person is at rest and simply
involves counting the number of breaths
for 1min by counting how many times the
chest rises. Normal respiration rates for
an adult person at rest range from 12 to 16
breaths per minute. Respiration rates may
increase with fever, illness, and other
medical conditions.
– Tachypnoea—It is termed when respi-
ratory rate >20 breaths/min at presentation. Tachypnoea is caused by airway
obstruction, pneumonia, pulmonary
brosis, pulmonary embolism, pneumothorax, pleural effusion, cardiac
failure.
– Bradypnea—It is termed when an
abnormally slow breathing rate <12/
min. It is caused by exhaustion in
severe airway obstruction, sedation,
raised intracranial pressure, opiate
overdose, intoxication, hypothyroidism, brain stem lesion, sleep apnoea
syndrome, CO poisoning and drug
overdose.
– Apnoea (no breathing)—It is termed
when there is a temporary halt in
breathing that is most common when a
person is sleeping.
– Hyperpnoea—This term is used when
a person breath in more air but not
necessarily breathing faster. It can
happen during exercise, heart failure
or sepsis.
– Kussmaul breathing—It is dened as
fast, deep breaths that can present in
patients with diabetic ketoacidosis.
– Hyperventilation—This is dened as
breathing faster to get rid of excessive
carbon dioxide. Hyperventilation can
be caused by exercise, anxiety, or
asthma and also can make a person feel
dizzy, weak or confused.
(f) Temperature—The temperature of a body is
another vital sign clinically checked by back
of the hand. It ranges from 97°F (36.1°C) to
99 °F (37.2 °C). The average normal body
temperature is generally 98.6 °F (37 °C).
Fever is a term used for increase body temperature above normal. Adult has a fever
when oral temperature >100.4°F (38°C) or
18
Table 1.8 Causes of hypothrmia
Disorders that produce excessive heat Disorders of diminished heat dissipation Disorders of hypothalamic function
Exertional hyperthermia
Heat stroke
Malignant hyperthermia
Lethal catamenia
Pheochromocytoma
Salicylate intoxication
Drug abuse
Status epilepticus
Generalized tetanus
Neuroleptic malignant syndrome
Fig. 1.12 Range
hypothermia to
hyperthermia
Dehydration
Anticholinergic drugs
Autonomous dysfunction
1 General History Taking andGeneral Examination
Cerebrovascular accident
Trauma
Sarcoidosis
Encephalitis
Hypothermia
Severe
<30°C
(80°F)
Moderate
30°–34°C
(80°– 93.2°F)
Mild
34°–36°C
(93.2°– 96.8°F)
a rectal or ear temperature >101°F (38.3°C).
A child has a fever when rectal temperature
is 100.4°F (38°C) or higher.
• Sites for temperature measurement—
There are various sites for measurement
of temperature.
– Oral temperature measurement for
fever in adults—This is the commonest
site for measurement of body temperature in adults.
– Axillary temperature in kids—Axilla
is the commonest site for the measurement of body temperature in kids.
– Anal temperature—This site can be
used for kids, sedated, comatose
patient.
• Types of disorder of temperature
– Hyperthermia—This is in general
term also called fever and is caused by
disruption of the body’s heat-regulation system by outside factors, leading
to a person’s internal temperature ris-
ing (Table1.8 and Fig.1.12b).
– Causes of hyperthermia
– Hypothermia—When body tempera-
ture becomes less than normal range of
Normothermia
36.5°–37.2°C
(97.7°– 98.96°F)
Hyperthermia Hyperpyrexia
>37.2°C
(98.96°F)
>41.5°C
(106.7°F)
body temperature, it is termed as hypothermia. There are ve stages of
hypothermia.
Stages of hypothermia
Stage 1—Mild hypothermia with
95–89.6 °F temperature, normal consciousness, shivering.
Stage 2—Moderate hypothermia with
89.6–82.4 °F, shivering stopped and
consciousness impaired
Stage 3—Severe hypothermia with
82.7–59°F, unconscious and difcult to
detect vital signs.
Stage 4—Apparent death with 75.2–59°F.
Stage 5—Leads to death
Causes of hypothermia (Table1.9)
(g) Blood pressure—Blood pressure is dened
as the force of blood pushing against the
arterial wall. It is measured in MM of mercury by a sphygmomanometer. It has two
components: systolic blood pressure and diastolic blood pressure. The blood pressure has
1.2 Examination ofPatient
Table 1.9 Causes of hyperthermia
Metabolic CNS Drugs Miscellaneous
Hypothyroidism,
hypoglycaemia, diabetic
ketoacidosis
Table 1.10 Interpretation of blood pressure readings
Blood pressure category Systolic BP Diastolic BP
Normal <120 <80
Elevated 120–130 <80
Pre-hypertension 130–140 80–89
Mild 140–159 90–100
Moderate 160–179 100–110
Severe 110–120
Hypertensive crisis >180 >120
Stroke, head
trauma, spinal
cord injury
Alcohol, opiates,
benzodiazepines
Sepsis, burn, trauma, malnutrition,
anorexia nervosa, pancreatitis,
extreme age
19
long-term effects on the heart, kidneys and
brain. Blood pressure can be measured by
three methods for clinic readings, selfmonitoring by the patient at home, and 24-h
ambulatory readings. The oscillometric technique is used for self-monitoring of blood
pressure at home.
• Methods of blood pressure measurement—The blood pressure is measured
either in a supine position or a sitting position. The standard site is cubital fossa
where brachial artery is easily palpable.
The auscultatory method is the ‘gold standard’ for blood pressure measurement
using a mercury sphygmomanometer. But
a widespread ban on the use of mercury
sphygmomanometers continues to diminish the role of mercury sphygmomanometers. The sphygmomanometer cuff is
placed or tied two ngers above the elbow
joint at roughly the same vertical height as
the heart, attached to a mercury or aneroid
manometer. A cuff of the appropriate size
is tted smoothly and also snugly.
Palpatory method—In this method, cuff
is inated manually while palpating the
radial artery until the loss of pulse, which
is the indicator of systolic blood pressure.
A minimum systolic value can be roughly
estimated by palpation and is most oftenly
used in emergency situations.
Auscultatory methods—In this method,
the cuff is inated up to 200 mmHg to
arterial ow of blood completely. Now
examiner will listen with the stethoscope
to the brachial artery at the antecubital
area of the elbow. The pressure in cuff is
slowly released to allow owing of blood
in the artery. Initially, the turbulent ow
creates a ‘whooshing’ or pounding rst
Korotkoff sound. The pressure at which
this sound is rst heard is noted as systolic
blood pressure. The cuff pressure is further released until no sound can be heard
noted as fth Korotkoff sound, which indicate the diastolic arterial pressure. The
auscultatory method is the predominant
method of clinical measurement of measurement of blood pressure. Systolic pressure is peak pressure in the arteries, which
occurs near the end of the cardiac cycle
when the ventricles are contracting and
diastolic pressure is the minimum pressure
in the arteries, which occurs near the
beginning of the cardiac cycle when the
ventricles are lled with blood. Normal
measured values for a resting, healthy
adult human are 120mmHg systolic and
80 mmHg diastolic (written as
120/80mmHg, and spoken as ‘one-twenty
over eighty’).
• Interpretation (Table1.10)
20
1 General History Taking andGeneral Examination
1.2.2 Systemic Examination
two hemispheres. Cerebrum performs
higher functions like olfaction, vision,
1. CNS (Central nervous system)
(a) Higher functions of the brain—The
brain consists of three main parts: the
cerebrum, cerebellum and brainstem. The
(b) Glasgow coma scale
interpreting touch, hearing, speech, reasoning, emotions, learning and ne control of movement.
cerebrum is the largest and composed of
Glasgow coma scale
Eye opening Verbal response Motor response Score
Obey command—6 Good—(15–13)
Oriented—5 Localizing—5 Average—(12–9)
Spontaneous—4 Confused—4 Normal exion—4 Poor—(3–8)
To sound—3 Words—3 Ab Flexion—3
To pressure—2 Sound—2 Extension—2
None—1 None—1 None—1
(c) Cranial nerve examination—There are
12 cranial nerves:
• Olfactory nerve—This is rst cranial
nerve or also known as nerve of
olfaction.
– Anatomy and pathway—The
olfactory nerve is the rst and
smallest of all cranial nerves. This
nerve passes from its receptors in
the olfactory mucosa to the forebrain through cribriform plate of
ethmoid. It conveys special sensory
information of smell from nose to
brain (Fig.1.13a).
– Clinical tests of olfactory nerve
Procedure to test the olfactory
nerve (smell tests)—Examiner
rst asks patient to close eyes then
close one nostril, now the examiner
put the certain readily identiable,
aromatic but innocuous substances,
such as asafoetida, clove oil, coffee
etc. and ask the patient to identify
(Fig.1.13b). Repeat the same procedure on opposite side.
• Optic nerve—This is second cranial
nerve and has more than one million of
bres. It is a pure sensory nerve with
unique bre pathway that connects the
retina of eye to the brain. It transmits
sensory information of vision from
eye to brain in the form of electrical
impulses.
– Anatomy and pathway
Anatomy—The optic nerve
begins in retina and passes
through the posterior orbit along
with ophthalmic artery and sympathetic chain. It then enters the
bony optic canal to emerge intracranially through optic foramen
on the under surface of brain and
above hypophysis fossa. Here,
both optic nerves come together
to form an X-shaped optic chiasma. At optic chiasma, approximately half of the nerve bres
from side continue on the same
side of the brain, and the remaining nerve bres cross over to
opposite side. This decussation
is essential for producing binocular vision (Fig. 1.14a). Optic
tract has nasal bre of opposite
side and temporal bre of same
side. It arises from optic chiasma, run posteriorly to lateral
geniculate body to visual cortex.
Olfactory
Olfactory
Olfactory
Olf
turbinat
turbinat
1.2 Examination ofPatient
21
Fig. 1.13 (a) Tract of
olfaction, (b) Testing of
olfactory nerve
actory
area
Middle
Inferior
Inferior
meatus
Palate
a
e
e
b
FSSSFS
bulb
nerves
tract
SS
1
Eyes closed
2
one nostril occluded
Pathway—Retina—optic
nerve—optic chiasma—optic
tract—lateral geniculate body—
geniculostriate tract—visual
cortex (Areas 17, 18 and 19).
– Clinical tests for optic nerve—
Clinical tests should be done sepa-
3
Stimulus is given to
another nostril
rately for both eyes for visual
acuity, visual elds and
accommodation.
Visual acuity test—This test is
to be performed in a well-lit
room, with the patient standing
or sitting at least 6m away from
22
LR
mporal
a
b
d
1 General History Taking andGeneral Examination
Nasal
Medial
Optic chiasm
Lateral
Optic nerve
Optic tract
Optic
nerve
Optic
tract
Visual
cortex
Te
Optic
chiasm
c
1
Pupil in dim light
Direct light reflex
Consensual light reflex
Fig. 1.14 (a) Optic nerve and tract, (b) Snellen chart, (c) Light reex, (d) Ishihara’s chart
the Snellen chart. If the patient
has distance glasses, then let
him/her wear for this examination. Examiner has to cover one
eye of patient and ask to read
the letters in each line on the
chart, from top to bottom until
they are no longer able to iden-
1.2 Examination ofPatient
23
tify the letters with the other
eye. A visual acuity score
(reported for each eye) of 6/6
means that at 6 m, the patient
can read letters that are 6 m
away (Fig. 1.14b). This test
assesses multiple modalities of
eye function, optical integrity
of the eyes, health of the retina
and the ability of the brain to
interpret the images.
Colour perception test/colour
vision—This test is done to
assess whether a person can perceive red or green colour. The
patient is given Ishihara charts
and asked to identify the numbers, which are designed as
mosaic images of different
shades of red and green. This is
a crude way of assessing redgreen colour blindness
(Fig.1.14d).
Visual reex test
Pupillary light reflex test—
This is done to check the direct
and consensual constriction of
the pupil in response to light
exposure. The patient is asked
to remove the spectacle if he is
wearing. Now examiner asks
patient to look at a point on the
front wall and a light source is
then shone into one eye. The
ipsilateral eye is observed for
constriction of that pupil. If
this occurs, then the direct
pupillary light reflex is intact.
Simultaneously, the contralateral eye is also observed for
pupillary constriction. If this
occurs, then the consensual
light reflex is intact
(Fig.1.14c).
Accommodation reex test—
Accommodation reex allows
eyes to focus on near and far
objects. This test is done by ask-
ing the patient rst to focus on a
distant object, then quickly
switch focus to object very close
to patient’s own face in the midline. In this reex, convexity of
lens, convergence of eyeballs
and pupillary constriction are
inspected. This is also known as
accommodation-convergence or
near reex. The pathway of
accommodation includes the
afferent pathway from optic
nerve—lateral geniculate
body—primary visual cortex
and efferent pathway is
midbrain- Edinger Westphal
nucleus—parasympathetic bre
activation—ciliary muscle contraction and contraction of
medial rectus muscle.
Visual body reex—It is
dened as reex raising of arms
to cover the face or close the
eyelids to protect the eyes in
response to perceived threat.
Visual elds—The confrontation method is used to assess the
visual eld. In this method, both
patient and examiner sit facing
each other at 1m distance, with
eyes at the same level. If the
right eye is to be tested, patient
will cover his left eye with left
palm and look at the left eye of
examiner who covers his right
eye and he is asked to look into
the examiner’s eye, not the
object. Now the examiner holds
either an object or his nger in a
plane midway between them.
Examiner brings the moving
object/nger from the periphery
till the examiner is able to see it.
If the patient has normal vision,
he will see object/nger at the
same time when examiner is
able to see. If patient is not able
to see object at this point, move
24
Fig. 1.15 Anatomy and
pathway of third, fourth
and sixth nerves
Superior
oblique muscle
Superior
rectus muscle
Lateral rectus
muscle
Inferior rectus
1 General History Taking andGeneral Examination
Optic nerve
Trochlear
nerve
Oculomotor
nerve
III Nerve
IV N.
VI N.
the object medially until he sees
it. This is comparative test and a
normal vision of examiner is
mandatory. There are several
features of the visual elds that
should be assessed like homonymous defect, peripheral visual
eld and central visual eld.
• Oculomotor nerve, trochlear and
abducent nerve—Cranial nerves
third, fourth and sixth provide motor
innervations to extra-ocular muscles.
The oculomotor nerve gives motor
innervation to all the extra-ocular muscles except the lateral rectus, which is
supplied by abducens nerve, and superior oblique, which is supplied by
trochlear nerve.
– Anatomy and pathway (Fig.1.15a)
Oculomotor nerve—It is third
cranial nerve and originates
from the oculomotor nucleus in
the midbrain of the brainstem
then passes inferiorly to the posterior cerebral artery and superiorly to the superior cerebellar
artery. At this point, nerve
pierces the dura mater to enter
Ciliary
ganglion
Medial
rectus muscle
Abducens
nerve
the lateral aspect of the cavernous sinus. It receives sympathetic branches from the internal
carotid plexus within the cavernous sinus but do not combine
with the nerve, only travel within
its sheath. The oculomotor
nerve exits the cranial cavity
via the superior orbital ssure
to enter orbit where it divides
into superior and inferior
branches:
Superior branch—This branch
of oculomotor nerve provides
motor innervation to the superior rectus muscle and levator
palpabrae superioris muscle.
Sympathetic bres run along
with supply superior tarsal
muscle.
Inferior branch—This branch
of oculomotor nerve gives motor
supply inferior rectus muscle,
medial rectus muscle and inferior oblique muscle. The preganglionic parasympathetic
bres along with this branch
relay in ciliary ganglion and
1.2 Examination ofPatient
25
nally innervate the sphincter
pupillae and ciliary muscles.
Trochlear nerve—It is a
motor/somatic efferent nerve that
innervates superior oblique mus-
cle of the eye. It is the smallest
nerve in terms of the number of
axons but has the largest in intracranial length. The trochlear
nerve is the only cranial nerve
that exits from the dorsal/rear
aspect of the brainstem. It
decussates within the brainstem
and emerges from the contralateral side of the brain stem at the
level of the inferior colliculus and
innervates the superior oblique
muscle of the opposite side. An
injury to the trochlear nerve
causes paralysis of the ipsilateral
superior oblique muscle and
injury of the trochlear nucleus
and above causes paralysis of the
contralateral side.
Abducent nerve—It is a
somatic efferent nerve that sup-
plies lateral rectus muscle,
which causes outward gaze of
the eye. This is also known as
sixth cranial nerve. It arises from
abducent nucleus at the level of
facial colliculus in pons. It exits
brainstem at the Ponto-
medullary junction, medial to
the facial nerve, and enters the
subarachnoid space. Now it
courses upward between the cli-
vus and the pons where it pierces
the dura mater and runs between
the dura and the skull through
Dorello’s canal. At the petrous
apex, it takes a sharp turn forward to enter the cavernous
sinus where it runs alongside the
internal carotid artery. Finally, it
enters the orbit through the
superior orbital ssure and
innervates the lateral rectus
muscle of the eye (Fig.1.16).
– Clinical examination of oculomo-
tor, trochlear, and abducent
nerves
Accommodation reex—
Patient is asked to watch the pen
which moves towards and away
from the eye (Fig.1.17).
Ocular movements—The
movements of eyes are tested by
standing 1 m in front of the
patient and asking him to follow
a target with eye only with no
head movement. Now, examiner
moves target in an H and patient
is asked to report any diplopia
(Fig.1.16 and Table1.11).
Fig. 1.16 Range of ocular movement and muscle involved
Fig. 1.17 Accommoda-
tion reex